c







 In children who have begun to walk, limping, toe walking and a waddling "duck-
like" gait are also signs.


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In addition to visual clues, doctors use careful physical examination tests to check
A malformation of the hip joint that is present at birth. Genetic factors likely play a for subtle signs of hip instability or dislocation in babies, such as listening and
role in this disorder. Features include hip dislocation, asymmetry of leg positions, feeling for "clunks." Hip X-rays also may be helpful in older infants and children.
asymmetric fat folds, and diminished movement on the affected side. Some children
will exhibit little or no features and must be diagnosed by physical examination of Treatment methods depend upon the child¶s age.
the hip joints.
c

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Clinical studies show a familial tendency toward Congenital hip dysplasia, with
Congenital hip dysplasia is an abnormal formation of the hip joint in which the ball more females affected than males. This disorder is found in many cultures around the
at the top of the thighbone (femoral head) is not stable in the socket (acetabulum). world. However, statistics show that the Native American population has a high
Also, the ligaments of the hip joint may be loose and stretched. The degree of incidence of hip dislocation. This has been documented to be due to the common
instability or looseness varies. A baby born with DDH may have the ball of his or her practice of swaddling and using cradleboards for restraining the infants. This places
hip loosely in the socket, the looseness may worsen as the child grows and becomes the infant's hips into extreme adduction (brought together). The incidence of
more active, or the ball may be completely dislocated at birth. congenital Congenital hip dysplasia is also higher in infants born by caesarian and
breech position births. Evidence also shows a greater chance of this hip abnormality
Left untreated, DDH or Congenital hip dysplasia leads to pain and osteoarthritis by in the first born compared to the second or third child. Hormonal changes within the
early adulthood. It may cause legs of different lengths or a "duck-like" walk and mother during pregnancy, resulting in increased ligament laxity, is thought to
decreased agility. DDH has a familial tendency. It usually affects the left hip and is possibly cross over to the placenta and cause the baby to have lax ligaments while
predominant in: still in the womb. Other symptoms of complete dislocation include a shortening of
the leg and limited ability to abduct the leg.
àV Girls.
àV First born children. 


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àV abies born in the breech position (especially with feet up by the
shoulders). The American Academy of Pediatrics now recommends
ultrasound screening of all female, breech babies.
Although Congenital hip dysplasia is usually noted in the newborn exam, treatment
is easier and safer the earlier the diagnosis is made. Hips found normal at birth can
be found abnormal later, but this is rare. Pediatricians screen for DDH at a
newborn¶s first exam and at every well-baby checkup thereafter. Otherwise, the
condition may not be noticed until a child begins to walk ± by which time treatment
is more complicated and uncertain.
ecause the abnormalities of this hip problem often vary, a thorough physical
examination is necessary for an accurate diagnosis of congenital Congenital hip
dysplasia. The hip disorder can be diagnosed by moving the hip to determine if the
head of the femur is moving in and out of the hip joint. One specific method, called
the Ortolani test, begins with each of the examiners hands around the infant's knees,
with the second and third fingers pointing down the child's thigh. With the legs
abducted (moved apart), the examiner may be able to discern a distinct clicking
sound with motion. If symptoms are present with a noted increase in abduction, the
test is considered positive for hip joint instability. It is important to note this test is
only valid a few weeks after birth.
j
 
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The arlow method is another test performed with the infant's hip brought together
with knees in full bent position. The examiner's middle finger is placed over the
Although some dislocated hips show no signs, contact a doctor if your baby has: outside of the hipbone while the thumb is placed on the inner side of the knee. The
hip is abducted to where it can be felt if the hip is sliding out and then back in the
àV Legs of different lengths. joint. In older babies, if there is a lack of range of motion in one hip or even both
àV uneven thigh skin folds. hips, it is possible that the movement is blocked because the hip has dislocated and
àV Less mobility or flexibility on one side. the muscles have contracted in that position. Also in older infants, hip dislocation is
evident if one leg looks shorter than the other.
X-ray films can be helpful in detecting abnormal findings of the hip joint. X rays
may also be helpful in finding the proper positioning of the hip joint for treatments of
casting. ultrasound has been noted as a safe and effective tool for the diagnosis of
congenital Congenital hip dysplasia. ultrasound has advantages over x rays, as
several positions are noted during the ultrasound procedure. This is in contrast to
hip problems. Avoiding excessive and prolonged infant hip adduction may help
prevent strain on the hip joints. Early diagnosis remains an important part of
prevention of congenital Congenital hip dysplasia.


 c

c

 




only one position observed during the x ray.
A malformation of the hip joint that is present at birth. Genetic factors likely play a

 c

 



 role in this disorder. Features include hip dislocation, asymmetry of leg positions,
asymmetric fat folds, and diminished movement on the affected side. Some children
The objective of treatment is to replace the head of the femur into the acetabulum will exhibit little or no features and must be diagnosed by physical examination of
and, by applying constant pressure, to enlarge and deepen the socket. In the past, the hip joints.
stabilization was achieved by placing rolled cotton diapers or a pillow between the
thighs, thereby keeping the knees in a frog like position. More recently the Pavlik 


c

c

 




harness and von Rosen splint are commonly used in infants up to the age of six
months. A stiff shell cast may be used, which achieves the same purpose, spreading Congenital Congenital hip dysplasia is a disorder in children that is either present at
the legs apart and forcing the head of the femur into the acetabulum. In some cases, birth or shortly thereafter. During gestation, the infant's hip should be developing
in older children between six to 18 months, surgery may be necessary to reposition with the head of the thigh bone (femur) sitting perfectly centered in its shallow
the joint. Also at this age, the use of closed manipulation may be applied socket (acetabulum). The acetabulum should cover the head of the femur as if it were
successfully, by moving the leg around manually to replace joint. Operations are not a ball sitting inside of a cup. In the event of congenital Congenital hip dysplasia, the
only performed to reduce the dislocation of the hip, but also to repair a defect in the development of the acetabulum in an infant allows the femoral head to ride upward
acetabulum. A cast is applied after the operation to hold the head of the femur in the out of the joint socket, especially when weight bearing begins.
correct position. The use of a home traction program is now more common.
However, after the age of eight years, surgical procedures are primarily done for pain
reduction measures only. Total hip surgeries may be inevitable later in adulthood. c



 
 c

c

 







 c

 


  Clinical studies show a familial tendency toward Congenital hip dysplasia, with
more females affected than males. This disorder is found in many cultures around the
world. However, statistics show that the Native American population has a high
Nonsurgical treatments include exercise programs, orthosis (a force system, often incidence of hip dislocation. This has been documented to be due to the common
involving braces), and medications. A physical therapist may develop a program that practice of swaddling and using cradleboards for restraining the infants. This places
includes strengthening, range-of-motion exercises, pain control, and functional the infant's hips into extreme adduction (brought together). The incidence of
activities. Chiropractic medicine may be helpful, especially the procedures of closed congenital Congenital hip dysplasia is also higher in infants born by caesarian and
manipulations, to reduce the dislocated hip joint. breech position births. Evidence also shows a greater chance of this hip abnormality
in the first born compared to the second or third child. Hormonal changes within the
 
  mother during pregnancy, resulting in increased ligament laxity, is thought to
possibly cross over to the placenta and cause the baby to have lax ligaments while
unless corrected soon after birth, abnormal stresses cause malformation of the still in the womb. Other symptoms of complete dislocation include a shortening of
developing femur, with a characteristic limp or waddling gait. If cases of congenital the leg and limited ability to abduct the leg.
Congenital hip dysplasia go untreated, the child will have difficulty walking , which
could result in life-long pain. In addition, if this condition goes untreated, the 
  c

c

 

 
abnormal hip positioning will force the acetabulum to locate to another position to
accommodate the displaced femur. ecause the abnormalities of this hip problem often vary, a thorough physical
examination is necessary for an accurate diagnosis of congenital Congenital hip


 dysplasia. The hip disorder can be diagnosed by moving the hip to determine if the
head of the femur is moving in and out of the hip joint. One specific method, called
Prevention includes proper prenatal care to determine the position of the baby in the the Ortolani test, begins with each of the examiners hands around the infant's knees,
womb. This may be helpful in preparing for possible breech births associated with with the second and third fingers pointing down the child's thigh. With the legs
abducted (moved apart), the examiner may be able to discern a distinct clicking  
  c

c

 

 
sound with motion. If symptoms are present with a noted increase in abduction, the
test is considered positive for hip joint instability. It is important to note this test is unless corrected soon after birth, abnormal stresses cause malformation of the
only valid a few weeks after birth. developing femur, with a characteristic limp or waddling gait. If cases of congenital
Congenital hip dysplasia go untreated, the child will have difficulty walking , which
The arlow method is another test performed with the infant's hip brought together could result in life-long pain. In addition, if this condition goes untreated, the
with knees in full bent position. The examiner's middle finger is placed over the abnormal hip positioning will force the acetabulum to locate to another position to
outside of the hipbone while the thumb is placed on the inner side of the knee. The accommodate the displaced femur.
hip is abducted to where it can be felt if the hip is sliding out and then back in the
joint. In older babies, if there is a lack of range of motion in one hip or even both 

 c

c

 

 
hips, it is possible that the movement is blocked because the hip has dislocated and
the muscles have contracted in that position. Also in older infants, hip dislocation is Prevention includes proper prenatal care to determine the position of the baby in the
evident if one leg looks shorter than the other. womb. This may be helpful in preparing for possible breech births associated with
hip problems. Avoiding excessive and prolonged infant hip adduction may help
X-ray films can be helpful in detecting abnormal findings of the hip joint. X rays prevent strain on the hip joints. Early diagnosis remains an important part of
may also be helpful in finding the proper positioning of the hip joint for treatments of prevention of congenital Congenital hip dysplasia.
casting. ultrasound has been noted as a safe and effective tool for the diagnosis of
congenital Congenital hip dysplasia. ultrasound has advantages over x rays, as
V
several positions are noted during the ultrasound procedure. This is in contrast to
only one position observed during the x ray.
A broader definition of DDH is simply abnormal growth of the hip. Abnormal
development of the hip includes the osseous structures, such as the acetabulum and

 c

c

 

  the proximal femur, and the labrum, capsule, and other soft tissues. This condition
may occur at any time, from conception to skeletal maturity. The author prefers to
The objective of treatment is to replace the head of the femur into the acetabulum use the term hip dysplasia because he believes this term is simpler and more
and, by applying constant pressure, to enlarge and deepen the socket. In the past, accurate. Internationally, this disorder is still referred to as congenital dislocation of
stabilization was achieved by placing rolled cotton diapers or a pillow between the the hip.
thighs, thereby keeping the knees in a frog like position. More recently the Pavlik
harness and von Rosen splint are commonly used in infants up to the age of six
More specific terms are often used to better describe the condition; these are defined
months. A stiff shell cast may be used, which achieves the same purpose, spreading
as follows:
the legs apart and forcing the head of the femur into the acetabulum. In some cases,
in older children between six to 18 months, surgery may be necessary to reposition
the joint. Also at this age, the use of closed manipulation may be applied àV Subluxation ± This is incomplete contact between the articular surfaces of
successfully, by moving the leg around manually to replace joint. Operations are not the femoral head and acetabulum.
only performed to reduce the dislocation of the hip, but also to repair a defect in the àV Dislocation ± This refers to complete loss of contact between the articular
acetabulum. A cast is applied after the operation to hold the head of the femur in the surface of the femoral head and acetabulum.
correct position. The use of a home traction program is now more common. àV Instability ± This consists of the ability to subluxate or dislocate the hip
However, after the age of eight years, surgical procedures are primarily done for pain with passive manipulation.
reduction measures only. Total hip surgeries may be inevitable later in adulthood. àV Teratologic dislocation ± This refers to antenatal dislocation of the hip.



 c

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 -

 
Nonsurgical treatments include exercise programs, orthosis (a force system, often
involving braces), and medications. A physical therapist may develop a program that
includes strengthening, range-of-motion exercises, pain control, and functional
activities. Chiropractic medicine may be helpful, especially the procedures of closed
manipulations, to reduce the dislocated hip joint.
àV The normal growth of the acetabulum depends on normal epiphyseal
growth of the triradiate cartilage and on the 3 ossification centers located
within the acetabular portion of the pubis (os acetabulum), ilium (acetabular
epiphysis), and ischium. Additionally, normal growth of the acetabulum
depends on normal interstitial appositional growth within the acetabulum.
 The presence of the spherical femoral head within the acetabulum is critical Also in older infants, hip dislocation may be present if one leg
for stimulating normal development of the acetabulum. looks shorter than the other.
àV The anatomy of the dislocated hip, especially after several months, often
àV X-ray films can be helpful in detecting abnormal findings of
includes formation of a ridge called the neolimbus. Closed reduction is
often unsuccessful at a later date, secondary to various obstacles to the hip joint. Œ
may also be helpful in finding the proper
reduction. These include adductor and psoas tendon contraction, positioning of the hip joint for treatment. ultrasound has been
ligamentous teres, a transverse acetabular ligament, and pulvinar and noted as a safe and effective tool for the diagnosis of
capsular constriction. With long-standing dislocations, interposition of the congenital hip dysplasia. ultrasound has advantages over x
labrum can also interfere with reduction.
rays, as several positions are noted during the ultrasound
àV c




 
 procedure. This is in contrast to only one position observed
àV Hormonal changes within the mother during pregnancy result
in increased ligament looseness or laxity and are thought to
possibly cross over the placenta and cause the baby to have lax
ligaments while still in the womb. Other symptoms of complete
dislocation include a shortening of the leg and limited ability to
abduct the leg, or move it outward.
àV 



àV ecause the abnormalities of this hip problem often vary, a
thorough physical examination is necessary for an accurate
diagnosis of congenital hip dysplasia. The hip disorder can be
diagnosed by moving the hip to determine if the head of the
femur is moving in and out of the hip joint. One specific
method, called the Ortolani test, begins with each of the
examiner's hands around the infant's knees, with the second
and third fingers pointing down the child's thigh. With the legs
abducted (moved apart), the examiner may be able to hear a
distinct clicking sound, called a hip click, with motion. If
symptoms are present with a noted increase in abduction, the
test is considered positive for hip joint instability. It is
important to note this test is only valid a few weeks after birth.
àV The arlow method is another test performed with the infant's
hip brought together with knees in full bent position. The
examiner's middle finger is placed over the outside of the

reduction measures
hipbone while the thumb is placed on the inner side of the
knee. The hip is abducted to where it can be felt if the hip is
sliding out and then back in the joint. In older babies, if there is
programs, orthosis (a
a lack of range of motion in one hip or even both hips, it is
possible that the movement is blocked because the hip has
dislocated and the muscles have contracted in that position.
during the x ray.
àV 

àV The objective of treatment is to replace the head of the femur
into the acetabulum and, by applying constant pressure, to
enlarge and deepen the socket. In the past, stabilization was
achieved by placing rolled cotton diapers or a pillow between
the thighs. The child may be dressed in two or three diapers,
called double or triple diapering. oth these techniques keep
the knees in a frog-like position. In the early 2000s, the Pavlik
harness and von Rosen splint are commonly used in infants up
to the age of six months to spread the legs apart and force the
head of the femur into the acetabulum. A stiff shell cast, called
a splint, may be also used to achieve the same purpose. In some
cases, older children between six to 18 months old may need
surgery to reposition the joint. Also at this age, the use of
closed manipulation may be applied successfully, by moving
the leg around manually to replace the joint. Operations are
performed to reduce the dislocation of the hip and to repair a
defect in the acetabulum. A cast is applied after the operation
to hold the head of the femur in the correct position. As of
2004 the use of a home traction program was more common.
However, after the child is eight years of age, surgical
procedures are primarily done for
only. Total hip surgeries may be inevitable later in adulthood.
àV 


àV Nonsurgical treatments include 
force system, often involving braces), and medications. A
physical therapist may develop a program that includes
strengthening, range-of-motion exercises, pain control, and
functional activities. Chiropractic medicine may be helpful,
 especially the procedures of closed manipulations, to reduce initial newborn exam, it is imperative that parents follow up
the dislocated hip joint. with their pediatrician for a more extensive examination of the
àV  


 hips soon after the newborn comes home.
àV unless corrected soon after birth, congenital hip dysplasia can àV *
 -j
cause a characteristic limp or waddling gait in children. If left àV 
XTurning away from the body.
untreated, the child will have difficulty walking and may àV XThe large cup-shaped cavity at the junction of
experience life-long pain. If diagnosed early, congenital hip pelvis and femur (thigh bone).
dysplasia treatment is highly effective. Children who have àV 
XMovement toward the body.
received casting, bracing, or surgery, usually go on to have àV 
Xusing orthopedic devices to hold joints or limbs in
normal hip and leg development. In individuals for whom the place.
diagnosis is made later, the prognosis is not as positive. These àV 
 
XThe displacement of bones at a joint or the
children may require more extensive surgery. After surgery, displacement of any part of the body from its normal position.
however, the prognosis for normal development of the hip and

XAbnormal changes in cells.
leg is excellent.
àV 



XAn external device, such as a splint or a brace, that
àV Prevention includes proper prenatal care to determine the
position of the baby in the womb. This may be helpful in
preparing for possible breech births associated with hip
problems. Avoiding excessive and prolonged infant hip
adduction, or forcing the legs in a straight position close

XA thin piece of rigid or flexible material that is used
together for periods of time (as in swaddling) may help prevent
strain on the hip joints. Early diagnosis remains an important
part of prevention of congenital hip dysplasia.
àV 



 hip (DDH) are identified during examination of the newborn.
àV It is important for infants suspected of having congenital hip
dysplasia to receive regular physical examinations. Since this
disorder of the hip is progressive and early detection and
treatment are essential, the American Academy of Pediatrics
has suggested guidelines for examination and treatment of
children suspected of having development hip dysplasia. They
suggest referral to a pediatric orthopedist if an infant has a
positive Ortolani or arlow test. For infants with mild hip
clicks, they suggest the child be seen by the regular
pediatrician in two weeks for follow up since most benign hip
clicks will resolve within that time period. If signs of hip
dysplasia are still present after two weeks, it is recommended
that the child be seen by a pediatric orthopedist. If double or
triple diapering is recommended by the pediatrician after the
àV 
àV —XThe thigh bone.
àV G
prevents or assists movement.
àV 
XThe organ that provides oxygen and nutrition from
the mother to the unborn baby during pregnancy. The placenta
is attached to the wall of the uterus and leads to the unborn
baby via the umbilical cord.
àV j
to restrain, support, or immobilize a part of the body while
healing takes place.
àV Early clinical manifestations of developmental dysplasia of the
The classic examination finding is revealed with the Ortolani
maneuver; a palpable "clunk" is present when the hip is
reduced in and out of the acetabulum and over the neolimbus.
A high-pitched "click" (as opposed to a clunk) in all likelihood
has little association with acetabular pathology.[22, 23] Ortolani
originally described this clunk as occurring with either
subluxation or reduction of the hip (in or out of the
acetabulum). More commonly, the Ortolani sign is referred to
as a clunk, felt when the hip reduces into the acetabulum, with
the hip in abduction.
àV To perform this maneuver correctly, the patient must be
relaxed. Only one hip is examined at a time. The examiner's
thumb is placed over the patient's inner thigh, and the index
finger is gently placed over the greater trochanter. The hip is
 abducted, and gentle pressure is placed over the greater
trochanter. In the presence of DDH, a clunk, similar to turning
a light switch on or off, is felt when the hip is reduced. The
Ortolani maneuver should be performed gently, such that the
fingertips do not blanch.[24]
àV arlow described another test for DDH that is performed with
the hips in an adducted position, in which slight gentle
posterior pressure is applied to the hips. A clunk should be felt
as the hip subluxes out of the acetabulum.[5]
àV The clinical examination for late DDH, when the child is aged
3-6 months, is quite different. At this point, the hip, if
dislocated, is often dislocated in a fixed position.[11] The
Galeazzi sign is a classic identifying sign for unilateral hip
dislocation (see image below). This is performed with the
patient lying supine and the hips and knees flexed. The
examination should demonstrate that one leg appears shorter
than the other. Although this finding is usually due to hip
dislocation, realizing that any limb-length discrepancy results
in a positive Galeazzi sign is important.
—
V V


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V VV VVV
VV V  V

V VV 
 V VV V
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V
V V