DEVELOPMENTAL

DYSPLASIA of the HIP

Muhammad Rizal, dr., SpOT

CDH DDH Klisic (1989)

Definition :
DDH : generic term describing a spectrum of
anatomic abnormalities of the hip, that
may be congenital or develop during
infancy or childhood

DDH : Unstable Hip :

1.
2.
3.

Dislocated Ortolani
test
Subluxated
Barlow test
Dislocatable

Obstetricians
Pediatricians
Family practitioners
Orthopaedists
Nurses
Midwifes

be familiar with
Ortolani & Barlow test

Incidence

USA : (1-2) per 1000 lives birth

: : (6-7) : 1
Left hip > right hip = 80%
1 in 5 cases : bilateral = 20%
Prevalent in certain area
In New York : Caucasian = 15.5 per 1000
Black = 4.9 per 1000
Lapps & North American Indians : (25-50) per 1000
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Incidence
Screening Unstable hips at birth
Barlow :

1 out 60 newborn infants

60% : spontaneous recover in 1st week
88% : recover in 1st two months

Health Dept.in UK :
Hip instability at birth :

20 per 1000 births

80% resolve without Tx
10% persist as subluxated or dysplastic hip
10% dislocated
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Etiology
Multifactorial :
1. Mechanical factor
2. Physiologic factor
3. Postnatal environmental factor

Mechanical factor
a. Fetal movement restriction
prevent limb folding

In 1st borns (60%)

Oligohydramnion
Fetal pelvis is trapped in maternal pelvis

b. Breech presentation (30-50)%

Knees are extended

genu recurvatum
genu dislocation

Breech born :

DDH 10x Vertex (Dunn)

associate deformity (Mercer)

mandibular
torticollis
postural scoliosis
DDH
genu recurvatum
talipes

= 22%
= 20%
= 42%
= 50%
=100%
= 22%

Physiologic factor

Maternal estrogen temporary laxity of

capsule
Estrogen metabolism error
DDH familial
inherited 20%
ethnic

Environmental factor
1st month infant after delivery

hip in flexion & mild abduction (physiologic)

extended :
swaddled DDH 10x greater
upside down in extended limbs

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Pathomechanics

Estrogen capsule (hip joint)

Fall out easily : reduced by Ortolani test
Head in the acetabulum is : maintained
normal hip
If dislocation persist :
soft tissue, bone will change
difficult to reduce

Muscles, acetabulum, head will change

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Recognition and Diagnosis

1. in Newborn & infant
2. in Older child
Condition raising suspicion of DDH :
breech
female
first born
family history
talipes
torticollis
other congenital anomalies (heart, kidney), any
syndrome.
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Newborn and Infant

The exam of the hip should conclude
Normal
Subluxatable
Dislocatable Barlow positive
Dislocated :
a. reducable : Ortolani test position
b. not reducable : teratologic dislocation

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Why is newborn DDH so often missed?

crying baby
tense baby
hungry baby
hurried doctor
inexperienced doctor (tests)
too firm in grip
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Older child
The signs of DDH change with the infants age
Inspection :
Skin fold
Galeazzis sign
Telescoping
Trendelenburgs test
Trendelenburg gait
Bilateral DDH :

perineum widen
hiperlordotic
waddling gait
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Diagnostic Imaging
Radiology
In newborn : seldom reliable (cartilaginous)
Reliable at the age 6 weeks
Arthography
By indication :

unsatisfactory reduction
hip redislocation

Ultrasonography (USG)
Valuable under age 4 months (ossification of
nucleus)
Dynamic study of DDH (similar to Ortolani/Barlow)
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Treatment
Goal
Reduce the head to normal position
Maintained until stable
Avoid avascular necrosis of the head
Correction of residual dysplasia
Delay in diagnostic and problems in management
Residual anatomic defect
Subsequent degenerative arthritis

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Treatment
Hip instability in neonatal period
Barlow
60% : spontaneous recovery in the first week
88% : spontaneous recovery in the first 2
months
Soon after Dx was made : Tx by :
triple diapers
Frejka pillow
Pavlic harness (the best)

Pekeh yes
Bodong no
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Reduction
Method of reduction depends on :
Age of the infant
Severety of DDH
A. Infant age (0-6) MO

Hip instability or established dislocations

Actively Tx until the hip clinically & radiologically normal
initial Tx: brace (Pavlic harness the best)

B. Infant age (6-18) MO

starts nonooperatively
skin traction
manipulation (anaesthesia) + adductor tenotomy
spica cast in safezone position
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Reduction
C. Children age (18-36) MO

Start by traction
Open reduction :
soft tissue release
pelvic osteotomy (acetabular dysplasia)
cast

D. Children age >36 MO

open reduction
+ femoral shortening,
+ derotation osteotomy
+ pelvic osteotomy
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Treatment scheme for DDH

Developmental Dysplasia of the Hip

Under
18
15 months

Over
15 months

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Thank you for your

attention
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