Developmental Dysplasia of the Hip

Definitions

The term .developmental dysplasia or dislocation of the hip. (DDH) refers to the complete spectrum of abnormalities involving the growing hip, with varied expression from dysplasia to subluxation to dislocation of the hip joint.

the traditional term .congenital dysplasia or dislocation of the hip (CDH) DDH is not restricted to congenital dislocation of the hip but includes developmental problems of the hip.This more comprehensive term refers to alterations in hip growth and stability in utero, in the newborn period,and in the neonatal period that may result in dysplasia, ranging from subluxation to dislocation of the joint.

congenital dysplasia or dislocation of the hip is the most common subset of disorders of DDH

The term .dysplasia. denotes an abnormality in development, such as an alteration in size, shape, or organization. Hip-joint dysplasia refers to alterations in the structure of the femoral head, the acetabulum,or both.

Anatomy

Hip Dysplasia in a child

Incidence6.4 per 1000 births in australia7.4 per 1000 births in SA (1986-1990)Female more then man (female : 80% of all dislocation)Breech female : 1 in 35 chance of DDH60 % of DDH are first born childLeft hip more than right hip 60 % left20 % right20 % bilateral

Etiology and CausativeFactors

E/ mutifactorial Intrauterine environmental factorsBreech deliveryFemale genderFirst bornPositif family history or ethnic backgroundPersisten hip asymmetryTorticollis, metatarsus varus, CTEV

Pathologic Anatomy

DiagnosisHistoryClinical presentationLimited abductionLimb shorteningAsymmetry of gluteal, thigh and labial foldPositif galeazzi signPositif ortolani and barlow signPositif Transdelenburg testIf bilateral waddling gait and hyperlordosisRadiographic and Ultrasonography

Physical ExaminationOrtholani sign

Physical ExaminationBarlow sign

Radiologic Examination

Diagnosis

ClassificationBy degreeType 1 : hip stable/normalType 2 : hip subluxableType 3 ; hip dislocatableType 4 : hip dislocated

Radiological (Tonnis)Type 1 : femoral capital epiphysis (FCE) medial to Perkins Line (PL) and below Hilgreiners Line (HL)Type 2 : FCE below HL but lateral to PLType 3 : FCE lateral to PL at the level of acetabular marginType 4 : FCE lateral to PL and above the acetabular rim

Treatment ( Birth to 6 months )

Treatment ( 6 to 18 months )

Treatment ( 18 to 48 months )

Pavlik Harness Indication:All neonates with dislocatable or dislocated hip

Relative Contraindication:Significant muscle imbalance ( e.q spina bifida)Excessive stifnessLigamentous laxity Over 6-8 month of age at the time of diagnosisDifficult family circumstance

Pavlik Harness

Pavlik Harness

Complications

Pavlik Harness diseaseInferior dislocationFemoral nerve palsyOsteonecrosis of the femoral headGrowth disturbance ( iatrogenic )

Summary Early diagnosis of DDH is important factorMost cases can be diagnosis based on history taking and physical examinationImaging modalities such as ultrasonography have increased the ability to detected early diagnosis of DDHConcentric reduction as early as possible is essential

Treatment with pelvic harness remain the standard of care for most children less than 6 month of age with a succes rate greater than 90% and few complicationSerial clinical and radiographical evaluation is important until skeletal maturity in order to monitoring for growth disturbance of femoral head and acetabular dysplacia