CDHCongenital Dislocation of the
HipProf. Mamoun Kremli
AlMaarefa College
Spectrum of diseases
• Abnormality of proximal femur and acetabulum
• Initial pathology is congenital, but• Progresses (becomes worse) if not
treated• Does not always result in dislocation
Nomenclature
• CDH: Congenital Dislocation of the Hip• DDH: Developmental Dysplasia of the
Hip• CDH: Congenital Dysplasia of the Hip• CHD: Congenital Heart Disease!
CDH - Spectrum
• Acetabular dysplasia:– Shallow acetabulum
• Unstable hip: – Dislocatable - Reducible
• Dislocated hip:– May or may not be reducible
• Teratologic hip:– Fixed dislocation at birth,
often with other major anomalies
Incidence
• Hip instability at birth: 0.5 – 1 %
• Classic CDH: 0.1%
• Mild dysplasia: Substantial– Up to 50%of hip arthritis in ladies have
underlying hip dysplasia
Incidence
Area Incidence per 1000
Canadian Indians188.5
Hungary28.7
Uppsala, Sweden20
USA Caucaseans Blacks
15.54.9
Malmo, Sweden2.18
Chinese, Hong Kong0.1
Bantus, Africa0.0 among (16678)
Etiology
Multi-factorial– Ligament laxity– Genetic– Mechanical factors
Etiology
1. Ligament laxity• Hormonal:
– Estrogen, Relaxin: hormones secreted by mothers before birth
– May affect baby girls more? – receptors
• Familial ligament laxity:– Mild – Moderate – Sever– Ehler Danlos Syndrome
Etiology
Ligament laxity: hypermobile joints
Etiology
2. Genetic factors• Twin studies
– Monozygotic: 38%– Dizygotic: 3% (similar to other siblings)– Positive family history
• Females: 4-6 X more than males– Could be hormonal – the effect of
Relaxin hormone produced by mother on female fetus
Etiology
3. Mechanical factors
• Prenatal:– Breach:
•Normally: 2-4%•In CDH: 16%
– The breach position in utero: extended knees, and flexed hips• cause dislocation of hip by ? stretch of
Hamstring muscles
Etiology
3. Mechanical factors• Postnatal:
– Swaddling / strapping hips adducted and extended, and knees extended
الكوفلة – – – الزمام القماط المهاد
Etiology
3. Mechanical factors• Postnatal:
– Swaddling / strapping hips adducted and extended, and knees extended
– Proven experimentally– Proven statistically– Mechanics
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 (Teratologic)
Clinical Examination
• External rotation• Short one side
Clinical Examination
• External rotation• Short one side• Lateralized contour• Wide perineum
– In bilateral
Clinical Examination
• External rotation• Short one side• Lateralized contour• Wide perineum
– In bilateral
• Asymmetrical folds– Anterior - posterior
Clinical Examination
• External rotation• Short one side• Lateralized contour• Wide perineum
– In bilateral
• Asymmetrical folds– Anterior - posterior
Clinical Examination
• Shortening– Might be difficult to
detect early
Clinical Examination
• Limitation of hip abduction in flexion
Clinical Examination
• Limitation of hip abduction in flexion
Clinical Examination
• Limitation of hip abduction in flexion
Clinical Examination
• Special test – Hip Instability:• Ortolani / Barlow
• Feel a Clunk, not hear a click!
Clinical Examination
Ortolani / Barlow
Clinical Examination
• Special test – Hamstring Stretch Sign:– Flex hip and knee 90o, and extend knee
gradually
• Normally:– feel resistance
• CDH:– no resistance
Clinical Examination
• After walking age:– Shortening – (if unilateral)– Limping:
• Unilateral: limping• Bilateral: waddling (like a duck)
Investigation: Radiology
• Early infancy:– X-ray is not reliable – all cartilage– Ultrasound is better
Radiology: X-ray
• After 2-3 months: more reliable
27o 39o
Radiology: X-ray
• After 2-3 months: more reliable
in out
Radiology: X-ray
• After 6 months: reliable– R hip out, and acetabulum open
(dysplastic)
Treatment
• Method depends on age• The earlier started, the easier it is• The earlier started, the better the
results are
• Should be detected EARLY
Treatment
• Birth – 6m– Pavlik harness or hip spica cast
• 6-12 m:– Closed reduction under GA and hip spica cast
• 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
Treatment: Neonatal
• Pavlik Harness– Dynamic, effective,
safe– Keeps hips abducted
and flexed – for 6 weeks
Treatment: 6-12 m
• Initially non-operative closed reduction UGA and immobilization in hip spica cast
Treatment: 6-12 m
• Possibly closed reduction– Stable and concentric reduction
• Possibly open reduction– Unstable or un-concentric reduction
• Arthrography-guided
Treatment: 6-12 m
• Arthrography-guided Closed Reduction
Well in Dislocated Not well in
Treatment: 6-12 m
Arthrography-guided Closed Reduction
Too lateralized Acceptable
Treatment: 18-24 m
• Open reduction – surgery• Acetabuloplasty - usually• Maybe: Femoral shortening – if high
Treatment: Above 2 years
• Open reduction, and• Acetabuloplasty, and• Femoral shortening
Salter’s Acetabuloplasty
Operated hip Dislocated hip
Pemberton’s Acetabuloplasty
need a lot of improvement in acetabular cover
Triple Steel Acetabuloplasty
• 12 years old,• Pain L hip
• L hip not wellcovered
• Osteotomy of:• Ilium, Pubic,
and Ischium• Rotation of
acetabulum
Summary
• Complex multi-factorial, endemic disease
• Screening programs are needed to detect and treat cases early
• Learning proper examination methods• Identify at risk groups• Efficient referral system• Proper management by specialized Drs
Summary - Infants at risk
• Positive family history: 10X• A baby girl: 4-6 X• Breach presentation: 5-10 X• Torticollis• Foot deformities• Knee deformities