Bones muscles

Definition

• A spectrum of disorders ranging from complete dislocation of the femoral head to a reduced hip joint with acetabular dysplasia

Types:

1. Complete hip dislocation.

2. Partial hip subluxation.

3. Hip dysplasia (incomplete development).

Risk factors:

• family history - may reflect laxity of ligaments
• Race- common in white 
• Breech  presentation - Exaggerated positioning in acute flexion and adduction in utero may occur
• Female sex - the presence of maternal relaxin in the fetal circulatory system
• large fetal size 
• First born child

Galeazzis test

• With the child is lying on a flat surface, flex the hips and knees so the heels rest flat on the table, just distal to the buttock . 
• A dislocated hip is signaled by relative shortening of the thigh compared with the normal leg, as shown by the difference in knee height level. 
• This test is almost always useless in children under 1 year of age and is negative if dislocation is bilateral.

Barlows test

• This is a provocative test that picks up an unstable but located hip; it is unsuitable for a dislocated hip. 
• Thighs are gently grasped in the hand, with the thumb at the lesser trochanter and fingers at the greater trochanter . The hip is adducted slightly and gently pushed posteriorly with the palm. 
• Detection of "pistoning," or the sensation of the femoral head subluxating over the posterior rim of the acetabulum, is a positive finding.

Ortolanis test:

• This test detects hips that are already dislocated. 
• The flexed limb is grasped as in Barlows test. The hip is abducted while the femur is gently lifted with the fingers at the greater trochanter. 
• In a positive test, there will be a sensation of the hip reducing back into the acetabulum. 

Clinical Manifestations

In newborn:

• We can diagnose DDH in this period by positive Ortolani’s test or Barlow’s test.
• Asymmetry of the skin fold may help, but its not specific. 
• Shortening of the limb at this age doesn’t exist.
• We cant use X-rays because the acetabulum and proximal femur are cartilaginous and wont be shown on X-ray.
• USG is the best method to Dx.

In the early childhood:

• Parents notice asymmetry of creases of groin, limitation of movement of affected hip or click every time hip is moved

In older children:

• Complaints of limping, waddling gait (bilateral DDH), Trendelenburg’s gait (unilateral DDH), lumbar lordosis, limitation of hip abduction, etc…

X-ray

Von Rosen view:

hips abducted 45º & medially rotated.

Anteroposterior.

We draw a line through the central axis of the femoral shaft.

        in normal hip ( ossific nucleus )will be inside the acetabulum.

        in dislocated hip it will be above acetabulum.

Delayed development of ossific nucleus / smaller

Horizontal line of Hilgenreiner:

   drawn between upper ends of tri-radiate cartilage of the acetabulum.

Vertical line of Perkins:

  drawn from the lateral edge of the acetabulum vertical to horizontal line.

4 quadrants:

Normal hip: the ossification center of the femoral hip lower medial quadrant.

Dislocated hip: upper lateral quadrant.

Acetabular index:

    angle between horizontal line of Hilgenreiner and the line between the two edges of the acetabulum.

    normal hip 20º-300 

    dilocated or dysplastic hip ≥ 30º

Shenton’s line:

    semicircle between femoral neck and upper arm of obturator foramen, in dislocated hip this line is broken.

Treatment:

The earlier the better. 

Exact treatment depends on patient age at presentation and degree of involvement

Goal is to:

1.Flex and abduct hips.

2.Reduce femoral head and maintaining it.

Reduction can be achieved by closed manipulation , traction followed by closed reduction and opened reduction  

 maintenance can be done using plaster cast(frog leg or Batchelor) or splint (von Rosen’s splint)

• Acetabular reconstruction procedure
• Salter’s osteotomy
• Chiari’s pelvic displacement osteotomy 
• Pemberton’s pericapsular osteotomy

• From (0-6 months)  

A dislocated hip at this age may spontaneously reduce over 2-3 weeks if the hip is held in a position of flexion. 

Reduction by closed manipulation and maintained with plaster cast or splint

• From 6 months -2 year

Gentle closed reduction of the dislocation under a general anesthetic and maintenance of a located position for 2-3 months in a hip spica cast usually stabilize the joint

• From the age of 2-6 years:

• 6-10 years

• After 10 years

The Giant Human Skeletons in Northern Ohio

History of the Maumee River Basin, 1905

Defiance County, Ohio,                                                                                                          

A mound was found on the high south bank of the Maumee River, a few rods west of the middle north and south line of section twenty and seven of Defiance Township… This mound was about four feet above the surrounding land, about thirty feet in diameter. Brice, who gave the writer this information, opened this mound in the year 1824. A small quantity of bony fragments were found which readily crumbled between the fingers on being handled. Human teeth were found, some of which were of large size.

History of Fulton County, Ohio, 1905

     Of the works examined in this county, those most worthy of mention are situated on the farm of the late Hon. D. W. H. Howard, in section 9, Pike Township. These mounds were explored during the summer of 1892.These mounds are in a group of twelve in number, of which eleven are located and clearly identical and the site of the twelfth is plainly indicated… The mound mentioned as being located in the public road is, as stated above, entirely obliterated, but in an early day Col. Howard found in its center a circle of stones about four feet diameter, containing within the circle about a bushel of charcoal and ashes. The stones are what are known as “nigger heads.”Nearly all of these mounds were opened and examined by judge Handy, and the report of two of them we will give in the judge’s own language. Of one he calls Mound No. 7 he writes, “Sandy soil, light yellow sand: about eighteen inches from surface found longest thigh bones yet discovered. No trace of fire-no disturbance of soil here to fore-bones crumbled on exposure-highest of the mounds-found near center skeleton with his head to the north, lying on his back and limbs extended-near hem found skeleton No. 2, with head to the east and lying on his face. Both being large men.About another mound in this group it was written: “The part of the skull above the nasal bones was well preserved, and compared with the skull of an Indian found intrusively buried in neighboring mound, was a distinctly different type of man.

Newark Daily Advocate, (Newark, Ohio) August 14, 1902

SkeletonFound in Bed of Sand in Northwestern Ohio-Man was Eight Feet High    Bowling Green, O., Aug. 14-While excavating for sand for building on the Charles Whirmer farm, Wm. Jones unearthed the skeleton of a gigantic man. It is in a fair state of preservation and will be preserved, as it is thought that it may have some scientific value.The skeleton was found in a sitting posture, and when the bones were placed in a horizontal position they indicated that the height of the man in life must have been over eight feet. The head is of enormous size, being 12 inches in diameter.It is believed that it is the skeleton of a member of a prehistoric race of giants. Further excavations will be made to see if other graves cannot be found.

Burial mounds in Northern Ohio varied in size from small dome shaped to large conical mounds. This set of 5 mounds is located on Nettles Lake in Williams County, Ohio. Photo from "The Nephilim Chronicles: A Travel Guide to the Ancient Ruins in the Ohio Valley."

History of the County of Williams, Ohio, 1905

On fractioned section 12, about 2 miles north of Montpelier, two large mounds which were six on seven feet in height and fifty or sixty feet in diameter… taking there from two skeletons, one very large and the other of ordinary size.


American Antiquarian, Vol., 3, 1880

  “A skeleton which is reported to have been of enormous dimensions” was found in a clay coffin, with a sandstone slab containing hieroglyphs during mound explorations by Dr. Everhart near Zanesville, Ohio.A mound near Toledo, Ohio held 20 skeletons, seated and facing east with jaws and teeth “twice as large as those of present day people” and beside each was a large bowl with “curiously wrought hieroglyphic figures.”


History of Lorain County, Ohio, 1879
Their mounds are a proof of their existence, for their character and the place and mode of their erection attest the handiwork of intelligent beings, while the bones, weapons of warfare, stone implements and arrow heads which have been discovered and are still found buried in these earthworks, furnish a still stronger proof of the existence of a pre-historic people. The skeleton remains of human beings of almost gigantic proportions were exhumed from their ancient cemeteries by the first settlers. The Indians, disclaiming them as kindred, could give no information in regard to them.”

American Antiquarian, Vol. 13, 1890
Bones in a Gravel Bed-- Some workmen in Auglaize County, Ohio, recently came across some human bones in a bed of gravel. Mr. Charles Jones, a well-known and wealthy landowner of Spencerville, Allen County, says of the discovery:

“There was a remarkable discovery of prehistoric remains in our section the other day. The instance came under my own observation. Last week I had occasion to visit the farm of I. Hemley, about two miles west of Kossuth, just across the border in Auglaize County. Some workmen were engaged in digging a well, and had descended to a depth of 32 feet, when they struck a gravel drift, from which they exhumed a skull, 38 inches in circumference. Further down the other bones were found. There can be no doubt as to the kind of remains. The thigh bone measured three feet two inches long. All the bones were in an excellent state of preservation, and were probably those of a prehistoric warrior who was killed in battle, as the skull seemed to have been crushed with a blunt instrument. The whole skeleton measured eight feet eleven and one-half inches in height, and when clothed in flesh must have been a tremendously powerful man. A huge stone ax weighing twenty-seven pounds and a flint spear head of seventeen pounds weight were found with the bones, and were, no doubt, swayed by the giant with the greatest ease. A copper medallion, engraved with several strange characters, was also found with the bones. This is a startling discovery. The scientific value of the discovery is also considerable, and may lead to some interesting developments.