CDH Congenital Dislocation of the Hip

The most common disorder affecting the hip in children Definition A progressive deformation of previously normally formed structures during the embryonic period

Etiology Multifactorial : -Mechanical Factors : all factors which tighten the space available for the fetus in the uterus, like contracted pelvis or tight unstretched uterine and abdominal musculature which prevents free movement of the fetus. -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 wraping the babies in positions which do not secure the femoral head inside the acetabulum

Pathology At the time of birth , the joint capsule is distended and elastic. After delivery the , the femoral head is loose within the joint and free to fall out of the acetabulum . At this early stage the shape of the head and acetabulum and soft tissues is very close to normal , so if the head is maintained within the acetabulum for few weeks , the 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 the dislocation is difficult to be reduced . The pathological changes may be in the acetabulum (shallow acetabulum) , or the femoral head & neck, capsule and ligamentum teres ( lax , redundant) Congenital dislocation of the hip occurs in a posterolateral and proximal direction

Clinical Diagnosis New Born: The mother may complain of asymmetric position of lower limbs or lack of normal movement of one side The most reliable methods for diagnosis are : -Ortolani Test :(Reduction Test),if the hip is dislocated, the femoral head can be returned into the acetabulum , by abducting the hips and pushing the thighs anteriorly (+ve sign ). -Barlow Test : ( Dislocation Test) , if the hip is unstable ( dislocatable) , it can be pushed posteriorly out of the acetabulum after flexing and adducting the thigh

Older Infants & Children : -Limping during walking . In case of bilateral hip dislocation , waddling gait . -Shortening of affected lower limb, skin and subcutaneous tissue are bunched up , extra skin folds are observed -Allis or Galeazi’s sign (shortening of affected thigh when the knees are flexed ) . -Telescoping or Pistoning test (with the hip flexed, pushing the thigh posteriorly no resistance is encountered ) -Trendlenburg test : ( if the patient is standing on the affected side ,pelvic tilt is observed)

Neonatal Examination External rotation attitude Lateralized contour LOOK : External rotation attitude Lateralized contour Wide perineum ( in bilateral )

Asymmetric thigh folds

Shortening ( not in neonates - Galeazzy sign

FEEL : Empty groin Weak Femoral pulse

CDH Neonatal Examination Ortolani Feel a Clunk Not hear a click !

CDH Neonatal Examination Barlow

CDH Clinical Examination The Walking Child Trendelenburgh: unilateral / bilateral (waddling)

Radiographic Diagnosis Newborn : In the first few days of life radiological diagnosis is almost always negative After the age of 6 months pathological changes are evident : - Shallow acetabulum ( Acetabulum Index), avarage 22-27 deg. - Short Neck (Increased angle of antivervsion) - Shenton’s Line - Shoemaker’s Line - Lateral migration of trochanter - Delayed ossification of the head

CDH Treatment Aims Obtain and Maintain concentric reduction In an Atruamatic fashion Without disrupting the blood supply

CDH Treatment Method depends on Age The earlier started, the easier the treatment The earlier started, the better the results Should be detected EARLY

Treatment Birth to 6 months : Pavlik harness or hip spica cast 6 months – 12 months : closed reduction UGA and hip spica casts 12 months – 18 months : possible closed / possible open reduction Above 18 months : open reduction and ? Acetabuloplasty Above 2 years : open reduction,acetabulplasty, and femoral osteotomy Above 8 years : open reduction,acetabulplasty cutting three bones, and femoral osteotomy

CDH Treatment Hip instability in the neonatal period Most resolve spontaneously Observation Pavlik harness Double /triple diapers ??

CDH Treatment Birth – 6 months Hip instability (dislocatable) Established dislocation (reducible) Should be actively treated until hip is normal clinically and radiographically Pavlik harness Hip Spica Cast

CDH Treatment Birth – 6 months Pavlik harness

CDH Treatment Birth – 6 months Other Devices - Frejka pillow - Craig - Von Rosen splint Soft abduction splints: Not good enough Rigid abduction splints: Risk AVN

Initially non operative – closed reduction CDH Treatment 6 – 12 months Initially non operative – closed reduction Reduction under anesthesia and immobilization in hip spica cast Position: Human Avoid severe abduction Avoid Frog position Must be stable and concentrically reduced otherwise needs open reduction Better Picture

Possibly closed reduction !! CDH Treatment 12 – 18 months Possibly closed reduction !! when hip stable and concentrically reduced Probably open reduction when hip unstable or not concentrically reduced Arthrography guided:

CDH Treatment Above 3 years Open reduction And acetabulplasty And femoral shortening