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DR. MOSI
DDH Coxa vara Genu valgum Genu varus Genu recarvatum
Spectrum of disorders including : Acetabular dysplasia Instability (dislocation and subluxation) Teratological malarticulation – dislocation in utero ,
irreducible at birth , pseudoacetabulum and associted with neuro muscular conditions eg arthrogyposis
Left > right Females > males at 7:1 20 % bilateral At birth dislocation is 1:1000 and dysplasia
1:100
Genetics Generalized joint laxity – dominant Shallow acetabular – polygenic
Hormonal factors High levels of progesterone and relaxin in last days of
pregnancy hence ligament laxity
Intrauterine malposition complete breech, oligohydraminos,packaging
deformities ( congenital muscular torticollis, metatarsus adductus, congenital knee dislocation
Postnatal factors
Initial instability leads to dysplasia Normal acetabulum but lax capsule Changes in the acetabulum and femoral
head occur from the instabilty but some from primary acetabular and femoral head dysplasia
Dislocation is posterolateral then superolateral
Cartilagenous head of normal size but nucleus appears late
Shallow anteverted socket Stretched capsule
Elongated and hypertrophied ligamentum teres
Superior limbus and capsule pushed into socket
On weightbearing above changes worsen False socket is created
Idelly diagonised at birth Barlows test Ortolanis test Galeazzis test limited abduction clicking hip asymetry in skin folds – thigh gluteal labial trendelenburg gait , waddling gait Ludolfs sign
Radiographs useful at 4-6 months after head begins to ossify
Helgenreiners line Shentons line Perkins line Acetabular index Center edge angle of wiberg
Ce 20 -25. ai- 30 20 <20
Ultrasound Dynamic ( Hacke) and static (graf) Useful before head ossification Alpha angle : lines along bony acetabulum and ilium ( >60) Beta angle : line along labrum and ilium (<55) Use in high risk group or in positive physical findings Monitoring of treatment
Confirmation after closed reduction Identification of possiblle blocks:
◦ Inverted labrum◦ Inverted limbus◦ Hour glass appearance
CT Scan : study of choice MRI : significant role
6 – 2yrs Failure of pavlicks harness Traction may be applied prior Under anaesthesia or gradually over about
three weeks 60 flexion, 40 abduction, 20 internal
rotation At 6 weeks convert to splint that prevents
adduction
> 2YEARS or in failed closed reduction between 6 mnths and 2 years
Anatomic changes such as anteversion and coxa valga
Traction preop may help Hip spica for three months the splinting
Older children Severe dysplasia with marked acetabular
changes Reduced potential of acetabular remodeling
Dega, ganz, permbenton
Avascular necrosisSeen in all treatment formsEscessive forceful abductionLate surgerydx. By late appearance of ossification centerBroadening of femoral neck or fragmentation
Failed reduction and recurence
Reduction in neck shaft angle <120 160 at birth 125 by adulthood
Developemental Congenital Dysplastic Acquired
Physis Metaphysis Subtrochanteric
Associated with congenital short femur and proximal femoral deficiency
Unilateral Subtrochanteric Ass with retroversion of femur and out
toeing High propensity of progression
Onset of ambulation, trendelenburg gait usually noted
Defective endochondral ossification posteromedialy (physeal defect)
Pathognomonic sign is a inferoposterior metaphyseal fragment
Underlying bone anomaly eg rickets, fibrous dysplaia
Usually bilateral
Commonly due to Trauma Infection iatrogenic
Halting deformity progression – investigate and treat renal osteodystrophy , rickets etc
Correct proximal femoral anatomy : Poximal valgus osteotomy
Trochanteric Subtrochanteric
Greater trochanter epiphysodesis Greater trochanter transfer
Pauwels Y-SHAPED OSTEOTOMY, Langenskiöld intertrochanteric osteotomy, BORDEN SUBTROCHANTERIC OSTEOTOMY
Averages 40 at birth but decreases to about 10 -15 in adults.
about 5 more in females Idiopathic or associated with other hip
disorders eg sufe ddh cp dcv In toeing gait but this usually resolves
Cosmesis Anterior knee pain due to patellar
malalignment
• Observation• Rotational osteotomy
Rarely indicated ( most children have no functional deficits)
Child over 10 – 12 years with internal rotation of > 80 and external rotation of <10
Intertrochanteric vs mid-diaphysis
Physiologic – usually <2 years and bilateral) Pathologic – trauma , infection, rickets,
dysplaisia of bone ,blounts disease, >2years Unilateral Severe Associated shortening Obesity
10m-15
Cosmesis Patellofemoral instability/ maltracking Altered gait - lateral thrust, circumduction Early walkers – genu varum
Full length standing Line should bisect knees
Md 11, 11 - 16
tibia vara or osteochondrosis deformans of the proximal tibia
Impaired ossification medial proximal tibia Hueter volkamn effect Infantile Juvenile Adolescents
Observation Bracing – children less than 2 yrs with early
blounts ( stage 1 and 2) Guided growth
Hemiepiphysiodesis on convex side using screws, staples, tension band paltes
In the past relied on growth charts Corrective osteotomy ( acute vs gradual
correction using an ilizarov ) Blounts – before 4 yrs and at stage 1 or 2( surgery differs
for 3&4,5&6) Children near maturity Permanent physeal issue
Mechanism Laxity of posterior capsule Abnormal inclination of tibia articular
surface Usually 14+/- 3.6 posterioly. Forward tilt if the anterior
physis is damaged
Observation – hypermobile, (10 -15 ) Bracing
Prevents hyper extension Can result in stiff knee Ankle orthosis holding at 5-10 shown to prevent recarvatum
in cerebral palsy Anterior wedge osteotomy Poserior closed wedge osteotomy Flexion supracondylar osteotomy of femur Gradual correction using an external fixator Epiphysiodesis :
When secondary to physeal damage
Reefing of the posterior capsule of the knee joint
Anterior patellar block Quadriceps lengthening
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