2. • CDH is old term
• Congenital means: condition existed at birth
• DDH is more representative of the wide range of
abnormalities seen in this condition
• embryonic, fetal, and infantile periods
• It includes congenital and those that are
developmental, incorporating subluxation,
dislocation, and dysplasia of the hip
3. • In the newborn, the term dysplasia refers to
any hip with a positive Ortolani sign
• Dysplasia has anatomical and radiological
definition.
Anteroposterior view at 15 years of age. Note
the bilateral anatomic dysplasia. The right hip
is radiographically dysplastic, and the left hip is
radiographically subluxated
4. • A cleft develops in the precartilaginous cells at
about the 7th week of gestation. This cleft
defines the acetabulum and the femoral head.
By the 11th week of intrauterine life, the hip
joint is fully formed
• Theoretically, the 11th week is the earliest
time at which a dislocation could develop,
although this rarely happens
5. • In normal hip at birth, the femoral head is
deeply seated in the acetabulum and held
within the confines of the acetabulum by the
surface tension of the synovial fluid
• It is extremely difficult to dislocate a normal
infant's hip, even after incising the hip joint
capsule
6.
7. • acetabular cartilage complex is a three-
dimensional structure that is triradiate
medially and cup-shaped laterally
8. w
• triradiate cartilage is a triphalangic structure. Each phalangis is composed of very cellular
hyaline cartilage
• labrum, or fibrocartilaginous edge of the acetabulum, is at the margin of the
acetabular cartilage. The hip joint capsule inserts just above the labrum
• capsule insertion is continuous with the labrum below, and with the periosteum of
the pelvic bones above
9. • In the infant the entire proximal end of
the femur is composed of cartilage
• Between the 4th and 7th months of
life, the proximal femoral ossification
center appears
• three main growth areas in the
proximal femur are the physeal plate,
the growth plate of the greater
trochanter and the femoral neck
isthmus
10.
11. • growth of the proximal femur is affected by
muscle pull, the forces transmitted across the
hip joint by weightbearing, normal joint
nutrition, circulation, and muscle tone
12. • Experimental studies and clinical findings in
humans with unreduced dislocations suggest
that the main stimulus for the concave shape
of the acetabulum is the presence of a
spherical femoral head
• Growth of the acetabular cartilage occurs by
means of interstitial growth within the
cartilage and appositional growth under the
perichondrium
13. Pathoanatomy
• tight fit between the femoral head and the
acetabulum is lost. The femoral head can be
made to glide in and out of the acetabulum
• DDH in the newborn refers to a spectrum of
anatomic abnormalities, from mild dysplastic
changes to the severe
14. • most common pathologic change in the
newborn with DDH is a hypertrophied ridge of
acetabular cartilage in the superior, posterior,
and inferior aspects of the acetabulum.
• This ridge was referred to by Ortolani as the
neolimbus
• neolimbus is composed of hypertrophied
acetabular cartilage
15. • There is empiric evidence that the pathologic
changes are reversible in the typical newborn
with DDH, because there is a 95% success rate
of treatment using simple devices such as the
Pavlik harness
16. Right acetabular cavity and femoral head of a newborn baby with bilateral
congenital hip dysplasia. There is an acetabular bulge (B) or neolimbus along the
upper acetabular cartilage, and the acetabular cavity is small. B: Frontal section
of the same hip. The femoral head is very large in relation to the acetabular
cavity. Note how the labrum is everted and adheres to the joint capsule above.
The neolimbus (B) is composed of hypertrophied acetabular cartilage.
17. Causes
• incidence of DDH as high as 25 to 50 in 1000
live births among Lapps and Native Americans
• very low rate among the southern Chinese
population and persons of African descent
• positive family history for DDH may be found
in 12% to 33%
– tenfold increase among the parents and a sevenfold increase
among siblings
18. • Intrauterine mechanical factors, such as
breech position or oligohydramnios, and
neuromuscular mechanisms such as
myelomeningocele
• first-born child (primigravida)
• high rate of association of DDH with other
intrauterine molding abnormalities, such as
torticollis and metatarsus adductus (crowding
theory)
19. • left hip
• more common among girls
• breech presentation
• Twice as many girls as boys are born breech
• Fifty-nine percent of breech presentations are
first-born children
• postnatal environment (swaddling)
20.
21. Diagnosis
• Neonates screening (ortolani)
• High-pitched soft tissue clicks are often elicited in
the hip examination of newborns. These clicks are
usually transmitted from the trochanteric region
or the knee and have no diagnostic significance
• This led to overdiagnosis
• If only “clicks” wait for one month prior to doing
an u/s as normal infant laxity with subluxation
mostly resolves.
22. • Some physicians make treatment decisions on
the basis of whether they feel that the hip is
Ortolani-positive rather than Barlow-positive, the
general opinion being that the Barlow-positive
hip is more stable and hence may stabilize
spontaneously
• Newborn clinical screening programs estimate
that 1 of every 100 newborns examined has
evidence of some hip instability (i.e., positive
Ortolani or Barlow sign), although the incidence
of true dislocation is reported to be between 1
and 1.5 cases per 1000 live births
23. • Complete irreducible dislocations are
extremely rare in newborns and are usually
associated with other generalized conditions,
such as arthrogryposis, myelodysplasia, and
other syndromes. These perinatal teratologic
dislocations are at the extreme end of the
DDH pathologic spectrum and account for
only 2%
24. Late Diagnosis
• most reliable physical finding in late-diagnosed
DDH is limitation of abduction
• opposite hip held in maximal abduction to lock
the pelvis
• Apparent femoral shortening (Galeazzi sign)
• asymmetry of the gluteal, thigh, or labial folds
• limb-length inequality
• In patients with bilateral dislocations, clinical
findings include a waddling gait and
hyperlordosis of the lumbar spine
25. • If DDH goes undetected, normal hip joint growth
and development are impaired. With increasing
age at detection and reduction, and particularly
in children older than 6 months, the obstacles
(intraarticular and extraarticular)
to concentric reduction become increasingly
difficult to overcome by simple treatment
methods such as use of the Pavlik harness, and
closed or open reduction usually must be
performed under general anesthesia
26.
27.
28. intraarticular obstacles to reduction in
late-diagnosed DDH
• ligamentum teres
• transverse acetabular ligament
• constricted anteromedial joint capsule (most
segnificant)
• rarely an inverted and hypertrophied labrum
29. Diagnostic Imaging and Radiography
• clinical examination remains the gold standard
• Ultrasonography
– Morphogenic
– Dynamic
• Its routine use in newborn nurseries has
resulted in overdiagnosis
31. • Some centers advocate the use of
ultrasonography in all Ortolani-positive infants
to assess stability at the completion of
treatment
• An ideal use for ultrasonography is for
monitoring the progress of reduction of a
subluxated or dislocated hip being treated in a
Pavlik harness
• US 7- to 10-day intervals to check the progress
of reduction of the hip and its stability during
Pavlik
32. • Other use of US is monitoring of the hip position
while the patient is in traction before attempting
reduction and evaluating closed reductions in the
operating room
• In the newborn, DDH is not a radiographic
diagnosis; the diagnosis should be made by
clinical evaluation, which may be enhanced by
ultrasonography if the examination results are
questionable
• After the newborn period (4 to 6 weeks of age),
the diagnosis of DDH should be confirmed by
radiography
33. • Because it is difficult to standardize the
radiographic positioning of infants, many
centers use positioning frames
• it is essential to notice changes in the
radiographic measurements over time, and
not to make significant decisions based on a
single radiograph.
• In late ddh (AE, shenton,
tear drop)
• CEA helpful if >5 yrs.
34. normal hip at maturity: note
intact Shenton line, well-
developed and appropriately
shaped teardrop, down-
sloping sourcil, and normal
gothic arch above the sourcil
35. • Because it is not possible to predict the
outcome of unstable hips in newborns, all
newborns with clinical hip instability, as
manifested by a positive Ortolani or Barlow
sign, should be treated
36. Course in adults
• depend of laterality and pewsence of well-
developed false acetabulum
• Worse in false acetabulum
• In unilateral complete dislocations, secondary
problems of limb-length inequality, ipsilateral
knee deformity and pain, scoliosis, and gait
disturbance are common
• Pt with subluxation presented earlier than
completely dislocated
37. Treatment
• treatment goals in DDH are the same,
regardless of the age
• first goal is to obtain reduction and maintain
that reduction to provide an optimal
environment for the development of the
femoral head and acetabulum
38. • acetabulum has the potential for development
for many years after reduction as long as the
reduction is maintained
• femoral head and femoral anteversion can
remodel if the reduction is maintained
• The later the diagnosis of DDH is made, the
less potential
• Triple diapers or abduction diapers have no
place in the treatment of DDH
39. • most commonly used device for the treatment
of DDH in the newborn is the Pavlik harness
• von Rosen splint, Frejka pillow
• before child able to stand in presence of
reducible hip
• Pavlik prevents hip axt. And adduction but
allows further abduction and flexion
• 95% resolve of hip instability if used 6/52 with
full-time basis
40. • After 6/12: 50% failure (difficult to maintain
active crawling Pt)
• failures of treatment result from problems
related to the physician, the device, or the
patient.
41. • Physician factors:
• Inappropriate application
• CIC:
– muscle imbalance, such as those with myelodysplasia or
cerebral palsy
– significant stiffness of the joints, such as children with
arthrogryposis
– excessive ligamentous laxity, as seen in Ehlers-Danlos
syndrome
• Not all pavlik are exactly the same
42. • chest strap, two shoulder straps, and two stirrups
• Each stirrup has an anteromedial flexion strap and a posterolateral
abduction strap
• applied with the child supine
• chest strap is fastened first, allowing enough room for three fingers
• shoulder straps are buckled to maintain the chest strap at the nipple line
• feet are placed in the stirrups one at a time
• hip is placed in flexion (90 to 110 degrees) and fix it by ant. straps
• lateral strap is loosely fastened to limit adduction, not to force
abduction. Excessive abduction to ensure stability is unacceptable
• knees should be 3 to 5 cm apart at full adduction in the harness
43. • US is a useful for documenting relocation of
the Ortolani-positive hip
• Used full time for 6-12/52
• Some recommend 6/52 more after stability is
reached
• Most hips stabelize in days or weeks
• Check every 7-10/7
• adjust straps for infant growth
44. • clinical examination is usually sufficient to check
on the progress at each visit; but if uncertainty is
present, US may be used
• Radiographs are unnecessary
• In a child younger than 6 months who has a
complete dislocation, Pavlik may be used in a
trial of US-monitored reduction
• Put in hyperflexion and abduction and monitor
with US in such case
• F/U 7-10/7
45. • If hip is reduced after 2-3 weeks of Pavlik’s
treatment f/u q 2weeks with serial examination
– Duration of treatment is determined by age of child at
hip stability + 3 months
– Pavlik harness worn full time for ½ the time of treatment
– At ½ mark child is taken out of Pavlik night before visit
– If clinical and radiologic / US assessment during visit
shows stability start weaning harness
46. – First third of remaining treatment period – kid out of
Pavlik for 4 hrs & if stability ok proceed
– Last third of treatment period – kid out of Pavlik for 12
hrs & if stability ok clinically and on x-ray d/c harness
47. • If not reduced by 2-3 weeks change tx – stop Pavlik
• Closed reduction under GA with spica casting if unreducable
or unreliable social situation – AT 3 MONTHS OF AGE
– GA
– If stiff in abduction – adductor tenotomy
– Arthrogram without reduction
– Arthrogram with hip in reduced : 5-7mm medal pooling
– Spica casting in “safe zone”
– CT post-op to confirm reduction
• Open reduction if stable concentric reduction cannot be
achieved by closed methods , usually in teratologic cases.
Wait untill child at least 10 months of age.
48. • Coplications
– Inferior dislocation
– Femoral n. compression (generaly improves after
removal of pavlik)
– Imp. To check quadrecips during visits.
– Brachial pluxes inj.
– Knee subluxation.
– Skin breakdown (mainly in groin)
49. • most disastrous consequence of Pavlik
harness treatment is damage to the
cartilaginous femoral head and the proximal
femoral physeal plate
