Society for Pediatric Radiology 2015 Hands on Session. DDH: Pitfalls and Practical Tips

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Transcription:

Society for Pediatric Radiology 2015 Hands on Session DDH: Pitfalls and Practical Tips

Michael A. DiPietro, M.D. John F. Holt Collegiate Professor of Radiology Professor of Pediatrics and Communicable Diseases Pediatric Radiology - C.S. Mott Children s Hospital University of Michigan Ann Arbor, MI

Missed DDH

Good judgment comes from experience. Experience... well that comes from poor judgment

Hips DDH

DDH Orientation to anatomy Static and dynamic aspects

Pediatric Musculoskeletal Ultrasound DDH Clicks / Clunks Lax hips Breech Torticollis Clubfoot / Metatarsus adductus Family History

Pediatric Musculoskeletal Ultrasound DDH Developmental dysplasia of the hip dislocated hip dislocatable hip subluxed/subluxable hip hip laxity (physiologic) acetabular dysplasia Static and dynamic aspects

Static (morphology) and Dynamic (stability/laxity) aspects

TWO VIEW MINIMUM EXAM PROPOSED 1993 Combines the Harcke and Graf techniques Accepted as STANDARD by ACR (1998)

DDH Pediatric Musculoskeletal Ultrasound Orientation Orientation Orientation Orientation Technique Technique Technique Technique

AE Schlesinger Coronal scanning

Coronal view Analogous to AP X-ray of left hip Ball in a socket

Coronal US orientation compared with AP radiograph US shows cartilage

Ball in a socket Is the ball in the socket? (located) Does the ball stay in the socket? (laxity) Is the socket well formed? (acetabulum mature)

Ball in a socket Is the ball in the socket? (located) Does the ball stay in the socket? (laxity) Is the socket well formed? (acetabulum mature)

Coronal US orientation compared with AP radiograph as appears on US screen Key concept

Normal

Slightly subluxed coronal

Subluxing right hip Case A. coronal

Case B. coronal Dislocated right hip

Coronal dislocated hip Femoral head Greater trochanter

Coronal acetabulum immature

Coronal posterior cartilaginous acetabulum

Newborn - Bilateral dislocated teratologic hips

Coronal dislocated note ilium

Coronal dislocated note ilium

Coronal dislocated note posterior acetabular cartilage

Transverse - dislocated Ant Post

HTHarcke

Transverse US compared with axial CT Key concept

Axial CT

Axial CT anterior posterior

Transverse US orientation compared with axial CT as appears on US screen Key concept

Subluxing left hip lateral posterior transverse

Subluxed hip transverse view

Coronal posterior acetabular cartilage

Transverse posterior acetabular cartilage

Transverse posterior acetabular cartilage

Transverse posterior acetabular cartilage

Trans Normal - cine

Trans Normal abd/add - cine

Testing for laxity - Barlow maneuver

Testing for laxity - Barlow maneuver

Dynamic case studies

Coronal Normal - cine

CINE 1. Right CORONAL slight laxity 1 DO

CINE 3. Left CORONAL 1 mo old Does not reduce fully

CINE 2. Left TRANSVERSE 7 do abduction adduction NORMAL

CINE 3. Left TRANSVERSE 1 mo old Lax and does not reduce fully

Another View Anterior Approach

Testing for laxity Barlow maneuver

Lt. (lat) Trans. view cine

Lt. Anterior view cine

Lt. Ant view cine

Ortolani maneuver dislocates reduces clunk

Anterior View - Ancillary Not as substitute for standard Confirmation Illustrative Education

Anterior View - Ancillary Save for the end of the study Babies cry Don t get pee d on

DDH ULTRASOUND Not Too Early Not Too Often Not Too Badly HTHarcke, M.D.

Some Pitfalls

Transducer misalignment

Coronal false abnormal - true normal - cine

Older patient

Coronal

14 mo Normal Coronal - cine

Impressions 1. Normal findings, see above discussion. 2. No evidence of DDH at this time. Acetabula appear mature. At this age, acetabular maturity is better assessed by radiography. 3. No gross laxity is apparent, but dynamic evaluation is limited as described above. 4. I doubt that this patient s out toeing has anything to do with DDH. 5.The parents were present throughout the study and were told the findings.

Hip flexion contracture or bowing

Right hip - in or out?? bowed femur - healing fracture 2 month old

Error Right hip thought to be out (greater trochanter * mistaken for femoral head) * coronal sonogram

Arthrogram right hip - in *

DDH Interpretative pitfall due to hip contracture or proximal femoral deformity e.g. Arthrogryposis PFFD Bowing (coxa vara) (be aware of plain radiograph)

Illustration of infant wearing a Pavlik harness The information on this Web page is provided for educational purposes. You understand and agree that this information is not intended to be, and should not be used as, a substitute for medical treatment by a health care professional. You agree that Lucile Salter Packard Children's Hospital

Newborn

13 days old

11 days old - Coronal

11 days old - Trans

6 wk old Doppler - Tran - Adducted

Doppler - Tran - Abducted

Cine loop Tran Abduction - Adduction

Doppler Coronal - Adducted

Doppler Coronal - Abducted

Cine loop Coronal Abduction - Adduction

Questions???? Questions??? Questions?????? Questions Questions???? answers Questions???? answers

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