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Developmental Dysplasia of the Hip (DDH ) for Orthopaedic Exams
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Developmental Dysplasia of the Hip (DDH ) for Orthopaedic Exams
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Language: EN.
Segment:0 .
Today I speak about DDH. My name is Dr Ahmady El-Gendy, I passed the FRCS last June 2020.
What are the objectives on the picture today? The definition, the risk factors for what, how the patient is presented by what is our diagnosis, how we can treat the patient and what are the complications? Overview the issue is this abnormal development resulting in dysplasia, subluxation and the dislocation of the hip. Treatment vary from public dressing to surgical reduction and totally depending on the age of the patient and the degree of disability.
Well, what they issue is varying from. Dysplasia, which is shallow, underdeveloped as far as you can see here, if we measure the cellular index in this side, look like the stubble index on this side, and that will speak about subluxation when there is displacement of the joint as there is some contact between the sexes, as we can see here. This side is not decide this election, but there is some contact between there and the slap and dislocations when there is complete displacement of the joint was no contact between the original.
What about the tragically hip? There is dislocation in neutral and the radius of the examination is present with a pseudo sternum. It's associated neuromuscular conditions and the genetic disorders, and it's the most common thing in both patients. And this is why this is important, because in this patient you are not using is above powerful economist.
This patient has to be done by close the reduction or production. I will speak about it. So what is the actual shortage in the comment section? This is why it's more common in women because women are more common have become more and more than males. Pre-natal positioning it's occurring in the Twins and the baby with the presentation and in the primary gravity.
Because this tightens, abdominal muscles and pelvis is moving in infant of muscle because this. And they have the big size baby postnatal postnatal positioning. It's common in babies to ask for an extension position more than a patient with a suction position. Also common due to hormonal and genetic elements. So what is the demographic? It's more common in female 6 to 1 and the common intimate because of two reasons.
Number one, because of the sex, as we said. Number two, because in during the pregnancy and early delivery, the maternal hormones like progesterone and relaxin crossing to the baby and this hormone leading to less in the female because you have many receptors more than the males. And it's more common in native americans, as we said, because they have are swaddling the baby an extension position, as we can see here.
But rarely seen in African-Americans because he just wanted the baby, the abduction position like this. So the hippies abducted, it's inside developments, as we can see here. What is instance the most common of a newborn dysplasia 1 to 100 and dislocation 1 to 1000? What is the most common injury?
And this is why, because if the patient is not breathing the same patient, the most common breast presentation is left occipital anterior. So the left hip of the patient, the baby is attacked against the lumbar spine. The curve of the curve is push the baby the hip of the baby in the left side, so it's due to the most common position left to continue. As we said, the red tape is abducted against the mother by.
It's bilateral in 20% What is the risk factor? As we said, it's first born baby due to strategic abdominal structures most common in females, as we said, due to the maternal hormones and the family history. If if we have one patient that has a first degree relative, the risk is 20% more. But if this patient has identical twins, the risk is 36 percent, which if you have to remember to think in the exam, you have to remember family, family history and the average.
We have three types of rich presentation we have Frank Frank rich, and we have complete rich and you have a rich. The most common deed, which is occurring with the Franklin bridge, as we can see here in this one. And as we said, because it is quite a permanent structures and there is no space for the baby to move. So did it also associated with packaging, is this why you have to take this into clinical care?
You have to say I will search for congenital muscular goodness, 20% of the patients I would search for persons of doctors, it's 10% of the patient that we can see here. And I have to see for congenital knee dislocation, as we can see here. What is what's happening for the patient? As we can see here in this diagram, this is the head, and this is the first is head is trying to suplex outside the. So the nimbus, as we can see here, it's inverted, mostly inverted and the capsule become redundant and this moves.
And here we can see the ligament tears become higher. But to fight and elongated, now the head is subluxation. Outside the head to the Olympus, become the labrum, become inverted and the slap lesion become filled with fiber nerve tissue. More than this, it's become more hypertrophic and deliberately become more inverted, and the transfers are stopped. This is a short of that standard.
This one, you have to open it during doing orbital reduction. We speak about it. And the last thing is the most important thing is aerial surveys, the aerial surveys is doing construction in the capsule. As you can see here, it's doing like our appearance and some say it's a Chinese little appearance. It seems same meaning. So what are the structures looking in the reduction?
This is very, very common question. Never a case of the will not be asked about it, as we can see here, just to diagram, you can classify it easily into Kessler Kessler tickler and the orchestra Doctor Lucas and the hélio source. You have to see the longest is tight, the resources are stretched, why the resources are stretched because the stretch of resources coming from the migration of the head down, but the heat is not going, so step up to the resources contraction.
Small size. As we can see here is the Olympus inverted fiber to fight the terrorists and the tissue and the transversal versus the inverted and the Olympus bronze versus ligament, the hip capsule is constructed as with hourglass appearance by the source and the bone tissue and also the ligament on. It is secondary anatomical changes if the patient is missed, the dislocation that neglected kids or kids coming after one year, as you can see here and just.
You can see the risk increase in the femoral activation and there is some flattening of that. There is increased level of introversion and increased obesity and decrease connectivity of the roof because the head is not inside. So the head is not indented in intending that. And also the recycling of the media because the head is not inside site, it is still outside to the ceiling of the media and all of that stuff ducking the heat inside.
And this is the typical deficiencies, antero-supero-lateral slap lesion, the deficiency in the supplements, interior and collateral. But it is best to exhibit the deficiency as opposed to the superior actually in CB. The deficiency is multi global in more than one direction, but the most common industry which is supposed to be superior position.
This is why, because there is tightness in the anterior muscles. So like posterior dislocation of the shoulder tightness in the anterior muscle leading to push the head posterior same as here in the city. Physical examination. Now coming to clinic, what you would do if the patient is less than 3 months, what is the most common complaint of issues like smart mother and intelligent mother?
She will tell you that I am taking sensation when I'm changing the diaper observation of the baby. All she can tell you that there is limitation, limitations, abduction. I'm changing diapers. There's one side opening this other side. And if she's more smart, more intelligent, she will tell you that there is an equal in the skin crease bilateral.
So there is asymmetry in the skin piece. So what you will do, you put the patient in comfortable position and you trying to do the battle on. Which one you are starting by? Then you start by, then you are trying to reduce the complexity. Don't try to push the head into subluxation position. Then you try to reduce it again. So you try to learn, starting by trying to feel that it's a feeling, not sensing.
You're not listening because you are feeling exactly so you are now starting by then you have to hold the baby. So I like this to some inside the picture's outside and you are trying to pushing, push it from doing abduction and by the little two fingers. You are, you are feeling is activity and you are trying to inside to stop the. As we can see here, this is the hit is abducted and the head is abducted, reduced again.
And then you do support egawa test. As we can see here, the aid is inside, it's outside, it's opposite to or to lend you to pollute abduction and trying to push inside. And this is important information, the latest are really boosted after three months. Why? because there is so much construction, so you cannot do battle until after three months.
3 to three months to 1 year, what we can see in the patient examination. Of course, there is the mutation in the hip abduction, as you can see here, this side in comparison to this side. This is Gary assisted. And it's important test. It's measuring the discrepancy. And this is as we can see here, this is a test how we can do both those saw patients together, and you can feel here there is one who is higher than us.
And this is called Zagros. And this is apparently just not true discrepancy in the lens. But it's apparent it means that if you measure the whole of the lower limb, it's identical to each other. And also, as we can see here, there is inequality, equality in the skin, asymmetry in the skin here in the fountain, here in the. What about this?
Do you think that if the patient is bilateral dislocation, how you can diagnose it because this patient will have it, has limitation and abduction bilaterally and has an equal increased bilateral? So how you can diagnose you do that, how we can do this, test you are putting your middle finger on the GTE. You are putting your index finger on the Soyuz antero-supero-lateral spine and you take one line in between.
This line has to be directed towards us. As you can see here, but if this patient has this location, this line is bluesbreakers and you compare to those outside. More than one year, the case the patient has been collecting, the patient has no locus, as we can see here, and there has to be walking. This is very, very, very common in this very common clinical scenario. And I remember one of the mentors and one of the examiners in the exam they are asking, is a patient coming to you one year old?
And he has unilateral tiptoeing. What is the most common differential diagnosis is Indian and then the examiner, and that's very characteristic mouthwash. I remember. I forget his name, but this is his question. He's asking every, every exam you have to say for him, it's age. And also, we have printed embedded egawa test and.
What's the difference between the test and the calendar and the test? If you are standing on the side, the pelvis is stable and it's liquid because this abductor is intact. But if to stand on the affected side? The pelvis is throbbing. This is called the lindenberg test. If the body lean toward the side. So this is a patient.
Walking goes by lateral. So now how we can do investigation for. First, we have to do ultrasound. But when you will do ultrasound, it's a force 4 to six weeks after delivery. Why? because the maternal hormones, as we say, progesterone and relaxin are declining in the plasma, in the baby after 4 to six weeks.
So if you do before, you can have a false idea about this, and the ultrasound is a primary imaging modality, an examination of the lesion in the. You are you do ultrasound until the appearance of the Civic Center at the age of 4 to six months. How we can do the ultrasound. You put the patient in the letter of the cubicles position and put ultrasound. How you can measure.
Just what you can see from the ultrasound. You can see this is the atrium. And this is a doctor. OK this is the problem. And this is a corporation. So you are now flipping this image like this. If you would this image like this, it would appear like the one that would be it. And you are measuring is alpha angle.
What is the alpha angle and the alpha angle, how you can measure it? You have to draw this three lines. You have to draw the line. And this line is parallel to the outer border of the area, as we can see here. Then you write, you draw the roof line, this line is rebuttal of contention to the bullet as a problem as we can see if it was a slow.
Then you drew the initial line, it's a tangential to the corporation, as you can see here. You measure the alpha angle and you measure the angle. You have to remember that the alpha angle is more than zero. If it is, then six zero. It means the patient has subluxation. So what is alpha and kidney means? There is a more amount of z inside the structure. We have two screening program, the universal screening program and the selective screening program.
So this is advanced. A bunch of everyone with universal screening means that any baby of three you do ultrasound selective screening, you are doing the screening only for the high risk patients. As we said, first presentation female both through breech presentation. In your case, you are depending on the selected view, not ultrasound screening.
Why? because it's most cost effective because you are going for every case, you are going for the case and it prevents overtreatment. But there is this advantage because it may lead to this presentation of the patient and most cases, or in some cases, you don't have any risk factor. So you can the patient can be compelling presentation or no family history and has.
The town you have, we have two classification for this one, for the ultrasound. And in this question, we have the great classification, the static classification according to the measurement of the alpha angle. If it's more than six degrees or between 34 and 60, this type to listen for non measurable is five, four, five, 3 and 5 for dislocated by this need close to production.
You can try both corners and type, but type 1 is only observation five. Two you have to move the patient and public colleagues for need close the production. So graph is a static alpha and beta angle measurement. Only key is for dynamic modification as you are doing, like test with ultrasound and to measure how much of the head subluxation. If more than 7 is considered abnormal, 4 to 6 is considered normal.
Now, the patient is 4 to six months. What you will do, you will do X-ray to see the Civic Center. First thing you will see you will see an equality in the Civic Center on this side to this side. So delaying in the appearance of the civic center, all of us knows the health, the limelight and the medical line. You have to draw this lines and you have to measure the index's most important thing because as no index, this is the one you will follow the patient for.
Of course, the symptom as you also. Treatment, the aim of the treatment or the principle is the treatment. You want this sentence? The principle of treatment is talking, isn't it? It's very, very good. Sentence if you set good marks talking, that means that you have concentric reduction and you have to have maintain stability.
It's not only you are putting the inside of stuff. This has to be concentric reduction, stable reduction. Number two, they have to promote. You have to promote the growth and development of say, you have to minimize the complication, not only reducing it, but reducing the head in a stable position without complication to have normal growth and development. This is simplest the algorithm for management to many, many algorithms.
If you search in papers and books, many algorithms. But this is the simplest way from 0 to 6 months, you put the patient on public forums six weeks to no reduction. You go to close the reduction. Six to eight months, you are doing post-production and it is vital. You you do also. Yes, you are so grown.
If no production, you have to do a production from 18 months to 36 months, you have to do all the production. Some say you can try close the production, but the incident is later on. The reduction is part. From three years to eight years, you have to do a production with shortening and. How you can decide how if you want to do a star system or know if one, then more than one third of that is visible.
So you have to do political scrutiny. I will speak about it. So you need this age based guidelines for treatment to be the age of the columnist for six weeks, 1 to six months, you put the patient on public forums for six weeks, six months to 18 months. You treat the patient with structure and close the reduction. This is debatable, and I will speak also about it from 18 to 12 to 24 months, which is the ratio of the reduction for to primary reduction.
From 24 months to six years, you do a primary introduction through an approach. Maybe the patient may need people are shortening with our tuberosity. Now the management. The most important thing now is that public morals and the most important and calmness.
It's a dynamic sprint. We are voting for the patient within six months. It's contraindicated. It's a patient, as we said, ahead or the patient has. Why? because this patient has no muscle to control the head inside. So this dynamic splint would not give any value for the patient. The most important thing, how you can put this public on this first step, this one at the Naval line or the Naval line, then the most important thing is the next step this one, it's a slap.
This a slap is the most important thing is doing deflection 90 to 100 degree, not more than 100 degree. Why? if you put more than 100 degree friction, this patient will have concerns. Now the bas status slap or actionscript this trap you are putting for the mission you are not fighting.
That is, if you try to thread, the patient will have public partners, and even the abduction of slap is the main idea of it is to prevent is to control the operation only, and the Bishop has to get more money to the. You have to after putting information on the public forums for the patient ultrasound. Within one week or two weeks after putting the public economist and they confirm the position and the full observation for 4 to six weeks.
Winning of the public, you put public gardens for 23 hours per day as more, or it's all the basis because the patient is a human being. We need to become watching the change, a diaper and. And you put it for at least six weeks, and some also say that you have to lose at opportunity for months at least. Winning is above economists at 6 to 8 weeks, we are moving up in the economy, but only at my time for the nap time observation.
If you put to public forums and it is not inside and do the ultrasound, the alpha angle is not increasing or it's less than six degrees 50 or 50. So you have to discontinue some of the calls. And the motivation in the abduction is for three weeks. What is the complication specific to the bubble economy? Why? because in terms of the civilian bench of the media people conflicts. It seems extreme abduction, as we said, if you tighten the threat of abduction more than six degree, the patient will have.
So you have to put up solar farms and you will speak about safe zones, and as we said, it was fiber connection. If you do help friction more than 100 degree, 100 degrees, so the ulnar nerve is obstructed between the interior strap and the ZBB napkin. So it's become compressed. How we can lose this one, it is in scripture. It will tell you that the vision is in Pavlik Harness for one week now, and he cannot kick, so this patient has been ulnar nerve claw palsy what you will do, you have to discontinue to remove it immediately.
And the most important thing, this popular cartoon is disease. If we put the patient in a position of dislocation, as we said, this patient to have the problem will become eroded and we have deficiency in the post-treatment world. This is why you have to discontinue the public if more than three to four weeks and the hate is not reduced. Close production, despite the costing, we do this for six to 18 months.
And the observation of powerful economists, there is three possible outcomes for this patient. You put the patient in trying too close to the law was also, of course, you have three. Possibly the first possibility is that the hip is reduced well and stable through a good range of motion. What you will do, you will treat a patient. And it will spike up for six weeks.
Then you change it to another speaker for more than six weeks. But if the irreducible due to destruction have to do with the reduction. Third option, the hip is reduced, but it needs to become stable in extreme position. What you will do, you have to increase the save from how you can do this, I will tell you. There is two controversy here.
And controversial issues and be the. In trying to close the first one. You have to do traction or no traction if you are doing close to production. He said that some also said that if you do traction the incident, the incidence of decreasing and the need of reduction to decrease. Number two. It's the timing of the reduction.
You do close the production with appearances of selection, but also its appearance of the selection. That's also said. And this is the most important $2 billion of them. You shouldn't do it to treat the hip until the new clause appeared. The growth potential of the slap lesion decrease with age. So we have to reduce it as soon as possible because if you didn't catch it this period in the first six months, the growth of the problem would be.
So some also recommended close the reduction of dislocated hips shouldn't be performed until the appearance of the civic center, as we said. And there is some work lexicon and the both of them said that if you wait for the appearance of the simple, the incidence of what's going on controversy and police said that no, no need for waiting for the appearance of the Civic Center.
Now, the closer the reduction of the hippest biker you do under general anesthesia, it's supposed to be two of us. The technique we took was the reduction in maneuver. You do ulnar claw. It also is important because it has to confirm the reduction. You can do the reduction without also drop. But let me be flexible. So it's a flexible period and you do after this, you have to get the patient inside the authority.
And in the long run this weekend, you must concentrate production with some millimeter of media to. If the media goal wasn't 7mm, this patient transport outcome and has adverse consequences, for instance. While also, globe is important because it helps you to identify the anatomical looking for. Oh, you can't do this after doing the reduction, you are feeling it out.
And centimeters from the insertion of you get your needle aiming to lateral. And then you are sending inserting is a needle. You will feel a hope that you are inside the capsule. Now you will be restricted to Kessler. You inject saline to inject saline inside. After you injecting saline, you inject your boy and you are trying to put the patient in the range of the motion until you have concentric production.
So as we said, you are injecting axilo paratrooper X-ray screening, then your injectors and then your zip is screened until you have good reduction. Once the hit is reduced, the range of motion of the hip remains reduced, must be. So now we will reduce the. After this, you are trying to know which positions it is dislocated in, so you get the patient abduction to abduction and you check the range of the motion, then you reduce the heat again, then you get sufficient flexion, extension, and the check the range of the motion.
Insufficient need has tightness in the tractor compartment or tightness on the flexion compartment. We have to do our Doctor tenotomy also tenotomy depending on this structure. The idea of this to increase a. It means that the patient will have good range from friction and friction or dislocation. And the good range from abduction to abduction. Our distribution.
It's a hip rotation, you have to also notice. The idea of all this is to immobilize the hip, we save zoo without extreme obstruction or friction in order to prevent the complication as we. So the position is 45 degree and abduction and deflection 90 degree with neutral rotation, this is almost the production of spike across. As we said, this is a safe school of the first one. They have rights of safety, as we can see say here, from abduction to abductions.
It is a very big degree in comparison to this one. This is not. Of the reduction, what you will do, you have to do it. What you have to see in cities, it's called selective cuts. We should confirm the deduction if you do see the patient. And the phone, the head is subjected to serious, you have to be patient and try to argue. And after you have you are now.
Sure of the production you can do for the patient changing as opposed to after six weeks. So I'm also not doing city after closed production do for him. From job doing MRI. Why is doing MRI to check the position and to check the muscularis of the head? Because they are afraid that you are doing like forcible production on the effectiveness of a square today?
This is how we come to close the production, as all we know. Open reduction, you are doing more than 18 months, and if there is failure of the reduction. You can do urban reduction is totally if more than two years with the residual desperation, as we said, there is anatomical changes in the air like a virgin flattening of the head and the stomach also is. And it's done in people, children, this and four years old after four years, you have to do political scrutiny.
Because you have this spiritual tape, and as we said, we have to measure the index. More than 40 years, it's indicated, and this decreased potential for remotely. This patient may have later on. What is a complication of organ reduction? As we said, if in why, if you put the patient in extreme obstruction, you didn't respect the policy.
The patient will have died each of us just because you are doing stretching on the circumference, how to prevent, as we said, you have motivation to the same. And as we said, we can do for him, if you source tenotomy or you can also. How you can do open approach through the medial approach or the lateral approach, medial approach, you do less than one year and through a lateral approach at any age, but better after one year.
Advantage of the media approach, you can reach the mechanical blocking to the production easier, and you didn't spirits up offices. But the disadvantage you cannot address the immediate past, you cannot do the most important thing, you cannot do good Kessler. And this is important for treatment or close protection. And there is also risk damage because you are entering the internet, possibly, and you can enjoy the meters are complex.
You can do any information. What is our approach you can address all by looking for the reduction? You can do good cuts and you are away from the complex. But the disadvantage you have to spirits up officers in order to reach the problem and the problem in this patient is very deep. You have to do good. And also, there is risk damage for us as we all.
This is a silly approach for the median reduction. We have one, we have Rudolph and Ferguson, all of them, depending on which nervous you are doing in between. When you are entering between, the victim is the victim. And this is a neurovascular bundle. To me, there's a conflict. Lugosi's is between the US. As our doctor and the doctor believes, and so the doctor inside and outside.
This is the most common of. Friction is between the doctor and the doctor and the doctor. What's the soft tissue blocking the reduction, as we say, the soft tissue blocking the reduction you have to do, you have to release all this structure and they have to remove the looking for the reduction. And as we have, we have how you can increase the same sort of post-operative you immobilize.
The patient was 15 degree of friction, 15 degree neutral rotation. With the aim of political system is to increase antero-supero-lateral coverage. It's increasing. That will increase the index. As we said, coverage is moving by the degree of tabloid coverage of the funeral. How much of that covering is ahead?
After you put the patient in extinction at a neutral location, if more than one third of that is visible in the position, you have to do some type of. OK peel-back, the last three photos, we have only one minute remaining staff are sorry for that in two minutes. It's only one want because it's a program. OK osteotomy.
We have two types of. We have the salvage osteotomy, where we have the reconstructed salvage you certainly are doing. For the patient who has no consent reproduction. You cannot do consent reproduction for him. So you do all or. Carrie, it's me. Idealizing goes tenotomy or capsule interposition as tenotomy or liberal support.
All these are names. We depend on doing so. Kessler osteotomy puts it in the roof of the idealizing every single time. And the reconstruction of reconstruction you are. You can classify the reconstruction into the reshaping and reorientation. Reshaping you are doing is like reshaping the ship by Pemberton osteotomy or Italy re-orientation.
You are trying to reel you in disaster like osteotomy the hinge on the subscapularis.
Segment:0 .
Today I speak about DDH. My name is Dr Ahmady El-Gendy, I passed the FRCS last June 2020.
What are the objectives on the picture today? The definition, the risk factors for what, how the patient is presented by what is our diagnosis, how we can treat the patient and what are the complications? Overview the issue is this abnormal development resulting in dysplasia, subluxation and the dislocation of the hip. Treatment vary from public dressing to surgical reduction and totally depending on the age of the patient and the degree of disability.
Well, what they issue is varying from. Dysplasia, which is shallow, underdeveloped as far as you can see here, if we measure the cellular index in this side, look like the stubble index on this side, and that will speak about subluxation when there is displacement of the joint as there is some contact between the sexes, as we can see here. This side is not decide this election, but there is some contact between there and the slap and dislocations when there is complete displacement of the joint was no contact between the original.
What about the tragically hip? There is dislocation in neutral and the radius of the examination is present with a pseudo sternum. It's associated neuromuscular conditions and the genetic disorders, and it's the most common thing in both patients. And this is why this is important, because in this patient you are not using is above powerful economist.
This patient has to be done by close the reduction or production. I will speak about it. So what is the actual shortage in the comment section? This is why it's more common in women because women are more common have become more and more than males. Pre-natal positioning it's occurring in the Twins and the baby with the presentation and in the primary gravity.
Because this tightens, abdominal muscles and pelvis is moving in infant of muscle because this. And they have the big size baby postnatal postnatal positioning. It's common in babies to ask for an extension position more than a patient with a suction position. Also common due to hormonal and genetic elements. So what is the demographic? It's more common in female 6 to 1 and the common intimate because of two reasons.
Number one, because of the sex, as we said. Number two, because in during the pregnancy and early delivery, the maternal hormones like progesterone and relaxin crossing to the baby and this hormone leading to less in the female because you have many receptors more than the males. And it's more common in native americans, as we said, because they have are swaddling the baby an extension position, as we can see here.
But rarely seen in African-Americans because he just wanted the baby, the abduction position like this. So the hippies abducted, it's inside developments, as we can see here. What is instance the most common of a newborn dysplasia 1 to 100 and dislocation 1 to 1000? What is the most common injury?
And this is why, because if the patient is not breathing the same patient, the most common breast presentation is left occipital anterior. So the left hip of the patient, the baby is attacked against the lumbar spine. The curve of the curve is push the baby the hip of the baby in the left side, so it's due to the most common position left to continue. As we said, the red tape is abducted against the mother by.
It's bilateral in 20% What is the risk factor? As we said, it's first born baby due to strategic abdominal structures most common in females, as we said, due to the maternal hormones and the family history. If if we have one patient that has a first degree relative, the risk is 20% more. But if this patient has identical twins, the risk is 36 percent, which if you have to remember to think in the exam, you have to remember family, family history and the average.
We have three types of rich presentation we have Frank Frank rich, and we have complete rich and you have a rich. The most common deed, which is occurring with the Franklin bridge, as we can see here in this one. And as we said, because it is quite a permanent structures and there is no space for the baby to move. So did it also associated with packaging, is this why you have to take this into clinical care?
You have to say I will search for congenital muscular goodness, 20% of the patients I would search for persons of doctors, it's 10% of the patient that we can see here. And I have to see for congenital knee dislocation, as we can see here. What is what's happening for the patient? As we can see here in this diagram, this is the head, and this is the first is head is trying to suplex outside the. So the nimbus, as we can see here, it's inverted, mostly inverted and the capsule become redundant and this moves.
And here we can see the ligament tears become higher. But to fight and elongated, now the head is subluxation. Outside the head to the Olympus, become the labrum, become inverted and the slap lesion become filled with fiber nerve tissue. More than this, it's become more hypertrophic and deliberately become more inverted, and the transfers are stopped. This is a short of that standard.
This one, you have to open it during doing orbital reduction. We speak about it. And the last thing is the most important thing is aerial surveys, the aerial surveys is doing construction in the capsule. As you can see here, it's doing like our appearance and some say it's a Chinese little appearance. It seems same meaning. So what are the structures looking in the reduction?
This is very, very common question. Never a case of the will not be asked about it, as we can see here, just to diagram, you can classify it easily into Kessler Kessler tickler and the orchestra Doctor Lucas and the hélio source. You have to see the longest is tight, the resources are stretched, why the resources are stretched because the stretch of resources coming from the migration of the head down, but the heat is not going, so step up to the resources contraction.
Small size. As we can see here is the Olympus inverted fiber to fight the terrorists and the tissue and the transversal versus the inverted and the Olympus bronze versus ligament, the hip capsule is constructed as with hourglass appearance by the source and the bone tissue and also the ligament on. It is secondary anatomical changes if the patient is missed, the dislocation that neglected kids or kids coming after one year, as you can see here and just.
You can see the risk increase in the femoral activation and there is some flattening of that. There is increased level of introversion and increased obesity and decrease connectivity of the roof because the head is not inside. So the head is not indented in intending that. And also the recycling of the media because the head is not inside site, it is still outside to the ceiling of the media and all of that stuff ducking the heat inside.
And this is the typical deficiencies, antero-supero-lateral slap lesion, the deficiency in the supplements, interior and collateral. But it is best to exhibit the deficiency as opposed to the superior actually in CB. The deficiency is multi global in more than one direction, but the most common industry which is supposed to be superior position.
This is why, because there is tightness in the anterior muscles. So like posterior dislocation of the shoulder tightness in the anterior muscle leading to push the head posterior same as here in the city. Physical examination. Now coming to clinic, what you would do if the patient is less than 3 months, what is the most common complaint of issues like smart mother and intelligent mother?
She will tell you that I am taking sensation when I'm changing the diaper observation of the baby. All she can tell you that there is limitation, limitations, abduction. I'm changing diapers. There's one side opening this other side. And if she's more smart, more intelligent, she will tell you that there is an equal in the skin crease bilateral.
So there is asymmetry in the skin piece. So what you will do, you put the patient in comfortable position and you trying to do the battle on. Which one you are starting by? Then you start by, then you are trying to reduce the complexity. Don't try to push the head into subluxation position. Then you try to reduce it again. So you try to learn, starting by trying to feel that it's a feeling, not sensing.
You're not listening because you are feeling exactly so you are now starting by then you have to hold the baby. So I like this to some inside the picture's outside and you are trying to pushing, push it from doing abduction and by the little two fingers. You are, you are feeling is activity and you are trying to inside to stop the. As we can see here, this is the hit is abducted and the head is abducted, reduced again.
And then you do support egawa test. As we can see here, the aid is inside, it's outside, it's opposite to or to lend you to pollute abduction and trying to push inside. And this is important information, the latest are really boosted after three months. Why? because there is so much construction, so you cannot do battle until after three months.
3 to three months to 1 year, what we can see in the patient examination. Of course, there is the mutation in the hip abduction, as you can see here, this side in comparison to this side. This is Gary assisted. And it's important test. It's measuring the discrepancy. And this is as we can see here, this is a test how we can do both those saw patients together, and you can feel here there is one who is higher than us.
And this is called Zagros. And this is apparently just not true discrepancy in the lens. But it's apparent it means that if you measure the whole of the lower limb, it's identical to each other. And also, as we can see here, there is inequality, equality in the skin, asymmetry in the skin here in the fountain, here in the. What about this?
Do you think that if the patient is bilateral dislocation, how you can diagnose it because this patient will have it, has limitation and abduction bilaterally and has an equal increased bilateral? So how you can diagnose you do that, how we can do this, test you are putting your middle finger on the GTE. You are putting your index finger on the Soyuz antero-supero-lateral spine and you take one line in between.
This line has to be directed towards us. As you can see here, but if this patient has this location, this line is bluesbreakers and you compare to those outside. More than one year, the case the patient has been collecting, the patient has no locus, as we can see here, and there has to be walking. This is very, very, very common in this very common clinical scenario. And I remember one of the mentors and one of the examiners in the exam they are asking, is a patient coming to you one year old?
And he has unilateral tiptoeing. What is the most common differential diagnosis is Indian and then the examiner, and that's very characteristic mouthwash. I remember. I forget his name, but this is his question. He's asking every, every exam you have to say for him, it's age. And also, we have printed embedded egawa test and.
What's the difference between the test and the calendar and the test? If you are standing on the side, the pelvis is stable and it's liquid because this abductor is intact. But if to stand on the affected side? The pelvis is throbbing. This is called the lindenberg test. If the body lean toward the side. So this is a patient.
Walking goes by lateral. So now how we can do investigation for. First, we have to do ultrasound. But when you will do ultrasound, it's a force 4 to six weeks after delivery. Why? because the maternal hormones, as we say, progesterone and relaxin are declining in the plasma, in the baby after 4 to six weeks.
So if you do before, you can have a false idea about this, and the ultrasound is a primary imaging modality, an examination of the lesion in the. You are you do ultrasound until the appearance of the Civic Center at the age of 4 to six months. How we can do the ultrasound. You put the patient in the letter of the cubicles position and put ultrasound. How you can measure.
Just what you can see from the ultrasound. You can see this is the atrium. And this is a doctor. OK this is the problem. And this is a corporation. So you are now flipping this image like this. If you would this image like this, it would appear like the one that would be it. And you are measuring is alpha angle.
What is the alpha angle and the alpha angle, how you can measure it? You have to draw this three lines. You have to draw the line. And this line is parallel to the outer border of the area, as we can see here. Then you write, you draw the roof line, this line is rebuttal of contention to the bullet as a problem as we can see if it was a slow.
Then you drew the initial line, it's a tangential to the corporation, as you can see here. You measure the alpha angle and you measure the angle. You have to remember that the alpha angle is more than zero. If it is, then six zero. It means the patient has subluxation. So what is alpha and kidney means? There is a more amount of z inside the structure. We have two screening program, the universal screening program and the selective screening program.
So this is advanced. A bunch of everyone with universal screening means that any baby of three you do ultrasound selective screening, you are doing the screening only for the high risk patients. As we said, first presentation female both through breech presentation. In your case, you are depending on the selected view, not ultrasound screening.
Why? because it's most cost effective because you are going for every case, you are going for the case and it prevents overtreatment. But there is this advantage because it may lead to this presentation of the patient and most cases, or in some cases, you don't have any risk factor. So you can the patient can be compelling presentation or no family history and has.
The town you have, we have two classification for this one, for the ultrasound. And in this question, we have the great classification, the static classification according to the measurement of the alpha angle. If it's more than six degrees or between 34 and 60, this type to listen for non measurable is five, four, five, 3 and 5 for dislocated by this need close to production.
You can try both corners and type, but type 1 is only observation five. Two you have to move the patient and public colleagues for need close the production. So graph is a static alpha and beta angle measurement. Only key is for dynamic modification as you are doing, like test with ultrasound and to measure how much of the head subluxation. If more than 7 is considered abnormal, 4 to 6 is considered normal.
Now, the patient is 4 to six months. What you will do, you will do X-ray to see the Civic Center. First thing you will see you will see an equality in the Civic Center on this side to this side. So delaying in the appearance of the civic center, all of us knows the health, the limelight and the medical line. You have to draw this lines and you have to measure the index's most important thing because as no index, this is the one you will follow the patient for.
Of course, the symptom as you also. Treatment, the aim of the treatment or the principle is the treatment. You want this sentence? The principle of treatment is talking, isn't it? It's very, very good. Sentence if you set good marks talking, that means that you have concentric reduction and you have to have maintain stability.
It's not only you are putting the inside of stuff. This has to be concentric reduction, stable reduction. Number two, they have to promote. You have to promote the growth and development of say, you have to minimize the complication, not only reducing it, but reducing the head in a stable position without complication to have normal growth and development. This is simplest the algorithm for management to many, many algorithms.
If you search in papers and books, many algorithms. But this is the simplest way from 0 to 6 months, you put the patient on public forums six weeks to no reduction. You go to close the reduction. Six to eight months, you are doing post-production and it is vital. You you do also. Yes, you are so grown.
If no production, you have to do a production from 18 months to 36 months, you have to do all the production. Some say you can try close the production, but the incident is later on. The reduction is part. From three years to eight years, you have to do a production with shortening and. How you can decide how if you want to do a star system or know if one, then more than one third of that is visible.
So you have to do political scrutiny. I will speak about it. So you need this age based guidelines for treatment to be the age of the columnist for six weeks, 1 to six months, you put the patient on public forums for six weeks, six months to 18 months. You treat the patient with structure and close the reduction. This is debatable, and I will speak also about it from 18 to 12 to 24 months, which is the ratio of the reduction for to primary reduction.
From 24 months to six years, you do a primary introduction through an approach. Maybe the patient may need people are shortening with our tuberosity. Now the management. The most important thing now is that public morals and the most important and calmness.
It's a dynamic sprint. We are voting for the patient within six months. It's contraindicated. It's a patient, as we said, ahead or the patient has. Why? because this patient has no muscle to control the head inside. So this dynamic splint would not give any value for the patient. The most important thing, how you can put this public on this first step, this one at the Naval line or the Naval line, then the most important thing is the next step this one, it's a slap.
This a slap is the most important thing is doing deflection 90 to 100 degree, not more than 100 degree. Why? if you put more than 100 degree friction, this patient will have concerns. Now the bas status slap or actionscript this trap you are putting for the mission you are not fighting.
That is, if you try to thread, the patient will have public partners, and even the abduction of slap is the main idea of it is to prevent is to control the operation only, and the Bishop has to get more money to the. You have to after putting information on the public forums for the patient ultrasound. Within one week or two weeks after putting the public economist and they confirm the position and the full observation for 4 to six weeks.
Winning of the public, you put public gardens for 23 hours per day as more, or it's all the basis because the patient is a human being. We need to become watching the change, a diaper and. And you put it for at least six weeks, and some also say that you have to lose at opportunity for months at least. Winning is above economists at 6 to 8 weeks, we are moving up in the economy, but only at my time for the nap time observation.
If you put to public forums and it is not inside and do the ultrasound, the alpha angle is not increasing or it's less than six degrees 50 or 50. So you have to discontinue some of the calls. And the motivation in the abduction is for three weeks. What is the complication specific to the bubble economy? Why? because in terms of the civilian bench of the media people conflicts. It seems extreme abduction, as we said, if you tighten the threat of abduction more than six degree, the patient will have.
So you have to put up solar farms and you will speak about safe zones, and as we said, it was fiber connection. If you do help friction more than 100 degree, 100 degrees, so the ulnar nerve is obstructed between the interior strap and the ZBB napkin. So it's become compressed. How we can lose this one, it is in scripture. It will tell you that the vision is in Pavlik Harness for one week now, and he cannot kick, so this patient has been ulnar nerve claw palsy what you will do, you have to discontinue to remove it immediately.
And the most important thing, this popular cartoon is disease. If we put the patient in a position of dislocation, as we said, this patient to have the problem will become eroded and we have deficiency in the post-treatment world. This is why you have to discontinue the public if more than three to four weeks and the hate is not reduced. Close production, despite the costing, we do this for six to 18 months.
And the observation of powerful economists, there is three possible outcomes for this patient. You put the patient in trying too close to the law was also, of course, you have three. Possibly the first possibility is that the hip is reduced well and stable through a good range of motion. What you will do, you will treat a patient. And it will spike up for six weeks.
Then you change it to another speaker for more than six weeks. But if the irreducible due to destruction have to do with the reduction. Third option, the hip is reduced, but it needs to become stable in extreme position. What you will do, you have to increase the save from how you can do this, I will tell you. There is two controversy here.
And controversial issues and be the. In trying to close the first one. You have to do traction or no traction if you are doing close to production. He said that some also said that if you do traction the incident, the incidence of decreasing and the need of reduction to decrease. Number two. It's the timing of the reduction.
You do close the production with appearances of selection, but also its appearance of the selection. That's also said. And this is the most important $2 billion of them. You shouldn't do it to treat the hip until the new clause appeared. The growth potential of the slap lesion decrease with age. So we have to reduce it as soon as possible because if you didn't catch it this period in the first six months, the growth of the problem would be.
So some also recommended close the reduction of dislocated hips shouldn't be performed until the appearance of the civic center, as we said. And there is some work lexicon and the both of them said that if you wait for the appearance of the simple, the incidence of what's going on controversy and police said that no, no need for waiting for the appearance of the Civic Center.
Now, the closer the reduction of the hippest biker you do under general anesthesia, it's supposed to be two of us. The technique we took was the reduction in maneuver. You do ulnar claw. It also is important because it has to confirm the reduction. You can do the reduction without also drop. But let me be flexible. So it's a flexible period and you do after this, you have to get the patient inside the authority.
And in the long run this weekend, you must concentrate production with some millimeter of media to. If the media goal wasn't 7mm, this patient transport outcome and has adverse consequences, for instance. While also, globe is important because it helps you to identify the anatomical looking for. Oh, you can't do this after doing the reduction, you are feeling it out.
And centimeters from the insertion of you get your needle aiming to lateral. And then you are sending inserting is a needle. You will feel a hope that you are inside the capsule. Now you will be restricted to Kessler. You inject saline to inject saline inside. After you injecting saline, you inject your boy and you are trying to put the patient in the range of the motion until you have concentric production.
So as we said, you are injecting axilo paratrooper X-ray screening, then your injectors and then your zip is screened until you have good reduction. Once the hit is reduced, the range of motion of the hip remains reduced, must be. So now we will reduce the. After this, you are trying to know which positions it is dislocated in, so you get the patient abduction to abduction and you check the range of the motion, then you reduce the heat again, then you get sufficient flexion, extension, and the check the range of the motion.
Insufficient need has tightness in the tractor compartment or tightness on the flexion compartment. We have to do our Doctor tenotomy also tenotomy depending on this structure. The idea of this to increase a. It means that the patient will have good range from friction and friction or dislocation. And the good range from abduction to abduction. Our distribution.
It's a hip rotation, you have to also notice. The idea of all this is to immobilize the hip, we save zoo without extreme obstruction or friction in order to prevent the complication as we. So the position is 45 degree and abduction and deflection 90 degree with neutral rotation, this is almost the production of spike across. As we said, this is a safe school of the first one. They have rights of safety, as we can see say here, from abduction to abductions.
It is a very big degree in comparison to this one. This is not. Of the reduction, what you will do, you have to do it. What you have to see in cities, it's called selective cuts. We should confirm the deduction if you do see the patient. And the phone, the head is subjected to serious, you have to be patient and try to argue. And after you have you are now.
Sure of the production you can do for the patient changing as opposed to after six weeks. So I'm also not doing city after closed production do for him. From job doing MRI. Why is doing MRI to check the position and to check the muscularis of the head? Because they are afraid that you are doing like forcible production on the effectiveness of a square today?
This is how we come to close the production, as all we know. Open reduction, you are doing more than 18 months, and if there is failure of the reduction. You can do urban reduction is totally if more than two years with the residual desperation, as we said, there is anatomical changes in the air like a virgin flattening of the head and the stomach also is. And it's done in people, children, this and four years old after four years, you have to do political scrutiny.
Because you have this spiritual tape, and as we said, we have to measure the index. More than 40 years, it's indicated, and this decreased potential for remotely. This patient may have later on. What is a complication of organ reduction? As we said, if in why, if you put the patient in extreme obstruction, you didn't respect the policy.
The patient will have died each of us just because you are doing stretching on the circumference, how to prevent, as we said, you have motivation to the same. And as we said, we can do for him, if you source tenotomy or you can also. How you can do open approach through the medial approach or the lateral approach, medial approach, you do less than one year and through a lateral approach at any age, but better after one year.
Advantage of the media approach, you can reach the mechanical blocking to the production easier, and you didn't spirits up offices. But the disadvantage you cannot address the immediate past, you cannot do the most important thing, you cannot do good Kessler. And this is important for treatment or close protection. And there is also risk damage because you are entering the internet, possibly, and you can enjoy the meters are complex.
You can do any information. What is our approach you can address all by looking for the reduction? You can do good cuts and you are away from the complex. But the disadvantage you have to spirits up officers in order to reach the problem and the problem in this patient is very deep. You have to do good. And also, there is risk damage for us as we all.
This is a silly approach for the median reduction. We have one, we have Rudolph and Ferguson, all of them, depending on which nervous you are doing in between. When you are entering between, the victim is the victim. And this is a neurovascular bundle. To me, there's a conflict. Lugosi's is between the US. As our doctor and the doctor believes, and so the doctor inside and outside.
This is the most common of. Friction is between the doctor and the doctor and the doctor. What's the soft tissue blocking the reduction, as we say, the soft tissue blocking the reduction you have to do, you have to release all this structure and they have to remove the looking for the reduction. And as we have, we have how you can increase the same sort of post-operative you immobilize.
The patient was 15 degree of friction, 15 degree neutral rotation. With the aim of political system is to increase antero-supero-lateral coverage. It's increasing. That will increase the index. As we said, coverage is moving by the degree of tabloid coverage of the funeral. How much of that covering is ahead?
After you put the patient in extinction at a neutral location, if more than one third of that is visible in the position, you have to do some type of. OK peel-back, the last three photos, we have only one minute remaining staff are sorry for that in two minutes. It's only one want because it's a program. OK osteotomy.
We have two types of. We have the salvage osteotomy, where we have the reconstructed salvage you certainly are doing. For the patient who has no consent reproduction. You cannot do consent reproduction for him. So you do all or. Carrie, it's me. Idealizing goes tenotomy or capsule interposition as tenotomy or liberal support.
All these are names. We depend on doing so. Kessler osteotomy puts it in the roof of the idealizing every single time. And the reconstruction of reconstruction you are. You can classify the reconstruction into the reshaping and reorientation. Reshaping you are doing is like reshaping the ship by Pemberton osteotomy or Italy re-orientation.
You are trying to reel you in disaster like osteotomy the hinge on the subscapularis.
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