Hip Dysplasia for the Primary Care Physician George Gantsoudes, MD. November 4, 2017

Transcription

1 Hip Dysplasia for the Primary Care Physician George Gantsoudes, MD November 4, 2017

2 Introduction Developmental Dysplasia of the Hip DDH - preferred term Teratologic hips Subluxation Dislocation-usually posterosuperior (reducible vs irreducible) Dysplasia (usually refers to acetabulum)

3 Developmental Dysplasia of the Hip Part of the packaging disorders DDH Metatarsus adductus Torticolis Clubfoot

4 Teratologic Dislocation Teratologic dislocation of the hip occurs in utero and is irreducible on neonatal examination. Pseudoacetabulum usually is present. This condition always accompanies other congenital anomalies or neuromuscular conditions, most frequently arthrogryposis and myelomeningocele. The hip has been out since at least gestation week 12

5 Fetal stuff Get Ready to Ignore 7 th week - acetabulum and hip formed from same mesenchymal cells 12 th week medial rotation of limb 18 th week muscles develop 36 th week positioning issues? Left occiput anterior positioning Left hip 3x more affected

6 Keep ignoring Epidemiology DDH: most common disorder of the hip in children 1 in 1,000 is born with a dislocated hip; 10 in 1,000 is born with hip subluxation or dysplasia. 80% of affected children are female. The left hip is more commonly involved (60%). DDH occurs more commonly in Native Americans and Laplanders; DDH is rarely seen in African-Americans.

7 Now memorize! First Female Family history Breech

8 Normal Hip Tight fit of head in acetabulum Transection of capsule Still difficult to dislocate as demostrated by Ponseti Surface tension

9 Pathoanatomy Ranges from mild dysplasia --> frank dislocation Bony changes Typically on acetabular side Shallow acetabulum Femoral anteversion

10 Obstacles to reduction Extraarticular Tight iliopsoas and adductors Intraarticular Labrum Ligamentum teres Transverse acetabular ligament Pulvinar Redundant capsule (hourglass) +/- limbus Tough Reductions

11 Diagnosis Newborn screening Warm, quiet environment with removal of diaper Hip abduction and Galeazzi Ortolani and Barlow maneuvers with a thorough history and physical Head to toe exam to detect any associated conditions (Torticollis, sacral dimples, etc) Baseline Neuro Moro and Babinski

12 Diagnosis Key physical findings Asymmetry Limb length- Galeazzi Abduction ROM Skin folds Limp Waddilng gait / hyperlordosis - bilateral involvement

13 Ortolani s Maneuver I always document this until age two!

14 Barlow s Maneuver I always document this until age two!

15 Most Important Test!

16 Galeazzi

17 Asymmetrical Folds

18 Barlow & Ortolani

19 Clunks, not Clicks Ortolani used the word scatto to refer to the clunk sensation of the hip reduction Low pitch Clicks tend to be snapping tendons, etc High pitch Guitar string

20 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 (all girls, +/- boys) Positive provocative maneuver (Ortolani or Barlow) Referral to Orthopaedist PHONE A FRIEND

21 Imaging Wait First four weeks with mildly positive signs > 90% resolution rate without treatment Preferred method Ultrasound (w/ dynamic)

22 Imaging X-rays Femoral head ossification center 4-7 months Ultrasound Operator dependent CT MRI Arthrograms Open vs closed reduction

23 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)

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28 Radiographs Summary Femoral head appears 4-7 months Shenton s line Perkin s and Hilgenreiner s lines Inferomedial quadrant Tear drop* Abnormal widening in DDH *may be only sign in mild subluxation

29 Treatment Options Age of patient at presentation Family factors Reducibility of hip Stability after reduction Amount of acetabular dysplasia

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31 Birth to Six Months Triple-diaper technique Prevents hip adduction Success no different in some untreated hips Pavilk harness (1944) Experienced staff* Very successful Allows free movement within confines of restraints *posterior straps for preventing add. NOT producing abd.

32 Birth to Six Months Pavlik harness Indications Fully reducible hip* Child not attempting to stand Family Close regular follow-up (every 1-2 weeks) For imaging and adjustments Duration Childs age at hip stability + 3 months

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34 Pavlik Harness Failures Poor parent compliance Improper use by the physician Inadequate initial reduction Failure to recognize persistent dislocation Viere et al 1990 Bilateral dislocation Absent Ortolani s sign > 7weeks of age

35 Rhino Cruiser

36 Birth - Six months Closed reduction General anesthesia Arthrogram Safe zone - avoid AVN

37 6 months - 4 years Present a more difficult problem Prolonged dislocation Contracted soft tissues 6-18 months Closed reduction +/- adductor tenotomy Abduction Orthosis - 6 months part time Open reduction (if closed fails) Capsulorraphy CT scan Spica for 6 wks followed by PT

38 Avascular Necrosis

39 22 month old

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43 TX Summary Best if treated before 6 weeks of age 0-6 months of age Pavlik 6-18 months Brace Closed vs open reduction and spica months Closed (not in my hands) Open +/- osteotomies

44 AAP Guidelines Dec 2016 If parents choose to swaddle their infants, encourage hip-healthy swaddling that allows freedom of hip motion and avoids forced position of hip extension and adduction Risk factors for which the pediatrician may wish to consider an imaging study in the child with a normal screening physical examination are: breech position in the third trimester both males and females family history of DDH history of improper swaddling history of abnormal hip physical examination in the neonatal period, which subsequently normalizes.

45 Screening Algorithm PHYSICAL EXAM!!! If +Ortolani REFER (stress to schedulers urgency); Follow-up! If +Barlow REFER (not urgent; before 6 weeks) If equivocal ( clicks ) Re-examine in 2 weeks If at 2 weeks not sure, REFER If breech, ALL BABIES get U/S at 6 weeks***

46 Final Thoughts Do s REFER all Barlow/Ortolani Re-examine equivocal Continue to follow bad hips that turn good Don t s Triple diaper Order ultrasounds before 4 wks No swaddling