CDH

Congenital Dislocation of the

Hip
 CDH
• The most common disorder affecting the hip in
children

• Spectrum of diseases/abnormalities of the hip with

different etiologies, pathologies, and natural
histories affecting the proximal femur and
acetabulum

• Initial pathology is congenital, progresses if untreated.

• Does not always result in dislocation.
 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 in

• 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 : 0.1 % of infants
• Mild Dysplasia : Substantial
Contributing to adult Osteoarthritis
Up to 50 % of Hip Arthritis in Ladies
Have underlying hip dysplasia
 CDH
Incidence
Area Incidence per 1000
Canadian Indians 188.5
Hungary 28.7
Uppsala, Sweden 20
USA Caucaseans 15.5
Blacks 4.9
Malmo, Sweden 2.18
Chinese, Hong Kong 0.1
Bantus, Africa 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:
Females > 4-6 X than males
• Twin studies:
Monozygotic 38 %
Dizygotic 3 % (similar to siblings)
 CDH
Etiology
Family Incidence and Genetic Counselling
Affected At risk Risk
One sibling Siblings 1 in 17
One parent Children 1 in 8
One parent, one sibling Children 1 in 3

2nd degree relative Nieces, nephews 1 in 100

 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
anterior
posterior

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
Thomas Test
SPECIAL :
• Loss of fixed flexion
FFD
deformity of hips Normal
( early infancy )
• Normally FFD
newborn 28o
No FFD
at 6 weeks 19o ?CDH
at 6 months 7o
 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

• Toddler : - Limited abduction

- Shortening ( Galeazzi )
- Hamstring stretch sign

• Walking : - Trendelenburgh
- Hamstring stretch sign
 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 : no need

• If hip clearly unstable : no need
• If suspicious : 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

out
in
 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
 CDH
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
Salter’s

Add Picture with K wires

 Pemberton’s

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 !
‫الدواء الداء‬
ِ ِ ‫وخير من بعض‬
ٌ

Painful stiff left hip Painful stiff right hip in adduction

 CDH
When Not to Treat !
‫الدواء الداء‬
ِ ِ ‫وخير من بعض‬
ٌ

Painful right hip & ankylosed left hip

 CDH

Summary
• Complex multi-factorial, endemic– treatable.
• Dr’s 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.