Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
CDH
Definition
A progressive deformation of previously normally formed structures during the embryonic period
NOT A malformation arising during the period of organogenesis
CDH Nomenclature
CDH Congenital Dislocation of the Hip DDH Developmental Dysplasia of the Hip CDH Congenital Dysplasia of the Hip CHD Congenital Heart Disease !
CDH Spectrum
Teratologic Hip : Fixed dislocation Occurrs prenatally Often with other anomalies Dislocated Hip : Completely out May or may not be reducible Subluxated Hip : Only partially Unstable Hip : Femoral head can be dislocated
CDH Incidence
Hip Instability at Birth : 0.5 1 % of infants Classic CDH Mild Dysplasia : 0.1 % of infants : Substantial
CDH
Incidence
Area Canadian Indians Hungary Uppsala, Sweden USA Caucaseans Blacks Malmo, Sweden Chinese, Hong Kong Bantus, Africa Incidence per 1000 188.5 28.7 20 15.5 4.9 2.18 0.1 0.0 among (16678)
CDH
Etiology
Multi-factorial
CDH
Etiology
Physiologic Factors Ligament Laxity : Hormonal : ( Estrogen, Relaxin) Females Familial hyper laxity : mild - moderate - Ehler Danlos
CDH
Etiology
Genetic Factors
Gender : Female
Most studies: shows that females are more commonly affected.
Twin studies:
Monozygotic 38 % Dizygotic 3 % (similar to siblings)
CDH
Etiology
Mechanical Factors Prenatal : - Breech position - Oligohydramnious - Primigravida - Cong. Knee recurvatum/dislocation - Metatarsus adductus - Torticollis
Postnatal : - Swaddling / Strapping Knees extended
CDH
Etiology
Mechanical Factors
Breech Presentation : Normally 2 4 % CDH 16 % The Breech position In Utero Extended knees and flexed hips
CDH
Etiology
Environmental & Mechanical Factors Swaddling / strapping ( Mihad ):
Knees extended & Hips adducted Proven experimentally Proven statistically
American Indians. Eskimos, and Saudi Arabia
Mechanics
Hip adduction and extension
CDH
Patients At Risk
Positive Family History : increases risk 10X A baby girl : increases risk 4-6 times Breech Presentation : increases risk 5-10 X Torticollis : CDH in 10-20 % cases Foot Deformities : ( calcaneovalgus & metatarsus adductus) signs of intrauterine crowding Knee Deformities : ( hyperextension & dislocation ) associated with Teratologic type
CDH
Cerebral palsy
FFD Normal
No FFD ?CDH
CDH
Neonatal Examination
Ortolani
Feel a Clunk
Not hear a click !
CDH
Neonatal Examination
Barlow
CDH
clunk
Ortolani
Barlow
CDH
Ortolani
Barlow
CDH
CDH
Toddler :
Walking :
CDH
CDH
Ultrasound Referral
If hip normal If suspicious : no need
If at risk factors
: U/S appropriate
CDH Ultrasound
Too sensitive detects a lot of hip anomalies most of which would develop normally Operator dependant Static Vs Dynamic
CDH
Radiography
Early infancy : not reliable By 2-3 months of age : reliable AP view - neutral position - draw reference lines - acetabular index - in early infancy < 30o : normal 30o 40o : questionable > 40o : abnormal Von Rosen view : 45o abduction
CDH Radiography
CDH Radiography
CDH Radiography
CDH Radiography
in out
in
out
CDH Radiography
27o
39o
CDH Radiography
in
out
CDH
Treatment
Aims
Obtain and Maintain concentric reduction In an Atruamatic fashion Without disrupting the blood supply
CDH
Treatment
Method depends on Age
The earlier started, the easier the treatment The earlier started, the better the results Should be detected EARLY
CDH
Treatment
Birth to 6 months : Pavlik harness or hip spica cast 6 months 12 months : closed reduction UGA and hip spica casts 12 months 18 months : possible closed / possible open reduction Above 18 months : open reduction and ? Acetabuloplasty Above 2 years : open reduction,acetabulplasty, and femoral osteotomy Above 8 years : open reduction,acetabulplasty cutting three bones, and femoral osteotomy
CDH
CDH
Treatment
CDH
Treatment
Birth 6 months
Hip instability (dislocatable) Established dislocation (reducible) Should be actively treated until hip is normal clinically and radiographically Pavlik harness Hip Spica Cast
CDH
Treatment
CDH
Treatment
Birth 6 months
Other Devices
- Frejka pillow - Craig - Von Rosen splint
CDH
Treatment
6 12 months
Initially non operative closed reduction Reduction under anesthesia and immobilization in hip spica cast Position:
Human Avoid severe abduction Avoid Frog position
CDH
Treatment
12 18 months
Possibly closed reduction !! when hip stable and concentrically reduced Probably open reduction when hip unstable or not concentrically reduced Arthrography guided:
CDH
Treatment
Too lateralized
Acceptable
CDH
Treatment
Above 18 months
Open reduction ? and acetabulplasty ? And femoral shortening if high
CDH
Treatment
Above 3 years
Open reduction
And acetabulplasty
And femoral shortening
Redirectional Acetabuloplasty
Salters
Pembertons
Triple Steel
CDH
CDH
CDH
CDH
Summary
Complex multi-factorial, endemic treatable. Drs awareness and health education. Screening programs are needed. Learning proper examination methods. Identify at-risk groups.
repeat examination & imaging.