Chapter 25- Neonatal Hip

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laterally, superiorly

In the subluxed/ dislocated coronal neutral view, the femoral head gradually migrates ____ and _____ with decreased coverage of the femoral head

developmental displacement of the hip

Indications for neonatal hip sonography include the presence of risk factor for __________, and abnormal hip examination, and the need to evaluate the response to treatment

yes

Is displacement of the hip common?

dynamic

Is the static or dynamic approach more commonly used in the diagnosis of DDH?

hyaline cartilage

Most common type of cartilage; it is found on the ends of long bones, ribs, and nose

acquired, teratogenic, developmental

Neonatal hip dislocation can be _____, _____, or ______

hypertension, growth, membranes, gestation, weight

Other risk factors for DDH include: *maternal _____ *fetal _____ restriction *oligohydramnios *premature rupture of ______ *prolonged ________ *increased birth ______ *potter's syndrome *neonatal intensive care

static

Professor Reinhard Graf, an Austrian orthopedic surgeon, introduced the _____ technique in the United States in 1980

alpha angle

The _____ is used in ultrasonographic assessment of developmental dysplasia of the hip. The angle is formed by the acetabular roof and the vertical cortex of the ilium

primigravid

The _____ uterus is smaller than the multigravida uterus and is therefore more confining and offers less mobility.

beta, labrum

The ______ angle is formed by the baseline iliac bone and the inclination of the anterior cartilaginous acetabular roof with the ______ as the key landmark

femoral artery, external iliac artery, profunda femoris

The ______ is the principal artery of the upper thigh. It is a continuation of the _______. The femoral artery branches into the _____, which is the main artery supply for the thigh muscles

sacroiliac, pubic symphysis

The ______ joints unite the two hip bones with the sacral part of the vertebral column. The _______ is where the two hip bones unite with each other anteriorly

piriformis

The ______ muscle is immediately posterior to the hip joint, and the obturator internus and the gemelli and quadrates femoris are lower down

coronal/neutral

The ______ view is performed with the infant in the supine position from the lateral aspect of the hip joint with the place of the transducer oriented coronally with respect to the hip joint

saphenous opening, great saphenous

The _______ is the gap in the fascia lata that is found about 4 cm inferior and lateral to the pubic tubercle. The ______ vein passes through this opening to enter the femoral vein

sciatic nerve

The _______ is the largest nerve in the upper thigh. It enters the gluteal region from the pelvis to run caudally down the back of the thigh

Barlow, ortolani

The ________ test determines whether the hip can be dislocated, and the ______ test determines the opposite if the dislocated hip can be reduced

alpha

The acetabulum may be assessed visually with the _____ and beta angles, noting the depth and angulation of the acetabular roof as well as the appearance of the labrum.

ace tabular roof, ilium

The alpha angle is composed of the _______ and the vertical cortex of the ______

alpha

The angle between the baseline and the acetabular roofline that represents the osseous acetabulum is the _______ angle

beta

The angle between the baseline and the inclination line is the _____ angle

acetabulum

The articulation of the head of the femur with the ______ of the hip bone forms the hip joint

neutral, flexion, flexion, neutral

The basic hip anatomy is imaged in four different views 1. coronal/ _______ 2. coronal/ ______ 3. transverse/ _______ 4. transverse/ ________

normal, subluxed, dislocated

The sonographic appearance of the femoral head is described as ____, ____, or _____

motion, stress

The stability of the hip os determined through guided _____ and the application of gentle _____

barlow, ortolani

The stress maneuvers of the sonographic exam are the imaging counterparts of the clinical ____ and ____ maneuvers

inguinal, gluteal

The thigh is the upper part of the lower extremity. The anterior surface of the thigh is continuous with the ______ region of the abdomen. The posterior surface of the thigh is inferior to the ______ region, which is at the back of the pelvis and hip joint

coronal/flexion

The transducer is maintained in the lateral position while the hip is moved into a 90 degree angle of flexion in the ______ view. During this assessment, the transducer is moved in an anteroposterior direction with respect to the body to allow visualization of the entire hip

femur, head

The upper part of the thigh is the ____, which is surrounded by muscles, ligaments, and tendons. The upper part of the femur, the _____, articulates with the hip bone to make a hip joint

developmental displacement of the hip

What is DDH?

closed reduction

What is the initial treatment of uncomplicated DDH?

labrum

When a hip is frankly dislocated, the _____ may be deformed

medially, laterally

When the trochanter moves forward, the femur rotates _____, and when the trochanter moves backward the femur rotates ______

iliac

With superior dislocations, the femoral head may rest against the _____ bone

2/3

____ of the femoral head should be covered by the acetabulum

stability

_____ testing is reported as normal, lax, subluxable, dislocatable, and reducible or irreducible

closed reduction

______ is accomplished by placing two diapers on the neonate or by using a spica cast, Pavlik harness, or brace.

extension

______ is bending backward

adduction

______ is moving sideways inward

abduction

______ is moving sideways outward

teratogenic

_______ dislocations occur in utero and are associated with neuromuscular disorders

flexion

_______ is bending forward

lateral rotation

_______ is turning outward

medial rotation

________ is turning inward

developmental displacement of the hip

__________ is a new term that includes dysplastic, sublimated, dislocatable, and dislocated hips.

breech, low

A _____ birth and _____ birth weight are also risk factors for DDH

acetabulum

A dislocated hip has no contact with or coverage by the _______

plane, position

A two word combination is used to label the views of the hip according to the ______ of the body and the ______ or the hips

traumatic, nontraumatic

Acquired causes of hip dislocation can be _____ or _____

adduction

An example of hip _____ is crossing your legs when in a seated position

galeazzi sign

By visual inspection, the dislocated hip shows asymmetric skin folds and shortening of the affected thigh. The knee is lower in position on the affected side when the patient is supine and the knees are flexed. This is called _______

labrum

Cartilage that forms a rim around the socket of the hip joint

20, hamstrings, gluteus maximus

Extension of the hip is limited to _____ degrees by tension in the iliofemoral ligament and the flexor muscles, and it is brought about by the ______ and _____

caucasians

DDH affects _____ more than african americans

firstborn, females

Developmental displacement of the hip usually affects the _____ child, with _____ affected more frequently

4

During the neonatal period, the first ____ weeks of life, there is a physiologic laxity of the ligaments about the hip that makes the hip unstable

60, 43, 30, 43, 77, 43

Graf's classification of neonatal hips: Type 1= normal; alpha angle less than ____ degrees Type 2= alpha angle between ___ and ___ degrees Type 3= alpha angle of less than _____ degrees and beta angle greater than ____ degrees Type 4= alpha angle less than _____ degrees, beta angle immeasurable

lazy "y"

Graf's standard sonographic image is acquired in the coronal plane at the midacetabular level. This image includes: 1. femoral head 2. acetabulum 3. labrum 4. iliac bone as it meets the triradiate cartilage *This produces a coronal image of the hip, which has a configuration of a _____

dynamic, lateral, posterolateral, orthogonal, adduction, abduction

Harcke and Graf formulated basic standards for ______ hip sonography, which is currently used in most clinical situations today. *All scanning is performed from the _____ or _____ aspect of the hip. The hip is imaged in _____ planes (coronal and transverse) *Images of the hip are obtained in the coronal/extension/flexion and transverse/extension/flexion positions *When the hip is flexed, the femur is moved through a range of ____ and _____, with stress views performed in the flexed position

4

How many different classifications are there in Graf's classification of neonatal hips?

1, 2

If the physical exam is abnormal at birth, sonography of the hip should be done within ___ to ___ weeks of age

sacrum, left, frank

In breech presentation, the fetus' hip rests against the maternal _______ and is usually flexed, which limits movement. This usually affects the _____ hip. The _____ breech presentation of the fetus is the highest risk because the hips are maximally flexed and the knees are extended.

triradiate

In posterior dislocations, the femoral head is seen lateral to the posterior lip of the _______ cartilage

posteriorly, laterally

In subluxation, the femoral head is displaced ______, ______, or both with respect to the acetabulum.

femoral head, acetabulum, iliac line

In the ball on a spoon description of the normal infant hip in the coronal plane, the _______ is the ball and the _______ forms the spoon. The _______ is the handle

irregular, angled, echogenic

In the case of hip dysplasia in the coronal/neutral view, the acetabular roof is _____ and ______. The labrum is defected superiorly and becomes _____ and thickened

femoral head, stretch, acetabulum

In the newborn period, the femoral head may dislocate in the lateral and posterosuperior position relative to the acetabulum. When this occurs, the femoral head can usually be reduced without deformity to the joint. When the dislocation is not recognized early, the muscles tighten and limit movements, which causes the acetabulum to become dysplastic because it lacks the stimulation of the _______. In turn, the ligamentous structures ______ and fibrofatty tissue occupies the _______, making it impossible to return the femoral head into the acetabulum.

subluxation

In the normal infant, the femoral head is congruently positioned within the acetabulum. Mild displacement, or _______, is when the head is either in contact with part of the acetabulum or is displaced, but partly covered.

normal, immature, dysplastic

Sonographic description of the acetabulum is assessed visually and is described as _____, _____, or ______

hypoechoic, echogenic

Sonographically, the femoral head is ______ because it is cartilaginous and contains focal ______ ossification nucleus

hypoechoic, echogenic

Sonographically, the femoral head is _______ because of its cartilaginous nature and it contains focal ______ ossification nucleus

high, linear

Sonography of the neonatal hip is performed with a ____ frequency _____ array transducer

triradiate cartilage

The Y shaped growth plate that separates the three separate hip bones in childhood is called _______ _____

alpha

The _____ angle measures the inclination of the posterior and superior osseous acetabular rim with respect to the lateral margin of the iliac bone

alpha, beta

The _____ angle reflects changes in the cartilaginous acetabulum, which occur more quickly than do changes in the osseous acetabulum and may therefore be more sensitive than the _____ angle

left

The _____ hip is more commonly affected with DDH, with only a small number of cases affecting both hips

femoral triangle

The _____ is formed by the inguinal ligament, the adductor longs (medially), and the sartorial (laterally)

acetabulum

The _____ is not usually visualized in a dislocation because the bony shaft of the femur blocks the view

labral, echogenic triangle, 77, alpha angle

The beta angle is used in the ultrasonographic assessment of developmental dysplasia of hip. The angle formed between the vertical cortex of the ilium and the triangular _____ firbocartilage, which appears as an _____ _____. The normal value is less than ______ degrees, but is only useful in assessing immature hips when combined with the _______.

ilium, ischium pubis, triradiate cartilage

The bony acetabulum consists of the ____, _____, and _____, which is joined by a growth plate known as the _________

pectineus, iliacis

The contents of the femoral triangle are separated from more deeply lying hip joint by muscles; the _____ is medial and the _______ is lateral

canal, vein, artery

The contents of the femoral triangle include the femoral ____, the femoral ______ and ______, and the femoral nerve

fascia lata

The deep fascia of the thigh, the ______, forms a tough connective tissue surrounding the muscles. The part of the fascia on the lateral part of the thigh is the iliotibial tract as it extends from the iliac crest to the lateral condyle of the tibia

females

The femoral head begins to ossify earlier in ______

cartilagenous, 2, 8

The femoral head is _____ at birth and begins to ossify between ____ and ____ months

echogenic

The femoral head sits within the acetabulum, which is _____ and has a deep concave configuration

echogenic

The femoral head sits within the acetabulum, which is _______ and has a deep concave configuration

sheath

The femoral vein and artery and the femoral canal are enclosed in a connective tissue sleeve called the femoral _____

4

The femur head should be stable within the acetabulum with stress after ____ weeks of age

minimus

The gluteus _____ muscle is the immediate cover for the upper part of the hip joint, whereas the orbturator externus is found winding below it from front to back

ilium, ischium, pubis

The hip bones are the fusion of three separate bones: the ____, ____, and _____

ball and socket

The hip is a _______ joint that is held together by ligaments

hyaline, hypoechoic

The labrum is composed of ______ cartilage and is _____, except at its hip

ball on a spoon

The normal infant hip should have the appearance of a ____________ on the coronal flexion view

60

The normal value for the alpha angle is greater or equal to _____ degrees

2, 8, girls, one

The ossification of the femoral head begins between ___ and ___ months of age, occurs earlier in ____, and is often completed by age __

iliofemoral ligament

The outside of the capsule that surrounds the hip joint is reinforced by ligaments. The most important of these is the ______, which blends with the front of the capsule.

flexors

The primary ______ of the hip are the psoas major, the iliacus, and the rectus femoris

capsule

The primary cause of DDH is thought to be a gradual migration of the femoral head from the acetabulum because of the loose, elastic joint ______. In addition, other factors, such as genetic, mechanical, and physiologic- are thought to play a role

position, stability, acetabulum

The primary objective of the dynamic hip assessment is to determine the ______ and ______ of the femoral head and the development of the _______

lateral, posterolateral

The primary sonographic imaging of the neonatal hip is performed from the _____ or ______ aspect of the hip while moving the hip from the neutral position at rest into one in which the hip is flexed

femur, acetabulum

The rounded shape of the _____ and the cup shape of the ______ form the ball and socket hip joint

dislocation, dysplasia, first, pain

There are two conditions in which sonography offers advantages over other imaging modalities: 1. developmental _____ or _____ (seen in ___ year of life) 2. hip _____, which may be caused by inflammatory or traumatic conditions

position, stability, acetabulum

Throughout the examination, the sonographer is able to assess the _____ and ______ of the femoral head in addition to assessing the development of the _______

pelvic girdle

Together, the ilium, ischium, and pubis form the ______

the patient walks

Treatment for DDH should occur before when?

barlow, ortolani

Two basic maneuvers are helpful in the diagnosis of DDH. The _____ maneuver determines if the hip can be dislocated. The _____ maneuver determines if the dislocated femoral head can be reduced back into the acetabulum.

static, dynamic

Two sonographic techniques are used in the diagnosis of DDH: _____ and ______

labrum

Two thirds of the femur head should be covered by the ________, which is narrow and has a triangular shape

acetabulum

the cup-shaped hollow in the hipbone into which the head of the femur fits to form a ball-and-socket joint


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