developmental dysplasia of the hip. description of DDH for medical practioners

1. Developmental dysplasia of the hip
(DDH)

2. • Definition
• Dysplasia of the hip that develop during fetal life
or in infancy.
• It ranges from dysplasia of the acetabulum
(shallow acetabulum) to subluxation of the joint
to complete dislocation.
• The old name was ‘‘congenital dysplasia of the
hip (CDH).’’ The name has changed to indicate
that not all cases are present at birth and that
some cases can develop later on during infancy
and childhood

3. • Types:
• DDH is classified into two major groups :
• Typical and teratologic .
• Typical DDH occurs in otherwise normal patients or
those without defined syndromes or genetic
conditions.
• Teratologic hip dislocations usually have identifiable
causes such as arthrogyposis or a genetic syndrome
and occur before birth.

4. Developmental Dysplasia of the Hip
1. Complete hip dislocation.
2. Partial hip subluxation.
3. Hip dysplasia (incomplete development).

5. Incidence
• Most newborn screening studies suggest that some
degree of hip instability can be detected in 1/100 to
1/250 babies, actual dislocated or dislocatable hips
are much less common, being found in 1-1.5 of 1000
live births.
• There is marked geographic and racial variation in
the incidence of DDH.
• More inidence of DDH IN Sweden,Yugoslavia and
Canada.

6. • African and Asian caregivers
have traditionally carried
babies against their bodies in a
shawl so that a child ’s hips are
flexed, abducted, and free to
move.
• This keeps the hips in the
optimal position for stability
and for dynamic molding of
the developing acetabulum by
the cartilaginous femoral
head.
• Children in Native American
and Eastern European
cultures, which have a
relatively high incidence of
DDH, have historically been
swaddled in confining
clothes that bring their hips
into extension.
• This position increases the
tension of the psoas
muscle-tendon unit and
might predispose the hips
to displace and eventually
dislocate laterally and
superiorly.

7. Recommended
Not recommended

9. Etiology
• A positive family history for DDH is found in 12-33%
of affected patients.
• DDH is more common among female patients
(80%). This is thought to be due to the greater
susceptibility of female fetuses to maternal
hormones such as relaxin, which increases
ligamentous laxity
• Primigravida.
• Breech presentation(2-3%).
• Oligohydramnios ,primi gravida and large baby
( crowding phenomenon ).
• Adduction and Extension postnatally.

10. • Torticollis
• metatarsus adductus
• calcaneovalgus feet
Associated conditions

11. • The left hip is the most commonly affected hip
• In the most common fetal position, this is the hip
that is usually forced into adduction against the
mother’s sacrum.
• Girls are affected 5 times more than boys.

12. CLINICAL FINDINGS
• IN NEWBORNS
• Usually asymptomatic and must be screened
by special maneuvers
• 1) Barlow test.
It is a provocative test that attempts to dislocate
an unstable hip.
- Flexion ,adduction, posteriorly.
- “Clunk”

13. Clinical Features : Neonates
BARLOW’S TEST ( bahar lo)

14. Clinical Features : Neonates
BARLOW’S TEST ( bahar lo)

15. • 2) Ortolani test
It is a maneuver to reduce a recently
dislocated hip.
• Flexion, abduction, anteriorly.
• We can`t use X-rays because the acetabulum
and proximal femur are cartilaginous and
wont be shown on X-ray.
• US is the best method to Dx.

16. Clinical Features : Neonates
ORTOLANI SIGN

17. Clinical Features : Neonates
ORTOLANI SIGN

18. Clinical Manifestations
• In infants:
• As the baby enters the 2nd and 3rd months of
life, the soft tissues begin to tighten and the
Ortolani and Barlow tests are no longer
reliable.
• Shortening of the thigh, the Galeazzi sign , is
best appreciated by placing both hips in 90
degrees of flexion and comparing the height
of the knees, looking for asymmetry
• Asymmetry of thigh and gluteal skin folds.

19. • The most diagnostic sign is Ortolani’s
limitation of abduction.
• Abduction less than 60 degrees is almost
diagnostic.
• X-rays after the age of 3 months can be
helpful esp. after the appearance of the ossific
nucleus of the femoral head
• US is 100% diagnostic.

20. Limitation of Abduction
MOST RELIABLE SIGN

21. Galeazzi’s Sign

22. Asymmetric gluteal, thigh, labial folds

24. In walking child
• In older children:
Complaints of limping, waddling (bilateral DDH),
lumbar lordosis, limitation of hip abduction,
toe-walking, wide perineum, etc…

26. Screening
• All neonates should have a clinical
examination for hip instability
• Risk factors :
– breech presentation
– family history
– torticollis
– oligohydramnios
– metatarsus adductus
USG SCREENING

27. CLINICAL USG
normal normal
&
normal ABnormal
REPEAT AT 6 WKS
normal
ABnormal
REPEAT AT 3 & 6 WKS
Clinical & USG normal
ABnormal
Closed / open reduction
F/U till maturity
ABnormal

28. DIAGNOSIS
• 1. ULTRA SOUND
• In the Graf technique, the transducer is placed over
the greater trochanter, which allows visualization of
the ilium, the bony acetabulum, the labrum, and the
femoral epiphysis
• The angle formed by the line of the ilium and a line
tangential to the boney roof of the acetabulum is
termed the α angle and represents the depth of the
acetabulum.
• Values > 60 degrees are considered normal, and those
< 60 degrees imply acetabular dysplasia.

29. • The β angle is formed by a line drawn tangential to
the labrum and the line of the ilium; this represents
the cartilaginous roof of the acetabulum.
• A normal β angle is < 55 degrees, as the femoral
head subluxates, the β angle increases.

31. Graf classification of DDH
[ simplified]
class Alpha angle Beta angle description
1 >60 <55 normal
2 43-60 55-77 Delayed
ossification
3 <43 >77 lateralization
4 unmeasurable unmeasurable dislocated

32. X-ray
 von rosen view:
hips abducted 45º &medially rotated.
Anteroposterior.
We draw a line through the central axis of the
femoral shaft.
in normal hip ( ossific nucleus )will be inside
the acetabulum.
in dislocated hip it will be above acetabulum.

35. X-ray
 Horizontal line of Hilgenreiner:
drawn between upper ends of tri-radiate cartilage
of the acetabulum.
 Vertical line of perkins:
drawn from the lateral edge of the acetabulum
vertical to horizontal line.
 4 quadrants:
Normal hip: the ossification center of the femoral
hip lower medial quadrant.
Dislocated hip: upper lateral quadrant.

36. Pe

39. X-ray
Acetabular index:
angle between horizontal line of hilgenreiner
and the line between the two edges of the
acetabulum.
normal hip 20º30
dilocated or dysplastic hip ≥ 30º
Shenton’s line:
semicircle between femoral neck and upper
arm of obturator foramen, in dislocated hip
this line is broken.

41. Treatment
• The earlier the better.
• Best time for treatment is in newborn period.
• It depends on the device and age of the
patient.
• Goal is to:
1.Flex and abduct hips.
2.Reduce femoral head and maintaining it.

42. • The goals in the management of DDH are to obtain
and maintain a concentric reduction of the femoral
head within the acetabulum to provide the optimal
environment for the normal development of both
the femoral head and acetabulum.
• The later the diagnosisof DDH is made, the more
difficult it is to achieve these goals, the less potential
there is for acetabular and proximal femoral
remodeling, and the more complex are the required
treatments

43. Treatment
• From (1-6 months) use Pavlik Harness.
• From 6 months -2 year use hip spica.
• From the age of >2 year
traction , adductor tenotomy , surgical closed
reduction, salter innominate osteotomy.

44. Infant 1 – 6 months of Age
First choice is PAVLIK
harness
Ensure hip > 90 degrees
flexion

45. Infant 1 – 6 months of age
weekly clinical examination & USG
By 3 weeks stable reduction must
Continue till radiographs show normal
acetabulum
Results :
 95% of initially dysplastic hips normal
 80% dislocated and not initially reducible were successfully reduced
 Higher dislocations had a higher failure rate
 The rate of AVN was 2.38%.

46. Pavlik harness
Standard of treatment worldwide
Upto 6 months
Contraindicated when there is major muscle
imbalance (myelomeningocele,ligamentous
laxity)

48. Complications of Pavlik Harness
• AVN
• Failure to reduce
• Femoral nerve
neuropathy
• Inferior dislocation
• Pavlik’s disease (flattening
posterolateral acetabulum)

49. Von Rosens splint

50. Child 6 months to 2 years of age
• Closed or open reduction + adductor
tenotomy
• If closed reduction fails then surgeon should
be prepared for an open procedure

51. Closed reduction
Force should be avoided
Check for safe zone
Post reduction:
Spica change every six
weeks plus stability
check
Continue spica for 3-4
months

52. Safe Zone
20 to 30 degrees from
maximum abduction
extended to below 90
degrees
without redislocation
Safe zone can be
improved
with adductor tenotomy

53. Management of DDH – Guidelines
0 to 6 months
Pavliks Harness
6 to 18 months 18 to 36 months 3 to 8 years
Traction
Closed reduction
Hip spica
Open reduction
Pri. open
reduction
Pelvic osteotomy
Pri, open
reduction with
Femoral
shortening
6 weeks no
reduction
Arthrography
No reduction >1/3rd head
visible

54. • A 6-week-old female infant is referred to your practice for concerns of developmental dysplasia of the hip. On physical exam, you note
a positive Ortolani test on the left side. Pavlik harness treatment is initiated. Which of the following imaging modalities should be
utilized at the two week follow-up visit?
•
1. Magnetic Resonance Imaging (MRI)
• 2. Computed Tomography (CT)
• 3. Ultrasound (US)
• 4. Plain Radiographs
• 5. Arthrogram and Dynamic Fluroscopy
•
Which of the following concepts regarding pediatric hips is true? Review Topic
•
1. The proximal femoral physis and greater trochanteric apophysis develop from different cartilaginous physes
• 2. The proximal femoral physis grows at a rate of 9 mm per year
• 3. Normal infant femoral anteversion is between 10-20 degrees
• 4. The ossific nucleus of the proximal femur is visible on radiographs by 6 months of age in most children
• 5. Slipped capital femoral epiphysis (SCFE) typically occurs through the zone of proliferation
• Failure to achieve reduction of a dislocated hip in an otherwise healthy 4 month old infant which did not reduce after 3 weeks in a
Pavlik harness and 3 weeks in an abduction brace is best treated with which of the following? Review Topic
•
1. Adjusting the harness to 75 degrees of abduction and maintaing 90 degrees of hip flexion
• 2. Adjusting the harness to 75 degrees of abduction and increasing hip flexion to 120 degrees
• 3. Closed reduction with hip arthrogram, adductor tenotomy if necessary, and hip spica casting
• 4. Open reduction and femoral shortening osteotomy
• 5. Open reduction, femoral shortening osteotomy, and pelvic acetabular osteotomy

55. • In patients older than 12-months of age with developmental dysplasia of the hip, all of the following physical exam findings are likely
present EXCEPT? Review Topic
•
1. Limited hip abduction
• 2. Positive Ortolani maneuver
• 3. Abnormal leg lengths on Galeazzi testing
• 4. Trendelenburg gait
• 5. Pelvic obliquity
•
n infants with developmental dysplasia of the hip (DDH), anatomic closed reduction may be prevented by all of the following anatomic
structure EXCEPT. Review Topic
•
1. Interposition of gluteus medius
• 2. Limbus formed by fibrous tissue and hyaline cartilage
• 3. Ligamentum teres and prominent fibrofatty pulvinar tissue
• 4. Contracted transverse acetabular ligament
• 5. Inverted acetabular labrum
• A five-year-old boy with cerebral palsy presents to the clinic with a dislocated right hip, what quadrant of the acetabulum is most likely
deficient? Review Topic
•
1. Anterior-inferior
• 2. Anterior-superior
• 3. Posterior-superior
• 4. Posterior-inferior
• 5. Anterior-inferior and anterior-superior
•