Congenital Hip Dislocation
Introduction
Hip dysplasia ,developmental dysplasia of the hip (DDH) or congenital
dysplasia of the hip (CDH) is a congenital or acquired deformation or
misalignment of the hip joint.
Congenital dislocation of hip is a condition present since birth in which the
head of the femur is detached from the acetabulum or can be moved in and
out of the acetabulum easily.
Some children are born with a hip problem called congenital hip dislocation
(dysplasia). The condition is usually diagnosed as soon as a baby is born.
Most of the time, it affects the left hip in first-born children, girls, and babies
born in the breech position.
Anatomy
In hip dislocation, the ball at the top of the thighbone (femoral head) does not
sit securely in the socket (acetabulum) of the hip joint. Surrounding ligaments
may also be loose and stretched. The ball may be loose in the socket or
completely outside of it.
Causes
Sex (females are more affected than males)
Statistics show that the Native American population has a high incidence of
hip dislocation.
Infants born by caesarian and breech position births.
1st born infants
Hormonal changes within the mother duringpregnancy
Other musculoskeletal disorders of intrauterine malpositioning or crowding
such as metatarsus adductus andtorticol lis Oligohydramnios
Hip dysplasia can be associated with underlying neuromuscular disorders,
such as cerebral palsy, myelomeningocele, arthrogryposis, and Larsen
syndrome, although these are not usually considered DDH
Family History (positive in up to one third of cases)
a. One affected sibling: 6% risk
b. One affected parent: 12% risk
c. One affected sibling and one affected parent: 36%
Types of Congenital Hip Dislocation
1. Classic congenital Hip Dislocation
2. Congenital Abduction Contracture of the Hip
3. Teratologic Congenital Hip Dislocation
a. Severe, prenatal fixed dislocation
b. Associated with genetic and neuromuscular disorders
Symptoms
In congenital dislocation, the earliest sign may be a “clicking” sound when the
newborn’s legs are pushed apart. If the condition goes undetected at the
newborn stage, eventually the affected leg will look shorter than the other one,
skin folds in the thighs will appear uneven, and the child will have less
flexibility on the affected side. When he starts to walk, he’ll probably limp, walk
on his toes, or “waddle” like a duck.
Legs of different lengths.
hip click
Uneven thigh skin folds.
Less mobility or flexibility on one side.
In children who have begun to walk, limping, toe walking and a
waddling "duck-like" gait are also signs.
Ankle fractures
buttocks folds also may not be symmetrical with more creases on the
dislocated side
Hip pain commonly manifests as knee or anterior thigh pain
Diagnosis
A careful physical examination of a newborn usually detects hip dislocation. In
older infants and children, hip x-rays can confirm the diagnosis.
Arthrograms are dynamic studies, performed by injecting dye into the
hip joint and then examining the patient with aid of fluoroscopy, usually with
the patient under anesthesia.
A careful physical examination of a newborn usually detects hip dislocation. In
older infants and children, hip x-rays can confirm the diagnosis.
Imaging
A. Dynamic Hip Ultrasound (infant aged 1-6 months)
1. Diagnostic for congenital Hip Dislocation
2. Evaluates for subluxation and reducibility
3. High false positive rate <6 weeks
B. Hip XRay
1. Not diagnostic for dislocation until >6 months
1. Femoral head not calcified under age 4-6 months
2. Diagnostic for Acetabular Dysplasia
a. Abnormal acetabular fossa will be seen
C. Evaluated with reference lines drawn over AP XRay
1. Hilgenreiner's Line
a. Horizontal line through triradiate cartilages
2. Perkin's Line
a. Vertical line along each lateral acetabulum
3. Shenton's Line
a. Femoral neck medial border
b. Superior border of obturator foramen
MEDICAL Management
A. Management indicated for hip instability beyond 5 days
B. Step 1: Pavlik Harness
1. Indicated as first-line if age <6 months
2. Start with harness trial for 3-4 weeks
3. Splints hips in flexed and abducted position
4. Long-term effect: 95% (80% if frank dislocation)
5. Ultrasound should demonstrate reduction at 3 weeks
a. Reduced: Continue harness for >6 weeks
b. Not Reduced: Go to Step 2
C. Step 2: Closed Reduction and Casting by Orthopedics
1. Indications
a. No reduction with Pavlik Harness in 3-4 weeks
b. Children over age 6 months
2. Attempted closed reduction under arthrogram
3. Hip Spica Casting for 12 weeks
4. Positioning confirmed by post-op MRI or CT
D. Step 3: Surgical Open reduction
1. Indicated in refractory cases
2. Requires multi-step procedure
a. Tendon lengthening
b. Clearing tissues obstructing relocation
c. Tightening hip capsule
d. Osteotomy if performed after age 18 month
3. Complicated by re-dislocation, osteonecrosis
Nursing Management
* Placing rolled cotton diapers or a pillow between the thighs, thereby
keeping the knees in a frog like position
* ROM exercise to unaffected Tissue
* Immobilization of hips in less than 60- degrees abduction per hip
* Meticulous skin care around the immobilized tissues
* For patients who have splints, remind parents to maintain good diaper area
care: change diapers frequently and wash area and apply an ointment such
as A and D ointkment, vaseline r Desitin at each diaper change since this can
lead to severe diaper rash
* Teach parents to swaddle the baby tightly because this action is comforting.
* For older patients encourage a balanced diet, foods that promote healing
such as protein rich foods and as well as vit c rich foods
* Maintain proper positioning and alignment to limit further injury
* Accompanying soft tissue injuries are treated by RICE therapy:
R- rest
I- ice
C-compression bandage
E- elevation with or without immobilization
* Stimulation of affected area by isometric and isotonic exercises also helps
promote healing
