HIP DISORDERS IN

CHILDREN
Marietta S, MD., Physiatrist

 Developmental dysplasia of the hip (DDH) is

a dislocation of the hip joint that is present
at birth. The condition is found in babies or
young children.

Causes, incidence, and risk

factors
The cause is unknown. Low levels of amniotic
fluid in the womb during pregnancy can increase
a baby's risk of DDH. Other risk factors include:
The first child
Female
Breech position during pregnancy, in which the
baby's bottom is down
Family history of the disorder
DDH occurs in about 1 out of 1,000 births.

Symptoms
There may be no symptoms. Symptoms that may
occur can include:
Leg with hip problem may appear to turn out more
Reduced movement on the side of the body with
the dislocation
Shorter leg on the side with the hip dislocation
Uneven skin folds of thigh or buttocks
After 3 months of age, the affected leg may turn
outward or be shorter than the other leg.

Signs and tests

The most common method of identifying the condition is a
physical exam of the hips, which involves applying pressure
while moving the hips. The health care provider listens for
any clicks, clunks, or pops.
Ultrasound of the hip is used in younger infants to confirm
the problem. An x-ray of the hip joint may help diagnose the
condition in older infants and children.
A hip that is truly dislocated in an infant should be detected
at birth, but some cases are mild and symptoms may not
develop until after birth, which is why multiple exams are
recommended. Some mild cases are silent and cannot be
found during a physical exam.

Treatment
When the problem is found during the first 6 months of
life, a device or harness is used to keep the legs apart
and turned outward (frog-leg position). This device will
usually hold the hip joint in place while the child grows.
This harness works for most infants when it is started
before age 6 months, but it is less likely to work for
older children.
Children who do not improve, or who are diagnosed
after 6 months often need surgery. After surgery, a cast
will be placed on the child's leg for a period of time.

 Expectations (prognosis)
If hip dysplasia is found in the first few months of life, it
can almost always be treated successfully with a
positioning device (bracing). In a few cases, surgery is
needed to put the hip back in joint.
Hip dysplasia that is found after early infancy may lead to
a worse outcome and may need more complex surgery to
fix the problem.
Complications
Bracing devices may cause skin irritation. Differences in
the lengths of the legs may persist despite appropriate
treatment.
Untreated, hip dysplasia will lead to arthritis and
deterioration of the hip, which can be severely debilitating.

Developmental dysplasia and

congenital dislocation of the hip
Definition
Developmental
dysplasia of the hip
(DDH): Inadequate
development of the hip
with impaired
ossification of the
lateral acetabular
epiphysis
Congenital
dislocation of the hip
(CDH): Displacement of
the femoral head from
its central position in

The dysplasia rate in

Central Europe (Germany,
Czech Republic, Austria,
Switzerland, Northern Italy)
used to be from 24% until
the late seventies. Today it
is much lower.
The dislocation rate (in
historical studies) was 0.5
1%.

 In the UK, the USA and

Scandinavia, the
dysplasia rate is 0.5
1%, and the dislocation
rate less than 0.05%.
In a recent study in the
UK, 88 dislocations
were found in 34723
neonates (=0,25%)

The absence of hip

dysplasia among the
primitive tribes of
Africa to the fact that
the infants are carried
by the mother at the
side, resting on the
pelvis, or on the back
with spread legs.
Other more northerly
located primitive
peoples, North
American Indian tribes
tend to wrap their
infants tightly and
accordingly experience
high dislocation rates.

Diagnosis

Clinical diagnosis in
the neonate History
Family history (hip
dysplasia or premature
osteoarthritis of the hip)
Firstborn child
Amniotic fluid
deficiency
Breech presentation .

ETIOLOGY
Since the introduction
of the ultrasound
screening method by
Graf, we know that, in
addition to dysplastic
and dislocated hips,
there are a large
number of immature
hips.
Percentages as high as
30% have been
reported.
As part of the
evolutionary
development of
humans, the upright

 To this immaturity
can be added a
number of other
factors:
genetic,
hormonal and
mechanical.

Dunn [22]
differentiated two
types of hip
dysplasia. The
general joint
hypermobility
dysplasia ofthe
acetabulum , without
any significant
ligament laxity

 The first group shows

general joint
hypermobility , which
manifests itself at birth
as hip instability.
Girls are
predominantly affected
(the ratio of boys to
girls in this group is
1:12)
Hormonal, genetic and
constitutional factors
play a major role in this
group

The second group is

characterized by dysplasia
of the acetabulum , without
any significant ligament
laxity.
increasingly observed
particularly in
oligohydramnios. This
acetabular immaturity,
breech presentation
connection with other
deformities or
malformations, e.g.
clubfoot, flat feet, facial
asymmetries and muscular
torticollis.
ratio of boys to girls 1:2,
and the left side is twice as
likely to be affected as the
right side.

dysplasia of the acetabulum , without any

significant ligament laxity

Mechanical factors associated with the lack of space for

the neonate in the uterus play a major role in this group.
The consequence is delayed ossification of the lateral
acetabular epiphysis, i.e. dysplasia, which leads to
secondary dislocation as a result of the inadequate
contouring of the acetabular roof
However, the dislocation itself very rarely occurs at
birth, but tends to occur secondarily during the course
of the first few months of life as a result of the
increasingextension in the hip.

 As the displacement
progresses, the femoral
head comes out of the
acetabulum, usually in
a craniodorsal
direction.
The acetabulum is
secondarily filled with
fatty and connective
tissue.
If the femoral head has
left the acetabulum,

shortening of the
iliopsoas muscle will
occur.
The tendon, which is
located right next to
and partially fused
with, the hip capsule,
strangles the capsule
and becomes an
obstacle to reduction.
The elevated position
of the femoral head
causes shortening of
the leg

 the abductors (particularly

the gluteus medius and
minimus muscles) & hip
extensors (gluteus
maximus) are shortened
and weakened.
to a flexion contracture
of the hip and, on the
other, to the inability to
stabilize the pelvis when
standing on one leg.
The consequence is an
abnormal pelvic tilt that is
compensated by
hyperlordosis of the
lumbar spine

Testing for shortening

of the thigh (a) in hip dislocation and for
abduction (b)

Clinical examination

Inspection
Asymmetry of skin folds :
Pronounced asymmetry
of the
skin folds can be an
indication of unilateral
dislocation.
skin folds in the infant are
almost never completely
symmetrical, this
examination is not very
informative
Leg length examination :
With the hip and knee
flexed at
right angles, the thigh on
the dislocated side is

ORTOLANI TEST
The hip and knee are flexed
at 90.
Grasp the knee, placing the
thumb on the inside of the
thigh and the index and
middle fingers around the
greater trochanter
First hold the legs in an
adducted position and apply
gentle pressure in the dorsal
direction.
Then perform an abduction
maneuver, applying slightly
greater pressure to the
greater trochanter

Ortolani.
If the femoral head had been subluxated in the adduction
position, a click is perceived as it snaps back into the
acetabulum.

Barlow Test
Barlows test is similar to
that of Ortolani, but places
less emphasis on the
abduction/adduction
maneuver, and more on the
thumb pressure.
Place the hips in a position
of central abduction.
First apply pressure to the
greater trochanter to test
the reduction maneuver
Then, from the same
abduction position, try to
dislocate the femoral head
by applying pressure
dorsally and laterally

If it snaps back into place,

the hip is
dislocatable.
Stabilize the pelvis with
the other hand by placing
the thumb on the feet
and encircling the sacrum
with the other fingers.
The Ortolani click and the
Barlow sign remain
positive for approx. 4
weeks in an unstable hip,

Barlowortolani

 Ludloffs dislocation
sign : Extension of the
knees is not normally
possible if the hip is
flexed by more than
90 because of the
tensing of the
hamstrings.
If the hip is dislocated
however, the knee can
be extended in this
position

ROM
Neonates usually show a
flexion contracture of
around 3040.
This is a physiological
finding, since both hips are
flexed more than 90 within
the uterus.
Since it is not possible
therefore to examine
rotation in the extended
position, rotation is
examined in the flexed
position in the usual way

 Since the femoral head

center starts to ossify
after a year or so, the
diagnosis must then be
made radiologically.
At this age, only the AP
view is normally
recorded
The AP view in the
infant should always be
an x-ray of both hips so
that the pelvic position
and the horizontal
situation can be
evaluated

Line.

The Hilgenreiner line joins the two

Y-lines of the triradiate cartilage
and thus forms the horizontal on
the pelvic view.
The Ombrdanne line is drawn from
the lateral edge of the acetabular
roof, i.e. the lateral acetabular
epiphysis (perpendicular to the
Hilgenreiner line) and crosses
through the Hilgenreiner line to
form four quadrants.
Normally the center of the femoral
head is in the lower inner quadrant

 Orientation line according to

Shenton and Mnard :
Normally the continuation of
the medial femoral neck
contour forms a smooth arc
as it passes through the
superior border of the
obturator foramen.
In a dislocated hip this arc
is disrupted because the
femoral neck is displaced
upwards.

Acetabular roof angle = AC

angle or acetabular index
angle between the
horizontal (Hilgenreiner line)
and the line joining the
Triadiate cartilage and the
lateral acetabular epiphysis.
The average angle at birth
is 30, at 1 year slightly
over 20 and at 3 years of
age under 20.

Mean value ACE

Hip arthrography
Hip arthrography is suitable for evaluating the
cartilaginous sections of the hip, the ligament of head of
femur and other soft tissues.
From the gluteal fold, a long needle is inserted under
sterile conditions and advanced up to the hip under
image-intensifier control. 23 ml of contrast medium
(Jopamiro) are injected

ULTRASOUND
At the start of the 1980s,
Graf developed a
sonographic screening
technique for the infant
hip that represented a
significant advance in the
diagnosis of congenital
dysplasia of the hip.
Sonography of the hip is
performed from a lateral
approach, and the ilium as
displayed on the image
must be parallel with the
ultrasound head.

Suitable frequencies are

the 7.5 MHz transducer
head for small infants
and the 5 MHz head for
larger infants.
Graf introduced two
angles as a guide to
evaluation: alpha angle
and beta angle

GRAFT
method

Graf subsequently
proposed a
classification taking
into account the
various conditions of
the hip :
Alfa angle (angle between the centering of the
the lateral acetabular
femoral head
epiphysis and triadiate
maturation of the bony
cartilage and the lateral
epiphysis
margin of the ilium)
beta angle (angle between steepness of the
the lateral border of the
acetabulum and
ilium and a line joining the
the age of the patient
lateral acetabular
epiphysis and labrum).

Ultrasound

Ultrasound

Screening with US
If general screening is not available, the
ultrasound examination should at least be
indicated if certain broadly interpreted risk
factors are present.
The corresponding risk factors are:
a family history of hip dysplasia or coxarthrosis,
premature birth ,
breech presentation,
other skeletal anomalies,
oligohydramnios ,
clinical suspicion of hip dysplasia.

Rehabilitation time line in DDH (Teclin)

16mo
612mo
>12m
o

Goal : maintain the femoral head within acetabulum

PAVLIK HARNESS maintain the hip flexed & abducted position
(stretch adductor muscles,allows femoral head to slide over
posteriorrim into acetabulum

Mabe difficult to relocate femoral head

TRACTION +Pavlik Harness
Ambulatory child Abduction orthosis

Rarely able to be relocated

Home traction followed by closed reduction before
Surgery

Conservative treatment
The following types of
treatment are
differentiated:
maturation
treatment,
closed reduction,
immobilization.

MATURATION TREATMENT
If an immature hip of type
IIa or IIc is detected on the
ultrasound scan, the
femoral head is not
dislocated and does not
therefore need to be
reduced
A maturation treatment
with abduction pants or a
Tuebingen splint

 The abduction pants were introduced by Frejka in 1941 These

are made of a plastic material and incorporate a rigid bar
placed between the legs.
The pants hold the legs in abduction and are worn over the
infants normal clothes.
The orthosis cannot be worn continuously since it must be
removed for nursing care purposes or when changing the
babys clothes.

 High rates of avascular

necrosis were reported during
the first few years of
abduction splinting [83], at a
time when these orthoses
were used for reductions.
Excessive abductions of up to
90 were also employed.
We therefore use the
Tuebingen splint developed by
A. Bernau for maturation
treatment

This produces less

pronounced abduction but
greater flexion than standard
abduction pants.
It is easy to handle and its
size can be adjusted to fit the
infant.
Since it is made from plastic,
hygiene is less of a problem
than with the Pavlik harness,
for example, which is made
of fabric

Reduction methods

We differentiate
between the
following options:
manual reduction
methods,
braces for
reduction,
traction methods.

Manual reduction
methods
Manual reduction
methods are of
historical significance
only as the associated
complication rates were
far too high.
Manual reductions
were described by
Lorenz 1895 and Lange

Reduction braces
The Pavlik harness
incorporates two shoulder
straps that cross over at the
back and are fastened to a
broad chest strap which
fastens at the front
The lower legs are enclosed
by stirrup-like straps, with
the topmost strap encircling
the leg just below the knee.
The distance between the
chest strap and the lower
legs can be adjusted
separately by means of
buckles at the front and
back

 The legs are first placed

in a flexion position of
approx. 110, which
should then be gradually
supplemented by
increasing abduction
An additional transverse
strap can prevent the
distraction from
exceeding 60.
This repositioning of the
dislocated hip can take a
few days in some
children, but may require
several weeks in others.

The dislocated hips reduce

themselves spontaneously
as a result of the babys
thrashing about, and no
actual reduction maneuver
is needed
The use of this harness
beyond the age of 9 months
is not recommended .
In the hands of skilled
practitioners, reduction with
the Pavlik harness is a
reliable method with few
complications
report a high number of
unsuccessful reductions and
complications

 On the one hand, these

findings were very
probably the result of
inadequate compliance
on the part of the
mothers.
The Pavlik harness is
relatively complicated &
the numerous straps can
be confusing for the
parents.
For hygienic reasons, the
harness has to be
changed frequently, and
the constant
readjustments can be
problematic.

The main problem : harness

very easily becomes soiled
by the child & cannot then
simply be wiped down like a
plastic splint.
one study that plastic
splints are much easier to
manage
the Pavlik harness is more
suitable for reducing
subluxated (Graf type III)
hips than completely
dislocated (Graf type IV)
hips
Another study a
relatively high necrosis rate
of 33% after reduction with
the Pavlik harness

Traction methods

There are two methods:

longitudinal traction
overhead traction
LONGITUDINAL TRACTION
Longitudinal traction for
reducing the hip is the
first known therapeutic
procedure and was
described by Pravaz in
1847
It is still used today, in
some cases as a homebased treatment

The traction is achieved

with plaster strapping
affixed to the legs.
Aboard placed beneath
the feet is designed to
avoid pressure on the
malleoli.
The traction weight is
initially 1/7 of the
infants weight, but can
subsequently be
increased to 1/4 or
more.

 The skin should be

monitored carefully.
Triangular pants can be
used to provide
counterforce, or else
the foot of the bed can
be elevated so that the
weight of the body is
shifted towards the
head.
The legs are abducted
by approx. 20

OVERHEAD TRACTION
Overhead traction
was introduced in
1955 by Craig &
remains a widely used
method even today.
This traction can also
be employed for older
children for whom a
Pavlik harness is no
longer appropriate.
Overhead traction
requires the fitting of
two bars at the side of
the bed which are
linked together above
the bed by a crossbar.

Overhead traction
A weight of 11.5 kg is
attached to the childs
legs with strapping and
exerts traction via a
cord that runs over
pulleys
The degree of traction
should initially be
adjusted to produce a
flexion of over 90.
The pulleys are then
shifted laterally to
gradually increase
abduction

Overhead traction
We shift the pulleys so as to
achieve an abduction of
around 70 after 8l0 days.
By this time spontaneous
reduction has occurred in
most cases, and this can be
checked by arthrography.
If the traction were
increasedto 90 abduction,
there would be an increased
risk of femoral head
necrosis.
Reduction with overhead
traction must be followed by
immobilization, for which we
use the Fettweis spica cast

Traction improves the

chances of a successful
closed reduction
and reduces the risk of
avascular necrosis of the
femoral head

immobilization

The following can be used for

immobilization:
plaster casts,
splints,
braces,
abduction pants
Plaster casts
Hip spica in the Lorenz position
This oldest known immobilization
treatment described by Lorenz in
1895

fixed the hips in an abduction

position of 90 (also known as the
frog position)
very many cases of avascular
necrosis of the femoral head have
occurred as a complication of
immobilization in this position
the intraarticular pressure
produced by pronounced
abduction and internal rotation is
excessive and causes
constrictionof the intra-epiphyseal
vessels in the soft cartilage

Immobilization in a squatting position

according to
Fettweis

In 1968 Fettweis
proposed a treatment of
reduction and
immobilization in a hip
spica in the squatting
position, in which the hips
are flexed by up to 110
120, but limiting the
abduction to approx. 50
60
the rate of avascular
necrosis is much lower, at
around 5%
The long-term treatment
with the Fettweis cast is
also very well tolerated

After a reduction use the

Fettweis cast for at least 8
weeks for immobilization
purposes
The cast must be changed
after 4 weeks.
The cast can be changed
under light sedation and
does not usually require
general anesthesia.
The feet do not need to be
included in the cast but can
be allowed to move freely.

 Various abduction splints

are used for immobilization
purposes.
These are particularly
suitable as follow-up
treatment after
immobilization in a Fettweis
hip spica.
The Denis Browne splint,
introduced in 1948 used to
be very popular since it was
very easy to manage.
However, since it suffers
from the drawback of having
been designed for an
abduction position of 90
this splint
should no longer be used.

Numerous modifications of
the Denis Browne splint ,
with the aim of producing a
better position, have been
proposed.
A well-known example is the
Tuebingen splint which we
tend to use.
After a congenital
dislocation of the hip, we
follow 3 months of
permanent immobilization in
the squatting cast with a
further 3 months of splint
treatment.

Tuebingen splint

Pelvic harness
The Pavlik harness is also
suitable for immobilization
purposes, although it is not
particularly appropriate for
use in infants older than 9
months.
Since the Pavlik harness is
not very practical for the
mother, we only use it
occasionally.
Various reports inthe
literature have described
failed reduction or
subsequent dislocation in
the caudal direction after
the use of the Pavlik harness
The treatment is only
suitable if the parents are

complication
Avascular necrosis of the Femoral head
The commonest and most serious complication of
treatment of congenital dislocation of the hip
In most cases, the necrosis is a consequence of
treatment and does not result from the dislocation
itself.
The necrosis can occur in the epiphyseal plate
either laterally, centrally or medially

Avascular necrosis
Results shortening of
the femoral neck, or
head in neck position,
and overgrowth of the
greater trochanter.
The same shortening of
the femoral neck and
overgrowth of the greater
trochanter is also seen
with central necrosis
Medial necrosis results in
a coxa vara. But the
necrosis can also affect
the acetabulum.

Follow up (min x ray)

THANK
YOU