Hip Surveillance in CP

Title of Guideline (must Guideline for surveillance for hip

include the word subluxation and dislocation in children and
“Guideline” (not protocol, young people with cerebral palsy
policy, procedure etc)
Contact Name and Job Title Janet Corderoy (Senior Physiotherapist),
(author) Jane Williams (Consultant Neurodisability)
James Hunter (Consultant paediatric
orthopaedic surgeon)
Katherine Halliday (Consultant Radiologist)
Katherine Martin (Consultant Neurodisability)
Directorate & Speciality Directorate: Family Health – Children
Speciality: General
Date of submission December 2013
Date on which reviewed December 2017
Explicit definition of patient This guideline applies to all children with
group to which it applies (e.g. bilateral Cerebral Palsy or similar diagnosis
inclusion and exclusion under the age of 18 years
criteria, diagnosis)
Abstract This guideline describes hip surveillance for
children and young people with cerebral palsy

Key Words Hip dysplasia, subluxation, dislocation, child,

young person, cerebral palsy

Statement of the evidence base of the guideline – has the guideline been
peer reviewed by colleagues?
1a meta analysis of randomised controlled
trials
2a at least one well-designed controlled study
without randomisation
2b at least one other type of well-designed
quasi-experimental study
3 well –designed non-experimental YES
descriptive studies
4 expert committee reports or opinions and /
or clinical experiences
5 recommended best practise based on the
clinical experience
Consultation Process All relevant Medical and Physiotherapy Staff
Target audience All staff caring for children with the above problem.
This guideline has been registered with the trust. However, clinical
guidelines are guidelines only. The interpretation and application of
clinical guidelines will remain the responsibility of the individual
clinician. If in doubt contact a senior colleague or expert. Caution is
advised when using guidelines after the review date.

Jane Williams Page 1 December 2013

Document Control

Document Amendment Record

Version Issue Date Author Description

V1 Oct 2009
V2 Dec 2013 Janet Corderoy (Senior Physiotherapist),
Dr Jane Williams (Consultant Paediatrician Neurodisability)
James Hunter (Consultant paediatric orthopaedic surgeon)
Katherine Halliday (Consultant Paediatric Radiologist)
Dr Katherine Martin (Consultant Paediatrician Neurodisability)

General Notes:

Summary of changes for new version:

Jane Williams Page 2 December 2013

1. INTRODUCTION

1.1 Hip subluxation (dysplasia)/dislocation in children with cerebral palsy (CP) increases with
the severity of the impairment and the risk are greatest in children who do not walk
independently (1). It is usually associated with bilateral CP, rarely hemiplegia (2).

1.2 Hip subluxation/dislocation occurs in 60% of children with CP who are not walking at 5
(3)
years . It can result in pain, increasing deformity, inability to sit, functional restrictions, daily
living problems and may lead to spinal deformity (1).

1.3 The mechanism of how this deformity develops has not been conclusively established. In
children with CP the hip joints appear normal at birth but the effects of delayed motor
development and tonal asymmetry lead to changes in the proximal femoral anatomy and the
acetabulum. Spasticity and shortening of muscles around the hip joint and lack of ambulation
also impact on the bony development and joint position.

1.4 Botulinum toxin has a role in the management of spasticity in this group but there is no
evidence that it will absolutely prevent the need for hip surgery. (4, 5)

Jane Williams Page 3 December 2013

2. HIP SUBLUXATION/DISLOCATION

2.1 There are two elements of hip subluxation/dislocation:

 acetabular dysplasia
 femoral head displacement (1).

2.2 For children with CP the most commonly used measure for subluxation (dysplasia) is the
migration percentage.

Migration percentage is the percentage of the bony width of the femoral capital
epiphysis which fall lateral to a line drawn vertically from the bony lateral margin of
the acetabulum, the Perkins line, on an AP pelvis X-Ray (6).

2.3 A hip is usually considered to be subluxed if the migration is ≥ 33 %( 6).

Studies on normal children have established a range of values that can be considered within
normal limits (Eklof et al, 1998), which include the annual rate of migration and actual
migration. The rate of migration is an important factor in determining risk (Vidal et al) found
that increases in annual rates of migration over 7% were indicative of future inability to walk in
children with bilateral CP. Scrutton and Baird (1997) outlined clear risk factors detectable at
30 months of age for differing degrees of hip migration.

2.4 A hip migration percentage of 33% or more signifies hip subluxation or dysplasia but the
point at which dislocation can be said to occur is controversial (1).

Jane Williams Page 4 December 2013

3. INVESTIGATION

Since the hip migration percentage and rate of migration are so important it is evident that the
method of measuring needs to be standardised, reliable and repeatable. The attached
information outlines the positioning required to achieve an X-Ray that will give an accurate
and repeatable measure for the migration percentage (Appendix 1).

3.1 It is possible to forecast the anatomical development of the dysplastic hip from initial X-
rays and the progress of hip displacement can give an indication of the level of locomotion
that will be achieved (7).

3.2 This can impact on the treatment regime related to surgery, botulinum injections, orthotics
and specialist positioning equipment

3.3 There is evidence to suggest that the acetabulum can adapt advantageously to a centred
femoral head up to the age of 4/5 years after which the rate of adaptability decreases and
ceases around 9 years.

3.4 Severity of disability has no significant influence on development of hip dysplasia at 18

months. Somewhere around 24-30 months when nearly all children with ‘normal’ locomotor
development would be walking the relationship changes and it is after 30 months that the
influences of severity are apparent.

Jane Williams Page 5 December 2013

4. IDENTIFICATION OF CHILDREN AT RISK

1. Diagnosis of bilateral CP with severe spasticity and tonal asymmetry

2. Children not sitting by 18 months (3)

2. Children not walking 10 steps alone (wearing orthotics if prescribed but no

upper limb support) at 5 years are of significant risk

If a child walks alone by age 5 years with cerebral palsy, there is 4.1% likelihood
that hips needed treatment; if they could not achieve walking the figure was 46%.

3. A migration percentage of 15% or greater at 30 months carries a greater

than 50% risk of dislocation and therefore needs careful monitoring.

4. Sitting ability: the skill measured is to get to sitting from lying and then sit
(any position on floor) without propping for 15 seconds.

Children achieving this by as young as 1 year had hips needing treatment by 5

years as did 39% of those achieving this by 30 months (2)

Jane Williams Page 6 December 2013

5. HIP SURVEILLANCE PROGRAMME

5.1 Clinical examination of hip stability at each review but this is insufficient and all
children with bilateral CP require a radiograph at 30 months.

5.2 When measured correctly, migration percentage is the best guide to hip
surveillance and the need for treatment.

5.3 Clinical signs (e.g. restricted abduction) or symptoms of hip problems before 30
Months may require an early X-Ray.

So it is advised that all children with bilateral CP should be x -rayed in a

standardised position at 30 months (2) (appendix 1)

6. HIP RADIOGRAPH (Appendix 1)

6.1 This should be done with a standardised position (Scrutton, Baird 1997) to allow
measurements to be repeatable and valid for accurate measure of hip migration
percentage over time.

6.2 If the migration index is more than 30% immediate referral to orthopaedic
surgeon.

6.3 If migration index over 15 % needs x-rays at 6-12 months up to age 7 years to
plot changes and enables early referral to orthopaedic surgeon.

6.4 If no changes or less 15% at 30 months then for alternate year x-ray until 7 years.

Jane Williams Page 7 December 2013

 7.1 Flow Chart Hip Surveillance Programme
NUH NHS Trust and Notts Community Teaching PCT

Child
(BILATERAL CEREBRAL PALSY
OR SIMILAR DIAGNOSIS)

First x ray 30 months

unless clinical problems before

MEASURE HIP MIGRATION PERCENTAGE

>30% 15-30% <15%

6-12 monthly Hip X ray X Ray alternate years

Refer Orthopaedic Opinion
Consider Botulinum Toxin Until age 7

If >15% If <15%

Jane Williams Page 8 December 2013

 Appendix 1 (5)

Jane Williams Page 9 December 2013

REFERENCES
1. Repeatability and Limits of Agreement in Measurement of Hip Migration Percentage in
Children with Bilateral Cerebral Palsy. Pountney, Green, Bard. Physiotherapy May 2003,
vol89, no 5

2. Hip Dysplasia in Bilateral Cerebral Palsy. Scrutton, Baird. Dev.Med. &Child Neurology
2001, 43:586-600

3. Consensus statement on hip surveillance for children with cerebral palsy: Australian
standards of care. Wynter, Gibson et al 2008

4. To Assess the Effectiveness of Postural Management Programmes in Reducing Hip

Dislocation in Children with Bilateral Cerebral Palsy. Pountney, Mandy, Green, Barton 1998-
2005

5. Does Botulinum Toxin A Combined with Bracing Prevent Hip Displacement in Children

With Cerebral Palsy and "Hips at Risk"? Kerr Graham et al. The Journal of bone and
Joint surgery 2008: 90: 23-33

6. Surveillance Measures of the Hips of Children with Bilateral Cerebral Palsy. Scrutton,
Baird. Archives of Disease in Childhood, 1997, vol 56, no 4, p 381-384

7. The Anatomy of the Dysplastic Hip in Cerebral Palsy related to Prognosis and Treatment.
Vidal, Deuillaume. International Orthopaedics, and 1985, 9:105-110

Jane Williams Page 10 December 2013