Developmental Dysplasia of the Hip *DDH*

Hamad Emad Dhuhayr

CONTENTS

1.SOEPEL

2.DEFINITION

3.EPIDEMIOLOGY

4.BASIC BACKGROUND

5.AETIOLOGY

6.RISK FACTORS

7.CLINICAL MANIFESTATIONS

8.INVESTIGATION

9.MANAGEMENT

10.REFERENCES

SUBJECT:

A 7 months old girl ( was brought to the vaccination clinic by her mother )

PRESENTING PROBLEM

The pediatrician refers the infant to the orthopedic surgeon after he noticed asymmetric skin folds in the upper thigh.

FURTHER HISTORY

The infant was born with the breech presentation

SOEPEL

OBJECTIVE:

taking history, physical examination ( musculoskeletal and neurological )

VITAL SIGNS:

* Not included

CLINICAL FINDINGS:

Palpable hip instabiulity

Unequal leg lengths

The abduction was limited on left side

Galezzi sign was positive

SOEPEL

EVALUATION (DD):

Developmental dysplasia of the hip

Acetabular immaturity

Proximal femoral focal deficiency

Residual effects of septic arthritis

PLAN: History, physical examination, Ultrasonography, plain X-ray

ELABORATION: Abduction splints, Hip Spica cast , reduction procedures

SOEPEL

LEARNING GOALS:

study developmental dysplasia of the hip

SOEPEL

Normal Development

Embryonic 7th week - acetabulum and hip formed from same

mesenchymal cells

11th week - complete separation between the two

Prox fem ossific nucleus - 4-7 months

Normal Hip

Tight fit of head in acetabulum

Transection of capsule Still difficult to dislocate

Surface tension

Definition

• Developmental dysplasia of the hip (DDH) is a spectrum of disorders of development of the hip that present in different forms at different ages.

• The common etiology is excessive laxity of the hip capsule with a failure to maintain the femoral

1/1,000 born with dislocated hip

10/10,000 born with subluxation or dysplasia

80% Female

Describtion

• In all cases of DDH, the socket (acetabulum) is shallow, meaning that the ball of the thighbone (femur) cannot firmly fit into the socket. Sometimes, the ligaments that help to hold the joint in place are stretched. The degree of hip looseness, or instability, varies among children with DDH.

• Dislocated. In the most severe cases of DDH, the head of the femur is completely out of the socket.

• Dislocatable. In these cases, the head of the femur lies within the acetabulum, but can easily be pushed out of the socket during a physical examination.

• Subluxatable. In mild cases of DDH, the head of the femur is simply loose in the socket. During a physical examination, the bone can be moved within the socket, but it will not dislocate.

Causes

• The cause is not clear. However, there are factors that are known to contribute to the chance of a baby being born with DDH. Only 1 in 75 babies with a risk factor have a dislocated hip. Risk factors include:

• Family history.

• Gender. About 8 in 10 cases of DDH are female.

• Pregnancy conditions. If there is only a small amount of fluid in the womb (uterus) this is called oligohydramnios.

• Firstborn baby. About 6 in 10 cases of DDH occur in firstborn children.

• Other abnormalities. If the baby has cerebral palsy, spinal cord problems or other nerve and muscle disorders, this increases the risk of developing DDH. 

• Breech position. If an unborn baby is in the breech position (feet down position in the uterus).

Symptomes

• Some babies born with a dislocated hip will show no outward signs. baby has:

• Legs of different lengths

• Uneven skin folds on the thigh

• Less mobility or flexibility on one side

• Limping, toe walking, or a waddling, duck-like gait

Diagnosis Newborn screening

Ortolani’s and Barlow’s maneuvers with a thorough history and physical

Warm, quiet environment with removal of diaper

Head to toe exam to detect any associated conditons (Torticollis, Ligamentous Laxity etc.)

Baseline Neuro and Spine Exam

Diagnosis

Key physical findings Asymmetry

Limb length- Galeazzi

Abduction ROM

Skin folds

Limp

Waddilng gait / hyperlordosis - bilateral involvement

Ortolani’s Maneuver

* After 3 months of age tests become negative

Barlow’s Maneuver

Imaging

X-rays Femoral head ossification center

4 -7 months

Ultrasound Operator dependent

CT

MRI

Arthrograms Open vs closed reduction

Ultrasonographer at work

UltrasoundFemoral head

Abductors

Ilium

UltrasoundFemoral head

Abductors

Ilium

UltrasoundFemoral head

Abductors

Ilium

UltrasoundFemoral head

Abductors

Ilium

UltrasoundGraf’s alpha angle

UltrasoundGraf’s alpha angle

>60 = normal

*line w/ ilium bisects head 50/50

Manegement

http://www.jaaos.org/content/vol8/issue4/images/large/0080232.ff023204.jpeg

Von rosen splint

• Surgical Treatment

• 6 months to 2 years. If a closed reduction procedure is not successful in putting the thighbone is proper position, open surgery is necessary. In this procedure, an incision is made at the baby's hip that allows the surgeon to clearly see the bones and soft tissues.

• In some cases, the thighbone will be shortened in order to properly fit the bone into the socket. X-rays are taken during the operation to confirm that the bones are in position. Afterwards, the child is placed in a spica cast to maintain the proper hip position.

• Older than 2 years. In some children, the looseness worsens as the child grows and becomes more active. Open surgery is typically necessary to realign the hip. A spica cast is usually applied to maintain the hip in the socket.