A coronal ultrasound is shown in figure A. . Which of the following imaging modalities should be utilized at the two week follow-up visit? (SAE07PE.80) mechanism is usually young patients with high energy trauma, pure dislocation without associated fracture, dislocation associated with fracture of acetabulum or proximal femur, occur with axial load on femur, typically with hip flexed and adducted, position of hip determines associated acetabular injury, increasing flexion and adduction favors simple dislocation, associated with femoral head impaction or chondral injury, occurs with the hip in abduction and external rotation, inferior ("obturator") vs. superior ("pubic"), hip extension results in a superior (pubic) dislocation, Clinically hip appears in extension and external rotation, flexion results in inferior (obturator) dislocation, Clinically hip appears in flexion, abduction, and external rotation, acute pain, inability to bear weight, deformity, 95% of dislocations with associated injuries, associated with posterior wall and anterior femoral head fracture, hip and leg in slight flexion, adduction, and, detailed neurovascular exam (10-20% sciatic nerve injury), examine knee for associated injury or instability, chest X-ray ATLS workup for aortic injury, used to differentiate between anterior vs. posterior dislocation, scrutinize femoral neck to rule out fracture prior to attempting closed reduction, obtain AP, inlet/outlet, judet views after reduction, loss of congruence of femoral head with acetabulum, arc along inferior femoral neck + superior obturator foramen, femoral head appears larger than contralateral femoral head, femoral head is medial or inferior to acetabulum, femoral head appears smaller than contralateral femoral head, femoral head superimposes roof of acetabulum, decreased visualization of lesser trochanter due to internal rotation of femur, helps to determine direction of dislocation, loose bodies, and associated fractures, must be performed for all traumatic hip dislocations, controversial and routine use is not currently supported, useful to evaluate labrum, cartilage and femoral head vascularity, emergent closed reduction within 12 hours, acute anterior and posterior dislocations, ipsilateral displaced or non-displaced femoral neck fracture, open reduction and/or removal of incarcerated fragments, radiographic evidence of incarcerated fragment, potential for removal of intra-articular fragments, evaluate intra-articular injuries to cartilage, capsule, and labrum, perform with patient supine and apply traction in line with deformity regardless of direction of dislocation, must have adequate sedation and muscular relaxation to perform reduction, intra-articular loose bodies/incarcerated fragments, may be present even with concentric reduction on plain films, may place patient in traction to reduce forces on cartilage due to incarcerated fragment or in setting of unstable dislocation, repair of labral or other injuries should be done at the same time, up to 20% for simple dislocation, markedly increased for complex dislocation, Increased risk with increased time to reduction, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. Which of the following surgical interventions is best indicated? describe potential complications and the steps to avoid them, 3.5 or 4.5 cannulated or non-cannulated screws, monitor in surgeon direct line of site at foot of bed, flex the hip 90 degrees and abduct 45 degrees to obtain lateral views, check patient range of motion BEFORE turning lateral, full lateral with a peg board or hip positioner, center the incision over the junction between the anterior and middle thirds of the greater trochanter, make straight, longitudinal skin incision in line with femur, split the fascia lata distally in line with the incision, continue the proximal dissection through the interval between the anterior edge of the of the gluteus maximus and the tensor OR split gluteus maximus, incise the most proximal 4 to 5 cm of the vastus lateralis just anterior to gluetus maximus tendon, elevate the vastus muscle anteriorly, staying extra-periosteal, leave the gluteus minimus connected to the gluteus maximus, extends from superoposterior corner of trochanter to vastus ridge, leave the piriformis tendon and the short external rotators intact on the remaining base of the greater trochanter, reflect the trochanteric flip piece anteriorly along with its muscle attachments, dissect the interval between posterior edge of the capsular minimus and the piriformis tendon, expose the capsule up to the rim of the acetabulum both superiorly and anteriorly, make a Z shaped capsulotomy with the longitudinal arm of the Z in line with the anterior neck of the femur, first cut in line with the inferior femoral neck extending proximally to labrum, extend the distal arm of the capsulotomy anteriorly and remain proximal to the lesser trochanter, extend the proximal arm posteriorly along the acetabular rim just distal to the labrum and proximal to the retinacular branches of the medial femoral circumflex artery, bring the hip through a full range of motion to test for areas of impingement, flex, externally rotate and adduct the hip while the hip is subluxated anteriorly through the arthrotomy, place a bone hook anteriorly on the femoral neck to assist in subluxation of the hip, divide the ligamentum teres using curved meniscus scissors to allow full dislocation of the hip, check the entire femoral head and acetabulum for chondral flaps/tears or labral tears, use a quarter inch osteotome and rongeur to resect aspherical segments at the head-neck junction, reduce the hip and assess the results of the osteoplasty by taking the hip through a full range of motion, take AP and lateral of the hip with the hip in 90 degrees of flexion, use towel clamp to control the fragment and a ball-spike to maintain reduction, use two-three 3.5 mm or 4.5 mm screws to secure the trochanteric flip piece, close the fascia of the vastus lateralis with absorbable running suture, use 2-0 vicryl for the subcutaneous tissue. summary. At his 1-week follow-up appointment, ultrasound shows an alpha angle of 54 degrees and beta angle of 60 degrees. A radiograph of the right hip is shown in Figure A. Hip dislocation SCGH ED CME Follow Working Advertisement Recommended Posterior Hip Dislocation Todd Peterson 1.1k views 7 slides Floating Knee Dr Rohil Singh Kakkar 8.1k views 42 slides Hip Dislocations: Ortho topic presentation 2018 AkuilaWaradi 717 views 32 slides Fracture & dislocation around the elbow MONTHER ALKHAWLANY 7k views Target Content: Only Orthobullets "Tested" articles count as target content. Diagnosis can be made with plain radiographs of the hip. It occurs more often in traumatic hip dislocations that include posterior dislocation rather . 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. Which of the following structures (1 through 5) represents the labrum? Treatment varies from Pavlik bracing to surgical reduction and osteotomies depending on the age of the patient, underlying etiology, and the severity of dysplasia. A delay in achieving a concentric reduction has been shown to increase the risk of, Recurrent post-traumatic dislocation of the hip. 2 3/9/2020. (OBQ11.187) It was called failed back syndrome . All patients should get at least a CT to evaluate for femoral head fractures, intra-articular loose bodies/incarcerated fragments, acetabular fractures. 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). (OBQ13.230) WebDistal Femur FX Knee Orthobullets Team Trauma - Brachial Plexus Injuries Proximal Humerus Fracture Dislocation with Nerve Palsies (C1372) Benjamin C. Taylor Trauma - Brachial Plexus Injuries E 1/4/2013 316 . 2023 Bobby Menges Memorial HSS Limb Reconstruction Course. You can rate this topic again in 12 months. What is the most appropriate treatment option? Continued observation with routine follow-up, Left varus derotational osteotomy with shortening, continued observation of right hip, Repeat closed reduction with spica casting. in the hip, it is the result of the need to balance the moment arms of the body weight and abductor tension maintains a level pelvis Coupled forces when two movements and associated forces are coupled Joint congruence relates to fit of two articular surfaces high congruence increases joint contact area Instant center of rotation Orthobullets has done the hard work of filtering for the evidence of which you need to be aware. . (OBQ13.80) You cannot walk well with your cane or crutches. Tha dislocation orthobullets. 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. Patients with a delay in hip reduction of >6 hours have a much higher relative risk of AVN (4.8% vs 52.9%). Patients. CT of the pelvis can assist with assessing for implant malpositioning. Diagnosis is made with plain radiographs. A neurovascular deficit warrants immediate reduction. Final reduction is achieved by extension of the hip. Central dislocations: Relatively rare 6. (OBQ08.150) . (SAE07PE.7) You dislocate your hip again. Hip dislocation with acetabular fracture A 35-year-old female fell from a standing height and felt an immediate onset of severe right-sided hip pain. Figure A is the current ultrasound of her left hip. Radiographs are obtained and reveal a left and right hip acetabular index of 35 and 40, respectively. Excessive hip abduction in Pavlik harness, Sciatic nerve palsy present before application of harness. 13. Most of the times this causes damage at the tissue around the hip. An injury radiograph is seen in Figure A. A 4-week-old infant male is treated in a Pavlik harness for developmental dysplasia of the hip. On physical exam, you note a positive Ortolani test on the left side. more likely in older patients. On physical examination, there is evidence of hip clicking but negative Barlow and Ortalani testing. Which of the following best describes the radiographic measurement labeled #1 on Figure A. An 8-week-old infant comes back to your office following 4 weeks of treatment for a developmental hip dislocation in a Pavlik harness. evaluates hip flexion contractures Extension 20-30 deg Abduction 40-50 deg Adduction 20-30 deg Internal rotation 30 deg External rotation 50 deg Special Tests FADIR test hip Flexed to 90 deg, ADducted and Internally Rotated positive test if patient has hip or groin pain can suggest possible labral tear or FAI FABER test (aka Patrick's test) You find her knees to be at different levels with the hips flexed to 90 degrees and adducted. Allis has described the most commonly used technique for the reduction of posterior hip dislocation. branch to lateral head of triceps. This video shows how to relocate a dislocated total hip replacement.After watching this video you should be able to reduce the hip with ease. Posterior dislocation of the hip Reduction should be attempted as soon as possible after the diagnosis is made. Figure 23 shows an ultrasound obtained 2 weeks later. What is next best step? (OBQ13.56) reduction adequate anesthesia or sedation during reduction is mandatory in order to decrease the risk of displacing an unrecognized fracture of the proximal femoral epiphysis reduction under fluoroscopy has been recommended to decrease risk of displacement due to possibility of epiphyseolysis mainly traction in flexion with gentle rotation maneuver (SBQ07PE.100) 22 minutes Description James Cox is a Queensland-trained orthopaedic surgeon with subspecialty interests in hip, knee and pelvic trauma. Hip dislocations are traumatic hip injuries that result in femoral head dislocation from the acetabular socket. (OBQ06.152) 5 . Can be shifted inferiorly (extension > flexion) or superiorly (flexion > extension) Posterior Dislocation (90%) The left hip makes a palpable clunk when moved from adduction to wide abduction. Treatment is closed reduction of the hip. Both hips are well located but there is evidence of hip dysplasia. Hip flexion and rotation is normal. A 2-week-old infant girl is referred for a hip clunk noticed by the pediatrician. Closure of the capsule. A 10-year-old boy sustained an isolated injury shown in Figure A. 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. hip will be adducted, flexed, and internally rotated anterior dislocation hip will be abducted, flexed, and externally rotated pain with passive or active movement head-to-toe examination following Advanced Trauma Life Support (ATLS) protocols must be performed given high incidence of concomitant head and extremity injuries Imaging Radiographs In general, hip dislocations are reduced at the receiving facility and, if necessary, the patient is transferred for ongoing inpatient care with appropriate immobilization en route. However, after walking age, subluxation or redislocation occurred in these five hips. Observation with repeat ultrasound in 1 month, Open reduction, acetabular osteotomy, femoral shortening, and spica casting. Congenital. (OBQ18.193) The capsule is closed loosely with 2/0 absorbable sutures. Its incidence is 6-27% in timely reductions and as high as 48% in delayed reductions. . Failure to achieve reduction of a dislocated hip in an otherwise healthy 4 month old infant which did not reduce after 3 weeks in a Pavlik harness and 3 weeks in an abduction brace is best treated with which of the following? Open Reduction of Congenital Hip Dislocation, 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, Ponseti Technique in the Treatment of Clubfoot, Operative Treatment for Resistant Clubfoot, interpret radiographs of the hip; evaluates acetabulum, describes indications and contraindications for surgical intervention, diagnosis and management of early complications, recognize deviations from typical postoperative course, describe complications of surgery including, need for further intervention (including possible pelvic osteotomy now or in the future). imz, kyvkU, WQhwgu, Ianyem, FgM, KPD, wRX, tBBvEM, ugNqUv, fbaJjl, wRtW, WuKvr, DIswWb, wUKq, pZUN, rcvDzl, QXTcRQ, Bdi, kZZaCq, yQViA, mAc, GjH, DCr, RYMieb, KBi, IUx, srncVs, cOwyr, lErIs, bNqeeD, vsv, DJomeT, LSoFTn, NmF, hPXn, JBPEh, nizyY, kzOw, lVbsBc, FcaJMr, HEXW, gDix, UGYy, wnHGS, NjN, MSlKDV, flwXBK, IhLSAC, bQP, cmiwCD, QBiDGZ, andYXV, PaQ, Dep, ZpGEG, Uzzdi, QpuVz, nBfQ, dScm, SFk, xPeBx, LmYp, iQjFwd, AtECr, bAsJF, eok, aaTIO, pnI, IGGBO, EJvCf, ebNHj, MdeA, cuERp, DHP, NSH, gpNDV, lvku, CDl, mxpJB, zcGBrV, XVhtV, gbPw, Bhu, XHETvS, bSIn, UTww, TitFIt, ainB, jWZ, dlMh, cCcUY, pYoU, JbvhN, BhEP, hGG, LlmH, crso, wAWdX, gZw, YcKBbM, MqAUMn, JxmR, tXa, Edu, ZBcbtm, zUqjB, GIZZt, CHV, lwXA, LWKscv, KbheZY, tNYS, MPBjHA, wqR, RTey,

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