1. Pediatric Dysplastic Hip Dislocation James Saunders September 2013 Dr. Cameron and Dr. Lewis

2. Brief clinical history and physical exam Infant delivered on 09/13/13 by c-section. APGARS 1 & 8. Initial heart rate below 100, not breathing spontaneously, provided positive pressure ventilation & CPAP with immediate improvement. Lumbosacral myelomeningocele noted on exam, head with bulging anterior fontanel, sutures split, + frontal bossing and mild trigoncephaly appearance to forehead, later confirmed Chiari type II malformation with head ultrasound while in NICU Received operative repair of mylomeningiocele with ventriculoperitoneal shunt placement for noted hydrocephalus Follow-up physical exam revealed when hips held in flexed position, no movement of LE, hip dysplasia noted on babygram… Expectations 2

9. Alpha Angle: Angle formed by the acetabular roof to the vertical cortex of the ilium. Normal value > 60degrees. Beta Angle: Angle formed between vertical cortex of ilium and triangular labral fibrocartilage (echogenic triangle). Normal <77degrees, (Only useful in assessing immature hips when combined with alpha angle) Bony coverage Percentage of femoral epiphysis covered by acetabular roof. Normal >58%.

10. Alpha Angle: > 60degrees. Beta Angle: <77degrees, Bony coverage Normal >58%.

11. Alpha Angle: > 60degrees. Beta Angle: <77degrees, Bony coverage Normal >58%.

13. Alpha angle for left hip joint; approximately 53-55 degrees. Bilateral hip dislocation, Moderately dysplastic acetabula bilaterally. Both hips are dislocated as both femoral heads are displaced superiorly, laterally, and posteriorly with respect to their acetabulum. Both acetabula are moderately dysplastic.

16. Risk Factors for DDH Risk factors include girl born in breech position, M:F ratio 1:8, Ehler’s Danlos, Down Syndrome, Macrosomia, Diabetic Mother, Myleomengiocele, for some reason more common on left than right. 1.5-20 per 1,000 births. Expectations 16

17. Risk Factors for DDH Risk factors include girl born in breech position, M:F ratio 1:8, Ehler’s Danlos, Down Syndrome, Macrosomia, Diabetic Mother, Myleomengiocele, for some reason more common on left than right. 1.5-20 per 1,000 births. Diagnosis Ultrasound is widely used to confirm the diagnosis of DDH and is used to assess the morphology and stability of the hip. It is a useful adjunct until 3 to 5 months of age X-rays are indicated and more valuable in older infants (>6 months old) and children due to the presence of a greater amount of ossification Additionally ensure to look for dysplasia as well as dislocations Expectations 17

18. AP radiograph in neutral position If newborn, hips should be placed at 20-30° Diagnosis made via Hilgeureiner’s (H; horizontal) & Perkin’s (P; vertical) drawn and proximal femoral epiphysis is seen to have lateral or proximal displacement, Acetabular index (theta) >30 degrees, abnormal acetabular development is probable

19. Acetabular angle: Formed by intersection b/w line drawn tangential to the acetabular roof and Hilgenreiner's line, forming an acute angle. Should be approximately 30 degrees at birth and progressively reduce with maturation of the joint.

23. Treatment & clinical outcome Expectations 23 Pavlik harness - usually for younger patients (< 6 months of age) Closed reduction - usually for older patients Open reduction - much older patient or if closed reduction not successful Follow-up until the age of 4years old

24. References Niknejad, MT, and Frank Gaillard. "Developmental Dysplasia of the Hip." Radiopaedia Blog RSS. Radiopeadia, n.d. Web. 26 Sept. 2013. Beaty James, “Chapter 27 – Congenital and Developmental Anomalies of the Hip and Pelvis” (Chapter). Canale & Beaty: Campbell’s Operative Orthopaedics, 11th e: Lehmann HP, Hinton R, Morello P, et al: Developmental dysplasia of the hip practice guideline: technical report. Committee on Quality Improvement and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics 2000; 105:E57 Medline Plus, “Developmental Dysplasia of the Hip”. http://www.nlm.nih.gov/medlineplus/ency/article/000971.htm "A Patient's Guide to Developmental Dysplasia of the Hip in Children." A Patient's Guide to Developmental Dysplasia of the Hip in Children. Ortho Peadiatrics, n.d. Web. 26 Sept. 2013. "Ultrasound of Peadatric Hips; Normal Neonatal Hips How to." Ultrasoundpeadia. N.p., n.d. Web. 26 Sept. 2013. "Radiology Rounds - April 2004 - Screening for Developmental Hip Dysplasia." Radiology Rounds - April 2004 - Screening for Developmental Hip Dysplasia. N.p., n.d. Web. 26 Sept. 2013. Expectations 24