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Congenital Hip Dislocation

Definition: congenital or acquired deformation or misalignment of thehip joint femoral head has an abnormal relationship to the acetabulum

In a normal hip, the head of the femur is firmly inside the hip socket.

In some cases of DDH, the thighbone is completely out of the hip socket.

Congenital dislocation of the left hip in an elderly person. Closed arrow marks the acetabulum, open arrow the femoral head. The hip is a ball and socket joint. The ball, called the femoral head, forms the top part of the thigh bone (femur) and the socket (acetabulum) forms in the pelvic bone.

Other Known Name: Developmental dysplasia of the hip(DDH) Congenital dysplasia of the hip (CDH)

Incidences: High as 1 in 100 newborns with evidence of instability, and 1 to 1.5 cases of dislocation per 1000 newborns. Eight times more frequent in females than in males More than 60% of hip instability became stable by age 1 week, and 88% became stable by age 2 months, leaving only 12% (of the 1 in 60 newborns, or 0.2%) with residual hip instability.

Peak case under 1 y/o and below 11 and 15 years old Racial background; among Native Americans and Laplanders, the prevalence of hip dysplasia is much higher (nearly 25-50 cases per 1000 persons) than other races Prevalence is very low among southern Chinese and black populations Risk: Breech position the femoral head tends to get pushed out of the socket. A narrow uterus also facilitates hip joint dislocation during fetal development and birth. Being female Family history of the disorder Generalized Ligamentous Laxity

Large Fetal size Increased by Maternal Estrogen and other hormone Associated with underlying neuromuscular disorders, such as cerebral palsy, myelomeningocele, arthrogryposis, and Larsen syndrome, although these are not usually considered DDH.

Associated with Congenital Abnormality: Metatarus adductus; Muscular Torticollis

Predisposing Factor o o o o o Gender (Female) Birth Order (1st born) Race Large Infant size Maternal hormone secretion: Relaxin o Intrauterine malpositioning or crowding as metatarsus adductus and torticollis o o

Precipitating Factor Delivery Type (Cesarian instead of NSD) Prenatal Positioniing (Breech Presentation) (Oligohydramios) (Associated Postural Abnormalities)

Types:

Types of misalignments of femur head to socket in hip dysplasia. A: Normal. B: Subluxation; C: Displaced Subluxed Mild Form Femur Rides up Flat Acetabulum Stretched Capsule and loose Some contact of femoral head with Acetabulum Displaced Femur Rides do far up Femoral head leaves the acetabulum Elongated Ligamentum Teres Displaced Femoral Head out of Acetabulum Teratologic Associated with Genetic and Neuromuscular Disorder Irreducible hip at birth Severe, prenatal, fixed Dislocation

The condition can be bilateral or unilateral:


If both hip joints are affected one speaks of "bilateral" dysplasia. In unilateral dysplasia only one joint shows deformity, the contralateral side may show

resulting effects. In the majority of unilateral cases the left hip has the dysplasia. Classification

Description

Dislocation

Femur and acetabulum show minimal abnormal development.

Less than 50% dislocation

II

The acetabulum shows abnormal development.

50% to 75% dislocation

III

The acetabula is developed without a roof. A false acetabulum develops opposite the dislocated femur head position. The joint is fully dislocated.

75% to 100% dislocation

IV

The acetabulum is insufficiently developed. Since the femur is positioned high up on the pelvis this class is also known as "high hip dislocation".

100% dislocation

Clinical Manifestation Asymmetrical gluteal folds and an apparent limb-length inequality can further indicate unilateral hip dysplasia. Leg with hip problem may appear to turn out more Less mobility or Flexibility on one side affected Reduced movement on the side of the body with the dislocation Shorter leg on the side with the hip dislocation -Seen when the infant is lying in supine position, thigh flexed to 90 degrees toward the abdmen Uneven skin folds of thigh or buttocks Waddling duck gait Ankle Fractures More creases on dislocated side Hip pain (+) Ortholanis Sign (+) Allis Galleazzis Sign Unequal Femoral Length Flex knee so that ankle touch the buttocks (+) not in level

After 3 months of age, the affected leg may turn outward or be shorter than the other leg.

Pathophysiology
Predisposing Factor o Gender (Female) Birth Order (1st born) Race Large Infant size Maternal hormone secretion: Relaxin Intrauterine malpositioning or crowding as metatarsus adductus and torticollis (Breech Presentation) (Oligohydramios) (Associated Postural Abnormalities) o o Precipitating Factor Delivery Type (Cesarian instead of NSD) Prenatal Positioniing

o
o o o

4-6 weeks Ossification center happens femoral head

7th week Development femoral and acetabulum

11th week Femoral Head flattens

Due Undevelope d femoral head & actabulum Absence tight fit b/w Acetabulum and femoral head Stretched Capsule: Loss of Atachment No longer be Manipulated by Diagnostic Studies maneuver: Undergo Surgical Management

Pulvincor (Fibrofatty tiisue) fills space between femoral head & Acetabulum Contraction of the hips

Hyperthrophi ed Ridge of Acetabular Cartilages

CONGENITA L HIP DISLOCATIO N

Manifestations will happen

Limitation abduction hip thus capsule constricts and narrows to less than diameter femoral head

a. Ortholanis maneuver b. Barlows Maneuver

-for 2-3mo. of age a. Lie the infant in a supine position and flex knee to 90 degrees b. Place Middle finger over lesser trochanter and thumb on internal side of thigh over lesser trochanter c. Abduct hips while applying upward pressure over greater trochanter, Listen to clicking sound d. Next, fingers in same position, hold hips and knees at 90 degrees flexon, apply a backward pressure (down laterally) & adduct the hips. Note feeling femoral head slipping down.

c. Arthrograms d. Dynamic Hip Ultasound

Dye is injected and visualized with the aid of flurouscopy Diagnose hip dislocation Indicated for 1-6months of age Shows morhology (Characteristics and assess stability)

e. MRI (Magnetic Resonance Imaging) f. Xray & Sonogram Medical Management

Identif underlying bony and soft tissue anatomically Reveal shallow acetabulum and lateral placement femoral head

a. Pavlik Harness Prevent hip extension and adduction but allows flexion and extension Less than 6 mo of age applied for 1-2months

b. Traction - Less than 6 mo. to years of age for 1-2 weeks

Bryants Traction- indicated for less than 3 years of age

c. Spica Cast: Frog Cast d. Frejka Splint - Firm pressure to abduct hip to place splint coorrectly Surgical Management 1. Open Reduction- Indicated for 2 years and above with thw use of wires, pins, plates and screw 2. Total hip arthroplasty (hip replacement) is complicated by a need for revision surgery (replacing the artificial joint) owing to skeletal changes as the body matures, loosening/wear or bone resorption.

3. Osteotomies are either used in conjunction with arthroplasty or by themselves to correct


misalignment. Indicated for more than 4 years old. 4. Endoprosthetic Replacement Implanting metal device Nursing Diagnosis

1. Acute Pain related to lack of continuity of bone to joint, edema and muscle spasms as evidence by facial grimace and crying 2. Impaired physical mobility related to musculoskeletal impairment secondary to hip dysplasia as manifested by less mobility and flexibility on one side of the leg 3. Knowledge deficit of Parent regarding home care

Nursing Responsibilities 1. Teach Parents how to maintain devices, provide nurturing activities to meet infants need to provide comfort 2. Placing pillow between the thighs To keep knee in frog like position 3. ROM exercises to unaffected side Promotion circulation and prevent bed sore 4. Meticulous skin care around immobilized tissue- Prevent infection 5. Check frequently forced areas, understraps and clothing- Check any skin breakdown 6. Avoid applying lotion and powders It could irritate the skin 7. Maintain Proper positioning and alignment- Prevent further injury

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Congenital Hip Dislocation

Presented by: Mary Ann Angelique L. Bucad BSN4-1 Group 2