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Developmental Dysplasia of the Hip and Ultrasound
- 1. Developmental Dysplasia of the Hip
- 2. Overview Introduction Normal Development of the Hip Etiology and Pathoanatomy Epidemiology and Diagnosis Ultrasound morphologic and dynamic
- 3. Introduction Developmental Dysplasia of the Hip • DDH - preferred term • Teratogenic hips • Subluxation • Dislocation-usually posterosuperior (reducible vs irreducible) • Dysplasia
- 4. Background Risk Factors • 1/1,000 born with dislocated hip • 10/10,000 born with subluxation or dysplasia • 80% Female • First born children • Family history (6% one affected child, 12% one affected parent, 36% one child + one parent) • Oligohydramnios • Breech (sustained hamstring forces) • Native Americans (swaddling cultures) • Left 60% (left occiput ant), Right 20%, both 20% • Torticollis or LE deformity
- 6. Associated Conditions Torticollis (15% have DDH) Metatarsus Adductus (1.5-10%have DDH)
- 7. Normal Development Embryonic • 7th week - acetabulum and hip formed from same mesenchymal cells • 11th week - complete separation between the two • Prox fem ossific nucleus - 4-7 months
- 8. Normal Hip Tight fit of head in acetabulum Transection of capsule • Still difficult to dislocate • Surface tension
- 9. Pathoanatomy Ranges from mild dysplasia --> frank dislocation Bony changes • Shallow acetabulum • Typically on acetabular side • Femoral anteversion
- 10. Pathoanatomy Soft tissue changes • Usually secondary to prolonged subluxation or dislocation Intraarticular • Labrum Inverted + adherent to capsule (closed reduction with inverted labrum assoc with increased Avascular Necrosis) • Ligamentum teres Hypertrophied + lengthened • Pulvinar Fibrofatty tissue migrating into acetabulum
- 11. Fatty Tissue (Pulvinar Thickens)
- 12. Teres ligament (elongated and thickened) Docking the head
- 13. subluxated dislocated Labrum: Cartilaginous acetabular lip. Neolimbus: a ridge of thickened articular cartilage
- 15. Hourglass shape of the capsule by the iliopsoas tendon
- 17. Pathoanatomy Soft Tissue (Intraarticular) • Transverse acetabular ligament Contracted • Limbus Fibrous tissue formed from capsular tissue interposed between everted labrum and acetabular rim Extraarticular • Tight adductors (adductor longus) • Iliopsoas
- 18. Tough Reductions… Obstacles to reduction • Extraarticular Tight iliopsoas and adductors • Intraarticular Labrum Ligamentum teres Transverse acetabular ligament Pulvinar Redundant capsule (hourglass) +/- limbus
- 19. Etiology and Epidemiology Multifactorial • Genetics and Syndromes Ehler’s Danlos Arthrogryposis Larsen’s syndrome • Intrauterine environmental factors Teratogens Positioning (oligohydramnios) • Neurologic Disorders Spina Bifida
- 20. Diagnosis Newborn screening • Ortolani’s and Barlow’s maneuvers with a thorough history and physical • Warm, quiet environment with removal of diaper • Head to toe exam to detect any associated conditons (Torticollis, Ligamentous Laxity etc.) • Baseline Neuro and Spine Exam
- 21. Diagnosis Key physical findings • Asymmetry Limb length- Galeazzi Abduction ROM Skin folds Limp Waddilng gait / hyperlordosis - bilateral involvement
- 22. Ortolani’s Maneuver * After 3 months of age tests become negative
- 24. CLINICAL PRESENTATION (THE NEONATE): Ortolani’s or Barlow’s sign Sonographic morphology.
- 25. CLINICAL PRESENTATION (THE NEONATE):
- 26. CLINICAL PRESENTATION(THE NEONATE): Barlow Ortolani clunk
- 27. CLINICAL PRESENTATION (THE INFANT): Limited Abduction Galeazzi Sign Hips 90degrees
- 29. CLINICAL PRESENTATION (THE INFANT): recognize a.bilateral dislocation Klisic Test Anterior superior iliac spine Greater trochanter Normal Dislocation
- 30. CLINICAL PRESENTATION (THE WALKING CHILD):
- 33. IMAGING STUDIES (ULTRASOUND) identify a silent hip
- 35. IMAGING STUDIES (ULTRASOUND) BASELINE: line of ilium which intersects the bony and the cartilaginous portions of the acetabulum. 15-29 As the femoral head subluxates: decreased ALPHA angle increased BETA angle
- 36. IMAGING STUDIES (ULTRASOUND) The Ultrasound ( before 3 mo. ) Ilium Abductor M.
- 38. Diagnosis Some cases still missed At risk groups should be further screened AAP • Recs further imaging (e.g. US) if exam is “inconclusive” AND First degree relative + female Breech Positive provocative maneuver (Ortolani or Barlow) • Referral to Orthopaedist
- 39. Imaging X-rays • Femoral head ossification center 4 -7 months Ultrasound • Operator dependent CT MRI Arthrograms • Open vs closed reduction
- 40. Imaging Ultrasound • Introduced in 1978 for eval of DDH • Operator dependent • Useful in confirming subluxation, identifying dysplasia of cartilaginous acetabulum, documenting reducibility • Prox Femoral Ossification Center interferes • Requires a window in spica cast (avoid)
- 46. Ultrasound Graf’s alpha angle >60° = normal *line w/ ilium bisects head 50/50
- 56. Fig. 5-A:: Figs. 5-A, 5-B, and 5-C: Ultrasonography of the infant hip with use of the dynamic technique. (Figures kindly provided by Prof. H. T. Harcke.) Fig. 5-A: Photograph showing the position of the transducer used to obtain the transverse flexion view. With the hip in this position of flexion and adduction, a posterior push is analogous to the Barlow test.
- 57. Fig. 5-B:: A transverse flexion ultrasonographic view of a normal hip shows the femoral head (F) remaining in contact with the ischium (arrows) during movement. A = anterior, L = lateral, and P = posterior.
- 58. Fig. 5-C:: With instability and displacement, the femoral head moves laterally and posteriorly. The laterally displaced head (F, open arrows) has no contact with the ischium (solid arrows). Fibrofatty tissue (T) with increased echogenicity fills the acetabulum. A = anterior, L = lateral, and P = posterior.