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DDH and Vertibral coloumn.ppt

  2. • Developmental dysplasia of the hip (DDH) describes a variety of conditions in which the ball and socket of the hip do not develop properly.
  3. • 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
  4. 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
  5. Features • Limp • Limited abduction • Pain after exercise
  6. Diagnosis • Barlow’s test: • Ortolani test: • Ultrasound: monitor early treatment or screening • Radiography
  7. 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
  8. NEONATE Hips that remain unstable at 6 weeks or that are dislocated at rest, are treated with harnesses or splints.
  9. • 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.
  10. • 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
  12. 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.
  13. • Aetiology may be congenital (underlying bony malformation),neuromuscular, syndromic or idiopathic
  14. • ANATOMY • All the bony elements are altered • 1)vertebra are wedge shaped • 2)Poorly developed concave side • 3)Pedicle rotated
  15. • 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
  16. 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.
  17. • The Cobb angle is a radiological measurement that defines severity and helps to guide treatment.
  18. • 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
  19. 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
  20. • 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.
  21. • 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.
  22. • 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.
  23. 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.
  24. ETIOLOGY • (1) Genetic factors • (2) Neurologic disorders • (3) Hormonal and metabolic dysfunctions • (4) Skeletal growth • (5) Environmental and lifestyle factors
  25. • 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.
  26. 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.
  27. • 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.
  29. • 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
  30. 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.
  31. • 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.
  32. • 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
  33. • On physical examination, patients with upper thoracic Scheuermann disease present with a kyphotic deformity. • This is best demonstrated in the forward flexed position.
  34. • Radiographic diagnosis • Irregularities of the vertebral endplates, • anterior vertebral body wedging, • decreased intervertebral disc space height
  35. 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.
  36. OPERATIVE TREATMENT • Indications • Progressive kyphosis >75 degrees • significant kyphosis associated with pain • that is not alleviated by conservative treatment methods.
  37. • 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)
  38. 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.
  39. • Clinical features • 1)Prominence of buttock • 2)Back pain • 3)Pain radiating to lower limb
  40. 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
  41. • 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.
  42. • 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
  43. Torticollis • head is tilted towards and rotated away from the tight sternocleidomast oid muscle
  44. • Congenital torticollis • Acquired torticollis
  45. 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.
  46. 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.