This document discusses developmental dysplasia of the hip (DDH), formerly known as congenital dislocation of the hip. DDH is a spectrum of pathology in the development of the immature hip joint, ranging from mild dysplasia to frank dislocation. Risk factors include increased joint laxity, female sex, breech presentation, tight intrauterine space, and family history. Diagnosis involves physical examination maneuvers in infants and imaging like ultrasound and x-rays in older children. Treatment depends on age, with harnesses and casting for young infants and open reduction and casting for older children. Complications can include avascular necrosis, redislocation, and residual deformities.

1. DEVELOPMENTAL DYSPLASIA
OF HIP
Dr Jo Martin Kuncheria
JR, Pediatrics

2. DDH
• Refers to a spectrum of pathology in the development of the
immature hip joint
• Formerly called congenital dislocation of hip
• Variable presentations include mild dysplasia as well as frank
dislocation
• Acetabular dysplasia – abnormal morphology and development
of acetabulum
• Hip subluxation – partial contact between the femoral head and
acetabulum
• Hip dislocation- hip with no contact between the articulating
surfaces of the hip

3. CLASSIFICATION
• Two major groups of DDH:-
Typical: Otherwise normal patients or those without
defined syndromes or genetic conditions
Teratologic: Have identifiable causes such as
arthrogryposis(joint contracture) or a genetic
syndrome and occur before birth.

4. ETIOLOGY AND RISK FACTORS
• Increased laxity of joint, fails to maintain a stable
femoro acetabular articulation
• 80% among female patients- greater susceptibility
of female fetuses to maternal hormones such as
relaxin
• A positive family history in 12 to 33% of affected
patients
• Incidence among breech presentation is 16-25%

5. ETIOLOGY AND RISK FACTORS
• Any condition that leads to a tighter intra
uterine space and less room for fetal motion
may cause DDH
• Include oligohydramnios , large birth weight,
and first pregnancy
• Called crowding phenomenon
• Left hip is commonly affected, usually forced
into adduction by mothers sacrum

6. EPIDEMIOLOGY
• Some degree of hip instability 1/100 to 1/250
babies
• Dislocated or dislocatable hip 1-1.5/1000 live
birth
• Based on Geography: 1.7/1000 babies in Sweden,
75/1000 in Yugoslavia, 188/1000 Manitoba, a
district in Canada
• 1% hip dysplasia and 0.1% hip dislocation in
white new born
• 0% in chinese and African new born

7. EPIDEMIOLOGY
• May be due to differences in child rearing
practices
• African and asian care givers carry babies
against their bodies in a shawl so that the
childs hip is flexed , abducted and free to move
• Keeps the hip in optimal position for stability
and for dynamic molding of the developing
acetabulum by the cartilaginous femoral head

8. PATHOANATOMY
• Fatty tissues in depth of socket called pulvinar
and ligamentum teres hypertrophy
• Transverse acetabular ligament thickening
• Shortening of iliopsoas tendon
• Dislocated femoral head places pressure on
acetabular rim and labrum cause labrum to
infold and become thick

9. CLINICAL FEATURES IN NEONATE
• Asymptomatic and screened by specific
maneuvers
• Barlow provocative maneuver:
Assess the potential for dislocation
Examiner adducts the flexed hip and gently pushes the
thigh posteriorly in an effort to dislocate the femoral head. In
positive test the hip is felt to slide out of the acetabulum and as
the examiner relaxes the proximal push the hip can be felt to slip
back into the acetabulum

10. CLINICAL FEATURES IN NEONATE
• Ortolani test:
Reverse of Barlow test.The examiner attempts to reduce a hip
that is dislocated at rest. The examiner grasps the childs thigh between
the thumb and index finger, lift the greater trochanter while
simultaneously abducting the hip
Test positive means the femoral head will slip into the socket
with a delicate clunk that is palpable but usually not audible

12. CLINICAL FEATURES IN INFANT
• 2-3 months the Barlow & Ortolani tests are not
reliable because the soft tissues begins to tighten
• Look for specific physical findings:
- Limited hip abduction (most reliable sign)
- Apparent shortening of thigh(Galeazzi sign)
- Proximal location of greater trochanter
- Asymmetry of gluteal folds or thigh folds(hip
dysplasia)
- Positioning of hip

13. CLINICAL FEATURES IN INFANT
• Galeazzi sign: place both hips in 90 degrees of
flexion and compare the height of knee for
asymmetry
• Klisic test: Examiner places the 3rd finger over
the greater trochanter and the index finger of
same hand on antr supr iliac spine. In a normal
hip an imaginary line drawn in between the 2
finger points to umbilicus.

14. Klisic test

15. CLINICAL FEATURES IN WALKING CHILD
• Waddling gait, affected side appears shorter, toe
walking on affected side
• Excessive lordosis is present, abductor lurch is
present as child walks
• Trendelenburg sign , when the patient stants on one
foot sagging rather than rising of unsupported
buttock occurs
• There is limited hip abduction on affected side and
knees are at different levels when hips are flexed(
Galeazzi Sign)

17. DIAGNOSIS
• 0-4 wks physical examination is preferred
• USG: Diagnostic modality of choice from 4wks
before appearance of femoral head ossific
nucleus(4-6m)
- USG provides dynamic information about the
stability of hip joint
- USG helps to monitor acetabular development
particularly of infants in Pavlik harness treatment,
can minimize the number of radiographs taken

18. DIAGNOSIS
• GRAF technique:
Transducer is placed over greater greater trochanter . The angle
formed by the line of ileum and a line tangential to the boney roof of
the acetabulum is termed the α angle and represents the depth of
acetabulum.
Values >60 degrees normal . <60 degrees acetabular dysplasia
β angle formed by a line tangential to labrum and a line to ilium which
represents the cartilaginous roof of acetabulum. Normal β angle is
<55 degrees, as femoral head subluxates β angle increases.

20. RADIOGRAPHY
• Radiographs recommended once the proximal femoral
epiphyxis ossifies by 4-6 m.
• AP view of pelvis can be interpreted by classic lines
• Hilgenreiners line: horizontal line drawn through the top of
both triradiate cartilages
• Perkins line: vertical line through the most lateral ossified
margin of roof of acetabulum drawn perpendicular to
Hilgenreiners line
• The ossific nucleus of femoral head should be located in the
medial lower quadrant of insertion of these 2 lines

22. RADIOGRAPHY
• Shentons line : curved line drawn from the medial
aspect of femoral neck to the lower border of superior
pubic ramus. Child with normal hips line is
continuous . In subluxation or dislocation line consists
of 2 separate arc (broken)
• Acetabular index: Angle formed between
Hilgenreiners line and a line drawn from the depth of
acetabular socket to the most lateral ossified margin
of roof of acetabulum
• New born acetabular index can be upto 40 degrees, by
4 months it should be not more than 30 degrees

23. TREATMENT
• Goal: Obtain and maintain a concentric
reduction of femoral head within the
acetabulum to provide optimal environment
for the normal development of both the
femoral head and acetabulum.

24. NEWBORNS & INFANTS YOUNGER THAN 6 MONTHS
• Pavlik harness soon on diagnosis ( MC used brace world
wide)
• Acetabular dysplasia, subluxation or dislocation can be
readily managed
• Other braces include Rosen splint, Frejka pillow
• Significant proportion of these hip normalize within 3-4 wk
• By 6 wks hip instability resolves in 75% cases
• After 6 m failure rate is > 50% (difficult to maintain active
moving child in harness)

25. NEWBORNS & INFANTS YOUNGER THAN 6 MONTHS
• Frequent examinations & readjustments necessary to ensure
harness correctly fitted
• Antr straps of harness are set to maintain hips in flexion (90-100
degrees)
• Excessive flexion cause Femoral nerve palsy
• Postr straps are designed to encourage abduction
• Forced abduction by harness lead to avascular necrosis of femoral
epiphysis
• Continued use of harness beyond 3-4 wks in a persistently
dislocated hip cause Pavlik harness disease / wearing away of
postr aspect of acetabulum which make ultimate reduction less
stable.

27. CHILDREN 6m TO 2 years
• GOAL: Treatment of late diagnosed dysplasia is to maintain reduction of hip
without damaging the femoral head
• Closed reductions done under general anaesthesia
• The hip is moved to determine the range of motion in which it remains reduced
• Reduction maintained in a well molded spica cast in moderate flexion and
abduction
• After reduction CT /MRI may be used to confirm the reduction
• 12 wks after closed reduction plaster cast is removed and an abduction orthosis is
used for remodelling of acetabulum
• Failure to get a stable hip with closed reduction indicates need for open reduction
• The potential for acetabular development after closed or open procedure is
excellent and continues for 4-8y after procedure

28. CHILDREN OLDER THAN 2Y
• Children 2-6y with hip dislocation require an open
reduction
• Concomitant femoral shortening osteotomy is
performed to reduce pressure on proximal femur
and minimize risk of osteonecrosis
• A pelvic osteotomy is performed as acetabular
development is markedly diminished
• Post operatively child is immobilized in a spica cast
for 6-12wks.

29. COMPLICATIONS OF DDH
• Avascular necrosis of femoral epiphysis(MC)
• Occlusion of epiphyseal vessels produce total / partial
infarction of epiphysis
• Redislocation
• Residual subluxation
• Acetabular dysplasia
• Wound infection

30. REFERENCE:-
• Nelson textbook of pediatrics – 21st edition
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