Congenital Hip Dislocation

A dislocation of the hip in newborns. A hip dislocation is where the ball joint at the
top of the leg is not sitting in the correct position in the hip joint. The condition
tends to be more common in girls and babies born in the breech position.

The condition may also be referred to as congenital hip dysplasia.

Ortolani, an Italian pediatrician in the early 1900s, evaluated, diagnosed, and began
treating hip dysplasia. Galeazzi later reviewed more than 12,000 cases of DDH and
reported the association between apparent shortening of the flexed femur and hip
dislocation.

Etiology

A developmental fault of the hip system produced by extrinsic factors—growth

circumstances—with a combination of hereditary and environmental faults which
alter the normal growth potential or the intrinsic mosaic pattern. Congenital
dislocation and congenital dysplasia are developmental deformities produced by
secondary adaptive changes. Inherited characteristics and environmental factors
may alter the intrinsic mosaic pattern by a faulty timing in development.

Risk Factors

1. Breech Presentation

2. Female gender

3. Family History (positive in up to one third of cases)

a. One affected sibling: 6% risk

b. One affected parent: 12% risk

c. One affected sibling and one affected parent: 36%

4. Firstborn

5. Oligohydramnios

Types of Congenital Hip Dislocation

1. Classic congenital Hip Dislocation

2. Congenital Abduction Contracture of the Hip

 3. Teratologic Congenital Hip Dislocation

a. Severe, prenatal fixed dislocation

b. Associated with genetic and neuromuscular disorders

Signs

A. Dislocation and Relocation maneuvers

1. Useful only in first 3 months of life

2. Repeat in 2 weeks if equivocal

3. Tests

a. Ortolani Test (relocate hip into acetabulum)

b. Barlow's Test (attempt to sublux unstable hip)

B. Pelvis symmetry

1. Galeazzi's Sign (compare the 2 femur lengths)

2. Observe for asymmetric skin folds

Symptoms

A. Painless limp in toddler (best if diagnosed earlier)

Anatomy and Pathophysiology

The hip is a ball and socket joint between the head of

the upper femur (thighbone) and the bony pelvis. The femoral head is the ball and
the acetabulum of the pelvic bone is the socket. The hip joint is lined with cartilage.
Cartilage is the smooth, gliding surface inside all joints. Joints are also lubricated
with a substance known as synovial fluid.
The hip bursae are fluid-filled areas in the soft tissues around the hip joint where
tendons and muscles pass over bony prominences. These fluid-filled sacs serve as a
cushion between tendons and bone and lubricate the region with synovial fluid.

Diagnostic Procedure

A careful physical examination of a newborn usually detects hip dislocation. In older

infants and children, hip x-rays can confirm the diagnosis.

Imaging

A. Dynamic Hip Ultrasound (infant aged 1-6 months)

1. Diagnostic for congenital Hip Dislocation

2. Evaluates for subluxation and reducibility

3. High false positive rate <6 weeks

B. Hip XRay

1. Not diagnostic for dislocation until >6 months

1. Femoral head not calcified under age 4-6 months

2. Diagnostic for Acetabular Dysplasia

a. Abnormal acetabular fossa will be seen

C. Evaluated with reference lines drawn over AP XRay

1. Hilgenreiner's Line

a. Horizontal line through triradiate cartilages

2. Perkin's Line

a. Vertical line along each lateral acetabulum

3. Shenton's Line

a. Femoral neck medial border

b. Superior border of obturator foramen

Medical Management

A. Management indicated for hip instability beyond 5 days

B. Step 1: Pavlik Harness

1. Indicated as first-line if age <6 months

2. Start with harness trial for 3-4 weeks

3. Splints hips in flexed and abducted position

4. Long-term effect: 95% (80% if frank dislocation)

5. Ultrasound should demonstrate reduction at 3 weeks

a. Reduced: Continue harness for >6 weeks

b. Not Reduced: Go to Step 2

C. Step 2: Closed Reduction and Casting by Orthopedics

1. Indications

a. No reduction with Pavlik Harness in 3-4 weeks

b. Children over age 6 months

2. Attempted closed reduction under arthrogram

3. Hip Spica Casting for 12 weeks

4. Positioning confirmed by post-op MRI or CT

D. Step 3: Surgical Open reduction

1. Indicated in refractory cases

2. Requires multi-step procedure

a. Tendon lengthening

b. Clearing tissues obstructing relocation

c. Tightening hip capsule

d. Osteotomy if performed after age 18 month

3. Complicated by re-dislocation, osteonecrosis

Nursing Care Management