Slide 007 — DDH presentation at 6

Clean FRCS notes with inline figures

•Presentation 6-18mths

Check *XR features of DDH

**Fig 1.** Radiograph / imaging - radiographtop left

Radiographic description

•Subluxation of hip

•Hilgenreiner’s line (horizontal line through superior edge of triradiate cartilage)

•Perkin’s line (lateral aspect of acetabular roof and perpendicular to H line)

•Quadrant, Shenton's line

Acetabulum morphology

•Tear drop morphology (internal and external acetabular wall)

•Acetabular index (normal range change according to age, <2y.o. → less than 30deg, >2y.o. → less than 20deg, take <25 deg)

•Small femoral ossification center

•→ Tonnis grade III DDH

•Also need Von Rosen views (Abduction IR view to assess dislocation)

•History should ask about birth history, breech presentation, first born child, FHx. Other perinatal complications

Examination

•Examine for other packaging disorders – torticollis, clubfoot, metatarsus adductus

•Look for other signs of neuromuscular conditions e.g. spina bifida, arthrogryposis, CP (teratogenic dislocation)

•Asymmetric groin crease, LLD, galeazzi test

•Barlow and Ortolani not relevant in these cases

•Check F/abd ROM

•Document NV status

•Cannot use PH beyond 6m

•Traction before reduction

•- Fallen out of favour (though still practice in France, Japan)

•Treatment: Arthrogram, CR +/- OR + hip spica cast (for 12 weeks)

•GA

•Gentle CR with Flexion, traction, abduction (Ortolani maneuver)

•Determine Ramsey safety zone (cut off 40 degrees)

•Adductor tenotomy (done first to reduce intracapsular pressure)

Arthrogram: Medial subadductor approach

•+/- OR

•Spica cast in human position

•Postop CT to assess for AP congruency

How to apply spica cast?

•Place child on spica table

•Place folded towel over anterior chest (allow fully stomach after eating)

•Apply stockinette over torso

•Apply cotton wrap/ gortex wrap

•Apply felt over bony prominence

•Apply cast in “human position” 100 flexion 50 degree abduction

•Trunk to foot for affected side, to thigh only for normal side

•Cast window to allow perineal care

•Cast for 6 weeks, then another 6 weeks in “human position” (cast 12 week total), followed by further 6 weeks in a removable abduction brace

#	lvl	marL	indent	logical	original note line
1	0	None	None	0	Presentation 6-18mths
2	0	None	None	0	Check *XR features of DDH
3	0	None	None	0	Describe Xray:
4	0	171450	-171450	1	Subluxation of hip
5	1	628650	-171450	2	Hilgenreiner’s line (horizontal line through superior edge of triradiate cartilage)
6	1	628650	-171450	2	Perkin’s line (lateral aspect of acetabular roof and perpendicular to H line)
7	1	628650	-171450	2	Quadrant, Shenton's line
8	0	171450	-171450	1	Acetabulum morphology
9	1	628650	-171450	2	Tear drop morphology (internal and external acetabular wall)
10	1	628650	-171450	2	Acetabular index (normal range change according to age, <2y.o. → less than 30deg, >2y.o. → less than 20deg, take <25 deg)
11	0	171450	-171450	1	Small femoral ossification center
12	0	0	0	0	→ Tonnis grade III DDH
13	0	None	None	0	Also need Von Rosen views (Abduction IR view to assess dislocation)
14	0	None	None	0	Go back to history enquiring about birth history, breech presentation, first born child, FHx. Other perinatal complications
15	0	None	None	0	PE:
16	0	None	None	0	Examine for other packaging disorders – torticollis, clubfoot, metatarsus adductus
17	0	0	0	0	Look for other signs of neuromuscular conditions e.g. spina bifida, arthrogryposis, CP (teratogenic dislocation)
18	0	None	None	0	Asymmetric groin crease, LLD, galeazzi test
19	0	None	None	0	Barlow and Ortolani not relevant in these cases
20	0	None	None	0	Check F/abd ROM
21	0	None	None	0	Document NV status
22	0	None	None	0	Cannot use PH beyond 6m
23	0	None	None	0	Traction before reduction
24	0	None	None	0	- Fallen out of favour (though still practice in France, Japan)
25	0	None	None	0	Treatment: Arthrogram, CR +/- OR + hip spica cast (for 12 weeks)
26	0	228600	-228600	1	GA
27	0	228600	-228600	1	Gentle CR with Flexion, traction, abduction (Ortolani maneuver)
28	0	228600	-228600	1	Determine Ramsey safety zone (cut off 40 degrees)
29	0	228600	-228600	1	Adductor tenotomy (done first to reduce intracapsular pressure)
30	0	228600	-228600	1	Arthrogram: Medial subadductor approach
31	0	228600	-228600	1	+/- OR
32	0	228600	-228600	1	Spica cast in human position
33	0	228600	-228600	1	Postop CT to assess for AP congruency
34	0	0	0	0	How to apply spica cast?
35	0	228600	-228600	1	Place child on spica table
36	0	228600	-228600	1	Place folded towel over anterior chest (allow fully stomach after eating)
37	0	228600	-228600	1	Apply stockinette over torso
38	0	228600	-228600	1	Apply cotton wrap/ gortex wrap
39	0	228600	-228600	1	Apply felt over bony prominence
40	0	228600	-228600	1	Apply cast in “human position” 100 flexion 50 degree abduction
41	0	228600	-228600	1	Trunk to foot for affected side, to thigh only for normal side
42	0	228600	-228600	1	Cast window to allow perineal care
43	0	0	0	0	Cast for 6 weeks, then another 6 weeks in “human position” (cast 12 week total), followed by further 6 weeks in a removable abduction brace

#	semantic level	section?	rewritten line
1	0		Presentation 6-18mths
2	0	yes	Check *XR features of DDH
3	0	yes	Radiographic description
4	1		Subluxation of hip
5	2		Hilgenreiner’s line (horizontal line through superior edge of triradiate cartilage)
6	2		Perkin’s line (lateral aspect of acetabular roof and perpendicular to H line)
7	2		Quadrant, Shenton's line
8	0	yes	Acetabulum morphology
9	2		Tear drop morphology (internal and external acetabular wall)
10	2		Acetabular index (normal range change according to age, <2y.o. → less than 30deg, >2y.o. → less than 20deg, take <25 deg)
11	1		Small femoral ossification center
12	1		→ Tonnis grade III DDH
13	1		Also need Von Rosen views (Abduction IR view to assess dislocation)
14	1		History should ask about birth history, breech presentation, first born child, FHx. Other perinatal complications
15	0	yes	Examination
16	1		Examine for other packaging disorders – torticollis, clubfoot, metatarsus adductus
17	1		Look for other signs of neuromuscular conditions e.g. spina bifida, arthrogryposis, CP (teratogenic dislocation)
18	1		Asymmetric groin crease, LLD, galeazzi test
19	1		Barlow and Ortolani not relevant in these cases
20	1		Check F/abd ROM
21	1		Document NV status
22	1		Cannot use PH beyond 6m
23	1		Traction before reduction
24	1		- Fallen out of favour (though still practice in France, Japan)
25	1		Treatment: Arthrogram, CR +/- OR + hip spica cast (for 12 weeks)
26	1		GA
27	1		Gentle CR with Flexion, traction, abduction (Ortolani maneuver)
28	1		Determine Ramsey safety zone (cut off 40 degrees)
29	1		Adductor tenotomy (done first to reduce intracapsular pressure)
30	0	yes	Arthrogram: Medial subadductor approach
31	1		+/- OR
32	1		Spica cast in human position
33	1		Postop CT to assess for AP congruency
34	0	yes	How to apply spica cast?
35	1		Place child on spica table
36	1		Place folded towel over anterior chest (allow fully stomach after eating)
37	1		Apply stockinette over torso
38	1		Apply cotton wrap/ gortex wrap
39	1		Apply felt over bony prominence
40	1		Apply cast in “human position” 100 flexion 50 degree abduction
41	1		Trunk to foot for affected side, to thigh only for normal side
42	1		Cast window to allow perineal care
43	1		Cast for 6 weeks, then another 6 weeks in “human position” (cast 12 week total), followed by further 6 weeks in a removable abduction brace

007. DDH presentation at 6–18 months

Clean FRCS notes with inline figures

Check *XR features of DDH

Radiographic description

Acetabulum morphology

Examination

Arthrogram: Medial subadductor approach

How to apply spica cast?

Direct Q&A

Subluxation of hip

Examine for other packaging disorders – torticollis, clubfoot, metatarsus adductus

+/- OR

Place child on spica table

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes