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Developmental Dysplasia of the Hip

Developmental dysplasia in the hip is the anatomical abnormalities of the hip joints in which the head of the femoral bone shows an abnormal relationship with the acetabulum. It includes several risk factors like first born status, female sex, positive family history breech presentation and oligohydraminos. Clinical presentations of the developmental dysplasia of hip depend on the age of the child. Generally it has been found that children born with hip disability, hip instability infants having limited to hip abduction on examination and older children with limping, joint pain and even sometimes osteoarthritis. Repeated careful testing of the children after the birth till their growing process should be continued. It can also include the provocative testing. Other similar symptoms that are visible in normal eye includes shorting in length of the femur with hips and knees flexed, asymmetry of the gluteal or thigh bones and discrepancy of leg lengths in potential clues. Treatment are mainly dependent on age presentations and outcomes are much better when the child is treated early particularly during the six months of age.

The Right Way to Diagnose and Treat Dysplasia of the Hip:

The term of development of dysplasia of the hip has replaced the congenital dislocation of the hip as it describes the full range of abnormalities affecting the immature hip more accurately. In some children the normal femora- acetabular relationship can be seen during the birth but latter on dysplasia or abnormalities are observed latter on.

It can be well defined as any kind of deformity in the shape, size or the orientation of the femoral head, acetabulum or both is often referred as dysplasia. It has been seen that majority of the abnormalities result due to maldevelopment of the acetabulum. The problem of femoral head is a secondary concern that results in non-physiological biomechanics from the anteverted acetabulum or as a result of treatment.  The instability of the hip occurs when it fits tight between the femoral head and the acetabulum is lost and the femoral head is able to move within or outside those confines the acetabulum. Generally the dislocated hip has no contact in between articular faces of the femoral head and the acetabulum. Generally the dislocated hip has no contact of the femoral head and the acetabulum. Teratology dislocation generally shows marked difference in the hip joint at the time of birth. It also includes other malfunctions such as spina bifida, arthrogryposis multiplex congenita, lumbosacral agenesis, chromosomal abnormalities, diastrophic dwarfism, Larsen syndrome and other rare syndromes.

Epidermology

The incidence of the developmental dysplasia of hip is really difficult to monitor because of the discrepancy in definition of the condition, type of examination used and different levels of skills of clinicians. The range of incidence includes as low as 1000 to as high as 34 per 1000. During ultrasound high incidences are reported which are also used in clinical examination. Several risk factors including first born status, female sex positive or not, family history, breech presentation and oligohydramnios.

Etiology

The several causes of the Developmental Dysplasia are multi factorial in nature. There are certain factors that lead to the development of dysplasia in hip which includes the ligament laxity, postnatal positioning and primary acetabular dysplasia. Hereditary ligament laxity and other neuropediatric disorders with an abnormal muscle tension, such as cerebral palsy, myelomeningocele and arthrogryposis, are the major factors for the inheritance of developmental dysplasia of hip. It also increased incidence of developmental dysplasia of hip in identical twins as compared to fraternal twins. It also suggests several genetic influences. Female new-borns are more prone to develop developmental dysplasia of hip. This is because as they respond to maternal relaxing hormones which may cross the placenta and induce laxity.

 It may also happen that intrauterine crowding also affects the developing hip in the placenta. There evolves the increased incidence of developmental dysplasia in hip in infants who are born in breech presentation, most notably when the knees are extended. There are 9 other factors which include first born child and oligohydramnios. In addition, postnatal positioning also plays a role in the development of developmental dysplasia in hip. A very high incidence of developmental dysplasia of hip is reported in babies wrapped with the hip in extended position. It is as compared to the babies wrapped in flexed and abducted position. Also, a permanent supine position of new-borns which can reduce the risk of sudden infant death seems to increase the risk of developmental dysplasia in hip.

Diagonosis

A careful clinical examination should be carried out on all new-born children especially those with risk factors for developmental dysplasia in hip.  For the purpose of examination of an older child also includes careful assessment of extremities for asymmetric skin folds or leg length discrepancy in case of unilateral hip dislocation. A positive Galeazzi sign is another indicator of hip dislocation. It is depicted by laying the child supine and flexing both hips and knees. It also provides positive sign is indicated by an inequality in the height of the knees. Certain limited abduction may be particularly helpful in diagnosing children with bilateral hip dislocation because the Galeazzi sign will be negative. The maximal abduction of hips should be greater than 60°.In neglected cases, developmental dysplasia in hip may be diagnosed when children approach walking age with a limp on the affected side (positive Trendelenberg’s sign) and hyperlordosis.

Management

The treatment of developmental dysplasia of hip is age-related.  It is the goal is to achieve and maintain concentric reduction of the femoral head into the acetabulum. The best outcome can be expected only if the treatment is started at a very early age. This has been achieved in the developed world through improved awareness and training. The increased surveillance (use of ultrasonography), and quicker access to paediatric orthopaedic surgeons including 21 of them. It must be noted that there are very few specialized paediatric orthopaedic surgeons in the developing world, and fellowship programs for paediatric orthopaedic surgery should be initiated to cater the needs and requirement.  Therefore this in addition to the myriad of other paediatric orthopaedic conditions.

Health Care

How does a Line Isolation Monitor (LIM) detect ground faults?

The Line isolation Monitor or the LIM is a censorious component of an outlying power system. The line isolation monitor constantly monitors the impedance of the isolated power system from all of the conductors to ground. Impedance includes both capacitive and resistive readings. The Total Hazard Current or the THC is then calculated by the value of these readings, which dictates if a patient were in contact to a ground with conductor what current could flow. The THC readings in advance warn about the issues that are present in the system.

A person’s body need be in contact with two distinct conductive materials, to receive a shock, at different voltage likely to complete a circuit. The most usual scenario of occurrence of shock is where a grounded body that lies in neutral voltage touches a hot wire that exists at a voltage of non-zero potentiality.

The grounded wiring system in modern housing, the neutral that is connected to the neutral wire of the Power Company and grounded wires that are connected to equipment, both are grounded. This is an absolute case like a hairdryer where a fault in equipment can prove to be disastrous. If the connection of hairdryer was done to an underground system and if a fault occurred, the person who is in touch with the hairdryer might offer an alternative pathway of low resistance receiving a shock, whereas if it was grounded then maximum electricity would pass all through the ground wire.

How Ground Faults are detected by LIM:

  • In Isolated System: – The Line Isolation Monitor in an operating room (OR) is mounted somewhere, where it gives reading of how much connection is there in between earth ground and the isolated wall power wires. The connection is probably below 2 miliAmperes (mA). Even though it is an effective leakage of current, you may think it as a current leakage that may or may not exist.

In your operating room the LIM may be placed into the circuit breaker box that will have a portion of remote alarm located somewhere in the OR if the circuit breakers are out the OR. It may also be on the wall of your OR.

In hot wire and isolated system case, the LIM immediately detects the connection of either of the isolated wires or between them, and also to the case of appliances since all metallic cases are connected to the ground. The LIM repeatedly scrutinise for possible current connections and then displays the existing or potential leakage. If the leakage exceeds above a safe threshold then the LIM sends an alarm immediately.

I such situation one should unplug all devices to find out where the problem lies.

  • In Broken Ground & Hot Wire & Isolated System: – In this case the circuit breaker will not protect the victim. Even if it was the case where the equipment is grounded through an intact with the wire, still there will be no current flow in the system since in an isolated system; ground is not a part of the power circuit. Whatsoever, if the ground wire and equipment are properly connected, and the Line Isolation Monitor is also active, then it would have given a strong alarm with a very high current indication. With even a single fault somewhere in the present devices inside the room, it would have warned you. No alarm goes off, with the broken ground and in that case of the device is then connected to the power system voltage.

The Line isolation systems protect victims from electrocution. It does so by turning a general grounded system which needs only a single fault to cause any electrocution within a protected system outside the operating room, where to deliver a shock two faults are needed. The LIM detects the isolation degree between the ground and the two power wires, and predicts what amount of current could flow if there develops a second short-circuit. If there is possibility of an intolerable amount of current to the ground the alarm goes off. This means the isolate system is no more in an isolated state, rather it is now grounded. This could result a shock with just any additional fault.

When the monitor alarms means there is a single fault in the system, but it requires one more to deliver a shock. If the alarm is going off means the last piece of equipment that is plugged is in suspect and should be unplugged.