Pediatric congenital anomalies.ppt

8/14/2019 Pediatric congenital anomalies.ppt

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Associated conditions

Torticollis 20%

Metatarsus adductus 5%


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Normal hip development.

The hip begins to form at the 7 th week ofgestation.The acetabulum at 11 th week.

At birth the acetabulum is composed ofcartilage with a thin rim of fibrocartilagecalled the labrum.The triradiate cartilageLarge part of the proximal femur iscartilagenous, head. Great and lesser

trochanters.Ossification of the head starts at 4-7 mons.Meyers dysplasia.


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Hip development in DDH

DDH development is gradually progressive. At birth the affected hip will slide in and outof the acetabulum, to do so theposteriosuperior labral rim should beflattened and thickened (neolimbus).This movement will produce a clunk orsacatto sound (Ortolani)Some hips return to act. And becomes

normal.Other hips remain out of the acet. anddevelop secondary barriers to reduction.


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Secondary barriers to reduction

In depth of acet. Fat tissue thickens (pulvinar) andmay impede reductionLigamentum teres may elongate and thickens andoccupy space to impede reduction.

The transverse acetabular ligament may enlargeand impede reduction.The inferior capsule portion of the hip forms anhourglass shape with an opening smaller than thefemoral head.The iliopsoas muscle contributes to the narrowingof the isthmus.


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When the femoral head is reduced the headgradually deepens into the acetabulum (dockingthe head) .If head remains dislocated, other changes occurein the acetabulum,

- Acetabular roof becomes more oblique.

- The concavity flattens and becomes straight .- The medial wall of acet. Thickens- The acet. Becomes more anteverted. Medial

twisting of the whole wing of the pelvis.

- All these changes are reversible until age of 4(harris), because growth of the acetabulumcontinues until age of 8.

- If dislocation remains and becomes irreversible apseudoscetabulum starts to form.


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TERMS

Unstable hip, hip instability + ortolani orBarlow tests.Stable hips, radiologically unstable.Coleman criteria of unstable hip:

- Jerk on exit and entry sign (ortolani sign).- Acetabular index more than 40 degree.- Lateral displacement of femoral head to the

vertical line of Perkins. Acetabular dysplasia Sublaxation, dislocation.


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Clinical presentationthe neonate

Femoral head ossificationClinical evaluation and USG


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Physical examinationBarlows test:

The examiner tend to subluxate ordislocate the head from theacetabulum by gentle adduction andposterior push off (Barlows sign).


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Physical examinationOrtolanis test

The reverse of barlows test , theexaminer relocate a dislocated hip byabduction and medial push.


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Radiological examination

X-rayUSG can show the delicate soft tissueanatomy of the hip joint.static and dynamic teqn.

Graf proposed a classification systembased on angles formed by thesonographic structures of the hip.


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The infant

By the second and thirdmons of life other signsappear.

Previous tests becomeless sensetiveLimitted abduction.Shortening of the thigh

(the Galeazzi sign).Both hips in 90 degreeof flexion.


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Asymetrical guteal folds (because ofdislocation) more thigh folds on theaffected side, be careful of a bilateraldislocation.


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THE Klisic test : Place the third finger over thegreat trochanter and the index finger over theSAIS, an imaginary line drown bwt tips of fingersshould pass through the umbilicus, when hip is

dislocated the line passes bwt the umbilicus andthe pubis.Nelatons line : is drawn between the ischialtuberosity and anterior superior iliac spine. In thenormal hip the tip of the greater trochanter lies at

or below Nelatons line whereas in the dislocatedhip it lies superior to the line.X-RAY


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The walking child

Dislocated side shorter than otherside, the baby will walk on toes(abductor lurch,Trendelenbergs gait)(trendelenbergs sign). Limited abductionGaleazzi signExcessive lordosisX-ray


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X-ray can show the dislocated hipeasily at any age but in neonatesunstable hips can be missed easilyFemoral head ossification 4-6 mons


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lines

Hilgenreiners line.Perkins - Ombredanne line.

Shentons line.


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Angles

The acetabular indexIn new borns averages 27.5 degrees

At 6 mons of age mean is 23.5 deg.By 2 years decrease to 2o degr.30 degree is consideredthe upper limit of normal.


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Central edge angle of Wilberg; measureship position.From 6-13 years old patients; angle of 19deg. is considered normal.Children of 14 yrs and older; angle of 25deg. And more is normal


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The Von Rosen view:- Both hips are abducted , internally

rotated,and extended.* In normal hips an imaginary line from

the femoral shaft intersect theacetabulum.


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TEAR DROP FIGURE

Seen on AP views of the pelvis.Formed by the acetabulum laterally,thewall of the lesser pelvis medially,and theacetabular notch.It appears bwt 6-24 mons in normal hips,and later in dislocated hips.Four types of tear drop bodies ( open,closed, reversed and crossed) .

It has tow shapes U and V , V shaped teardrops associated with dysplastic hips andcarry a poor prognosis.


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treatment

Neonate: place in Pavlik Harness for 6weeks.1 to 6 mons: place in pavlik harness for 6weeks after hip reduces.6 to 18 mons: traction and reduction andplacement in cast for 3 mons, if openreduction doesn't succeed open reductionis done.18 to 24 mons: try close reduction.24 to 6 years: open reduction is done,


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In open reduction

To correct acetabular dysplasia;acetabular osteotomiies can be done.Innominate osteotomy. Salterosteotomy.Pembertons osteotomy Dega osteotomySteel , chiari, ganz.etc.


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THANX

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Pediatric congenital anomalies.ppt