• Developmental dysplasia of the hip describes a spectrum of disorders related to abnormal development of the hip.
• It may develop at any time during fetal life, infancy, or childhood in which there is a shallow acetabulum, subluxation, or dislocation.
• Incidence: 10 per 1000 live births.
• Eighty percent of the patients are female.
Developmental Dysplasia of the Hip (DDH)
• Abnormal development of the components of the hip joints, Which are:
• Head of the femur
• Surrounding capsules and soft tissues
Two common types of DDH
1. laxity of the supporting capsule
2. a result of an abnormality of the acetabulum.
• The excessive laxity of the joint may prevent detection in early infancy. The femoral head remains in contact with the acetabulum until additional stress (such as standing) moves it away.
Degrees of DDH
1- Acetabular dysplasia
Acetabular dysplasia (or preluxation)-The mildest form, in which there is neither subluxation nor dislocation.
• The dysplasia reflects an apparent delay in acetabular development evidenced by
• hypoplasia of the acetabular roof, which is oblique and shallow, although the cartilaginous roof is comparatively intact.
• The femoral head remains in the acetabulum.
• Subluxation-Accounts for the largest percentage of congenital hip dysplasias.
• Subluxation implies incomplete dislocation or displaceable hip. It is an intermediate state in the development from primary dysplasia to complete dislocation.
• The femoral head remains in contact with the acetabulum, but a stretched capsule and ligamentum teres cause the head of the femur to be partially displaced.
• Pressure on the cartilaginous roof inhibits ossification and produces a flattening of the socket.
• Dislocation-The femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly over the fibrocartilaginous rim.
• The ligamentum teres is elongated and taut.
Causes of DDH
• birth order
• family history
• intrauterine position
• breech delivery
• joint laxity
• postnatal positioning (swaddling)
• Neurological disorders like in meningo-myelocele
• Other predisposing factors
– physiologic (maternal hormone secretion)
– mechanical (intrauterine posture pelvic laxity medication)
Clinical Manifestations of DDH
• In the newborn period dysplasia usually appears as hip joint laxity rather than as outright dislocation.
• Positive Ortolani and Barlow tests. The tests are most reliable from birth to 2 or 3 months of age. Adduction contracture’s develop at about 6 to 10 weeks, and the Ortolani sign disappears.
• After this time the most sensitive test is limited hip abduction
• Other signs are shortening of the limb on the affected side (Allis sign, Galleazzi sign)
• Trendelenburg test: standing with affected leg elevated, dislocated hip rises
• Asymmetric thigh and gluteal folds: The baby is held upright, it would be observed that the tow hips do not correspond in position
Assessment of Developmental Dysplasia of the Hip
• Signs of developmental dysplasia of the hip.
• Asymmetry of gluteal and thigh folds
• Limited hip abduction
• Apparent shortening of the femur as indicated by the level of the knees in flexion.
• Ortolani click (if infant is under 4 weeks of age).
• Positive Trendelenburg sign or gait (if child is weight bearing).
Diagnostic Evaluation of Developmental Dysplasia of the Hip
• Assessment: DDH is often not detected at the initial examination after birth; thus all infants should be carefully monitored for hip dysplasia at follow-up visits throughout the first year of life.
• X-Ray: Radiographic examination in early infancy is not reliable because ossification of the femoral head does not normally take place until the third to sixth month of life.
• Ultrasound: The cartilaginous head can be visualized directly with high-resolution ultrasonography. The ultrasonographic examination can detect slight subluxations and dislocations as well as monitor progress over time.
In older infants and children
• Radiographic examination is useful in confirming the diagnosis. An upward slope in the roof of the acetabulum (the acetabular angle) greater than 40 degrees with upward and outward displacement of the femoral head is a frequent finding in older children.
• A CT scan may be useful to assess the position of the femoral head relative to the acetabulum following closed reduction and casting.
Therapeutic Management of Developmental Dysplasia of the Hip
• Treatment is begun as soon as the condition is recognized because early intervention is more favorable to the restoration of normal bony architecture and function.
• The longer treatment is delayed, the more severe the deformity, the more difficult the treatment, and the less favorable the prognosis.
• The treatment varies with the age of the child and the extent of the dysplasia.
• The goal of treatment is to obtain and maintain a safe, congruent position of the hip joint in order to promote normal hip joint development. Newborn to Six Months.
• The hip joint is maintained by dynamic splinting in a safe position with the proximal femur centered in the acetabulum in an attitude of flexion. A variety of abduction devices are available for maintaining the femur in the acetabulum.
• The harness is a dynamic splint that is worn continuously until the hip is clinically and radiographically stable, usually about 3 to 5 months. It is highly effective when the device is well constructed, follow-up care is adequate, and the parents follow instructions in its use.
• The Pavlik harness does not rigidly immobilize the hip but acts to prevent hip extension or adduction. Because of the infant’s rapid growth rate, the straps should be checked every 1 to 2 weeks for possible adjustments. Improper positioning may cause vascular or nerve damage.
• When adduction contracture is present, other devices (such as skin traction) are employed to slowly and gently stretch the hip to full abduction, after which wide abduction is maintained until stability is attained.
• Older Child. Correction of the hip deformity in the older child is more difficult.
• Operative reduction, which may involve preoperative traction, tenotomy of contracted muscles.
• Successful reduction and reconstruction become increasingly difficult after the age of 4 years and are usually impossible or inadvisable after age 6 because of severe shortening and contracture of muscles and deformity of the femoral and acetabular structures.
Nursing care plan Developmental Dysplasia of the Hip
1. Impaired physical mobility R/T dislocation of hip, and presence of splint or cast
1. Maintain the correct position of the hip.
2. Explain the components and purposes of splint or cast.
3. Enhance play and using the upper portion of the body.
4. Teach walking with cast
5. Support the casted limp and avoid pressure on heels
2. Potential for injury, neurovascular impairment R/T compression by cast.
1. Watch for signs of compression
2. Observe pedal pulse and ability to move fingers
3. Ask for tingling, numbness, pain, or burning sensation
4. Assess for tightness by inserting finger between cast and skin
3. Knowledge deficit of parent regarding home care:
1. Teach how to care of the child
2. Different treatment procedures
3. Involve parent in care of the child
4. Regular Follow up