An orthopedician adducts the flexed hip and gently pushes the thigh posteriorly in an effort to dislocate the femoral head of a neonate. What is this maneuver called?
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Correct Answer:
Barlow test
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D i.e. Barlow testRef: Nelson, Textbook of Pediatrics, 20th edition, page 3274Developmental Dysplasia of the Hip (DDH)Ranges from simple acetabular dysplasia, acetabular dysplasia plus subluxation to dislocation of the hip joint.Two major groups:Typical (otherwise normal individuals without defined syndromes or genetic conditions); andTeratologic (with identifiable causes) - small, shallow acetabulum and a stiff hip joint at birth.1-1.5 of 1000 live births, multifactorial etiology, involving both genetic and intrauterine environmental factors.Marked geographic and racial variation (Positive family history 12-33% of affected patients).Common - female patients, left hip (maternal hormones such as relaxin, which increases ligamentous laxity) and delivered by cesarean section.High rate of association in tighter intrauterine space (oligohydramnios, large birth weight, and first pregnancy) which supports the "crowding phenomenon" theory.Untreated typical DDH have changes may include (hypertrophy of the lateral cartilage of the acetabulum (neolimbus formation), hypertrophy of the ligamentum teres, capsular laxity, hourglass constriction of the hip capsule and hypertrophy of the transverse acetabular ligament, and excess femoral anteversion).Clinical Findings:CharactersBarlow testOrtolani testIntroductionProvocative maneuver / assesses the potential for dislocation of a nondisplaced hipNonforced maneuver / reverse of Barlow test- attempt to reduce a dislocated hipMethodAdducts the flexed hip and gently pushes the thigh posteriorly in an effort to dislocate the femoral headGrasps the child's thigh between the thumb and index finger and, with the 4th and 5th fingers, lifts the greater trochanter while simultaneously abducting the hipPositive testThe hip will be felt to slide out of the acetabulum and while relaxing the proximal push, the hip can be felt to slip back into the acetabulumThe femoral head will slip into the socket with a delicate "clunk" that is palpable but usually not audible Hip click - high-pitched sensation (or sound) felt at the very end of abduction during testing for DDH with Barlow and Ortolani maneuvers (originate in the ligamentum teres or occasionally in the fascia lata or psoas tendon and do not indicate a significant hip abnormality).Hip clunk - which is felt as the hip goes in and out of joint (signifies hip abnormality).Infant (1 to 3 months of age ) - hip is no longer reducible, limited hip abduction (most reliable sign of a dislocated hip), apparent shortening of the thigh, proximal location of the greater trochanter, asymmetry of the gluteal or thigh folds and pistoning of the hip.Galeazzi sign (Shortening of the thigh): Placing both hips in 90 degrees of flexion and comparing the height of the knees, looking for asymmetry.Klisic testPlaces the 3rd finger over the greater trochanter and the index finger of the same hand on the anterior superior iliac spine.* Normal hip - an imaginary line drawn between the two fingers points to the umbilicus.* Dislocated hip - the trochanter is elevated, and the line projects halfway between the umbilicus and the pubis.Walking child-Limp (toe-walk on the affected side), a waddling gait, leg-length discrepancy, positive trendelenburg sign and excessive lordosis.Ultrasonographic Findings:In < 6 mo of age - acetabulum and proximal femur are cartilaginous and not visible on plain radiographs and are best visualized with ultrasonography,Dynamic assessment about the stability of the hip joint.Monitor acetabular development, particularly of infants in Pavlik harness treatment.Radiographic Findings:> 6 mo of age. Anteroposterior view of the pelvis - use of several classic lines drawn on itLineTypeLandmarksInterpretationHilgenreiner lineHorizontallineDrawn through the top of both triradiate cartilages (the clear area in the depth of the acetabulum).* Perpendicular to the Hilgenreiner line* Ossific nucleus of the femoral head should be located in the medial lower quadrant of the intersection of these two linesPerkins lineVerticallineThrough the most lateral ossified margin of the roof of the acetabulumShenton lineCurvedlineDrawn from the medial aspect of the femoral neck to the lower border of the superior pubic ramus* Line is a continuous contour - normal* Two separate arcs / "broken" - in DDHAcetabular indexAngleFormed between the Hilgenreiner line and a line drawn from the depth of the acetabular socket to the most lateral ossified margin of the roof of the acetabulum (angle measures the development of the osseous roof of the acetabulum)* Newborn, the acetabular index can be up to 40 degrees* By 4 months in the normal infant, it should be no more than 30 degreesIn older childCenter-edge angleAngleFormed at the juncture of the Perkins line and a line connecting the lateral margin of the acetabulum to the center of the femoral head* 6-13 years old, an angle >19 degrees - normal* >14 years and older, an angle >25 degrees - normal Treatment Goals: Obtain and maintain a concentric reduction of the femoral head within the acetabulum.AgeTreatment< 6 months of age* Triple diapers or abduction diapers no role.* Pavlik harness - In normal newborns with all degrees of hip dysplasia.* Other braces - von Rosen splint, Frejka pillow.* 1 and 6 mo of age - Pavlik harness (full-time basis for 6 weeks), hip instability resolves in 95% of cases.* 6 months of age, the failure rate for the Pavlik harness is >50% (increasingly active and crawling child).6 months to 2 years* Closed reductions under general anesthesia. And casting in human position of moderate flexion and abduction for 12 weeks.* The replaced by an abduction orthotic device for 2 months (until acetabular development is normal).* Failure to obtain a stable hip needs open reduction.Older than 2 years of age* Open reduction is usually necessary.Sequlae: Avascular necrosis of the Capital Femoral epiphysis (< 6 months of age), redislocation, residual subluxation, and acetabular dysplasia.
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