CDHCongenital Dislocation of the

Hip

Mamoun KremliProfessor / Consultant Pediatric Orthopedics

College of Medicine & King Khalid University Hospital

CDH

• The most common disorder affecting the hip in children

• Spectrum of diseases/abnormalities of the hip with different etiologies, pathologies, and natural histories affecting the proximal femur and acetabulum

• Initial pathology is congenital, progresses if untreated.• Does not always result in dislocation.

CDH

Definition• A progressive deformation of previously

normally formed structures during the embryonic period

NOT A malformation arising during the period of organogenesis

CDHNomenclature

• CDH Congenital Dislocation of the Hip• DDH Developmental Dysplasia of the Hip• CDH Congenital Dysplasia of the Hip

• CHD Congenital Heart Disease !

CDH Spectrum

• Teratologic Hip : Fixed dislocation Occurrs prenatally Often with other anomalies

• Dislocated Hip : Completely out May or may not be reducible

• Subluxated Hip : Only partially in

• Unstable Hip : Femoral head can be dislocated

• Acetabular Dysplasia : Shallow Acetabulu

Head Subluxated or in place

CDHIncidence

• Hip Instability at Birth : 0.5 – 1 % of infants

• Classic CDH : 0.1 % of infants

• Mild Dysplasia : Substantial

Contributing to adult Osteoarthritis

Up to 50 % of Hip Arthritis in Ladies

Have underlying hip dysplasia

CDH

Incidence Area Incidence per 1000

Canadian Indians 188.5

Hungary 28.7

Uppsala, Sweden 20

USA Caucaseans

Blacks

15.5

4.9

Malmo, Sweden 2.18

Chinese, Hong Kong 0.1

Bantus, Africa 0.0 among (16678)

CDH

Etiology

Multi-factorial

CDH

Etiology

Physiologic Factors

Ligament Laxity :

Hormonal :

( Estrogen, Relaxin) Females

Familial hyper laxity :

mild - moderate - Ehler Danlos

ADD Picture of knee hyperextension

CDH

Etiology

Genetic Factors• Gender : Female

Most studies:

Females > 4-6 X than males

• Twin studies:

Monozygotic 38 %

Dizygotic 3 % (similar to siblings)

CDH

Etiology

Family Incidence and Genetic Counselling

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

CDH

Etiology Mechanical Factors Prenatal : - Breech position - Oligohydramnious - Primigravida - Cong. Knee recurvatum/dislocation - Metatarsus adductus - Torticollis

Postnatal : - Swaddling / Strapping – Knees extended

CDH

EtiologyMechanical Factors

• Breech Presentation :

Normally 2 –4 %

CDH 16 %

The Breech position In Utero Extended knees and flexed hips

CDH

EtiologyEnvironmental & Mechanical Factors

• Swaddling / strapping ( Mihad ): Knees extended & Hips adducted

– Proven experimentally– Proven statistically

• American Indians.• Eskimos, and • Saudi Arabia

– Mechanics• Hip adduction and extension

CDHPatients At Risk

• Positive Family History : increases risk 10X• A baby girl : increases risk 4-6 times• Breech Presentation : increases risk 5-10 X• Torticollis : CDH in 10-20 % cases• Foot Deformities : ( calcaneovalgus & metatarsus adductus) signs of intrauterine crowding• Knee Deformities : ( hyperextension & dislocation )

associated with Teratologic type

CDH

Risk Factors

When Risk Factors Are Present• The infant should be examined repeatedly

• The hip should be imaged

( by U/S or X-ray )

CDHNeonatal Examination

The infant should be quiet and comfortable

CDHNeonatal Examination

LOOK :

•Wide perineum

( in bilateral )

•Lateralized contour

•External rotation attitude

CDHNeonatal Examination

LOOK :• Asymmetric thigh

folds

anterior

posterior

CDHClinical Examination

• Look :

Shortening ( not in neonates )

- Galeazzy sign

- in supine

CDHNeonatal Examination

FEEL :

• Empty groin

• Weak Femoral pulse

CDHNeonatal Examination

MOVE :• Hip instability

in early infancy• Limited hip abduction

in flexion - later

(careful in bilateral)

if <600 on both sides:

request imaging

Cerebral palsy

Clinical AssessmentHip Flexion Deformity

SPECIAL :• Loss of fixed flexion

deformity of hips

( early infancy )• Normally FFD

newborn 28o

at 6 weeks 19o

at 6 months 7o

FFDNormal

No FFD?CDH

Thomas Test

CDH

Neonatal ExaminationOrtolani

Feel a ClunkNot hear a click !

CDH

Neonatal ExaminationBarlow

CDHNeonatal Examination

Ortolani / Barlow

clunk

Ortolani Barlow

CDHNeonatal Examination

Ortolani / Barlow

Ortolani Barlow

CDHNeonatal Examination

Hamstring Stretch Sign• Flex hip and knee 900 each.• Keep hip flexed and gradually extend the knee• Normally a resistance is felt towards the end of

knee extension (caused by the hamstrings which are pulled from both

ends)

• In cases of CDH, no resistance is felt (when the hip is dislocated, the origin of the hamstrings are

not pulled by hip flexion)

CDHNeonatal Examination

Hamstring Stretch Sign

CDHClinical Examination

• Neonate (up to 2-3 months) : - Instability/ Ortolani-Barlow - Thomas test

• Infant ( > 2-3 months) : - Limited abduction - Shortening ( Galeazzi ) - Hamstring stretch sign

• Toddler : - Limited abduction - Shortening ( Galeazzi ) - Hamstring stretch sign

• Walking : - Trendelenburgh - Hamstring stretch sign

CDHClinical Examination

CDHClinical Examination

CDH

Clinical ExaminationThe Walking Child

• Trendelenburgh: unilateral / bilateral (waddling)

CDHScreening Program

• Clinical screening proven to be effective

• Performed by Trained personnel

• Must be DYNAMIC

with periodic examination till walking

• Adjunctive use of U/S controversial

CDHUltrasound Screening

• Incidence of hip instability declines rapidly to 50 % within the first week of neonatal life

• Better to delay U/S screening

CDHUltrasound Screening

• Early U/S screening not recommended

• Delayed U/S screening :

- Older than 6 weeks

- Those at risk only - by

History

Clinical exam

CDH

Ultrasound Referral

• If hip normal : no need

• If hip clearly unstable : no need

• If suspicious : U/S appropriate

• If at risk factors : U/S appropriate

CDHUltrasound

• Too sensitive

detects a lot of hip anomalies most of which would develop normally

• Operator dependant

Static Vs Dynamic

CDH

Radiography

• Early infancy : not reliable• By 2-3 months of age : reliable

AP view - neutral position

- draw reference lines

- acetabular index - in early infancy

< 30o : normal

30o – 40o : questionable

> 40o : abnormal

Von Rosen view : 45o abduction

CDHRadiography

CDHRadiography

CDHRadiography

CDHRadiography

Von Rosen view

in out

in out

CDHRadiography

27o 39o

CDHRadiography

in out

CDH

Treatment

Aims

• Obtain and Maintain concentric reduction

• In an Atruamatic fashion

• Without disrupting the blood supply

CDH

Treatment• Method depends on Age

• The earlier started, the easier the treatment

• The earlier started, the better the results

• Should be detected EARLY

CDH

Treatment• Birth to 6 months : Pavlik harness or hip spica cast• 6 months – 12 months : closed reduction UGA and hip spica casts• 12 months – 18 months : possible closed / possible open reduction• Above 18 months : open reduction and ? Acetabuloplasty• Above 2 years : open reduction,acetabulplasty, and femoral osteotomy• Above 8 years : open reduction,acetabulplasty cutting three bones, and femoral

osteotomy

CDHTreatment

Hip instability in the neonatal period

Most resolve spontaneously• Observation

• Pavlik harness

• Double /triple diapers ??

CDH

Treatment

Hip instability in the neonatal period

Double / Triple Diapers• Often inadequate : therefore inappropriate• Gives illusion patient is in “treatment” while

wasting valuable time• Most hip instability improves spontaneously in

early infancy , giving this ineffective management credit

CDH

Treatment

Birth – 6 months

Hip instability (dislocatable)

Established dislocation (reducible)

• Should be actively treated until hip is normal clinically and radiographically

• Pavlik harness

• Hip Spica Cast

CDH

Treatment

Birth – 6 monthsPavlik harness

CDH

Treatment

Birth – 6 months

Other Devices - Frejka pillow - Craig

- Von Rosen splint Soft abduction splints: Not good enough

Rigid abduction splints: Risk AVN

• Initially non operative – closed reduction• Reduction under anesthesia and immobilization in hip

spica cast• Position: Human

Avoid severe abduction

Avoid Frog position

• Must be stable and concentrically reduced otherwise needs open reduction

CDHTreatment

6 – 12 months

Better Picture

CDH

Treatment

12 – 18 months

• Possibly closed reduction !!

when hip stable and concentrically reduced• Probably open reduction

when hip unstable or not concentrically reduced• Arthrography guided:

CDHTreatment

ArthrographyClosed Reduction

Too lateralized Acceptable

CDHTreatment

Above 18 months

• Open reduction

? and acetabulplasty

? And femoral shortening – if high

CDHTreatment

Above 3 years

• Open reduction

• And acetabulplasty

• And femoral shortening

Redirectional Acetabuloplasty

Salter’s

Add Picture with K wires

Pemberton’s

Need for a lot of improvement in coverNeed for a lot of improvement in cover

Triple Steel

CDH

When Not to Treat ?!Bilateral High Posterior Dislocation

good function – not painful

CDH

When Not to Treat !

الدواِء� بعضِ من وخيٌرالداِء�

Painful stiff left hip Painful stiff right hip in adduction

CDH

When Not to Treat !

الدواِء� بعضِ من وخيٌرالداِء�

Painful right hip & ankylosed left hip

CDH

Summary

• Complex multi-factorial, endemic– treatable.• Dr’s awareness and health education.• Screening programs are needed.• Learning proper examination methods.• Identify at-risk groups.

– repeat examination & imaging.

• Efficient referral system.• Proper management in referral centers.