A Parents Guide to Treatment for Development Dysplasia of the Hip

7/31/2019 A Parents Guide to Treatment for Development Dysplasia of the Hip

1/16


2/16

IntroductionFor some children, when a splint such as the Pavlik harness has not worked or DDH is notdiagnosed until a ter they are six months old, surgery is required. This booklet will explain the

treatment options available.

No matter how big or small your concern our helpline team are available to o er an expertear and support in complete con dence. Telephone 01925 750271 or [email protected] i you have any urther questions.

The nal outcome rom DDH will depend on the severity o your childs condition and theirresponse to treatment. However, most children are treated success ully and go on to lead a

healthy active li e with no long term problems.

ContentsWhat is Developmental dysplasia o the hip (DDH) Page 1

How can DDH be treated? Pages 2, 3

Explaining various types o Osteotomy Pages 4,5

Going into hospital Pages 6,7

Cast and Wound Care Pages 8, 9

Cast removal what to expect Pages 10, 11

Glossary Page 12/13


3/16

A parents guide to later treatment for developmental dysplasia of the hip (DDH)

What is Developmental dysplasia o the hip (DDH)?The hip is a ball and socket joint. Normally the top o the thigh bone (femur) has a roundball shape which ts into a cup like socket on the pelvis (acetabulum) . There are a range o

developmental hip conditions that can a ect babies.

Developmental dysplasia o the hip (DDH) describes a range o conditions in which the balland socket o the hip joint do not develop properly.

In the mildest orms o hip dysplasia, the socket may ail to develop correctly or the joint issimply too lax to hold the ball rmly in the socket. I le t untreated, in the more severe orms,the emoral head or ball may be displaced completely out o the socket and be dislocated.

Why does it happen?

When DDH occurs, it is important to understand that a childs hips developed this way ontheir own. Even though as parents you may be distressed at discovering your baby has a hipcondition, your baby will not nd the condition pain ul, although he or she may strongly objectto being examined. The condition can be treated success ully with early detection.

About 4 babies in every 1,000 born will have a hip that is not stable at birth. O theseabout 2 in 1000 will go on to need treatment in plaster. This can be due to various actorssuch as: A amily history o hip problems Breech position in the last three months o pregnancy

Breech birth Girls are more o ten a ected than boys, particularly the rst born Children born with other health problems e.g. oot and neck de ormities. A prolonged or di cult labour

1


4/16

How can DDH be treated?For some children, when a splint such as the Pavlik harness has not worked or DDH isnot diagnosed until a ter they are six months old, the consultant may recommend surgery.

The most common type o surgery is a reduction , a procedure in which the emoral head(ball) is relocated into the acetabulum (socket). Some children may also go on to need bonesurgery to correct bony de ormities, care ul controlled surgical division o a bone is called anosteotomy.

For all types o surgery, your child will require a general anaesthetic. As part o the procedureto reduce the hip, the surgeon will usually per orm an arthrogram (x-ray with dye). Thearthrogram shows the surgeon the hip structure and whether a closed or open reduction is

best or your child. (see page 4 or de nitions o these terms)

A ter surgery, your child will be put into a hip spica cast or a minimum o 6 weeks. At around6 weeks your child will need a review o their hip under a general anaesthetic to check thereduction and the stability o the hip an xray with dye (arthrogram) may be per ormedunder general anaesthetic to con rm the hip reduction.

It is probable that a urther period o at least 6 weeks in a hip spica will be needed to allow

the hip to stabilise securely.

A parents guide to later treatment for developmental dysplasia of the hip (DDH)2


5/16


Closed reductionDuring a closed reduction, thesurgeon gently manipulates the emur(thigh bone) so that the emoralhead (the ball) is placed in the socketwithout making an incision (cut). Inorder to achieve a stable and tension

ree reduction, it is o ten necessaryto release the tight tendon in thegroin called the adductor tendon.This is achieved by per orming a tinycut (incision) in the groin (adductortenotomy). Once the emoral headis in place, a hip spica is applied. Thetime in cast can vary depending on

the severity o the hip dysplasia. Thechild is sometimes put into a splinta ter the cast is removed to maintaincorrection.

Open reductionIn an open reduction procedure,surgery is undertaken to bring thehead o the emur (the ball) into theacetabulum (hip socket). Surgery isper ormed through a cut (incision)in the groin. Care ul release o tight

tendons and ligaments is per ormedto ensure the socket is clear and atension ree reduction o the ballinto the socket is easily achievable.The joint capsule is then repaired toaid the maintenance o the reduction.

To complete the open reduction the

surgeon may also need to correctbony de ormities and restorenormal anatomy by per orming acare ully controlled division o abone (osteotomy see below orexplanation o terms). A ter surgeryis completed, the leg is placed in aposition where the hip joint is most

stable. This means that the leg maybe set at an odd angle in the hipspica cast.

3


6/16


Explaining various types o Osteotomy

Femoral osteotomyA emoral osteotomy is sometimescalled a rotation osteotomy orderotation osteotomy. The type o surgery depends on the structure o the hip joint and the age o the child.

During the emoral osteotomy thetop end o the emur (the thigh bone)is realigned to give better stability tothe hip. The emur is care ully dividedsurgically just below the emoral neck and rotated to the best position. The

emoral osteotomy is then securedin the correct position with a metal

plate and screws or metal pins andexternal xator dependent uponyour childs surgeons pre erence. Thechild is then put in a hip spica cast

or up to eight weeks. I metal platesare used, they are usually le t in place

or about a year, when the child hasa more minor operation to remove

them. I pins and an external xatoris used, these are removed when thehip spica is removed.

Pelvic osteotomyA pelvic osteotomy is a generalterm or surgery to reconstructthe hip socket by changing its angle(reorientation) or its volume and isusually only undertaken when otherless invasive methods or normal

growth will not correct the socketunderdevelopment (acetabulardysplasia). The surgeon cuts the bonein the pelvis and moves it to improvethe structure o the hip socket andto improve support or the emoralhead. There are many di erenttypes o pelvic osteotomy and your

surgeon will advise you which heintends to use or your child. Oneo the most commonly used is theSalter Osteotomy.

All involve realigning the pelvis andmay involve temporary insertiono metal pins and bone gra ts. Most

young children are immobilised ina hip spica, but older children andteens may be allowed to movearound on crutches.

4


7/16


Salter osteotomyThe Salter osteotomy may beper ormed with an open reduction

or children who are older than 18months at the time o their rstsurgery. It may also be per ormedas a stand alone procedure or

residual acetabular dysplasis (poorsocket development). A cut is madethrough the pelvis above the socketwhere the emoral head sits. Thesurgeon tilts the acetabulum tocorrect its angle and inserts a gra to bone (taken rom another part o the pelvis through the same incision).

One or two pins are insertedthrough all the pieces o the boneto hold them together while they all

join together over a ew weeks. Atypical scar is about 6cm long.

Chiari osteotomyThis surgery makes the hip socketdeeper and the surgeon slides boneoutward to e ectively widen theshel o bone above the emoral head.Steel pins are o ten used. A ter thesurgery, only partial weight can be

put on the leg or three months.

Pemberton osteotomy

This procedure is undertaken totreat acetabular dysplasia where thesurgeon cuts the hip bone and tilts

the roo o the acetabulum (socket)to correct its angle, lling the gapwith a wedge o bone.

5


8/16


Going into hospitalBeing told your child needs to go into hospitaland ace possible surgery can be one o the

most stress ul experiences you go through as aparent. Hospitals vary on the type and level o

acilities they provide or parents and childrenso it is worth checking be orehand what youneed to bring and what is allowed.

We have compiled a Going into hospitalchecklist which lists some items you and your

child might want to bring into hospital to makeyour stay more com ortable, please re er toseparate sheet.

Communicating with Doctors

It is important to understand exactly what your childs treatment will be and how it will helpyour child. Preparing in advance a list o questions or topics that you want to discuss at yourhospital appointments will make it more likely that everything is covered.

You should not be a raid to ask questions. Parents o ten get a lot o in ormation in a shortamount o time during a typical visit. I you are not given a handout with the in ormationwritten down, ask or one, or take notes and ask questions about things you dont understand.I you dont ask any questions, your doctor will likely assume that you understand everything.

Another way to ensure you really grasp whats going on during the appointment is to bring apartner or riend along who can serve as another set o ears. I there are two o you there,youre more likely to get a balanced perspective. You can discuss what you heard a terwards.Also, everyone orgets a certain amount o what a doctor says - having another person therecan help you remember key acts.

6


9/16


Getting a second opinion

I you would like to consult with another expert about your childs treatment plan you mayask or a second (or urther) opinion. Getting a second opinion should not o end the original

doctor, provided that you stress that you require one so that you have as much in ormation aspossible to base your decisions on. Be ore asking or a second opinion, it is worth asking yourdoctor to go over and explain anything you do not understand. Although you do not have alegal right to a second opinion, you do have the right to ask or one.

Going to theatre

It is per ectly normal to eel anxious about your child going to theatre and having ananaesthetic. Anaesthesia is a very sa e procedure, but do talk to the doctors and nurses onthe ward about any speci c concerns you have. Tell them i your child has a cold or has beenunwell, as in certain circumstances, it is better to delay the operation and wait until the childis better. Most hospitals allow parents in the anaesthetic room so that you can reassure yourchild whilst they are going to sleep. The nurses on the ward will tell you what to expect andexplain how long your child will need to go without ood.

Returning rom theatre

Waiting or your child to come back rom theatre can eel like orever. Although it may bedi cult, try and occupy your mind which will help to make the time go aster. You will be toldwhen your child is ready to return to the ward. In some hospitals you will be allowed in therecovery room to be with your child when he/she wakes up. Remember your child will still beheavily sedated rom the anaesthetic, so wont remember much. Try to be calm and reassuring.The sound o your voice will help him/her to settle.

A ter bigger operations your child may come back rom theatre with a drip in the arm or oot.This is used to deliver medicines, such as painkillers and also stops your child rom becomingdehydrated. Some children also have a tube coming out rom the wound. This stops fuid romcollecting at the site o the wound and helps healing.

Most children recover very quickly. They will only be allowed to sip small amounts o waterto begin with, but as soon as they are ully awake they will be able to eed normally. A ter asimple procedure like a cast change you may be able to leave the hospital the same day. A ter abigger operation you may be in hospital a ew days.

7


10/16


Cast and Wound Care: when to seek medical adviceIt is per ectly normal or your child to eel upsetand touchy when the plaster is rst put on,

especially as they have just undergone surgery.Extra love, a ection and reassurance will usuallyhelp to settle your child and make them eelmore relaxed. Cuddles are a bit awkward, butyou will soon nd the easiest way o holdingyour child.

Severe pain or swelling not relieved bymedication or elevating the leg.

Numbness or pins and needlessensation under the cast that does not

go away a ter position is changed. I their toes/ eet are cold to touch and

become numb or bluish in color.Your childs toes should be pink andwarm to the touch and be able towiggle their toes and eel you aretouching them.

Unexplained ever above 101F.

Inability to move toes on the castedside, compared to the other side. Thespica should t properly. ie. The plasteris not too tight or too loose. I

concerned get this checked, you willsoon have a good idea o what iscorrect.

Severe skin irritation or rash aroundcast edges.

Cast becomes broken, cracked, looseor so t.

I any kind o object gets stuck insidethe cast.

Once your child has been discharged rom hospital, i you notice any o the ollowingsymptoms listed below please seek medical advice immediately by either contacting yourGP or hospital ward or advice.

8


11/16


Wound Care:

I your child has had an open reduction or osteotomy, when they return rom theatre you maybe able to see that there is a small dressing in place over the wound in their groin. This needs

stay in place or 5-7 days at least, but should it all o be ore this time, then let one o thenursing sta know and it will be replaced. You should be observing the wound once your childhas been discharged rom home.

Oozing fuids rom the wound such as blood, clear fuid or pus. Pus is only present i the wound is in ected.

Redness to the wound area Your child has a temperature or is unwell. You can smell an odour, omitting rom the wound The wound may be eel hot to touch.

Pain relie

When you are discharged rom hospital you may be given some pain relie medication(paracetamol and ibupro en) to take home with you. These are given just in case your childmay experience any pain or discom ort whilst at home. Please ollow the instructions onthe labels or how much to give, and how o ten. I you nd your child is in pain and theparacetamol and ibupro en are not working su ciently then please contact your GP orhospital or advice.

9


12/16


Cast removal what to expectThe hip spica cast may be taken o in outpatients without an anaesthetic, or in theatre undera general anaesthetic, but you will need to check with your hospital to nd out their policy.

Children can become upset when the hip spica is removed without anaesthetic and thiscan also be upsetting or parents as well. Whilst its not a pain ul procedure the noise andvibration o the plaster saw may righten your child. Distraction may help and you are allowedto be near to your child to com ort them.

The plaster technician will try to get through the procedure as quickly as possible.Once the plaster has been removed you may notice your childs skin looks red, faky and/or

scaly. This is per ectly normal and will soon settle down but you may be advised to apply anintensive moisturiser to help remove the dead skin.

An x-ray is usually taken to ensure that the hip joint is developing satis actorily and you mayalso have an appointment with your consultant or a review.

10


13/16


Li e a ter cast

The cast removal is probably the moment you have been waiting or a ter weeks or maybeeven months o your child in plaster. However, dont be worried i this is not initially the happytime you envisaged and your child appears upset and unsettled without the cast. It can take abit o time or your child to adjust to having legs again as their skin will be very sensitive.

You can pick your child up as normal but it is advised to support their bottom and hips.Even though your child may have previously loved bath time, it can take several weeks to getthem used to it again so do not be surprised i they initially get upset when in the water. Timespent in the cast may also mean that the development o some physical skills seems to havegone backwards, but they will catch up.

Also be aware that your childs legs will not return to the normal position immediately andthey may hold their legs in the plaster position. It is a case o waking up the muscles, tendonsand joints reminding them that they can move.

This can take some time and you may be re erred to Physiotherapy who will discuss somesimple exercises which you can do at home with your child. Swimming is also an excellent

orm o Physiotherapy, as its weightless and your child will o ten not realise that they are

moving their legs. The key to your child mobilising is to let them do it in their own time, anddo not orce or push them to stand or walk.

11


14/16


Glossary o terms or DDH

12

Abduction To move a limb or any other part away rom the midline o thebody

Acetabulum Cup shaped socket o the hip bone

Adducted/adducted To move a limb or any other part towards the midline o thebody

Arthrogram x-ray with dye

Bilateral A ecting both sides

Breech Position o the baby in the womb, so that it will be deliveredbuttocks rst

Congenital Present around the time o birth

DDH Developmental Dysplasia o the Hip

Developmental Arising in in ancy or childhood and dependent on growth

Dislocated The head o the thighbone is positioned outside the socket andcannot be re-centred. (displaced)

Dysplasia Lack o normal growth, in the hip o ten re ers to underdevelopment.

Femoral head Ball shaped top o the thigh bone

Femur Thigh bone

Gait Style o walking

Idiopathic A condition o which the cause is not known

Instability In the hip re ers to a joint which has too much movement

Lax Loose

Ligament Tough band o connective tissue that links two bones together ata joint

Orthopaedics A branch o medicine that deals with bones and joints

Osteoarthritis Disease o wear and tear in a joint, causes pain and lack o mobility in the joint.

Osteotomy Surgical division o the bone. Please re er to pages 4/5 orexplanations


15/16

Prognosis A prediction o a uture outcome

Reduction To restore a joint to its correct position, Closed reduction isdone by manipulation. Open reduction is done by an surgery

Subluxated Partial dislocation o a joint, so that the bones are mis-aligned,but still in contact.

Tendon A tough brous tissue that connects muscle to the bone

Tenotomy Surgical division o the tendon

Ultrasound A technique which uses high requency sound waves to build up apicture o so t tissue and organs in the body.

Unilateral A ecting one side

X-ray A technique which uses very low dose radiation to image partso the body, especially use ul or imaging bones.

A parents guide to later treatment for developmental dysplasia of the hip (DDH)13


16/16

s tepsWe dont take walking for granted

Acknowledgements

www.steps-charity.org.uk Helpline: 01925 750271

[email protected]

STEPS, Warrington Lane, Lymm, Cheshire WA13 OSASTEPS Registered charity number 1094343Company number 4379997

STEPS wishes to thank Mr Tahir Khan, Consultant Orthopaedic Surgeon and Honorary lecturer, Central ManchesterUniversity Hospitals; Mr Mark Cornell FRCS(Tr & Orth), Consultant Paediatric Orthopaedic Surgeon, East Kent HospitalsNHS Trust and all the parents who provided eedback and photos or the production o the Hip Spica Care leafet.

Externally reviewed June 2010 and published November 2010

Supporting and guidingT raining and educatingEmpowering and enablingP roviding and connecting

Seeking and campaigning

Documents

A Parents Guide to Treatment for Development Dysplasia of the Hip