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CONGENITAL

DYSLOCATION OF
THE HIP

Introduction
Congenital hip dislocation occurs
when the connection between the
thighbone and the pelvic
bone is out of socket or dislocated.
A child may have one or both hips
dislocated.
Congenital hip dislocation is also
called developmental dysplasia of the
hip (DDH).

In these cases, the acetabulum is in an

antero-superior position as a
consequence of the excessive
anteversion, this way becoming
progressively flat and oblique.
This occurs as a consequence of lack of
contact between the acetabulum and
the femoral head, which is generally in a
15 anteversion.

Congenital dislocation of the hip (CDH.)


is commoner in girls and is associated
with a shallow acetabulum with an
altered angle of the femoral head. In
the child the femoral head is angled
forward, ante-verted, to a greater
angle than in the adult. This angle is
even larger in CDH. The maximum
normal of 35 degrees decreases
gradually to the adult 15 degrees. In
CDH. this angle may be as large as 70
degrees.

Incidence :
5-20 per 1000 live birth
Girls are much more commonly affected
than boys, the ratio about 7 : 1
The left hip is more often
In 1 in 5 cases the condition is bilateral

in girls than in boys and more common


in first-born children than in laterborn children.

ETIOLOGI
Genetic factors
Wynne-Davies (1970) identified two
heritable features which could
predispose to hip instasbility :
generalize joint laxity (a dominant
trait) and shallow acetabuli (a
polygenic trait which is seen mainly in
girls and their mothers)

Hormonal factors
Oestrogen,progesteron, and relaxin
in the last few weeks of the
pregnancy may aggravate ligamentous
in the infant
Intauterine malposition
especially a breech position with
extended legs, this so called
packaging disorder is linked with
the higher incidence in first-born
babies

Post natal factors


contribute to persistence of neonatal
instability and acetabular
maldevelopment. Common in north
America Indians who swaddle their
babies and carry them with legs
together,hips and knees fully
extended, and is rare in southern
Chinese and black African who carry
their babies astride their backs with
legs widely abducted

Yamamuro and Ishida,1984


The experimental evidence that
simulteneous hip and knee axtension
leads to hip dislocation during early
development

At birth the hip, though unstable, is


probably normal in shape but the
capsule is often stretched and
redundant
The capsule is stretched and the
ligamentum teres becomes elongated
and hypertrophied
Capsular edge may be pushed into the
socket by the dislocated femoral
head

After weightbearing commences,


both the acetabulum and the femoral
neck remain anteverted and the
pressure of the femoral head induces
a false socket to form above the
shallow acetabulum
The capsule,squeezed between the
edge of the acetabulum and the
psoas muscle,develops an hourglass
appearance,for long time the muscle
become adaptively shortened

Every newborn child should be


examined for sign of hip instability
Family history of congenital
instability
oligohydramnion
Breech presentation
The testing for instability :

Ortolanis test
The babys thigh are held with the thumbs
medially and the fingers resting on the
greater trochanters,the hips are flexed

To 90o and gently abducted,normally


Abduction 90o. In congenital dislocation is
impeded, but if pressure is applied to
the greater trochanter
clunk, and
then the hip abdutcs fully ( the jerk of
entry ).
If abduction stops half-way and there is
no jerk of entry
irreducible
dislocation

Barlows test
the thumb is placed in the
groin and by grasping the
upper thigh, to lever the
femoral head in and out of the
acetabulum during abduction
and adduction, normally in the
reduce position,if the slip out
of the socket and back in
again
dislocatable

Every hip with signs of instabilityhowever slight


examined
ultrasonography
Shows the shape of the cartilaginous
socket and the position of the
femoral head
An observant mother spot asymetry,
a clicking hip or difficulty in applying
the napkin because of limited
abduction

With unilateral dislocation the skin


creases look asymmetrical,the leg is
slightly short and externally rotated
A thumb in the groin feel the femoral
head is missing
Bilateral dislocation there is an
abnormally wide perineal gap

Imaging
X-ray of infants are difficult to
interpret because the acetabulum and
femoral head are largely cartilaginous
Ultrasound scanning has largely replaced
radiography for imaging hips in the
newborn

Management
If there is any abnormality the infant is
placed in a splint with the hip flexed and
abducted
The hip that are unstable at birth,8090% will stabilize spontaneously in 2-3
weeks
Do not to start splintage immediately
unless the hip is already dislocated

This reduces the small risk of


epiphyseal necrosis that attends any
form of restrictive splintage in the
neonate
If a 3 weeks the hip is still unstable,
reduce position and abduction
splintage is applied from the outset
until the hip is stable and X-ray
shows a good acetabular roof (usually
3-6 months)

Splintage
The object of splintage is to hold the
hips somewhat flexed and abducted
For the newborn,double nakins or a soft
abduction pillow may suffice
Von rosens splint is an H-shaped
malleable splint
The pavlik harness is more difficult to
apply but gives the child more freedom
while still maintaining position

The three golden rules of splintage


are :
The hip must be properly reduced
before it is splinted
Extreme position must be avoided
The hip should be able to move

Persisten dislocation 6-18 months


Closed reduction

This is the ideal but risk damaging the blood


supply to the femoral head and causing
necrosis

Splintage
The concentrically reduced hip is held in a
plaster spica at 60o of flexion, 40o of
abduction and 20o of internal rotation

Operation
The psoas tendon is divided : obstructing
tissues ( redundant capsule,thickened
ligamentum teres).
If stability can be achieved only by markedly
internally rotating the hip
subtrochantericosteotomy

Persistent dislocation : 18 months 4


years
Many surgeons would proceed straight to
anthrography and open reduction
Pambertons operation
Acetabuloplasty pericapsular reconstruction of
the acetabular roof

Unilateral dislocation in the child over 8


years of age often with a mobile hip and
little pain
open operation and
acetabular reconstruction

Bilateral dislocation the deformity


and the waddling gait
Most surgeon avoid operation above
the age of 4 years unless the hip is
painful or deformity unusually severe