Slide 003 — DDH

Clean FRCS notes with inline figures

DDH

**Fig 3.** Radiograph / imaging - radiographmiddle left

Overall treatment principle:

•< 6 months

•Pavlik Harness

•Teratogenic irreducible → CR + arthrogram at 4 months

•6-18 months, or < 6 months fail Pavlik Harness

•Arthrogram + Closed reduction

•Open reduction

•> 18 months

•Open reduction +/- secondary femoral and acetabular procedures

Clinical photographs

**Fig 1.** Clinical photograph - clinical photographtop left

•Asymmetrical proximal skin crease

•Limited abduction of left thigh

•Galeazzi test left femur shortening

•r/o DDH

History

•FMHx, 1st born, female, breech, oligohydramnios, twin

Examination

•Asymmetrical thigh crease

•Ortolani (test whether hip is reducible, by elevation and abduction of the flexed femur)

•Barlow (test whether hip is subluxable, by adduction and depression of the flexed femur)

•Abduction ROM symmetrical? (Flexion abduction, most sensitive)

•Galeazzi test (false –ve on bilateral)

•Klisic sign (GT to ASIS, normal if at or above umbilicus)

•Older child: waddling gait with hyperlordosis of lumbar spine

•Ortolani and barlow both specific but not sensitive

Systemically look for associated features (packaging syndrome)

•Torticollis, congenital recurvatum / knee dislocation, calcaneovalgus feet, clubfoot, metatarsus adductus

•Rule out teratogenic dislocation

•Arthrogryposis

•CP / spina bifida

Type / group	Definition / note
Ix	USG (static and dynamic)

Management:

•Subluxable <2week → can be physiological，double napkin

•Dislocated + reducible or >2 weeks subluxable → Pavlik harness

•No need wait for USG to start PH if dislocatable and reducible clinically

•If dislocated and not reducible: can still try PH X 1 mth

Proposed aetiology:

•Genetic

•Mechanical: breech + knee in extension (strong hamstring act on hip)

•Maternal hormone: ligamental laxity esp in female fetus

•More common over the left side

What’s your view on screening program for DDH?

•Universal screening for DDH using USG has been an area of debate. Overall, found to have low sensitivity (89%) and poor PPV (62%), which leads on over diagnosis and treatment. Does not meet the WHO / Wilson criteria for universal screening.

•Wilson and Jungner criteria 1968

Diagnosis:

•Important health issue. Disease has high enough prevalence to allow screening

Natural history known

•Early sx phase + early treatment > late treatment

Test:

•Accepted by patient

•High sensitivity

•Available facilities

•Cost effective

Screen population features:

Accepted and effective treatment

•Patient are willing to undergo further evaluation and treatment

•2 studies

•2002 JBJS Norwegian group

Universal screening with USG – missed 1 case

Selective screening with USG – missed 5 cases

•No significant difference

•2009 JBJS international hip dysplasia institute

•3 groups

Universal screening

No screening

Selective screening

Selective screening found to be most cost effective

AAP suggest selective screening for:

•Abnormal PE

#	lvl	marL	indent	logical	original note line
1	0	None	None	0	DDH
2	0	None	None	0	Overall treatment principle:
3	0	None	None	0	< 6 months
4	1	None	None	1	Pavlik Harness
5	1	None	None	1	Teratogenic irreducible --> CR + arthrogram at 4 months
6	0	None	None	0	6-18 months, or < 6 months fail Pavlik Harness
7	1	None	None	1	Arthrogram + Closed reduction
8	1	None	None	1	Open reduction
9	0	None	None	0	> 18 months
10	1	None	None	1	Open reduction +/- secondary femoral and acetabular procedures
11	0	0	0	0	--------
12	0	0	0	0	Describe photos:
13	0	0	0	0	Asymmetrical proximal skin crease
14	0	0	0	0	Limited abduction of left thigh
15	0	0	0	0	Galeazzi test left femur shortening
16	0	171450	-171450	1	r/o DDH
17	0	0	0	0	Hx:
18	0	171450	-171450	1	FMHx, 1st born, female, breech, oligohydramnios, twin
19	0	0	0	0	PE
20	0	171450	-171450	1	Asymmetrical thigh crease
21	0	171450	-171450	1	Ortolani (test whether hip is reducible, by elevation and abduction of the flexed femur)
22	0	171450	-171450	1	Barlow (test whether hip is subluxable, by adduction and depression of the flexed femur)
23	0	171450	-171450	1	Abduction ROM symmetrical? (Flexion abduction, most sensitive)
24	0	171450	-171450	1	Galeazzi test (falve –ve on bilateral)
25	0	171450	-171450	1	Klisic sign (GT to ASIS, normal if at or above umbilicus)
26	0	171450	-171450	1	Older child: waddling gait with hyperlordosis of lumbar spine
27	0	0	0	0	Ortolani and barlow both specific but not sensitive
28	0	0	0	0	Systemically look for associated features (packaging syndrome)
29	0	171450	-171450	1	Torticollis, congenital recurvatum / knee dislocation, calcaneovalgus feet, clubfoot, metatarsus adductus
30	0	0	0	0	Rule out teratogenic dislocation
31	1	628650	-171450	2	Arthrogryposis
32	1	628650	-171450	2	CP / spina bifida
33	0	0	0	0	Ix: USG (static and dynamic)
34	0	0	0	0	Management:
35	0	171450	-171450	1	Subluxable <2week → can be physiological，double napkin
36	0	171450	-171450	1	Dislocated + reducible or >2 weeks subluxable → Pavlik harness
37	0	171450	-171450	1	No need wait for USG to start PH if dislocatable and reducible clinically
38	0	0	0	0	If dislocated and not reducible: can still try PH X 1 mth
39	0	0	0	0	------------------------------
40	0	0	0	0	Proposed aetiology:
41	0	171450	-171450	1	Genetic
42	0	171450	-171450	1	Mechanical: breech + knee in extension (strong hamstring act on hip)
43	0	171450	-171450	1	Maternal hormone: ligamental laxity esp in female fetus
44	0	0	0	0	More common over the left side
45	0	0	0	0	What’s your view on screening program for DDH?
46	0	0	0	0	Universal screening for DDH using USG has been an area of debate. Overall, found to have low sensitivity (89%) and poor PPV (62%), which leads on over diagnosis and treatment. Does not meet the WHO / Wilson criteria for universal screening.
47	0	0	0	0	Wilson and Jungner criteria 1968
48	0	0	0	0	Dx:
49	0	228600	-228600	1	Important health issue. Disease has high enough prevalence to allow screening
50	0	228600	-228600	1	Natural history known
51	0	228600	-228600	1	Early sx phase + early treatment > late treatment
52	0	0	0	0	Test:
53	0	228600	-228600	1	Accepted by patient
54	0	228600	-228600	1	High sensitivity
55	0	228600	-228600	1	Available facilities
56	0	228600	-228600	1	Cost effective
57	0	0	0	0	Screen population features:
58	0	228600	-228600	1	Accepted and effective treatment
59	0	228600	-228600	1	Patient are willing to undergo further evaluation and treatment
60	0	0	0	0	2 studies
61	0	0	0	0	2002 JBJS Norwegian group
62	0	171450	-171450	1	Universal screening with USG – missed 1 case
63	0	171450	-171450	1	Selective screening with USG – missed 5 cases
64	0	171450	-171450	1	No significant difference
65	0	0	0	0	2009 JBJS international hip dysplasia institute
66	0	171450	-171450	1	3 groups
67	0	171450	-171450	1	Universal screening
68	0	171450	-171450	1	No screening
69	0	171450	-171450	1	Selective screening
70	0	171450	-171450	1	Selective screening found to be most cost effective
71	0	0	0	0	AAP suggest selective screening for:
72	0	171450	-171450	1	Abnormal PE
73	0	171450	-171450	1	Patients with risk factor: FHx, breech

#	semantic level	section?	rewritten line
1	0		DDH
2	0	yes	Overall treatment principle:
3	1		< 6 months
4	1		Pavlik Harness
5	1		Teratogenic irreducible → CR + arthrogram at 4 months
6	1		6-18 months, or < 6 months fail Pavlik Harness
7	1		Arthrogram + Closed reduction
8	1		Open reduction
9	1		> 18 months
10	1		Open reduction +/- secondary femoral and acetabular procedures
11	0		——
12	0	yes	Clinical photographs
13	1		Asymmetrical proximal skin crease
14	1		Limited abduction of left thigh
15	1		Galeazzi test left femur shortening
16	1		r/o DDH
17	0	yes	History
18	1		FMHx, 1st born, female, breech, oligohydramnios, twin
19	0	yes	Examination
20	1		Asymmetrical thigh crease
21	1		Ortolani (test whether hip is reducible, by elevation and abduction of the flexed femur)
22	1		Barlow (test whether hip is subluxable, by adduction and depression of the flexed femur)
23	1		Abduction ROM symmetrical? (Flexion abduction, most sensitive)
24	1		Galeazzi test (false –ve on bilateral)
25	1		Klisic sign (GT to ASIS, normal if at or above umbilicus)
26	1		Older child: waddling gait with hyperlordosis of lumbar spine
27	1		Ortolani and barlow both specific but not sensitive
28	0	yes	Systemically look for associated features (packaging syndrome)
29	1		Torticollis, congenital recurvatum / knee dislocation, calcaneovalgus feet, clubfoot, metatarsus adductus
30	1		Rule out teratogenic dislocation
31	2		Arthrogryposis
32	2		CP / spina bifida
33	1		Ix: USG (static and dynamic)
34	0	yes	Management:
35	1		Subluxable <2week → can be physiological，double napkin
36	1		Dislocated + reducible or >2 weeks subluxable → Pavlik harness
37	1		No need wait for USG to start PH if dislocatable and reducible clinically
38	1		If dislocated and not reducible: can still try PH X 1 mth
39	0		——
40	0	yes	Proposed aetiology:
41	1		Genetic
42	1		Mechanical: breech + knee in extension (strong hamstring act on hip)
43	1		Maternal hormone: ligamental laxity esp in female fetus
44	1		More common over the left side
45	0	yes	What’s your view on screening program for DDH?
46	1		Universal screening for DDH using USG has been an area of debate. Overall, found to have low sensitivity (89%) and poor PPV (62%), which leads on over diagnosis and treatment. Does not meet the WHO / Wilson criteria for universal screening.
47	1		Wilson and Jungner criteria 1968
48	0	yes	Diagnosis:
49	1		Important health issue. Disease has high enough prevalence to allow screening
50	0	yes	Natural history known
51	1		Early sx phase + early treatment > late treatment
52	0	yes	Test:
53	1		Accepted by patient
54	1		High sensitivity
55	1		Available facilities
56	1		Cost effective
57	0	yes	Screen population features:
58	0	yes	Accepted and effective treatment
59	1		Patient are willing to undergo further evaluation and treatment
60	1		2 studies
61	1		2002 JBJS Norwegian group
62	0	yes	Universal screening with USG – missed 1 case
63	0	yes	Selective screening with USG – missed 5 cases
64	1		No significant difference
65	1		2009 JBJS international hip dysplasia institute
66	1		3 groups
67	0	yes	Universal screening
68	0	yes	No screening
69	0	yes	Selective screening
70	0	yes	Selective screening found to be most cost effective
71	0	yes	AAP suggest selective screening for:
72	1		Abnormal PE
73	0	yes	Patients with risk factor: FHx, breech

003. DDH

Clean FRCS notes with inline figures

DDH

Overall treatment principle:

Clinical photographs

History

Examination

Systemically look for associated features (packaging syndrome)

Management:

Proposed aetiology:

What’s your view on screening program for DDH?

Diagnosis:

Natural history known

Test:

Screen population features:

Accepted and effective treatment

Universal screening with USG – missed 1 case

Selective screening with USG – missed 5 cases

Universal screening

No screening

Selective screening

Selective screening found to be most cost effective

AAP suggest selective screening for:

Patients with risk factor: FHx, breech

Direct Q&A

Asymmetrical proximal skin crease

FMHx, 1st born, female, breech, oligohydramnios, twin

Asymmetrical thigh crease

Torticollis, congenital recurvatum / knee dislocation, calcaneovalgus feet, clubfoot, metatarsus adductus

Rule out teratogenic dislocation

Genetic

Early sx phase + early treatment > late treatment

No significant difference

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes