Lower limbs

hip

HISTORY

Pain arising in the hip joint is felt in the groin, down the front of the thigh and, sometimes, in the knee; occasionally knee pain is the only symptom. Pain at the back of the hip is seldom from the joint: it usually derives from the lumbar spine.

HISTORY

Stiffness may cause difficulty with putting on socks sitting in a low chair.

HISTORY

Limp is common, and sometimes the patient complains that the leg is 'getting shorter'. walking distance may be curtailed or, reluctantly. the patient starts using a walking stick.

CLINICAL EXAMINATION

SIGNS WITH THE PATIENT UPRIGHT
The gait is noted. Antalgic gait. Or shortening (short-leg limp) or to Abductor weakness (Trendelenburg Lurch).

FriedrichTrendelenburg

The Trendelenburg test

The patient is asked to stand, unassisted, on each leg in turn; while standing on one leg, he or she has to lift the other leg by bending the knee

Normally

the weight-bearing hip is held stable by the abductors and the pelvis rises on the unsupported side.

if the hip is unstable, or very painful, the pelvis drops on the unsupported side.

is found in Dislocation or subluxation of the hip. Weakness of the abductors. Shortening of the femoral neck. Painful disorder of the hip.
A positive Trendelenburg test

SIGNS WITH THE PATIENT LYING SUPINE

Look
if one leg seems to be shorter than the other. Look for scars or sinuses, swelling or wasting and any obvious deformity or malposition of one of the limbs. (In babies) Asymmetry of skin creases may be important.

Feel

Bone Contour are felt when leveling the pelvis and judging the height of the greater trochanters.

Move

The assessment of hip movements is difficult because any limitation can easily be obscured by movement of the pelvis.

Hip Range of Motion

FLEXION

EXTENSION

Internal Rotation

External Rotation

Adduction

Abduction

SIGNS WITH THE PATIENT LYING PRONE

THE DIAGNOSTIC CALENDAR

Hip disorders are characteristically seen in certain well-defined age groups.

Age of onset

Age years birth 10-20 0-5 5-10 Adults
Probable diagnosis Developmental dysplasia. Infections. Perthes' disease. Slipped epiphysis. Arthritis.

Historical reviewFOR DDH

Dupuytren – Paris (1800’s) Dissected DDH specimens. he did not think condition could be treated.



Paletta – Milan – 1820 First anatomic description of congenitally dislocated hip(15 day old boy –Bilateral DDH).

Diagnosing DDH Early

La Damanay –Rennes – 1908.

Ortolani – Italy –1937.

Normal Growth and Development
Embryologically the acetabulum, femoral head develop from the same primitive mesenchymal cells cleft develops in precartilaginous cells at 7th week and this defines both structures 11wk hip joint fully formed.

femoral head deeply seated in acetabulum by surface tension of synovial fluid and very difficult to dislocate. in DDH this shape and tension is abnormal in addition to capsular laxity.

The condition formerly known as congenital dislocation of the hip and now called developmental dysplasia of the hip (DDH). WHY?

Frank dislocation during the neonatal period; Subluxation (partial displacement) Shallow acetabulum (acetabular dysplasia) without actual displacement. dislocatable. dislocation.
DDH Comprises a spectrum of disorders:

Incidence of neonatal hip

instability is 5-20 per 1000 live births. however, most of these hips stabilize spontaneously. Re-examination 3 weeks after birth the incidence of instability is only 1 or 2 per 1000 infants.


Girls are much more commonly affected than boys, The ratio being about 7: l. The left hip is more often affected than the right. in 1 in 5 cases the condition is bilateral

Risk Factors

80% Female First born children Family history 6% one affected child. 12% one affected parent. 36% one child + one parent)

Oligohydramnios.

Breech (sustained hamstring forces).

Swaddling cultures.

Left 60% (left occiput ant), Right 20%. both 20%

Torticollis

Or foot deformity

Aetiology and pathogenesis

Genetic factors

must be important, for DDH tends to run in families and even in entire populations (e. g, along the northern.

Hormonal changes

in late pregnancy may aggravate ligamentous laxity in the infant.

Intrauterine malposition

especially a breech position with extended legs, would favor dislocation.

Postnatal factors

play a particular in maintaining any tendency to instability.

Clinical features

The ideal, still unrealized, is to diagnose every case at birth. When there is a family history of congenital dislocation, and with breech presentations (presence of risk factors). For this reason, every newborn child should be examined for signs of hip instability.

Neonatal diagnosis

There are several ways of testing for instability. Ortolani’s test

the baby's thighs are held with the thumbs medially and the fingers resting on the greater trochanters; the hips are flexed to 90 degrees and gently abducted. Normally there is smooth abduction to almost 90 degrees.

Barlow's test

In DDH the movement is usually impeded, but if pressure is applied to the greater trochanter . there is a soft 'clunk' as the dislocation reduces, and then the hip abducts fully (the 'jerk of entry').

Barlow’s Provocative test

Performed in a similar manner
but here the examiner's thumb is placed in the groin and, by grasping the upper thigh, an attempt is made to lever the femoral head in and out of the acetabulum during abduction and adduction.

If the femoral head normally in the reduced position, can be made to slip out of the socket and back in again. the hip is classed as 'dislocatable' (i.e. unstable).


INVESTIGATIONSIN EARLY INFANCY

Every hip with signs of instability – however slight - should be examined by ultrasonography.This provides a dynamic assessment of the shape of the cartilaginous socket and the position of the femoral head

Late features

Ideally, all children should be examined again at 6 months. 12 months . and 18 months of age, so as to be sure that late-appearing signs of DDH are not missed.

With unilateral dislocation. are asymmetrical creases. the hip does not abduct fully . the leg is slightly short and rotated internally.

Galleazi sign flex both hips and one side shows apparent femoral shortening

Bilateral dislocation is more difficult to detect because there is no asymmetry and the characteristic waddling gait may be mistaken .

Perineal gap is abnormally wide and abduction is limited.

hyperlordosis in bilateral cases


Investigations in late DDH For diagnosis

X-ray examination

is helpful in older children. The ossific centre of the femoral head is underdeveloped, and from its position it may be apparent that the head is displaced upwards and outwards

Plain Radiographs

Hilgengreiner’s line is across the triradiate cartilage.Perkins line is vertical along the lateral border of the acetabulum.Shenton’s line.


Acetabular index is the angle between the acetabulum and hilgenreiner’s lineIt should be less than 30 degrees in a newborn

X-ray findings Delayed appearance of ossific nucleus Small ossific nucleus Dysplastic acetabulum Proximal displacement of femur
The Limping Child: Age 1 – 3DDH

TREATMENT

Treatment under 6 months of age
The simplest and safest policy is to regard all infants with a positive Ortolanis or Barlow test as DDH . SO



Nurse them in double napkins. or with an abduction pillow between the legs for the first 6 weeks.

those with persistent instability are treated by more formal abduction splintage until the hip is stable. and x-ray shows that the Acetabular roof is developing satisfactorily (usually 3-6 months).

Splintage

Arnold Pavlik 1902-1962

Pavlik’s Father – Harness Maker

Pavlik and his Harness
1946 –Pavlik introduces his leather harness : Czech Ortho Society, Prague

Modern Day Pavlik –San Diego

Treatment of persistent dislocation; 6 months to 6years

If, after early treatment, the hip is still incompletely reduced, or if the child presents late with a 'missed' dislocation, the hip must be reduced and held reduced until acetabular development is satisfactory this done by

Closed reduction

Manipulation under anaesthesia carries a high risk of femoral head necrosis. To minimize this risk. reduction must be gradual traction is applied to both legs, preferably on a vertical frame, and abduction is gradually increased until, by 3 weeks by gallows traction,

to over come.

A vascular necrosis

Then

Splintage

If concentrically reduced, the hips (both) are held in a plaster spica at 60 degrees of flexion, 40 degrees of abduction and 20 degrees of internal rotation. After 6 weeks, the plaster is replaced by a splint that prevents adduction but allows movement.


If
FAILED

Open reduction

at any stage, concentric reduction has not been achieved by conservative methods.

open operation is needed.

Treatment after the age of 6 years

For unilateral dislocation

operative reduction is still feasible. it may be necessary to combine this with corrective osteotomy of the femur or innominate osteotomy of the pelvis.

With bilateral dislocation

the deformity is symmetrical and therefore less noticeable; Therefore, most surgeons avoid operation unless pain or deformity is unusually severe.

ALGORITHM FOR TREATMENT OF DDH

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