Developmental dysplasia (or dislocation) of the hip

Treatment

Harnesses, casts, and traction

Early hip dysplasia can often be treated using a Pavlik harness or the Frejka pillow/splint
in the first year of life with usually normal results. Cases of femoral head avascular
necrosis have been reported with the use of the Pavlik harness, but whether these cases
were due to improper application of the device or a complication encountered in the
course of the disorder remains unresolved. Complications arise mainly because the sheet
of the iliopsoas muscle pushes circumflex artery against the neck of the femur and
decreases blood flow to the femoral head. That is the reason why the Frejka pillow is not
indicated in all the forms of the developmental dysplasia of the hip.

baby wearing a Pavlik harness

Diagram of Pavlik harness

Diagram of Frejka pillow

Traction

Developmental Dislocation (Dysplasia) of the Hip (DDH)

Cause
Symptoms
Doctor Examination
Nonsurgical Treatment
Surgical Treatment
Complications

Developmental dysplasia (dislocation) of the hip (DDH) is an abnormal formation

of the hip joint in which the ball on top of the thighbone (femur) is not held firmly
in the socket. In some instances, the ligaments of the hip joint may be loose and
stretched.

The degree of hip looseness, or instability, varies in DDH. In some children, the
thighbone is simply loose in the socket at birth. In other children, the bone is
completely out of the socket. In still other children, the looseness worsens as the
child grows and becomes more active.

In a normal hip, the head of the femur is firmly inside In some cases of DDH, the thighbone is completely out of
the hip socket. the hip socket.

Pediatricians screen for DDH at a newborn's first examination and at every well-
baby checkup thereafter. When the condition is detected at birth, it can usually
be corrected. But if the hip is not dislocated at birth, the condition may not be
noticed until the child begins walking. At this time, treatment is more complicated
and uncertain.

Left untreated, DDH can lead to pain and osteoarthritis by early adulthood. It may
produce a difference in leg length or a "duck-like" gait and decreased agility. If
treated successfully (and the earlier the better), children regain normal hip joint
function. However, even with appropriate treatment, especially in children 2 years
or older, hip deformity and osteoarthritis may develop later in life.

Cause

DDH tends to run in families. It can be present in either hip and in any individual.
It usually affects the left hip and is predominant in:
 • Girls
• First-born children
• Babies born in the breech position (especially with feet up by the shoulders). The American
Academy of Pediatrics now recommends ultrasound DDH screening of all female breech babies.

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Symptoms

Some babies born with a dislocated hip will show no outward signs.

Contact a pediatrician if your baby has:

• Legs of different lengths

• Uneven skin folds on the thigh
• Less mobility or flexibility on one side
• Limping, toe walking, or a waddling, duck-like gait

How is hip dysplasia diagnosed?

Diagnosis of hip dysplasia in the infant is based on the physical examination findings. Your
doctor will feel for a "hip click" when performing special maneuvers of the hip joint. These
maneuvers, called the Barlow and Ortolani tests, will cause a hip that is out of position to
"click" as it moves in and out of the proper position.

If a hip click is felt, your doctor will usually obtain a hip ultrasound to assess the hip joint. An
x-ray does not show the bones in a young baby until at least 6 months of age, and therefore a
hip ultrasound is preferred. The hip ultrasound will show the doctor the position and shape of
the hip joint. Instead of the normal ball-in-socket joint, the ultrasound may show the ball
outside of the socket, and a poorly formed (shallow) socket. The hip ultrasound can also be
used to determine how well the treatment is working.

What is the treatment of hip dysplasia?

The treatment of hip dysplasia depends on the age of the child. The goal of treatment is to
properly position the hip joint ("reduce" the hip). Once an adequate reduction is obtained, the
doctor will hold the hip in that reduced position and allow the body to adapt to the new
position. The younger the child, the better capacity to adapt the hip, and the better chance of
full recovery. Over time, the body becomes less accommodating to repositioning of the hip
joint. While treatment of hip dysplasia varies for each individual baby, a general outline
follows:

• Birth to 6 months
Generally in newborns, a hip dysplasia will reduce with the use of a special brace called a
Pavlik harness. This brace holds the baby's hips in a position that keeps the joint reduced.
Over time, the body adapts to the correct position, and the hip joint begins normal
formation. About 90% of newborns with hip dysplasia treated in a Pavlik harness will
recover fully. Many doctors will not initiate Pavlik harness treatment for several weeks after
birth.
• 6 months to 1 year
In older babies, Pavlik harness treatment may not be successful. In this case, your
orthopedic surgeon will place the child under general anesthesia. This usually allows the hip
to assume the proper position. Once in this position, the child will be placed in a spica cast.
The cast is similar to the Pavlik harness, but allows less movement. This is needed in older
children to better maintain position of the hip joint.
• Over age 1 year
Children older than one year old often need surgery to reduce the hip joint into proper
 position. The body can form scar tissue that prevents the hip from assuming its proper
position, and surgery is needed to properly position the hip joint. Once this is done, the
child will have a spica cast to hold the hip in the proper position.

The success of treatment depends on the age of the child, and the adequacy of the reduction.
In a newborn infant with a good reduction, there is a very good chance of full recovery. When
treatment begins at older ages, the chance of full recovery decreases. Children who have
persistent hip dysplasia have a chance of developing pain and early hip arthritis later in life.
Surgery to cut and realign the bones (hip osteotomy), or a hip replacement, may be needed
later in life.

Doctor Examination

In addition to visual clues, the doctor will use careful physical examination tests
to check for DDH, such as listening and feeling for "clunks" as the hip is
manipulated. For older infants and children, X-rays of the hip may be taken.
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Nonsurgical Treatment

Treatment methods depend on the child's age.

Newborns

Newborns are placed in a Pavlik harness for 1 to 2 months to treat DDH.

Newborns are placed in a Pavlik harness for 1 to 2 months to treat DDH. The
baby is placed in a soft positioning device, a Pavlik harness, for 1 to 2 months to
keep the thighbone in the socket. This will help tighten the ligaments around the
hip joint and promote normal hip socket formation.

1 to 6 months
The baby's thighbone is repositioned in the socket using a harness or similar
device. The method is usually successful. But if it is not, the doctor may have to
anesthetize the baby and move the thighbone into proper position, and then put
the baby into a body cast (spica).
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Surgical Treatment

6 months to 2 years
The child is placed under anesthesia, and the thigh bone is manipulated into the
proper position in the socket. Open surgery is sometimes necessary. Afterwards,
the child is placed into a body cast (spica) to maintain the hip position.

Older than 2 years

Deformities may worsen, making open surgery necessary to realign the hip.
Afterwards, the child is placed into a body cast (spica) to maintain the hip in the
socket.
In many children with DDH, a body cast and/or brace is required to keep the hip
bone in the joint during healing. X-rays and other regular follow-up monitoring are
needed after DDH treatment until the child's growth is complete.
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Complications

Complications of treatment may include a delay in walking if the child was placed
in a body cast. The Pavlik harness and other positioning devices may cause skin
irritation, and a difference in leg length may remain. Growth disturbances of the
upper thigh rarely occur.