DEVELOPMENTAL DYSPLASIA

OF HIP

Moderator - Dr B JOHNY PRASAD

(ASSISTANT PROFESSOR)
Presenter – Dr. SWETHA PGY2
 HIP DEVELOPMENT

 Normal hip growth

occurs as a result of
genetically
determined balanced
growth of the
acetabular and
triradiate cartilages
and the presence of a
properly located
femoral head.
 Absence of a normal femoral
head within the acetabulum
during acetabular growth
results in a flat shape of both
the femoral head and
acetabulum.
 Secondary changes can be
observed in the surrounding
soft tissue, with contractures,
thickening of the ligamentum
teres, increased pulvinar fat,
and interposition of iliopsoas
tendon and hip joint capsule.
 DDH is more common in girls (M:F = 1:6).
 The condition is usually unilateral
(left:right::11:1), but both hips may be involved.
 Causes of DDH are multifactorial, with a
combination of hormonal, familial, and
mechanical factors
 Mechanical factor involves utero spatial
constraint and compression of the fetus seen in
oligohydramnios and breech position.
 CLINICAL EXAMINATION

Asymmetrical skin folds, shortened

thigh, irritability of the hip
A “click” during the Ortolani
reduction test performed by flexing
the hip 90° with gentle abduction
 Abnormal Barlow dislocation
test performed by grasping the thigh
in abduction with downward pressure
on the hip indicates instability.
 IMAGING

Absolute indications
Family history of DDH
Neonatal hip instability
Limb shortening and
Limitation of hip abduction in flexion.
 The relative indications
If more than two are present, imaging
should be done are:
Breech presentation
First-born child
Cesarean section
Other congenital anomalies and
Excessive fetal molding.
 RADIOGRAPHY

By 4-6 months once the femoral head

ossifies Radiographs becomes more
reliable
Several classic lines are helpful when
evaluating the hip Shenton’s line,
Hilgenreiner’s line and Perkin’s
line, acetabular angle.
 HILGENREINRS LINE

Drawn horizontally
through the
superior aspect of
both triradiate
cartilages.
It should be
horizontal
 Mainly used as
reference for
perkins line and
measurement of the
 PERKINS LINE

 Drawn perpendicular to
hilgenreiners line
intersecting the lateral
most aspects of the
acetabular roof
 The upper femoral
epiphysis should be
seen in the inferomedial
quadrant ( below the
hilgenreiners line and
medial to the Perkins
line )
 SHENTONS LINE

 Drawn along the inferior

border of the superior pubic
ramus and should continue
laterally along the
inferomedial aspect of the
proximal femur as a smooth
line
 If there is a superolateral
migration of the proximal
femur due to DDH then this
line will be discontinuous.
 ACETABULAR ANGLE

 The Acetabular angle is

formed by the
intersection between a
line drawn tangential to
the acetabular roof and
hilgenreiners line ,
forming an acute angle.
 Should be
approximately 30
degrees at birth and
progressively reduce
with the maturation of
the joint
 ULTRASONOGRAPHY

 Primary imaging technique in the diagnosis and

follow-up of DDH and has been shown to be more
accurate than either clinical or radiographic
assessment.
 Ultrasound examination has the following
advantages
a) Visualizes the nonossified cartilage of the
femoral epiphyses and the cartilaginous labrum and
b) Permits dynamic assessment of stability.
 It cannot be used over the age of 12 months due
to acoustic shadowing from the developing
ossification center of the epiphysis.
The sonographic features to be noted
in an infant hip include the following:
• Position of femoral head, its
coverage, and change in position with
stress
• Assessment of acetabular dysplasia
• Acetabular roof—horizontal or
inclined
• Acetabular edge—sharp, rounded,
or flattened
• Acetabular fossa for presence of
interposed soft tissues such as
excessive fat or hypertrophied
ligamentum teres
• Labrum—everted or inverted
 A static coronal image of the hip is obtained for
interpretation.
 The baby is supported in a lateral decubitus
position, knees slightly flexed.
 The hip is positioned in approximately 20° of
flexion and slight internal rotation - this represents
the neutral position for an infant.
 The transducer is positioned over. the greater
trochanter and held perpendicular to the skin and
parallel to the table in order to obtain a coronal
image of the acetabulum showing its maximum
depth.
 The cardinal landmarks are
the inferior edge of the
ilium, the lateral margin
of the ilium projected as a
horizontal line, and the
acetabular labrum.
 The appearance of this
standard plane has been
likened to a “ball on spoon”
appearance, with the femoral
head representing the ball,
the acetabulum representing
the bowl of the spoon, and
the ilium representing the
handle of the spoon
 The proper coronal view contains three
elements:
1. The echoes from the bony ilium should be in a
straight line parallel to the transducer
2. The transition between the os ilium and the
triradiate cartilage should be seen definitively
3. The echogenic tip of the labrum should be in
the same plane as the other two
 First baseline A is drawn along the straight
lateral margin of the ilium, where the
perichondrium meets the ilium.
 Second inclination line B connects osseous
convexity to labrum and
 The third roof line C connects the lower
edge of acetabular roof medially to
osseous convexity.
 One between acetabular roof line and
baseline measures the α angle, which
denotes inclination of the acetabulam.
 A small α angle indicates a shallow bony
acetabulum
 The β angle is measured between the baseline
and the line of inclination, giving an indication
of coverage of femoral head by cartilaginous
acetabular rim.
 A large β angle indicates lateral migration of
femoral head
 Calculation of α and β angles is not possible if
the femoral head is dislocated in anterior or
posterior direction
 CT
 Useful for the preoperative evaluation of DDH.
 CT is used for the detection of iliopsoas muscle
deformity
 Intra-articular soft-tissue obstacles such as
hypertrophied fibrofatty pulvinar which can
make it difficult to achieve concentric reduction
by the closed method
 Determination of femoral torsion and acetabular
configuration.
 CT can be performed even when the patient is in
a cast and is most useful in postoperative
assessment of reduction
 MRI

MRI is used in the evaluation of

dysplasia of the hip when there is
 (i) A complex dysplasia
(ii)There has been inadequate response
to treatment
(iii) In late presentation and
(iv) In teratological dislocation.
The value of MR imaging in
preoperative planning is due to its
ability to portray the cartilaginous
part of the pelvis and also analyze the
relationship of the femoral head to
the acetabulum and labrum.
In the immediate postoperative
period, MR imaging is useful in
evaluation of proper reduction of the
dislocated femoral head and its
vascular health.
 DIFFERENTIAL DIAGNOSIS OF
DDH
 congenital hypothyroidism -shallow acetabulum
with high-angled roof ,lateral and cephalad
displacement of the upper end of the femur and
small ossification center for the head can be seen.
 Traumatic epiphyseal separation of femoral
neck in very young infants may simulate
congenital dislocation.
 Trauma may be considered if there is history of an
abnormal presentation/difficult labor.
 Acquired nontraumatic dislocation may develop in
pyoarthrosis of hip
THANK YOU