DDH (Developmental Dysplasia of Hip).pptxRakesh Singha
Developmental Dysplasia of the Hip is a disorder of abnormal development resulting in dysplasia, subluxation, and possible dislocation of the hip secondary to capsular laxity and mechanical instability.Diagnosis can be confirmed with ultrasonography in the first 4 months and then with radiographs after femoral head ossification occurs (~ 4-6 months).
Treatment varies from Pavlik bracing to surgical reduction and osteotomies depending on the age of the patient, underlying etiology, and the severity of dysplasia.
Principles of use and abuse of suture 1Drkabiru2012
Academic presentation during junior residency rotation at Aminu Kano Teaching Hospital Surgery Department, General Surgery unit by
Dr kabiru SALISU
kbmed2003@yahoo.com
Preoperative preparation of diabetes patientDrkabiru2012
Academic presentation during junior residency rotation at Anaesthesia Department of Aminu Kano Teaching Hospita Kano, by
Dr Kabiru SALISU
kbmed2003@yahoo.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
3. Introduction
Developmental Dysplasia of the Hip (DDH)
Is a spectrum of intra-capsular hip pathology
that ranges from instability, subluxation or
Dislocation of the Hip; before, during or after
birth.
5. DDH is the commonest Orthopaedic disorder
in new born. It has excellent prognosis when
detected at birth. However, Poses a treatment
challenge when present late.
10. Epidemiology
• 1 per 1000 live births
• Barlow (1962) described an incidence of
instability 1:60 however 60 per cent stabilized
by one week and 88 per cent by 8 weeks
• Common in native Americans and Lapps
11. • Female: Male = 6:1
• Left: Right = 5:1
• Bilateral in 20%
12. Risk factors
- First born
- Female
- Faulty intrauterine position (eg Breech)
- Family history
- OTHER condition
Oligohydramnios
Torticollis 15- 20%
metatarsus adductus 1.5 -10%
15. Pathological changes in DDH
• At Birth - Normal, dysplasia & Stretched
capsule
• During infancy- Adaptation to persistent
instability and dislocation
• After weight bearing commences;- Persistent
dislocation and adaptation to lording
16. CHANGES IN THE BONES
• Acetabulum
• The femoral Head
• The neck of the femur
• The pelvis
17. CHANGES IN THE SOFT TISSUES
• The capsule
• Ligamentum teres and TAL
• The Muscle – Palvifemoral ;- Shortened
- Pelvitrochantric ;-
- Gluteal
21. - Difficulty in applying diaper
- Delay walking
- Limping & tip toeing
- Limb shortening
- Late presentation
Painless limp
Hip pain
Back pain /deformity
29. Radiologic investigation
1 - ULTRASOUND SCAN
• Static (Graf technique)
- To determine dysplastic changes in the hip
• Dynamic (Hercke and Clarke)
- To determine instability
31. Graf classification
Class Alpha angle Beta angle Definition Treatment
I >60 <55 Normal -
II 43-60 55-77 Abnormal Observe/
harness
III <43 >77 Subluxated Pawlik harness
IV unmeasurable unmeasurable Dislocated Pawlik harness/
closed vs open
reduction
42. Non Operative Care
• 1- Close observation
Indication;- USS feature of instability
No Dysplasia
No dislocation
Weekly USS or clinical Examination for 6weeks
43. 2- Abduction splinting and bracing (Pavlik
Herness)
Indication ;- Child < 6month with
-Instability + dysplasia or dislocation
- Persistent instability > 6weeks
Success rate;- 90%
61. West African experience
• Poor knowledge of risk factors
• Lack of screening programs
• Late presentation with complications
62. Conclusion
• DDH is one of the commonest Orthopaedic
conditions at the neonatal period with good
prognosis when identified early.
• Identification of babies at risk, screening at
birth and early institution of treatment are
known to improve outcome.
63. References
• John AH. Tachjian’s Paediatric Orthopaedics5th edition. Elservier
Sounders;2014. Chapter 16; Developmental Dysplasia of the Hip:483-535
• Duthei RB. Mercer’s orthopaedic surgey 9th edition. Arnold. Chapther 3.
Congenital Malformations: 152- 172
• Solomon L, Ganz R, Leunig M, Mousell F, Learmonh L. Apley’s system of
orthopaedics and fractures 9th edition. Holder Arnold.Chapter 19; The Hip;
Developmental Dysplasia of the hip: 498-504
• Cris S. Developmental dysplasia of the hip. Orthobullet
• Developmental Dysplasia of the hip. www.orthinfo.org
• Agrawal U. Developmental Dysplasia of the hip. Ppt
• Agarwal A, Gupta N. Risk factor and diagnosis of DDH in children. J clin
Orthop trauma. 2012;3:10-14
• Thawrani D. Pelvic osteotomies. Medscape;2015
The term congenital dislocation of the hip dates back to the time of Hippocrates. This condition, also known as hip dysplasia or developmental dysplasia of the hip (DDH), has been diagnosed and treated for several hundred years. Most notably, Ortolani, an Italian pediatrician in the early 1900s, evaluated, diagnosed, and began treating hip dysplasia. Galeazzi later reviewed more than 12,000 cases of DDH and reported the association between apparent shortening of the flexed femur and hip dislocation. Since then, significant progress has been made in the evaluation and treatment of DDH
DDH encompasses a spectrum of disease that includes dysplasia
a shallow or underdeveloped acetabulum
subluxation
dislocation
teratologic hip
dislocated in utero and irreducible on neonatal exam
presents with a pseudoacetabulum
associated with neuromuscular conditions and genetic disorders
commonly seen with arthrogryposis, myelomeningocele, Larsen's syndrome
late (adolescent) dysplasia
mechanically stable and reduced but dysplastic
4th week from single mesenchyme
Separation occur 7-8wks
Development is completed 11wks
Acetabulum & femoral head are mainly cartilaginous at birth
Development continue post op.
The reported incidence of neonatal hip instability in
northern Europe is approximately 1 per 1000 live
births, but this is dependent on the definition of
‘instability’. Barlow (1962) described an incidence of1:60; however 60 per cent stabilized by one week and
88 per cent by 8 weeks
Aetiology and pathogenesis
Genetic factors must play a part in the aetiology, for DDH tends to run in families and even in entire populations (e.g. in countries along the northern and
eastern Mediterranean seaboard). Wynne-Davies (1970) identified two heritable features which could predispose to hip instability: generalized joint laxity (a
dominant trait), and shallow acetabula (a polygenic trait which is seen mainly in girls and their mothers). However, this cannot be the whole story because in 4 out of 5 cases only one hip is dislocated.
Hormonal factors (e.g. high levels of maternal oestrogen, progesterone and relaxin in the last few weeks of pregnancy) may aggravate ligamentous laxity in the infant. This could account for the rarity of instability in premature babies, born before the hormones reach their peak.
Intrauterine malposition (especially a breech position with extended legs) favours dislocation; this socalled
‘packaging disorder’ is linked with the higher incidence in first-born babies, among whom spontaneous version is less likely. Unilateral dislocation usually affects the left hip; this fits with the usual vertex presentation (left occiput anterior) in which the left hip is adjacent to the mother’s sacrum, placing it in an adducted position. Other manifestations of intrauterine crowding, including plagiocephaly, congenital torticollis
and postural foot deformities, are also associated with a higher than usual incidence of DDH.
Postnatal factors may contribute to persistence of neonatal instability and acetabular maldevelopment. Dislocation is very common in Lapps and North American Indians who swaddle their babies and carry them with legs together, hips and knees fully extended, and is rare in southern Chinese and African Negroes who carry their babies astride their backs with legs widely abducted. There is also experimental evidence that simultaneous hip and knee extension leads to hip dislocation during early development (Yamamuro and Ishida, 1984
At birth the hip, though unstable, is probably normal in shape but the capsule is often stretched and redundant.
After weightbearing commences, these changes are`intensified. Both the acetabulum and the femoral neck remain anteverted and the pressure of the femoral head induces a false socket to form above the shallow acetabulum. The capsule, squeezed between the edge of the acetabulum and the psoas muscle, develops an hourglass appearance. In time the surrounding muscles become adaptively shortened
Acetabulum – shallow
Posterior superior defect
Poor acetabular cartilage
Covered by fibrocartilage Pulvin
The femoral Head
- Relatively bigger the acetabulum
- later became flattened on it medial and posterior aspect
The neck of the femur
- Marked shortening
Anteversion increase to up to 900
The pelvis- tilted forward
- hyper lordosis
The capsule
Stretched, laxed and redundant
Assume hour glass appearance
Ligamentum teres and TAL elongated and hypertrophied
Palvifemoral;- shortened and
secondary barriers to reduction develop. In the depths of the acetabulum, the fatty tissue known as the pulvinar thickens and may impede reduction (Fig. 1. The ligamentum teres also elongates and thickens, and it may take up valuable space within the acetabulum. The transverse acetabular ligament is often hypertrophic as well, and it may impede reduction.112 More important, the inferior capsule of the hip assumes an hourglass shape, eventually presenting an opening that is smaller in diameter than the femoral head. The iliopsoas, which is pulled tight across this isthmus, contributes to this narrowin. The capsule also narrows through a “Chinese finger-trap” mechanism. The femoral changes include increase anteversion and flattening of the femoral head
Prenatal history ; suggestive oligohydramnios
In Ortolani’s test, the baby’s thighs are held with the thumbs medially and the fingers resting on the greater trochanters; the hips are flexed to 90 degrees and gently abducted. Normally there is smooth abduction to almost 90 degrees. In congenital dislocation the movement is usually impeded, but if pressure is applied to the greater trochanter there is a soft ‘clunk’ as the dislocation reduces, and then the hip abducts fully (the ‘jerk of entry’). If abduction stops halfway and there is no jerk of entry, there may be an irreducible dislocation
Barlow’s test is performed in a similar manner, but here the examiner’s thumb is placed in the groin and, by grasping the upper thigh, an attempt is made to lever the femoral head in and out of the acetabulum during abduction and adduction. If the femoral head is normally in the reduced position, but can be made to slip out of the socket and back in again, the hip is classed as ‘dislocatable’ (i.e. unstable).
.
A potentially perilous situation for the unwary examiner is the child with bilateral hip dislocation. This child has no asymmetry on abduction, and the flexed knees are at the same level. Combined abduction is limited, but this is difficult to detect because the limitation is symmetric. One test that can help the examiner to recognize a bilateral dislocation is the Klisic test, in which the examiner places the third finger over the greater trochanter and the index finger on the anterior superior iliac spine. An imaginary line drawn between the fingers should point to the umbilicus.
With each step, the pelvis drops as the dislocated
hip adducts, and the child leans over the dislocated
hip; this is known as an abductor lurch or Trendelenburg gait
- Femur head ossifies at 4-6month thus uss is 100% sensitive and specific
shows the soft anatomy of the hip and the relationship of the femoral head and the acetabulum very well. Technical advances have improved image quality, and dynamic techniques add significant information to that obtained from static images.
Graf Technique – Morphologic assessment, relies on anatomic landmarks
3 lines-
Baseline- line of ilium as it intersects bony and cartilaginous portions of acetabulum
Inclination line – Line along the margin of cartilaginous acetabulum
Acetabular roofline – Along the bony roof
Angle between roof and base line – Alpha - >60 ,
evaluates bony acetabulum
Angle between inclination and base line- Beta - <55 ,
evaluates cartilaginous acetabulum
On Xrays- Hilgenreiners line
- Perkins line
- Shenton’s line
- Acetabular Index
- Centre-edge angle of wilberg
- Acetabular depth to width – normally >38%
- Widened acetabular tear-drop
Von-Rosen’s view – with hip abducted internally rotated, and extended
In a normal hip, the medial beak of the femoral metaphysis lies in the lower, inner quadrant produced by the juncture of the Perkin and Hilgenreiner lines. The Shenton line is smooth in the normal hip. In the dislocated hip, the metaphysis lies lateral to the Perkin line; the Shenton line is broken because the femoral neck lies cephalic to the line from the pubis
Another useful measurement is the acetabular index, which is an angle formed by the juncture of the Hilgenreiner line and a line drawn along the acetabular surface. In normal newborns, the acetabular index averages 27.5 degrees. At 6 months of age, the mean is 23.5 degrees. By 2 years of age, the index usually decreases to 20 degrees. Thirty degrees is considered the upper limit of normal
Von Rosen’s lines: with the hips abducted 45° the femoral shafts should point into the acetabula. In each case the left side is shown to be abnormal.
A helpful radiographic projection is the Von Rosen view,
in which both hips are abducted, internally rotated, and
extended.292 In the normal hip, an imaginary line extended
up the femoral shaft intersects the acetabulum. When the
hip is dislocated, the line crosses above the acetabulum
The Wilberg center–edge angle, which is the angle that is formed between the Perkin line and a line drawn from the lateral lip of the acetabulum through the center of the femoral head. This angle, which is a useful measure of hip position in older children, is considered normal if it is more than 10 degrees
in children between the ages of 6 and 13 years. It increases with age.
CT- scan- delineation of acetabular and femoral anatomy in older age group
MRI- further delineation of block to reduction
All infants require screening Physical exam
successful screening requires repetitive screening until walking age
Ultrasound
ultrasound screening of all infants occurs in many countries, however, it has not been proven to be cost effective
USA recommendations is to perform ultrasound at 4 to 6 weeks in patients with
risk factors
positive physical findings
utilized to follow Pavlik treatment or for equivocal exams
abduction splinting/bracing (Pavlik harness) indications
DDH < 6 months of age and reducible hip
Pavlik harness treatment is contraindicated in teratologic hip dislocations
is a dynamic splint that requires normal muscle function for successful outcomes
contraindicated in patients with spina bifida or spasticity
outcomes
overall Pavlik harness has success rate of 90%
dependent upon age at initiation of treatment and time spent in the harness
abandon pavlik harness treatment if not successful after 3-4 weeks
If pavlik harness fails, convert to semi-rigid abduction brace with weekly ultrasounds for an addition 3-4 weeks before considering further intervention
The three golden rules of splintage are: (1)
the hip must be properly reduced before it is splinted;
(2) extreme positions must be avoided; (3) the hips
should be able to move
closed reduction and spica casting indications
DDH in 6 - 18 months of age
failure of Pavlik treatment
depending on radiological evidence of satisfactory
acetabular development.
The concentrically reduced hip is held in a
plaster spica at 60 degrees of flexion, 40 degrees of
abduction and 20 degrees of internal rotation. After 6
weeks the spica is changed and the stability of the hips
open reduction and spica casting
indications
DDH in patient >18 months of age
failure of closed reduction
open reduction and femoral osteotomy
indications
DDH > 2 yr with residual hip dysplasia
anatomic changes on femoral side (e.g., femoral anteversion, coxa valga)
femoral head should be congruently reduced with satisfactory ROM, and reasonable femoral sphericity
best in younger children (< 4 yr)
after 4 yr, pelvic osteotomies are utilized
used to correct excessive femoral anteversion and/or valgus
femoral osteotomy and shortening may be needed to prevent AVN
decrease tension produced by reduction of a previously dislocated hip
open reduction and pelvic osteotomy
indications
DDH > 2 yr with residual hip dysplasia
severe dysplasia accompanied by significant radiographic changes on the acetabular side (increased acetabular index)
used more commonly in older children (> 4 yr)
decreased potential for acetabular remodeling as child ages
Pemberton (pericapsular) osteotomy
The Pemberton osteotomy is used for anteriorly and laterally deficient acetabula in patients older than 18 months who still have an open triradiate cartilage.
A Smith-Peterson approach is used to access the inner and outer table of the iliac wing. The outer iliac cortex is osteotomized, with the cut started just above the anterior inferior iliac spine and carried out posteriorly and parallel to the capsule in the direction of the triradiate cartilage. The inner table is osteotomized if anterior coverage is necessary. Care must be taken to remain halfway between the anterior edge of the sciatic notch and the posterior rim of the acetabulum
Dega osteotomy
The concept of the Dega osteotomy [37] is similar to that of the Pemberton osteotomy—that is, to change the configuration or shape of the capacious acetabulum by hinging the fragment through the open triradiate cartilage. However, unlike the Pemberton osteotomy, which increases anterolateral coverage, the Dega osteotomy involves cutting only the lateral aspect of the ilium and thus provides posterolateral coverage
The Chiari osteotomy is made just above the
acetabulum, in the region of insertion of the hip capsule.‖
The osteotomy curves to match the acetabular contour, and
it slopes upward from lateral to medial. The level of the
osteotomy and the slope of the cut must be precise for the
displaced iliac wing to cover the femoral head without
impinging on it. The acetabular fragment is displaced medially
almost the full width of the ilium at that level, and it
is held there with pin or screw fixation
Osteonecrosis seen with all forms of treatment
increased rates associated with
excessive or forceful abduction
previous failed closed treatment
repeat surgery
diagnosis based on radiographic findings that include
failure of appearance or growth of the ossific nucleus 1 year after reduction
broadening of femoral neck
increased density and fragmentation of ossified femoral head
residual deformity of proximal femur after ossification
Delayed diagnosis bilateral dislocations
patients typically functions better if hips are not reduced if 6 years of age or older
unilateral dislocation
better outcomes without surgical treatment if patient is 8 years of age or older
epiphysiodesis can be performed for treatment of limb length discrepancy
Recurrence approximately 10% with appropriate treatment
requires radiographic follow-up until skeletal maturity
Transient femoral nerve palsy seen with excessive flexion during Pavlik bracing