Congenital Hip Dislocation

Definition:

congenital or acquired deformation or misalignment of thehip joint femoral head has an abnormal relationship to the acetabulum

In a normal hip, the head of the femur is firmly inside the hip socket.

In some cases of DDH, the thighbone is completely out of the hip socket.

Congenital dislocation of the left hip in an elderly person. Closed arrow marks the acetabulum, open arrow the femoral head.

The hip is a ball and socket joint. The ball, called the femoral head, forms the top part of

the thigh bone (femur) and the socket (acetabulum) forms in the pelvic bone.

Other Known Name:

Developmental dysplasia of the hip(DDH)

Congenital dysplasia of the hip (CDH)

Incidences:

High as 1 in 100 newborns with evidence of instability, and 1 to 1.5 cases of dislocation per 1000 newborns.

Eight times more frequent in females than in males More than 60% of hip instability became stable by age 1 week, and 88% became stable

by age 2 months, leaving only 12% (of the 1 in 60 newborns, or 0.2%) with residual hip instability.

Peak case under 1 y/o and below 11 and 15 years old

Racial background; among Native Americans and Laplanders, the prevalence of hip dysplasia is much higher (nearly 25-50 cases per 1000 persons) than other races

Prevalence is very low among southern Chinese and black populations

Risk:

Breech position the femoral head tends to get pushed out of the socket. A narrow uterus

also facilitates hip joint dislocation during fetal development and birth.

Being female

Family history of the disorder

Generalized Ligamentous Laxity

Large Fetal size

Increased by Maternal Estrogen and other hormone

Associated with underlying neuromuscular disorders, such as cerebral

palsy, myelomeningocele, arthrogryposis, and Larsen syndrome, although these are not

usually considered DDH.

Associated with Congenital Abnormality: Metatarus adductus; Muscular Torticollis

Predisposing Factor Precipitating Factor

o Gender (Female)

o Birth Order (1st born)

o Race

o Large Infant size

o Maternal hormone secretion:

Relaxin

o Intrauterine malpositioning or

crowding as metatarsus adductus

and torticollis

o Delivery Type (Cesarian instead of

NSD)

o Prenatal Positioniing

(Breech Presentation)

(Oligohydramios)

(Associated Postural

Abnormalities)

Types:

A B CTypes of misalignments of femur head to socket in hip dysplasia.

A: Normal. B: Subluxation; C: Displaced

Subluxed Displaced Teratologic Mild Form Femur “Rides up” Flat Acetabulum Stretched Capsule and

loose Some contact of

femoral head with Acetabulum

Femur “Rides do far up” Femoral head leaves the

acetabulum Elongated Ligamentum

Teres Displaced Femoral Head

out of Acetabulum

Associated with Genetic and Neuromuscular Disorder

Irreducible hip at birth

Severe, prenatal, fixed Dislocation

The condition can be bilateral or unilateral:

If both hip joints are affected one speaks of "bilateral" dysplasia.

In unilateral dysplasia only one joint shows deformity, the contralateral side may show

resulting effects. In the majority of unilateral cases the left hip has the dysplasia.

Classification

Description Dislocation

I Femur and acetabulum show minimal abnormal development.Less than 50%

dislocation

II The acetabulum shows abnormal development.50% to 75%

dislocation

IIIThe acetabula is developed without a roof. A false acetabulum develops

opposite the dislocated femur head position. The joint is fully dislocated.

75% to 100%

dislocation

IV The acetabulum is insufficiently developed. Since the femur is positioned 100% dislocation

high up on the pelvis this class is also known as "high hip dislocation".

Clinical Manifestation

Asymmetrical gluteal folds and an apparent limb-length inequality can further indicate unilateral hip dysplasia.

Leg with hip problem may appear to turn out more Less mobility or Flexibility on one side affected Reduced movement on the side of the body with the dislocation Shorter leg on the side with the hip dislocation

-Seen when the infant is lying in supine position, thigh flexed to 90 degrees toward the abdmen

Uneven skin folds of thigh or buttocks Waddling duck gait Ankle Fractures More creases on dislocated side Hip pain (+) Ortholani’s Sign (+) Alli’s Galleazzi’s Sign – Unequal Femoral Length

- Flex knee so that ankle touch the buttocks- (+) not in level

After 3 months of age, the affected leg may turn outward or be shorter than the other leg.

Pathophysiology

Predisposing Factor Precipitating Factor

o Gender (Female)

o Birth Order (1st born)

o Race

o Large Infant size

o Maternal hormone secretion: Relaxin

o Intrauterine malpositioning or crowding as

metatarsus adductus and torticollis

o Delivery Type (Cesarian instead of NSD)

o Prenatal Positioniing

(Breech Presentation)

(Oligohydramios)

(Associated Postural Abnormalities)

4-6 weeks

Ossification center happens femoral head

7th week

Development femoral and acetabulum

11th week Femoral Head flattens

Due Undeveloped femoral head & actabulum

Pulvincor (Fibrofatty tiisue) fills space between femoral head & Acetabulum

Hyperthrophied Ridge of

Acetabular Cartilages

Contraction of the hips

Absence tight fit b/w Acetabulum and femoral head

Stretched Capsule: Loss of Atachment

CONGENITAL HIP

DISLOCATIONManifestations will happen

Diagnostic Studies

a. Ortholani’s maneuver

b. Barlow’s Maneuver

-for 2-3mo. of age

a. Lie the infant in a supine position and flex knee to 90 degrees

b. Place Middle finger over lesser trochanter and thumb on internal side of thigh over lesser trochanter

c. Abduct hips while applying upward pressure over greater trochanter, Listen to clicking sound

d. Next, fingers in same position, hold hips and knees at 90 degrees flexon, apply a backward pressure (down laterally) & adduct the hips. Note feeling femoral head slipping down.

c. Arthrograms Dye is injected and visualized with the aid of flurouscopy

d. Dynamic Hip Ultasound Diagnose hip dislocationIndicated for 1-6months of ageShows morhology (Characteristics and assess stability)

Limitation abduction hip thus capsule constricts and narrows to less than diameter

femoral head

No longer be Manipulated by maneuver: Undergo Surgical Management

e. MRI (Magnetic Resonance Imaging) Identif underlying bony and soft tissue anatomically

f. Xray & Sonogram Reveal shallow acetabulum and lateral placement femoral head

Medical Management

a. Pavlik Harness

Prevent hip extension and adduction but allows flexion and extension

Less than 6 mo of age applied for 1-2months

b. Traction

- Less than 6 mo. to years of age for 1-2 weeks

Bryant’s Traction- indicated for less than 3 years of age 

c. Spica Cast: Frog Cast

d. Frejka Splint

- Firm pressure to abduct hip to place splint coorrectly

Surgical Management

1. Open Reduction- Indicated for 2 years and above with thw use of wires, pins, plates and screw

2. Total hip arthroplasty (hip replacement) is complicated by a need for revision surgery

(replacing the artificial joint) owing to skeletal changes as the body matures, loosening/wear or

bone resorption.

3. Osteotomies are either used in conjunction with arthroplasty or by themselves to correct

misalignment. Indicated for more than 4 years old.

4. Endoprosthetic Replacement – Implanting metal device

Nursing Diagnosis

1. Acute Pain related to lack of continuity of bone to joint, edema and muscle spasms as evidence by facial grimace and crying

2. Impaired physical mobility related to musculoskeletal impairment secondary to hip dysplasia as manifested by less mobility and flexibility on one side of the leg

3. Knowledge deficit of Parent regarding home care

Nursing Responsibilities

1. Teach Parents how to maintain devices, provide nurturing activities to meet infant’s need – to provide comfort

2. Placing pillow between the thighs – To keep knee in frog like position

3. ROM exercises to unaffected side – Promotion circulation and prevent bed sore

4. Meticulous skin care around immobilized tissue- Prevent infection

5. Check frequently forced areas, understraps and clothing- Check any skin breakdown

6. Avoid applying lotion and powders – It could irritate the skin

7. Maintain Proper positioning and alignment- Prevent further injury

Republic of the PhilippinesCavite State University

Don Severino delas Alas CampusIndang, Cavite

In Partial Fulfillment of the Course Requirement

Congenital Hip Dislocation

Presented by: Mary Ann Angelique L. Bucad

BSN4-1Group 2

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historic Cavite recognized for

excellence in the development of

globally and competitive

morally upright individuals.

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Cavite State University shall provide excellent equitable and relevant educational opportunities in the arts, science and technology through quality instruction and responsive research and development activities. It shall