CONGENITAL HIP DISLOCATION

DEFINITION…

Is an abnormal formation in the hip joint in which the ball at the top of the thigh bone (femoral
head) is not stable in the socket (acetabulum). Also, the ligaments of the hip joint may be loose
and stretched. In here, although the hip is in the right place, the socket does not grow properly
and is too shallow. If the socket is shallow, this may allow the ball to move from the position it
should occupy. Furthermore, the head of the femur is usually dislocated post-superiorly.
There is complete loss of contact between articular surface of femoral and head and
acetabulum.
Dislocation may either be partial or complete and may be either be unilateral or bilateral.
May develop at any time during fetal life, infancy or childhood.
Includes hip that are unstable, subluxated, dislocated, and have malformed acetabula.

INCIDENCE…

The incidence of hip instability is approximately 10 per 1000 live births. The left hip is involved in
60% of the cases, the right hip in 20%, and both hips in 20%. Sixty percent of the patients are
girls. Caucasian children have a higher incidence of CHD than other groups. The peak age of this
condition is under 1 year old and between 11 and 15 years old.

PROGNOSIS…

The prognosis of this condition is very good. If hip dysplasia is identified in the first few months
of life, it can always be treated successfully with a positioning device (bracing). In a few cases,
surgery is necessary to put the hip back in joint.
Hip dysplasia identified after early infancy may be associated with a worse outcome and may be
complex surgery to repair the problem.

ETIOLOGY…

The cause is unknown, but the following are considered the contributing factors:

Gender- female
Birth order- first born child
Race- Caucasians
Family history
Intrauterine position- breech position
Delivery type- normal spontaneous delivery
Joint laxity
Postnatal positioning
Multiple fetuses
 Maternal hormone secretion
Large infant size
Oligohydraminous

ANATOMY…

The normal growth of the acetabulum depends on normal epiphyseal growth of the triradiate
cartilage and on the 3 ossification centers located within the acetabular portion of the pubis (os
acetabulum), ilium (acetabular epiphysis), and ischium. Additionally, normal growth of the acetabulum
depends on normal interstitial appositional growth within the acetabulum. The presence of the spherical
femoral head within the acetabulum is critical for stimulating normal development of the acetabulum.

The anatomy of the dislocated hip, especially after several months, often includes formation of a ridge
called the neolimbus. Closed reduction is often unsuccessful at a later date, secondary to various
obstacles to reduction. These include adductor and psoas tendon contraction, ligamentous teres, a
transverse acetabular ligament, and pulvinar and capsular constriction. With long-standing dislocations,
interposition of the labrum can also interfere with reduction.

In a normal hip, the head of the

In cases of DDH, the thighbone is
femur is firmly inside the hip
completely out of the hip socket.
socket.
PATHOPHYSIOLOGY…

Non-modifiable factors:
Modifiable Factors:
Gender- female
Birth order- first born Delivery type- CS instead of NSD
Race- Caucasians Postnatal positioning
Family history
Breech positioning
Multiple fetuses
Large infant size
Maternal hormone secretion

Acetabular dysplasia
(shallow acetabulum)

Femoral head dislocates from

acetabulum

Femoral head dislocates from

acetabulum

CONGENITAL HIP DISLOCATION

 Congenital Hip Dysplasia is often used in reference to the dislocatable hip of the newborn.
Acetabular dysplasia describes changes in the hip socket that is demonstrable on radiographs
after the age of 3 to 4 months.
Congenital subluxation refers to the hip that is neither completely dislocated nor is
concentrically seated in the acetabulum.

Associated Conditions:

1. Congenital Torticollis
2. Clubfoot

Degrees of Congenital Hip Dislocation

Acetabular Dysplasia or Preluxation

- Mildest form
- Femoral head remains in the acetabulum, but its development is delayed as evidenced by an
oblique and shallow roof.
Subluxation
- Largest percentage
- Incomplete dislocation or disclosable hip
- Femoral head remains in contact with the acetabulum but a stretched capsule and round
ligament of femur cause the head of femur cause the head of femur to be partially
displaced.
Dislocation
- Most severe form
- The femoral head losses contact with acetabulum
- The round ligament is elongated and taut

Types of Congenital Hip Dislocation

1. Classis Congenital Hip Dislocation

2. Congenital Abduction Contracture of the Hip
3. Teratologic Congenital Hip Dislocation- severe, prenatal fixed dislocation; associated with
genetic and neuromuscular disorders.

CLINICAL MANIFESTATIONS…

1. Ortolani’s Sign
2. Barlow’s Sign
 3. Asymmetry of gluteal and thigh folds
4. Limited hip abduction, as seen in flexion
5. All’s/Galeazzi’s Sign
6. Positive trendelenburg Sign (if child is weight bearing)
7. Limping, toe walking, or waddling, duck-like gait

*The Ortolani and Barlow tests are most reliable from birth to 2-3 months of age.

Other Signs and Symptoms

1. Telescoping Sign
-in older infant and child, the affected leg will be shorter than the other
2. Dislocation Maneuvers (useful only in first three months of life)
a. thigh abduction
b. thigh extension
3. Relocation Maneuvers
a. Thigh flexion
b. Thigh abduction
DIAGNOSTIC EVALUATION…

1. Initial examination after birth

2. Radiographic examination/Hip X-ray (in infants than age 4 months and in children)
>It is not reliable in early infancy because ossification of the femoral head does not normally
take place until the third to six month of life.
>evaluated with reference lines drawn over AP x-ray:
a) Hilgenreiner’s Line.- horizontal line through triradiate cartilages
b) Perkin’s line- vertical line along lateral acetabulum
c) Shenton’s Line- femral neck medial border; superior border of obturator foramen
3. CT scan is useful to assess the position of the femoral head relative to the acetabulum after
closed reduction and casting.
4. Dynamic Hip Ultrasound
- for infants aged 1 -6 months
- diagnostic for congenital hip dislocation
- evaluates for subluxation and reducibility
- high false positive rate for <6 weeks old

MANAGEMENT. . .

General Interventions:

a. Range of motion exercises

b. Orthosis (a force system, involving braces)
c. Chiropractic medications for procedures of closed manipulations between 6 – 18
months to reduce the dislocated hip joint
d. Pain control
 e. Functional activities

Age Management
Less than 6 months Pavlik harness
More than 6 months Traction, closed reduction
More than 2 years old Open reduction: Anterolateral/Smith Petersen Approach
More than 3 years old Femoral shortening + hip spica cast + abduction orthosis
More than 4 years old Pelvic osteotomy

Newborns are placed in a Pavlik harness for

1 to 2 months to treat DDH.

This will help tighten the ligaments around

the hip joint and promote normal hip
socket formation.

Management indicated for hip instability beyond 5 days:

Step 1: Pavlik Harness

- indicated as first-line if <6 months old

- start with harness trial for 3 – 4 weeks

- it splints hips in flexed and abducted position

- ultrasound should demonstrate reduction at 3 weeks:

a. Reduced: continue harness for more than 6 weeks

b. Not reduced: Go to step 2

Stpe 2: Closed Reduction and Casting by Orthopedics

a. Removable protective Abduction Brace – used in children aged more than 6 months
b. Hip spica casting for 12 weeks ( 6 – 18months old)
- Positioning confirmed by post-op MRI or CT scan
 c. Gradual reduction by traction – for approximately 3 weeks
d. Abduction splint
- Must be maintained if the radiographic evidence of residual dysplasia is still present.
e. Plaster Treatment (Frog Cast)
- Involves a large plaster around the lower body and both legs, with a hole cut to allow
baby to pass urine and empty the bowels.

Step 3: Surgical Management

Surgical Open Reduction ( if hips are not reducible and is indicated for older children )

- Indicated for refractory cases

- Requires multi-step procedures:
a. Tendon lengthening
b. Clearing tissues obstructing relocation
c. Tightening hip capsule
d. Osteotomy if performed after age 18 month

Nursing Management:

1. Teach the parents how to maintain devices, provide nurturing activities to meet the
infant’s need.
2. Prevent skin breakdown by putting undershirt under the chest straps of the pavlik harness
and put knee socks under the foot and leg pieces to prevent the straps from rubbing the
skin.
3. Check frequently for red areas under the straps and the clothing.
4. Gently massage healthy skin under the straps once a day to stimulate circulation.
5. Avoid lotions and powder they can cake and irritate the skin.

Complications. . .

Complications of treatment may include a delay in walking if the child was placed in a body
cast. The pavlik harness and other positioning devices may cause skin irritation, and a difference in leg
length may remain. Growth disturbances of the upper thigh rarely occur. The complications of surgical
interventions can be re-dislocation and the severe form, osteonecrosis.