P T PT

Developmental Dysplasia h D, C
I, C of Hip
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh Chapter 30
 Objectives
At the end of this discussion, YOU will be able to:
CP T PT
h D, I, C
N, P C IM
• Familiar with developmental dislocation
r, R h
of
D , hip DDH
sa , P
Nas , R N
• Identify factors associated
a h a witha saDDH
m y H a l
O aila
• Discuss the types SofuhDDH

• Explain the therapeutic Management

• Discuss the Nursing management

 Introduction
• Disorders related to abnormal development of the hip

CP T PT
• It may develop at any time during fetal h D , I, C or childhood
, P life, infancy,
IM
, RN D , C
sa r , P h
N as , R N
• A change in terminology
a h a fromascongenital
a hip dysplasia (CHD) to
m y H a l
Developmental ODislocation
ila of Hip (DDH)
u ha
S
• DDH more properly reflects a variety of hip abnormalities in which there is
a shallow acetabulum, subluxation, or dislocation
 Developmental Dislocation of Hip

• The incidence is 1-2 infants per 1000 live births

T
, CP PT
h D I, C
• Girls are more affected than boys N, P , CIM
r, R hD
s sa , P
Na
• Positive family historyhincreases , N
R for DDH
risk
a a a sa
m y H a l
O aila
• 7-40% of infants born
u h with DDH have breech intrauterine position (Loder
S
& Schopelja, 2011).

5/7/23 4
 Incidence
• Approximately 30% to 50% of infants with DDH were born breech
(Thompson, 2004a) PT T , C P
h D I, C
N , P C IM
r, Rcases,hthe
D ,
• The left hip is involved in 60%s saof , P right hip in 20%, and both hips
in 20% Na , R N
a h a a sa
y a l
Om aila H
Suhchildren are girls
• Sixty percent of the
 • https://www.youtube.com/watch?v=69kWyAsSMRE
• This video describes the development dysplasia
T of the hip and the
, CP P T
Pavlik Harness hD , P I, C IM
, RN D, C
sa r , P h
Nas , R N
• https://www.youtube.com/watch?v=Qy3uSkDhMZs
a h a a sa
m y H a l
O aila
S uh

05/07/2023 Suhaila Halasa RN, PhD, CIMI 6

 Normal Hip/DDH

CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

05/07/2023 https://www.drugs.com/cg/developmental-dysplasia-of-the-hip-in-children.html
7
 Normal Hip/ DDH

CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

05/07/2023 8
 Normal Hip/ DDH

CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

05/07/2023 https://www.alamy.com/congenital-hip-dysplasia-dislocated-hip-image7712768.html
9
 Pathophysiology

Predisposing factors associated with DDH: PT T

C D, , CP
, Ph IMI
, RN D , C
• Physiologic factors: sa r , P h
Nas , R N
a h a a sa
• Maternal hormone
m y secretion
H a l
O aila
S uh
• Intrauterine positioning
 Pathophysiology

CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

https://www.bettersafercare.vic.gov.au/sites/default/files/inline-images/breech-exampl.jpg

05/07/2023 11
 Pathophysiology

• The cause is unknown but certain CP T PT

h D, I, C
N, P C IM
r, R
• Predisposing factors associatedsawith DDH: hD ,
as , R N , P
a N a
y a h la s
m
O aila H a
- Physiologic factors
S u h
- Mechanical factors
- Genetic factors
 Pathophysiology

Predisposing factors associated with DD:

CP T PT
• Mechanical factors:
h D, I, C
N, P C IM
• Breech presentation
r, R hD ,
sa , P
Nas , R N
• Multiple fetus
a h a a sa
m y H a l
O aila
S uh
• Oligohydramnios

• Large infant size (LGA)

• Continued maintenance of the hips in adduction and extension that will in time cause a
dislocation (tight swaddling )‫لقماط‬%%‫ا‬
 Pathophysiology
• Predisposing factors associated with DD:
CP T PT
• Genetic factors: h D, I, C
N , P C IM
r, R hD ,
s
s ina , P
• Higher incidence (6%) N aDDH
of , R N
siblings of affected infants
a h a a sa
m y H a l
O aila
• Greater incidence
S u h (36%) of recurrence if sibling and one parent were
affected.

05/07/2023 Suhaila Halasa RN, PhD, CIMI 14

 Pathophysiology

• Some experts categorize DDH into two major groups:

CP T PT
1. Idiopathic in which the infant is neurologicallyh D, I,
intactC
N , P C I M
r, R hD ,
sa , P
Nas a, RN defect such as:
2. Teratologic: it involves a aneuromuscular
yah alas
Om aila H
-------
S uh
- Arthrogryposis (congenital fixation of a joint in an extended or flexed position) or

- Myelodysplasia (developmental anomaly of the spinal cord)

• The teratologic forms usually occur in utero and are much less common
 Three degrees of DDH
• Acetabular dysplasia

CP T PT
h D, I, C
N, P C IM
• Subluxation r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
• Dislocation S uh

https://www.alamy.com/stock-photo/hip-dysplasia.html
 CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh
 Acetabular Dysplasia
• Mildest form of DDH
CP T PT
h D, I, C
• There is neither subluxation nor dislocation. N, P C IM
r, R hD ,
sa , P
Nas , R N
a h
• There is a delay in acetabulara development
a sa
y a l evidenced by osseous
m la H roof that is oblique and shallow, although the
hypoplasia of the O i
acetabular
a
h
cartilaginous roof isSucomparatively intact.

• The femoral head remains in the acetabulum.

 Subluxation
• The largest percentage of DDH
• It implies incomplete dislocation of the hip andTis sometimes
, CP PT
h D I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh
 Subluxation
• The femoral head remains in contact with the acetabulum, but a stretched
capsule and ligamentum teres cause the head of the femur to be partially
displaced. CP T PT
h D, I, C
• Pressure on the cartilaginous roof R N, P
inhibits C IM
ossification and produces a
r, , Ph D ,
flattening (destruction) sa
Nas , R N
of the socket. a h a a sa
y
Om aila H al
S uh
 Dislocation
• The femoral head loses contact with the acetabulum and is displaced
posteriorly and superiorly over the fibrocartilaginous rim.
CP T PT
h D, I, C
N , P C IM
• The ligamentum teres is elongatedr, Rand taut
hD , (tight, rigid).
ssa , P
N a , R N
a
ah alas a
y
Om aila H
S uh
 Diagnostic Evaluation

• DDH is often not detected at the initial examination

T after birth; In the
, CP PT
h D I, C
newborn period dysplasia usually appears
N, P asIM
C
hip joint laxity rather than as
r, R hD ,
sa , P
outright dislocation
Nas , R N
a h a a sa
m y H a l
• All infants should
O be acarefully
ila monitored for hip dysplasia at follow-up
S uh
visits throughout the first year of life.
 Diagnostic Evaluation
• Some experts suggest that ultrasound be
PT used to screen hips
, C PT
h D I, C
at 2 weeks after birth in infants N , P
with IM signs of DDH,
clinical
C
r, R hD ,
s sa , P
infants with a higher Na
risk of R
DDH,
, N and to monitor the efficacy of
a h a a sa
y
m la H a l
O
treatment in infantsa i with DDH
S u h
 Diagnostic Evaluation

• In infants older than age 4 months and in children, radiographic

CP T PT
h D, I, C
examination is useful in confirming N ,
the P C IM
diagnosis.
r, R hD ,
sa , P
Nas , R N
a h a a sa
• Computed tomography
m y (CT) H a lscan may be useful to assess the position of
O aila
S uh
the femoral head relative to the acetabulum after closed reduction and

casting.
 Diagnostic Evaluation
• Ultrasonography useful in neonatal period
• Plain x-rays unreliable for infant older than 6 months
T to confirm diagnosis
, CP PT
h D I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

https://hipdysplasia.org/developmental-dysplasia-of-the-hip/infant-diagnosis/x-ray-screening/
 Diagnostic Evaluation
• Subluxation and the tendency to dislocate can be demonstrated by the
CP T PT
Ortolani or Barlow tests h D, I, C
N, P C IM
r, R hD ,
sa , P
N as , R N
• The Ortolani and Barlowa h atests aare
sa most reliable from birth to 2 or 3 months
y a l
Om aila H
uhDDH are shortening of the limb on the affected side
of age. Other signsSof
(Galeazzi sign, Allis sign) asymmetric thigh and gluteal folds (Fig 31-14, A),
and broadening of the perineum (in bilateral dislocation) (Box 31-4).
 • https://www.youtube.com/watch?v=Qy3uSkDhMZs

CP T PT
h
• This video describes hoe to test forPnewborn D, I, C dysplasia
hip
N, C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

05/07/2023 Suhaila Halasa RN, PhD, CIMI 27

 Diagnostic Evaluation

 The Ortolani and Barlow tests are most reliable from birth to 4
weeks of age CP T PT
h D, I, C
N , P C IM
r, R hD ,
sa , P
Nas , R N
 Other signs of DDH are shortening of the limb on the affected side
a h a a sa
my H a l
O aila
 Asymmetric thighSu h gluteal folds
and

 Decrease hip abduction on the affected side

5/7/23 28
 Diagnostic Evaluation

CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

05/07/2023 https://www.pinterest.com/pin/562738915925438479/ 29
 Diagnostic Evaluation

CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

05/07/2023 https://www.tumblr.com/tagged/ddh 30
 Clinical Manifestations of DDH

CP T PT
, C
Clinical Manifestations N , Ph D
, C IM I, of DDH
R
r, , Ph D
BoxNa 29-5
ssa
, R N page 961
a
ah alas a
y
Om aila H
S uh

05/07/2023 Suhaila Halasa RN, PhD, CIMI 31

 Clinical Manifestations of DDH

Box 29-5 page 961

CP T PT
h D, I, C
INFANT N , P C IM
r, R hD ,
• Shortening of limb on affected
ssa side P
(Galeazzi
, sign /Allis sign)
Na , R N
• Restricted abduction a
ahof hipalon
a a
s affected side
y
m la H
O
• Unequal gluteal folds
a i(infant prone)
Su h
• Positive Ortolani test
• Positive Barlow test

5/7/23 32
 Clinical Manifestations of DDH

Box 29-5 page 961

Infant CP T PT
h D, I, C
• Shortening of limb on affected side N, P C IM
r, R D ,
(Galeazzi sign/Allis sign) assa N, Ph
a N a , R
yah alas
Om aila H
S uh

5/7/23 https://www.pinterest.com/pin/59180182585221307/ 33
 Clinical Manifestations of DDH

Box 29-5 page 961

Infant CP T PT
h D, I, C
• Restricted abduction of hip N, P C IM
r, R hD ,
on affected side sa , P
N as , R N
• Unequal gluteal foldsyaha lasa
m H a
(infant prone) O haila
Su

5/7/23 https://radiologykey.com/infant-and-pediatric-hip/ 34
 Clinical Manifestations of DDH

Box 29-5 page 961

Infant CP T PT
h D, I, C
• Positive Ortolani test
N, P C IM
r, R hD ,
• Positive Barlow test sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

5/7/23 https://quizlet.com/204037800/infantschildren-part-2-finished-flash-cards/ 35
https://link.springer.com/chapter/10.1007/978-1-4614-7126-4_6
 Clinical Manifestations of DDH

CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

05/07/2023 36
Clinical Manifestations of DDH

CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh
Clinical Manifestations of DDH

CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh
 Clinical Manifestations of DDH

Older Infant and Child

CP T PT
• Affected leg shorter than the other PhD, MI, C
N , , C I
r, R hD
• Telescoping or piston mobility s a
s of joint , P
N a , R N
• Head of femur can be a
ahfelt toamove
a a
s up and down in buttock when extended thigh
y l
Om achild's
is pushed first toward ila H head and then pulled distally
S uh
• Marked lordosis (bilateral dislocations)

• Waddling gait ‫( مشية متمايلة‬bilateral dislocations)

5/7/23 39
 Clinical Manifestations of DDH

Trendelenburg sign
CP T PT
• When child stands first on
h D, I, C
N , P C IM
r, R hD ,
one foot and then on the other (holdingsa onto
, P
N as , R N
aha bearing
a chair, rail, or someone'syhands) a la sa weight
Om aila H
h downward on
Sutilts
on an affected hip, pelvis

normal side instead of upward, as it would with

normal stability
 Clinical Manifestations of DDH

CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

https://www.pinterest.com/pin/643944446689438665/ 41
Clinical Manifestations of DDH

CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh
 Therapeutic Management

• The goal of treatment is to obtain and maintain CP T PT

h D, Ia
, safe,
C congruent
N , P C IM
position of the hip joint to promoter, R normalhD , hip joint development.
ssa , P
N a , R N
a
• It depends on child’syaage sa
h andladegree of the dysplasia
Om aila H a
uhmore favorable to the restoration of normal bony
• Early interventionSis
architecture and function.

5/7/23 43
 Newborn to Age 6 Months

•The hip joint is maintained by dynamic splinting in a safe position with the
CP T PT
proximal centered in the acetabulum in anhattitudeD, ,
of
I Cflexion
N, P C IM
r, R hD ,
a
•The Pavlik’s harness is the mostswidely P
used
,
Nas , R N
a h a a sa
•The harness is wornm y
continuously
H a l until the hip is proved stable on clinical and
O aila
S u h
radiographic examination, usually in about 6 to 12 weeks

•Double/triple diapering is unaffected and not recommended.

5/7/23 44
 Newborn to Age 6 Months
Pavlik’s harness
CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

https://www.tradeindia.com/products/pavlik-harness-cdh-splint-c4159398.html 45
Newborn to Age 6 Months

CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh
 Newborn to Age 6 Months
• Surgical closed reduction of the hip

CP T PT
h D, I, C
N , P C IM
• Application of hip Spica cast ar, R PhD,
a ss N ,
a N a , R
yah alas
Omperiodically
The cast is changed
a ila H
S uh
to meet child's growth

https://www.texaschildrens.org/health/developmental-dysplasia-hip-ddh
 Newborn to Age 6 Months

CP T PT %‫لعظم‬%%‫ ا‬%‫قويم‬%%%‫ت‬
• After 3 months, a removable hip abduction orthosis is
applied h D, I, C
P N, IM C
• The duration of orthosis depends R
r, on ,thehD ,
sa P development of acetabulum
Nas , R N
a h a a sa
m y H a l
O aila
S uh

https://rhinopod.com/products/
 Age 6 to 24 Months

• In this age-group the dislocation is not recognized

T until the child begins
, CP PT
h D I, C
N , P C IMof the limb and
to stand and walk, when attendant
r, R shortening
hD ,
sa , P
Nas , R N
a h a and
contractures of hip adductor a sa flexor muscles become apparent
y a l
Om aila H
S uh
 Age 6 to 24 Months

• Use of hip abduction orthosis  (brace, splint, CP T PT

h D, or other
I, C artificial external
N , P C IM
device serving to support the limbs r, R or spine
hD , or to prevent or assist
s sa , P
Na , R N
relative movement) ah a a sa
my H a l
O aila
Suh depends on the development of acetabulum
• The duration of orthosis
 Hip Abduction Orthosis  

CP T PT
h D, I, C
N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

05/07/2023 Suhaila Halasa RN, PhD, CIMIhttps://rhinopod.com/products/ 51

 Older Child

Operative Reduction:
CP T PT
h D, I, C
•Involve preoperative traction, tenotomy N , P IM muscles, and any one
of contracted
C
r, R hD ,
sa , P
of several innominate osteotomy Nas procedures
, R N designed to construct an
a h a a sa
y
m larequired
H a l
acetabular roof, isOusually
a i
S uh
•After cast removal and before weight bearing is permitted, range of motion
exercises help restore movement

. 5/7/23 52
 Older Child

Rehabilitation measures such as: CP T PT

h D, I, C
N, P C IM
r, R hD ,
• Muscle strengthening sa , P
Nas , R N
• Walker use a h a a sa
m y H a l
• Gait training O aila
S uh

. 5/7/23 https://www.pbuysites.xyz/D-hip-dysplasia-baby-treatment.html 53
 Nursing Care Management

The primary nursing goal is: T PT

, CP
h D I, C
N , P C IM
• Teaching parents to apply andamaintain
r, R hD ,
the reduction device
a s s N , P
a N a , R
ya h la s
m
• The Pavlik harness H a
O aila easy handling of the infant and usually
allows for
S uh
produces less apprehension in the parent than heavy braces and casts
 Nursing Care Management

• The Pavlik harness allows for easy handling CP T P T

h D, of the
I, infant
C and usually
N , P C IM
produces less apprehension in athe r, Rparent hD ,
than heavy braces and casts.
a ss N , P
a N a , R
ahrapidalgrowth,
• Because of the infant's
y a s the straps should be checked every 1
Om aila H
Suh adjustments
to 2 weeks for possible
 Nursing Care Management
• Nurses has unique role in the detection of DDH

CPT nurturing
• During the infant assessment process and routine PT activities the
, h C
D MI,
N, P C I
hips and extremities are inspectedr, Rfor anyhD,
deviations from normal
ssa , P
Na , R N
a a
ah ainlasthe care of an infant or child in a cast or
• The major nursing problems
y
Om aila H
Suh to maintenance of the device and adaptation of
other device are related
nurturing activities to meet the needs of the infant or child.

5/7/23 56
 Nursing Care Management
• Care of an infant or small child with a device/cast requires nursing
CP T PT
innovation to: h D, I, C
N, P C IM
r, R hD ,
- reduce irritation sa , P
Nas , R N
a h a a sa
m y ofHboth
- maintain cleanliness a l the child and the cast, particularly in the
O aila
S u h
diaper area
- maintain the device/ cast in its place
- adapt of nurturing activities to meet their needs
 Nursing Care Management
Measures to prevent skin breakdown:
CP T PT
h D, I, C
• Check frequently at least two to three
N, P
time C for
IM red area, skin folds or
r, R hD ,
sa , P
under straps Nas , R N
a h a a sa
m y H a l
• Gentle massageOfor healthy
ila skin under the strap once a day
u ha
S
• Place diaper under strap

• Parents should not adjust the harness without supervision

 Nursing Care Management
• Measures to prevent skin breakdown:
CP T PT
• Sponge bath h D, I, C
N , P C IM
r, R hD ,
sa , P
• Daily assessment of the skin Nasfor irritation
, R N
a h a a sa
y a l
Om ailafrom
• To prevent skin irritation H straps, long socks and shirt are worn
S uh
• Powder or oil should not be used, causing balls underneath clothing

5/7/23 59
 Nursing Care Management

• Because of the infant's rapid growth, the strapsT should be checked every 1
, CP PT
h D I, C
N, P C IM
to 2 weeks for possible adjustments.
r, R hD ,
sa , P
Nas , R N
a h a a sa
y
• It is important thatmparents H a l
understand the correct use of the appliance,
O aila
S uh
which may or may not allow for its removal during bathing.
 Nursing Care Management

• The child should be examined by the practitioner

T before any adjustment
, CP PT
h D I, C
, P
N areDin C IM
is attempted to make certain the, Rhips
r h , correct placement before the
sa , P
Nas , R N
harness is resecured.a h a a sa
m y H a l
O aila
S uh
 Nursing Care Management

• It is important for nurses, parents, and Pother T Pcaregivers

T to
D, C , C
, Ph IM I
, RN D , C
r
understand that childrenssina corrective , P h devices need to be
Na , R N
a h a a sa
y
m activities
H a l
involved in allOthe a ila of any child in the same age group.
S u h
 CP T PT
h D, I, C

Thank You N, P C IM
r, R hD ,
sa , P
Nas , R N
a h a a sa
m y H a l
O aila
S uh

05/07/2023 Suhaila Halasa RN, PhD, CIMI 63