Congenital Hip Dislocation

Introduction Hip dysplasia ,developmental dysplasia of the hip (DDH) or congenital dysplasia of the hip (CDH) is a congenital or acquired deformation or misalignment of the hip joint. Congenital dislocation of hip is a condition present since birth in which the head of the femur is detached from the acetabulum or can be moved in and out of the acetabulum easily. Some children are born with a hip problem called congenital hip dislocation (dysplasia). The condition is usually diagnosed as soon as a baby is born. Most of the time, it affects the left hip in first-born children, girls, and babies born in the breech position. Anatomy In hip dislocation, the ball at the top of the thighbone (femoral head) does not sit securely in the socket (acetabulum) of the hip joint. Surrounding ligaments may also be loose and stretched. The ball may be loose in the socket or completely outside of it. Causes Sex (females are more affected than males) Statistics show that the Native American population has a high incidence of hip dislocation. Infants born by caesarian and breech position births. 1st born infants Hormonal changes within the mother duringpregnancy Other musculoskeletal disorders of intrauterine malpositioning or crowding such as metatarsus adductus andtorticol lis Oligohydramnios Hip dysplasia can be associated with underlying neuromuscular disorders, such as cerebral palsy, myelomeningocele, arthrogryposis, and Larsen syndrome, although these are not usually considered DDH Family History (positive in up to one third of cases) a. One affected sibling: 6% risk b. One affected parent: 12% risk c. One affected sibling and one affected parent: 36%

Types of Congenital Hip Dislocation 1. Classic congenital Hip Dislocation 2. Congenital Abduction Contracture of the Hip 3. Teratologic Congenital Hip Dislocation a. Severe, prenatal fixed dislocation b. Associated with genetic and neuromuscular disorders

Symptoms In congenital dislocation, the earliest sign may be a “clicking” sound when the newborn’s legs are pushed apart. If the condition goes undetected at the newborn stage, eventually the affected leg will look shorter than the other one, skin folds in the thighs will appear uneven, and the child will have less flexibility on the affected side. When he starts to walk, he’ll probably limp, walk on his toes, or “waddle” like a duck. Legs of different lengths. hip click Uneven thigh skin folds. Less mobility or flexibility on one side. In children who have begun to walk, limping, toe walking and a waddling "duck-like" gait are also signs. Ankle fractures buttocks folds also may not be symmetrical with more creases on the dislocated side Hip pain commonly manifests as knee or anterior thigh pain

Diagnosis A careful physical examination of a newborn usually detects hip dislocation. In older infants and children, hip x-rays can confirm the diagnosis. Arthrograms are dynamic studies, performed by injecting dye into the hip joint and then examining the patient with aid of fluoroscopy, usually with the patient under anesthesia. A careful physical examination of a newborn usually detects hip dislocation. In older infants and children, hip x-rays can confirm the diagnosis. Imaging

A. Dynamic Hip Ultrasound (infant aged 1-6 months) 1. Diagnostic for congenital Hip Dislocation 2. Evaluates for subluxation and reducibility 3. High false positive rate <6 weeks B. Hip XRay 1. Not diagnostic for dislocation until >6 months 1. Femoral head not calcified under age 4-6 months 2. Diagnostic for Acetabular Dysplasia a. Abnormal acetabular fossa will be seen C. Evaluated with reference lines drawn over AP XRay 1. Hilgenreiner's Line a. Horizontal line through triradiate cartilages 2. Perkin's Line a. Vertical line along each lateral acetabulum 3. Shenton's Line a. Femoral neck medial border b. Superior border of obturator foramen MEDICAL Management A. Management indicated for hip instability beyond 5 days B. Step 1: Pavlik Harness 1. Indicated as first-line if age <6 months 2. Start with harness trial for 3-4 weeks 3. Splints hips in flexed and abducted position 4. Long-term effect: 95% (80% if frank dislocation) 5. Ultrasound should demonstrate reduction at 3 weeks a. Reduced: Continue harness for >6 weeks b. Not Reduced: Go to Step 2 C. Step 2: Closed Reduction and Casting by Orthopedics 1. Indications a. No reduction with Pavlik Harness in 3-4 weeks b. Children over age 6 months 2. Attempted closed reduction under arthrogram 3. Hip Spica Casting for 12 weeks 4. Positioning confirmed by post-op MRI or CT D. Step 3: Surgical Open reduction 1. Indicated in refractory cases 2. Requires multi-step procedure a. Tendon lengthening b. Clearing tissues obstructing relocation c. Tightening hip capsule d. Osteotomy if performed after age 18 month 3. Complicated by re-dislocation, osteonecrosis

Nursing Management

* Placing rolled cotton diapers or a pillow between the thighs, thereby keeping the knees in a frog like position * ROM exercise to unaffected Tissue * Immobilization of hips in less than 60- degrees abduction per hip * Meticulous skin care around the immobilized tissues * For patients who have splints, remind parents to maintain good diaper area care: change diapers frequently and wash area and apply an ointment such as A and D ointkment, vaseline r Desitin at each diaper change since this can lead to severe diaper rash * Teach parents to swaddle the baby tightly because this action is comforting. * For older patients encourage a balanced diet, foods that promote healing such as protein rich foods and as well as vit c rich foods * Maintain proper positioning and alignment to limit further injury * Accompanying soft tissue injuries are treated by RICE therapy: R- rest I- ice C-compression bandage E- elevation with or without immobilization * Stimulation of affected area by isometric and isotonic exercises also helps promote healing

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