This paediatric hip condition was previously known as congenital dislocation of the hip (CDH). Recently the name was changed to DDH as it was recognised that in this condition the hip may exhibit a spectrum abnormalities, which only in a minority of cases it presents as a dislocated hip at birth (<25%). In most cases the hip shows various degrees of dysplasia or subluxation (partial dislocation). In a small number of cases the hip may actually be normal at birth, but become abnormal later in life.
The incidence of this condition is about 2-4 cases per 1000 live births. Females are more frequently affected than males by 4:1. It may be bilateral in 25% of cases.
The Natural History. If this condition is left untreated, it would lead to serious complications such as a severe limp, limb shortening or early onset of osteoarthritis as an adult. Following subgroup of children are particularly at risk of DDH:
• Breech presentation.
• Positive family history.
• Babies with lower limb abnormalities at birth.
• Babies with spinal deformities at birth.
• Syndromic children.
If this condition is detected early within the first few months of life, it could easily be treated with a short period of bracing with successful outcome in over 95% of cases.
Late presentation for example in a walking child is associated with a much worse prognosis. Treatment in the walking age group is generally more complex and prolonged, often requiring open surgical procedures. Early detection and treatment is therefore paramount to ensure a successful outcome and to avoid the need for major surgery.
Screening for this condition In United Kingdom is mandatory and is carried out at birth, 6 weeks and 8 months of age. Most cases are therefore detected at an early age and treated appropriately.
Clinical Features of DDH are:
• Limitation of abduction in flexion (all age groups).
• Hip or thigh asymmetry (all age groups).
• Extra deep crease around the back of the thigh.
• Positive Barlow or Ortolani Tests (<2 months of age).
• Short leg or limping (walking age group).
It is important to note that these physical signs are more obvious in unilateral cases due to limb asymmetry. In bilateral cases these signs could easily be overlooked. Limited abduction (<60°) in both hips should raise the suspicion that both hips may be abnormal.
In difficult cases or high risk groups further investigations is recommended. For a child younger than 5 months ultrasound examination is indicated and for over 5 months plain radiographs.
Treatment. The basic principals for treatment are:
• Reduce the dislocation or subluxation.
• Hold the reduction until hip stabilises.
• Careful follow-up until skeletal maturity.
In a child less than 6 months of age the reduction can easily be achieved by flexing and abducting the hips (frog position). The reduction is usually maintained using a brace such as a Pavlik harness for a period of 2-3 months.
In a child in the age group of 6-18 months this condition is associated with major soft tissue contractures. To achieve reduction a period of traction for 1 week is usually necessary. This is then followed by an attempt of closed reduction under general anaesthesia. The reduction would require confirmation using an arthrogram (injection of dye into the hip joint under X-ray control). In the cases that there is resistance to reduction, additional surgical procedures such as tenotomy (muscle release) or limited open reduction of the hip may be necessary. Following this procedure the reduction is maintained using a frog plaster for a period of at least 4 months.
In a walking age child (>18 months) major surgery is often required to reduce and stabilise the hip. this could be in the form of an open reduction of the hip +/- pelvic or femoral osteotomy. Postoperatively a period of casting in a hip spica is necessary for 10 weeks.
Prognosis for this condition is directly related to the age of the child at the time of presentation and the severity of the hip dysplasia.
In children less than 6 months of age 98% success rate is generally expected. This is reduced to 95% if the child is within the age group of 6-24 months and 85-90% if the child is over the age of 2 years at the time of treatment.
Careful follow-up until skeletal maturity (age 16 years) is needed to confirm satisfactory progress and to identify complications such as recurrent dysplasia or avascular necrosis (loss of blood supply to femoral head) at an early stage.
Limited Abduction & Extra Thigh Crease
Barlow & Ortolani Tests
Ultrasound & Radiographs
Pavlik Harness – Frog Plaster
Gallows’ Traction & Arthrogram
Open Reduction with Femoral or Pelvic Osteotomy
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