The document provides a comprehensive overview of developmental dysplasia of the hip (DDH), including its terminology, incidence, risk factors, aetiology, pathogenesis, screening, diagnosis, investigations, and treatment protocols based on the patient's age. It highlights the importance of early diagnosis and intervention to prevent permanent deformities and details various imaging modalities used for assessment. Treatment approaches are tailored based on age, with the best outcomes associated with early intervention, often utilizing harnesses, splints, and surgical options if necessary.

1. ‫الرحمن‬ ‫هللا‬ ‫بسم‬
‫الرحيم‬
‫علما‬ ‫زدنى‬ ‫رب‬ ‫وقل‬
Orthopedics
Dr. Hosam Elshikh
FRCS Tr. & Orth.

2. INTRODUCTION
• Terminology :
 Before this condition was called CDH (CONGENTAL DISLOCATION HIP)
 The term congenital is replaced by developmental because not all cases are evident at
birth, and also postnatal factors contribute in production of hip instability and
subsequent dislocation .
 The term dislocation is replaced by dysplasia as most of cases after improvement of
radiological modalities find to be only anatomical dysplasia and not dislocated.
• Embryonic
• 7th week - acetabulum and hip formed from same mesenchymal cells
• 11th week - complete separation between the two
• Proximal femoral ossific nucleus - 4-6 months

3. INCIDENCE
1/1,000 born with dislocated hip.
10/10,000 born with subluxation or dysplasia.
Left 60% (left occiput ant), Right 20%, both 20%.
Risk Factors
Female baby 80%
Higher incidence in culture where swaddling
First born children (tight pelvic muscles)
Family history
Breech
Intrauterine backing disorders
Twins
Over birth weight
Short maternal stature and narrow pelvis
Oligohydramnios

4. AETIOLOGY
Multifactorial :
 Mechanical Factors : all factors which tighten the space available for the fetus in the uterus,
First born children (tight pelvic muscles)
Family history
Breech
Intrauterine backing disorders
Twins
Over birth weight
Short maternal stature and narrow pelvis
Oligohydramnios
 Hormonal Factors : maternal estrogens are increased before delivery to relax the pelvic muscles ,
this leads to laxity of the capsule and instability of the hip.
 Postnatal environmental Factors : some people have traditional habits of wrapping the
babies in positions which do not secure the femoral head inside the acetabulum.

5. pathogenesis
• At the time of birth
• joint capsule is distended and elastic.
• After delivery
• femoral head is loose within the joint and free to fall out of the acetabulum . At this
early stage the anatomy of the head, acetabulum and soft tissues is close to normal ,
so if head is maintained inside acetabulum for few weeks joint will return to its normal
configuration and become stable.
• If the dislocation is allowed to persist for long time
• the bone and soft tissues undergo adaptive changes , and dislocation is difficult to be
reduced
• Congenital dislocation of the hip occurs in a posterolateral and proximal
direction

6. • Bony changes
• Shallow acetabulum
• Increased femoral neck anteversion
• Increased femoral neck shaft angle
• Soft tissue changes
Intraarticular and Extraarticular
• Extraarticular
• Tight adductors (adductor longus muscle)
• Tight Iliopsoas tendon
• Intraarticular
• Labrum (inverted limbus)
• Ligamentum teres elongation , hypertrophy and thickening
• Transverse acetabular ligament tightness
• Pulvinar (hypertrophied fibro fatty tissue filling acetabular
cavity)
• Redundant capsule (hourglass shaped by iliopsoas pressure)

7. Newborn screening
Early diagnosis and ttt is crucial for preventing perminant deformity, so In many
countries screening systems developed:
• Exam should be under Warm, quiet environment with removal of diaper
• Head to toe exam to detect any associated conditions (Torticollis, Ligamentous
Laxity, spina bifida , meningocele. etc.)
• Ortolani’s and Barlow’s maneuvers.
• u/s hip screening systems.

8. From time of delivery
till walking age
• mother complain of asymmetric
position of lower limbs or lack of
normal movement of one side .
oAsymmetry of:
Limb length- Galeazzi test.
Uneven Knees
limited ROM in Abduction
Skin folds (extra napkin skin)
diagnosis

9. Barlow’s TesT
• Identifies unstable hip that lies in
reduced position but can be passively
dislocated.
• 90% will normalize with no treatment
within 9 weeks
• Hips are examined one at a time.
• Hip flexed & thigh adducted, while
pushing posteriorly in line of the shaft
of femur, causing femoral head to
dislocate posteriorly from acetabulum.
• Dislocation is palpable as femoral head
slips out of acetabulum.

10. Older Infants & Children after walking age:
By time the significance of these test is reduced.
Shortening of affected lower limb, extra skin folds are observed

11. limited abduction test:
• By comparison limited abduction of
affected side (active and passive) by
mechanical block.
Telescoping or Pistoning
test:
• with the hip flexed , pulling or
pushing The thigh anteriorly or
posteriorly no resistance is
encountered )

12.  Galeazzi's sign:
• shortening of affected thigh when
knees and hips are flexed ) .
 Gluteus disfunction:
• To understand abductor disfunction,
gluteus Medius muscle anatomy and
function should be understood

13. Trendelenburg test :
• if the patient is standing on the affected side ,pelvic tilt is observed to the
opposite site.
 Limping during walking:
• In case of unilateral hip dislocation, Trendelenburg gate.
• In case of bilateral hip dislocation , waddling gait .

14. investigations
Ultrasound.
• Indications
• primary imaging modality from birth to 4
months.
• Ultrasound screening of high risk group.
• Used as part of screening systems.
• Findings
• evaluates for acetabular dysplasia and/or the
presence of a hip dislocation
• allows view of bony acetabular anatomy,
femoral head, labrum, ligamentum teres, hip
capsule.
• Disadvantages:
• Operator dependent

15. X-ray.
• Indications
• primary imaging modality at 4-6 months
after the femoral head begins to ossify.
• positive physical exam , leg length
discrepancy.
• recommended views: AP pelvis.
• Measurements:
• Hilgenreiner's line
• Perkin's line
• Shenton's line
• Delayed ossification of the femoral head.
• Acetabular index (AI)

16. Hilgenreiner's line: horizontal line
through the right and left triradiate
cartilage.
• femoral head ossification should be
inferior to this line.
Perkin's line: line perpendicular to
Hilgenreiner's line through a point at
the lateral margin of the acetabulum.
• femoral head ossification should be medial
to this line.
Shenton's line: arc along the inferior
border of the femoral neck and the
superior margin of the obturator
foramen.
• arc line should be continuous.

17. Acetabular index (AI): angle
formed by Hilgenreiner's line and a
line from a point on the lateral
triradiate cartilage to a point on
lateral margin of acetabulum
(Shallow acetabulum).
• should be < 25° in patients older than
6 months.

18. Arthrogram:
• indications
• used to confirm reduction after closed reduction under
anesthesia
• identify blocks to reduction:
• inverted labrum ,the labrum may be inverted and
mechanically block reduction.
• transverse acetabular lig becomes contracted and block
reduction
• hip capsule is constricted by iliopsoas tendon causing
hourglass deformity.
• Pulvinar fibrofatty tissue within the acetabulum that block
reduction
• ligamentum teres lengthens and hypertrophies and block
to reduction

19. • Left hip DDH ARTHROGRAM:
• collected contrast ( blue arrow ) in a
widened joint space
• a filling defect superiorly ( yellow
arrow ) inverted labrum
• femoral head ( green oval ) which
remains outside acetabulum ( red
star ).

20. treatment
Aim of treatment is congruent reduction of femoral head into the
acetabulum and maintain as both head and acetabulum
development depends on congruity.
Lines of treatment depends on age of the patient.
Best prognosis if treatment starts before 6 weeks of age.
0 - 6 months of age
• Pavlik harness.
6 - 18 months
• Closed vs open reduction and spica cast.
18 - 48 months
• Open reduction and spica cast.
• Open +/- osteotomies and spica cast.

21. (0 to 6) Months
Triple-diaper technique
Prevents hip adduction but high failure rate.
Abduction splint Pavlik harness
Indications:
• Less than 6 months
• Reducible hip
Advantages
• Non invasive
• Very successful
• Allows free movement within restraints
Duration
• Worn for 23 hours/ day for 6 weeks or until
hip become stable.
• Weaning for 6 to 8 weeks after hip become
stable
• Stop if reduction failed after 3 to 4 weeks of
usage
 Anterior straps for hip flexion 100 and
prevent extension
 posterior straps for preventing add.
NOT producing abd.

22. (6 to 18) months
Closed reduction +/- adductor
tenotomy.
Spica in human position of 100
degrees of flexion and about 55
degrees abduction (3 months).
Abduction Orthosis 4 wks. full time/4
wks. Nighttime.
Open reduction (if failed)
• Spica for 6 wks.

23. (18m - 4y) triple attack
Open reduction.
Post-surgery spica cast x 6-12 wks.
May require other surgical procedures to
pelvis and/or femur.
• It still Tight - femoral shortening.
• pelvic osteotomy: if Persistent instability.

24. Complications of d.d.h.
management:
Avascular necrosis
Etiology
• excessive hip abduction leads to:
Femoral head compression
Injury to blood supply
Femoral nerve palsy
• Hyperflexion

25. Thank You