Skip to main content
UploadLanguage (EN)Support
BusinessMobileSocial MediaMarketingTechnologyArt & PhotosCareerDesignEducationPresentations & Public SpeakingGovernment & NonprofitHealthcareInternetLawLeadership & ManagementAutomotiveEngineeringSoftwareRecruiting & HRRetailSalesServicesScienceSmall Business & EntrepreneurshipFoodEnvironmentEconomy & FinanceData & AnalyticsInvestor RelationsSportsSpiritualNews & PoliticsTravelSelf ImprovementReal EstateEntertainment & HumorHealth & MedicineDevices & HardwareLifestyle
Uploaded byBaktaGiri4
PPTX, PDF180 views

developmental dysplasia of the hip or DDH.pptx

Developmental dysplasia of the hip (DDH) is defined as an abnormal relationship between the femoral head and the acetabulum, with risk factors including breech birth positions and varying incidence rates across different racial groups. Diagnosis involves clinical tests such as the Barlow and Ortolani tests, and imaging techniques like ultrasonography and X-rays are utilized for assessment. Treatment primarily involves the use of a Pavlik harness for infants, while older children may require closed or open reduction procedures to ensure proper hip alignment.

Health & Medicine◦
Download to read offline
Developmental Dysplasia of the Hip
DEFINITION  The American Academy of Pediatrics  DDH as a condition in which the femoral head has an abnormal relationship to the acetabulum.  Dislocation  complete displacement of a joint, with no contact between the original articular surfaces.  Subluxation  displacement of a joint with some contact remaining between the articular surfaces.  Dysplasia  deficient development of the acetabulum.
INCIDENCE
RACIAL PREDILECTION  Blacks and Asians  relatively low incidences of DDH (0.1 per 1000 to 5 per 1000)  Whites and Native Americans  higher incidences (15 per 1000).
ETIOLOGY
The breech position, which is associated with developmental dysplasia of the hip (DDH). A, A double breech position is associated with a low incidence of DDH. B, A single footling breech is associated with a 2% risk of DDH. C, A frank breech, especially with the knee(s) extended, is associated with a 20% risk of DDH.
Postnatal positioning in extension, contributes to developmental dysplasia of the hip
PRIMARY ACETABULAR DYSPLASIA  The primary failure of acetabular development has been proposed as a cause of DDH.  Early cadaver studies  acetabulum is shallower at birth than during the earlier fetal period; full coverage does not occur until 3 years of age.  Beals  acetabular dysplasia is inherited  precursor of dislocation.  After birth, the acetabulum becomes deeper throughout childhood, and it eventually covers the head completely.
Torticollis should alert the examiner to the possibility of developmental dysplasia of the hip; up to 15% of infants with torticollis have hip instability. There is an association between metatarsus adductus and developmental dysplasia of the hip, with up to 10% of infants with metatarsus adductus having developmental dysplasia of the hip.
CLINICAL FEATURES
NEONATUS  Barlow sign  the examiner attempts to subluxate or dislocate the femoral head from within the acetabulum  The hip is adducted, and a gentle push is applied to slide the hip posteriorly.  The examiner’s fingers are positioned over the greater trochanter, and the trochanter is allowed to move laterally.  Positive test  the hip will be felt to slide out of the acetabulum  if examiner relaxes the proximal push, the hip can be felt to slip back into the acetabulum.
The Barlow test for developmental dislocation of the hip in a neonate. A, With the infant supine, the examiner holds both of the child’s knees, gently adducts one hip, and pushes posteriorly. B, When the examination is positive, the examiner will feel the femoral head make a small jump (arrow) out of the acetabulum (Barlow sign). When the pressure is released, the head is felt to slip back into place.
NEONATUS  The Ortolani test is the reverse of the Barlow test  the examiner attempts to reduce a dislocated hip  The examiner grasps the child’s thigh between the thumb and the index finger and, with the fourth and fifth fingers, lifts the greater trochanter while simultaneously abducting the hip.  Positive result  the femoral head will slip into the socket with a delicate “clunk” that is palpable but not audible.  The other hip is then examined in the same manner.
The Ortolani test for developmental dislocation of the hip in a neonate. A, The examiner holds the infant’s knees and gently abducts the hip while lifting up on the greater trochanter with two fingers. B, When the test is positive, the dislocated femoral head will fall back into the acetabulum (arrow) with a palpable (but not audible) “clunk” as the hip is abducted (Ortolani sign). When the hip is adducted, the examiner will feel the head redislocate posteriorly.
The Klisic test for developmental dysplasia of the hip. The examiner places the middle finger over the greater trochanter and the index finger on the anterior superior iliac spine. A, with a normal hip, an imaginary line drawn between the two fingers points to the umbilicus. B, when the hip is dislocated, the trochanter is elevated, and the line projects halfway between the umbilicus and the pubis.
INFANT  When the hip is no longer reducible, specific physical findings appear  limited abduction, shortening of the thigh, proximal location of the greater trochanter, asymmetry of the thigh folds, and pistoning of the hip.  The limitation of abduction  the most reliable sign of a dislocated hip
Developmental dysplasia of the right hip. One physical finding is limited abduction of the affected hip.
Galeazzi sign  there is an apparent shortening of the femur as demonstrated by the difference in knee levels as assessed for a child lying on a firm table with the hips and knees flexed at right angles.
With developmental dysplasia of the right hip, there may be asymmetry of the thigh folds, popliteal and gluteal creases, with apparent shortening of the extremity on the right.
WALKING CHILD  The affected side appears to be shorter than the normal extremity  With each step, the pelvis drops as the dislocated hip adducts, and the child leans over the dislocated hip  abductor lurch or Trendelenburg gait  When the child attempts to stand on that foot with the other elevated off of the floor, he or she leans toward the affected side  Trendelenburg sign
Trendelenburg gait The Trendelenburg test is positive on the dislocated right side. A, As the child stands with the weight on the normal side, the pelvis is maintained in the horizontal position by the contraction and tension of the normal hip abductor muscles. B, As the child shifts weight to the side of the dislocated hip, the pelvis on the opposite and normal side drops as a result of the weakness of the hip abductor muscles on the affected side. The sideways lean of the body toward the affected side is known as the Trendelenburg sign.
Bilateral hip dislocation. Note the excessive lordosis that occurs as a result of hip flexion contracture.
RADIOGRAPHIC FINDINGS  Ultrasonography  X-ray  Arthrography  MRI
ULTRASONOGRAPHY  The neonate’s hip is a difficult structure to image with standard radiographic techniques  the hip is composed primarily of cartilage  Graf, who pioneered the use of ultrasonography for the evaluation of the infant hip  Hyaline articular cartilage  little echo  Capsule and muscles  moderate echo  Fibrocartilaginous labrum (as well as the juncture of the femoral neck and the cartilaginous upper femur)  strong echo.  Graf recommended  lateral imaging technique with the transducer placed over the greater  examination should take no more than 2 to 3 minutes.
RADIOGRAPHY  Several classic lines are helpful when evaluating the immature hip  Hilgenreiner line  through the triradiate cartilages.  Perkin line  drawn at the lateral margin of the acetabulum, is perpendicular to the Hilgenreiner line.  Shenton line  curved line that begins at the lesser trochanter, goes up the femoral neck, and connects with a line along the inner margin of the pubis.  In a normal hip :  The medial beak of the femoral metaphysis lies in the lower, inner quadrant  the juncture of the Perkin and Hilgenreiner lines.  The Shenton line is smooth in the normal hip.  In the dislocated hip:  The metaphysis lies lateral to the Perkin line;  The Shenton line is broken  the femoral neck lies cephalic to the line from the pubis.
Radiographic measurements that are useful for evaluating developmental dysplasia of the hip. The Hilgenreiner line is drawn through the triradiate cartilages. The Perkin line is drawn perpendicular to the Hilgenreiner line at the margin of the bony acetabulum. The Shenton line curves along the femoral metaphysis and connects smoothly to the inner margin of the pubis. Dimension H (height) is measured from the top of the ossified femur to the Hilgenreiner line. Dimension D (distance) is measured from the inner border of the teardrop to the center of the upper tip of the ossified femur. Dimensions H and D are measured to quantify proximal and lateral displacement of the hip and are most useful when the head is not ossified.
ARTHROGRAPHY  The arthrographic anatomy of the hip was well described by Severin in 1941.  In the normal hip  the free border of the labrum is easily seen as a sharp “thorn” overlying the femoral head  A recess of joint capsule overlies this thorn  capsule expands beyond this recess and is then constricted by the ring-like zona orbicularis.  In a child with DDH, when the hip dislocated  the acetabular edge is seen, and the capsule is enlarged  The capsule is constricted at its middle portion into an hourglass shape by the iliopsoas tendon.
Anteroposterior arthrogram of a normal hip in a neutral position. Note the sharp lateral acetabular margin (the “thorn”) with a recess of joint capsule overlying it.
 Performed under general anesthesia prefer the median, subadductor approach with image intensification  The needle is inserted just beneath the adductor longus, approximately 2 cm distal to its origin.  If the starting point is too close to the adductor’s origin  needle will encounter the inferior portion of the acetabulum rather than the joint itself.
MRI  MRI affords excellent anatomic visualization of the infant hip, but it is not commonly used because of the expense involved and the need for sedation.  MRI findings : 1. the widening of the iliac bone 2. the lateral drift of the superior and posterior portions of the acetabular floor 3. the overgrowth of the acetabular cartilage 4. the convexity of the posterior portion of the acetabular cartilage
TREATMENT
NEONATUS  The first indication for Pavlik Harness :  Hip dislocated and that can be reduced by the examiner (Ortolani sign).  Immediate Pavlik harness treatment for hips that can be subluxated by the examiner (Barlow sign).  Excessive flexion must be avoided  it will occur if the harness is not properly adjusted as the child grows.  Hyperflexion of the hips  produce a femoral nerve palsy as the nerve becomes compressed by the diapers between the thigh and abdomen.  Hyperflexion cause the femoral head to dislocate inferiorly  Inadequate flexion (i.e., <900 )  fail to reduce the hip
The Pavlik harness. The transverse chest strap should be placed just below the nipple line. The hips should be flexed to 1200 , and the posterior straps should not produce forced abduction.
PLANNING OF TREATMENT  Most infants outgrow the initial harness after 3 to 4 weeks, and a larger harness is then fitted.  After 3 weeks in the harness , progress of the hip can be monitored by repeating the ultrasonographic study  the hip usually remains reduced.  After 6 weeks of treatment, the hip is examined with the child out of the harness, and ultrasonography is performed  USG shows a well-located hip and the clinical examination is negative  harness is discontinued  3 to 4 months old ,a radiograph of the pelvis is obtained  If the hip is normal, seen when he or she is 1 year old, and a standing radiograph is obtained  normal annual or biennial
 If the hip is unstable at 3 weeks  substituted with an abduction orthosis  If the hip is reduced at 3 weeks but dislocates during examination  harness should be worn for 3 to 6 more weeks until the hip stabilizes.  If the hip remains dislocated after 3 to 4 weeks of harness wear  harness should be discontinued  hip should be examined under anesthesia.
YOUNG CHILD (1 TO 6 MONTHS OLD)  The Pavlik harness  first choice of treatment for this age group.  To be effective  the harness must hold the hips in > 900 of flexion, with the position of the upper femoral metaphysis pointed toward the triradiate cartilage.
PLANNING OF TREATMENT  Similar to that for younger infants, but management must be continued until hip stability is assured  The child is examined weekly, and reduction is evaluated by clinical and USG  If reduction is not obtained within 3 to 4 weeks  harness discontinued  other treatment begun.  If reduction is confirmed  harness should be continued for approximately 6 weeks after stability is established.  When harness treatment is completed  place the child in abduction splint for several more months  to encourage acetabular development.
Radiographic appearance in a 7- month-old child after the successful treatment of developmental dysplasia of the hip with a Pavlik harness. The notch (arrow) at the lateral margin of the acetabulum represents ossification beneath the labrum and is often seen after successful early treatment of developmental dysplasia of the hip.
TREATMENT OF THE CHILD (6 MONTHS TO 2 YEARS OLD)  The child who is between 6 months and 2 years old  dislocated hip and the child in whom initial splintage has failed  The goals  to obtain and maintain the reduction of the hip without damaging the femoral head.  The two principal methods of treatment are closed reduction and open reduction  preceded by a period of traction.
TRACTION  Level of the femoral head was determined and traction was continued until the head was below the Hilgenreiner line  spend 3 weeks or more in the hospital  traction not only to stretch the soft tissues around the hip but to reduce the femoral head.  This “traction reduction” method  immobilizing the child in bed and applying gradually increasing skin traction to bring the femoral head below the acetabulum.  The hips are then gradually abducted and internally rotated until the hip is reduced  cast is applied.
Traditional traction position with a frame in the bed and the hips flexed 300 (inset). The Bryant traction position. The child lies in a bed or crib with the hips flexed 90 degrees (inset) and the knees extended.
CLOSED REDUCTION  Closed reduction of the hip  performed with the use of general anesthesia or deep sedation  The hip is reduced  placing it in flexion beyond 900 and gradually abducting it while gently lifting the greater trochanter, as is done during the Ortolani maneuver.  Minimal force should be applied.  After a palpable reduction is felt  the hip is moved to determine the ROM in which it remains reduced.
 The range of motion in which the hip remains reduced is compared with the maximum range of motion  “safe zone” is constructed  If the zone is relatively wide, the reduction is considered stable.  if wide abduction or more than 10 or 150 of internal rotation is required to maintain reduction  the reduction is considered unstable.  At times, an adductor tenotomy will increase the safe zone by allowing for a wider range of abduction.  Wide abduction and excessive internal rotation should avoided  can cause AVN.
Zones of safety A, Wide zone of safety B, Moderate zone of safety C, Narrow zone of safety D, Femoral head dislocates
 If the reduction is stable  immobilized in a spica cast in a safe and stable position.  The cast should maintain the hip in a position:  >900 of flexion and enough abduction to maintain the reduction.  internal rotation may be used, but no more than 10 to 150  never to the limit of internal rotation.  abduction to 30 or 400 acceptable  After 6 weeks of immobilization  the cast is removed under anesthesia  the hip examined for stability  hip putting the hip through a moderate ROM  no effort to dislocate  AP view of pelvis is obtained  if the hip is reduced  new cast is applied again  After 6 weeks, the second cast is also removed  begin abduction splinting after 12 weeks in a cast
OPEN REDUCTION  Indication  a failure to obtain a stable hip with a closed reduction  Medial Approach : Advantage:  Minimal dissection is required  Obstructions to reduction are encountered directly Disadvantage:  Limited view of the hip,  Possible interruption of the medial femoral circumflex artery  Inability to perform a capsulorrhaphy.  Anterior Approach  Better exposure  Allows the surgeon to perform a capsulorrhaphy
 The choice of a medial or anterior approach is also related to  the presence of ligamentous laxity that requires capsulorrhaphy  the patient’s age  surgeon’s training and experience
COMPLICATIONS Avascular Necrosis (AVN) of Femoral Head  AVN diagnosed  femoral head fails to ossify or to grow within 1 year after being reduced  Presence of AVN :  Widening of the femoral neck within 1 year of reduction  changes in the bone density of the femoral head  residual deformity that suggests growth disturbance  AVN occurs  excessive pressure is applied for an extended time to the femoral head  occluding its vascular perfusion.  The most common cause  immobilization in a position that places excessive pressure on the femoral head, such as extreme abduction or internal rotation.  Internal rotation increases pressure on the femoral head  contort the capsular vessels.  AVN may occur when the muscles crossing the hip are so contracted  compress the reduced femoral head against the acetabulum.
THANK YOU