Developmental Dysplasia of the Hip and Ultrasound

Developmental Dysplasia of the Hip

OverviewOverview

IntroductionIntroduction Normal Development of the HipNormal Development of the Hip Etiology and PathoanatomyEtiology and Pathoanatomy Epidemiology and DiagnosisEpidemiology and Diagnosis Ultrasound morphologic and dynamicUltrasound morphologic and dynamic

IntroductionIntroduction

Developmental Dysplasia of the HipDevelopmental Dysplasia of the Hip• DDH - preferred termDDH - preferred term• Teratogenic hipsTeratogenic hips• SubluxationSubluxation• Dislocation-usually posterosuperior Dislocation-usually posterosuperior

(reducible vs irreducible)(reducible vs irreducible)• DysplasiaDysplasia

BackgroundBackground Risk FactorsRisk Factors

• 1/1,000 born with dislocated hip 1/1,000 born with dislocated hip • 10/10,000 born with subluxation or dysplasia10/10,000 born with subluxation or dysplasia• 80% Female80% Female• First born childrenFirst born children• Family history (6% one affected child, 12% one affected Family history (6% one affected child, 12% one affected

parent, 36% one child + one parent)parent, 36% one child + one parent)• OligohydramniosOligohydramnios• Breech (sustained hamstring forces)Breech (sustained hamstring forces)• Native Americans (swaddling cultures)Native Americans (swaddling cultures)• Left 60% (left occiput ant), Right 20%, both 20% Left 60% (left occiput ant), Right 20%, both 20% • Torticollis or LE deformityTorticollis or LE deformity

Breech PresentationBreech Presentation

Associated ConditionsAssociated Conditions

Torticollis (15% have DDH) Metatarsus Adductus (1.5-10%have DDH)

Normal DevelopmentNormal Development EmbryonicEmbryonic

• 7th week - acetabulum and hip formed 7th week - acetabulum and hip formed from same mesenchymal cellsfrom same mesenchymal cells

• 11th week - complete separation 11th week - complete separation between the twobetween the two

• Prox fem ossific nucleus - 4-7 monthsProx fem ossific nucleus - 4-7 months

Normal HipNormal Hip

Tight fit of head in Tight fit of head in acetabulumacetabulum

Transection of Transection of capsulecapsule• Still difficult to Still difficult to

dislocatedislocate• Surface tensionSurface tension

PathoanatomyPathoanatomy

Ranges from mild dysplasia --> frank Ranges from mild dysplasia --> frank dislocationdislocation

Bony changesBony changes• Shallow acetabulumShallow acetabulum• Typically on acetabular sideTypically on acetabular side• Femoral anteversionFemoral anteversion


Soft tissue changesSoft tissue changes• Usually secondary to prolonged subluxation or Usually secondary to prolonged subluxation or

dislocationdislocation IntraarticularIntraarticular

• LabrumLabrum Inverted + adherent to capsule (closed reduction Inverted + adherent to capsule (closed reduction

with inverted labrumwith inverted labrum assoc with increased assoc with increased Avascular Necrosis)Avascular Necrosis)

• Ligamentum teresLigamentum teres Hypertrophied + lengthenedHypertrophied + lengthened

• PulvinarPulvinar Fibrofatty tissue migrating into acetabulumFibrofatty tissue migrating into acetabulum

Fatty Tissue (Pulvinar Thickens)Fatty Tissue (Pulvinar Thickens)

Teres ligament (elongated and thickened)Teres ligament (elongated and thickened)Docking the headDocking the head

subluxated dislocated

Labrum: Cartilaginous acetabular lip.Neolimbus: a ridge of thickened articular cartilage

Transverse ligament (hypertrophic)

Hourglass shape of the capsule by the iliopsoas tendon

Shortened of pelvifemoral muscles

progressive


Soft Tissue (Intraarticular)Soft Tissue (Intraarticular)• Transverse acetabular ligamentTransverse acetabular ligament

ContractedContracted

• LimbusLimbus Fibrous tissue formed from capsular tissue Fibrous tissue formed from capsular tissue

interposed between everted labrum and interposed between everted labrum and acetabular rimacetabular rim

ExtraarticularExtraarticular• Tight adductors (adductor longus)Tight adductors (adductor longus)• IliopsoasIliopsoas

Tough Reductions…Tough Reductions… Obstacles to Obstacles to

reductionreduction• ExtraarticularExtraarticular

Tight iliopsoas and Tight iliopsoas and adductorsadductors

• IntraarticularIntraarticular LabrumLabrum Ligamentum teresLigamentum teres Transverse acetabular Transverse acetabular

ligamentligament PulvinarPulvinar Redundant capsule Redundant capsule

(hourglass)(hourglass) +/- limbus+/- limbus

Etiology and EpidemiologyEtiology and Epidemiology

MultifactorialMultifactorial• Genetics and SyndromesGenetics and Syndromes

Ehler’s DanlosEhler’s Danlos ArthrogryposisArthrogryposis Larsen’s syndromeLarsen’s syndrome

• Intrauterine environmental factorsIntrauterine environmental factors TeratogensTeratogens Positioning (oligohydramnios)Positioning (oligohydramnios)

• Neurologic DisordersNeurologic Disorders Spina BifidaSpina Bifida

DiagnosisDiagnosis Newborn screeningNewborn screening

• Ortolani’s and Barlow’s maneuvers with Ortolani’s and Barlow’s maneuvers with a thorough history and physicala thorough history and physical

• Warm, quiet environment with removal Warm, quiet environment with removal of diaperof diaper

• Head to toe exam to detect any Head to toe exam to detect any associated conditons (Torticollis, associated conditons (Torticollis, Ligamentous Laxity etc.)Ligamentous Laxity etc.)

• Baseline Neuro and Spine ExamBaseline Neuro and Spine Exam

DiagnosisDiagnosis

Key physical Key physical findingsfindings• AsymmetryAsymmetry

Limb length- Limb length- GaleazziGaleazzi

Abduction ROMAbduction ROM Skin foldsSkin folds Limp Limp Waddilng gait / Waddilng gait /

hyperlordosis - hyperlordosis - bilateral involvementbilateral involvement

Ortolani’s ManeuverOrtolani’s Maneuver

* After 3 months of age tests become negative

Barlow’s ManeuverBarlow’s Maneuver

CLINICAL PRESENTATIONCLINICAL PRESENTATION((THE NEONATETHE NEONATE):):

Ortolani’sOrtolani’s or or Barlow’sBarlow’s sign sign

SonographicSonographic morphology. morphology.

CLINICAL PRESENTATION CLINICAL PRESENTATION ((THE NEONATETHE NEONATE):):

CLINICAL PRESENTATIONCLINICAL PRESENTATION((THE NEONATETHE NEONATE):):

Barlow Ortolani

clunk

CLINICAL PRESENTATION CLINICAL PRESENTATION ((THE INFANTTHE INFANT):):

Limited Abduction Galeazzi Sign

Hips 90degrees

CLINICAL PRESENTATIONCLINICAL PRESENTATION((THE INFANTTHE INFANT):):

Asymmetric Folds

CLINICAL PRESENTATION CLINICAL PRESENTATION ((THE INFANTTHE INFANT):):

Klisic Test

recognize a bilateral dislocation.

Greater trochanter

Anterior superior iliac spine

Normal Dislocation

CLINICAL PRESENTATION CLINICAL PRESENTATION ((THE WALKING CHILDTHE WALKING CHILD):):

Femoral Neck AnteversionFemoral Neck Anteversion

IMAGING STUDIES (IMAGING STUDIES (ULTRASOUNDULTRASOUND))

identify identify a silent hip a silent hip

IMAGING STUDIES(IMAGING STUDIES(ULTRASOUNDULTRASOUND))


15-2915-29

BASELINE: line of ilium which intersects the bony and the cartilaginous portions of the acetabulum.

As the femoral head subluxates:

decreased ALPHA angle

increased BETA angle


The Ultrasound ( before 3 mo. )The Ultrasound ( before 3 mo. )

Abductor M.Ilium


DiagnosisDiagnosis

Some cases still missedSome cases still missed At risk groups should be further At risk groups should be further

screenedscreened AAPAAP

• Recs further imaging (e.g. US) if exam is Recs further imaging (e.g. US) if exam is “inconclusive” AND“inconclusive” AND

First degree relative + femaleFirst degree relative + female BreechBreech Positive provocative maneuver (Ortolani or Positive provocative maneuver (Ortolani or

Barlow)Barlow)

• Referral to OrthopaedistReferral to Orthopaedist

ImagingImaging

X-raysX-rays• Femoral head ossification centerFemoral head ossification center

4 -7 months4 -7 months UltrasoundUltrasound

• Operator dependentOperator dependent CTCT MRIMRI ArthrogramsArthrograms

• Open vs closed reductionOpen vs closed reduction

ImagingImaging

UltrasoundUltrasound• Introduced in 1978 for eval of DDHIntroduced in 1978 for eval of DDH• Operator dependentOperator dependent• Useful in confirming subluxation, Useful in confirming subluxation,

identifying dysplasia of cartilaginous identifying dysplasia of cartilaginous acetabulum, documenting reducibilityacetabulum, documenting reducibility

• Prox Femoral Ossification Center Prox Femoral Ossification Center interferesinterferes

• Requires a window in spica cast (avoid)Requires a window in spica cast (avoid)

UltrasoundUltrasound

Femoral head

Abductors

Ilium


Femoral head

Abductors

Ilium


Femoral head

Abductors

Ilium


Femoral head

Abductors

Ilium


Graf’s alpha angle


Graf’s alpha angle

>60 = normal

*line w/ ilium bisects head 50/50

Fig. 5-A:: Figs. 5-A, 5-B, and 5-C: Ultrasonography of the infant hip with use of the dynamic technique. (Figures kindly provided by Prof. H. T. Harcke.)Fig. 5-A: Photograph showing the position of the transducer used to obtain the transverse flexion view. With the hip in this position of flexion and adduction, a posterior push is analogous to the Barlow test.

Fig. 5-B:: A transverse flexion ultrasonographic view of a normal hip shows the femoral head (F) remaining in contact with the ischium (arrows) during movement. A = anterior, L = lateral, and P = posterior.

Fig. 5-C:: With instability and displacement, the femoral head moves laterally and posteriorly. The laterally displaced head (F, open arrows) has no contact with the ischium (solid arrows). Fibrofatty tissue (T) with increased echogenicity fills the acetabulum. A = anterior, L = lateral, and P = posterior.

Health & Medicine

Developmental Dysplasia of the Hip and Ultrasound