Orthopedics CDH,Perthes

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Orthopedics CDH,Perthes

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Disorders of the Hip in ChildhoodTypes of hip diseases disorders1. Congenital2. Acquired Posttraumatic(extremely rare in children) Non traumatic abnormality of the hip joint due to changes in anatomy, ie. deformities (eg. coxa vara) Inflammatory disorders (eg. rheumatoid arthritis, tuberculosis,gout) leading to destruction of articular cartilage Avascular necrosis of femoral head (Gauchers disease, posttraumatic )

CDH Congenital Dislocation of the HipAll degrees of displacement are included from subluxation to complete dislocation of hip jointOther term: congenital dysplasia of hip joint

Incidence Incidence: 0,5% - frequent congenital anomaly (1/1000 neonates) Geographical incidence: highest in Middle- Europe and Japan , lowest in China and Black Africa Gender: male female ratio: 1 - 6Causal factorsGenetic: joint laxity dominant inheritrance, predisposes for CDH diagnosed within the 1st week of life Acetabular dysplasia polygenetic inheritance, most cases are diagnosed in later lifeEnvironment: Intrauterine malpositiion (breech position, with extended legs) Postnatal: babies swaddled tightly with hips fully extended - rare, if babies are carried on mothers back with hips abducted

Forms of CDH according to etiology Hip Dysplasy : acetabular hypoplasy Generalised laxity: hip dislocates either in utero, or at delivery Symptomatic dislocation of hip: part of other congenital anomaly - eg. Ehler- Danlos syndrome- generalized joint laxity or arthrogryposis multiplex congenita generalized stiffness of joints) Secondary hip dislocation: due to neuro-muscular disorder of the infant

Types , degrees of CDH: dysplasia, subluxation, dislocation

Pathology of hip joint in CDHBony elements: Acetabular hypoplasy (primary pathological factor) Antetorsion of proximal femur - due to deficient anterior wall of acetabulum Coxa valga counterpressure of acetabular floor is missing , abnormal collo- diaphyseal angle is resultedCollo diaphyseal angle ( normally 135) and torsion of femoral neck ( normally ~ 40 at birth, 10 at adult age)

Blood supply of femoral head from below (from femoral artery) abundant blood supply through ascending cervical arteries

Blood supply of femoral head through lig.teres

Pathology of hip joint in CDH: capsule hourgall shaped, thick labrum is interposed between head and acetabulum

Anatomical pathological changes in CDH: hour glass shaped capsule, iliopsoas muscle in lateral position, compressing on joint capsule

Pathology of hip joint in CDHSoft tissue elements: Capsule is hourglass in shape Cartilaginous labrum (limbus) is too large and is folded into acetabulum Ligamentum teres is too thick Muscles arising from pelvis (m. iliopsoas, m. adductors) become shortened Gluteus medius- minimus becomes insufficient

Symptomatology of CDH in neonate1. Suspicion: family history of CDH, problems with pregnancy2. Clinical signs: assymetrical skin creases (thigh, gluteus), leg shorter, in slight external rotation limitation of abduction (normal position of neonate: hip in 70 - 90 abduction (Lorenz- position), passive abduction is significantly limited (on one side) Ortolanis jerk of entry: pressure on femoral head in abduction - clunk as the dislocation reduces Barlows sign femoral head reduced with thumb Clinical signs: assymetrical skin creases (thigh, gluteus), leg shorter, in slight external rotation limitation of abduction (normal position of neonate: hip in 70 - 90 abduction (Lorenz- position), passive abduction is significantly limited (on one side) Ortolanis jerk of entry: pressure on femoral head in abduction - clunk as the dislocation reduces. hip is reduced in abduction with a clickBarlows sign: femoral head is reduced with thumb

See the early physical sign: limitation of abduction, assymetry of skin creases

Advanced stage in CDH: leg shorter, externally rotated, assymetrical skin creases, later hyperlordosis (at walking age), Trendelenburg gait (waddling gait)

Special importance of these signs: CDH can be detected at the earliest age (in few weeks) when the hip is reducible (in most cases) and after conservative treatment it will be normal. Imaging procedures of CDH: In neonate (