DEVELOPMENTAL DYSPLASIA OF
HIP (DDH)

• Developmental dysplasia of the hip (DDH)
describes a variety of conditions in which the
ball and socket of the hip do not develop
properly.

• The hip is a 'ball and socket' joint.
• Femur Head & Acetabulum
• In case of DDH the acetabulum may not be develop fully or it
may be shallow
• Unilateral or bilateral.
• Incidence of congenital dislocated hip is about 2 per 1000 live
birth

Aetiology
• 4–5 times more common in girls
(hormonal factors causing temporary joint laxity)
• is more common in firstborns and in the left hip because of
the common fetal position (LOA –left occipitoanterior)
• Oligohydramnios
• Breech presentation
• Family history (risk is increased 30 times)
• spina bifida
• Racial factors

Features
• Limp
• Limited abduction
• Pain after exercise

Diagnosis
• Barlow’s test:
• Ortolani test:
• Ultrasound: monitor early treatment or
screening
• Radiography

Management
• Many hips that are unstable in the first few
days/weeks of life do not need treatment as
they improve spontaneously
• Up to age 4–6 months, a harness or splint is
effective treatment
• In older babies, closed reduction is often
possible and preferable to an open reduction
• For failed closed treatment, open surgical
reduction is required

NEONATE
Hips that remain unstable at 6
weeks or that are dislocated at
rest, are treated with harnesses
or splints.

• INFANT
• Successful treatment using a harness is unusual after the age
of 4–6 months.
• EUA >>>>>>closed reduction.
• A psoas/ adductor release can be performed as necessary.
• Following a closed reduction, the hip will need to be held
reduced with a hip spica cast for several months.

• YOUNG CHILD OR TODDLER
• The older the child, the less likely it is that reduction by closed
methods
• open reduction via an anterior approach around the age of 9–
12 months.
• pelvic osteotomy, femoral shortening or derotation
osteotomies
• Surgery is often avoided in children over the age of 6–8
years (bilateral cases) and the age of 8–10 in unilateral cases

SPINAL DEFORMITIES
• SCOLIOSIS
• KYPHOSIS
• LORDOSIS
• Torticollis
• Flat back

SCOLIOSIS
• Is defined as a lateral deviation of the normal
vertical line of the spine. The lateral curvature
of the spine also is associated with rotation of
the vertebrae.

• Aetiology may be congenital (underlying bony
malformation),neuromuscular, syndromic or
idiopathic

• ANATOMY
• All the bony elements
are altered
• 1)vertebra are wedge
shaped
• 2)Poorly developed
concave side
• 3)Pedicle rotated

• Infantile scoliosis
occurs from birth to 3 years of age
• Juvenile idiopathic scoliosis
between the ages of 4 and 10 years
• Adolescent idiopathic scoliosis
between 10 years of age and skeletal
maturity.
• Idiopathic>>most common

Infantile idiopathic scoliosis
• Is a structural, lateral curvature of the
spine occurring in patients younger than
age 3 years.
• Most are self limiting and spontaneously
resolve (70% to 90%);
• some curves may be progressive, usually
increasing >>result in significant deformity
and pulmonary impairment.

• The Cobb angle is a
radiological
measurement that
defines severity and
helps to guide
treatment.

• Curves <20° do not need treatment,
• progressive curves of 25–40° may be braced,
and
• those >40° are considered for surgery, which
involves instrumenting the spine and fusing it
• Back pain associated with scoliosis may be
due to infection or tumour

Juvenile idiopathic scoliosis
• Appears between the ages of 4 and 10 years
• It was found that 67% of patients younger
than age 10 years showed curve progression
• The risk of progression was 100% in patients
younger than 10 years who had curves of
more than 20 degrees

• For curves <20 degrees,observation is
indicated,
• With examination and standing PA
radiographs every 4 to 6 months.
• Evidence of progression on the radiographs as
indicated by a change of at least 5 to 7
degrees warrants brace treatment.

• The success of nonoperative treatment is
variable; 27% to 56% require spinal fusion for
progressive disease.
• It found that patients who wore a brace part
time (after school and at night) had good
outcomes.
• Patients with curvatures of greater than 45
degrees at the onset of bracing all eventually
underwent spinal fusion.

• Another important consideration is the
crankshaft phenomenon. With a solid
posterior fusion, continued anterior growth of
the vertebral bodiescauses the vertebral body
and discsto bulge laterally toward the
convexity, causing loss of correction, increase
in vertebral rotation, and recurrence of the rib
hump.

Adolescent idiopathic scoliosis
• Is present when the spinal deformity is
recognized after the child is 10 years of age
but before skeletal maturity.
• most common type of idiopathic scoliosis.

ETIOLOGY
• (1) Genetic factors
• (2) Neurologic disorders
• (3) Hormonal and metabolic dysfunctions
• (4) Skeletal growth
• (5) Environmental and lifestyle factors

• The effect of progressive curves on adults
with untreated scoliosis has been studied by
several investigators.
• Four consideration
A) Back pain
B) Pulmonary function
C) Curve progression, lumbar &thoracolumbar
curves
D) Mortility>>thoracic curves greater than 100
degrees, with resultant cor pulmonale.

Kyphosis
• In the sagittal plane, the normal spine has four
balanced curves:
• the cervical spine is lordotic;
• the thoracic spine is kyphotic (20 to 50
degrees), with the curve extending from T2 or
T3 to T12; the lumbar region is lordotic (31 to
79 degrees); and
• the sacral curve is kyphotic. On standing, the
thoracic kyphosis and lumbar lordosis are
balanced.

• Kyphosis of 50 degrees or more in the thoracic
spine usually is considered abnormal.
• Kyphotic deformity may occur if the anterior
spinal column is unable to withstand
compression, causing shortening of the
anterior column.

• 1)POSTURAL KYPHOSIS
• 2)SCHEUERMANN KYPHOSIS
• 3)CONGENITAL KYPHOSIS

• 1)POSTURAL KYPHOSIS
• Most common type
• More common in girls
• It is caused by weakening of muscles and poor
posture
• It progressively gets worse with time.
• These people will have symptoms of pain and
muscle fatigue

Scheuermann Kyphosis
• Scheuermann kyphosis is a structural sagittal
plane deformity in the thoracic or the
thoracolumbar spine. Patients have an
increased kyphosis in the thoracic or
thoracolumbar spine with associated
diagnostic radiographic changes.

• Normal thoracic kyphosis is generally
accepted to be between 20 and 45°. The
degree of kyphosis in the thoracic spine
increases with age. Kyphosis should never be
present at the thoracolumbar junction. Any
kyphotic deformity present at this level is
considered abnormal.

• Clinically, most patients with thoracic
Scheuermann kyphosis present with pain
(80%). usually intermittent in nature. It is
characterized as dull and aching and is
generally activity related and relieved by rest

• On physical
examination, patients
with upper thoracic
Scheuermann disease
present with a kyphotic
deformity.
• This is best
demonstrated in the
forward flexed position.

• Radiographic diagnosis
• Irregularities of the vertebral endplates,
• anterior vertebral body wedging,
• decreased intervertebral disc space height

NONOPERATIVE TREATMENT
• OBSERVATION
• Adolescents with mildly increased kyphosis of
less than 50 degrees without evidence of
progression can be evaluated with repeated
standing lateral radiographs every 4 to 6
months.

OPERATIVE TREATMENT
• Indications
• Progressive kyphosis >75 degrees
• significant kyphosis associated with pain
• that is not alleviated by conservative
treatment methods.

• The biomechanical principles of correction
of kyphosis include lengthening the
anterior column (anterior release),
providing anterior support (interbody
fusion), and shortening and stabilizing the
posterior column (compression
instrumentation and arthrodesis)

Lordosis
• It is an inward curvature of a portion of
lumbar or cervical vertebra column.
• It may be due to achondroplasia and
spondylolisthesis.
• It is associated with poor posture, a
congenital problem with vertebra,
neuromuscular problem and back surgery
• In childrens, rickets may lead to lordosis.

• Clinical features
• 1)Prominence of
buttock
• 2)Back pain
• 3)Pain radiating
to lower limb

TREATMENT
• Based on- Childs age, overall health,
medical history, cause and extent of the
condition.
• Goal of treatment is to stop the
progression of the curve, prevent
deformity.
• Simple exercises are sufficient , If Lordosis
is associated with poor posture

• Spondylolysis defines a defect in the pars
interarticularis of the vertebra. There are six
types: congenital (dysplastic facet joints),
isthmic (weak or elongated pars),
degenerative, post-traumatic, pathological
and post-surgical.

• Spondylolisthesis occurs when the upper
vertebra slips forward on the lower; it is
graded according to the percentage slip,
measured by relating the slipped vertebra
to the one below

Torticollis
• head is tilted
towards and
rotated away
from the tight
sternocleidomast
oid muscle

• Congenital torticollis
• Acquired torticollis

Congenital torticollis
• Intrauterine moulding
• Sternocleidomastoid contracture
• a palpable ‘tumour’
• There is a strong correlation with DDH
• Most cases resolve with stretching but persistent
cases develop facial asymmetry and require
surgical release of the sternocleidomastoid at
one or both ends.

Acquired torticollis
• Acquired torticollis is less common and may
be caused
• by gastro-oesophageal reflux,
• posterior fossa tumour
• regional abnormality, inflammation/infection,
ocular problems or atlantoaxial rotatory
subluxation.