(OBQ14.122) 95% of shoulder dislocations are anterior. Dislocation of hip Ponnilavan Ponz Fractures of Pelvic Eneutron Rotatory cuff syndrome & Scapular Dyskinesia Dr. Manoj Parida Posterior shoulder dislocation 2 Shoulder Library Orthopedics 2 Ghassan Al kefeiri Ankle and foot injuries Amardeep kaur Femur fracture muhammad bilal The congenital and acquired diseases of spine VakulychMyroslav Figure A depicts an ultrasound of a newborn infant's hip. A hip dislocation is when the thighbone separates from the hip bone (). (SAE07PE.80) The pain is worse with activity and she notices that she has fatigue and pain that extends to the thighs and knees following a soccer match. (OBQ17.98) Hip flexion and rotation is normal. Which of the following surgical interventions is best indicated? unilateral dislocations are more difficult to reduce but more stable after reduction, bilateral dislocation are easier to reduce (PLL torn) but less stable following reduction . Osteonecrosis. Diagnosis can be confirmed with ultrasonography in the first 4 months and then with radiographs after femoral head ossification occurs (~ 4-6 months). posterior cutaneous nerve of the forearm. . Subtalar Dislocations. Open reduction is indicated for dislocations associated with a medial epicondyle fracture with an incarcerated fragment. Based on the findings shown in Figure 3, what is the most appropriate type of pelvic osteotomy for the right hip? The capsule is closed loosely with 2/0 absorbable sutures. describe potential complications and the steps to avoid them, right angle clamp; non absorbable suture (size 0 or 1 Ethibond);spica table and spica casting materials, setup OR with standard radiolucent operating table, monitor in surgeon direct line of site on opposite side (or foot) of OR table, spica table available for cast placement at end of procedure, small bump under hip (under iliac crest not buttock so gluteal muscles fall away), prep medially to umbilicus, superiorly to 12th rib and posteriorly as far as possible, skin incision 1 cm below iliac crest and inguinal ligament with 2/3 posterior to ASIS, 1/3 anterior to ASIS (approx 6cm posterior and 3cm anterior in toddlers), perform a sharp dissection through the subcutaneous tissue down to the deep fascia, identify the interval between the sartorius and the tensor fascia latae (TFL) muscles, identify and protect the lateral femoral cutaneous nerve, identify plane (with fat stripe) beginning with hemostat or dissecting scissors, continue dissection with army-navy or similar right angle retractors, feather external oblique off iliac crest slightly to visualize apophysis, incise the iliac apophysis down the middle with a 15 blade, "pop" off the lateral half of the apophysis and dissect off the outer table, the apophysis on the medial side is left in place unless a pelvic osteotomy is necessary, elevate the periosteum on either side and pack, connect TFL-Sartorius interval to proximal window (exposed ilium), place a retractor along the medial aspect of the AIIS onto the superior pubic ramus, identify the psoas tendon in its groove on the superior pubic ramus, place a right angle (e.g. Diagnosis can be made with hip radiographs to determine the direction of dislocation and CT scan studies to assess for associated injuries. Observation with repeat ultrasound in 1 month, Open reduction, acetabular osteotomy, femoral shortening, and spica casting. Developmental Dysplasia of the Hip (DDH) Pathway, Supracondylar Humerus Fx Closed Reduction and Percutanous Pinning (CRPP), Supracondylar Humerus Fx Open Reduction and Internal Fixation, Tibial Eminence (Spine) Avulsion Fracture ORIF, Open Reduction of Congenital Hip Dislocation, Ponseti Technique in the Treatment of Clubfoot, Operative Treatment for Resistant Clubfoot, describes accepted indications and contraindications for surgical intervention, diagnose and management of early complications, continue one sixth body weight partial weightbearing, recognize deviations from typical postoperative course, document flexion, extension, rotation in both flexion and extension, abduction, and adduction while feeling for SOFT end points, AP and true lateral radiographs of the hip held in 15 to 20 degrees of internal rotation, Modified Dunn to show asphericity of the femoral head, describe complications of surgery including. A 3-year-old male is an unrestrained backseat passenger in a car involved in a head-on collision. . if excessive abduction is required to maintain the reduction), immobilize in 100 of hip flexion and 45 of abduction with neutral rotation for 3 months, wide abduction associated with AVN (aim for < 55 abduction), most commonly used due to decreased risk of injury to the medial femoral circumflex artery, capsulorrhaphy can be performed after reduction, performed between the pectineus and adductor longus and brevis, performed between neurovascular bundle and pectineus, performed superficially between the adductor longus and gracilis, and deep between the adductor brevis and adductor magnus, remove possible anatomic blocks to reduction, iliopsoas contracture, capsular constriction, inverted labrum, pulvinar, hypertrophied ligamentum teres, perform adductor tenotomy if the patient has an unstable safe zone (i.e. A five-year-old boy with cerebral palsy presents to the clinic with a dislocated right hip, what quadrant of the acetabulum is most likely deficient? On physical exam, the patient is unable to kick his right leg and holds his knee in a flexed position. CT or MRI studies are indicated post-reduction to assess for joint congruity and articular injuries. A 6-week-old female infant is referred to your practice for concerns of developmental dysplasia of the hip. With an assistant stabilizing the pelvis, the operator applies traction in line with the femur while flexing the hip up to 90 degrees by holding the patient's knee. Pediatric Pelvis Trauma Radiographic Evaluation, Pediatric Hip Trauma Radiographic Evaluation, Pediatric Knee Trauma Radiographic Evaluation, Pediatric Ankle Trauma Radiographic Evaluation, Distal Humerus Physeal Separation - Pediatric, Proximal Tibia Metaphyseal FX - Pediatric, Chronic Recurrent Multifocal Osteomyelitis (CRMO), Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy), Anterolateral Bowing & Congenital Pseudoarthrosis of Tibia, Clubfoot (congenital talipes equinovarus), Flexible Pes Planovalgus (Flexible Flatfoot), Congenital Hallux Varus (Atavistic Great Toe), Cerebral Palsy - Upper Extremity Disorders, Myelodysplasia (myelomeningocele, spinal bifida), Dysplasia Epiphysealis Hemimelica (Trevor's Disease). A delay in achieving a concentric reduction has been shown to increase the risk of, Recurrent post-traumatic dislocation of the hip. Figure A is the current ultrasound of her left hip. most common orthopaedic disorder in newborns, due to cultural traditions such as swaddling with hips together in extension, due to the most common intrauterine position being left occiput anterior (left hip is adducted against the mother's lumbrosacral spine), due to unstretched uterus and tight abdominal structures compressing the uterus, due to increased ligamentous laxity that transiently exists as the result of circulating maternal hormones and the estrogens produced by the fetal uterus, more commonly seen in female children, firstborn children, and pregnancies complicated by oligohydramnios, higher risk of DDH with frank/single breech position compared to footling breech position, DDH encompasses a spectrum of disease that includes, displacement of the joint with some contact remaining between the articular surfaces, complete displacement of the joint with no contact between the original articular surfaces, dislocated in utero and irreducible on neonatal exam, associated with neuromuscular conditions and genetic disorders, commonly seen with arthrogryposis, myelomeningocele, Larsen's syndrome, Ehlers-Danlos, mechanically stable and reduced but dysplastic, initial instability thought to be caused by maternal and fetal laxity, genetic laxity, and intrauterine and postnatal malpositioning, typical deficiency is anterior or anterolateral acetabulum, in spastic cerebral palsy, acetabular deficiency is posterosuperior, dysplasia leads to subluxation and gradual dislocation, repetitive subluxation of the femoral head leads to the formation of a ridge of thickened articular cartilage called the, development of secondary barriers to reduction, transverse acetabular ligament hypertrophies, hip capsule and iliopsoas form hourgass configuration, increased obliquity and decreased concavity of the acetabular roof, associated with "packaging" deformities which include, conditions characterized by increased amounts of type III collagen, Can be classified as a spectrum of disease involvement (phases), Ortolani-positive early when reducible; Ortolani-negative late when irreducible, mainstay of physical diagnosis is palpable hip subluxation/dislocation on exam, apparent limb length discrepancy due to a, femur appears shortened on dislocated side, Barlow and Ortolani are rarely positive after 3 months of age because of soft-tissue contractures that form around the hip, most sensitive test once contractures have begun to occur, occurs as laxity resolves and stiffness begins to occur, decreased symmetrically in bilateral dislocations, line from the long finger placed over the greater trochanter and the index finger over the ASIS should point to the umbilicus, if the hip is dislocated, the line will point halfway between the umbilicus and pubis, in response to hip contractures resulting from bilateral dislocations in a child of walking age, attempt to compensate for the relative shortening of the affected side, becomes primary imaging modality at 4-6 mo, horizontal line through the right and left triradiate cartilage, line perpendicular to Hilgenreiner's line through a point at the lateral margin of the acetabulum, arc along the inferior border of the femoral neck and the superior margin of the obturator foramen, delayed ossification of the femoral head is seen in cases of dislocation, acetabular teardrop not typically present prior to hip reduction for chronic dislocations since birth, development of teardrop after reduction is thought to be a good prognostic sign for hip function, angle formed by Hilgenreiner's line and a line from a point on the lateral triradiate cartilage to a point on lateral margin of acetabulum, should be < 25 in patients older than 6 months, angle formed by Perkin's line and a line from the center of the femoral head to the lateral edge of the acetabulum, primary imaging modality from birth to 4 months, may produce spurious results if performed before 4-6 weeks of age, risk factors (family history or breech presentation), AAP recommends an US study at 6 weeks in patients who are considered high risk (family history or breech presentation) despite normal exam, most studies show it is not cost effective for routine screening, evaluates for acetabular dysplasia and/or the presence of a hip dislocation, allows view of bony acetabular anatomy, femoral head, labrum, ligamentum teres, hip capsule, normal ultrasound in patients with soft-tissue clicks will have normal acetabular development, angle created by lines along the bony acetabulum and the ilium, angle created by lines along the labrum and the ilium, femoral head is normally bisected by a line drawn down from the ilium, used to confirm reduction after closed reduction under anesthesia, help identify possible blocks to reduction, labrum enhances the depth of the acetabulum by 20% to 50% and contributesto the growth of the acetabular rim, in the older infant with DDH, the labrum may be inverted and may mechanically block concentric reduction of the hip, represents a pathologic response of the acetabulum to abnormal pressures caused by superior migration of the femoral head, located at the caudal perimeter of the acetabulum, in persistent hip dislocation, becomes contracted and can act as a block to reduction, fibrofatty tissue within the acetabulum that can act as a block to reduction, spontaneously regresses after the hip is reduced, acts as minor source of blood supply to femoral head, in persistent hip dislocation, it lengthens and hypertrophies and can act as a block to reduction, increasingly used to evaluate reduction of hip after closed reduction and spica casting in order to minimize radiation compared to CT, successful screening requires repetitive screening until walking age, ultrasound screening of all infants occurs in many countries; however, it has not been proven to be cost-effective, USA recommendation is to perform ultrasound at 4-6 weeks in patients with, also utilized to follow Pavlik treatment or for equivocal exams, contraindicated in teratologic hip dislocations and patients with spina bifida or spasticity, requires normal muscle function for successful outcomes, > 2 years old with residual hip dysplasia, anatomic changes on femoral side (e.g., femoral anteversion, coxa valga), after 4 years old, pelvic osteotomies are utilized, severe dysplasia accompanied by significant radiographic changes on the acetabular side (increased acetabular index), used more commonly in older children (> 4 yr), decreased potential for acetabular remodeling as child ages, risk, complexity, and complications are increased with delays in diagnosis, anterior straps flex the hips to 90-100 flexion and prevent extension, posterior straps prevent adduction of the hips, confirm position with ultrasound or radiograph and monitor every 4-6 weeks, worn for 23 hours/day for at least 6 weeks or until hip is stable, wean out of harness over 6-8 weeks after hip has stabilized until normal anatomy develops, discontinue if hip is not reduced by 3-4 weeks to prevent Pavlik disease, due to impingement of the posterosuperior retinacular branch of the medial femoral circumflex artery, prevent via placement of abduction within safe zone, zone located between the angle of maximal passive hip abduction and the angle of hip adduction at which the femoral head displaces from the acetabulum when the hips are in 90 of flexion, erosion of the pelvis superior to the acetabulum and prevention of the development of the posterior wall of the acetabulum due to prolonged positioning of dislocated hip in flexion and abduction, important to discontinue the harness if the hip is not reduced by 3-4 weeks, dependent upon age at initiation of treatment and time spent in the harness, abandon Pavlik harness treatment if not successful after 3-4 weeks, If Pavlik harness fails, consider converting to semi-rigid abduction brace with weekly ultrasounds for an addition 3-4 weeks before considering further intervention, reduce using the Ortolani maneuver (hip flexion and abduction while elevating the greater trochanter), must obtain concentric reduction with < 5mm of contrast pooling medial to femoral head and no interposition of the limbus, medial dye pool > 7mm associated with poor outcomes and AVN, perform if the patient has an unstable safe zone (i.e. (OBQ18.193) Which of the following is the most likely responsible for these findings? Pediatric surgical hip dislocation and many more surgical approaches described step by step with text and illustrations. Reduction of native hip should occur within 6hr due to high risk of avascular necrosis Hip prosthetic dislocation is more common and less emergent High-energy trauma is primary mechanism for native hip dislocation Dashboard impact, fall from height, sports injury Low-energy trauma can cause hip prosthetic dislocation The proximal femoral physis and greater trochanteric apophysis develop from different cartilaginous physes, The proximal femoral physis grows at a rate of 9 mm per year, Normal infant femoral anteversion is between 10-20 degrees, The ossific nucleus of the proximal femur is visible on radiographs by 6 months of age in most children, Slipped capital femoral epiphysis (SCFE) typically occurs through the zone of proliferation. Which of the following is accurate regarding this clinical pathology? (SBQ13PE.34) Anterior hip dislocations are usually the result of a significant force, such as trauma, or from a poorly positioned total hip arthroplasty. describe key steps of the operation verbally to attending prior to beginning of case. rotator cuff tear. All patients should get at least a CT to evaluate for femoral head fractures, intra-articular loose bodies/incarcerated fragments, acetabular fractures. Which of the following structures (1 through 5) represents the labrum? The left hip makes a palpable clunk when moved from adduction to wide abduction. Such dislocations frequently occur when patients fall and suddenly grasp an object above their heads, causing hyperabduction. Congenital. An abduction internal rotation view shows an incongruous joint. In the first manuver, keeping the leg straight, flex the hip up to 90 degrees, looking for pain in the posterior/buttocks region. According to Colonna's description of Delbet's classification traumatic paediatric hip injuries were classi-fied into type I: transepiphyseal separations with or without dislocation of the femoral head from the acetab- 0000019713 00000 n Target Content: Only Orthobullets "Tested" articles count as target content. A 3-month-old infant is brought in for a routine well-child evaluation. You dislocate your hip again. Dislocated Artificial Hip Reduction 319,085 views Nov 4, 2012 1.8K Dislike Share Save Larry Mellick 581K subscribers The reduction technique for a dislocated hip is demonstrated in this. Copyright 2022 Lineage Medical, Inc. All rights reserved. The majority of all hip dislocations are due to motor vehicle accidents. An injury radiograph is seen in Figure A. . Traumatic Hip Dislocations in the pediatric population areusually posteriorand may occur due to low energy sports injuries in children less than 10 years of age and high energy trauma in children greater than 10. Congenital hip dislocation is now considered part of the spectrum of developmental dysplasia of the hip (see this article for further information) 4. What is the most appropriate treatment option? Treatment varies from Pavlik bracing to surgical reduction and osteotomies depending on the age of the patient, underlying etiology, and the severity of dysplasia. Which of the following concepts regarding pediatric hips is true? Hip and Pelvis Conditions Surgical Hip Dislocation Open Reduction of Congenital Hip Dislocation VDRO of Proximal Femur Periacetabular Osteotomy Dega Osteotomy Percutaneous Pinning of SCFE Leg Conditions Pediatric Foot Cavus Deformities Planus Deformity Pediatric Syndromes Cerebral Palsy IOEN Vail Arthroplasty Course Jan 12 - Jan 15, 2023 Vail, CO Diagnosis is made with plain radiographs of the hip joint. A 10-year-old boy sustained an isolated injury shown in Figure A. Immediate closed reduction was performed in the emergency room with conscious sedation. (OBQ11.249) . Traumatic Hip Dislocation - Pediatric . Patients. Treatment is urgent reduction to minimize risk of avascular necrosis followed by CT scan to assess for associated injuries that may require surgical treatment (loose bodies, femoral head fractures, acetabular fractures). 682 talking about this. These injuries are true orthopedic emergencies and should be reduced expediently. Hip dislocations are traumatic hip injuries that result in femoral head dislocation from the acetabular socket. Hip revision surgery is a major undertaking, and for that reason it is unusual to perform revision for a single dislocation episode (unless there is a fracture, hardware loosening or stem pullout, or the dislocation happens soon after the index surgery and there is gross component malpositioning). Hip dislocation is a relatively rare entity and may be congenital or acquired. (OBQ13.80) summary. Treatment is urgent reduction to minimize risk of avascular necrosis followed by CT scan to assess for associated injuries that may require surgical treatment (loose bodies, femoral head fractures . Anatomy She has a history of a normal spontaneous vaginal delivery and is otherwise healthy. Can be shifted inferiorly (extension > flexion) or superiorly (flexion > extension) Posterior Dislocation (90%) Full-time Pavlik followed by ultrasound in Pavlik in 7-10 days, Night-time Pavlik followed by ultrasound in Pavlik in 7-10 days, Full-time Pavlik followed by ultrasound out of Pavlik in 7-10 days, Night-time Pavlik followed by ultrasound out of Pavlik in 7-10 days. You find her knees to be at different levels with the hips flexed to 90 degrees and adducted. Osteonecrosis of the femoral head may be caused by traumatic hip dislocation, occurring secondary to acute interruption of the femoral head's vascular supply from the ligamentum teres and retinaculum. posterior dislocation (90%) occur with axial load on femur, typically with hip flexed and adducted axial load through flexed knee (dashboard injury) position of hip determines associated acetabular injury increasing flexion and adduction favors simple dislocation associated with osteonecrosis posterior wall acetabular fracture. What is the next step? 2-4% of shoulder dislocations are posterior. Five hip dislocations were diagnosed before 10 months of age, and nonoperative treatment (closed reduction) resulted in successful reduction and maintenance. Tha dislocation orthobullets. Posterior hip dislocations are the most common type, with anterior occurring only about 10% of the time. Treatment is usually closed reduction followed by brief immobilization. Allis has described the most commonly used technique for the reduction of posterior hip dislocation. However, no rating system can reliably predict the patient's outcome and prognosis based on the initial presentation and classification. It usually occurs from a significant traumatic injury. . Hip dislocation is the second most common complication of hip joint replacements and occurs in ~5% (range 0.5-10%) of patients with ~60% of dislocations being recurrent 5. What is next best step? She has no pain with adduction of the hip. (Artificial hip replacements are somewhat easier to dislocate.) Which of the following figures shows Perkin's line? Hip and Pelvis Conditions Surgical Hip Dislocation Open Reduction of Congenital Hip Dislocation VDRO of Proximal Femur Periacetabular Osteotomy Dega Osteotomy Percutaneous Pinning of SCFE Leg Conditions Pediatric Foot Cavus Deformities Planus Deformity Pediatric Syndromes Cerebral Palsy 29th Annual Tampa Shoulder Course: Arthroplasty & Sports Final reduction is achieved by extension of the hip. You cannot walk well with your cane or crutches. Between 2017 and 2019, nine cases of Pipkin fractures came to the Emergency Department at the Trauma Center of our Hospital in Rome. (OBQ11.187) The commonly used classification systems of hip dislocation are based on the direction of the dislocation and the presence of associated lesions. shoulder dislocations constitute approximately half of all joint dislocations. (SAE07PE.68) (OBQ04.175) Pavlik harness treatment is initiated. Treatment varies from Pavlik bracing to surgical reduction and osteotomies depending on the age of the patient and degree of dysplasia. Exam: Adduction and Internal Rotation Test Technique Compare both sides Reach behind back as if to scratch low back and reach for opposite Scapula Measure to which Vertebra e thumb can reach From this position can also test subscapularis Muscle Strength See Lift-Off Subscapularis Test . < 1% of shoulder dislocations are inferior. Figure A is an AP radiograph of the pelvis during the visit. Closure of the capsule. Treatment is urgent closed reduction under general anesthesia or sedation. The year 2020 was excluded from the time interval, due to a progressive reduction of the emergency activities not COVID-19-related in our Hospital [].All fractures were caused by high-energy traffic accidents resulting in posterior hip dislocation. Central dislocations: Relatively rare 6. (OBQ11.235) 16 large series documented 804 dislocations in 4 Most pub-lished studies are from high-volume medical centers, yet most hip re-placements are done by surgeons. What acetabular procedure for developmental dysplasia of the hip does not require a concentric reduction of the femoral head in the acetabulum? Continued observation with routine follow-up, Left varus derotational osteotomy with shortening, continued observation of right hip, Repeat closed reduction with spica casting. Open reduction may be required if there is an intraarticular fragment following reduction. 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