1. CDH Congenital Dislocation of the Hip
بسم الله الرحمن الرحيم
CDH Congenital Dislocation of the Hip
Prof. Mamoun Kremli
AlMaarefa College

2. Spectrum of diseases Abnormality of proximal femur and acetabulum
Initial pathology is congenital, but
Progresses (becomes worse) if not treated
Does not always result in dislocation

3. Nomenclature CDH: Congenital Dislocation of the Hip
DDH: Developmental Dysplasia of the Hip
CDH: Congenital Dysplasia of the Hip
CHD: Congenital Heart Disease!

4. CDH - Spectrum Acetabular dysplasia: Unstable hip: Dislocated hip:
Shallow acetabulum
Unstable hip:
Dislocatable - Reducible
Dislocated hip:
May or may not be reducible
Teratologic hip:
Fixed dislocation at birth, often with other major anomalies

5. Incidence Hip instability at birth: 0.5 – 1 % Classic CDH: 0.1%
Mild dysplasia: Substantial
Up to 50%of hip arthritis in ladies have underlying hip dysplasia

6. Incidence Area Incidence per 1000 Canadian Indians 188.5 Hungary 28.7
Uppsala, Sweden 20
USA Caucaseans
Blacks
15.5
4.9
Malmo, Sweden
2.18
Chinese, Hong Kong
0.1
Bantus, Africa
among (16678)

7. Etiology
Multi-factorial
Ligament laxity
Genetic
Mechanical factors

8. Etiology 1. Ligament laxity Hormonal: Familial ligament laxity:
Estrogen, Relaxin: hormones secreted by mothers before birth
May affect baby girls more? – receptors
Familial ligament laxity:
Mild – Moderate – Sever
Ehler Danlos Syndrome

9. Ligament laxity: hypermobile joints
Etiology
Ligament laxity: hypermobile joints

10. Etiology 2. Genetic factors Twin studies
Monozygotic: 38%
Dizygotic: 3% (similar to other siblings)
Positive family history
Females: 4-6 X more than males
Could be hormonal – the effect of Relaxin hormone produced by mother on female fetus

11. Etiology 3. Mechanical factors Prenatal: Breach: Normally: 2-4%
In CDH: 16%
The breach position in utero: extended knees, and flexed hips
cause dislocation of hip by ? stretch of Hamstring muscles

12. Etiology 3. Mechanical factors Postnatal:
Swaddling / strapping hips adducted and extended, and knees extended
المهاد – القماط – الزمام – الكوفلة

13. Etiology 3. Mechanical factors Postnatal:
Swaddling / strapping hips adducted and extended, and knees extended
Proven experimentally
Proven statistically
Mechanics

14. 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 (Teratologic)

15. Clinical Examination
External rotation
Short one side

16. Clinical Examination External rotation Short one side
Lateralized contour
Wide perineum
In bilateral

17. Clinical Examination External rotation Short one side
Lateralized contour
Wide perineum
In bilateral
Asymmetrical folds
Anterior - posterior

18. Clinical Examination External rotation Short one side
Lateralized contour
Wide perineum
In bilateral
Asymmetrical folds
Anterior - posterior

19. Clinical Examination
Shortening
Might be difficult to detect early

20. Clinical Examination
Limitation of hip abduction in flexion

21. Clinical Examination
Limitation of hip abduction in flexion

22. Clinical Examination
Limitation of hip abduction in flexion

23. Clinical Examination Special test – Hip Instability: Ortolani / Barlow
Feel a Clunk, not hear a click!

24. Clinical Examination
Ortolani / Barlow

25. Clinical Examination Special test – Hamstring Stretch Sign: Normally:
Flex hip and knee 90o, and extend knee gradually
Normally:
feel resistance
CDH:
no resistance

26. Clinical Examination After walking age: Shortening – (if unilateral)
Limping:
Unilateral: limping
Bilateral: waddling (like a duck)

27. Investigation: Radiology
Early infancy:
X-ray is not reliable – all cartilage
Ultrasound is better

28. Radiology: X-ray
After 2-3 months: more reliable
39o
27o

29. Radiology: X-ray
After 2-3 months: more reliable
out in

30. Radiology: X-ray After 6 months: reliable
R hip out, and acetabulum open (dysplastic)

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

32. Treatment Birth – 6m 6-12 m: 12 - 18 m: 18 – 24 m: 2-8 years:
Pavlik harness or hip spica cast
6-12 m:
Closed reduction under GA and hip spica cast 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
No surgery
One surgery
Two surgeries
Three surgeries
Complex surgeries

33. Treatment: Neonatal Pavlik Harness Dynamic, effective, safe
Keeps hips abducted and flexed – for 6 weeks

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

35. Treatment: 6-12 m
Initially non-operative closed reduction UGA and immobilization in hip spica cast

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

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

38. Treatment: 6-12 m Arthrography-guided Closed Reduction Well in
Dislocated
Not well in

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

40. Treatment: 18-24 m Open reduction – surgery Acetabuloplasty - usually
Maybe: Femoral shortening – if high

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

42. Acetabuloplasties
Many types

43. Salter’s Acetabuloplasty
Operated hip
Dislocated hip

44. Pemberton’s Acetabuloplasty
need a lot of improvement in acetabular cover

45. Triple Steel Acetabuloplasty
Osteotomy of:
Ilium, Pubic,
and Ischium
Rotation of
acetabulum
12 years old,
Pain L hip
L hip not well
covered

46. Summary Complex multi-factorial, endemic disease
Screening programs are needed to detect and treat cases early
Learning proper examination methods
Identify at risk groups
Efficient referral system
Proper management by specialized Drs

47. Summary - Infants at risk
Positive family history: 10X
A baby girl: 4-6 X
Breach presentation: 5-10 X
Torticollis
Foot deformities
Knee deformities