3. Congenital Hip Dislocation

Congenital




Hip





Dislocation































1

Learning Outline









1. Definition of congenital dislocation of the hip



2. Pathological congenital dislocation of the hip



3. The cause of congenital dislocation of the hip



4. Clinical manifestations of congenital dislocation of the hip



5. Research methods of congenital dislocation of the hip



6. Management and nursing care for patients with congenital


dislocation of the hip



7. Complications of congenital dislocation of the hip









2

The hip









• "ball-and-socket" joint.









• In a normal hip, the ball at the upper end of the thighbone


(femur) fits firmly into the socket, which is part of the large


pelvis bone.
























3

The Hip


























































4

CHD








• Other name is Developmental


Dislocation (Dysplasia) of the

Hip (DDH)







• In babies and children with


developmental dysplasia

(dislocation) of the hip (DDH),

the hip joint has not formed


normally. The ball is loose in

the socket and may be easy

to dislocate.








5

CHD









• Although DDH is most often present at birth


➢it may also develop during a child's first year of life.








• Recent research shows that babies whose legs are swaddled tightly


with the hips and knees straight are at a notably higher risk for


developing DDH after birth.


➢swaddling may lead to problems like DDH.

















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swaddling baby




































7

Incidence









• Significant DDH = 2 per 1000 live births



• Unstable hips at birth = 5-20 per 1000



• F:M = 7:1




• Left hip > right hip




























8

Incidence









• More common if:


➢Female


➢Breech (decr. intrauterine space)


➢First born (decr. intrauterine space)


➢Oligohydramnios (decr. intrauterine space)


➢Family History







• Associated with other 'packaging disorders' like torticollis &

Metatarsus Adductus












9

Etiology















1. Ligament laxity


2. Genetic factors



3. Mechanical factors

PHYSIOLOGIC FACTORS








1. Ligament Laxity









a. Hormonal :




• ( Estrogen, Relaxin) Females

PHYSIOLOGIC FACTORS








Ligament Laxity









b. Familial hyper laxity :




• mild - moderate - Ehler Danlos



➢(inherited disorders that affect


your connective tissues —


primarily your skin, joints and



blood vessel walls - flexible


joints and stretchy, fragile skin)

2. GENETIC FACTORS









a. Gender : Female



• Females > 4-6 X than males




• increases risk 4-6 times









b. Twin studies:




• Monozygotic 38 %



• Dizygotic 3 % (similar to siblings)

FAMILY INCIDENCE AND GENETIC COUNSELLING


(increases risk 10X)






Affected At risk Risk









One sibling Siblings 1 in 17





One parent Children 1 in 8






One parent, one sibling Children 1 in 3








2nd degree relative Nieces, nephews 1 in 100

3. MECHANICAL FACTORS








Prenatal :



• Breech position - increases risk 5-10 X



• Breech Presentation :


Normally 2 –4 %



CDH 16 %







• The Breech position In Utero


Extended knees and flexed hips

3. MECHANICAL FACTORS









• Breech Presentation :



Normally 2 –4 %



CDH 16 %








• The Breech position In Utero



Extended knees and flexed hips



(Frank breech)

3. MECHANICAL FACTORS








Prenatal :



• Oligohydramnious


• Primigravida



• Metatarsus adductus - signs of intrauterine crowding


• Torticollis - CDH in 10-20 % cases



• Cong. Knee recurvatum/dislocation - associated with Teratologic type

(fixed dislocation at birth with limited range of motion of the hip)
















Torticollis

Knee Recurvatum



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3. MECHANICAL FACTORS









Postnatal :



• Swaddling / Strapping – Knees extended

Pathogenesis




































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Pathogenesis






• Excessive capsular laxity & a shallow acetabulum at birth are


the primary initiating factors.








• Femoral head: - is pulled proximally & laterally by hip


abductors; misshapen & flattened; delayed ossification of

capital epiphysis;









• Hip joint fills with fibrofatty debris ( pulvinar)














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Pathogenesis






• Acetabular labrum -


enlarged along the superior,

posterior, and inferior rim; -


may infold into joint


(inverted limbus); - limbus


blocks reduction of femoral


head























22

Pathogenesis











• Acetabulum - flattened (dysplastic) because it is not


stimulated to develop around the absent femoral head





































23

Pathogenesis






• Ligamentum teres

lengthened, hypertrophic &

redundant








• Transverse acetabular

ligament: - is pulled

superiorly w/ capsule which


blocks lower portion of

acetabulum

















24

Pathogenesis






• Capsule of hip joint

becomes expanded







• Muscles - crossing the hip


joint (hamstring, hip

adductors, & psoas) >

shortened and contracted;


>> blocking reduction




















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Clinical Presentation




































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Clinical presentation









• Not painful, may not have any obvious signs of a hip defect.



• some babies with this problem may have:


➢One leg that seems shorter than the other.


➢Extra folds of skin on the inside of the thighs.



➢A hip joint that moves differently than the other.

























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Clinical presentation














• A child who is walking may:


➢Walk on the toes of one foot with the heel up off the floor.


➢Walk with a limp (or waddle if both hips are affected).






























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Late Sign









• limited abduction



• leg discrepancy



• Asymmetrical skin folds are not a accurate clinical sign



• Galeazzi sign - affected side shorter



• walking age –limp



• Painful hip after strenuous exercise



• Trendelenburg sign













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Leg Discrepancy






















































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Galeazzi sign






















































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Weight bearing children






Abnormal: If the abductor


mechanism is defective, the


unsupported side of pelvis drops


and this is known as positive



trendelenburg’s test.































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EXAMINATION




































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CLINICAL EXAMINATION SUMMARY









• Neonate (up to 2-3 months) : • Toddler : - Limited abduction


- Instability/ Ortolani-Barlow - Shortening ( Galeazzi )


- Thomas test - Hamstring stretch sign






• Infant ( > 2-3 months) : • Walking : - Trendelenburgh



- Limited abduction - Hamstring stretch sign


- Shortening ( Galeazzi )


- Hamstring stretch sign

Examination









1. Barlow's Test



• identifies unstable hip that lies in the reduced position but



can be passively dislocated (and hence unstable)



• less than 2% of infants will have a positive Barlow test




• 90% will normalise with no treatment after 9 weeks






















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Examination









• Technique:


➢hips are examined one at a time



➢hip is flexed, & thigh adducted, while pushing posteriorly in line of

the shaft of femur, causing femoral head to dislocate posteriorly


from acetabulum


➢dislocation is palpable as femoral head slips out of acetabulum



➢diagnosis is confirmed with Ortolani's test


















36

Barlow

Examination








2. Ortolani's Test



• Identifies dislocated hip that can reduced in early weeks of


life



• Ortolani sign is the palpable sensation of the gliding of the


femoral head in and out of the acetabulum


























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Examination








• Technique:



• hips are examined one at a time


• flex infant's hips & knees to 90 deg



• thigh is gently abducted & bringing femoral head from its


dislocated posterior position to opposite the acetabulum,

hence reducing femoral head into acetabulum



• in positive finding, there is a palpable & audible clunk as


hip reduces














39

Ortolani












































Feel a Clunk




Not hear a click !

Examination









• Ortolani sign as the palpable reduction of an infant's dislocated hip








• Barlow's Test is used to describe the provoked dislocation of an

unstable hip by gently adducting flexed hip while pushing posteriorly


in line of shaft of femur


























41

Investigation








Radiographs



• > 6 months of age.







Ultrasound


➢Gives accurate diagnosis of dislocation, dislocatability and


dysplasia.


➢More accurate than radiographs under the age of six months.


➢Non-invasive, accurate


➢Reduces the need for arthrograms.










42

Management








Non-operative




Operative




















43

Non-operative












1. Double napkins



2. Pavlik harness



3. Soft abduction pillow



4. Von Rosen’s malleable splint



5. Knee plasters with a cross bar



6. Bryan’s traction


















44

Pavlik harness


























































45

Soft abduction pillow


46

Von Rosen’s malleable splint












• H- shaped malleable


splint



• Easy to apply



• Easy to come out






























47

Knee plasters with a cross bar

48

Bryant traction






















































49

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.








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