Home Dysplazja i zwichniecie stawu biodrowego dlaczego badamy po urodzeniu
Dysplazja i zwichniecie stawu biodrowego dlaczego badamy po urodzeniu PDF Drukuj Email

Dlaczego badamy  na oddziale noworodkowym zaraz po urodzeniu?




Noworodki powinny być badane zaraz po urodzeniu: ponieważ,nie marnujemy czasu potrzebnego do profilaktyki i leczenia małych pacjentów.W tej kwestii czas działa na naszą niekorzyść,im szybciej zbadamy i wykryjemy ewentualną wadę stawu tym szybciej podejmiemy odpowiednie postępowanie by całkowicie odbudować niedorozwój panewki a to  w ostateczności skróci czas leczenia.Tydzień leczenia wady wykrytej u dziecka zaraz po urodzeniu jest wart tyle co miesiąc leczenia w późniejszym terminie.

Wrodzona wada bioder (CDH)   występującą rodzinnie(ponad 10%)  stwarza  najwięcej problemów jeśli chodzi o diagnostyką i leczenie, dlatego też warto dowiedzieć się wcześniej czy w  rodzinie występował   czy u blisko spokrewnionej rodziny(rodzice, rodzeństwo, dziadkowie, wujkowie, ciotki i ich dzieci )  jakieś  choroby bądź wady bioder  w okresie niemowlęcym np:

  • Operacje albo bóle w biodrze
  • Zburzenia mięśniowo- ruchowe
  • Zburzenia neurologiczne

jeśli tak to należy wykonać badanie USG stawów biodrowych na oddziale noworodkowym.


Skreening na oddziale noworodkowym jest badaniem dynamicznym i bardzo trudnym  dla doktora, gdyż wymaga ono dużej wiedzy i doświadczenia.Łatwo jest się pomylić ze względu na poporodową wiotkość tkanek umożliwiającą  dużą ruchomość głowy w panewce, która daje taki sam obraz i objawy jak w przypadku wrodzonego zwichnięcia.Aż  1/3  niestabilności u zdrowych dzieci, jest fałszywie dodatnia.(11)


Rozpoznanie tuż po urodzeniu zmniejsza pięciokrotnie liczbę dzieci wymagających leczenia, wystarczy tylko profilaktyka wykonywana przez rodziców.Natura sama chroni i umożliwia prawidłowy rozwój stawu biodrowego za pomocą  przykurczu mięśni, który zapewnia właściwe ułożenie kończyn. Nie należy więc podczas pielęgnacji i ubierania prostować zgiętych nóżek dziecka, tylko pomagać mu w utrzymaniu tej korzystnej dla bioder pozycji. 
Noworodki  z CDH rodzą się z płytką panewką(typ D) ale głowa utrzymywana jest w panewce, wyjątkowo jest inaczej, wszyscy są co do tego zgodni. Ligamentum teres  ,które  utrzymuje głowę w stawie zaczyna się wydłużać i rozrastać z każdym ruchem nogi , jest to proces nieodwracalny. Nie jesteśmy w stanie skrócić wydłużonego więzadła ani będących w nim zakończeń nerwowych,odpowiedzialnych za utrzymanie głowy w panewce.
Nieprawidłowe położenie głowy zmienia również przebieg mięśnia ilipsoas ,który uciska tętnice okalającą przyśrodkową(główne naczynie odżywcze) do brzegu panewki hamując w niej przepływ krwi  oraz uniemożliwia wprowadzenie głowy do panewki.Zmniejszony dopływ krwi hamuje wzrost głowy  lub niszczy ją jeżeli dochodzi do niego nagle .
Powyższe zmiany są kluczowe dla leczenia i rokowania, jeśli dopuścimy do ich wystąpienia, efekt nigdy nie jest w pełni satysfakcjonujący.
według wyników niemieckich tylko u prawie 1: 25 000 niemowląt z prawidłowymi stawami występuje rozwojowa dysplazja stawów biodrowych(1u) jest to 5X mniej w porównaniu z badaniami angielskimi, również pięciokrotnie zmniejszyła się liczba operacji od czasu wprowadzenie przesiewowego badania usg bioder.

Tylko 13% operowanych stawów(alloplastytka) w najwcześniejszych latach jest wykrywanych badaniem klinicznym  zaraz po urodzeniu.
Nadal jednak, mimo rozwiniętej profilaktyki i obowiązkowym badaniom usg stawów biodrowych w Niemczech,  10% niemowląt nie pojawia się do obowiązkowej kontroli,  dlatego rozpoznanie na oddziale noworodkowym jest ważne.        
Nie znaleziono również   dowodów na to że,stosowana w USA profilaktyka( przesiewowych, wielokrotnych badań klinicznych) do wykrywania DDH skutkuje zmniejszeniem liczby zabiegów operacyjnych albo  późniejszym lepszym funkcjonowaniem dzieci  stwierdziła USPSTF(amerykańska rządowa agencja ds profilaktyki)  jak pisze  Amerykańskie Stowarzyszenie Ortopedów Dziecięcych  w 2007r.(1),co potwierdzają publikacje podobnej instytucji  angielskiej(3,4) na temat profilaktyki wykonywanej na podobnych zasadach w Anglii


Świadczy to również o tym że, jeśli nie wykryjemy DDH zaraz po urodzeniu i pozwolimy na rozwiniecie zmian wtórnych ( wtedy można je wykryć  za pomocą badaniu klinicznego ),dochodzi do trwałego zaburzenia funkcji stawu biodrowego.

 

 

 

PS:
Wprowadzenie przez  Państwowych Ubezpieczycieli w danym kraju  nie w pełni skutecznej profilaktyki, znacznie pogarsza rokowania dzieci z CDH ,ponieważ ani rodzice ani  pracownicy medyczni nie biorą pod uwagę takiego rozpoznania   ,wierząc w  pełną efektywność  zalecanej przez ich Państwo profilaktyki.
(4)

 

 

Pomaga nam w  naszych badaniach nad stawami biodrowymi

 

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   Pomaga nam w  naszych badaniach nad stawami biodrowymi







Publikacje


1).Screening the newborn for developmental dysplasia of the hip: now what do we do?
Schwend RM, Schoenecker P, Richards BS, Flynn JM, Vitale M; Pediatric Orthopaedic Society of North America.
Section of Orthopaedics, Children's Mercy Hospital, Kansas City, MO, USA. Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.
Comment in:
J Pediatr Orthop. 2007 Sep;27(6):605-6.
The Pediatric Orthopaedic Society of North America recommends that all health care providers who are involved in the care of infants continue to follow the clinical practice guideline for early detection of developmental hip dysplasia (DDH) outlined by the American Academy of Pediatrics. Although evaluation of children with risk factors for DDH is important, most DDH occurs in infants who have no risk factors. For all infants, a competent newborn physical examination using the Ortolani maneuver is the most useful procedure to detect hip instability. Early treatment of an unstable hip with a Pavlik harness or similarly effective orthosis is effective, safe, and strongly advised.

Despite having had normal newborn and infant hip examinations, there remains the possibility of a late-onset hip dislocation needing treatment in approximately 1 in 5000 infants.(Mimo prawidlowego wyniku badania klinicznego u noworodka i niemowląt,dalej pozostaje mozliwość wystapienia zwichniecia biodra wymagającego leczenia u około 1 na 5000 niemowląt)

No direct evidence that  screening for DDH, results in less surgery or better functional outcomes,althoug there was evidence that screening leads to earlier identification was found. ( Nie ma bezposredniego dowodu że badanie(kliniczne) przesiewowe w celu znalezienia (rozwojowej dysplazji stawu biodrowego) DDH skutkuje mniejsza ilościa zabiegów operacyjnych albo lepszym funkcjonowaniem ,chociaz udowodniono że skrining prowadzi do wcześniejszego rozpoznania)


2)Developmental dysplasia of the hip Carol Dezateux, Karen Rosendahl
In its severest form, developmental dysplasia of the hip is one of the most common congenital malformations. The
pathophysiology and natural history of the range of morphological and clinical disorders that constitute developmental
dysplasia of the hip are poorly understood. Neonatal screening programmes, based on clinical screening examinations,
have been established for more than 40 years but their eff ectiveness remains controversial. Whereas systematic
sonographic imaging of newborn and young infants has aff orded insights into normal and abnormal hip development
in early life, we do not clearly understand the longer-term outcomes of developmental hip dysplasia, its contribution
to premature degenerative hip disorders in adult life, and the benefi ts and harms of newborn screening. High quality
studies of the adult outcomes of developmental hip dysplasia and the childhood origins of early degenerative hip
disease are needed, as are randomised trials to assess the eff ectiveness and safety of neonatal screening and earlytreatment.

Lancet 2007; 369: 1541–52Centre of Epidemiology forChild Health, Institute of ChildHealth, London, UK(Prof C Dezateux FMedSci);
Section for Radiology,University of Bergen, Bergen,Norway; and Department ofImaging, Great Ormond StreetHospital for Children, London,
UK (Prof K Rosendahl PhD)Correspondence to:Prof Carol DezateuxMedical Research Council Centreof Epidemiology for Child Health,
Institute of Child Health,University College London,30 Guilford Street, LondonWC1N 1EH, Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.
Developmental dysplasia of the hip is an important cause of childhood disability. This disorder underlies up to 9%
of all primary hip replacements and up to 29% of thosein people aged 60 years and younger.In the past, without detection by screening,developmental dysplasia of the hip usually presented
clinically after walking age, and at least 50% of patientsstarted treatment by 5 years of age.121 The recognised
longer-term complications of untreated developmentaldysplasia of the hip include pain in the hip, knee, and
lower back; disturbances of gait; and degenerativechanges in the hip joint. However, the risk of such
complications is not well defi ned. Some reports suggestthat, without treatment, functional impairment due to
developmental dysplasia of the hip is common, and thatit increases with age but is not inevitable.42,121,122 When
followed up for an average of 50 years, 11–41% of thosewith untreated dislocation remained free of pain.42,121,122

3) Lancet. 1998 Apr 18;351 (9110):1149-52 9643684 (P,S,G,E,B) Cited:3
Surgery for congenital dislocation of the hip in the UK as a measure of outcome of screening. MRC Working Party on Congenital Dislocation of the Hip. Medical Research Council.
S Godward, C Dezateux
BACKGROUND: Universal clinical screening for congenital dislocation of the hip to detect hip instability in neonates was introduced in the UK as a national policy in 1969, but its effectiveness is not known. We aimed to assess the extent to which surgery for congenital dislocation of the hip is the result of a failure of detection through screening or follows non-surgical treatment after detection by screening. METHODS: We established a national orthopaedic surveillance scheme and used routine hospital data for inpatients for 20% of births in the UK (Scotland and the Northern and Wessex regions) to ascertain the number of children aged under 5 years per 1000 livebirths who had received at least one operative procedure for congenital dislocation of the hip from April, 1993, to April, 1994. Estimates of the incidence of operative procedures were adjusted for under-ascertainment by capture-recapture techniques. FINDINGS: The ascertainment-adjusted incidence of a first operative procedure for congenital dislocation of the hip in the UK was 0.78 per 1000 livebirths (95% CI 0.72-0-84). Congenital dislocation of the hip had not been detected by routine screening in 222 (70%) of 318 children reported to the national orthopaedic surveillance scheme. In 112 (35%) children the diagnosis was made primarily as a result of parental concern. 67 (21%) children had previously received non-surgical treatment. In Scotland and the Northern and Wessex regions, 81 cases were notified to the national orthopaedic surveillance scheme, 62 cases were identified only through routine hospital data on inpatients, and an estimated 20 cases were not identified by either source, making a total of 163 cases. Thus, 81 (50%) of these 163 cases were identified by surveillance, 125 (77%) by routine data, and 143 (88%) by both sources. INTERPRETATION: The incidence of a first operative procedure for congenital dislocation of the hip in the UK was similar to that reported before screening was introduced. In most children who received surgery, congenital dislocation of the hip was not detected by screening. Formal evaluation of current and alternative screening policies, including universal primary ultrasound imaging, is needed

4)  FAILURES OF SCREENING AND MANAGEMENT OF ONGENITAL DISLOCATION OF THE HIP
I. A. C. LENNOX, J. McLAUCHLAN, R. MURALI
From the Royal Aberdeen Children’s Hospital, Scotland
We report the screening of 67 093 infants for congenitaldislocation of the hip from 1980 to 1989 and comparethe results with those during the preceding two decades.More dislocations have been missed at neonatal examination during the last decade (0.13% of livebirths). Operative treatment was needed in 54 children(0.08% of live births) some of whom had been diagnosedat birth. We discuss the reasons for the failure ofneonatal screening.Boneloint Surg[Br] 1993;75-B:72-5.Received 11 May 1992; Accepted l2June 1992
Congenita ldislocation ofthe hip(CDH) is still potentiall ycrippling although Roser (1879), Le Damany (1912) andPutti (1927) showed that neonatal diagnosis and simplesplinting were successful as treatment. Ortolani described his test in 1937 and Barlow (1962) modified it for the dislocatable hip by applying posterolateral pressure. I twas thought that by screening every child at birth, usinga combination of these two tests, and splinting everyaffected child, the late results of congenital dislocationwould be eliminated.A regional service was started in Aberdeen in 1960,whereby every child born in the Grampian region ofScotland was screened at birth. Those thought to have evidence of CDH were referred to a special clinic for reexaminationand splinting if necessary. The result of this programme has, however, fallen short of the original expectations. Thirty years later, some children stillpresent for treatment long after the neonatal period,despite having been screened in a specialist clinic. Their prognosis may be worse than that before screening began,because the diagnosis is not suspected by doctors and health workers who believe that neonatal screening is fully effective

The value of any screening programme must be judged by its failures



5): J Orthop Res. 1992 Nov;10(6):800-6. Links
Acute effect of traction, compression, and hip joint tamponade on blood flow of the femoral head: an experimental model.
Naito M, Schoenecker PL, Owen JH, Sugioka Y.
Department of Orthopedic Surgery, Kyushu University, Fukuoka, Japan.
Blood flow rates of the canine femoral head were experimentally determined during traction, compression, and hip joint tamponade using the hydrogen washout technique. In puppies, blood flow rate of the femoral head was significantly decreased with either traction or compression applied at one half body weight. Either maneuver, when combined with hip joint tamponade, reduced blood flow rate of the femoral head an average of more than 70% as compared with the initial control rate. In adult dogs, combinations of either traction or compression, at one-half body weight, with hip joint tamponade did not significantly decrease blood flow rate of the femoral head as compared with control values. Perfusion defect of blue silicone could be observed only in puppies around the hip during combinations of traction or compression with hip joint tamponade and involved the posterior superior capital branches of the medial circumflex artery and the arteries in the ligamentum teres. These experimental data may have important implications for the pathogenesis of iatrogenic avascular necrosis in the treatment of congenitally dislocated hip, Legg-Perthes dis1: Orthop Nurs. 1995 Jan-Feb;14(1):33-40. Links





6) : Clin Orthop Relat Res. 2008 Apr;466(4):791-801. Epub 2008 Feb 21.   Links
Imaging in the surgical management of developmental dislocation of the hip.
Grissom L, Harcke HT, Thacker M.
Alfred I. duPont Hospital for Children, 1600 Rockland Road, PO Box 269, Wilmington, DE, 19899, USA. Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.
Although the use of ultrasound in the diagnosis and early treatment of developmental dysplasia of the hip (DDH) has reduced the number of patients diagnosed late and decreased the number of operative procedures, surgical treatment is still needed in some patients. Late cases continue to occur as a result of missing the screening examination, being normal at initial screening and missing followup. Dysplasia may persist despite appropriate nonoperative or operative treatment. Many of these patients subsequently undergo closed or open reduction and femoral or acetabular reconstruction. Ultrasound of the hips is generally used up to 6 or 8 months of age, during which time the hips are largely cartilaginous, and radiographs after that time when bony development is more complete. Options to supplement ultrasound and radiography include arthrography, computed tomography, and magnetic resonance imaging. Several advances have been made in the imaging of DDH and its complications including acetabular labral pathology and of femoroacetabular impingement (FAI). We review imaging techniques other than ultrasound used in the management of DDH. LEVEL OF EVIDENCE: Level V, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

7)

: J Pediatr Orthop. 1994 Jan-Feb;14(1):16-23. Links
Changes in soft tissue interposition after reduction of developmental dislocation of the hip.
Tanaka T, Yoshihashi Y, Miura T.
Department of Orthopedic Surgery, Nagoya University School of Medicine, Japan.
Changes occurring in soft tissue interposition in 111 cases of developmental dislocation of the hip (DDH) reduced by overhead traction (OHT) were assessed by arthrogram. Soft tissue interposition was classified into five types based on the shape of the limbus, and changes in tissue thickness in the acetabular floor were examined. Thickness of soft tissue interposition was in the normal range in 92 hips of 111 hips (82.9%), but in hips in which a thick pad of the soft tissue was apparent at the acetabular floor both in the dislocated and reduced positions, soft tissue did not recede in 61.5% of hips.
8). Free nerve endings in the ligamentum capitis femoris
Michael Leunig1, Martin Beck1, Edouard Stauffer2, Ralph Hertel1 and Reinhold Ganz1
Departments of 1Orthopedic Surgery and 2Pathology, University of Bern, Inselspital, CH-3010 Bern, Switzerland
Tel +41 31 632 2222. Email: Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.
Submitted 99-12-09. Accepted 00-04-16

ABSTRACT – We report the presence of free nerve endings (FNE) in the ligamentum capitis femoris
(LCF). Qualitative and quantitative measurements onthe incidence of FNE, as assessed by immuno-histochemistry
for the S-100 protein, were obtained from18 patients undergoing hip surgery. We found FNE in
all LCF, with no association to age. The presence ofFNE in the LCF suggests a role in noci-/proprioception
of the hip.

Propriocepcja Proprioception


Czucie głębokie, czyli czucie proprioceptywne, wraz z towarzyszącymi mechanizmami nerwowo-mięśniowego sprzężenia zwrotnego, stanowią istotny element funkcjonalnej stabilizacji stawów. Kontrola nerwowo-mięśniowa i stabilizacja stawu,kierowana jest pierwotnie przez ośrodkowy układ nerwowy.

Receptory odbierające bodźce zewnętrzne, tzn. mechanoreceptory oraz receptory znajdujące się w narządzie wzroku i przedsionkowym, przesyłają informacje do mózgu i rdzenia przedłużonego, gdzie są one przetwarzane. Suma odbieranych informacji przejawia się w świadomej zdolności rozpoznawania, poruszania i położenia stawów, nieświadomej stabilizacji stawów, za którą odpowiadają zabezpieczające odruchy rdzeniowe.

Dotychczasowe badania, prowadzone nad skutkami urazów mięśni i stawów oraz wpływu zabiegów rekonstrukcyjnych i rehabilitacji na czucie głębokie, dotyczyły przede wszystkim stawu kolanowego i skokowego. Prace te wykazują różnice w propriocepcji, wynikające z następstw urazów torebkowo-więzadłowych, sposobu i czasu rekonstrukcji więzadeł .



Proprioception, together with accompanying neuromuscular feedback mechanisms, constitutes an important component of creating and maintaining functional stability of joints. Neuromuscular control and joint stabilisation are mediated primarily by the central nervous system. A multisite sensory input, originating from the somatosensory, visual and vestibular systems, is received and processed by the brain and spinal cord. The accumulated and processed information results in a conscious awareness of position and motion, unconscious joint stabilisation through protective spinal reflexes, and the maintenance of posture and balance. Clinical research aimed at determining the effects of articular injuries of musculo-skeletal origin, and of surgery and rehabilitation on joint proprioception, neuromuscular control and balance, has focused on the knee and ankle joints. Such studies demonstrated alterations in proprioception resulting from capsuloligamentous injuries, partial restoration of proprioceptive acuity following ligament reconstruction




9).The development of the ligament of the head of the femur
S. F. Brewster *
Department of Anatomy, Charing Cross and Westminster Medical School, London W6 8RF, England
*Correspondence to S. F. Brewster, Department of Surgery, Bristol Royal Infirmary, Marlborough St., Bristol, Avon, BS2 8HW, England
The hip joints of 30 human male and female fetuses and stillborns between 20 mm and 350 mm crown-rump length were studied by light microscopy.
The ligament of the head of the femur developed in situ as a condensation of mesenchyme at the end of the second month of intra-uterine life (IUL), and was vascularized by branches of acetabular vessels early in the fourth month. In the majority of fetuses older than 5.5 months IUL, vessels in the ligament passed a short way into the femoral head within cartilage canals, to supply a small region around the fovea capitis. The remainder of the head was supplied by vessels in canals from around the upper part of the neck.
The ligament changed from predominantly cellular to fibrous during the last 4 months of IUL. This increase in strength suggested significant mechanical functions in utero: limitation of adduction-flexion and opposition to postero-superior dislocation were the most likely.


10).Free nerve endings and morphological features of the ligamentum capitis femoris in developmental dysplasia of the hip.
J Pediatr Orthop B.  2007; 16(5):351-6 (ISSN: 1060-152X)
Sarban S; Baba F; Kocabey Y; Cengiz M; Isikan UE
Department of Orthopaedic Surgery, Harran University Faculty of Medicine, Turkey. Adres poczty elektronicznej jest chroniony przed robotami spamującymi. W przeglądarce musi być włączona obsługa JavaScript, żeby go zobaczyć.
A conflict exists on whether the ligamentum capitis femoris has the neuro-morphological structures required for nociception or proprioception of the hip joint. Therefore, we investigated the morphological features and the presence of mechanoreceptors in 24 ligamentum capitis femoris biopsies obtained at open reduction in patients with developmental dysplasia of the hip. Of these 24 hips, 16 were completely dislocated and eight were subluxated. The mean age was 33.8 months (range 13-52 months) at the time of surgery. En bloc ligamentum capitis femoris and pulvinar were taken for biopsy specimen. Ligamentum capitis femoris was dissected and the weight of each ligament was determined using a highly sensitive balance. Specimens were stained with hematoxylin and eosin and Masson trichrome for routine histolopathological evaluation and examined immunohistochemically using monoclonal antibody against S-100 protein. All specimens were graded on a four-grade system according to the amount of coarse-thick collagen bundles and hyalinization. The mean number and type of mechanoreceptors of each specimen were recorded. When the mean age, the patient's weight and the ligamentum capitis femoris weight of each group (completely dislocated vs. subluxated) were compared, there were no significant differences. In the ligamentum capitis femoris of the dislocated hips, the cells were irregularly distributed, had different shapes, and appeared to be in different stages of functional activity. The collagen fiber bundles were thicker than in the subluxated hips, distributed and of varied thickness. The elastic fibers of the dislocated hips were thicker and more numerous than those in the subluxated hips. We found a significant difference between the two groups with regard to the grade of collagen and hyalinization of ligamentum capitis femoris (P<0.004). We found type IVa, free nerve endings in 16 of 24 samples of ligamentum capitis femoris. The 66.6% presence of free nerve endings in the ligamentum capitis femoris suggests a role in nociception/proprioception of the hip in developmental dysplasia of the hip. Interestingly, the percentage and the mean numbers of free nerve endings containing ligamentum capitis femoris were similar in completely dislocated hip group and the subluxated group (62.5 vs. 75%, 12.13+/-9.07 vs. 9.37+/-9.24, respectively). We conclude that the morphological features of ligamentum capitis femoris are influenced by the severity of developmental dysplasia of the hip, whereas the distribution of free nerve endings are not influenced.

11).
From Institute of Experimental Research in Surgery, University of Copenhagen,

(Head: H. H. Wandall) andThe Orthopedic Hospital, Department I., Copenhagen, (Head : A. Bertelsen)
with support from Fondet ti1 Videnskabens Fremme.

THE VASCULAR SUPPLY TO
THE FElMORAL HEAD FOLLOWING DISLOCATION

OF THE HIP JOINT

An Experimental Study in New-Born Rabbits

B€l

H. BOHRK, . BAADSGAAaRndD P H.S AGER

It was shown by Langenskjold, Sarpio & Michelsson (1962) that
the characteristic deformities in the acetabulum and the femoral head

following congenital dislocation in man can be produced by traumatic

dislocations of the hip joint in new born rabbits. In the present investigation

similar dysplastic changes have been demonstrated

 
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