Orthopedic course overview Introduction Epidemiology Etiology and pathogenesis Pathology Clinical Features and tests Imaging Treatment Complications Questions References

1. DEVELOPMENTAL DYSPLASIA
OF THE HIP ( DDH )
Diaa Mohammad Srahin
5th year Medical Student
Al-Quds University
Orthopedic course
Dr. Ziyad Al-Zeer

2. Overview
 Introduction
 Epidemiology
 Etiology and pathogenesis
 Pathology
 Clinical Features and tests
 Imaging
 Treatment
 Complications
 Questions
 References

3. Introduction
Definition Of DDH
Dysplasia of the hip that develop during fetal life or in infancy.
• 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.

4. DDH comprises a spectrum of disorders including:
 Acetabular dysplasia
 a shallow or underdeveloped acetabulum.
 Subluxation
 Dislocation
 Teratologic hip
 dislocated in utero and irreducible on neonatal exam
 associated with neuromuscular conditions and genetic disorders ,
commonly seen with arthrogryposis, myelomeningocele.

5. Epidemiology
 Incidence
 most common orthopedic disorder in newborns.
 dysplasia is 1:100
 dislocation is 1:1000
 Location
 most common in left hips in females
 bilateral in 20%
 Risk factors
 first born
 female (6:1 over males)
 breech
 family history
 oligohydramnios

6. Etiology and pathogenesis
Genetic factors
 must be important, for DDH tends to run in families and even in entire
populations.
 Two heritable features which could predispose to hip instability are :
 generalized joint laxity (a dominant trait).
 shallow acetabula (a polygenic trait which is seen mainly in girls and their
mothers).
.

7. Hormonal changes
Hormonal changes in late pregnancy may aggravate ligamentous laxity in the
infant. This could account for the rarity of hip instability in premature babies.
Intrauterine malposition
especially a breech position with extended legs, would favor dislocation.
Normal womb position. Breech womb position.

8. Postnatal factors
play a part in maintaining any tendency to instability. This may account for the
unusually high incidence of DDH in Inuit and Sami peoples, who swaddle their babies
and carry them with hips and knees fully extended; compare the rarity of DDH in
African peoples, who carry their babies astride their backs with hips abducted.
Tight car seats prevent legs
from spreading apart.
Wider car seats provide
room for legs to be apart,
putting the hips in a better
position.
Baby carriers that force the
baby’s legs to stay together
may contribute to hip
dysplasia.
Baby carriers should support
the thigh and allow the legs to
spread to keep the hip in a
stable position.

9. Pathology
 The acetabulum is unusually shallow (shaped like a saucer instead of a
cup).
 The femoral head slides out posteriorly and then rides upwards
“ Superiolaterally “.
 The capsule is stretched and the ligamentum teres becomes elongated
and hypertrophied.
 The acetabular labrum and its capsular edge may be pushed into the
socket by the dislocated femoral head; this firocartilaginous limbus may
obstruct any attempt at closed reduction of the femoral head.
 Maturation of the acetabulum and femoral epiphysis is retarded
and the femoral neck is unduly anteverted.

10. Clinical features
 The ideal, is to diagnose every case at birth. For this reason, every
newborn child should be examined for signs of hip instability.
 Where there is a family history of congenital instability, and with breech
presentations or signs of other congenital abnormalities, extra care is
taken and the infant may have to be examined more than once. Even
then some cases are missed.
 In the neonate, there are several ways of testing for instability e.g.
Ortolani’s test , Barlow’s test.

11.  Mainstay of physical diagnosis is palpable hip subluxation
dislocation on exam
 Barlow
 dislocates a dislocatable hip by adduction and depression of the flexed
femur
 Ortolani
 reduces a dislocated hip by elevation and abduction of the flexed femur
 Galeazzi (Allis)
 apparent limb length discrepancy due to a unilateral dislocated hip with
hip and knee flexed at 90 degrees
 femur appears shortened on dislocated side
 Hip clicks are nonspecific findings.
 Barlow and Ortolani a rarely positive after 3 months of age
because of soft-tissue contractures about the hip

12. Ortolani’s test
 In Ortolani’s test, the baby’s thighs are held with the thumbs
medially and the fingers resting on the greater trochanters; the
hips are flexed to 90 degrees and gently abducted. Normally
there is smooth abduction to almost 90 degrees.
 In congenital dislocation the movement is usually impeded,
but if pressure is applied to the greater trochanter there is a
soft ‘clunk’ as the dislocation reduces.
 If abduction stops halfway and there is no jerk of entry, there
may be an irreducible dislocation.

14. Barlow’s test
 Barlow’s test is easily performed by adducting the hip while
applying light pressure on the knee, directing the force
posteriorly.
 If the hip is dislocatable - that is, if the hip can be popped out
of socket with this maneuver - the test is considered positive.
 The Ortolani maneuver is then used, to confirm the positive
finding (i.e., that the hip actually dislocated).

16.  Every hip with signs of instability – however slight – should be examined by
ultrasonography. This shows the shape of the cartilaginous socket and the
position of the femoral head.
 Late features An observant mother may spot asymmetry, a clicking hip, or
difficulty in applying the napkin (diaper) because of limited abduction.
 With unilateral dislocation the skin creases look asymmetrical and the leg is
slightly short (Galeazzi’s sign) and externally rotated; With bilateral dislocation
there is an abnormally wide perineal gap.
 Abduction is decreased.
 Contrary to popular belief, late walking is not a marked feature; nevertheless,
in children who do not walk by 18 months dislocation must be excluded.
Likewise, a limp or Trendelenburg gait, or a waddling gait could be a sign of
missed dislocation

17. Asymmetrical thigh creases Limited abduction
Galeazzi’s signwaddling gait

18. • If the patient stands
on the healthy side,
his abductor muscles
will support his
weight, the
contralateral side will
not tilt down.
• While if the patient
stands on the
affected side,
because of his weak
abductor, the pelvis
will drop on the other
side

19. Imaging
 Because the proximal femur at birth is all cartilaginous, radiographs
cannot be used to detect the position of the head of the femur in
relation to the acetabulum.
 Ultrasound is used to assess the position of the head of the femur until
the age of 4–6 months when the ossific center of the proximal femur
starts to develop.
 Dynamic ultrasound: Using ultrasound to assess the stability of the
head of the femur in the acetabulum during various movement of the
hip joint.
 After the ossific center is formed (around 4–6 months), the ultrasound
waves cannot penetrate the ossific center. Plain radiographs are used to
assess the hip joint.

20. Dynamic ultrasound. Assessment of the hip position by
ultrasound during various positions. a To the left with hip
adduction, the femoral head (dotted circle) lies outside a line
along the pelvic bone (dotted line). b With hip abduction, partial
reduction occurs.

21. Interpretation of the ultrasound of the hip
Alpha angle
 It represents the bony acetabulum.
 Normal is more than 55 degree.
 This indicates good bony coverage of the head of the femur (deep
acetabulum).
Beta angle
 It represents the cartilaginous acetabulum.
 Beta angle should be less than 50 degree.
 This indicate that the head of the femur is not subluxated
(Big Beta Bad).

22. Ultrasound assessment of the hip joint. Alpha
angle is the angle between the ileum (thick line)
and a line extending from the triradiate (arrow) to
the edge of the acetabulum (thin line). Beta angle
is the angle between the ilium (thick line) and line
extending from the edge of the bony acetabulum to
the edge of the labrum (dotted linea)

23. Diagnosis of missed DDH after the age of six months
 Limited abduction of the affected hip .
 Limb length discrepancy (LLD) (‘‘positive Galeazzi sign’’).
 Limping (for unilateral cases) and waddling gait (for
bilateral cases).
 Pain is NEVER a symptom of UNTREATED DDH until the
development of hip arthritis (usually by the 4th decade
of life).

24. Radiographs of missed DDH
• The femoral head is ossified.
• Femoral head is out of the acetabulum [in the upper lateral
quadrant formed by crossing of Hilgenreiner line and Perkins’ line.
• Broken Shenton’s line (imaginary line between the obturator
foramen and lower border of the neck of femur).
• Increased acetabular index (normal acetabular index should
be less than 24 degree at age of 24 months).
• Delayed ossification of the femoral head (the affected side is
smaller than the normal side).

25. Anteroposterior pelvis radiographs of 14-month-old girl with left hip DDH. The
radiograph shows the ossific center on the left side (arrow) smaller than the right side
and lying in the upper lateral quadrant of the crossing two lines (Hilgenreiner and
Perkins) (the normal right side lies in the lower medial quadrant). The Shenton’s line
(curved line across the obturator foramen and lower border of the neck) is intact on the
right side (continuos curved line) and broken in the left side (curved dotted line). The
dislocated side shows increased acetabular index (the angle between the Hilgenreiner
line and line from the triradiate to the lateral part of the acetabulum) compared to the

26. Treatment
 Nonoperative
• abduction splinting/bracing (Pavlik harness)
 indications
 DDH < 6 months of age and reducible hip
 is a dynamic splint that requires normal muscle function for successful
Outcomes.
 contraindicated in patients with teratologic hip dislocations, spina
bifida or spasticity.
 outcomes
 overall Pavlik harness has success rate of 90%.
 dependent upon age at initiation of treatment and time spent in
the harness.
 abandon pavlik harness treatment if not successful after 3-4 weeks
 If pavlik harness fails, convert to semi-rigid abduction brace with
weekly ultrasounds for an addition 3-4 weeks before considering
further intervention.

27. • closed reduction and spica casting
 indications
 DDH in 6 - 18 months of age
 failure of Pavlik treatment
 arthrography performed at time of reduction
 medial dye pool >7mm associated with poor outcomes and
osteonecrosis
Pavlik harness spica cast

28.  Operative
• open reduction and spica casting
 indications
 DDH in patient >18 months of age
 failure of closed reduction
• open reduction and femoral osteotomy
 indications
 DDH > 2 yr with residual hip dysplasia
 anatomic changes on femoral side (e.g., femoral anteversion,
coxa valga)
 femoral head should be congruently reduced with satisfactory
ROM, and reasonable femoral sphericity
 best in younger children (< 4 yr)
 after 4 yr, pelvic osteotomies are utilized

29. • open reduction and pelvic osteotomy
 Indications
 DDH > 2 yr with residual hip dysplasia
 severe dysplasia accompanied by significant radiographic
changes on the acetabular side (increased acetabular
index)
 used more commonly in older children (> 4 yr)
 decreased potential for acetabular remodeling as child
ages

30. Complications
 Osteonecrosis
 Delayed diagnosis
 Recurrence
 approximately 10% with appropriate treatment
 requires radiographic follow-up until skeletal
maturity
 Transient femoral nerve palsy

32. Evaluation of a 4 week infant who has a hip click reveals a positive
ortolani sign. Treatment should include:
A. traction, closed reduction, and spica casting.
B. triple diapers and reassessment in 1 month
C. an AP pelvis x-ray at age 4 months
D. Fitting of a Pavlik harness and reassessment in 2 weeks
E. an US of the hip, fitting of a Pavlik, and reevaulation in 3 months.
The Answer is D

33. A healthy 5-mo-old infant w/ DDH of the L hip has been treated
in a Pavlik for 3 months. Exam shows limited ABD and a Galeazzi
sign. Management should consist of:
 A. an arthrogram and closed reduction
 B. a change of the Pavlik to a Frejka pillow
 C. no further Rx until the child is 6mos
 D. Adjustment of the Pavlik and continuation of Rx
 E. open reduction through a medial approach and spica
The answer is A

34. This is an x-ray of a 9-month-old infant who has intoeing. Exam
of the hips show ABD of the Left hip to 75 degrees and the Right
to 90 degrees. Both the Ortolani and Barlow signs are negative.
Management should include:
 A. observation
 B. application of a Pavlik harness
 C. closed reduction of the Left hip
 D. open reductino of the Left hip
 E. open reduction of the left hip with innominate
osteotomy

38. This is an x-ray of a 9-month-old infant who has intoeing. Exam
of the hips show ABD of the Left hip to 75 degrees and the Right
to 90 degrees. Both the Ortolani and Barlow signs are negative.
Management should include:
 A. observation
 B. application of a Pavlik harness
 C. closed reduction of the Left hip
 D. open reductino of the Left hip
 E. open reduction of the left hip with innominate
osteotomy
 The Answer is C

39. The x-ray shows a AP pelvis of a 6yo girl who presents with a
limp and intermittent pain in the right groin. Management
should include:
 A. A varus derotational osteotomy of the right femur
 B. open reduction and adductor tenotomy
 C. open reduction with femoral and pelvic osteotomies
 D. PT for muscle strengthening and ROM exercises
 E. longitudinal traction, closed reduction, and adductor
tenotomy

41. The x-ray shows a AP pelvis of a 6yo girl who presents with a
limp and intermittent pain in the right groin. Management
should include:
 A. A varus derotational osteotomy of the right femur
 B. open reduction and adductor tenotomy
 C. open reduction with femoral and pelvic osteotomies
 D. PT for muscle strengthening and ROM exercises
 E. longitudinal traction, closed reduction, and adductor
tenotomy
 The Answer is C

42. References
 Apley’s System of Orthopaedics and Fractures 9th ed. by Louis Solomon, David
Warwick, Selvadurai Nayagam.
 Pediatric Orthopedics: A Handbook for Primary Care Physicians. By Amr
Abdelgawad, Osama Naga.
 https://www.orthobullets.com