Hip Prevention

Prevention
of Hip Problems
DDH
CDH
Paralytic Dysplasia of the Hip

PDH?? Poop Hip??

 

"An ounce of prevention is worth a pound of cure."
This is about as true a truism as can be found.

 

 

 

The hip is a ball & socket joint. Genetically joints are formed with the information of shape on one side (this case the ball), and the ability to conform in shape on the other side (in hip's case, the socket). So there is a ball on the upper end of the femur and a zone on the side of the pelvis that can shape to the ball, creating a socket.

The conformable socket tissue is cartilage, not bone. In the image at left, the unseen (on x-ray) adaptive cartilage of the socket is depicted in orange. The unretouched x-ray is on the left. Notice that one visually  underestimates the hip socket and ball dimensions because the cartilage components are unseen. They can be viewed with ultrasound, however.

Note that the sharp upper edge of the socket is like an awning. It covers the ball and points downward and outward. Growth follows that edge, downward and outward. Thus the hip gets deeper as it grows taller with the ball. But that tissue is soft, like your ear. If the hip ball slams repeatedly upward and outward (very apt to do so with the legs crossed), then the soft cartilage, like a boxer's nose, gets flattened. It gets flattened upward.

With the leading edge growing upward, the socket becomes taller beyond that of its own inner wall growth and becomes more vertical. It becomes vertical and shallow. The socket cup, by way of disoriented growth, becomes a dish, a shallow dish. The slope of motion of the ball in that dish only slams the upper edge more. The ball, under muscle tension migrates steadily upward and out over the poorly containing edge. Subluxation (migration from centered position) evolves into dislocation (hip out of the socket altogether.

The x-ray image on the right shows the largely unseen ball of the infant hip (which is also cartilage - but tougher) in yellow. One hip is "located" (centered where it belongs) and the opposite hip is "dislocated".

DDH:
If pressure in the womb presses the fetal leg too severely, the socket can flatten. It may well go unnoticed. The softer the cartilage (girls are softer because they react to mom's hormones) and the more the push (usually the left leg gets it worse as it is usually up against the spine), the more the odds of a flattened socket. Girl babies get hip dysplasia (socket flattening) 9 times more than boys. Breech position is just plain nasty to the hips and squashes hips about a third of the time.

Unless aggravated, small amounts of flattening might resolve spontaneously. Cultures that carry babies with the child's legs spread apart, such as riding on the mother's hip, have, by far, the lowest incidence of hips that go on to be bad. African mothers have the best track record of all. Their protective way of carrying babies is unbeaten - held in an open-legged position by a sling-bandana. Cultures that wrap legs together in one way or another (swaddling etc.) just plain destroy hips. Swaddling of children leads to waddling adults.

The actual dislocation of the hip may well come about later. The initial loss of hip edge integrity, with time, kicking, standing and life's forces leads to slow further degradation of hip relative depth with time. It may dislocate. It may just wear badly and become osteoarthritis is the young adult.

 

PARALYTIC  HIP  DYSPLASIA
Children with abnormal muscle forces around the hip do not need an abnormal starting point to get their hips into trouble. Perpetual slamming forces that get directed outward on the socket edge come from overactive hip adductors and hamstrings (hamstrings are not called "adductors" but are nevertheless powerful adducting muscles.

What is adduction? Cross your right leg over into left leg territory. That is adduction . In that posture, pull along the axis of the thigh bone points right out of the socket.

1) Pelvis (innominate bone) with the socket. At the bottom is some fat. If the hip displaces, the fat enlarges and fills in. It is a tough gritty kind. It may block the hip from getting back.
2) A line along the lower edge of pubis lines up smoothly with the neck of the femur. If not, the femur has drifted (subluxation or dislocation).
3) The hip capsule (brown) is a tough sleeve that covers the hip and keeps in the lubrication.
4) The iliopsoas muscle, if shortened from subluxation may well prevent getting the hip recentered. It often forces lengthening.
5) The cartilage top edge of the socket is paired with the top hip capsule quite closely. If it is deformed from the awning down and out direction at the bone edge, it may need to be redirected if growth is to  become reoriented.

A special adaptation of wheelchair positioning, "the Mary Chair" is also very helpful in the care of very spastic patients.

 

Prevention :

You have to be aware that nature can play dirty tricks. If there are risk factors such as a family history of hip dysplasia; a baby that is born large, or mother is small (tight packaging, potential for odd-ball positions in the womb, especially breech); a baby whose left leg seems to fall naturally along the body's midline rather than out to the sides - whatever - don't wait for waddeling gait to react. Why? That ability of the socket tissue to conform gets diminished with time. It is a bell-shaped curve thing. It may well be gone by age two! If the hip is very flattened and the child is almost two, there may well be insufficient time to undo it. Some kids luck out and retain that growth reshaping capability to nearly 5 years, at least to some degree.

A simple harness that mimics the baby astride the mother (
as mentioned above) does well to let those hips reshape. But it is important to be certain.

 

Children with paralytic diseases must simply be monitored. They can go from looking just fine to awful in very short periods of growth. It is especially
common to see hips go bad after an unrelated illness. Why? Anything that increases the muscular tone just increases the chances of the hips not being able to withstand the pounding. We recommend, as a generality,  that all children with cerebral palsy, for example, get a yearly x-ray of the pelvis for viewing hips.

Earlier detection of problems usually allows simpler and better remedies.

 

Poop Hip?

That's not what it sounds like, is it?
Kind of. But let us first explore how this concept is not as weird as it might sound. We know there is an embarrassing eponym for arm posturing (embarrassing because it missed the boat). It says that arm waving or posturing may be due to esophageal irritation - reflux. That is true, but it is like saying coughing may be a throat irritation. Yeah. Where's the rest? Can't just drop it there. One item in a list. The list please? Some of the worst arm posturing comes from sinusitis, toothache, splinters, broken finger, and just about any noxious stimulus above the diaphragm and a few nearby things below as well. Take inventory.

INVENTORY

Inventory is your friend. You don't need to be smart. Just be diligent. Check each bit for something nasty. You'll find it and then you can pretend to be smart.

Also remember General Custer! When you report an arrow through your chest:

    I have an arrow through my chest General Custer!
    That's OK son, all my men have that.

ToxicMegacolon

Ever had a distended bowel? Wasn't it called a 'belly ache'?  So what do kids do, who already have dystonic posturing, when they have belly pain? They posture HARDER and they posture LONGER and they posture FURTHER.

OK, that's logical enough. But what happens when hips get adducted as part of that harder, longer further posturing?

They wear down and eventually dislocate. Poop hip.

The main point, though, is easy to miss. The bowels have their own nervous system and also are hugely influenced by sympathetic and parasympathetic nervous system events which are very much attuned to the VISCUS!

Viscus? What's a viscus?

Viscus is a very important word. Not being  aware of this word and what it means can cost you or somebody you know - their life.  Any inner organ that's hollow is a viscus. A urinary bladder is a  viscus. A gallbladder is a viscus. The esophagus, the small intestines, the colon are all viscus structures. So in the movies the boat will soon explode and the good guys jump in the water. Safe! No. The shock wave through water will cause viscus structures to explode. Sorry. The guy who hasn't hit the water yet has a better chance.

In neck injury type quadriplegia, a distended urinary bladder can kill. The disconnected (untempered) lower spinal reflexes can cause such severe reflex response and cause rapid and extensive stroke. Blood pressure goes right off the chart. Response to viscus distention is real and generally not reasonably proportioned to its cause. Run amok it does severe things.
(The above is a movie. Click on it.)

But in CP and other neurologic conditions the reflexes are not detached, right? Well maybe. At least not fully and well tempered as normal. Certain things can still magnify. So windswept postures ... grind ... and then grind away.

Peristalsis-20But it is worse than that. As the colon distends - over time - propulsion is lost.  No one part can fully squeeze closed so that the next squeeze downstream causes anything to go any where. Solid waste bloats the colon. Fluid may well go around this and disguise the blockage severity. Symptoms are often poor eating and reflux (that's way upstream). So folks are chasing reflux and gas and poor nutrition is just a skinny kid - they're all skinny General Custer!

But that large bloat also contains a big clump of bacteria whose natural properties are way off. So toxins are being produced in a dead pool. The condition is called 'Toxic Megacolon'. It saps the life out of children. It kills. This may be the whining of your whining kid! We have had to argue with  G.I. specialists to fix this as the hip x-rays were getting worse. They do not make this connection. We have frequently seen hip problems reverse (early) when this was the only treatment.

Peristalsis-00

The river has to run or else it turns green. Basic, huh? Plugged ears ( eustachian tubes ) infect. Same here.

<=(Peristalsis, the movie. Click on it.)

Peristalsis ( the sequential squeezing of the viscus to move things along) must be effective. Just tossing in water retaining (sponge) mixtures does not fix this. Once the megacolon is emptied (probably needs a hospital stay to actually do it) it needs time to shrink. The distended stretched viscus walls are poor for power and need to thicken as the viscus shrinks and become able to fully squeeze tightly.

So do we give this one item an eponym? (PLEEEESE not MY name. I would like my name on something more upbeat - like a - mmmmm - Harley! brummmmmmm brummmmmmm.). Anyway, that would miss the bigger picture once again.

Urinary tract infections can also do this. Renal stones can and do do this. Stuff that does not feel good does this.

But

But here's the trick. The circuits that convey the FEELING of feeling bad (the conscious awareness of it) may be down. There may well be no pain, no feeling of bloating or aching or whatever. The reflexes, intact, carry on in an exaggerated way when they are NOT monitored from above by higher neurological mechanisms.

That is where you come in. Pit bull inventory taker. Attention to details. Why is all this posturing happening now? What has changed?

Hot weather: renal stones and dehydration are the biggest ones to just pop up. And remember, narcotics just about knock out motility. That a short course of narcotic began the process which then maintained itself is a common story. When giving narcs, put on your plumbers hat.

 

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