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Um I also look after older Children with D DH and I also run a club foot clinic. Um So I see lots of babies um with these conditions. So we'll get started. Uh a starter for 10, which is the abnormal hip, right or left to it. Yeah. Left. Brilliant, good. Ok. So what is D DH, so D DH isn't actually a thing. It's a spectrum of disorders and it involves an abnormal relationship between the ace and the femoral head and it can range all the way from just a touch of mild ace dysplasia all the way through to an irreducible high duplicate dislocation. And those two entities are very different things and DDH covers the whole spectrum. So what's the incidence? The incidence of a true dislocated hip is one in 1000. So actually quite common and the incidence of hip dysplasia is one in 100. So what are the risk factors? There are three risk factors which there is absolutely no doubt about. Ok. So female, because if you're female, you're four times more likely to have DDH than male if you breach presentation during the third trimester. And if there is a family history of D DH. So there is no doubt all of the um all the literature, all the publications confirm that. However, there is much debate about these other risk factors. So if a baby is tight within the uterus and is molded, inverted commas, so may also have torticollis, metatarsus, a ducts or calcanea valgus foot. There is some evidence that they may be at increased risk of D DH but that there are other studies which say that isn't the case and there is some evidence that it's probably increasing. Now that if a baby is born with a club foot, there are also an increased risk of having D DH. So in my club foot clinic, every baby who has a club foot gets an ultrasound um of their hips, but that isn't on the guidelines. So when you see a baby and you're assessing their hips, um what do we do? Well, the one that we're all taught in medical school is to check for instability within the hips and that's auto and Barlow tests. So the auto maneuver is this one and the way I remember it is or 00 for auto is oh And you put in the hips out as if to make an O shape. OK. So or, and what you're doing, your fingers on the top of the knees, you abduct the hips and your fingers underneath are pushing up on the femoral heads and what you're trying to do is push those femoral heads back into joint. So you will only get a positive or, or test if the hips are dislocated. And what you're doing is you're putting the dislocated hips pop back into joint. So there is a posterior dislocation and you're pushing them back up. A Barlow maneuver is the opposite. So you have a indicated hip and you're pushing back on it. So you put the knees at 90 degree, the hip, hips at 90 degrees flection, you put your thumbs on top of the knees and you're pushing backwards. And what you're doing is you are dislocating a hip that is in joint. So if you dislocate it, you're gonna go all and push it back in with your fingers. Ok? So they, they're doing the exact opposite things. If you have a high hip dislocation that is irreducible, your Barlow and auto maneuvers will be negative. Ok? So if the, if it's dislocated hip, that's irreducible, these will be negative. So just because these are negative does not mean you have a normal hip, ok? And that's a mistake. A lot of people make. So what other tests do we have? Because we know that Ala and Barlow are very, um, well, you, they, they're unreliable. So, a gal test is a good test. The way I do it is I flex the hips at 90 degrees and I put my thumbs on top of the knees and I look all my thumbs level because if the hip is dislocated, it is dislocated posteriorly. Um And the knee will be lower. Ok. So you will have unequal silence. So if you have unequal silence, so a positive Galii test, the chances are is that the hip is dislocated. Of course, you could have a dysplasia of the femur, you could have a short femur, but it's much, much more likely that the hip is dislocated. In previous studies, it was shown that the most reliable test for DDH is restricted hip abduction. Um There are studies since that showing that this may not be the case and the Gazi is better but restricted hip abduction. You can see that there's subtly restricted reduction here on the right compared to the left, it's often only 10 degrees. And if you're standing over the baby, you won't see it. You have to sort of look from the bottom of the bed to see the difference in the hip abduction. Um But you must do that. There is debate over whether asymmetric groin increases or thigh skin folds are important or not. I always look. Um but there are lots of other reasons, just a an unusual distribution of fat, for instance. So if you have that sign, it's a weak sign, you should always ultrasound. Um but it, it may be negative. So what happens if D DH has been missed and the child is ambulant because the child will walk and they'll probably walk at a reasonably normal time if they have a dislocated hip, um, they could present with a leg length discrepancy. And a few years ago before I worked at a Brooks, I worked at the children's hospital and the area I did most was, um, limb deformity. And I had a nine year old come to me with a four centimeter leg length discrepancy. And I sent him for his long leg X ray as I did for every child and he had a dislocated hip. His actually his legs were the same length and it had been missed all that time. He was nine. So in a leg length discrepancy, always think dislocated hip before you think about a difference in a long bone dense if they have a limp, so different on one side, if they're trendelenberg positive on one side, because the hip abductors aren't working properly because you haven't got a hip joint for them to work around. And what's very difficult to pick up sometimes is a bilateral dislocation. But of course, they're symmetrical, especially if there are a high irreducible dislocation because will be negative. Balo will be negative G will be negative because the legs are the same density, actually, they will examine normally. Um But they have bilateral high hip dislocation and when they start walking, they kind of have a waddle, they go side to side and they often have an increased lumbar or dosis. Um So whenever you see an abnormal gait in a child, always X ray, their hips. So what imaging do we do in most hospitals up until the age of six months, um we'll do an ultrasound. If you were to Great Ormond Street, they'll change to an X ray at three months. But most hospitals will do ultrasound up until six months of age at six months of age. The aci N starts to appear within the femoral head and the ultrasound um waves don't go through properly, they're deflected by the bone and you don't get a very good ultrasound of the hip and that's why we move on to X ray. So over the age of six months of age, we do a plain a PX ray of both hips and we often do a frog lateral as well. There are certain scenarios such as SUFI where you should always do a frog lateral and there are certain scenarios where it's not necessary and we'll talk through that as we go another imaging about modality, we sometimes use a hip arthrogram because as I was saying in, as the hip develops um in the femoral head, it starts off completely cartilaginous. So in a young baby underneath under six months, when you x ray the hip, you will essentially see nothing, you'll see an acetone, but you won't see a femoral head. And in order to see the femoral head, you need to put some radiopaque dye into the joint that outlines the head and further on in the talk, I'll show you some arthrograms following a closed or an open hip reduction. You must always do 3D imaging x rays in theater are not good enough because a hip that looks like it may be enjoyed. It may be anterior, it may be posterior ok. And posterior dislocations are common and it may look fine on your two DX ray. But you need 3D imaging. You need a seat. Well, ideally, you need an MRI because there's no radiation. But every hospital I've worked out, you cannot get an MRI. So you, you get a CT because it's easier to get not as good for the child, but it's just what's possible um in, in adolescence. So in your young adult tips, which I'm sure a lot of you guys know more about than I do, you will do different views such as false profile views. But that's something I'm not going to go into today and something I don't do. So we're gonna come on to ultrasounds and hip baby hip ultrasounds are difficult and you're never going to be asked to interpret a baby hip ultrasound, but you need to know just a few basics. OK. Um What we are looking at when we do ultrasounds of the hip. Well, primarily we're looking is the ball in the socket. OK. Um So is it in, so is it indicated and they normally say, is it centered? That's the terminology, the the use or is it decentered? In other words, is it dislocated? And when it's centered, they look at how well the acetabulum is forming the bony acetabulum. And that's to do with the alpha angle which I'll come on to in a minute. And then they look at how well the labrum, the cartilaginous roof is forming and that is to do with the beta angle which will come on to in a second. So it's the graph methods. Graph is an Austrian chap and this sort of became widely used in about the 19 nineties. Before that, there was lots of different methods um for assessing hips and there still are different methods. But most people in the UK will now use the graph method. And the main thing you need to know about is the alpha angle which I'll come on to in a moment and the graph method splits hips up into 123 or four. And what you need to know.