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Developmental dysplasia of thehip

(DDH)

M O H A M M E D R J O U B

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Developmentaldysplasia of the hip

Definition

It is a congenital or acquired deformation ormisalignment of the hip joint; at birth, the hips are

usually not dislocated but rather dislocatable. Classification

1. Typical.

2. Teratologic.

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Developmental Dysplasia of the Hip

Types:

1. Complete hip dislocation.

2. Partial hip subluxation.

3. Hip dysplasia (incomplete development). Incidence:

- 7 per 1000 in Jordan

-Female predominance9 times more likely.-Depends on race and geographical variations.

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Etiology

Generalized relaxation of the hip joint.

-Family history.

-Generalized ligamentous Laxity; due to maternal

estrogen and other hormones which prevents thematuration of collagen.

-Primigravida.

-Breech presentation.

-Oligohydramnios.

-Adduction and Extension postnatally.

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Clinical Manifestations

Girls are affected 5 times more than boys.

The left hip is affected in 45%, right one 20% and35% of the cases are bilateral.

2 facts about DDH: 1-not all hip dislocation are present at birth. But

they all occur before the age of 3 months

2-newborns have hypotonic muscles in the 1st6wks till 3 m so not all cases of DDH can be diagnosedat that time.

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To diagnose DDH we have many method:

1) Barlow test.

It is a provocative test that attempts to dislocate an

unstable hip.- Flexion ,adduction, posteriorly.

- Click

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2) Ortolani test

It is a maneuver to reduce a recently dislocated hip.

- Flexion, abduction, anteriorly.

- 3) X-rays.- 4)US

- 5)Galeazzis sign

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Clinical Manifestations

In newborn:

We can diagnose DDH in this period by +veOrtolani test.

Asymmetry of the skin fold may help, but its notspecific.

Shortening of the limb at this age doesnt exist.

We cant use X-rays because the acetabulum and

proximal femur are cartilaginous and wont beshown on X-ray.

US is the best method to Dx.

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In the intermediate age (after 3 months):

The most diagnostic sign is Ortolanis limitation ofabduction.

Abduction less than 60 degrees is almost diagnostic. Shortening of the limb is more obvious

now.(Galeazzis test)

X-rays after the age of 3 can be helpful esp. after theappearance of the ossific nucleus of the femoral head

US is 100% diagnostic.

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In older children:

Complaints of limping, waddling (bilateral DDH),lumbar lordosis, limitation of hip abduction, toe-

walking, wide perineum, etc

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X-ray

von rosen view:

hips abducted 45 &medially rotated.

Anteroposterior.

We draw a line through the central axis of thefemoral shaft.

in normal hip ( ossific nucleus )will be inside theacetabulum.

in dislocated hip it will be above acetabulum.

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X-ray

Horizontal line of Hilgenreiner:

drawn between upper ends of tri-radiate cartilage ofthe acetabulum.

Vertical line of perkins:

drawn from the lateral edge of the acetabulumvertical to horizontal line.

4 quadrants:

Normal hip: the ossification center of the femoral hiplower medial quadrant.

Dislocated hip: upper lateral quadrant.

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X-ray

Acetabular index:

angle between horizontal line of hilgenreiner andthe line between the two edges of the acetabulum.

normal hip 2030dilocated or dysplastic hip 30

Shentonsline:

semicircle between femoral neck and upper arm of

obturator foramen, in dislocated hip this line isbroken.

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Treatment

The earlier the better.

Best time for treatment is in newborn period.

It depends on the device and age of the patient.

Goal is to:1.Flex and abduct hips.

2.Reduce femoral head and maintaining it.

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Treatment

From (1-6 months) use Pavlik Harness.

From 6 months -1 year use hip spika.

From the age of 1 year to 3 years:

traction , adductor tenotomy , surgical closedreduction, salter innominate osteotomy.

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Thank You