CDH Congenital Dislocation of the Hip

By Musa khan final year mbbs

Peshawar medical college

CDH

Definition
A progressive deformation of previously normally formed structures during the embryonic period
NOT A malformation arising during the period of organogenesis

CDH Nomenclature
CDH Congenital Dislocation of the Hip DDH Developmental Dysplasia of the Hip CDH Congenital Dysplasia of the Hip CHD Congenital Heart Disease !

CDH Spectrum
Teratologic Hip : Fixed dislocation Occurrs prenatally Often with other anomalies Dislocated Hip : Completely out May or may not be reducible Subluxated Hip : Only partially Unstable Hip : Femoral head can be dislocated

Acetabular Dysplasia : Shallow Acetabulu Head Subluxated or in place

CDH Incidence
Hip Instability at Birth : 0.5 1 % of infants Classic CDH Mild Dysplasia : 0.1 % of infants : Substantial

Contributing to adult Osteoarthritis

Up to 50 % of Hip Arthritis in Ladies

Have underlying hip dysplasia

CDH

Incidence
Area Canadian Indians Hungary Uppsala, Sweden USA Caucaseans Blacks Malmo, Sweden Chinese, Hong Kong Bantus, Africa Incidence per 1000 188.5 28.7 20 15.5 4.9 2.18 0.1 0.0 among (16678)

CDH

Etiology

Multi-factorial

CDH

Etiology
Physiologic Factors Ligament Laxity : Hormonal : ( Estrogen, Relaxin) Females Familial hyper laxity : mild - moderate - Ehler Danlos

ADD Picture of knee hyperextension

CDH

Etiology

Genetic Factors
Gender : Female
Most studies: shows that females are more commonly affected.

Twin studies:
Monozygotic 38 % Dizygotic 3 % (similar to siblings)

CDH

Etiology
Mechanical Factors Prenatal : - Breech position - Oligohydramnious - Primigravida - Cong. Knee recurvatum/dislocation - Metatarsus adductus - Torticollis
Postnatal : - Swaddling / Strapping Knees extended

CDH

Etiology
Mechanical Factors
Breech Presentation : Normally 2 4 % CDH 16 % The Breech position In Utero Extended knees and flexed hips

CDH

Etiology
Environmental & Mechanical Factors Swaddling / strapping ( Mihad ):
Knees extended & Hips adducted Proven experimentally Proven statistically
American Indians. Eskimos, and Saudi Arabia

Mechanics
Hip adduction and extension

CDH

Patients At Risk
Positive Family History : increases risk 10X A baby girl : increases risk 4-6 times Breech Presentation : increases risk 5-10 X Torticollis : CDH in 10-20 % cases Foot Deformities : ( calcaneovalgus & metatarsus adductus) signs of intrauterine crowding Knee Deformities : ( hyperextension & dislocation ) associated with Teratologic type

CDH

Risk Factors When Risk Factors Are Present

The infant should be examined repeatedly The hip should be imaged ( by U/S or X-ray )

CDH Neonatal Examination

The infant should be quiet and comfortable

CDH Neonatal Examination

LOOK :

External rotation attitude Lateralized contour Wide perineum ( in bilateral )

CDH Neonatal Examination

posterior anterior

LOOK : Asymmetric thigh folds

CDH Clinical Examination

Look : Shortening ( not in neonates )
- in supine - Galeazzy sign

CDH Neonatal Examination

FEEL : Empty groin Weak Femoral pulse

CDH Neonatal Examination

MOVE : Hip instability in early infancy Limited hip abduction in flexion - later (careful in bilateral) if <600 on both sides: request imaging

Cerebral palsy

Clinical Assessment Hip Flexion Deformity

SPECIAL : Loss of fixed flexion deformity of hips ( early infancy ) Normally FFD newborn 28o at 6 weeks 19o at 6 months 7o
Thomas Test

FFD Normal

No FFD ?CDH

CDH

Neonatal Examination

Ortolani

Feel a Clunk
Not hear a click !

CDH

Neonatal Examination

Barlow

CDH

Neonatal Examination Ortolani / Barlow

clunk

Ortolani

Barlow

CDH

Neonatal Examination Ortolani / Barlow

Ortolani

Barlow

CDH

Neonatal Examination Hamstring Stretch Sign

Flex hip and knee 900 each. Keep hip flexed and gradually extend the knee Normally a resistance is felt towards the end of knee extension
(caused by the hamstrings which are pulled from both ends)

In cases of CDH, no resistance is felt

(when the hip is dislocated, the origin of the hamstrings are not pulled by hip flexion)

CDH

Neonatal Examination Hamstring Stretch Sign

CDH Clinical Examination

Neonate (up to 2-3 months) : - Instability/ Ortolani-Barlow - Thomas test Infant ( > 2-3 months) : - Limited abduction - Shortening ( Galeazzi ) - Hamstring stretch sign - Limited abduction - Shortening ( Galeazzi ) - Hamstring stretch sign - Trendelenburgh - Hamstring stretch sign

Toddler :

Walking :

CDH Clinical Examination

CDH Clinical Examination

CDH

Clinical Examination The Walking Child

Trendelenburgh: unilateral / bilateral (waddling)

CDH Screening Program

Clinical screening proven to be effective Performed by Trained personnel Must be DYNAMIC with periodic examination till walking Adjunctive use of U/S controversial

CDH Ultrasound Screening

Incidence of hip instability declines rapidly to 50 % within the first week of neonatal life Better to delay U/S screening

CDH Ultrasound Screening

Early U/S screening not recommended Delayed U/S screening : - Older than 6 weeks - Those at risk only - by History Clinical exam

CDH

Ultrasound Referral
If hip normal If suspicious : no need

If hip clearly unstable : no need

: U/S appropriate

If at risk factors

: U/S appropriate

CDH Ultrasound
Too sensitive detects a lot of hip anomalies most of which would develop normally Operator dependant Static Vs Dynamic

CDH

Radiography
Early infancy : not reliable By 2-3 months of age : reliable AP view - neutral position - draw reference lines - acetabular index - in early infancy < 30o : normal 30o 40o : questionable > 40o : abnormal Von Rosen view : 45o abduction

CDH Radiography

CDH Radiography

CDH Radiography

CDH Radiography
in out

in

out

Von Rosen view

CDH Radiography

27o

39o

CDH Radiography

in

out

CDH

Treatment

Aims
Obtain and Maintain concentric reduction In an Atruamatic fashion Without disrupting the blood supply

CDH

Treatment
Method depends on Age
The earlier started, the easier the treatment The earlier started, the better the results Should be detected EARLY

CDH

Treatment
Birth to 6 months : Pavlik harness or hip spica cast 6 months 12 months : closed reduction UGA and hip spica casts 12 months 18 months : possible closed / possible open reduction Above 18 months : open reduction and ? Acetabuloplasty Above 2 years : open reduction,acetabulplasty, and femoral osteotomy Above 8 years : open reduction,acetabulplasty cutting three bones, and femoral osteotomy

CDH

Treatment Hip instability in the neonatal period Most resolve spontaneously

Observation Pavlik harness Double /triple diapers ??

CDH

Treatment

Hip instability in the neonatal period Double / Triple Diapers

Often inadequate : therefore inappropriate Gives illusion patient is in treatment while wasting valuable time Most hip instability improves spontaneously in early infancy , giving this ineffective management credit

CDH

Treatment

Birth 6 months
Hip instability (dislocatable) Established dislocation (reducible) Should be actively treated until hip is normal clinically and radiographically Pavlik harness Hip Spica Cast

CDH

Treatment

Birth 6 months Pavlik harness

CDH

Treatment

Birth 6 months

Other Devices
- Frejka pillow - Craig - Von Rosen splint

Soft abduction splints:

Not good enough

Rigid abduction splints: Risk AVN

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Treatment

6 12 months
Initially non operative closed reduction Reduction under anesthesia and immobilization in hip spica cast Position:
Human Avoid severe abduction Avoid Frog position

Must be stable and concentrically reduced otherwise needs open reduction

Better Picture

CDH

Treatment

12 18 months
Possibly closed reduction !! when hip stable and concentrically reduced Probably open reduction when hip unstable or not concentrically reduced Arthrography guided:

CDH

Treatment

Arthrography Closed Reduction

Too lateralized

Acceptable

CDH

Treatment

Above 18 months
Open reduction ? and acetabulplasty ? And femoral shortening if high

CDH

Treatment

Above 3 years
Open reduction

And acetabulplasty
And femoral shortening

Redirectional Acetabuloplasty

Salters

Add Picture with K wires

Pembertons

Need for a lot of improvement in cover

Triple Steel

CDH

When Not to Treat ?!

Bilateral High Posterior Dislocation

good function not painful

CDH

When Not to Treat !

Painful stiff left hip

Painful stiff right hip in adduction

CDH

When Not to Treat !

Painful right hip & ankylosed left hip

CDH

Summary
Complex multi-factorial, endemic treatable. Drs awareness and health education. Screening programs are needed. Learning proper examination methods. Identify at-risk groups.
repeat examination & imaging.

Efficient referral system. Proper management in referral centers.