Congenital dislocation of the hip

1. CDH CONGENITAL DISLOCATION OF THE HIP

2. Nomenclature

CDH : Congenital Dislocation of the Hip
DDH : Developmental Dysplasia of the Hip

3. NORMAL PELVIS

4.

Normal hip
Dislocated hip

5. Patterns of disease

Dislocated
Dislocatable
Sublaxated
Acetabular dysplasia

6. Radiology

After 6 months: reliable

7.

8. Causes (multi factorial)

Hormonal
Relaxin, oxytocin
Familial
Lig.laxity diseases
Genetics
Female 4 X male --- twins 40%
Mechanical
Pre natal
Post natal

9. Mechanical causes

Pre natal
Breach , oligohydrominus , primigravida , twins
(torticollis , metatarsus adductus )
Post natal
Swaddling , strapping

10. Infants at risk

Positive family history: 10X
A baby girl:
4-6 X
Breach presentation: 5-10 X
Torticollis: CDH in 10-20% of cases
Foot deformities:
Calcaneo-valgus and metatarsus adductus
Knee deformities:
hyperextension and dislocation

11. Infants at risk

When risk factors are present
The infant should be reviewed
Clinically
radiologically

12. Clinical examination

The infant should be
quiet
comfortable

13.

Look:
External rotation
Lateralized contour
Shortening
Asymmetrical skin folds
Anterior – posterior

14.

15.

Move
Limited abduction

16.

Special test
Galiazzi
Ortolani , Barlow test
Trendelenburgh sign
Limping ( waddling gait if bilateral)

17. Special test

Galiazzi test

18. Special test

Ortolani test

19. Special test

Barlow test

20. Special test

Trendelenburgh sign

21. Screening programs

Clinical screening proven to be effective
Performed by trained personnel
Must be dynamic
Repeated with periodic examination
U/S screening is controversial

22. Investigations

0-3 months
U/S
> 3months X-ray pelvis AP + abduction

23. U/S Screening

Incidence of hip stability declines rapidly to
50% within the first week of neonatal life.
Better to delay U/S screening

24. U/S - Problems

Too sensitive:
Detects a lot of hip abnormalities, most of which
would develop normally if left alone
Operator-dependant

25. Radiology

Early infancy: not reliable

26. Radiology

After 2-3 months: more reliable

27. Radiology

After 2-3 months: more reliable
27o
39o

28. Radiology

After 2-3 months: more reliable
Von Rosen view
in
out
in
out
in
out

29. Radiology

After 2-3 months: more reliable
in
out

30. Radiology

After 6 months: reliable

31. Radiology

After 6 months: reliable

32. Treatment - Aims

Obtain concentric reduction
Maintain concentric reduction
In a non-traumatic fashion
Without disrupting the blood supply to
femoral head

33. Treatment

Method depends on age
The earlier started, the easier it is
The earlier started, the better the results are
Should be detected EARLY

34. Treatment

Birth – 6m
Pavlik harness or hip spica
6-12 m:
Closed reduction under GA and hip spica
12 - 18 m:
Open reduction
18 – 24 m:
Open reduction and Acetabuloplasty
2-8 years:
Open reduction, Acetabuloplasty, and femoral shortening
Above 8 years:
Open reduction, Acetabuloplasty cutting all three pelvic bones, and
femoral shortening

35. Treatment: Neonatal hip instability

Most resolve spontaneously
Can initially wait
Avoid adduction swaddle
Apply double diapers – to bring back!!
See at 2weeks of age

36. Treatment: Neonatal hip instability

Unstable at 2 weeks:
Double / Triple diapers: inadequate
Gives illusion that patient is “in treatment” while
wasting valuable time

37. Treatment: Neonatal hip instability

Unstable at 2 weeks:
Pavlik Harness
Dynamic, effective, safe

38. Treatment: 6-12 m

Initially non-operative closed reduction UGA and
immobilization in hip spica cast
Position:
Avoid sever abduction
Avoid frog position
Must obtain stable concentric reduction,
otherwise needs surgery

39. Treatment: 6-12 m

Possibly closed reduction
Stable and concentric reduction
Possibly open reduction
Unstable or un-concentric reduction
Arthrography-guided

40. Treatment: 6-12 m

Arthrography-guided Closed Reduction

41. Treatment: 6-12 m

Arthrography-guided Closed Reduction
Too lateralized
Acceptable

42. Treatment: 6-12 m

Treatment: 18-24 m
Open reduction – surgery
Possibly: Acetabuloplasty

43. Treatment: 18-24 m

Treatment: Above 2 years
Open reduction, and
Acetabuloplasty, and
Femoral shortening

44. Treatment: Above 2 years

Acetabuloplasties
Many types

45. Acetabuloplasties

46.

Treatment
Birth – 6m
Pavlik harness or hip spica
6-12 m:
Closed reduction under GA and hip spica
12 - 18 m:
Open reduction
18 – 24 m:
Open reduction and Acetabuloplasty
2-8 years:
Open reduction, Acetabuloplasty, and femoral shortening
Above 8 years:
Open reduction, Acetabuloplasty cutting all three pelvic bones, and
femoral shortening

47. Treatment

CDH - Summary
Complex multi-factorial, endemic disease
Health education and Drs. awareness
Screening programs are needed
Learning proper examination methods
Identify at risk groups
Efficient referral system
Proper management by specialized Drs

48. CDH - Summary

49.

50.

Examples