Describe Radiographic findings of the X-ray

 

AP radiograph showing a dislocated left hip and dysplastic acetabulum.Shenton's line is broken.Femoral head is lateral and supreior to inferomedial quadrant(made by intersection of Perkin's and Hilgenreiner's lines )



How to proceed to management in such cases ? 

Full History 

        
            risk factors - positive family history

                                 Ist born (low intrauterine space ) 

                                       Breech

                                        Oligohydraminous

                                        Associated - Spina Bifida/ Arhtrogryposis
    
                                    
    
                     
                                
 Examination 
            
             Inspection - Trendelenburg Gait
                
                                Asymmetric gluteal folds , LLD, 

             Palpation   - Prominent trochanter  , 

            Movement   - Decreased Abduction 

            Special Tests - Barlow and Ortloani tests , Thomas tests ,Galeazi tests, 
    
             Measurement - LLD, FFD, Measurement to show infra or supratrochanteric shortening drawing  a Bryants triangle 

( examination important in hip long or a short case but be able to articulate in viva what we see in this section  )


Investigations 

        USG
        X-ray of Pelvis - AP and lateral view of affected hip
        EUA , Arthrogram to delineate anatomy of acetabulum ,soft tissues and proximal femur. 
        MRI - done late to check if hip is enlocated.
Management 
    
         Closed Reduction     

         OR- Failure to CR, unstable and irreducible hip, soft tissue interposition preventing a congruent 

            reduction.

             Hip spica applied after CR/OR.

            OR +/- Femoral Osteotomy +/- Pelvic supporting Ostetomy is required after 2 years 
            
        
            Blocks to reduction 
        
                                            1.Inverted Limbus    
                                            2. Elongated Ligamentous Teres 
                                            3. Hour Glass contracture of capsule 
                                            4. Psoas Tendon
                                            5. Pulvinar 


What are the approaches you would use to reduce hip ? 

    Modified Anterior (Ileofemoral ) approach
        
                Skin incision given parallel and distal to iliac crest (2cm distal to ASIS and extends medially                     within groin crease 

                Protect lateral cutaneous nerve of thigh

                Internervous plane - TFL (Superior Gluteal Nerve ) and 
                                                  Sartorius (Femoral Nerve )
                  straight head of rectus femoris divided . Capsule opened using a T-shaped incision and hip                     joint exposed.clear acetabulum off Pulvinar and redundant ligamentum teres (not labrum).
        
                 Inverted labrum everted with one or more radial cuts. 

                 Release inferior capsule, Iliopsoas tendon to reduce hip.

                Then assess need for femoral shortening osteotomy or pelvic osteotomy. 

                For Pelvic osteotomy

                Splitting Iliac Crest Apophysis
                                                elevate muscles en-masse on both the sides of pelvis down to sciatic                                                        notch
                                            
                        
                Hip reduced, confirmed using Arthrography.
        
                Then Double breasted capsular repair of hip done. Closing done in layers. 
        
                Hip spica applied. Abduction - 30 degrees with Internal Rotation.
    
                Continue for 3 months. 
        
                Post operative - look for Spica Syndrome 



                Long term follow up if hip develops normally.
















        



                                
                                   

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