cdh congenital dislocation of the hip prof. mamoun kremli almaarefa college
TRANSCRIPT
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CDHCongenital Dislocation of the
HipProf. Mamoun Kremli
AlMaarefa College
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Spectrum of diseases
• Abnormality of proximal femur and acetabulum
• Initial pathology is congenital, but• Progresses (becomes worse) if not
treated• Does not always result in dislocation
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Nomenclature
• CDH: Congenital Dislocation of the Hip• DDH: Developmental Dysplasia of the
Hip• CDH: Congenital Dysplasia of the Hip• CHD: Congenital Heart Disease!
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CDH - Spectrum
• Acetabular dysplasia:– Shallow acetabulum
• Unstable hip: – Dislocatable - Reducible
• Dislocated hip:– May or may not be reducible
• Teratologic hip:– Fixed dislocation at birth,
often with other major anomalies
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Incidence
• Hip instability at birth: 0.5 – 1 %
• Classic CDH: 0.1%
• Mild dysplasia: Substantial– Up to 50%of hip arthritis in ladies have
underlying hip dysplasia
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Incidence
Area Incidence per 1000
Canadian Indians188.5
Hungary28.7
Uppsala, Sweden20
USA Caucaseans Blacks
15.54.9
Malmo, Sweden2.18
Chinese, Hong Kong0.1
Bantus, Africa0.0 among (16678)
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Etiology
Multi-factorial– Ligament laxity– Genetic– Mechanical factors
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Etiology
1. Ligament laxity• Hormonal:
– Estrogen, Relaxin: hormones secreted by mothers before birth
– May affect baby girls more? – receptors
• Familial ligament laxity:– Mild – Moderate – Sever– Ehler Danlos Syndrome
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Etiology
Ligament laxity: hypermobile joints
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Etiology
2. Genetic factors• Twin studies
– Monozygotic: 38%– Dizygotic: 3% (similar to other siblings)– Positive family history
• Females: 4-6 X more than males– Could be hormonal – the effect of
Relaxin hormone produced by mother on female fetus
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Etiology
3. Mechanical factors
• Prenatal:– Breach:
•Normally: 2-4%•In CDH: 16%
– The breach position in utero: extended knees, and flexed hips• cause dislocation of hip by ? stretch of
Hamstring muscles
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Etiology
3. Mechanical factors• Postnatal:
– Swaddling / strapping hips adducted and extended, and knees extended
الكوفلة – – – الزمام القماط المهاد
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Etiology
3. Mechanical factors• Postnatal:
– Swaddling / strapping hips adducted and extended, and knees extended
– Proven experimentally– Proven statistically– Mechanics
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Infants at risk
• Positive family history: 10X• A baby girl: 4-6 X• Breach presentation: 5-10 X• Torticollis: CDH in 10-20% of cases
• Foot deformities:– Calcaneo-valgus and
metatarsus adductus
• Knee deformities:– hyperextension and dislocation (Teratologic)
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Clinical Examination
• External rotation• Short one side
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Clinical Examination
• External rotation• Short one side• Lateralized contour• Wide perineum
– In bilateral
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Clinical Examination
• External rotation• Short one side• Lateralized contour• Wide perineum
– In bilateral
• Asymmetrical folds– Anterior - posterior
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Clinical Examination
• External rotation• Short one side• Lateralized contour• Wide perineum
– In bilateral
• Asymmetrical folds– Anterior - posterior
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Clinical Examination
• Shortening– Might be difficult to
detect early
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Clinical Examination
• Limitation of hip abduction in flexion
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Clinical Examination
• Limitation of hip abduction in flexion
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Clinical Examination
• Limitation of hip abduction in flexion
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Clinical Examination
• Special test – Hip Instability:• Ortolani / Barlow
• Feel a Clunk, not hear a click!
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Clinical Examination
Ortolani / Barlow
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Clinical Examination
• Special test – Hamstring Stretch Sign:– Flex hip and knee 90o, and extend knee
gradually
• Normally:– feel resistance
• CDH:– no resistance
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Clinical Examination
• After walking age:– Shortening – (if unilateral)– Limping:
• Unilateral: limping• Bilateral: waddling (like a duck)
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Investigation: Radiology
• Early infancy:– X-ray is not reliable – all cartilage– Ultrasound is better
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Radiology: X-ray
• After 2-3 months: more reliable
27o 39o
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Radiology: X-ray
• After 2-3 months: more reliable
in out
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Radiology: X-ray
• After 6 months: reliable– R hip out, and acetabulum open
(dysplastic)
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Treatment
• Method depends on age• The earlier started, the easier it is• The earlier started, the better the
results are
• Should be detected EARLY
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Treatment
• Birth – 6m– Pavlik harness or hip spica cast
• 6-12 m:– Closed reduction under GA and hip spica cast
• 12 - 18 m:– Open reduction
• 18 – 24 m:– Open reduction and Acetabuloplasty
• 2-8 years:– Open reduction, Acetabuloplasty, and femoral
shortening
• Above 8 years:– Open reduction, Acetabuloplasty cutting all three pelvic
bones, and femoral shortening
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Treatment: Neonatal
• Pavlik Harness– Dynamic, effective,
safe– Keeps hips abducted
and flexed – for 6 weeks
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Treatment: 6-12 m
• Initially non-operative closed reduction UGA and immobilization in hip spica cast
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Treatment: 6-12 m
• Possibly closed reduction– Stable and concentric reduction
• Possibly open reduction– Unstable or un-concentric reduction
• Arthrography-guided
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Treatment: 6-12 m
• Arthrography-guided Closed Reduction
Well in Dislocated Not well in
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Treatment: 6-12 m
Arthrography-guided Closed Reduction
Too lateralized Acceptable
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Treatment: 18-24 m
• Open reduction – surgery• Acetabuloplasty - usually• Maybe: Femoral shortening – if high
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Treatment: Above 2 years
• Open reduction, and• Acetabuloplasty, and• Femoral shortening
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Salter’s Acetabuloplasty
Operated hip Dislocated hip
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Pemberton’s Acetabuloplasty
need a lot of improvement in acetabular cover
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Triple Steel Acetabuloplasty
• 12 years old,• Pain L hip
• L hip not wellcovered
• Osteotomy of:• Ilium, Pubic,
and Ischium• Rotation of
acetabulum
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Summary
• Complex multi-factorial, endemic disease
• Screening programs are needed to detect and treat cases early
• Learning proper examination methods• Identify at risk groups• Efficient referral system• Proper management by specialized Drs
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Summary - Infants at risk
• Positive family history: 10X• A baby girl: 4-6 X• Breach presentation: 5-10 X• Torticollis• Foot deformities• Knee deformities