MSK Flashcards
What is developmental dysplasia of the hip (DDH)?
A spectrum of conditions related to the development of the hip in infants and young children.
Spectrum includes abnormalities of stability (dislocation, dislocatability and subluxation/subluxability) and abnormalities of the shape of the femoral head and acetabulum (dyspasia)
What causes DDH?
Ligamentous laxity predisposes the developing hip to mechanical forces that cause eccentric contact between the femoral head and the acetabulum
Abnormal contact results in abnormal development of the acetabulum and femoral head
What are risk factors for developmental dysplasia of the hip?
Female sex, breech position in third trimester, positive family history, swaddling with the hips in extension and abduction. (Although most patients with DDH have no risk factors aside from female sex according to UTD)
Females affected 7X more than males – due to estrogen-induced ligamentous laxity in utero
60% of patients with DDH are firstborn
Higher risk if postmature
During what age range is it important to assess the hips for DDH?
Hip examination should occur soon after birth and at every health supervision visit until approximately 9 months old and/or until the child is walking independently
*Especially important at 2 and 4 week visits
There are two maneuvers that are used for the hip assessment in the neonate? What are their names? Describe them.
Ortolani maneuver – use abduction and elevation to feel for reducibility
Barlow maneuver – use gentle adduction without downward pressure to feel for dislocatability
The sensation of reducibility or dislocatability is distinct and is felt as a jerk or a clunk
What are other findings that may be present with DDH?
Asymmetry of femur length, skin folds or gait (apparent shortening of the femur is called Galeazzi sign)
Decreased hip abduction
(these findings are less specific than the Ortolani and Barlow)
T/F: Bilateral DDH occurs in up to 10% of cases
False: Bilateral DDH occurs in 20-37% of cases.
How is the diagnosis of DDH made? Is imagining required?
The diagnosis can be made based on physical exam findings of hip instability, asymmetry (in unilateral cases) and/or limited hip abduction
Imaging can be useful if diagnosis is uncertain – usually US if in first 4 months of life
UTD recommends referral to orthopedic surgeon experienced in this diagnosis
How does the physical assessment vary between a neonate and an older child?
Infants <3 months – look for hip instability using the Ortolani and Barlow maneuvers
Infants >3 months – instability less helpful b/c the hip stabilized in the abnormal position. Look for limited abduction, apparent thigh-length discrepancy (if unilateral) and the Galeazzi (when laying down with knees bent and feet on table, one knee appears lower)
In walking children – may have a positive Trendelenburg pelvic tilt (when standing on one leg, pelvis turns down toward unaffected side) and a Trendelenburg lurch when walking
US is recommended for asymptomatic infants at 4-6 weeks age with normal physical exam if they have which risk factors?
Breech positioning at 34 weeks gestation or later
Family history of DDH
History of clinical instability on examination
Hip instability in the neonate occurs in 11.5-17% of live births. How often does this persist and lead to DDH?
Most hip instability stabilized soon after birth
60% of cases resolve by 1 week of age, 90% resolve by 2 months of age
What are the long-term effects of untreated dislocation and/or dysplasia?
Functional disability, pain and early osteoarthritis
What is the Graf score?
A classification system of the severity of the hip pathology
What is the goal of DDH treatment?
Obtain and maintain concentric reduction of the hip to provide the optimal environment for the development of the femoral head and acetabulum and reduce risk for early osteoarthritis
What does treatment for DDH consist of?
Age < 6 months: Abduction splints – Pavlik harness
(with hip dislocation or persistently dislocatable/subluxatable hips or acetabular dysplasia without dislocation (Graf type IIa or worse))
Age 6 months +: reduction under anesthesia (closed or open)
T/F: the pavlik harness treatment has a success rate of 95%
True – Pavlik harness achieves and maintains hip reduction in 95% of infants
T/F: long term follow-up is required for DDH
True – children who have been treated for DDH should be monitored with regular hip xrays until they reach skeletal maturity to evaluate hip development and complications
Where is the scaphoid bone?
The scaphoid bone is one of the carpal bones – on the thumb side of the wrist, just below the radius.
Kids of what age are able to use a numeric rating scale for pain?
8+
What is “total pain”
conceives of pain as having 4 interrelated domains: physical, psychological, social, and spiritual.
The WHO has a 2 step strategy for pain management in pediatrics. What are the STEP 1 medications for mild pain?
acetaminophen and ibuprofen
Oral if can…
In certain cases, intravenous acetaminophen or ketorolac tromethamine may be used. Adjuvants may be
added if appropriate. Acetaminophen can be given orally or rectally.
Compounded ibuprofen can be given rectally.
A child who is anxious and in pain may benefit from an adjuvant medication such as….
Benzos or haldol
