Original Article

Management of hip dislocation with

postural management
Teresa Pountney,* Anne Mandy,† Elizabeth Green* and Paul Gard†
*Chailey Heritage Clinical Services, North Chailey, East Sussex, and †Clinical Research Centre, University of
Brighton, Eastbourne, East Sussex, UK

Accepted for publication 13 November 2001

Abstract
B a c kg ro u n d Hip dislocation in children with cerebral palsy has a well-documented history and
morbidity.
O b j e ct i ve This paper presents a retrospective study of children with bilateral cerebral palsy who
had various postural management and its effect on hip deformity.The most widely accepted
theoretical model of hip subluxation/dislocation is that an imbalance in muscle length and strength
around the hip leads to acetabular dysplasia and consequent hip subluxation. Maintenance of
muscle length and strength and loadbearing is therefore a logical prevention. Research on normal
infants’ postures has provided biomechanical data to form the theoretical basis of 24 h postural
management equipment.
M e t h od s The notes and X-rays of 59 children with bilateral cerebral palsy from East and West Sussex
and Oxfordshire were examined and measured to determine whether a relationship existed between
postural management and the level of hip subluxation/dislocation. X-rays were measured using
Reimers’ hip migration percentage. Postural management support was divided into three groups for
analysis. Category 1: use of a 24-h postural management approach using Chailey Adjustable Postural
Support (CAPS) systems in lying, sitting and standing; category 2: two items of CAPS (either
lying/sitting or sitting/standing supports); category 3: use of the CAPS seat only and/or any other
postural supports. Hip status was recorded for analysis as both hips safe (under 33% migrated), or
one/both hips subluxed.
Keywords R e s u l t s Children using ‘All CAPS’ before hip subluxation maintained significantly more hip integrity
cerebral palsy, postural than other groups (c2 P < 0.05).
management, hip
dislocation, paediatric,
C o n c l u s i o n s Postural management interventions have an important role in the prevention of hip
deformity dysplasia.

methods of controlling this deformity have been

Introduction
tried over the years with varying amounts of suc-
Hip subluxation and dislocation in children with cess, including bony and soft-tissue surgery, or-
Correspondence:
Teresa Pountney, Chailey cerebral palsy has a well-documented history and thotic devices, seating and standing supports
Heritage Clinical Services, morbidity but, as yet, successful conservative (Banks & Green 1960; Reimers 1980; Brunner 1994;
North Chailey, East Sussex
management of this problem has not been achieved Barrie & Galasko 1996). The heterogeneity of chil-
BN8 4JN, UK
E-mail:Teresa.Pountney@ (Fulford & Brown 1976; Nakamura & Ohamu 1980; dren with bilateral cerebral palsy and the variety of
southdowns.nhs.uk Hoffer 1986; Bower 1990; Cornell 1995). Numerous surgical interventions available has resulted in very

© 2002 Blackwell Science Ltd 179

180 T. Pountney e t a l.

few rigorous studies of the long-term outcome of oped out of a need to prevent musculoskeletal
many of these interventions, particularly in the area deformities while improving the ability of children
of conservative management of hips. This paper with low motor abilities to participate more active-
will present the findings of a retrospective study of ly in life with the use of powered mobility and
59 children with bilateral cerebral palsy who had a communication aids. The approach combines pos-
mixture of postural management interventions to tural control in the positions of lying, sitting and
control hip deformity. standing with hands-on therapy, active exercise
The most widely accepted theoretical model of programmes, such as cycling, horseriding and
hip subluxation and dislocation of the hip is that an swimming, and is supported by education pro-
imbalance of muscle length and strength around grammes for parents and professionals. The pos-
the hip joint disrupts the femoral head contact with tures simulate a higher level of physical ability by
the acetabulum causing acetabular dysplasia and changing the loadbearing surface and positioning
consequent hip subluxation. Muscle spasticity, par- the head, shoulder girdle, trunk, pelvis and legs. The
ticularly of the hip flexors and adductors, has often postures that the children adopt within the equip-
been cited as the initiator of this process (Baker et al. ment are based on a scheme of assessment, the
1962; Fujiwara et al. 1976; Bleck 1987; Grenier 1988; Chailey Levels of Ability (Pountney et al. 1990,
Nwaobi & Sussman 1990; Buckley et al. 1991). 1999b; Green et al. 1995). The levels detail the posi-
Current knowledge of musculoskeletal plasticity, tion of the head, shoulder and pelvic girdle and
however, suggests that apparent spasticity has a limbs and the loadbearing pattern of infants from
greater component of muscle and connective tissue birth through lying and sitting to achieving inde-
shortening than neurological hyperexcitability pendent standing. This research provided a wealth
(Chapman & Wiesendanger 1982; Dietz & Berger of biomechanical data on infants’ postures, which
1983; Carr et al. 1995). These theories suggest that has formed the theoretical basis of our equipment.
the imbalance of muscle length and strength The equipment provides a starting position for
between opposing muscle groups and the conse- movement and encourages movement within
quent impact of bony development should be pre- limited boundaries. Each item of equipment allows
ventable. The effects of muscle imbalance around a range of movement, within which the child can
the hip are present from the earliest stages of devel- move and recover balance. With a stable base, the
opment in children with bilateral cerebral palsy. A child’s use of their head, arms and legs can be more
normally developing infant achieves symmetry of controlled. Control of the hip, pelvis and spine is
posture at about 3 months of age; persisting asym- achieved by applying corrective forces via the sup-
metry beyond this age can insidiously lead to the porting surface, lateral thoracic and pelvic control
long-term gross asymmetry of posture seen in older and kneeblocks (Scrutton 1978; Nelham 1981).
children with bilateral cerebral palsy. Early changes Figures 1–4 illustrate the items of equipment.
in the acetabulum and proximal femur have been The main aim of this paper is to present the find-
documented in previous studies (Vidal et al. 1985; ings of a retrospective study of children using a
Scrutton & Baird 1997). Children with bilateral variety of postural management interventions to
cerebral palsy at 18 months had hip X-rays, which determine how effective they have been in control-
were different from those of a normally developing ling deformities of the hip and spine.
child and, at 30 months, a prediction of hip status at
5 years could be made. Maintenance of muscle
Methods
length and strength along with loadbearing to pro-
vide joint compression would be a logical solution The records of children attending Chailey Heritage
to this problem. School now or in the recent past; the Chailey
At Chailey Heritage Clinical Services, a 24-h Heritage Clinical Services Posture Clinic; children
approach to postural management has been from East and West Sussex Health Authority areas;
researched and developed over the past 15 years and the Oxfordshire Wheelchair Service were
(Pountney et al. 1999a). The approach was devel- reviewed. Children included in the study had

© 2002 Blackwell Science Ltd, C h i l d : C a re , H e a l t h & De v e l o p m e n t, 28, 2, 179–185

 Management of hip dislocation 181

Figure 1. Prone lying support.

Figure 2. Supine lying support.

Figure 3. CAPS 11 seating system.

Figure 4. Chailey standing support.

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182 T. Pountney e t a l.

bilateral cerebral palsy with no other condition author with a standard error of measurement of
likely to affect their musculoskeletal development, ±3.2. The number of invalid X-rays that could not
had used postural management equipment for a be measured and were discarded was 11%.
minimum of 2 years and had sufficient data avail-
able for analysis.
Postural management
The history of each child’s progress was docu-
mented using information from each child’s For the purposes of statistical analysis, the types of
medical, physiotherapy and rehabilitation engi- postural management used were collapsed into
neering notes. The information collected from three categories. The variety of postural supports
these notes included the child’s Chailey Levels of was numerous and would not allow statistical
Ability in lying, sitting and standing, the type of analysis on an individual basis. The three categories
positioning equipment used and the age of provi- were divided according to the degree of postural
sion. Use of equipment was recorded only if the control provided by the equipment. Category 1 (All
child was using the equipment on a regular basis CAPS) was use of all Chailey Adjustable Support
as recommended. The information collected was (CAPS) systems in lying, sitting and standing; cate-
rationalized in suitable time periods, and the posi- gory 2 (2 CAPS) was use of two items of CAPS; and
tioning equipment was categorized according to category 3 (No CAPS) was use of the CAPS seat only
type in order to ease analysis of the data. and or any other postural supports. The prolonged
The child’s hip radiographs were measured and time period and retrospective approach meant that
the date recorded. The hip measurements were complete accuracy on equipment use was not pos-
taken using the method of measuring migration sible. Children were categorized according to the
percentage described by Reimers (1980) and modi- category of postural management used most
fied by D. Scrutton (personal communication) consistently. In the case of the ‘All CAPS’ category,
using a parallel arm drafting machine, tracing paper children consistently slept in their lying supports.
and fine pencil lines. A standard error of measure- The use of ‘All CAPS’ and ‘2 CAPS’ was restricted
ment study on the modified measurement method to Chailey Heritage Clinical Services and East and
was undertaken and found standard errors of mea- West Sussex. The Oxfordshire wheelchair service
surement of ± 4%, the accuracy of which is suffi- had a 15% use of the CAPS seating system as their
cient to monitor annual migration rates. main seat but did not use either the lying or stand-
The acetabular index was measured on X-rays ing supports.
in children under 8 years of age. In children over
8 years of age, it was not measured, as it is consid-
Hip measures
ered to be unreliable (Broughton et al. 1989).
The desired outcome for each child was to have
both hips safe (< 33% migrated). Changes in single
Results
hip status were not considered significant if the
The records of 59 children were reviewed. The opposite hip remained subluxed or dislocated. The
minimum age at which the first entry in the records outcome measures used were therefore both hips
was documented was 5 months and the maximum safe (both under 33%) or one/both hips subluxed.
9.8 years. The minimum age for the final entry was Hips were considered subluxed over 33% migrated
3.2 years, maximum 18.4 years. The length of the and dislocated at over 80% migrated (Cooperman
review period was between 1.2 years and 16.9 years et al. 1987; Eklof et al. 1988; Heinrich et al. 1991).
(mean review period 7 years). At the first data entry,
93% of the children were at Chailey Level of Ability
Relationship between hip migration and
2 or below in sitting, indicating that they were
postural management
unable to sit independently. At the final measure,
this had decreased to 60%. A total of 533 X-rays A significant difference was found between children
(430 hip and 103 spinal) were measured by the using ‘All CAPS’, ‘2 CAPS’ or ‘No CAPS’ before hip

© 2002 Blackwell Science Ltd, C h i l d : C a re , H e a l t h & De v e l o p m e n t, 28, 2, 179–185

 Management of hip dislocation 183

Table 1. Final hip status of the 41 children who used associated with dislocation of the hip (Fabry et al.
postural management before hip subluxation
1973; Fujiwara et al. 1976; Stuberg 1992). Coxa
All CAPS 2 CAPS No CAPS valga may be persistent in children with cerebral
Both hips safe 13 5 1 palsy when muscle imbalance around the hip joint
One/Both hips subluxed 7 7 8 prevents the hip abductors functioning normally
and consequently disrupts the contact of the
femoral head with the acetabulum (Laplaza et al.
1993). If these theories are correct, the introduction
subluxation (c2p < 0.05, d.f. 2). This result indi- of a programme of postural management that
cated that children using the Chailey 24-h postural maintains muscle length, encourages normal
management programme before hip subluxation movement patterns and provides joint compression
were significantly more likely to maintain hip should interrupt the current mechanism of hip dys-
integrity than children exposed to other systems, plasia seen in this group of children.
see Table 1. It is necessary to identify the group of children at
risk of hip subluxation early in their development
to ensure that the process is arrested early. Grenier’s
Discussion
(1988) work indicates that the group of children
This study suggests that conservative management born very preterm may begin to experience muscle
using the 24-hour Chailey postural approach before and bony changes around the hip joint during the
the development of hip subluxation can reduce hip neonatal period, which can compromise their
dislocation in children with bilateral cerebral palsy. later development. The Chailey Levels of Ability
This approach offers more than traditional splint- (Pountney et al. 1999a) constitute a scheme that can
ing and bracing programmes. The equipment posi- be used to identify children with persisting asym-
tions children at higher ability levels that allow metry beyond the normal age.
movement from a position of symmetry to encour-
age changes in neuronal selection and the possibil-
Conclusion
ity of developing improved patterns of movement
(Hadders-Algra 2000), which will in turn have a This retrospective study gives a clear indication that
beneficial impact on muscle and bony development conservative management of hip deformity can be
around the acetabulum and proximal femur. Many successful if implemented before the development
authors have theorized about the fact that the of hip subluxation. Postural management over the
effects of delayed motor development and abnor- 24-h period is essential to help direct movement
mal patterns of movement lead to dysplasia. The patterns towards ensuring maintenance of muscle
exact mechanism of how this occurs has not been length and joint range. Interventions need to be
established, but many authors suggest that asym- acceptable for the child and family and easily inte-
metrical activity of the muscles surrounding the hip grated into their lifestyles. Postural control in lying
and their effect on bony development are the main at night can provide a long period of stretch at a
cause of dislocation (Baker et al. 1962; Fujiwara time when muscle activity does not counteract gen-
et al. 1976; Grenier 1988; Nwaobi & Sussman 1990; tle stretch. Standing support, which allows some
Buckley et al. 1991). Others suggest that lack of movement at the hip joint, aids the compression
ambulation and the consequent failure of the hip to needed for hip joint development. Currently, there
loadbear is the most significant factor in hip devel- is a prospective study under way to assess the effec-
opment (Stuberg 1992). The consequence of asym- tiveness of introducing a 24-h postural manage-
metrical muscle pull and failure to loadbear can be ment programme in a longitudinal cohort of
seen in the development of the acetabulum and the children under the age of 18 months. This will pro-
proximal end of the femur. Children with bilateral vide greater insight into the length of time that
cerebral palsy have increased femoral anteversion positioning is required to be effective in controlling
compared with the normal population, and this is deformity.

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184 T. Pountney e t a l.

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