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Developmental Dysplasia of the Hip
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Contents
Other Names
- Developmental Dysplasia of the Hip (DDH)
- Congenital Dislocation of the Hip (CDH)
Background
- This page refers to Developmental dysplasia of the hip (DDH) which represents abnormal development of the hip resulting in dysplasia, subluxation, and possible dislocation
History
Epidemiology
- Most common orthopedic disorder of newborns (need citation)
- Dysplasia (1:100) is about 10x more common than dislocation (1:100) (need citation)
- DDH 5.5 per 1000 children using US at 2 days of life, which drops to 0.5 per 1000 at 2 weeks[1]
- 8 fold more common in females than males[2]
- Suspected to be due to increased estrogen increasing ligament laxity
- 60% of cases are seen in left hip (need citation)
- Due to in utero position: left occiput anterior, left hip adducted against mothers spine
- Up to 20% are bilateral (need citation)
Pathophysiology
- DDH encompasses
- Dysplasia: shallow, underdeveloped acetabulum
- Subluxation: displacement of joint with some articular contact
- Dislocation: complete displacement with no articular contact
- Teratogenic hip: dislocated in utero with abnormal acetabular development, i.e. pseudoacetabulum
- Associated with genetic disorders including arthrogryposis, myelomeningocele, Larsen's syndrome, Ehlers-Danlos
- Late: adolescent form which is mechanically stable with laxity
- Initial instability leads to dysplasia
- Dysplasia leads to subluxation, gradual dislocation
- Chronic dislocation can lead to barriers of reduction, anatomic changes
Etiology
- Often no clear cause
- Complex interaction of genetic risk factors, maternal and fetal laxity, intrauterine and postnatal malpositioning
Screening
- AAP guidelines[3]
- Newborns: Screening with physical exam, US not recommended
- Positive: referral to orthopedics
- Equivocal: repeat in 2 weeks
- Two weeks of age
- Normal: follow up routine child visits
- Positive: referral to orthopedics
- Equivocal: referral to orthopedics or order US for week 3-4
- Newborns: Screening with physical exam, US not recommended
Pathoanatomy
- Hip Joint
- Formed by the articulation of the Acetabulum and Femoral Head
Associated Conditions
Risk Factors
- Race
- Increased risk among Canadians, Native Americans, Laplanders
- Decreased risk among African, Chinese individuals
- Prenatal/Neonatal
- Breech position at birth
- First born baby in a primagravida
- Oligohydromnios[4]
- Use of swaddling, cradle boards
- Neurological
- Cerebral Palsy
- Spinal Cord Lesions
- Other neuromuscular disorders
- Other
Differential Diagnosis
- Fractures And Dislocations
- Arthropathies
- Muscle and Tendon Injuries
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatric Pathology
- Transient Synovitis of the Hip
- Developmental Dysplasia of the Hip (DDH)
- Legg-Calve-Perthes Disease
- Slipped Capital Femoral Epiphysis (SCFE)
- Avulsion Fractures of the Ilium (Iliac Crest, ASIS, AIIS)
- Ischial Tuberostiy Avulsion Fracture
- Avulsion Fractures of the Trochanters (Greater, Lesser)
- Apophysitis of the Ilium (Iliac Crest, ASIS, AIIS)
Clinical Features
- History
- Clinical manifestation depends on the age of the child
- Newborn may present with limited abduction
- Toddler may present with antalgic gait
- In an adult, hip pain, degenerative arthritis
- Physical Exam (<3 months)
- Primarily Barlow Sign, Ortolanis Sign and Geleazzi Sign
- "clicks" are not specific findings
- Inspect for asymmetric skin folds, which may be normal in up to 25% of babies
- Physical Exam (3 months to 1 year)
- Look for positive Klisic Test, leg length discrepancy
- Limited hip abduction may be only finding in babies over 3 months of age (Se 69%, Sp 54%)[7]
- Physical Exam (1 year and older)
- Pelvic obliquity
- Exaggerated lumbar lordosis
- Trendelenburg Gait
- Toe walking
- Special Tests
- Ortolanis Sign: In newborn, with ips and knees flexed to 90° , gently abduct hips
- Barlow Sign: In newborn, apply posterolateral pressure to patient in attempt to dislocation hip
- Geleazzi Sign: hips flexed to 45°, knee flexed to 90°, look for asymmetry at the level of the knees
- Klisic Test: Place both index fingers on ASIS, middle fingers on greater trochanter, line should pass through umbilicus
Evaluation
Ultrasound
- Useful up to 4-6 months of age
- Operator dependent, requires experience
- Current recommendation is to perform at 4 weeks to avoid high false positive rate when performed earlier
- Static Acetabular Images (Graf[8])
- Measures: alpha angle (osseous acetabular roof angle), beta angle (position of the echogenic acetabular labrum)
- Classification
- Normal hip: No need for intervention
- Immature hip: Needs follow-up
- Progressive unstable hip or frankly dislocated hip
- Dynamic Stress Images (Harcke[9])
- Perform the Barlow and Ortolani maneuver and observe the relationship between the femoral hip and the acetabulum in real time
Radiographs
- Standard Radiographs Hip, Standard Radiographs Pelvis
- Of limited value in first 3 months, femoral head is mostly cartilage
- More useful at 4-6 months of age
- Indications
- Assess the hips in children with a clinical diagnosis of DDH
- To monitor hip development after treatment
- To assess long-term outcomes
- Hilgenreiner’s Line
- Line drawn horizontally through the superior aspect of both triradiate cartilages.
- Normal: It should be horizontal.
- Perkin’s Line
- Drawn perpendicular to Hilgenreiner's Line, passes thorough the lateral- most aspect of the acetabular roof
- Femoral head should be seen in the inferomedial quadrant, lie below Hilgenreiner’s line, and medial to Perkin’s line.
- If ossified nucleus of the femoral head is not visible, the femoral metaphysis should be used.
- Lateral or superior displacement of the femoral head occurs in DDH.
- Shenton’s line
- Line passes from the medial border of the femoral neck to the superior border of the obturator foramen
- Normal hip: continuous
- DDH: line contour will be interrupted
- Note: intact in “subluxation”, disrupted in “dysplasia.
- Acetabular index
- Angle formed between Hilgenreiner’s line and a tangential line to the lateral ossific margin of the roof of the acetabulum.
- The acetabular index is helpful in measuring the development of the osseous roof of the acetabulum.
- Normal values: <35° at birth; <25° at 1 year; <20° between 1 and 3 years.
Arthrogram
- Used to confirm reduction under general anesthesia
- Can be used to find blocks to reduction including[10]
- Inverted labrum
- Inverted limbus
- Transverse acetabular ligament
- Hip capsule is constricted by iliopsoas tendon
- Pulvinar
- Ligamentum teres
MRI
- Often used after closed reduction, casting to minimize radiation exposure (compared to CT)
CT
- Historical study of choice to evaluate hip after closed reduction, falling out of favor for MRI
Classification
- Subluxable: Barlow-suggestive[10]
- Dislocatable: Barlow-positive
- Dislocated: Ortolani-positive early when reducible; Ortolani-negative late when irreducible
Management
Prognosis
0 to 6 months
- Pavlik Harness with success rates of 85% - 95%
- Most commonly used and considered gold standard
- Purpose: maintain the hip in flexion and abduction position
- This brings the femoral head as close to the acetabular ring as possible
- Plaster > Fiberglass > soft cast
- Immediately after placement, radiograph needs to be performed to confirm position
- Two weeks after placement, US to confirm stability of hip
- Recommendations to discontinue vary from weening over time to removal at 6 weeks
- Should repeat XR at 6 months and 12 months
- Alternative splint options: Rosen Splint, Wagner Stocking
- Use of double or triple diapers is not recommended under 1 year[11]
6 months to 2 years
- Procedure: Closed reduction under general anesthesia
- Possible arthrogram in operating room
- Application of Spica Cast which remains on for 3 months
- Failure of closed reduction requires need for open reduction
Older than 2 years
- Procedure: Open reduction alongside, possibly femoral or pelvic osteotomies
- Application of Spica Cast which remains on for 6-12 weeks
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play
- Needs to be updated
Complications
- Delayed Diagnosis
- can be seen in bilateral cases
- Recurrence
- Transient Femoral Nerve Palsy
- Avascular Necrosis
- Most devastating complication of pavlik harness
- Incidence estimates range from 0 to 26%[12]
- Postoperative
- Hip stiffness
- Hypertonicity of musculature
See Also
- Internal
- External
- Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/
References
- ↑ Bialik V, Bialik GM, Blazer S, Sujov P, Wiener F, Berant M. Developmental dysplasia of the hip: a new approach to incidence. Pediatrics. 1999;103:93-99.
- ↑ Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics. 2006;117:e557-e576.
- ↑ Lehmann HP, Hinton R, Morello P, Santoli J. Developmental dysplasia of the hip practice guideline: technical report. Pediatrics. 2000;105:E57.
- ↑ Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics. 2006;117:e557-e576.
- ↑ Wynne-Davies R. Acetabular dysplasia and familial joint laxity: two etiological factors in congenital dislocation of the hip. A review of 589 patients and their families. J Bone Joint Surg Br. 1970;52:704-716.
- ↑ Shi D, Dai J, Ikegawa S, Jiang Q. Genetic study on developmental dysplasia of the hip. Eur J Clin Invest. 2012;42:1121-1125.
- ↑ Castelein RM, Korte J. Limited hip abduction in the infant. J Pediatr Orthop. 2001;21:668-670.
- ↑ Graf R. Classification of hip joint dysplasia by means of sonography. Arch Orthop Trauma Surg. 1984;102:248-255.
- ↑ American College of Radiology (ACR) appropriateness criteria. Developmental dylsplasia of the hip-child. www.acr.org/Quality-Safety/Appropriateness-Criteria. Accessed March 21, 2014.
- ↑ 10.0 10.1 https://www.orthobullets.com/pediatrics/4118/developmental-dysplasia-of-the-hip-ddh
- ↑ Novacheck TF. Developmental dysplasia of the hip. Pediatr Clin North Am. 1996;43:829-848.
- ↑ Tiruveedhula M, Reading IC, Clarke NM. Failed Pavlik harness treatment for DDH as a risk factor for avascular necrosis [published online June 24, 2014]. J Pediatr Orthop. 2014 Jun 24
Created by:
John Kiel on 5 July 2019 08:51:17
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Last edited:
5 October 2022 13:10:32
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