Standard Treatment Guidelines for Bone Tumours & Tumourous Conditions

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Bone Tumours, Tumourous Conditions & Developmental Disorders Mimicking Bone Tumours. Following are the major recommendations :

1.Name of the conditon: Benign Bone Tumours - Ivory Osteoma

Introduction : Benign bone tumour arising from osteoblasts, Bony (ivory) hard in consistency, 1 or 2 cm in size, over a flat bone, usually frontal bone asymptomatic unless the deeper extension is pressing on the brain which is very unusual

Incidence : Not worked out in our country, not very common

Differential Diagnosis : None

A)Prevention: Nil

B) Counselling: to report if symptomatic

Situation 1. Non-metro Hospital

a) Clinical Diagnosis : Hard painless swelling over frontal bone

b) Investigation : X-ray

c) Treatment : Usually left alone; can be excised for cosmetic reasons

d) referral criteria : If enlarging in size or symptoms of compression on brain

Situation 2. Metro location hospital

a) Clinical Diagnosis : Hard painless swelling over frontal bone

b) Investigation : X-ray, CT Scan if necessary

c) Treatment : Asymptomatic lesions left alone, Excision of symptomatic ones or for cosmetic reasons

Resources Required:

Situation 1. Doctor, X-ray machine

Situation 2: Doctor (Orthopedic Surgeon / Neuro surgeon), X-ray machine, CT Scanner

2) Name of the condition : Benign Bone tumour – Osteoid Osteoma

Introduction : Benign bone tumour, vascular and very painful, about 1 cm in size; elicits sclerotic reaction by the parent bone when the lesion is in the cortical bone; In cancellous bone the lesion is limited by a thin rim of sclerotic bone; in the spine it can cause scoliosis; if the lesion is in the metaphysis which is intraarticular can produce symptoms of arthritis; If the lesion is in the evolving stage it may not be seen routine plain radiography.

Incidence : Not uncommon; 10% of benign bone tumours

Differential Diagnosis : usually None in cortical bone, occasionally chronic osteomyelitis; In the cancellous bone – Brodie’s abscess, arthritis, unusual form of tuberculosis

Prevention : Nil

Situation 1: Non metro hospital:

a) clinical diagnosis may be difficult

b) Investigation X-ray

c) Treatment may be difficult

d) referral criteria – suspicion, inability to diagnose

Situation 2. Metro hospital a) clinical diagnosis as per description in introduction b) Investigation: X-ray, CT scan, MRI if necessary c0 Treatment: Excision in toto (enbloc in cortical bone); curettage in cancellous bone; In inaccessible locations – radiofrequency / laser ablation under CT guidance; curetted/excised material sent for histopathology

Resources required:

Situation 1: Doctor, x-ray machine

Situation 2: Orthopedic surgeon, Interventional Radiologist, X-ray machine, CT Scanner, MRI scanner, Radiofrquency ablator / Laser machine. Histopathologist, Facilities for surgery

3. Name of the condition: Benign Bone tumeour – Osteoblastoma

Introduction : Benign bone tumour arising from osteoblasts

Incidence : Very rare

Differential Diagnosis : Other tumourous conditions like Aneurysmal bone cyst, Fibrous dysplasia

Prevention : Nil

Situation 1. Non metro Hospital

a) clinical diagnosis – nothing specific

b)Investigation –X-ray

c)Referral criteria: If facilities and know-how are not available for curettage and bone grafting

Situation 2:

a)clinical Diagnisis is difficult. Diagnosis is usually radiological – multi loculated lytic expansile lesion with some new bone formation

b) Investigations: Plain Xray and CT scan

c) Treatment: curettage and bone grafting; material sent for histopathology

Resources required:

Situation 1: Doctor, X-ray machine

Situation 2: Orthopedic surgeon, operating facilities, Histopathologist

4. Name of the condition: Benign Bone tumour Osteochondroma

Introduction : Benign tumour arising from Chondroblasts of the growth plate; it can be of two types – pedunculated or sessile; the lesions grow as long as the skeleton grows and stop when the growth plates fuse

Incidence : most common benign tumour from bone; 30 to 50 % of benign bone tumours, 10 to 15 % of all bone tumours

Differential diagnosis : Chondrosarcoma (secondary), parosteal sarcoma may be mistaken for osteochondroma

Prevention : Nil

Situation 1.

a) clinical diagnosis – hard painless swelling in the metaphysis with negligible growth in recent past

b) Investigations- X-ray

c) Treatment – excision in toto if the lesion is solitary

d) referral criteria – recent fast growth, recent onset of pain, nerve palsy distal to tumour or interference with mobility pf neighbouring joint

Situation 2.

a)clinical diagnosis – same as above

b) Investigations – plain Xray, CT scan, MRI

c)Treatment – differentiation between benign and malignant transformation; if benign excision in toto; If malignant – investigate for lung metastasis followed by wide excision / amputation as the case may be

5) Name of the condition: Benign Bone tumour Enchondroma

Introduction: Benign bone tumour arising from chondroblasts; usually present in the small bones of hands and feet and asymptomatic for long time; patient presents usually with a pathological fracture or sometimes pain.

Incidence: not uncommon; 25 % of all benign tumours, most common primary tumour in the hand

Differential Diagnosis: Aneurysmal bone cyst, Tubercular dactylitis, Giant cell tumour, clear cell chondrosarcoma & acrometastases. The latter two are extremely rare.

Prevention: Nil

Situation 1. a) clinical diagnosis: swelling small bones of hands with minimal pain or a pathological fracture b) Investigations: X-ray c) Treatment: may not be possible in non metro scenario d) referral criteria: lytic lesion in small bones where diagnosis & treatment are not possible at non metro level hospital

Situation 2. a) clinical diagnosis: same as above b) Investigations: X-ray of the part, X-ray of chest, Needle Biosy, Mantoux test if necessary, Blood for Quanteferon Gold test, c) Treatment: curettage and auto/allo cancellous bone grafting, if there is a pathological fracture – needs fixation with plate and screws.(small fragment set)

6) Name of the condition: Benign Bone Tumours – Benign Chondroblastoma ) & Chondromyxoid Fibroma

Introduction: Benign cartilaginous tumours; the former is also called “Codman’s Tumour”. They may show specks of calcification signifying their cartilaginous origin. The latter can be aggressive; ends of bone are commonly involved especially tibia , proximal humerus and proximal femur

Incidence: rare tumours; less than 1 % of all primary bone tumours

Differential Diagnosis: Aneurysmal bone cyst, GCT

Prevention: Nil

Situation 1. a) clinical diagnosis – pain and vague swelling, restricted movemets of the neighbouring joints due to reflex spasm b) Investigation – X-ray c) Treatment –Plaster slab application; further management may not be possible in non-metro scenario d) referral criteria – for precise diagnosis and further management

Situation 2. a)clinical diagnosis – same as above b)Investigation X-ray, MRI, wide bore needle biopsy c)Treatment – curettage and bone grafting (auto or allo)

7) Name of condition: Benign Bone tumour – Non-ossifying Fibroma

Introduction: Benign bone tumour arising from fibroblasts. Usually seen in the metaphyseal region of immature skeleton and most of the times it is asymptomatic. It may be an incidental finding in a x-ray taken for some other purpose or bigger lesions may present as pathological fractures. They have a characteristic radiological appearance of serpigenous margins which have pencil lined sclerotic borders.

Incidence: not uncommon

Differential Diagnosis: none

Prevention: nil

Situation 1. a) clinical dianosis may not be possible b) Investigation – plain x-ray c) Treatment: asymptomatic, small and incidental lesions are left alone and observed. d) Referral criteria: big lesions and pathological fractures

Situation 2. a) clinical diagnosis may not be possible. Big lesions are curetted prophylactically to prevent pathological fractures and bone grafted. Once they present with a pathological fracture – either they are immobilized in plaster cast till the fracture unites and then curetted and bone grafted or the fracture is openly reduced and internally fixed and at the same time the lesion is curetted and bone grafted.

8) Name of condition: Benign tumourous conditions – Simple Bone Cyst, Aneurysmal Bone cyst & Fibrous Dydplasia

Introduction: These lesions mimic tumours and they look alike. Usually occur in adolescents. Lytic lesions with clear cut zones of transition. ABC may show fluid levels in MRI; Fibrous dysplasia has ground glass matrix They may present with pain and swelling or with pathological fracture.

Incidence : not very common

Differential Diagnosis: GCT, cartilaginous tumours

Prevention: Nil

Situation 1. a) clinical – nothing specific except pan]in ful swelling, not large or may present with pathological fracture.

b) Investigation: x-ray

c) referral criteria – Lytic lesion in bone seen on x-ray picture with or without pathological fracture

d) Treatment plaster slab and referral to higher centre

Situation 2. a) clinical: same as above

b) Investigations – X-ray, CT scan / MRI, needle biopsy

c) Treatment – curettage and bone grafting; if the patient has a pathological fracture, either the limb is immobilized in plaster cast till the fracture unites and then curettage and bone grafting carried out or the lesion is curetted and bone grafted and at the time the fracture is internally fixed.

9) Name of condition: Benign Tumourous condition – Fibromatosis

Introduction: A benign very slow growth of in the subcutaneous tissue or intermuscular connective tissue – does not metastasize but recurrence rate after excision is very high.

Incidence: rare

Differential Diagnosis: Other malignant soft tissue tumours like synovial sarcoma or fibrosarcoma.

Prevention Nil

Situation 1. a) clinical: Firm swelling in the soft tissue of long duration, minimally painful b) Investigations – x-ray- may not reveal any information c) Treatment: cannot be treated in small centres – to be referred to higher centres

Situation 2. a) clinical : same as above b) Investigations: plain x-ray, CT scan, MRI, CT chest, Trucut needle biopsy c) Treatment: wide excision with a little surrounding soft tissue to prevent recurrence

10) Name of condition: Benign developmental disorders mimicking bone tumours: SMultiple Osteochondromatosis, Muliple enchondromatosis, Ollier’s disease

Introduction: Freak outgrowths from the growth plates – multiple osteochondromatosis- which is familial and producing remodeling and growth abnormalities and ten times more potent for malignancy than its solitary counterpart. Freak inclusions of cartilaginous masses from growth plates into the metaphysic producing streaks of lucency is Ollier’s disease – usually present in one side of the body and produces marked growth anomalies. Proliferation of cartilage in the medullary substance of small bones of hands and feet producing globular swellings is multiple enchondromatosis. This condition is not familial and is also associated with growth disturbances.

Incidence: The former is quite common whereas the other two are rare; multiple osteochondromatosis is 10 times less common than solitary osteochondroma.

Differential Diagnosis: usually none; One has to be vizilant to look for a malignant transformation in one of the lesions - the more proximal the lesion is to the axial skeleton more are the chances of malignancy.

Prevention: prevent consanguineous marriages

Situation 1. a) clinical: multiple hard swellings in the metaphyseal regions of long bones or on the flat bones or multiple globular swellings in the short long bones of hands and feet with growth disturbances. Recent increase in size and onset of pain to be enquired. Mechanical restriction of motion of a neighbouring joint or compression of a nearby nerve are to be looked into b) Investigation – Only plain x-ray is possible d) referral criteria – all cases to be referred to higher centres.

Situation 2. a) clinical – same as above b) Investigation : Plain x-ray, CT scan, MRI, wide bore needle biopsy; Caution: Histology cannot be relied upon in diagnosing malignancy in cartilaginous lesions; One has to rely on clinical findings like pain and fast growth to diagnose malignancy. A cartilaginous cap of more than 1 cm thickness as seen in MRI is suggestive of malignancy. c) Treatment: Lesions with complications should be excised. Lesions very proximal to the axial skeleton should be excised prophylactically

11) Name of condition: Benign Aggressive tumour – Giant Cell Tumour (Osteoclastoma)

Introduction: .A benign bone tumour arising from undifferentiated connective tissue cells of bone marrow. Occurs in the mature skeleton usually around knee and at wrist. It is an aggressive tumour and the chances of recurrence following curettage are very high. A small percentage might even metastasise to lungs.

Incidence: much more common in India, especially South India (4 to 6 times), than the western world.

Differential Diagnosis: Aneurysmal bone cyst, Benign Fibrous histiocytoma and aggressive chondromyxoid fibroma., Hyperparathyroidism.

Prevention: Nil

Situation 1. a) clinical: a globular eccentric swelling in a mature skeleton around the knee bones or lower radius. Other sites are less common. Swelling may start before pain. The patient may present with a pathological fracture. b) Investigation – x-ray. c) Treatment not possible in non metro hospitals. d) referral criteria- all suspected cases must be referred to higher centre

Situation 2. a) clinical: same as above b) Investigations: Plain x-ray, CT scan, MRI, wide bore needle biopsy c) Treatment: Curettage with h igh speed burr, curettage with usage of adjuvants like phenol or liquid nitrogen (cryosurgery) have been in usage. However, extended curettage has the least chances of recurrence. Excision in toto is ideal if the bone involved is expendable (like lower ulna, proximal fibula). In instances like lower radius, excision and reconstruction using proximal fibula is practiced. In weight bearing bones like distal femur or proximal tibia, when the the bone is totally destroyed, resection arthrodesis (Enneking procedure) is ideal if the patient belongs lower socioeconomic group. But if the patient belongs to higher strata where the load demands are less, excision and custom mega prosthesis may be practiced. In fungating cases or after repeated recurrences, an amputation may be the last resort.

12) Name of condition: Malignant bone tumour: Osteosarcoma & its variants

Introduction: occurs in second decade of life.

Incidence: most common malignant tumour in the immature skeleton

Differential Diagnosis: Early lesions are difficult to diagnose unless one has high index of suspicion. Any pain in the metaphyseal region following a minor injury and disproportionate to the injury or if the pain is slowly increasing day by day after minor injury and especially without fever should lead the clinician to suspect this sinister disease. If it occurs after skeletal maturity, Giant cell tumour also must be thought of.

Prevention: Genetic engineering is under trial to prevent the lesion in children who are genetically prone to suffer.

Situation 1. a) clinical: as described earlier in diff. diag. In late cases pain preceding a spindle shaped swelling in the metaphysic of long bone must give suspicion of osteosarcoma. b) Investigations: plain x-ray c) referral criteria: any suspicion that the swelling is malignant.

Situation 2.

a) clinical: same as above

b) Investigations: plain x-ray, x-ray chest, Serum alkaline phosphatase, MRI of lesion, CT Chest, needle biopsy

c) Treatment: In early cases – chemotherapy for 6 weeks followed by limb sparing surgery (excision of tumour in toto and replacement by custom mega prosthesis), after histological examination of the excised tumour for tumour necrosis, the chemotherapy may be suitably altered. Patient followed at frequent intervals for local recurrence and lung metastases. In cases of late presentation where tumour excision is not feasible a course of chemotherapy is followed by amputation of the limb – chemotherapy is continued. Where lung metastases are present amputation of the limb is palliative.

13) Name of condition: Malignant bone tumour – Chondrosarcoma

Introduction: Chondrosarcoma is a malignant bone tumor arising from chondroblasts. The lesion may arise de novo (primary chondrosarcoma) or there may be malignant transformation of an existing benign cartilaginous lesion - osteochondroma / enchondroma (secondary chondrosarcoma). Thus the lesions may be central or peripheral The lesions are frequently calcified (c-shaped or o-shaped calcifications)

Incidence: not rare; third most common bone malignancy; 25 % of all sarcomas

Differential Diagnosis: Non aggressive lesions may be mistaken for benign tumours especially Fibrous Dysplasia.

Prevention: Secondary chondrosarcomata may be prevented by proper treatment of primary cartilaginous lesion.

Situation 1. a) clinical: nothing specific. Recent fast growth and onset of pain in a primary cartilaginous lesion should make one suspect secondary Chondrosarcoma b) Investigations: x-ray., needle biopsy c) referral criteria – inability to treat at the primary centre

Situation 2. a) Clinical: same as above b) Investigations: CT scan of part involved, CT scan Chest, MRI, Isotope bone scan, Needle Biopsy c) Treatment: Chondrosarcomata are resistant to chemo and radiotherapies. Hence excision in toto, short of amputation, is the only alternative. Secondary and peripheral chondrosarcomata may be amenable for excision. Primary or secondary chondrosarcomata of the limb girdle may be difficult to treat surgically but excision and reconstruction may be tried depending on the situation. Custom made prostheses may be tried for chondrosarcomata of proximal humerus and femur if the lesions are intracompartmental. Inoperable tumours need disarticulation.

14) Name of condition: Malignant bone tumour – Ewing’s sarcoma

Introduction: A malignant bone tumour where the cell of origin is uncertain; usually occurring in the diaphyses of children. It can also occur in the metaphyseal regions. When the tumour occurs in adults the ilium is more commonly involved. It is a fast growing tumour with a lot of soft tissue swelling.

Incidence – Rare

Differential Diagnosis: Osteomyelitis is a major competitor for diagnosis not only clinically but also radiological and histological. Other round cell tumours of bone also should be thought of.

Prevention – Nil

Situation 1.

a) clinical: Painful, spindle shaped swelling in the diaphysis of of a child without trauma should be viewed with suspicion. Fever points a finger at osteomyelitis but acute diaphyseal osteomyelitis is very uncommon. b) Investigations: x-ray, blood counts and ESR. c) Treatment- not possible in non-metro situation d) referral criteria: suspicion of tumour

Situation 2.

a) clinical: same as above

b) Investigations: x-ray, CBP & ESR, MRI of the part, CT scan of chest, wide bore needle aspiration – material must be sent for histopathology and culture of pyogenic organisms as well. The dictum “culture a tumour and biopsy an infection” holds good here.

c) Treatment: Though earlier on Radiotherapy was best suited for Ewing’s sarcoma, present day sheet anchor is Chemotherapy. After an initial course of chemotherapy, wherever feasible, the tumour is resected and reconstruction done (appropriate surgery). For a recurrence of the tumour radiotherapy is preferred since the recurrence is from cells which are resistant to chemotherapy given earlier. Where resection of the tumour is not possible amputation is performed.

15) Name of condition: Makignant bone tumour Plasmacytoma/Multiple myeloma

Introduction: It is a malignant tumour of the marrow elements where plaslymacytes multiply cancerously in an elderly individual. The condition must be suspectd when an elderly individual complains of vague pains all over the body and not responding to usual analgesics

Incidence: not rare; 10 % of hematological malignancies., 1 % of all forms of cancer.

Differential Diagnosis: The main contender is osteoporosis with compression fractures; Multiple metastases especially from prostate in males and breast in females should be thought of; Osteomalacia in late adulthood and Fibromyalgia syndrome are also to be differentiated.

Prevention: Nil

Situation 1.

a) clinical: a high index of suspicion in the elderly is very important when the patient complains of generalized body aches of sufficiently long duration not responding to analgesics. Sternal tenderness is an important sign in multiple myeloma. c) Treatment: Once suspected the patient must be referred to a metro level hospital both for conformation of diagnosis and management d) referral criteria: Undiagnosed generalized body aches which are not responding to usual analgesics

Situation 2. a) clinical – same as above

b) Investigations: CBP, ESR, S.Calcium, Phosphorus, Alkaline phosphatase, Bone marrow examination (sternal puncture), serum protein electrophoresis

c) Treatment: Chemotherapy and cortisones

16) Name of condition: Malignant bone tumour – Metastatic Bone Tumours

Introduction: Tumours metastatic to bone are usually from Prostate, Female genital organs, Breast, Lungs, Kidney, Thyroid and GIT. Patients usually complain of either localized or generalized pains. Patient may also present with a pathological fracture with no other symptoms. It is important to note that symptoms due to the primary disease are often lacking and only the secondary deposits cause symptoms. It is also interesting to note that quite often one fails to locate the primary lesion inspite of investigations

Incidence: Not uncommon

Differential Diagnosis: Multiple myeloma, osteoporosis, hyperparathyroidism etc

Prevention. Nil

Situation 1. After suspecting a metastatic deposit, after x-ray examination patient has to be referred to a metro level hospital.

Situation 2. a) clinical: Localised or generalized pains in an elderly individual not responding to analgesics must be investigated. They have a pathology unless proved otherwise. A detailed clinical examination of the systems from which a primary is likely to occur should be carried out b) Investigations: CBP, ESR, x-ray chest, CT chest, Serum Ca, P, ALP, PTH, Serum protein electrophoresis, wide bore needle aspiration biopsy of the lytic lesion detected on x-ray. Other blood investigations to detect cancers of the respective organs (like PSA , Ca 128 etc.) are to be carried out c) Treatment: of the primary depends on the cause. For a pathological fracture (or an impending fracture), curettage of the lesion, filling with bone cement and internal fixation preferably with an intramedullary nail is palliative and gives comfort for the rest of the life.

Standard Treatment Guidelines For Congenital Orthopedic Anomlies

Of the many congenital anomalies of Orthopedic interest, only two conditions which are common are discussed here – they are CTEV (Congenital Talipes Equino Varus) and (Congenital Dislocation of Hip). Others are to be treated in specialized centres.

1) Name of Condition: CTEV (Congenital Talipes Equino Varus)

Introduction: The most common congenital anomaly seen in Orthopedics also referred to as CLUB FOOT. The deformity can be unilateral or bilateral. The common question that needs to be answered by the primary clinician is whether the foot is normal at birth – when dorsiflexed the dorsum of the neonatal foot touches the shin of tibia. If it does not , there is mild equinovarus deformity. In CTEV, the foot has four components of the deformity – plantar flexion at ankle, inversion of foot at subtalar joint, varus of the forefoot at the midtarsal joints and internal torsion of tibia.

Incidence: most common congenital anomaly in orthopedics

Differential Diagnosis: Other conditions which produce the talipes equino varus deformity should be thought of – meningomyelocele (or spina bifida occulta in adolescents as revealed by external tell tale scars like fobrofatty nodule in the lumbar spine, tuft of hair or pigmented skin patch), Cerebral palsy of lower limbs, Arthrogryposis congenita, nerve injuries to lateral popliteal nerve, anterior poliomyelitis.

Prevention: Avoiding consanguineous marriages might prevent, at least partly, the incidence of congenital anomalies

Situation 1. Non metro hospitals.

a) clinical – minimal deformity in neonates can be diagnosed as explained in Introduction. Deformities of bigger magnitude are obvious. Clinician has to examine to find out a cause for the deformity as explained in differential diagnosis. Depending on how much deformity is passively correctible, it can be classified as mild, moderate and severe. The chil must be examined for the presence of other congenital anomalies – orthopedic and non-orthopedic

b) Investigations: x-ray in an older child.

c) Treatment: the clinician has to familiarize himself with the technique of manipulation and serial plaster casting. Otherwise the patient has to be referred to metro hospitals.

d) Referral criteria – if the clinician does not know the technique of manipulation and plaster cast application; if there is no progress in correction of deformity after 6 to 8 manipulations ; if the child presented for the first time at the age of one year or the complication of rocker bottom foot has developed.

Situation 2: metro hospital:

a) clinical: same as above

b) in a bigger child- x-ray of the part and x-ray of spine, x-ray pelvis to rule out DDH if suspected clinically

c) Treatment: manipulation of foot, preferably by Ponseti technique, even if the child is more than one year age to make the foot supple before surgery. Serial plaster casts appled. If the improvement is not satisfactory by 8 months of age surgery in the form of posteromedial release is suggested followed by serial plaster casts. Once correction is achieved and the child is not yet walking a Denis-Browne splint is prescribed. Corrective shoes are to be given after the child starts walking. If the heel varus is persisting even at 6 yrs age, Dwyer’s calcaneal osteoteotomy is advised. For persisting round contour of the lateral border of the foot one of the lateral column shortening operations is performed. A supramalleolar osteotomy of tibia is indicated for persisting excessive tibial torsion. If the surgeon is conversant JESS application is a viable alternative. In neglected cases beyond 12 yrs of age a triple arthrodesis may be performed.

2) Name of condition: Developmental Dysplasia of Hip

Introduction: In teratological conditions, the hip is found dislocated at birth. In other conditions of DDH, the hip is lax and waiting to dislocate if some forces act on it – the dislocatable hip or the hip is found dislocated and can easily be reduced – reducible hip. If the child comes late with a dislocated hip, it cannot be reduced by closed manipulation and needs surgery

Incidence: The exact incidence in India is not worked out though the condition is not very rare.

Differential Diagnosis: Proximal Femoral Focal Deficiency (PFFD), Congenital short femur, sequelae of septic arthritis of hip

Prevention: prevention of consanguinous marriages might reduce incidence.

Situation 1. non-metro hospital

a) Clinical: Barlow’s and Ortolani’s signs to diagnose dislocatable or reducible hips. Dislocated hip has a short limb, increased creases on the inner aspect of thighs, femoral head present anteriorly , abduction of hip is restricted and telescopy positive.

b) Investigations: X-ray of pelvis – normal view and von Rosen’s view

c) whether the hip is dislocatable or dislocated, closed manipulation performed to reduce the hip and a POP spica applied in human position. d) if the diagnosis is doubtful or hip cannot be reduced by closed manipulation the patient must be referred to higher centre.

Situation 2. metro hospitals:

a) clinical –same

b) investigations: plain x-ray of pelvis for both hips; Ultrasound examination of hip if the child is 6 months or less of age. In failed closed reductions an arthrogram of the hip may be performed. CT & MRI are very rarely indicated.

c) Treatment: in an infant closed manipulation of hip and plaster spica in human position. In a slightly older infant, a preliminary traction might help closed reduction. In an older infant, open reduction may be required followed by plaster spica. If the acetabular coverage is not enough, Salter’s innominate osteotomy is indicated. If the acetabulum is roomy, Pemberton osteotomy may be performed. In a slightly older child, in addition femoral shortening derotational osteotomy may be beneficial. A shelf operation to augment acetabular coverage may be required.

Guidelines by The Ministry of Health and Family Welfare :

Dr. P.K. DAVE, Rockland Hospital, New Delhi, Dr. P.S. Maini, Fortis Jessa Ram Hospital, New Delhi

Reviewed By

Dr. V.K. SHARMA Professor Central Instiute of Orthopaedics Safdarjung Hospital New Delhi