Pediatric Hip Powerpoint
In the transverse/flexion view, the echoes from the bony acetabulum appear posteriorly to the femoral head and in the normal hip, a _____ is produced.
"U" configuration
the rounded shape of the femur and the cup shape of the acetabulum for the ____ hip joint.
"ball and socket"
ossific nucleus
bony formation appearing in the center of the femoral head (begins b/w 2-8 months of age)
all ___ babies should be scanned
breech
acetabular labrum (limbus cartilage)
cartilaginous ring surround the periphery of the acetabulum that aids in stabilizing the femoral head within the acetabulum
a displacement of the hip is a relatively common _____, which can be diagnosed in the early neonatal period.
congenital abnormality
(alpha and beta angles) acetabular roofline -
connects the lower edge of the medially acetabular roof to the osseous acetabular convexity
(alpha and beta angles) inclination line -
connects the osseous acetabular convexity to the labrum
(alpha and beta angles) baseline -
connects the osseous acetabular convexity to the point where the joint capsules and perichondrium unite
a two word combination is used to label the views according to the plane of the body: _____ and the position of the hips: ____
coronal or transverse neutral or flexed
In this view, a normal hip gives the appearance of a "Ball on a spoon" in the mid acetabulum. **the femoral head is the ball, the acetabulum forms the spoon, and the iliac line is the handle**
coronal/flexion
the alpha and beta angles may be measure from this view:
coronal/neutral
which view is stabilized with a physiologic amount of flexion?
coronal/neutral
In this view, the acetabular roof should have a concave configuration and cover at least half of the femoral head.
coronal/neutral view
In this view, the hypoechoic cartilage of the acetabular roof extend lateral to the acetabular lip, terminating in the echogenic labrum.
coronal/neutral view
in the ____ the femoral head is resting against the bony acetabulum.
coronal/neutral view
pavlik harness
corrective harness that supports the hips in flexion and abduction without force
acetabulum
cup shaped structure that articulates with the femoral head
Ortolani maneuver
determines if the dislocated hip can be reduce
a ____ hip is one in which the proximal femur can be displaced out of the acetabulum but can be reduced.
dislocatable
____ is the key to treatment, now evaluated as part of newborn physical exam.
early detection
in the transverse/flexion view, the bony shaft of the femur gives bright reflected ____ and is adjacent to the femoral head.
echoes anteriorly
the femoral head sits within the acetabulum, which is _____ and has a deep concave configuration (shape)
echogenic
The upper part of the femur (the head) articulates with the hip bone to make the ____.
hip joint
During the first 4 weeks of life there is physiologic laxity of the ligaments about the hip that allows the _____
hip to be unstable
(based on angle measurements hips are classified by types) type II =
hips must be monitored and follow up studies are required
(based on angle measurements hips are classified by types) Typy III and IV =
hips must be treated
the labrum is composed of ____ and is hypoechoic (except at its tip which is echogenic because of its fibrous content)
hyaline cartilage
the femoral head appears as a ____ with smooth borders containing numerous tiny echoes (bc it is cartilaginous and contains a focal echogenic ossification nucleus)
hypoechoic circle
Movements of Hip (abduction)
moving away from body/stabilizes
movements of hip (adduction)
moving toward body/stresses
the incidence of DDH is small, ranging from _____ per 1000 live births
1.5 - 1.7
newborns with a risk factor for DDH can be examined at ____ weeks.
4 - 6
the femoral head should be stable within the acetabulum with stress after ____ of age
4 weeks
the coronal/flexion view is performed the same as ___
neutral. then flex infants hip 90 degrees to bring femoral shaft perpendicular to table top. slide transducer posterior to visualize the posterior portion of the triradiate cartilage.
(based on angle measurements hips are classified by types) Type I =
normal
the "ball on the spoon" in the mid acetabulum in the coronal/flexion view describes a ____ hip.
normal
Hips are classified according to their behavior under stress as ____
normal, unstable, or dislocated
if dislocation is ____ in early infancy the muscles tighten and limit movement and the acetabulum is filled with fibrofatty tissue. It then becomes impossible to return the femoral head to the acetabulum with simple manipulation.
not recognized
subluxed
occurs when the femoral head moves posteriorly and remains in contact with the posterior aspect of the acetabulum
the greater trochanter of the femur form a _____ at the side of the region.
palpable knob
The primary objective of the dynamic hip assessment is to determine the ____
position and stability of the femoral head (as well as the development of the acetabulum)
Hip stability may ___ itself
resolve
left hip technique:
sonographer grasps the left leg with left hand and scans with right hand
right hip technique:
sonographer grasps the right leg with right hand and scans with left hand
transverse/neutral view Normal -
sonolucent femoral head is positioned against the bony acetabulum over the triradiate cartilage
a ____ hip is one in which the proximal femur moves (greater than 6mm on the left and 4mm on the right) within the acetabulum, but cannot be displaced out of it. Normal newborns may have minimal subluxation.
subluxable
when lesser degrees of abnormality, such as ___ are included, as many as 10 infants per 1000 live births may show some features of the disorder.
subluxation
baby should be ____ with feet toward the sonographer
supine
Coronal/Neutral view is performed with the infant in the ____ from the lateral aspect of the hip joint with the plane of the transducer oriented coronally with respect to the hip joint
supine position
push and pull maneuver in the coronal/flexion view: normal hip -
the femoral head is never seen over the posterior lip of the acetabulum
sublimated or dislocated
the head will migrate laterally and posteriorly, will have echogenic soft tissue b/w femoral head and acetabulum
Frank dislocation
the hip is laterally and posteriorly displaced to the extent that the femoral head has no contact with the acetabulum and the normal "U" configuration cannot be obtained on ultrasound
frank dislocation
the hip is laterally and posteriorly displaced to the extent that the femoral head has no contact with the acetabulum and the normal "U" configuration cannot be obtained on ultrasound
Barlow maneuver subluxation -
the hip will be normally positioned or mildly displaced at rest and there will be further lateral displacement from the medial acetabulum with stress, but the femoral head will remain in contact with a portion of the ischium.
The coronal/neutral view of the subluxed infant hip demonstrates
the mid portion of the acetabulum with the straight iliac line superiorly and the inferior tip of the ilium medially within the acebabulum (the echogenic tip of the labrum also should be visualized)
Ortolani maneuver is done in conjunction with the ___ view
transverse/flexion
from the ____ view the leg is brought down into a neutral position.
transverse/flexion
the this view the transducer is rotated 90 degrees and moved posteriorly into a posterolateral position over the hip joint
transverse/flexion
in this view the femoral head should sit firmly upon the ischial and pubic portions and centered over the triradiate cartilage
transverse/neutral
this plane passes through the femoral head into the acetabulum at the center of the triradiate cartilage.
transverse/neutral
____ of the femoral head should be covered by the labrum
two - thirds
Metaphysis
wide portion of a long bone between the epiphysis and the narrow diaphysis (considered apart of the growth plate)
Should the radiologist be present?
yes, since observing movement of the femoral head in relation to the acetublum is crucial.
Indications for hip sonography
- the presence of risk factors for developmental displacement of the hip -an abnormal hip examination -the need to evaluate the response to treatment
Possible treatments
-Ortilani Maneuver -Pavlov Harness -surgery
When exam is performed
-sonography can be performed until the femoral head ossifies (once the femoral head is completely ossified it is difficult to obtain adequate sonographic images bc of artifact) - not done until 3-4 wks after birth due to physiologic laxity -ossification of the femoral head begins between 2 and 8 months of age -occurs earlier in girl than boys -Is often complete by 1 year
if the physical examination is abnormal at birth, sonography of the hip should be done within ____ weeks.
1 - 2
2 components of the coronal/flexion view:
1. "push and pull" maneuver 2. the Barlow maneuver
List the 3 bones that make up the pelvis:
1. Ilium 2. Ischium 3. Pubis
The basic hip anatomy is imaged if 4 different views:
1. coronal/neutral 2. coronal/flexion 3. transverse/flexion 4. transverse/neutral
which maneuver determines if the hips can be dislocated?
Barlow maneuver
the term congenital dysplasia includes a very wide spectrum of pathology that usually occurs after birth. therefore the term has been replaced by _____
Development displacement of the hip (DDH) this term includes dysplastic, subluxated, dislocatable and dislocated hips.
Type of transducer and range?
Linear Array 5 - 7.5 MHz (can range higher or lower depending on age and size of patient **3 - 12MHz**)
In the normal hip, the femoral head is ___ seen over the posterior lip of the acetabulum.
Never
push and pull maneuver in the coronal/flexion view: unstable hip -
a portion of the femoral head appears over the posterior lip of the triradiate cartilage as the femur is pushed.
developmental displacement of the hip (DDH)
abnormal condition of the hip that results in congenital hip dysplasia. (Includes terms: dysplastic, sublimated, dislocatable, and dislocated hips)
Neonatal hip dislocation can be:
acquired -traumatic and non traumatic etiologies teratogenic - occur in utero and are associated with neuromuscular disorders developmental - (was formally known as congenital hip dysplasia)
The Barlow maneuver
adduction and gentle posterior pushing against the knee to see if the hip can be dislocated
Abduction is movement __________ from the body and stabilizes the hip.
away
Movements of Hip (extension)
bending leg backward
Movements of the hip (flexion)
bending leg forward
femur
bone of the upper thigh; surrounded by muscles, ligaments, and tendons.
Risk factors included with DDH
females (4:1) left hip more than rt. or both breech presentations oligohydramnios family history firstborns Caucasian other -maternal hypertension, IUGR, premature rupture, of membranes, prolonged gestation, increased birth weight, potter's syndrome, neonatal intensive care
transverse/neutral view suvluxed/dislocated -
femoral head usually moves posteriorly and remains in contact with the posterior aspect of the acetabulum
Barlow maneuver Normal -
femoral head will remain deeply in the acetabulum in contact with the ischium with stress.
pelvic girdle
formed by 3 hip bones: ilium, ischium, and pubis
the femoral head completely displaced out of the acetabulum describes what condition?
frank dislocation
Ortolani maneuver
gentle pulling and abduction of the femur
the joint Is not directly palpable because ___
it is surrounded and protected by muscles of the upper thigh
the ____ is narrow and has a triangular shape.
labrum
triradiate cartilage
landmark that connects the illium, ischium, and pubis (becomes ossified and fused in the teen years)