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Orthopaedics
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1. Congenital dislocation of the hip. Classification, clinical picture,diagnosis and treatment.
Firstly, consider some of the details of the muscles of the hip, the insertion points of the main
muscles are listed in the table below.
The hip joint is a ball-and-socket joint between the acetabulum and the head of the femur. Its range
of movement is limited by the acetabulum and the ligaments around the cavity. The range of
movement for the hip joint is:
Extension-flexion - 10-0-130
Abduction-Adduction - 40-0-30
Lateral rotation-medial rotation - 50-0-40
Developmental dysplasia of the hip (DDH) is an important group of pediatric diseases. It is a term
that refers to abnormal hip development resulting in dislocation (D), subluxation (C) or
laxity/dysplasia (B) of the hip (A is normal).
,Within the spectrum of diseases, DDH includes:
Dysplasia - shallow or underdeveloped acetabulum
Subluxation - displacement of the joint with some contact remaining between articular surfaces
Dislocation - complete displacement of the joint with no contact between the original articular
surfaces
Teratologic hip - dislocation in utero and irreducible on exam, presents with pseudoacetabulum and
is associated with neuromuscular conditions (e.g. Ehlers-Danlos)
The condition is the most common orthopaedic disorder in newborns with an incidence as high as
1:100 for the dysplastic form (1:1000 for the dislocation form). It is more common in females, and in
the left left. Risk factors include being the firstborn, having a family history of the disease, being
breech and oligohydramnios.
The pathogenesis is thought to be initial instability of the joint that leads to dysplasia. Dysplasia can
then lead to subluxation and gradual dislocation. If not resolved shortly after birth then there are
severe consequences to the natural history of the disease:
Development of secondary barriers to reduction
Pulvinar thickens
Ligamentum teres thickens and elongates
Transverse acetabular ligament hypertrophies
Hip capsule and iliopsoas form hourglass shape
Anatomic changes
Increased femoral anteversion
Flattening of femoral head
Increased acetabular anteversion
Increased obliquity and decreased concavity of the acetabular roof
Thickening of the medial acetabular wall
DDH is commonly missed unless screened for in newborns. There are three examinations that can be
done to check for DDH:
Barlow maneuver
Adduct the hip, while bending the knee to 90, and put pressure posteriorly through the hip joint, feel
for a ‘clunk’
Ortolani maneuver
Flex the hip and knees of the infant to 90 degrees then then place anterior pressure on the greater
trochanters, gently and smoothly abducting the infant's legs using the examiners thumbs
Galeazzi
Flex the infants knees when lying down so that ankles touch the buttocks. If the knees are not level
then the test is positive, indicating that the legs are different lengths and that there is a potential
congenital hip malformation
Barlow and Ortolani can both be done in the first six months, however are less useful after this due
to the ossification of the femur and the soft tissue contraction.
,Confirmation of the suspected diagnosis is done on x-ray, where certain measurements are taken to
assess the hip.
Hilgenreiner’s line
Horizontal line through right and left triradiate cartilage (inferior tip of the ilium)
Femoral head ossification should be inferior to this line
Perkin’s line
Line perpendicular to Hilgenreiner's line through a point at the lateral margin of the acetabulum
Femoral head ossification should be medial to this line
Shenton’s line
Arc along the inferior border of the femoral neck and superior margin of the obturator foramen
Arc should be continuous
Center-edge angle (CEA) of Widberg
The angle formed between perkins line and the line from the center of the femoral head to the
lateral edge of the acetabulum (should be <20 degrees)
Only reliable if patient older than 5 years old
Acetabular index (AI)
Angle formed by hilgenreiner's line and a line from a point on the lateral triradiate cartilage to a
point on the lateral margin of acetabulum (should be <25 degrees in patient older than 6 months)
Treatment goal is to obtain and maintain concentric reduction
0-6 months: Pavlik harness or Cambridge splint
6-24 months: Closed reduction, spica cast; open reduction if this fails
2-4 years: Open reduction with or without femoral osteotomy
>4 years: Acetabular osteotomy; teratologic hips need open treatment
, Left image is normal, right image is hip with dislocation
2. Congenital curved feet. Pes equinovarus congenitus. Classification,
clinical picture, diagnosis and treatment.
Congenital clubfoot (Talipes Equinovarus aka Equinovarus)
Incidence is around 1:1000, most cases are sporadic, however there are some AD cases, it is
bilaterally in about 50% of patients, in such patients both feet are generally of the same severity. The
underlying cause is unknown, the best theory is that of a primary germplasm defect in the talus
causes continued plantarflexion and inversion of the bone with subsequent soft-tissue changes.
There are four basic components in clubfoot, these are:
Cavus (fixed plantar flexion/a high arch)
Adduction (foot moves inwards)
Varus (foot points inwards (medial angulation of distal foot)
Equinus (upward bending motion of the ankle joint lis limited, with sole permanently flexed so
walking is on the toes)
The diagram below shows the pathological process nicely, but it can be summed up as the following
steps:
Neck of the talus is deviated downwards, while the body is rotated outwards
The downwards deviation of the talus causes calcaneal pivoting, with the distal part moving laterally
and the proximal part moving laterally
The navicular and forefoot are then forced into a rotational shift and supinated
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