Orthopedics 5th year, 1st & 2nd lectures (Dr. Bakhtyar)

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The lecture has been given on Oct. 6th - Dec. 18th, 2010 by Dr. Bakhtyar.

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Orthopedics 5th year, 1st & 2nd lectures (Dr. Bakhtyar)

  1. 1. D.D.H (Developmental Dysplasia of the Hip)
  2. 3. <ul><li>Anatomy of the hip </li></ul>
  3. 4. <ul><li>DDH includes : </li></ul><ul><li>1- Dislocation </li></ul><ul><li>2- Subluxation </li></ul><ul><li>3- Acetabular dysplasia </li></ul>
  4. 5. <ul><li>Incidence </li></ul><ul><li>Instability 5-20 per 1000 livebirths </li></ul><ul><li>After 3 weeks 1-2 per 1000 infants </li></ul><ul><li>( i.e spontaneous correction) </li></ul><ul><li>Girls ⁄ Boys 7 ⁄ 1 </li></ul><ul><li>Left > Right </li></ul><ul><li>20% bilateral </li></ul>
  5. 6. <ul><li>Aetiology </li></ul><ul><li>1- Genetic factors( families, even in entire population) </li></ul><ul><li>2- Hormonal changes in late pregnancy-> lig. laxity </li></ul><ul><li>3- Intrauterine malposition( breech + extended legs) </li></ul><ul><li>4- Postnatal factors( swaddling+ Beshka) </li></ul>
  6. 7. <ul><li>Pathology </li></ul><ul><li>Acetabulum (1) Shallow(looks like a saucer instead of a cup) </li></ul><ul><li>(2) The roof slopes too steeply </li></ul><ul><li>(3) Anteverted </li></ul><ul><li>Femoral head (1) Dislocated(post. and sup.) </li></ul><ul><li>(2) Delayed ossific center </li></ul><ul><li>Femoral neck : Unduly anteverted </li></ul><ul><li>Capsule : (1) Stretched </li></ul><ul><li>(2) ± hourglass by iliopsoas </li></ul><ul><li>Limbus : Superiorly the acetabular labrum and its capsular edge may be </li></ul><ul><li>pushed into the socket by the dislocated femoral head . This </li></ul><ul><li>fibrocartilagenous structure may obstruct closed reduction. </li></ul><ul><li>Lig. Teres : (1) Elongated </li></ul><ul><li>(2) Hypertrophied </li></ul>
  7. 8. <ul><li>Clinical features </li></ul><ul><li>Neonate : (1) Ortolani’s test +ve </li></ul><ul><li>(2) Barlow’s test +ve </li></ul>
  8. 9. <ul><li>Late features </li></ul><ul><li>Unilateral DDH </li></ul><ul><li>(1)Asymmetrical skin creases </li></ul><ul><li>(2) Difficulty in applying napkins( ↓ abduction) </li></ul><ul><li>(3) Shorter leg </li></ul><ul><li>(4) Delayed walking </li></ul><ul><li>(5) Limping </li></ul><ul><li>(B) Bilateral DDH </li></ul><ul><li>(1) ↓abduction </li></ul><ul><li>(2) Delayed walking </li></ul><ul><li>(3) Waddling gait </li></ul><ul><li>(4) Wide perineal gap </li></ul>
  9. 10. <ul><li>X- Ray </li></ul><ul><li>Acetabulum : Shallow and sloping </li></ul><ul><li>(Acetabular roof angle normally< 30) </li></ul><ul><li>(B)Femoral head : Underdeveloped and out </li></ul><ul><li>Perkin’s lines = Vertical line at the outer edge of acetabulum </li></ul><ul><li>Hilgenreiner’ line = Horizontal line through the triradiate cartilages. </li></ul><ul><li>Normally the head is medial to vertical </li></ul><ul><li>and below the horizontal </li></ul>
  10. 11. ( C) Shenton’line is broken (Inferior border of superior ramus and inferior border of the neck) (D) Von Rozen line = Hips abducted 45 Femoral shaft should point into the acetabulum
  11. 12. <ul><li>Treatment </li></ul><ul><li>0-6 months </li></ul><ul><li>6 m – 6 years </li></ul><ul><li>> 6years </li></ul><ul><li>0-6 months </li></ul><ul><li>+ve Ortolani </li></ul><ul><li>+ve Barlow </li></ul><ul><li>+ve US </li></ul><ul><li>Double napkins OR Abduction pillow for 6 weeks </li></ul><ul><li>Stable hip = follow-up for 6 months </li></ul><ul><li>Persistent instability = Splint for 3-6 months (Pavlic harness) </li></ul>
  12. 13. <ul><li>Principles </li></ul><ul><ul><li>Reduction before applying it </li></ul></ul><ul><ul><li>100 flexion + slight abduction </li></ul></ul><ul><ul><li>Extreme positions are avoided( Frog position is only for frogs) </li></ul></ul><ul><ul><li>Some movement is allowed </li></ul></ul>
  13. 14. <ul><li>6monthes- 6 years </li></ul><ul><li>Reduce + hold reduced </li></ul><ul><li>Closed reduction </li></ul><ul><li>Gradual abduction 3 weeks </li></ul><ul><li>Hip spica 6weeks followed by few months Splint which prevents adduction </li></ul><ul><li>( 60 flexion </li></ul><ul><li>40 abduction </li></ul><ul><li>20 internal rotation ) </li></ul><ul><li>Open reduction if closed reduction failed </li></ul><ul><li>+ hip spica 3 months </li></ul>
  14. 15. <ul><li>6years </li></ul><ul><li>Unilateral up to 10 years surgery </li></ul><ul><li>Bilateral = No treatment </li></ul><ul><li>1- Symmetrical deformity </li></ul><ul><li>2- Less noticeable </li></ul><ul><li>3- Failure in one side leads to asymmetrical deformity </li></ul><ul><li>4- In future THR </li></ul>

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