Congenital Deformities

Congenital deformitiesCongenital deformities
LectureLecture

CongenitalCongenital
MuscularMuscular
TorticollisTorticollis

 Congenital muscular torticollis (CMT)Congenital muscular torticollis (CMT)
is caused by fibromatosis within theis caused by fibromatosis within the
sternocleidomastoid muscle. A masssternocleidomastoid muscle. A mass
either is palpable at birth or becomeseither is palpable at birth or becomes
so, usually during the first 2 weeks. It isso, usually during the first 2 weeks. It is
mo-re common on the right side thanmo-re common on the right side than
on the left side. It may involve theon the left side. It may involve the
muscle diffusely, but more often it ismuscle diffusely, but more often it is
localized near the cla-vicularlocalized near the cla-vicular
attachment of the muscleattachment of the muscle

 Various hypotheses of the cause ofVarious hypotheses of the cause of
CMT include malposition of the fetusCMT include malposition of the fetus
in utero, birth trauma, infection, andin utero, birth trauma, infection, and
vascular injuryvascular injury
 CMTCMT holds second place in congenitalholds second place in congenital
deformities in children, average of 5-deformities in children, average of 5-
12%.12%.

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 Any permanent torticollis slowlyAny permanent torticollis slowly
becomes worse during growth.becomes worse during growth.
 The head becomes inclined toward theThe head becomes inclined toward the
affected side and the face toward theaffected side and the face toward the
opposite side.opposite side.
 If the deformity is severe, theIf the deformity is severe, the
ipsilateral shoulder becomes elevated,ipsilateral shoulder becomes elevated,

conservative treatmentconservative treatment
 conservative treatmentconservative treatment is indicatedis indicated
during infancy. The parents should beduring infancy. The parents should be
instructed to stretch the sternocleido-instructed to stretch the sternocleido-
mastoid muscle by manipulating themastoid muscle by manipulating the
child's head manually.child's head manually.

Congenital Muscular TorticollisCongenital Muscular Torticollis
 did not resolve spontaneously if itdid not resolve spontaneously if it
persisted beyond the age of 1 yearpersisted beyond the age of 1 year
 exercise program is more likely to beexercise program is more likely to be
successful if the restriction of motion issuccessful if the restriction of motion is
less than 30 degrees and there is noless than 30 degrees and there is no
facial asymmetryfacial asymmetry
 Nonoperative therapy after the age of 1Nonoperative therapy after the age of 1
year is rarely successfulyear is rarely successful..

 severe deformity could and shouldsevere deformity could and should
be prevented by surgery duringbe prevented by surgery during
early childhood.early childhood.
 Surgery performed before the ageSurgery performed before the age
of 6 to 8 years may allowof 6 to 8 years may allow
remodeling of any facial asymmetryremodeling of any facial asymmetry
and plagiocephaly.and plagiocephaly.
 Usual Surgery performed in ageUsual Surgery performed in age
after 2 yearsafter 2 years

 Оpen tenotomy of theОpen tenotomy of the
sternocleidomastoidsternocleidomastoid
muscle could be followedmuscle could be followed
by tethering of the scar toby tethering of the scar to
the deep structures, re-the deep structures, re-
attachment of the clavi-attachment of the clavi-
cular head or the sternalcular head or the sternal
head of the sternocleido-head of the sternocleido-
mastoid muscle,mastoid muscle,

 clamp SCM muscleclamp SCM muscle
and resect 2.5 cm ofand resect 2.5 cm of
their inferior ends.their inferior ends.

SSurgical correction in children with severeurgical correction in children with severe
deformity operation usually requires a bipo-deformity operation usually requires a bipo-
lar release of the sternocleidomastoid muscle.lar release of the sternocleidomastoid muscle.
 A,A, Skin incisionsSkin incisions.. B,B,
mastoid attach-mentmastoid attach-ment
of SCM mus-cle isof SCM mus-cle is
cut, and Z-plasty iscut, and Z-plasty is
performed onperformed on
sternal origin.sternal origin.
 C - CompletedC - Completed
operation;operation;

Postoperative periodPostoperative period
 Physical therapy, consisting of stretching,Physical therapy, consisting of stretching,
muscle strengthening, and active range-of-muscle strengthening, and active range-of-
motion exercises, is instituted in the earlymotion exercises, is instituted in the early
postoperative period. Head-halter tractionpostoperative period. Head-halter traction
or a cervical collar also can be used duringor a cervical collar also can be used during
the first 6 to 12 weeks after surgerythe first 6 to 12 weeks after surgery

Postoperative periodPostoperative period
 The use of plaster casts or braces usually isThe use of plaster casts or braces usually is
unnecessaryunnecessary
 At 1 week physical therapy, includingAt 1 week physical therapy, including
manual stretching of the neck to maintainmanual stretching of the neck to maintain
the overcorrected position, is begun.the overcorrected position, is begun.
Manual stretching should be continuedManual stretching should be continued
three times daily for 3 to 6 months;three times daily for 3 to 6 months;

Congenital Elevation ofCongenital Elevation of
ScapulaScapula
(Sprengel Deformity)(Sprengel Deformity)

Clinical manifestationClinical manifestation
• The scapula lies moreThe scapula lies more
superiorly than it shouldsuperiorly than it should
in relation to the thoracicin relation to the thoracic
cage and usually is hypo-cage and usually is hypo-
plastic and misshapenplastic and misshapen..

• Other congenital anomalies may beOther congenital anomalies may be
present such as cervical ribs,present such as cervical ribs,
malformations of ribs, andmalformations of ribs, and
anomalies of the cervical vertebraeanomalies of the cervical vertebrae
(Klippel-Feil syndrome);(Klippel-Feil syndrome);

• if the deformity isif the deformity is
severe, the scapula issevere, the scapula is
very small and can bevery small and can be
so elevated that itso elevated that it
almost touches thealmost touches the
occiput.occiput.

• The patient's head often is deviatedThe patient's head often is deviated
toward the affected side. Sometimes antoward the affected side. Sometimes an
extra ossicle is present;extra ossicle is present;
this is a rhomboidal pla-this is a rhomboidal pla-
que of cartilage andque of cartilage and
bone that extends frombone that extends from
the superior angle ofthe superior angle of
the scapula to the spi-the scapula to the spi-
nous process.nous process.

Operative treatmentOperative treatment
• If deformity and impairment are mild,If deformity and impairment are mild,
no treatment is indicated;no treatment is indicated;
• if they are more severe, surgery may beif they are more severe, surgery may be
indicatedindicated
• An operation to bring the scapulaAn operation to bring the scapula
inferiorly to near its normal positioninferiorly to near its normal position
can be attempted after the child iscan be attempted after the child is
about 3 years old.about 3 years old.

• The earlier surgery is performedThe earlier surgery is performed
after 3 years of age, the better theafter 3 years of age, the better the
results, because the operationresults, because the operation
becomes more difficult as the childbecomes more difficult as the child
grows.grows.
• In older children an attempt toIn older children an attempt to
bring the scapula inferiorly to itsbring the scapula inferiorly to its
normal level can injure the brachialnormal level can injure the brachial
plexus.plexus.

• Some surgical techniques are commonlySome surgical techniques are commonly
usedused
• Surgical release of muscles from the scapulaSurgical release of muscles from the scapula
along with excision of the supraspinatusalong with excision of the supraspinatus
portion of the scapula and any omoverteb-portion of the scapula and any omoverteb-
ral bone.ral bone.
• The scapula is then moved inferiorly to aThe scapula is then moved inferiorly to a
more normal position and the muscles aremore normal position and the muscles are
reattachedreattached

Skin has been incised in midline. Origins ofSkin has been incised in midline. Origins of
trapezius and of rhomboideus major andtrapezius and of rhomboideus major and
minor have been freed from spinous proces-minor have been freed from spinous proces-
ses, and have been retracted laterally. Anyses, and have been retracted laterally. Any
omovertebral bone, is to be excised.omovertebral bone, is to be excised.

Scapula and attached sheet of muscles haveScapula and attached sheet of muscles have
been displaced inferiorly, and aponeuroses ofbeen displaced inferiorly, and aponeuroses of
trapezius and rhomboids have beentrapezius and rhomboids have been
reattached to spinous processes at morereattached to spinous processes at more
inferior level. D - free upper and below edgesinferior level. D - free upper and below edges
have been overlapped and sutured in place.have been overlapped and sutured in place.

• State and functionState and function
after operativeafter operative
treatmenttreatment

Congenital Anomalies of
Lower Extremities

Congenital ClubfootCongenital Clubfoot
(Talipes Equinovarus)(Talipes Equinovarus)

Congenital Clubfoot (TalipesCongenital Clubfoot (Talipes
Equinovarus)Equinovarus) The incidence of con-The incidence of con-
genital clubfoot is approximately 1 ingenital clubfoot is approximately 1 in
every 1000 live births.every 1000 live births.
Bilateral deformities occur in 50%Bilateral deformities occur in 50%
of patients.of patients.

EtiologyEtiology
 Several theories have been proposedSeveral theories have been proposed
regarding the cause of clubfoot. One isregarding the cause of clubfoot. One is
that a primary germ plasm defect inthat a primary germ plasm defect in
the talus causes continued plantarthe talus causes continued plantar
flexion and inversion of this bone, withflexion and inversion of this bone, with
subsequent soft tissue changes in thesubsequent soft tissue changes in the
joints and musculotendinousjoints and musculotendinous
complexes.complexes.

EtiologyEtiology
 Another theory is that primary softAnother theory is that primary soft
tissue abnormalities within thetissue abnormalities within the
neuromuscular units cause secondaryneuromuscular units cause secondary
bony changes. Clinically, children withbony changes. Clinically, children with
clubfoot have a hypotrophic anteriorclubfoot have a hypotrophic anterior
tibial artery in addition to the obvioustibial artery in addition to the obvious
atrophy of the musculature about theatrophy of the musculature about the
calfcalf

 The three basic components of club-The three basic components of club-
foot are equinus, varus, and adductionfoot are equinus, varus, and adduction
deformities. However, the deformitydeformities. However, the deformity
varies in severity; and the conditionvaries in severity; and the condition
may be much less severe, with the footmay be much less severe, with the foot
being in only a mild equinus and varusbeing in only a mild equinus and varus
positionposition

Late clinical manifestationLate clinical manifestation
 Clubfoot is accompanied by internalClubfoot is accompanied by internal
tibial torsion. The ankle, midtarsal, andtibial torsion. The ankle, midtarsal, and
subtalar joints all are involved in thesubtalar joints all are involved in the
pathological process.pathological process.
 If the clubfoot is allowed to remainIf the clubfoot is allowed to remain
deformed, many other late adaptivedeformed, many other late adaptive
changes occur in the bones.changes occur in the bones.

Врожденная косолапостьВрожденная косолапость

Late clinical manifestationLate clinical manifestation
 These changes depend on the severityThese changes depend on the severity
of the soft tissue contractures and theof the soft tissue contractures and the
effects of walking. In untreated adults,effects of walking. In untreated adults,
some of the joints may spontaneouslysome of the joints may spontaneously
fuse, or they may develop degenerativefuse, or they may develop degenerative
changes secondary to the contractures.changes secondary to the contractures.

NONOPERATIVENONOPERATIVE
TREATMENTTREATMENT
 The initial treatment of clubfoot is nonope-The initial treatment of clubfoot is nonope-
rative. Various treatment regimens haverative. Various treatment regimens have
been proposed, including the use of correc-been proposed, including the use of correc-
tive splinting, taping, and casting.tive splinting, taping, and casting.
Treatment consists of weekly serialTreatment consists of weekly serial
manipulation and casting during the first 6manipulation and casting during the first 6
weeks of life, followed by manipulation andweeks of life, followed by manipulation and
casting every other week until the foot iscasting every other week until the foot is
clinically and roentgenographicallyclinically and roentgenographically
correctedcorrected

Congenital club footCongenital club foot
- Treatment of club foot by staging elastic- Treatment of club foot by staging elastic
dressing.dressing.
- by staging plaster casts- by staging plaster casts
- Orthopaedic shoes- Orthopaedic shoes

NONOPERATIVENONOPERATIVE
TREATMENTTREATMENT
 The order of correction by serialThe order of correction by serial
manipulation and casting should be asmanipulation and casting should be as
follows: first, correction of forefootfollows: first, correction of forefoot
adduction; next, correction of heel varus;adduction; next, correction of heel varus;
and finally, correction of hindfoot equinus.and finally, correction of hindfoot equinus.
Correction should be pursued in this orderCorrection should be pursued in this order
so that a rocker-bottom deformity will beso that a rocker-bottom deformity will be
prevented by dorsiflexing the foot throughprevented by dorsiflexing the foot through
the hindfoot rather than the midfoot.the hindfoot rather than the midfoot.

NONOPERATIVE TREATMENTNONOPERATIVE TREATMENT
 If the clubfoot is corrected by the time theIf the clubfoot is corrected by the time the
child is 6 months of age, this should bechild is 6 months of age, this should be
documented by both the clinicaldocumented by both the clinical
appearance and repeated anteroposteriorappearance and repeated anteroposterior
and dorsiflexion lateral stressand dorsiflexion lateral stress
roentgenograms. The foot can be placed inroentgenograms. The foot can be placed in
an ankle-foot orthosis that can be usedan ankle-foot orthosis that can be used
part-time on children with compliantpart-time on children with compliant
families.families.

OPERATIVE TREATMENTOPERATIVE TREATMENT
 The more rigid the initial deformity,The more rigid the initial deformity,
noncorrectedinitial deformity thenoncorrectedinitial deformity the
more likely that surgical treatmentmore likely that surgical treatment
will be requiredwill be required

 Surgery in clubfoot is indicated forSurgery in clubfoot is indicated for
deformities thatdeformities that do not respond to con-do not respond to con-
servative treatmentservative treatment by serial manipu-by serial manipu-
lation and casting.lation and casting.
Surgery in the treatment of clubfootSurgery in the treatment of clubfoot
must bemust be tailored to the age of the childtailored to the age of the child
and toand to the deformity to be corrected.the deformity to be corrected.

club footclub foot -- Operative treatmentOperative treatment
elongation ofelongation of elongationelongation
- incisions- incisions tendones of heel tendon,tendones of heel tendon,
capsulotomycapsulotomy

 Triple arthrodesis andTriple arthrodesis and
talectomy generally are salvagetalectomy generally are salvage
operations for uncorrectedoperations for uncorrected
clubfoot in older children andclubfoot in older children and
adolescentsadolescents

Triple arthrodesis and talectomy generallyTriple arthrodesis and talectomy generally
are salvage operations for uncorrectedare salvage operations for uncorrected
clubfoot in older children and adolescentsclubfoot in older children and adolescents
- Area between- Area between
broken lines repre-broken lines repre-
sents amount ofsents amount of
bonebone
removed from mid-removed from mid-
tarsal region andtarsal region and
subtalar joint in mo-subtalar joint in mo-
derate fixed defor-derate fixed defor-

Congenital and DevelopmentalCongenital and Developmental
Dysplasia of Hip (DDH)Dysplasia of Hip (DDH)
oror
Congenital dislocation of HipCongenital dislocation of Hip
(DDH)(DDH)

 Congenital dysplasia of the hip generallyCongenital dysplasia of the hip generally
includes subluxation (partial dislocation)includes subluxation (partial dislocation)
of the Congenital Anomalies femoralof the Congenital Anomalies femoral
head, acetabular dysplasia, and completehead, acetabular dysplasia, and complete
dislocation of the femoral head from thedislocation of the femoral head from the
true acetabulum.true acetabulum.
 The incidence of congenital dysplasia ofThe incidence of congenital dysplasia of
the hip has been estimated to bethe hip has been estimated to be
approximately 1 in 1000 live birthsapproximately 1 in 1000 live births

EtiologyEtiology
 Several theories regarding the cause ofSeveral theories regarding the cause of
congenital dysplasia of the hip havecongenital dysplasia of the hip have
been proposed, including mechanicalbeen proposed, including mechanical
factors, hormone-induced joint laxity,factors, hormone-induced joint laxity,
primary acetabular dysplasia, andprimary acetabular dysplasia, and
genetic inheritance. Breech delivery,genetic inheritance. Breech delivery,
with the mechanical forces of abnormalwith the mechanical forces of abnormal
flexion of the hips, can easily be seen asflexion of the hips, can easily be seen as
a cause of dislocation of the femorala cause of dislocation of the femoral
head.head.

 An increased incidence of congenitalAn increased incidence of congenital
dysplasia of the hip has been reporteddysplasia of the hip has been reported
in cultures that place infants inin cultures that place infants in
swaddling clothes with the hip inswaddling clothes with the hip in
constant extension.constant extension.
 And decreased incidence of congenitalAnd decreased incidence of congenital
dysplasia has been reported indysplasia has been reported in
cultures that place infants with the hipcultures that place infants with the hip
in constant abduction (African people)in constant abduction (African people)

 In a newborn with true congenitalIn a newborn with true congenital
dislocation of the hip the femoral headdislocation of the hip the femoral head
can be dislocated and reduced into andcan be dislocated and reduced into and
out of the true acetabulum.out of the true acetabulum.
 In an older child the femoral headIn an older child the femoral head
remains dislocated and secondaryremains dislocated and secondary
changes develop in the femoral headchanges develop in the femoral head
and acetabulumand acetabulum

clinical presentationclinical presentation
 The clinical presentation of congenitalThe clinical presentation of congenital
dysplasia of the hip varies according to thedysplasia of the hip varies according to the
age of the child.age of the child.
 In newborns (up to 6 months of age) it isIn newborns (up to 6 months of age) it is
especially important to perform a carefulespecially important to perform a careful
clinical examination becauseclinical examination because
roentgenograms are not absolutely reliableroentgenograms are not absolutely reliable
in making the diagnosis of congenitalin making the diagnosis of congenital
dysplasia of the hip in this age group.dysplasia of the hip in this age group.

 Routine clinical screening should includeRoutine clinical screening should include
both the Ortolani test and the provocativeboth the Ortolani test and the provocative
maneuver of Barlow.maneuver of Barlow.
The provocative maneuver of Barlow detectsThe provocative maneuver of Barlow detects
any potential subluxation or posteriorany potential subluxation or posterior
dislocation of the femoral head by directdislocation of the femoral head by direct
pressure on the longitudinal axis of thepressure on the longitudinal axis of the
femur while the hip is in adduction. Bothfemur while the hip is in adduction. Both
these tests require a relaxed and pacifiedthese tests require a relaxed and pacified
childchild

 The Ortolani test is performed by gentlyThe Ortolani test is performed by gently
abducting and adducting the flexed hip toabducting and adducting the flexed hip to
detect any reduction into or dislocation ofdetect any reduction into or dislocation of
the femoral head from the true acetabulum.the femoral head from the true acetabulum.

 As the child reaches the age of 6 to 18As the child reaches the age of 6 to 18
months, several factors in the clinicalmonths, several factors in the clinical
presentation change. Once the femoral headpresentation change. Once the femoral head
is dislocated and the ability to reduce it byis dislocated and the ability to reduce it by
abduction has disappeared, several otherabduction has disappeared, several other
clinical signs become obvious. The first andclinical signs become obvious. The first and
most reliable is a decrease in the ability tomost reliable is a decrease in the ability to
abduct the dislocated hip because of aabduct the dislocated hip because of a
contracture of the adductor musculaturecontracture of the adductor musculature

 Clinical signs of congenital dislocationClinical signs of congenital dislocation
of hip in 13-month-old girlof hip in 13-month-old girl
 Decrease in abduction of right hip withDecrease in abduction of right hip with
adduction contracture.adduction contracture.

Asymmetrical skin folds areAsymmetrical skin folds are
commonly mentioned as a sign to lookcommonly mentioned as a sign to look
for, but unfortunately this sign is notfor, but unfortunately this sign is not
always reliable because normal childrenalways reliable because normal children
may have asymmet-may have asymmet-
rical skin folds, andrical skin folds, and
children with disloca-children with disloca-
ted hips may haveted hips may have
symmetrical folds.symmetrical folds.

Positive GaleazziPositive Galeazzi
sign with apparentsign with apparent
shortening of rightshortening of right
lower extremity.lower extremity.

 The Galeazzi sign is noted when theThe Galeazzi sign is noted when the
femoral head becomes displaced notfemoral head becomes displaced not
only laterally but also proximally,only laterally but also proximally,
causing an apparent shortening of thecausing an apparent shortening of the
femur on the side of the dislocated hipfemur on the side of the dislocated hip
Bilateral dislocations may appearBilateral dislocations may appear
symmetrically abnormalsymmetrically abnormal

In a child of walking ageIn a child of walking age
with an undetectedwith an undetected
dislocated hip, familiesdislocated hip, families
describe a "waddling"describe a "waddling"
type of gait, indicatingtype of gait, indicating
dislocation of thedislocation of the
femoral head and afemoral head and a
Trendelenburg gaitTrendelenburg gait
pattern.pattern.

 Although roentgenograms are notAlthough roentgenograms are not
always reliable in making the diagnosisalways reliable in making the diagnosis
of congenital dysplasia of the hip inof congenital dysplasia of the hip in
newborns, screening roentgenogramsnewborns, screening roentgenograms
may reveal any acetabular dysplasia ormay reveal any acetabular dysplasia or
a teratological dislocation.a teratological dislocation.

 As a child with a dislocated hip agesAs a child with a dislocated hip ages
and the soft tissues become contracted,and the soft tissues become contracted,
the roentgenograms become morethe roentgenograms become more
reliable and helpful in the diagnosisreliable and helpful in the diagnosis
and treatmentand treatment

X-ray of the child 3 months old with hipX-ray of the child 3 months old with hip
dysplasiadysplasia

X-ray of the normal hip joints of theX-ray of the normal hip joints of the
child 3 months oldchild 3 months old

X-ray of hip joints of helthy child inX-ray of hip joints of helthy child in
1 year old1 year old

Schemes for X-ray interpretationSchemes for X-ray interpretation

The most commonly used lines of referenceThe most commonly used lines of reference
are the vertical line of Perkins (b) and theare the vertical line of Perkins (b) and the
horizontal line of Hilgenreiner (A). Both usedhorizontal line of Hilgenreiner (A). Both used
toto assessassess the position of the femoral head.the position of the femoral head.

Reference lines for the evaluation of theReference lines for the evaluation of the
acetabulum include the acetabular indexacetabulum include the acetabular index
and the center edge (CE) angle ofand the center edge (CE) angle of
Wiberg.Wiberg.

 The acetabular index (The acetabular index (ά)ά) in a newbornin a newborn
generally is 30 degrees or less. Anygenerally is 30 degrees or less. Any
significant increase in this measurementsignificant increase in this measurement
may be a sign of acetabular dysplasia.may be a sign of acetabular dysplasia.

In addition, the Shenton line will beIn addition, the Shenton line will be
disrupted in an older child with a dislo-disrupted in an older child with a dislo-
cated hip.cated hip.

 the superior gap (distance between thethe superior gap (distance between the
proximal metaphysis and Hilgenreiner'sproximal metaphysis and Hilgenreiner's
line) and the medial gap (distance betweenline) and the medial gap (distance between
the femoral calcar and the lateral pelvicthe femoral calcar and the lateral pelvic
wall at that level)wall at that level)

Normally the metaphyseal beak of theNormally the metaphyseal beak of the
proximal femur lies within the innerproximal femur lies within the inner
lower quadrant of the reference lineslower quadrant of the reference lines
noted by Perkins and Hilgenreinernoted by Perkins and Hilgenreiner..

TreatmentTreatment
 The treatment ofThe treatment of
congenital orcongenital or
developmentaldevelopmental
dysplasia of the hip isdysplasia of the hip is
age related andage related and
tailored to the specifictailored to the specific
pathological conditionpathological condition

TreatmentTreatment
Five treatment groups related to ageFive treatment groups related to age
have been designated:have been designated:
 (1) newborn, birth to 6 months of age,(1) newborn, birth to 6 months of age,
 (2) infant, 6 to 18 months of age,(2) infant, 6 to 18 months of age,
 (3) toddler, 18 to 36 months of age,(3) toddler, 18 to 36 months of age,
 (4) child and juvenile, 3 to 8 years of age,(4) child and juvenile, 3 to 8 years of age,
 (5) adolescent and young adult, beyond 8(5) adolescent and young adult, beyond 8
years of age.years of age.

Newborn (Birth to 6 Months of Age)Newborn (Birth to 6 Months of Age)
 From birth to approximately 2 - 2.7From birth to approximately 2 - 2.7
months of age, treatment is directed atmonths of age, treatment is directed at
stabilizing the hip that has a positivestabilizing the hip that has a positive
Ortolani or Barlow test or reducing theOrtolani or Barlow test or reducing the
dislocated hip with abducted sweddlingdislocated hip with abducted sweddling
or abducted pampersesor abducted pamperses

Newborn (Birth to 6 Months of Age)Newborn (Birth to 6 Months of Age)
During the first fewDuring the first few
months of lifemonths of life
Children have beenChildren have been
treated in the Pavliktreated in the Pavlik
harness.harness.

When properly applied andWhen properly applied and
maintained, the Pavlik harness is amaintained, the Pavlik harness is a
dynamic flexion abduction orthosisdynamic flexion abduction orthosis
that can producethat can produce
excellent results in theexcellent results in the
treatment of dysplastictreatment of dysplastic
and dislocated hips inand dislocated hips in
infants approximately 4infants approximately 4
to 6 months of age.to 6 months of age.

A roentgenogram of the patient in theA roentgenogram of the patient in the
harness can help to confirm that theharness can help to confirm that the
femoral neck is directed toward thefemoral neck is directed toward the
triradiate cartilage.triradiate cartilage.
After several weeksAfter several weeks
of harness wear,of harness wear,
when the hip feelswhen the hip feels
stable clinically,stable clinically,
ultrasound is helpfulultrasound is helpful
to confirm reductionto confirm reduction
of the hip.of the hip.

The Pavlik harness should be worn full-timeThe Pavlik harness should be worn full-time
until stability is attained, as determined byuntil stability is attained, as determined by
negative Barlow and Ortolani tests.negative Barlow and Ortolani tests.
 If any of patterns of dislocation orIf any of patterns of dislocation or
subluxation persist for more than 3 to 6subluxation persist for more than 3 to 6
weeks, treatment in the Pavlik harnessweeks, treatment in the Pavlik harness
should be discontinued and a newshould be discontinued and a new
program initiated; in most patients,program initiated; in most patients,
this consists of optional traction, closedthis consists of optional traction, closed
or open reduction, and casting.or open reduction, and casting.

Infant (6 to 18 Months of Age)Infant (6 to 18 Months of Age)
 Once a child reaches crawling ageOnce a child reaches crawling age
(approximately 4 to 6 months), success(approximately 4 to 6 months), success
with the Pavlik harness decreaseswith the Pavlik harness decreases
significantly. A child aged 6 to 18significantly. A child aged 6 to 18
months with a dislocated hip probablymonths with a dislocated hip probably
will require either closed manipulationwill require either closed manipulation
or open reduction.or open reduction.

 Children in this age group often areChildren in this age group often are
seen initially with a shortenedseen initially with a shortened
extremity, limited passive abduction,extremity, limited passive abduction,
and a positive Galeazzi sign. If the childand a positive Galeazzi sign. If the child
is walking, a Trendelenburg gait mayis walking, a Trendelenburg gait may
be present.be present.

Roentgenographic changes includeRoentgenographic changes include
delayed ossification of the femoraldelayed ossification of the femoral
head, lateral and proximalhead, lateral and proximal
displacement of the femoral head, anddisplacement of the femoral head, and
a shallow, dysplastic acetabulum.a shallow, dysplastic acetabulum.

 Treatment in this age group shouldTreatment in this age group should
follow a standard regimen, whichfollow a standard regimen, which
includes adequate preoperativeincludes adequate preoperative
traction, adductor tenotomy, andtraction, adductor tenotomy, and
closed reduction and arthrogram orclosed reduction and arthrogram or
open reduction in children with a failedopen reduction in children with a failed
closed reduction.closed reduction.

 Preoperative traction, adductorPreoperative traction, adductor
tenotomy, and gentle reduction with antenotomy, and gentle reduction with an
acceptable "safe zone" are especiallyacceptable "safe zone" are especially
helpful in the prevention of avascularhelpful in the prevention of avascular
necrosis of the femoral head.necrosis of the femoral head.

Preoperative tractionPreoperative traction
 Lower limb trac-Lower limb trac-
tion in uprighttion in upright
direction. I positiondirection. I position
 Lower limbLower limb
traction in leveltraction in level
direction.direction.
II positionII position

Gentle closed reduction is accomplishedGentle closed reduction is accomplished
with the child under general anesthesia.with the child under general anesthesia.
 Adductor TenotomyAdductor Tenotomy. A percutaneous or. A percutaneous or
open adductor tenotomy under sterileopen adductor tenotomy under sterile
conditions can be performed for a mildconditions can be performed for a mild
adduction contracture.adduction contracture.

 The findings of the clinical examinationThe findings of the clinical examination
and of arthrography at the time ofand of arthrography at the time of
attempted closed reduction determineattempted closed reduction determine
if the hip will be stable or may requireif the hip will be stable or may require
open reduction.open reduction.

AA,, Developmental dislocation of left hip in 5-Developmental dislocation of left hip in 5-
month-old girl.month-old girl.
BB -- IntraoperativeIntraoperative
arthrogram ofarthrogram of
irreducible left hipirreducible left hip
showing excessiveshowing excessive
pooling of dye.pooling of dye.

Application of Hip SpicaApplication of Hip Spica

After confirmation of a stable reduction, aAfter confirmation of a stable reduction, a
hip spica cast is applied with the hip joint inhip spica cast is applied with the hip joint in
95 degrees of flexion and 40 to 45 degrees of95 degrees of flexion and 40 to 45 degrees of
abduction. This "human position" as bestabduction. This "human position" as best
for maintaining hip stability andfor maintaining hip stability and
minimizing the risk of avascular necrosis.minimizing the risk of avascular necrosis.

 The final view of the spica with about 40 toThe final view of the spica with about 40 to
45 degrees of abduction and 95 degrees of45 degrees of abduction and 95 degrees of
flection. Excessive abduction should beflection. Excessive abduction should be
avoided.avoided.

Spica cast immobilization isSpica cast immobilization is
continued for 4 months.continued for 4 months.
- The cast can be changed at 2 months- The cast can be changed at 2 months
with the patient under general anesthesia.with the patient under general anesthesia.
Roentgenograms can be obtained to be sureRoentgenograms can be obtained to be sure
that the femoral head is reduced anatomi-that the femoral head is reduced anatomi-
cally into the acetabulum. Clinical andcally into the acetabulum. Clinical and
roentgenographic follow-up is essentialroentgenographic follow-up is essential
until the hip is considered normal. CTuntil the hip is considered normal. CT
scanning is useful in the postoperativescanning is useful in the postoperative
assessment of reduction.assessment of reduction.

AA -- Anteroposterior roentgenogram of pelvisAnteroposterior roentgenogram of pelvis
obtained with patient in spica cast afterobtained with patient in spica cast after
closed reduction. Note difficulty in assessingclosed reduction. Note difficulty in assessing
position of femoral head.position of femoral head.
B -B - CT scan of pelvis toCT scan of pelvis to
confirm bilateralconfirm bilateral
reduction of femoralreduction of femoral
head into truehead into true
acetabulum.acetabulum.

Open ReductionOpen Reduction
 In children in whom efforts to reduce aIn children in whom efforts to reduce a
dislocation without force have failed,dislocation without force have failed,
open reduction is indicated to correctopen reduction is indicated to correct
the offending soft tissue structures andthe offending soft tissue structures and
to reduce the femoral headto reduce the femoral head
concentrically in the acetabulum.concentrically in the acetabulum.

Anterior open reductionAnterior open reduction in congenitalin congenital
dislocation of hip. A, incision. B, Division ofdislocation of hip. A, incision. B, Division of
sartorius and rectus femoris tendons. C-D, T-sartorius and rectus femoris tendons. C-D, T-
shaped incision of capsule, capsulotomy ofshaped incision of capsule, capsulotomy of
hip. E-F, Reduction and capsulorrhaphyhip. E-F, Reduction and capsulorrhaphy

 Roentgenograms or CT scans can be usedRoentgenograms or CT scans can be used
to confirm reduction of the femoral headto confirm reduction of the femoral head
into the acetabulum.into the acetabulum.
 The cast is worn for 10 to 12 weeks.The cast is worn for 10 to 12 weeks.
 If roentgenograms show satisfactoryIf roentgenograms show satisfactory
position of the hip 4 to 6 weeks afterposition of the hip 4 to 6 weeks after
surgery, the portion of the cast below thesurgery, the portion of the cast below the
knee is removed to allow knee motion andknee is removed to allow knee motion and
some hip rotation.some hip rotation.

After removal of theAfter removal of the
total cast, an abductiontotal cast, an abduction
brace is worn full-timebrace is worn full-time
for 4 to 8 weeks;for 4 to 8 weeks;
Then it is worn only atThen it is worn only at
night and during napsnight and during naps
for 1 to 2 years, untilfor 1 to 2 years, until
normal acetabularnormal acetabular
development is evidentdevelopment is evident

Toddler (18 to 36 Months of Age)Toddler (18 to 36 Months of Age)
 Because of widespread screening of new-Because of widespread screening of new-
borns, it is becoming less common for con-borns, it is becoming less common for con-
genital dysplasia of the hip to go undetectedgenital dysplasia of the hip to go undetected
beyond the age of 1 year. The older childbeyond the age of 1 year. The older child
with this condition has a wide perineum,with this condition has a wide perineum,
shortened lower extremity, and hyperlor-shortened lower extremity, and hyperlor-
dosis of the lower spine as a result of femo-dosis of the lower spine as a result of femo-
ropelvic instability.ropelvic instability.

 For these children with well-establishedFor these children with well-established
hip dysplasia, open reduction withhip dysplasia, open reduction with
femoral or pelvic osteotomy, or both,femoral or pelvic osteotomy, or both,
often is required.often is required.

These techniques are described on InfantThese techniques are described on Infant
(6 to 18 months of age), and Toddler (18 to 36(6 to 18 months of age), and Toddler (18 to 36
months of age) respectively,months of age) respectively,

Scheme of technique for open reduction,Scheme of technique for open reduction,
primary femoral shortening, and Salterprimary femoral shortening, and Salter
osteotomy. A, Segment of femur is resected.osteotomy. A, Segment of femur is resected.
B, Proximal femur is abducted, capsule isB, Proximal femur is abducted, capsule is
incised, head of femur is reducted. C, Salterincised, head of femur is reducted. C, Salter
osteotomy is com-osteotomy is com-
pleted with graftpleted with graft
in place.in place.
Femoral frag-Femoral frag-
ments are fixedments are fixed
with pediatric hipwith pediatric hip
screwsscrews

SolterSolter′′ss
osteotomyosteotomy

Juvenile or Child (3 to 8 YearsJuvenile or Child (3 to 8 Years
of Age)of Age)
 The management of untreated congenitalThe management of untreated congenital
dislocation of the hip in a child over 3 yearsdislocation of the hip in a child over 3 years
of age is difficult. By this age adaptiveof age is difficult. By this age adaptive
shortening of the periarticular structuresshortening of the periarticular structures
and structural alterations in both theand structural alterations in both the
femoral head and the acetabulum havefemoral head and the acetabulum have
occurred. Dislocated hips in this age groupoccurred. Dislocated hips in this age group
require open reduction. Preoperativerequire open reduction. Preoperative
skeletal traction should not be used.skeletal traction should not be used.

Adolescent and Young Adult (OlderAdolescent and Young Adult (Older
Than 8 to 10 Years of Age)Than 8 to 10 Years of Age)
 In children older than 8 to 10 years ofIn children older than 8 to 10 years of
age or in young adults in whom theage or in young adults in whom the
femoral head cannot be repositionedfemoral head cannot be repositioned
distally to the level of the acetabulum,distally to the level of the acetabulum,
only palliative salvaging operations areonly palliative salvaging operations are
possible.possible. AA reconstructive operation suchreconstructive operation such
as a total hip arthroplasty may be indicatedas a total hip arthroplasty may be indicated
at the appropriate age.at the appropriate age.

In bilateral dislocations in this age groupIn bilateral dislocations in this age group
the hips should be left unreduced andthe hips should be left unreduced and
total hip arthroplasties may be carriedtotal hip arthroplasties may be carried
out during adulthoodout during adulthood

Congenital Deformities

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