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Transcript of Ddh residents
Developmental Developmental Dysplasia of the HipDysplasia of the Hip
Dr.Abdulmonem Al SiddikyDr.Abdulmonem Al SiddikyAssistant professor & ConsultantAssistant professor & Consultant
Ped.Ortho.,Ped.Spine & Spinal deformitiesPed.Ortho.,Ped.Spine & Spinal deformities
KKUH , KSUKKUH , KSU
OverviewOverview
IntroductionIntroduction Normal Development of the HipNormal Development of the Hip Etiology and PathoanatomyEtiology and Pathoanatomy Epidemiology and DiagnosisEpidemiology and Diagnosis TreatmentTreatment ComplicationsComplications
IntroductionIntroduction
Developmental Dysplasia of the HipDevelopmental Dysplasia of the Hip DDH - preferred termDDH - preferred term Teratogenic hipsTeratogenic hips SubluxationSubluxation Dislocation-usually posterosuperior (reducible Dislocation-usually posterosuperior (reducible
vs irreducible)vs irreducible) DysplasiaDysplasia
SummarySummary
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 Family history (6% one affected child, 12% one
affected parent, 36% one child + one parent)affected 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
Normal DevelopmentNormal Development
EmbryonicEmbryonic 7th week - acetabulum and hip formed from 7th week - acetabulum and hip formed from
same mesenchymal cellssame mesenchymal cells 11th week - complete separation between the 11th week - complete separation between the
twotwo 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
PathoanatomyPathoanatomy
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 with Inverted + adherent to capsule (closed reduction with inverted labruminverted labrum assoc with increased Avascular Necrosis) assoc with increased Avascular Necrosis)
Ligamentum teresLigamentum teres Hypertrophied + lengthenedHypertrophied + lengthened
PulvinarPulvinar Fibrofatty tissue migrating into acetabulumFibrofatty tissue migrating into acetabulum
PathoanatomyPathoanatomy
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 acetabular interposed between everted labrum and acetabular rimrim
ExtraarticularExtraarticular Tight adductors (adductor longus)Tight adductors (adductor longus) IliopsoasIliopsoas
Tough Reductions…Tough Reductions… Obstacles to reductionObstacles to reduction
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 a Ortolani’s and Barlow’s maneuvers with a thorough history and physicalthorough history and physical
Warm, quiet environment with removal of Warm, quiet environment with removal of diaperdiaper
Head to toe exam to detect any associated Head to toe exam to detect any associated conditons (Torticollis, Ligamentous Laxity conditons (Torticollis, Ligamentous Laxity etc.)etc.)
Baseline Neuro and Spine ExamBaseline Neuro and Spine Exam
DiagnosisDiagnosis
Key physical findingsKey physical findings AsymmetryAsymmetry
Limb length- GaleazziLimb length- Galeazzi Abduction ROMAbduction ROM Skin foldsSkin folds Limp Limp Waddilng gait / Waddilng gait /
hyperlordosis - bilateral hyperlordosis - bilateral involvementinvolvement
Ortolani’s ManeuverOrtolani’s Maneuver
* After 3 months of age tests become negative
Barlow’s ManeuverBarlow’s Maneuver
DiagnosisDiagnosis
Some cases still missedSome cases still missed At risk groups should be further screenedAt risk groups should be further screened 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 Barlow)Positive provocative maneuver (Ortolani or 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
RadiographsRadiographs
ImagingImaging
RadiographsRadiographs
ImagingImaging
RadiographsRadiographs
ImagingImaging
RadiographsRadiographs
ImagingImaging
Acetabular IndexAcetabular Index
ImagingImaging
Acetabular IndexAcetabular Index
ImagingImaging
Acetabular IndexAcetabular Index
< 30° wnl
ImagingImaging
ImagingImaging
ImagingImaging
ImagingImaging
Radiographs SummaryRadiographs Summary
Femoral head appears 4 - 7 monthsFemoral head appears 4 - 7 months Shenton’s lineShenton’s line Perkin’s and Hilgenreiner’s linesPerkin’s and Hilgenreiner’s lines
Inferomedial quadrantInferomedial quadrant
Center Edge Angle (< 20 abnormal)Center Edge Angle (< 20 abnormal) Acetabular indexAcetabular index
Normal < 30 (Weintroub et al)Normal < 30 (Weintroub et al)
Tear drop*Tear drop* Abnormal widening in DDHAbnormal widening in DDH*may be only sign in mild subluxation*may be only sign in mild subluxation
ImagingImaging
UltrasoundUltrasound Introduced in 1978 for eval of DDHIntroduced in 1978 for eval of DDH Operator dependentOperator dependent Useful in confirming subluxation, identifying Useful in confirming subluxation, identifying
dysplasia of cartilaginous acetabulum, dysplasia of cartilaginous acetabulum, documenting reducibilitydocumenting reducibility
Prox Femoral Ossification Center interferesProx Femoral Ossification Center interferes Requires a window in spica cast (avoid)Requires a window in spica cast (avoid)
UltrasoundUltrasound
Femoral head
Abductors
Ilium
UltrasoundUltrasound
Femoral head
Abductors
Ilium
UltrasoundUltrasound
Femoral head
Abductors
Ilium
UltrasoundUltrasound
Femoral head
Abductors
Ilium
UltrasoundUltrasound
Graf’s alpha angle
UltrasoundUltrasound
Graf’s alpha angle
>60° = normal
*line w/ ilium bisects head 50/50
Natural HistoryNatural History
NewbornNewborn Variable Variable > 6 months> 6 months more aggressive tx required more aggressive tx required
due to more extensive pathology and due to more extensive pathology and decreased potential for acetabular decreased potential for acetabular remodelingremodeling
Abnormal Gait, Decreased Abduction and Abnormal Gait, Decreased Abduction and Strength, Increased DJDStrength, Increased DJD
Unilateral worse than BilateralUnilateral worse than Bilateral Subluxation worse than Dysplasia Subluxation worse than Dysplasia
Treatment OptionsTreatment Options
Age of patient at presentationAge of patient at presentation Family factorsFamily factors Reducibility of hipReducibility of hip Stability after reductionStability after reduction Amount of acetabular dysplasiaAmount of acetabular dysplasia
Birth to Six MonthsBirth to Six Months
Triple-diaper techniqueTriple-diaper technique Prevents hip adductionPrevents hip adduction ““Success” no different in some Success” no different in some
untreated hipsuntreated hips
Pavilk harness (1944)Pavilk harness (1944) Experienced staff*Experienced staff* Very successfulVery successful Allows free movement within Allows free movement within
confines of restraintsconfines of restraints
*posterior straps for preventing add. NOT producing abd.
Birth to Six MonthsBirth to Six Months
Pavlik harnessPavlik harness IndicationsIndications
Fully reducible hip*Fully reducible hip* Child not attempting to standChild not attempting to stand FamilyFamily
• Close regular follow-up (every 1-2 weeks)Close regular follow-up (every 1-2 weeks)• For imaging and adjustmentsFor imaging and adjustments
• DurationDuration• Childs age at hip stability + 3 monthsChilds age at hip stability + 3 months
Pavlik HarnessPavlik Harness
FailuresFailures Poor parent compliancePoor parent compliance Improper use by the physicianImproper use by the physician
Inadequate initial reductionInadequate initial reduction Failure to recognize persistent dislocationFailure to recognize persistent dislocation
Viere et al 1990Viere et al 1990 Bilateral dislocationBilateral dislocation Absent Ortolani’s signAbsent Ortolani’s sign > 7weeks of age> 7weeks of age
Pavlik HarnessPavlik Harness
ComplicationsComplications Avascular necrosisAvascular necrosis
Forced hip abductionForced hip abduction Safe zone (abd/adduction and flexion/extension)Safe zone (abd/adduction and flexion/extension)
Femoral nerve palsyFemoral nerve palsy HyperflexionHyperflexion
*Be aware of Pavlik Harness Disease*Be aware of Pavlik Harness Disease
*Follow until skeletal maturity*Follow until skeletal maturity
Birth - Six monthsBirth - Six months
Closed reduction + SpicaClosed reduction + Spica Failure after 3 weeks of Pavlik trialFailure after 3 weeks of Pavlik trial
Birth - Six monthsBirth - Six months
Closed reductionClosed reduction General anesthesiaGeneral anesthesia ArthrogramArthrogram Safe zone - avoid AVNSafe zone - avoid AVN +/- adductor tenotomy+/- adductor tenotomy Open reduction if concentric reduction not Open reduction if concentric reduction not
possiblepossible Usually teratogenic hips in this age groupUsually teratogenic hips in this age group
Open ReductionOpen Reduction
Medial approachMedial approach Pectineus / adductor longus + brevisPectineus / adductor longus + brevis Cannot address simeoultaneous bony workCannot address simeoultaneous bony work
Antero -lateralAntero -lateral Smith-petersonSmith-peterson Sartorius / Tensor Fascia lataSartorius / Tensor Fascia lata
Open ReductionOpen Reduction
6 months - 4 years6 months - 4 years
Present a more difficult problemPresent a more difficult problem Prolonged dislocationProlonged dislocation Contracted soft tissuesContracted soft tissues
6 - 18 months6 - 18 months Closed reduction +/- adductor tenotomyClosed reduction +/- adductor tenotomy Spica in human position of 100 degrees of flexion and Spica in human position of 100 degrees of flexion and
about 55 degrees abduction (3 months)about 55 degrees abduction (3 months) Abduction Orthosis 4 wks full time/4 wks nighttimeAbduction Orthosis 4 wks full time/4 wks nighttime Open reduction (if closed fails)Open reduction (if closed fails)
CapsulorraphyCapsulorraphy CT scanCT scan Spica for 6 wks followed by PTSpica for 6 wks followed by PT
6 months - 4 years6 months - 4 years
18 months - 4 years18 months - 4 years Closed reductionClosed reduction
Reducibile - check arthrogram and Reducibile - check arthrogram and medial dye poolmedial dye pool Irreducible - Open reductionIrreducible - Open reduction
Open redcutionOpen redcution Tight - femoral shorteningTight - femoral shortening
Stable - +/- pelvic osteotomyStable - +/- pelvic osteotomy
Femoral ShorteningFemoral Shortening
Schoenecker + Strecker 1984Schoenecker + Strecker 1984 Traction vs. Femoral shorteningTraction vs. Femoral shortening 56% AVN in traction group56% AVN in traction group 0% AVN in femoral shortening0% AVN in femoral shortening
Pelvic OsteotomyPelvic Osteotomy
Persistent instability + dysplasia after Persistent instability + dysplasia after open reduction + femoral shorteningopen reduction + femoral shortening
Requires concentric reduction of a Requires concentric reduction of a reasonably spherical femoral headreasonably spherical femoral head
Usually based on surgeon preferenceUsually based on surgeon preference Salter and Pemberton 2 m/c in USSalter and Pemberton 2 m/c in US
Pelvic Osteotomy Pelvic Osteotomy
Volume changingVolume changing Pemberton Pemberton
Hinges on triradiateHinges on triradiate Requires remodeling of “new” incongruityRequires remodeling of “new” incongruity Provides more anterolateral coverageProvides more anterolateral coverage
Dega’sDega’s
PembertonPemberton
Pelvic OsteotomyPelvic Osteotomy
RedirectingRedirecting SalterSalter
Osteotomy thru sciatic notchOsteotomy thru sciatic notch Hinge thru pubic symphysisHinge thru pubic symphysis
Triple innominateTriple innominate GanzGanz DialDial
Pelvic OsteotomyPelvic Osteotomy
RedirectingRedirecting SalterSalter
Osteotomy thru sciatic notchOsteotomy thru sciatic notch Hinge thru pubic symphysisHinge thru pubic symphysis
Triple innominateTriple innominate GanzGanz DialDial
Salter OsteotomySalter Osteotomy
Salter OsteotomySalter Osteotomy
Salter OsteotomySalter Osteotomy
Salvage or Shelf proceduresSalvage or Shelf procedures
ChiariChiari Requires capsular metaplasiaRequires capsular metaplasia Pain - main indicationPain - main indication Treatment of chronic hip pain in adolescentsTreatment of chronic hip pain in adolescents
Chiari OsteotomyChiari Osteotomy
Chiari OsteotomyChiari Osteotomy
Chiari OsteotomyChiari Osteotomy
Chiari OsteotomyChiari Osteotomy
Chiari OsteotomyChiari Osteotomy
Avascular NecrosisAvascular Necrosis
Avascular NecrosisAvascular Necrosis
Most commonMost common Not part of the natural history of DDHNot part of the natural history of DDH IatrogenicIatrogenic Etiology unknownEtiology unknown
Femoral head compressionFemoral head compression Injury to blood supplyInjury to blood supply
Excessive abductionExcessive abduction Sullivan et al 1997Sullivan et al 1997 Sig Sig ↓↓ blood flow w/ increasing abd angle blood flow w/ increasing abd angle
TX SummaryTX Summary
Best if treated before 6 weeks of ageBest if treated before 6 weeks of age 0 - 6 months of age0 - 6 months of age
PavlikPavlik
6 - 18 months6 - 18 months Closed vs open reduction and spicaClosed vs open reduction and spica
18 - 48 months18 - 48 months ClosedClosed Open +/- osteotomiesOpen +/- osteotomies
SummarySummary
Femoral shortening better than tractionFemoral shortening better than traction Pelvic osteotomiesPelvic osteotomies
Dega, PembertonDega, Pemberton Salter, triple innominate, GanzSalter, triple innominate, Ganz ChiariChiari
QuestionsQuestions
Evaluation of a 4week infant who has a Evaluation of a 4week infant who has a hip click reveals a positive Ortolani sign. hip click reveals a positive Ortolani sign. Treatment should include:Treatment should include:
A.A. traction, closed reduction, and spica casting.traction, closed reduction, and spica casting. B.B. triple diapers and reassessment in 1 monthtriple diapers and reassessment in 1 month
C.C. an AP pelvis x-ray at age 4 monthsan AP pelvis x-ray at age 4 months D. D. Fitting of a Pavlik harness and reassessment in 2 Fitting of a Pavlik harness and reassessment in 2
weeksweeks E.E. an US of the hip, fitting of a Pavlik, and an US of the hip, fitting of a Pavlik, and
reevaulation in 3 months.reevaulation in 3 months.
Evaluation of a 4week infant who has a Evaluation of a 4week infant who has a hip click reveals a positive Ortolani sign. hip click reveals a positive Ortolani sign. Treatment should include:Treatment should include:
A.A. traction, closed reduction, and spica casting.traction, closed reduction, and spica casting. B.B. triple diapers and reassessment in 1 monthtriple diapers and reassessment in 1 month
C.C. an AP pelvis x-ray at age 4 monthsan AP pelvis x-ray at age 4 months D. D. Fitting of a Pavlik harness and reassessment in Fitting of a Pavlik harness and reassessment in
2 weeks2 weeks E.E. an US of the hip, fitting of a Pavlik, and an US of the hip, fitting of a Pavlik, and
reevaulation in 3 months.reevaulation in 3 months.
A healthy 5-mo-old infant w/ DDH of the L hip A healthy 5-mo-old infant w/ DDH of the L hip has been treated in a Pavlik for 3 months. has been treated in a Pavlik for 3 months. Exam shows limited ABD and a Galeazzi sign. Exam shows limited ABD and a Galeazzi sign. Radiographs in harness were taken. Radiographs in harness were taken. Management should consist of:Management should consist of:
A.A. an arthrogram and closed reductionan arthrogram and closed reduction B.B. a change of the Pavlik to a Frejka pillowa change of the Pavlik to a Frejka pillow C.C. no further Rx until the child is 6mosno further Rx until the child is 6mos D. D. Adjustment of the Pavlik and continuation of RxAdjustment of the Pavlik and continuation of Rx E.E. open reduction through a medial approach and spicaopen reduction through a medial approach and spica
A healthy 5-mo-old infant w/ DDH of the L hip A healthy 5-mo-old infant w/ DDH of the L hip has been treated in a Pavlik for 3 months. has been treated in a Pavlik for 3 months. Exam shows limited ABD and a Galeazzi sign. Exam shows limited ABD and a Galeazzi sign. Radiographs in harness were taken. Radiographs in harness were taken. Management should consist of:Management should consist of:
A.A. an arthrogram and closed reductionan arthrogram and closed reduction B.B. a change of the Pavlik to a Frejka pillowa change of the Pavlik to a Frejka pillow C.C. no further Rx until the child is 6mosno further Rx until the child is 6mos D. D. Adjustment of the Pavlik and continuation of RxAdjustment of the Pavlik and continuation of Rx E.E. open reduction through a medial approach and spicaopen reduction through a medial approach and spica
A healthy 5-mo-old infant w/ DDH of the L hip A healthy 5-mo-old infant w/ DDH of the L hip has been treated in a Pavlik for 3 months. has been treated in a Pavlik for 3 months. Exam shows limited ABD and a Galeazzi sign. Exam shows limited ABD and a Galeazzi sign. Radiographs in harness were taken. Radiographs in harness were taken. Management should consist of:Management should consist of:
A.A. an arthrogram and closed reductionan arthrogram and closed reduction B.B. a change of the Pavlik to a Frejka pillowa change of the Pavlik to a Frejka pillow C.C. no further Rx until the child is 6mosno further Rx until the child is 6mos D. D. Adjustment of the Pavlik and continuation of RxAdjustment of the Pavlik and continuation of Rx E.E. open reduction through a medial approach and spicaopen reduction through a medial approach and spica
This is an x-ray of a 9-month-old infant who This is an x-ray of a 9-month-old infant who has intoeing. Exam of the hips show ABD of has intoeing. Exam of the hips show ABD of the Left hip to 75 degrees and the Right to 90 the Left hip to 75 degrees and the Right to 90 degrees. Both the Ortolani and Barlow signs degrees. Both the Ortolani and Barlow signs are negative. Management should include:are negative. Management should include:
A.A. observationobservation
B.B. application of a Pavlik harnessapplication of a Pavlik harness C.C. closed reduction of the Left hipclosed reduction of the Left hip D.D. open reductino of the Left hipopen reductino of the Left hip E.E. open reduction of the left hip with innominate open reduction of the left hip with innominate
osteotomyosteotomy
This is an x-ray of a 9-month-old infant who This is an x-ray of a 9-month-old infant who has intoeing. Exam of the hips show ABD of has intoeing. Exam of the hips show ABD of the Left hip to 75 degrees and the Right to 90 the Left hip to 75 degrees and the Right to 90 degrees. Both the Ortolani and Barlow signs degrees. Both the Ortolani and Barlow signs are negative. Management should include:are negative. Management should include:
A.A. observationobservation
B.B. application of a Pavlik harnessapplication of a Pavlik harness C.C. closed reduction of the Left hipclosed reduction of the Left hip D.D. open reductino of the Left hipopen reductino of the Left hip E.E. open reduction of the left hip with innominate open reduction of the left hip with innominate
osteotomyosteotomy
This is an x-ray of a 9-month-old infant who This is an x-ray of a 9-month-old infant who has intoeing. Exam of the hips show ABD of has intoeing. Exam of the hips show ABD of the Left hip to 75 degrees and the Right to 90 the Left hip to 75 degrees and the Right to 90 degrees. Both the Ortolani and Barlow signs degrees. Both the Ortolani and Barlow signs are negative. Management should include:are negative. Management should include:
A.A. observationobservation
B.B. application of a Pavlik harnessapplication of a Pavlik harness C.C. closed reduction of the Left hipclosed reduction of the Left hip D.D. open reductino of the Left hipopen reductino of the Left hip E.E. open reduction of the left hip with innominate open reduction of the left hip with innominate
osteotomyosteotomy
The x-ray shows a AP pelvis of a 6yo girl who The x-ray shows a AP pelvis of a 6yo girl who presents with a limp and intermittent pain in presents with a limp and intermittent pain in the right groin. Management should include:the right groin. Management should include:
A.A. A varus derotational osteotomy of the right femurA varus derotational osteotomy of the right femur
B.B. open reduction and adductor tenotomyopen reduction and adductor tenotomy C.C. open reduction with femoral and pelvic osteotomiesopen reduction with femoral and pelvic osteotomies D.D. PT for muscle strengthening and ROM exercisesPT for muscle strengthening and ROM exercises E.E. longitudinal traction, closed reduction, and adductor longitudinal traction, closed reduction, and adductor
tenotomytenotomy
The x-ray shows a AP pelvis of a 6yo girl who The x-ray shows a AP pelvis of a 6yo girl who presents with a limp and intermittent pain in presents with a limp and intermittent pain in the right groin. Management should include:the right groin. Management should include:
A.A. A varus derotational osteotomy of the right femurA varus derotational osteotomy of the right femur
B.B. open reduction and adductor tenotomyopen reduction and adductor tenotomy C.C. open reduction with femoral and pelvic osteotomiesopen reduction with femoral and pelvic osteotomies D.D. PT for muscle strengthening and ROM exercisesPT for muscle strengthening and ROM exercises E.E. longitudinal traction, closed reduction, and adductor longitudinal traction, closed reduction, and adductor
tenotomytenotomy
The x-ray shows a AP pelvis of a 6yo girl who The x-ray shows a AP pelvis of a 6yo girl who presents with a limp and intermittent pain in presents with a limp and intermittent pain in the right groin. Management should include:the right groin. Management should include:
A.A. A varus derotational osteotomy of the right femurA varus derotational osteotomy of the right femur
B.B. open reduction and adductor tenotomyopen reduction and adductor tenotomy C.C. open reduction with femoral and pelvic open reduction with femoral and pelvic
osteotomiesosteotomies D.D. PT for muscle strengthening and ROM exercisesPT for muscle strengthening and ROM exercises E.E. longitudinal traction, closed reduction, and adductor longitudinal traction, closed reduction, and adductor
tenotomytenotomy
Thank YouThank You