ANOMALIES OF THE HIP AND

PELVIS
Congenital Hip Dislocation and
Developmental Dysplasia of the
Hip
 Congenital Hip Dislocation (CHD) and
Developmental Dysplasia of the Hip (DDH)

• 1:1000 live births have fixed dislocation

• .4-.6:1000 births have late dislocation,
subluxation, dysplasia
• Hip dislocation may cause dysplasia
• 6:1 female predominance
• 25% of cases are bilateral, but asymmetric
• risk factors:
– breech fetal position
– oligohydramnios
– first born
• associated with neuromuscular disorders,
congenital torticollis, skull and foot
deformities
 CHD evaluation

• Orthopedic examination
– Barlow maneuver (adduction, A-P)
– Ortolani maneuver (flexion, abduction)

• Imaging considerations
– Diagnostic ultrasound 0-4 months
– X-ray (AP and frog-leg) after 4 months
 CHD treatment
Key info: Hips need to be held in
flexion, abduction, and external
rotation for the majority of the day
for several months.
FYI:
• Pavlik harness is used during the
first two postnatal months
• Spica casting after four months,
holding the hip in flexion and
abduction
 CHD continued…
• X-rays are most useful during 4-8
months of age
• Classic radiographic findings- Putti’s
triad
• Key radiographic findings:
– Small or absent femoral capital epiphysis
– Lateral displacement of the femur
– Shallow acetabulum with increased
inclination of acetabular roof >30 degrees
Instructions:
1. Draw Perkin’s line: a vertical line (plumb
line) at the lateral edge of the acetabulum.
Hint: this is usually the pointy part
between the ASIS and tri-radiate cartilage
(orange dots).
2. Draw Hilgenreiner’s line: a horizontal
line drawn through and beyond the left
and right tri-radiate cartilage (orange
dots).
3. Draw the acetabular angle (white
triangle): Connect the lateral acetabulum
to the tri-radiate cartilage, and measure
the angle formed with Hilgenreiner’s line.
This angle should be less than 30 degrees
Patients with CHD (*note, these are two different patients); frog-leg
x-ray (left) versus AP pelvis x-ray (right). Notice how the hip
dislocation is reduced when the patient’s hips are flexed, abducted,
and externally rotated (frog-leg position).
Example of a long-standing case of untreated bilateral hip
dislocation. Included for reference, but you won’t see a case like this
on an exam.
 Coxa Vara

• Femoral angle (Mikulicz’s angle)

measures less than 120 degrees.
The normal measurement is 120-130
degrees
• Failure of growth of medial side of
the proximal femoral physeal plate
• Painless limp around 2 years of age
• Equal incidence in male and female,
bilateral in 1/3 of patients
 Coxa Valga

• Femoral angle measures over 130

degrees
• Less common than coxa vara
• Most common cause is
neuromuscular disease (cerebral
palsy)
– Lack of stimulation to the growth plate
combined with muscular imbalance
Y-Line of the Ilium
Iliolumbar ligament
calcification
Sacrotuberous ligament
ossification
Paraglenoid sulcus
Paraglenoid sulci and osteitis
condensans ilii (OCI)
Phleboliths
 Synovial Herniation Pit
• Pitt’s pit, fibrocystic conversion defect
• Present in up to 5% of the population
• Etiology is unknown. May be due to
ingrowth of fibrous and cartilaginous
elements through perforations in the
cortex
• Most often found in the anterosuperior
femoral neck
• Asymptomatic – some large defects
may produce pain and may be treated
with excision
• May be associated with femoral
acetabular impingement syndrome
• May increase or decrease in size
Os acetabulum
Os acetabulum
 Femoroacetabular
Impingement (FAI)
• A cause of hip pain resulting from
contact of the femoral head-neck
junction against the acetabulum
(especially with flexion and internal
rotation)
• May result in early degenerative joint
disease and labral tears
• Types of FAI: CAM, pincer,
combination
 --Normal configuration of hip with sufficient joint clearance allows unrestricted range of motion
(top)

Tannast, M. et al. Am. J. Roentgenol. 2007;188:1540-1552

Copyright © 2007 by the American Roentgen Ray Society

 --Clinical tests to assess femoroacetabular impingement

Tannast, M. et al. Am. J. Roentgenol. 2007;188:1540-1552

Copyright © 2007 by the American Roentgen Ray Society

 CAM Impingement
• An aspherical femoral head results in
contact with the acetabular rim
• May result in abrasion of the
acetabular cartilage or avulsion from
the subchondral bone
• Much more common in males (14:1)
 CAM impingement
• May see a “pistol grip” deformity of
the femoral neck on AP hip views
• May also be associated with:
– Slipped femoral capital epiphysis
– Legg-Calve-Perthes disease
– Coxa vara
– Retroversion of the femoral neck
 CAM Morphology

Tannast, M. et al. Am. J. Roentgenol. 2007;188:1540-1552

Copyright © 2007 by the American Roentgen Ray Society

 Pincer Impingement
• Due to acetabular overcoverage of
the femoral head
• Produces contact between the
acetabular rim and femoral head-
neck junction
• More common in females (3:1)
 Pincer Impingement
• Associated conditions:
– Protrusio acetabuli
– Legg-Calve-Perthes
– Slipped Femoral Capital Epiphysis
 --Schematic (left) and radiographic (right) presentations of protrusio acetabuli (detailed view of
anteroposterior pelvic radiograph) in 42-year-old woman

Tannast, M. et al. Am. J. Roentgenol. 2007;188:1540-1552

Copyright © 2007 by the American Roentgen Ray Society

 --Schematic (left) and radiographic (right) presentations of focal anterior overcoverage of hip in
29-year-old woman

Tannast, M. et al. Am. J. Roentgenol. 2007;188:1540-1552

Copyright © 2007 by the American Roentgen Ray Society

 --Schematic (left) and radiographic (right) presentations of too-prominent posterior wall (PW)
show posterior wall line running laterally to femoral head center in 30-year-old man

Tannast, M. et al. Am. J. Roentgenol. 2007;188:1540-1552

Copyright © 2007 by the American Roentgen Ray Society

Associated Radiographic Changes

• Os acetabulum – acetabular rim

fracture
• Synovial herniation pits
 --Secondary radiographic signs of femoroacetabular impingement

Tannast, M. et al. Am. J. Roentgenol. 2007;188:1540-1552

Copyright © 2007 by the American Roentgen Ray Society