Torticollis and hipdysplasia

Treatment of Newborns with
Congenital Torticollis and/or
dysplasia of the hip Through
Osteopathy
Line Rølvaag Juberg
Aim for the workshop
• Obtain a common set of definitions of the
conditions
• Get an overview of related research in the
field
• Get a repetition of anatomy of the newborn
hip and neck
• Become more aware of the diagnostic process
• Improve treating skills in the related areas
• Discuss the importance of interprofessional
colloboration around the treated children
Hipdysplasia
• The term congenital dislocation of the hip dates
back to the time of Hippocrates. This condition,
also known as hip dysplasia or developmental
dysplasia of the hip (DDH), has been diagnosed
and treated for several hundred years. Most
notably, Ortolani, an Italian pediatrician in the
early 1900s, evaluated, diagnosed, and began
treating hip dysplasia (1)
• Since then, significant progress has been made in
the evaluation and treatment of DDH (2,3,4,5,)
Hipdysplasia -definition
• Developmental dysplasia of the hip comprises
a spectrum of abnormalities, ranging from
laxity of the joint and mild subluxation to fixed
dislocation (3)
• Developmental dysplasia of the hip (DDH)
affects 1.5 of every 1,000 caucasian Americans
and less frequently affects African Americans.
• Early diagnosis of DDH usually leads to lowrisk treatment with a harness. Late diagnosis
of DDH in children may lead to increased
surgical intervention and complications. (3)
• For infants with a positive hip instability exam,
there is conflicting evidence about whether a
period of observation or immediate brace
treatment leads to a difference in later
dysplasia or persistent hip instability leading
to later brace treatment (8)
Under three months
• The Ortolani and Barlow tests are the most common
clinical tests for newborn babies:In the
• Ortolani test, the examiner applies forward pressure to
each femoral head in turn, in an attempt to move a
posteriorly dislocated femoral head forwards into the
acetabulum. Palpable movement suggests that the hip
is dislocated or subluxed, but reducible.
• In the Barlow test, backward pressure is applied to the
head of each femur in turn, and a subluxable hip is
suspected on the basis of palpable partial or complete
displacement. (7)
• Benign hip clicks,
resulting from soft tissues
snapping over bony
prominences during hip
movement, should be
distinguished from the
clunks produced during
the Ortolani manoeuvre
as the dislocated femoral
head is reduced and from
the subluxation felt
during the Barlow test. (7)
Limited hip abduction
• Both the Barlow and
Ortolani tests detect an
unstable hip but do not
detect a dislocated,
irreducible hip, which is
best detected by
identifying limited
abduction of the flexed
hip) or a stable hip with
abnormal anatomy - eg,
acetabular dysplasia
Children aged 3 to 6 months
• If the hip is dislocated it is in a
fixed position.
• The Galeazzi sign:
– Unilateral femoral shortening
may signify hip dislocation or
rarer abnormalities of the
femur.
– False negative results may
occur with bilateral hip
dysplasia or when the pelvis is
not level.
– A positive sign is that one leg
appears shorter than the other.
– This is usually due to
dislocation of the hip; however,
any discrepancy of limb length
will produce a positive sign.
Bilateral dislocation of the hip
• DDH is bilateral in about 20% of cases. (7)
• It can be quite difficult to diagnose, especially
after the neonatal period.
• There is often a waddling gait with hyperlordosis.
• The Galeazzi sign for hip shortening is often
absent, as are asymmetrical thigh and skin folds,
or asymmetrically decreased abduction.
• Careful examination is needed with a high level of
suspicion.
Most important sign
• Stable hips may be dysplastic. Limited hip
abduction (less than 60°) when the hip is
flexed to 90° is the most important sign of a
dislocated or dysplastic hip (7)
Other signs for late dislocation (7)
• Asymmetry of the gluteal
thigh
• Assymetry of labral skin
folds
• discrepancy in leg length
• Widened perineum on the
affected side
• Buttock flattening
• Asymmetrical thigh skin
folds decreased abduction
on the affected side
• Standing or walking with
external rotation of the
affected leg
• Clinical evaluation for DDH should be performed
periodically at each well-baby visit until the age
of 12 months.. Consideration for screening with
ultrasound is balanced between the benefits of
early detection of DDH and the increased
treatment and cost factors
• In the United States, hip ultrasound is selectively
performed in infants with risk factors, such as
family history of DDH, breech presentation, and
inconclusive findings on physical examination (3)
Risk factors
• Some studies confirm significance for selective prospective
screening by ultrasound in infants with history of possible clinical
instability and/or risk factors; breech and family history to prevent
late dislocations and need for surgery (14,15)
• Vaginal delivery of babies with breech presentation is associated
with a 17-fold increased risk of hip dysplasia; there is a 7-fold
increase for breech babies delivered by elective caesarean section.
Restriction of movement as with oligohydramnios increases the
risk. (7)
• Some studies also show no statistical significance for familiy history
(16)
• Evidence are not found to include foot abnormalities, gender,
oligohydromnios and torticollis as risk factors for DDH (8)
• From a total of 49240 children we found 576
abnormalities:
• 326 dislocations
• 250 abnormally lax hips
• On babies examined on the first day of birth
there os an incidence of 1 in 40.
• Those examined when seven days old have an
incidence rate of 1 in 100.
• Spontaneous recovery during the first week of
60% (6)
von Rosen splint, Pavlik, Craig, or
Frejka splints ?
• There are no high quality comparative
effectiveness studies between different types
of braces for the treatment of DDH. (8)
Van Rosen
Pavlik
Frejkas
• For infants with a positive hip instability exam,
there is conflicting evidence about whether a
period of observation or immediate brace
treatment leads to a difference in later
dysplasia or persistent hip instability leading
to later brace treatment. (9,10,11,12,13)
• There is considerable confusion related to the
terminology and definitions that have been
used in research related to DDH and about
what defines a pathologic condition versus an
expected developmental variation based upon
the age and status of a child is needed (8)
Guideline
• An evidencebased clinical practice Guideline
about ”DETECTION AND NONOPERATIVE
MANEGEMENT OF PEDIATRIC DDH IN INFANTS
UP TO 6 MONTHS” was adopted by the
American Academy of Orthopaedic Surgeons
Board Directors and endorsed by these
organizations:
They found ;
• (Out of 39990 citations
• 42 articles were included)
• ..significants gap in the evidence to be used for a
guideline
• ..considerable confusion in the terminology related to
DDH
• ..gaps in knowledge about pathophysiology of DDH
• ..gaps in the optimal diagnostic tools to be used to
detect the condition
• ..relative efficacy and value of recommended
interventions
For future research they hope for:
• A research design that is applicable to routine
practice situations and allow for comparison of
alterative methods of diagnosis and treatment.
• Except criterias, terminology,etc, they also wants
to:
• Establish universally accepted and reproduceable
ranges of normal values across ages for measures
for normal hip development.
• DDH may develop during the first weeks of the infant’s
life, caused by
1. severe non physiological sphenobasilar strains
2. vertebral lesions
3. fascial tensions including those coming from the
viscera or the thoracic diaphragm
• DDH may also develop during the intrauterine period,
and postnatally is characterized by presence of
distinctly palpated lesions in the pelvis and hip joint or
joints with intra-osseous strains of the innominate
bones, sacrum and coccyx.
Anatomy of the newborn hip
• Os coxa (coxae)
• Develops from fusion of
the ilium, ischium and
pubis
• Ischium and pubis fuse at
age 4-8
• Ilium to the ischiopubic
fuses between 11-14 in
females and 14-17 in
males
• (17)
Os coxae/innominate (no name)
Lumbar vertebrae
• At birth the lubar vertebrae
are caracterized by the
three main components.
The neural arches of the
upper lumbar vertbrae
begin to fuse together
posteriorly by about age of
1, although fusion in L5 may
not occur until the fifth
year. Between the ages two
and three the centrum and
neural arches begin to fuse,
culminating with L5 by age
of four. (17)
Congenital muscular Torticollis (CMT)
definition
• Congenital unilateral
contraction of the
Sternicleido mucle with
inclination of the head
towards the side of the
contracted muscle,
rotation towards the
opposite side and facial
assymetry (18)
• ”Our son was born with a torticollis and a partiell
rupture of a muscle in the neck after a though delivery.
He had big problems turning his head to one side, and
one of his shoulders were constantly elevated before he
got osteopathic treatment.” ( Teacher/Parent in the IPC
study) (23)
• A typical example is is children with multiple problems
like unsetteled babies who stuggle in breastfeeding and
have problems looking to one side. And after
osteopathic treatment I could see that they suddenly
could breastfeed easy from both breasts.(Nurse at the
Healthcare Station – from the IPC study) (23)
Occiput
• Congenital anomalies of the occipital condyles
and upper cervical spine must be ruled out
before performing a release of the
sternocleidomastoid muscle in a child who
fails to improve with physical therapy. (19)
Newborn occiput
• Fusion of the four
elements occurs in
sequences, beginning
posteriorly, usually
ending by age of 6-8
years. (17)
• In a retrospective review of 159 children they found that torticollis can
predispose to plagiocephaly without synostosis (PWS), but in a large
proportion of the cases of PWS, torticollis appeared to develop secondary
to plagiocephaly, and that the number of presentations is escalating. (20)
• An other retrospective chart review was performed among 97 consecutive
patients between 1/1/2003 and 9/1/2012 with CMT who had hip imaging
performed
• They concluded that in the care of a patient with CMT, it is important that
the clinician remains vigilant about screening for DDH. An ultrasound or
radiograph of the hips should be strongly considered as part of the
evaluation of a child with CMT. (21)
• The coexistence rate for CMT and DDH requiring treatment is 4.5%,
which is lower than the commonly accepted 20%. (22)
20%
• There are definately
coxistence of conditions
and confusion about what
conditions are recognized
,in terms of those 20%, to
be defined as common
coexistance.
• But what does this mean
for osteopaths ?
4,5%
12%
Anatomy and palpatory skills
”Your first lesson is anatomy,
your last lesson is anatomy and
………………………all your lessons
are anatomy” A.T.Still
•
33
….and look at the patient in their
context!
Interprofessional colloborative
approach
• WHY?
• WHO?
• COMMUNICATION
(oral/written)
CONTEXT
• Parents
• Siblings
• Physicians
• Physiotherapist
• Nurse
• …..
Parents want to know..
•
•
•
•
What is wrong?
Will my baby be ok?
How long time will it take?
What can we do ourselves?
The diagnostic process
Positivist
diagnosis
Diffriential
diagnosis
Etiological
diagnosis
Conventional
medicine
Identifying
pathology
Differentiate
between different
conditions with
same or similar
pattern of
sympthoms
Seeking for a
pathological
explanation
osteopathy
Identifying a
pathogenesis
Same as
conventional
medicine
Factor analysis
Making a
hypothesis:
hieraky of
dysfunctions
Seeking the
patogene
explanation/chain
The whole is bigger than the summary of all the parts
WHAT TO DO?
• Are the identified
dysfunctions
significant?
• Can they be linked
together?
• From what view can we
look at the current
problem ( the clinical
presentation) ?
Osteopathic treatment is often
interpreted within one or more of the
following models:
•
•
•
•
Postural and Biomechanical Model
Neurological and Autonome Model
Respiratory and Sirculatory Model
Biophsycosocial Model
NECK
PELVIS
Important areas to adress
LAB
1.
2.
3.
4.
5.
6.
7.
8.
1. rib
SCM
Scalenii
Cervicals (c2-c6 for all the scalenii)
Thoracic vertebrae
Pelvic basket
Balancing the acetabulum
Umbilical ligaments
1. Rib technic
• Supine or sitting
2. SCM
• Insertion:
• Lateral surface of mastoid
processand the nuchal
line of occipital bone
• Origin:
• Upper part of the anterior
surface of manubrium
• Superior border/anterior
surface of medial third of
clavicle
3. Scalenii
• Scalenus Anterior
• Origin: Anterior tubercles of
the transverse processes of
(C3-C6)
Insertion: Scalene tubercle
and cranial crest of first rib
Action: Flexion of the
cervical spine, Lateral
flexion of the cervical spine,
Innervation: Ventral rami of
(C3-C8)
Blood Supply: Branches of
the cervical artery
• Scalenus Medius
• Origin: Posterior tubercles
of the transverse processes
of (C2-C7)
Insertion: Cranial surface of
the first rib
Action: Flexion of the
cervical spine, Lateral
flexion of cervical spine
Innervation: Ventral rami of
(C3-C8)
Blood Supply: Branches of
the cervical artery
• Scalenus Posterior
• Origin: By tendons from
the posterior tubercles
of the transverse
processes of (C4–C6)
Insertion: Outer surface
of 2nd rib
Action: Lateral flexion of
the neck
Innervation: Ventral rami
of (C3-C8)
Blood Supply: Branches
of the cervical artery
4. Cervicals (c2-c6)
• Supine or sitting
5. Thoracic vertebrae
6. Pelvic basket
7. Os coxae in three parts
8. Umbilical ligaments
(21 p.219)
Thank you for your attention
Line
Bibliography
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