DDH HIP ORTHO

1. CDH
DR.RAVI KIRAN
M.S (ORTHO)
ASSOCIATE PROFESSOR
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• Congenital dislocation of
hip
o a spontaneous dislocation
of the hip
o can occur before, during
or shortly after birth.
o Why is it uncommon in
India (MCQ)
n In Indian culture ,mother
carries the child on the
side of her waist with the
hips of the child abducted

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o Aetiology
n Hereditary predisposition to joint laxity(MCQ)
n Why CDH is 3-5 times more common in
females(MCQ)
• maternal relaxin that crosses the placental
barrier cause relaxation of ligaments if the
foetus is a female (MCQ)

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nincidence of
CDH is about 10
times more in
newborns with
breech
presentation
than those with
vertex
presentation.
(MCQ)

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172. Breech presentation is a risk factor for the
following condition- (PGMEE 2015)
a. CTEV
b. SCFE
c. DDH
d. Perthes disease

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o Pathology
n Changes seen in a dislocated joint
• Femoral head
o dislocated upwards and laterally(MCQ) its
epiphysis is small and ossifies late.
• Femoral neck is excessively anteverted.
(MCQ)
• Acetabulum is shallow, with a steep sloping
roof.

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• Ligamentum teres is hypertrophied. (MCQ)
• Fibro-cartilaginous labrum of the acetabulum
(limbus) may be folded into the cavity of the
acetabulum (inverted limbus). (MCQ)
• Capsule of the hip joint is stretched.
• Adductors of hip, undergo adaptive
shortening. (MCQ)

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182. Primary pathology in CDH- (PGMEE
2012)
a. Large head of femur
b. Everted limbus
c. Excessive retroversion
d. Shallow acetabulum

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o Clinical features
n In 1/3 of all cases both hips are affected.
n At birth: Routine screening of all newborns is
necessary
n Early childhood:
• asymmetry of creases of the groin (MCQ)
• limitation of movements of the affected hip
• a click everytime the hip is moved. (MCQ)
n Older child:
• child walks with a 'peculiar gait' though there
is no pain. (MCQ)

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Resting posture in
right sided CDH

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The child is positioned as shown. The knee
is lower on the affected side because of
posterior displacement in the
developmentally dysplastic hip.

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o Examination
o Barlow's test: The test has two parts(MCQ)
o First part of test
n What is the aim : to adduct knee and feel the
dislocation of femoral head from acetabulum
n Procedure
• the surgeon faces the child's perineum
• He grasps the upper part of each thigh, with his
fingers behind on the greater trochanter and
thumb in front
• The child's knees are fully flexed and the hips
flexed to a right angle

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• The hip is now gently adducted.
• As this is being done, gentle pressure is
exerted by the examining hand in a proximal
direction while the thumb tries to 'push out' the
hip.
• As the femoral head rolls over the posterior lip
of the acetabulum, it may, if dislocatable (but
not, if dislocated) slip out of the acetabulum.
• One feels an abnormal posterior movement,
appreciated by the fingers behind the greater
trochanter.
• There may be a distinct 'clunk'.

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n Interpretation :
• If nothing happens
o the hip may be normal
o hip may already be dislocated where second
part of the test would be more relevant

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o Second part of the test
n What is the aim : to abduct an adducted knee and
feel the relocation of femoral head into acetabulum
n Procedure
• with the hips in 90° flexion and fully adducted, thighs
are gently abducted
• The examiner's hand tries to pull the hips while the
fingers on the greater trochanter exert pressure in a
forward direction, as if one is trying to put back a
dislocated hip.
• If the hip is dislocated, either because of the first part
of the test or if it was dislocated to start with, a 'clunk'
will be heard and felt, indicating reduction of the
dislocated hip.

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n Interpretation :
• If nothing happens
o the hip may be normal
o it is an irreducible dislocation.
• Normal vs irreducible dislocation – How do
we know what is the correct diagnosis
(MCQ)
o In a normal hip , it is possible to abduct the
hips till the knee touches the couch.
n In the irreducible dislocation., there will be
limitation of hip abduction.

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o Ortolani's test (MCQ)
n This test is similar to the second part of
Barlow's test.
n The hips and knees are held in a flexed
position and gradually abducted
n A 'click of entrance' will be felt as the femoral
head slips into the acetabulum from the
position of dislocation.

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176. Ortoiani test is positive when the examiner
hears the- (PGMEE 2015)
a. Clunk of entry on abduction and flexion of hip
b. Clunk of entry on extension and adduction of
hip
c. Click of exit on abduction and flexion of hip
d. Click of exit on extension and adduction of hip

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o Clinical findings in in an older child: (MCQ)
n Limitation of abduction of the hip.
n Asymmetrical thigh folds
n Higher buttock fold on the affected side.
n Galenzzi's sign(MCQ)
• The level of the knees are compared in a
child lying with hip flexed to 70° and knees
flexed
• There is a lowering of the knee on the
affected side

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n Ortolani's test may be positive.
n Trendelenburg's test is positive:
• The child is asked to stand on the affected
side
• The opposite Anterior Superior Iliac spine -
ASIS (that of the normal side) dips down

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n The limb is short and slightly externally
rotated. (MCQ)
n There is lordosis of the lumbar spine. (MCQ)
n Telescopy positive(MCQ)
• In a case of a dislocated hip, it will be
possible to produce an up and down piston-
like movement at the hip.
• This can be appreciated by feeling the
movement of the greater trochanter under
the fingers

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n Gait in CDH
• A child with unilateral dislocation (MCQ)
o exhibits a typical gait in which the body
lurches to the affected side as the child
bears weight on it (Trendelenburg's gait).
• In a child with bilateral dislocation(MCQ)
o there is alternate lurching on both sides
[waddling gait).

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173. Congenital dislocation of hip in older child
most common sign appreciated is- (PGMEE
2015)
a. Barlow test
b. Ortoiani test
c. Painful ROM
d. Limited abduction of Lower Limb

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174. Patients with bilateral CDH walk with the
following gait- (PGMEE 2015)
a. Waddling
b. Stumbling
c. Knock knee
d. Antalgic

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o Radiological features
n Why is it difficult to diagnose a dislocated hip
on plain X-rays of the pelvis of an infant ?
(MCQ)
• In a child below the age of 1 year, the
epiphysis of the femoral head is not ossified,

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n Von Rosen's view may help. (MCQ)
n
Von Rosen view:
hips abducted 45º & medially rotated.
-

49. Ultrasound examination is useful in early diagnosis at
birth. (MCQ)
n In an older child, important X-ray findings: (MCQ)
• Delayed appearance of the ossification centre of the
head of the femur.
• Retarded development of the ossification centre of
the head of the femur.
• Sloping acetabulum.
• Lateral and upward displacement of the ossification
centre of the femoral head.
• A break in Shenton's line
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50. ULTRASOUND
• ALPHA & BETA ANGLES MEASURED
FOR DDH ON ULTRASOUND
• APLHA ANGLE DECREASES AND
BETA ANGLE INCREASES WITH AGE
AND SEVERITY OF DDH
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H = a horizontal line drawn between the two triradiate cartilage centers of
the hips defines a horizontal planne and an approximation to flexion axis
of the hips. Hilgenreiner's Line P = a perpendicular line to the
horizontal line drawn at the edge of the boney part of the socket (there's
more in cartilage that can't be seen). Perkin's Line

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175. Perkin's Hoe on X-ray is used for diagnosis
of- (PGMEE 2015)
a. Perthe's disease
b. CDH
c. CTEV
d. AVNHip

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• Treatment
o Aim of treatment
n to achieve reduction of the head into the
acetabulum
n maintain head until the
• hip becomes clinically stable
• a 'round' acetabulum covers the head.
o In most cases, it is possible to reduce the hip
by closed means

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o Once the head is inside the acetabulum, in
younger children, under the mould-like effect
of the head, it develops into a round
acetabulum.
o If reduction has been delayed for more than
2 years, acetabular remodelling may not
occur even after the head is reduced for a
long time. Hence, in such cases, surgical
reconstruction of the acetabulum may be
required. (MCQ)

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• Methods of reduction:
o Closed manipulation
n It is sometimes possible in younger children to reduce
the hip by gentle closed manipulation under general
anaesthesia.
o Traction followed by closed manipulation:
n In cases where the manipulative reduction requires a
great deal of force or if it fails, the hip is kept in
traction for some time, and is progressively abducted.
n As this is done, it may be possible to reduce the
femoral head easily under general anaesthesia.
n An adductor tenotomy is often necessary in some
cases to allow the hip to be fully abducted.

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o Open reduction:
n This is indicated if closed reduction fails
n Reasons of failure of closed reduction
• presence of fibro-fatty tissue in the
acetabulum
• a fold of capsule and acetabular labrum
(inverted limbus) between the femoral head
and the superior part of the acetabulum.
n In such situations, the hip is exposed, the
soft tissues obstructing the head excised or
released, and the head repositioned in the
acetabulum.

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Medial Approach incision represented by
black dotted line

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• Maintenance of reduction
o Plaster cast:
n A frog leg or Bachelor's cast(MCQ)
o

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179. Bachelors' cast is used in- (PGMEE 2013)
a. Fracture radius
b. Club foot
c. DDH
d. Fracture calcaneum

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72. Splint:
n Some form of splint such as Von Rosen's
splint(MCQ)
n External splints can be removed once the
acetabulum develops to a round shape.
n The hip is now mobilised, and kept under
observation for a period of 2-3 years for any
recurrence.
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o Acetabular reconstruction procedures:
n Salter's osteotomy: (MCQ)
• This is an osteotomy of the iliac bone, above
the acetabulum
• The roof of the acetabulum is rotated with
the fulcrum at the pubic symphysis, so that
the acetabulum becomes more horizontal,
and thus covers the head

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Salter Innominate
Osteotomy: Distal
fragment is pulled
downward and
forward

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n Chiari's pelvic displacement osteotomy:
(MCQ)
• The iliac bone is divided almost
transversely immediately above the
acetabulum
• lower fragment (bearing the acetabulum) is
displaced medially
• The margin of the upper fragment provides
additional depth to the acetabulum

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Chiari Osteotomy

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Dega
Osteotomy

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Anterior view of
pelvis
demonstrating
lines of Ganz
Periacetabular
Osteotomy

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n Pemberton's pericapsular osteotomy: (MCQ)
• A curved osteotomy is made.
• The roof of the acetabulum is deflected
downwards over the femoral head, with the
fulcrum at the triradiate cartilage of the
acetabulum.

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181. Sailer's pelvic osteotomy is done for
treatment of- (PGMEE 2013)
a. CTEV
b. SCFE
c. DDH
d. None

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n a varus derotation osteotomy(MCQ)
• Indication : If reduction of the hip is possible
only in extreme abduction or internal rotation
of the thigh
• done at the sub-trochanteric region
• The distal fragment is realigned and the
osteotomy fixed with a plate.

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• Treatment plan: (A Very High yield area for
MD Entrance often tested in Exam)
o Birth to 6 months: (MCQ)
n The femoral head is reduced into the
acetabulum by closed manipulation
n maintained with plaster cast or splint.
o 6 months to 6 years: (MCQ)
n Upto 2 years
• It may be possible up to 2 years to reduce
the head into the acetabulum by closed
methods.

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n After 2 years, (MCQ)
• it is difficult and also unwise to attempt
closed reduction.
o Reasons
n when the head has been out for some time,
the soft tissues around the hip become tight
n Such a hip, if reduced forcibly into the
acetabulum, develops avascular necrosis of
the femoral head.

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• In these cases, reduction is achieved by
open methods, and an additional femoral
shortening may be required.
• In older children, an acetabular
reconstruction may be performed at the
same time or later.
• Salter's osteotomy is preferred by most
surgeons.

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o 6-20 years: (MCQ)
n The first question to be adressed in children at this
age is whether or not to treat the dislocation at all.
n Bilateral dislocations
• No treatment may be indicated for children with
bilateral dislocations because of the following
reasons:
o The limp is less noticeable.
o Although having some posture and gait
abnormalities, these patients tend to live
o normal lives until their 40's or 50's.
o Results of treatment are unpredictable and a series
of operations may be required.

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n Unilateral dislocation(MCQ)
• In unilateral cases, an attempt at open
reduction with reconstruction of the
acetabulum may be made.
• A derotation osteotomy is needed in most
cases.

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o 11 years onwards: (MCQ)
n Indication for treatment in these patients is
pain.
n If only one hip is affected, a total hip
replacement may be practical once
adulthood is reached.
n Sometimes, arthrodesis of the hip may be a
reasonable choice.

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178. 2 year old child with congenital dislocation
of hip treatment of choice- (PGMEE 2014)
a. Closed reduction
b. Hip spica
c. Open reduction
d. Acetabular osteotomy

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