CDH CONGENITAL DISLOCATION OF THE HIP Dr. ABDULMONEM ALSIDDIKY , MD , SSCO. Assistant Professor & Consultant pediatric Ortho.& Spinal Deformities KSU,KKUH Riyadh , Saudi Arabia

Nomenclature CDH : Congenital Dislocation of the Hip DDH : Developmental Dysplasia of the Hip

NORMAL PELVIS

Normal hip Dislocated hip

Patterns of disease Dislocated Dislocatable Sublaxated Acetabular dysplasia

Radiology After 6 months: reliable

Causes (multi factorial) Unknown Hormonal Relaxin, oxytocin Familial Lig.laxity diseases Genetics Female 4 X male --- twins 40% Mechanical Pre natal Post natal

Mechanical causes Pre natal Post natal Breach , oligohydrominus , primigravida , twins (torticollis , metatarsus adductus ) Post natal Swaddling , strapping

Infants at risk Positive family history: 10X A baby girl: 4-6 X Breach presentation: 5-10 X Torticollis: CDH in 10-20% of cases Foot deformities: Calcaneo-valgus and metatarsus adductus Knee deformities: hyperextension and dislocation

When risk factors are present Infants at risk When risk factors are present The infant should be reviewed Clinically radiologically

Clinical examination The infant should be quiet comfortable

Look: External rotation Lateralized contour Shortening Asymmetrical skin folds Anterior – posterior

Move Limited abduction

Special test Galiazzi Ortolani , Barlow test Trendelenburgh sign Limping ( waddling gait if bilateral)

Special test Galiazzi test

Special test Ortolani test

Special test Barlow test

Special test Trendelenburgh sign

Screening programs Clinical screening proven to be effective Performed by trained personnel Must be dynamic Repeated with periodic examination U/S screening is controversial

Investigations 0-3 months U/S > 3months X-ray pelvis AP + abduction

U/S Screening Incidence of hip stability declines rapidly to 50% within the first week of neonatal life. Better to delay U/S screening

U/S - Problems Too sensitive: Operator-dependant Detects a lot of hip abnormalities, most of which would develop normally if left alone Operator-dependant

Radiology Early infancy: not reliable

Radiology After 2-3 months: more reliable

Radiology After 2-3 months: more reliable 39o 27o

Radiology in out After 2-3 months: more reliable Von Rosen view in out

Radiology After 2-3 months: more reliable out in

Radiology After 6 months: reliable

Radiology After 6 months: reliable

Treatment - Aims Obtain concentric reduction Maintain concentric reduction In a non-traumatic fashion Without disrupting the blood supply to femoral head

Treatment Method depends on age The earlier started, the easier it is The earlier started, the better the results are Should be detected EARLY

Treatment Birth – 6m 6-12 m: 12 - 18 m: 18 – 24 m: 2-8 years: Pavlik harness or hip spica 6-12 m: Closed reduction under GA and hip spica 12 - 18 m: Open reduction 18 – 24 m: Open reduction and Acetabuloplasty 2-8 years: Open reduction, Acetabuloplasty, and femoral shortening Above 8 years: Open reduction, Acetabuloplasty cutting all three pelvic bones, and femoral shortening

Treatment: Neonatal hip instability Most resolve spontaneously Can initially wait Avoid adduction swaddle Apply double diapers – to bring back!! See at 2weeks of age

Treatment: Neonatal hip instability Unstable at 2 weeks: Double / Triple diapers: inadequate Gives illusion that patient is “in treatment” while wasting valuable time

Treatment: Neonatal hip instability Unstable at 2 weeks: Pavlik Harness Dynamic, effective, safe

Treatment: 6-12 m Initially non-operative closed reduction UGA and immobilization in hip spica cast Position: Avoid sever abduction Avoid frog position Must obtain stable concentric reduction, otherwise needs surgery

Treatment: 6-12 m Possibly closed reduction Possibly open reduction Stable and concentric reduction Possibly open reduction Unstable or un-concentric reduction Arthrography-guided

Treatment: 6-12 m Possibly closed reduction Possibly open reduction Stable and concentric reduction Possibly open reduction Unstable or un-concentric reduction Arthrography-guided

Treatment: 6-12 m Arthrography-guided Closed Reduction

Arthrography-guided Closed Reduction Treatment: 6-12 m Arthrography-guided Closed Reduction Too lateralized Acceptable

Treatment: 18-24 m Open reduction – surgery Possibly: Acetabuloplasty

Treatment: Above 2 years Open reduction, and Acetabuloplasty, and Femoral shortening

Acetabuloplasties Many types

Treatment Birth – 6m 6-12 m: 12 - 18 m: 18 – 24 m: 2-8 years: Pavlik harness or hip spica 6-12 m: Closed reduction under GA and hip spica 12 - 18 m: Open reduction 18 – 24 m: Open reduction and Acetabuloplasty 2-8 years: Open reduction, Acetabuloplasty, and femoral shortening Above 8 years: Open reduction, Acetabuloplasty cutting all three pelvic bones, and femoral shortening

CDH - Summary Complex multi-factorial, endemic disease Health education and Drs. awareness Screening programs are needed Learning proper examination methods Identify at risk groups Efficient referral system Proper management by specialized Drs

Examples

THANKS