DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) And Nursing Care Plan

DDH Operation

Terminology:

The modern term developmental dysplasia of the hip (D.D.H.) has replaced the traditional term congenital dislocation of the hip (C.D.H.).

Recently, it was realized that some hips were normal at birth and gradually became dysplastic or dislocated later.

Incidence:

  • Race : Rare in Egypt , common in Europe.
  • Sex : 3 times more common in girls.
  • Side : Unilateral more common, Left hip more common.
  • Birth presentation: 10 times more common in breech presentation.
  • Hereditary factors: +ve family history in 25%.

 

Pathology:

1 – Bone Changes:

1. Acetabulum: Shallow, anteverted and occupied by a mass of fibro-fatty tissue (pulvinar).

2. Femoral Head: Delayed appearance of 2ry centre of ossification (normally at 3-6 m.).

3. Femoral neck: Short , anterverted.

DDH Pathology

 

2- Soft Tissue Changes:

1. Capsule: Elongated & grooved anteriorly by the ilio-psoas tendon.

2. Ligamentum Teres: Elongated & hypertrophied ( obstacle to reduction).

3. Labrum (Limbus): Inverted (obstacle to reduction).

4. Muscles: Ilio-psoas, adductors and abductors are shortened.

 

DDH Diagnosis:

I- In the Newborn:

  • D.D.H. should be detected early for better results.
  • Risk factors: +ve family history, breech presentation, associated congenital anomalies.

A. Clinical Diagnosis:

1. Asymmetrical skin creases (unilateral cases).

2. Limitation of hip abduction in flexion.

3. Barlow’s test & Ortolani’s test:

• The hips are adducted and pushed backwards to dislocate the hip. A +ve Barlow’s sign is a palpable clunk of exit of the femoral head slipping outside the acetabulum.

• The hips are abducted and pushed forewards to relocate the hip. A +ve Ortolani’s sign is a palpable sensation of the femoral head slipping into the acetabulum.

Ortolani’s testBarlow's sign

 

B. Ultrasound Diagnosis:

  • Most valuable up to 3 months since the cartilaginous structure of the hip doesn’t show up on radiographs.
  • The angle of the slope of the acetabular roof and the shape and position of the femoral head are inspected.

 

II- In Older Children:

A. Clinical Diagnosis:

1. History of delayed walking with limping.

2. Galeazzi test: Baby lies on his back with hips and knees flexed. A lower height of the knee on the dislocated side.

3. Limitation of hip abduction in flexion.

4. Hyperlordosis in bilateral cases.

5. +ve Trendelenburg test and gait.

Galeazzi test

Hyperlordosis

 

B. Radiographic Diagnosis:

1.Delayed appearance and smaller size of ossific nucleus.

2.A horizontal line is drawn between the two triradiate cartilages (Hilgenreinger’s line), and a vertical line is drawn down at the outer margin of the acetabulum (Perkin’s line), the epiphsis of femoral head should lie in the inner, lower quadrant.

3. The acetabular roof has an upwards slope. Acetabular index ( the angle between Hilgenreiner’s line and acetabular roof) is increased (Normal about 30o).

4. Shenton line: Disturbed.

acetabular line

 

 Hilgenreinger’s line, Perkin’s line, Shenton’s line

Bilateral DDH

 

TREATMENT OF D.D.H.

Treatment of D.D.H. should start as early as possible because:

1- Early reduction stimulates normal development of the hip joint.

2- Reduction becomes more difficult as the child becomes older.

A. Treatment At Birth:

  • If the hip is reducible it is held by a Pavlik harness (flexion – abduction orthosis) for 8-12 weeks.
  • If the hip is stable (as shown with U.S.), the harness is removed.
  • The Pavlik harness is not indicated in children older than 6 months.

Pavlik Harness

B. Treatment Before Walking Age:

If hip is irreducible, “Gallow’s” skin traction is applied for 2-3 weeks, followed by clinical examination and arthrography under anaesthesia in the operating theatre.

 

1- Closed reduction:

When closed reduction is possible without an obstacle, a hip spica is applied in the human position (90o flexion and 45o abduction of the hip) for 6-12 weeks followed by an abduction brace.

2- Open reduction:

Indications:

a. Failure of conservative treatment.

b. Neglected cases.

DDH surgery

C. Treatment After Walking Age:

  • Combined open reduction and Salter’s pelvic osteotomy (rotates the acetabulum downwards, forwards and laterally to increase coverage of femoral head).
  • Femoral shortening may be needed to aid in reduction.

D. Treatment After Walking Age:

  • Above age of 5-10 years reduction is difficult and unwise because of the high risk of AVN.
  • the hip is best left alone until age is suitable for total hip replacement.

 

Nursing Care plan for DDH

  • Pain relief
  • protect operated joint from further injury
  • RICE therapy (Rest, Ice, Compression, Elevation)
  • Immobilization
  • Family support
  • Making sure that the family understand the rehabilitation program
  • Demonstrating the adaptation required for patients in cast
  • making sure that the family understand how to check for suture line infections and if there are drainage or bad odor from the cast and the importance of reporting them immediately

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