DEVOLOPMENTAL DYSPLASIA OF HIP

DEVOLOPMENTAL DYSPLASIA OF HIPBYE.D.PRASANNA

DEFINITIONThe definition of developmental dysplasia of the hip (DDH) is not universally agreed upon. Typically, the term DDH is used when referring to patients who are born with dislocation or instability of the hipDevelopmental dysplasia of the hip is the condition in which the femoral head has an abnormal relationship to the acetabulum.DDH encompasses a spectrum of disorders

DYSPLASIAA shallow or underdeveloped acetabulumIt can either be stable or unstable

DISLOCATION reducible or non reducible

SUBLUXATION

This refers to antenatal dislocation of the hip.

TERATOLOGIC DISLOCATION

ETIOLOGY

FAMILIALIncidence is more in First Degree RelativesHereditary predisposition to joint laxity

FEMALE SEXMaternal hormone relaxin

Crosses the placenta

If foetus is female , it causes laxity of foetal joint

Dislocation

BREECH PRESENTATION

Reduced Uterine volumeFirst bornMultiple pregnancyoligohydramnios

Packaging Disorders LikePlagiocephaly , Torticollis , Foot Deformities

RACE AND CULTURESwaddling of the babyIncreased incidence in Native Americans

PATHOLOGICAL CHANGES

Elongated capsuleFemoral head displaced upwars and laterally

Hip jointfills w/ fibrofatty debris known as pulvinarAcetabular labrum - becomes enlarged along the superior, posterior, and inferior rim; - may infold into joint (inverted limbus); - limbus blocks reduction of femoral head;

CLINICAL FEATURES

FROM BIRTH TO 3 MONTHSMainstay for diagnosis are

Ortolani testBarlow testGaleazzis sign

BARLOWS TESTFacing childs perineumHold upper part of the childs thigh fingers behnd the greater trochanter thumbs in frontPosition knees fully flexed , hips flexed to right angleHip is now adductedsimultaneously pressure is exerted in proximal direction trying to push out the hipIf the hip is dislocatable abnormal posterior movement will be felt along with a distinct clunkNothing is noted then hip is either stable or it has already been dislocated

Hips are in 90 flexion and fully adductedThighs are gently abductedForward pressure is exerted on the greater trochanter while abductionIf the hip was dislocated , a clunk will be heard or felt as femur is reduced into acetabulumIf nothing is noted , there my be no dislocation or irreducible dislocation is present

ORTOLANIS TESTHips and knee of child held in flexed positionGradually abducted Clunk of entrance felt as dislocated femoral head slips back into acetabulumTest is negative if no dislocation or irreducible dislocation is present

ASYMMETRICAL GLUTEAL AND THIGH FOLDS

GALEAZZIS SIGN

Seen in Unilateral dislocation Limb length is shorter on affected side

AFTER 3 MONTHS Ortolani and barlow become negative due to development of adaptive shortening

LIMITATION OF ABDUCTION

ASYMMETRICAL GLUTEAL AND THIGH FOLDS

POSTIVE TELESCOPY

Hip to be tested in flexed postionPlace thenar eminence of one hand on ASIS and finger on trochanter Using other hand , hold knee and give a gentle push pull along long axis of femur Up and down movement of femur indicates positive telescopy

Place the middle finger over the greater trochanter, and the index finger on the anterior superior iliac spine

With a normal hip, an imaginary line drawn between the two fingers points to the umbilicusWhen the hip is dislocated, the trochanter is elevated and the line projects halfway between the umbilicus and the pubisKLISIC TEST

WALKING AGE OR > 1 YEAR

TRENDELENBERG TEST

LORDOSIS OF LUMBAR SPINE

GAIT Trendelenberg gaitWaddling gait

Waddling gait

IMAGING

X ray

Perkins line: This is a vertical line drawn at the outer border of the acetabulum Hilgenreiners line: This is a horizontal line drawn at the level of triradiate cartilage Shentons line: This is a smooth curve formed by the inferior border of the neck of the femur with the superior margin of the obturator foramenAcetabular index: The angle is formed by Hilgenreiner line and a line which extends along the acetabular roofs.Normal is < 30 degrees

IMAGING

the head lies in the upper and outer quadrantthe continuity of Shentons line is broken

ULTRASOUND

Femoral head

Abductors

Ilium

Alpha angle is formed by the acetabular roof to the vertical cortex of the ilium.

GRAFS CLASSIFICATION

COMPUTED TOMOGRAPHY

Document reduction postoperativelyPre operative planning

Done preoperativelyAssess the position of femoral head in relation to other structuresFind out any obstructions to reductionARTHOGRAPHY

TREATMENT

TREATMENT PRINCIPLES

TECHNIQUES OF REDUCTIONClosed reductionTraction followed by closed reductionOpen reduction

MAINTENANCE OF REDUCTIONPlaster cast

Von Rosen Splint

ACETABULAR RECONSTRUCTION PROCEDURESSatlers osteotomyChiaris OsteotomyPemberton Osteotomy

SALTERS OSTEOTOMYRoof of acetabulum is rotated so that it covers head of femurFulcrum through pubic symphysis

PEMBERTON OSTEOTOMYRoof of acetabulum is deflected downwards so that it covers head of femurFulcrum through triradiate cartilage

CHIARIS OSTEOTOMYUsed when no other osteotomy can be performedIliac bone is divided transversely above acetabulumLower portion is displaced medially Margin of upper portion provide depth to acetabulum

Closed reductionSuccessfulMaintain in a cast for 3 monthesBraceAcetabulum developsRemove the bracePhysiotherapy

Acetabulum does not developAcetabular reconstructionphysiotherapy

DISLOCATION DIAGNOSED AT BIRTH

Not successfulTraction Closed reductionsuccessfulTreat as before

Not successfulOpen reductionacetabular reconstructionDerotation osteotomy

DISLOCATION AT LATER AGES

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