Quality Education for a Healthier Scotland Multidisciplinary Developmental Dysplasia of the Hip.
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Transcript of Quality Education for a Healthier Scotland Multidisciplinary Developmental Dysplasia of the Hip.
Quality Education for a Healthier Scotland
Multidisciplinary
Developmental Dysplasia of the Hip
Quality Education for a Healthier Scotland
Multidisciplinary
“Developmental dysplasia of the hip”
Dysplasia Subluxation Dislocated
Quality Education for a Healthier Scotland
Multidisciplinary
The aim of treatment
A normal hip
Quality Education for a Healthier Scotland
Multidisciplinary
Natural history
Hip arthritis in early adulthood
Quality Education for a Healthier Scotland
Multidisciplinary
Early diagnosis
Treatment success high
Treatment late cases
Less successful
More surgery
More complications
Quality Education for a Healthier Scotland
Multidisciplinary
How common is DDH?
Clinically unstable hips – 1 in 64 babies
Quality Education for a Healthier Scotland
Multidisciplinary
Scottish Needs Assessment Program Report July 1993
Number of late cases not reduced by neonatal screening
Possible increase in number of late presenting cases
Quality Education for a Healthier Scotland
Multidisciplinary
National Screening Committee recommendations
All babies must be screened by clinical examination Ultrasound if clinical abnormality or risk factors
Clinically abnormal hips should be seen by a specialist
Quality Education for a Healthier Scotland
Multidisciplinary
National Screening Committee (cont.)
Second hip check before 8 weeks
Personal Child Health Record lists signs and symptoms suggesting DDH
If DDH suspected, referral to someone with the appropriate expertise
Quality Education for a Healthier Scotland
Multidisciplinary
Clinical examination “24-hour check”
Five points: History of risk factors Leg length difference Groin/buttock creases Range of abduction Tests of stability
Quality Education for a Healthier Scotland
Multidisciplinary
Point 1 – History of risk factors
Breech presentation
Family history of DDH
Abnormalities of the lower limbs, e.g. clubfoot
Torticollis
Quality Education for a Healthier Scotland
MultidisciplinaryLook
Point 2 - Leg length difference
Hips and knees flexed
Check level of knees – should be level
If not level then refer
Point 3 - Labial or groin folds and buttock creases
(Reprinted from Jones: Hip Screening of the Newborn – A Practical Guide, 1998, with permission from Elsevier.)
Quality Education for a Healthier Scotland
Multidisciplinary
Move
Point 4 - Range of abduction
Point 5 - Tests of stability
Barlow
Ortolani
Restricted abduction and asymmetrical groin folds
Quality Education for a Healthier Scotland
Multidisciplinary
Instability tests
In Out
Stable Normal Fixed dislocation
Unstable Barlow + Ortolani +
Quality Education for a Healthier Scotland
MultidisciplinaryResting position
Test one hip at a timeHip and knee flexedFinger on greater trochanterStabilise pelvisCompare sidesTake your time, be gentle
Quality Education for a Healthier Scotland
MultidisciplinaryClinical tests
Barlow test
Abnormal if femur moves Backwards relative to the fixed pelvis
Test for a located but dislocatable hip
Quality Education for a Healthier Scotland
MultidisciplinaryClinical tests 2
Ortolani testPositive if greater trochanter moves forwards as hip locates Hip is Out, but can be reducedTests for a dislocated but reducible hip
Quality Education for a Healthier Scotland
MultidisciplinaryBarlow & Ortolani
Quality Education for a Healthier Scotland
Multidisciplinary
Examining infants hips - can it do harm?
“Over enthusiastic or repeated clinical examination may provoke instability”
Take your time, be gentle
Lowry et al (2005) Archives of Diseases in Childhood 90 (6): 579-81
Quality Education for a Healthier Scotland
Multidisciplinary
Barlow positive Incidence?
• 15 to 20/1000 Barlow positive • Many resolve without treatment • Decision to treat may be delayed• Need careful watching
Quality Education for a Healthier Scotland
Multidisciplinary
Ortolani positive. Incidence?
• 1 to 2/1000 Ortolani positive• Most will need treatment• Some centres splint from birth • Careful follow up
Quality Education for a Healthier Scotland
Multidisciplinary
‘Teratologic' or fixed dislocation
• Dislocated irreducible hip• Dislocation before birth• Association with arthrogryposis or myelomeningocele • Surgery usually required
Quality Education for a Healthier Scotland
MultidisciplinaryBaby Hippy
‘Life-like’ model of a female newborn Barlow positive hipOrtolani positive hip Expensive and delicate ++
Quality Education for a Healthier Scotland
MultidisciplinaryClinical examination “24-hour check”
Five points:
History of risk factorsLeg length differenceGroin/buttock creasesRange of abductionTests of stability
BarlowOrtolani
Questions?
Quality Education for a Healthier Scotland
MultidisciplinaryThe unstableneonatal hip
• What happens to them?• Hip can become normal• Progress to subluxation • Progress to dislocation• Remain located but remain dysplastic
We cannot tell which will get better on their own - they need watched
Quality Education for a Healthier Scotland
Multidisciplinary
Controversies in DDH
• The natural history not completely understood • Effectiveness of treatment not clear• Screening – Who? How? When?• Why are we still missing so many?
Quality Education for a Healthier Scotland
MultidisciplinaryClinical examination
• Not universally successful• Failed to eliminate late presentations• Dysplasia may not be detectable • Detection improves when performed by a limited number
of experienced examiners
Quality Education for a Healthier Scotland
MultidisciplinaryMissed?
•Some are missed•Others present late•Importance of 6-week and 36-month checks•Late signs
–Limp–Leg length difference–Restricted abduction
Age 5 years: bilateraldislocations
Quality Education for a Healthier Scotland
Multidisciplinary
Hip screening with ultrasound
Options
Universal screening
Screening of high risk babies
Quality Education for a Healthier Scotland
MultidisciplinaryUniversal U/Sscreening
• Difficult to organise• High number of immature hips – rescan• Expensive• ?Cost effective• Conclusion – not proven, although some very impressive
results
Quality Education for a Healthier Scotland
Multidisciplinary
Selective U/Sscreening
• Only high risk and clinically abnormal hips• Consultant radiologists and dedicated sonographer• ? Effectiveness• Manageable
Quality Education for a Healthier Scotland
Multidisciplinary
X-ray examination
X-rays before 4 months of age unreliable
Very important in older children for diagnosis and monitoring of treatment
Dislocation age 15 months.
Quality Education for a Healthier Scotland
MultidisciplinaryLate signs of DDH
Asymmetric abduction
Leg length discrepancy
DDH must be excluded
Quality Education for a Healthier Scotland
MultidisciplinaryTreatment
Abduction splint – Pavlik, von Rosen
Monitoring for hip development and complications
Quality Education for a Healthier Scotland
Multidisciplinary
How not to examine a baby’s hips!
Quality Education for a Healthier Scotland
MultidisciplinaryThank you.
Any questions?
Quality Education for a Healthier Scotland
MultidisciplinarySummary
Aim – to reduce incidence of hip arthritis
The Five points of the examination History of risk factors Leg length difference Groin/buttock creases Range of abduction Tests of stability