Developmental Dysplasia of the Hip

Developmental Dysplasia of the Hip: 

Developmental Dysplasia of the Hip By Michael Hyland and Darice Hofstein February 12, 2012

Developmental Dysplasia of the Hip (DDH)4: 

Developmental Dysplasia of the Hip (DDH) 4 Also known as congenital hip dislocation (CHD). Condition of developing hip apparent at birth or during early development. Characterized by misalignment of femoral head and acetabulum due to shallow or small acetabulum with poor lateral borders.

Developmental Dysplasia of the Hip (DDH): 

Developmental Dysplasia of the Hip (DDH) Four grades 4 Subluxatable – Femoral head partially displaced to rim of acetabulum . Slides laterally, not completely out of socket. Dislocated – Femoral head completely outside socket, can be reduced with manual pressure. Dislocatable – Femoral head is in socket, can be displaced completely outside of acetabulum with manual pressure. Teratologic – Femoral head completely outside hip socket and cannot be reduced with manual pressure.

Developmental Dysplasia of the Hip (DDH): 

Developmental Dysplasia of the Hip (DDH) Example: Dislocatable http://www.surgical-tutor.org.uk/default-home.htm?specialities/paediatric/cdh.htm~right . Updated January 29, 2012. Accessed February 9, 2012.

Developmental Dysplasia of the Hip (DDH): 

Developmental Dysplasia of the Hip (DDH) Image Findings: Right femoral head dislocation Marked decrease in right femoral head development Immature bilateral femoral epiphysis Under developed bilateral ischial tuberosity

Developmental Dysplasia of the Hip (DDH): 

Developmental Dysplasia of the Hip (DDH) Image Findings Continued: Biomechanical Impairments – Decreased congruency of right hip joint. Physical Impairments – Abnormality and/or inability of gait, discomfort and/or inability of standing.

Incidence of DDH4: 

Incidence of DDH 4 Dysplasia or subluxation effects 1 out of every 100 births and 1 out of 1000 for dislocation in the US 8:1 ratio female:male Higher incidence with firstborn child, left hip, breech delivery, multiple births, family Hx , and those of Native American and Japanese ethnicity

Signs and Symptoms4: 

Signs and Symptoms 4 Limited ROM in hip abduction Asymmetrical skin folds in buttock and adductor region Leg length discrepancy Positive Barlow or Ortolani special tests Gait abnormalities Contractures limiting hip flexion/extension or abduction, and possibly knee flexion

Diagnosis: 

Diagnosis Clinical examination Confirmation by diagnostic ultrasound, MRI, and standard radiography. Imaging plays a crucial role.

Prognosis: 

Prognosis Secondary to subluxation of hip or dysplasia, there is probability for 20% - 50% degenerative OA. 5 With use of Pavlik harness, there is 85% success in the treatment of DDH. 5 If DDH is found within first few months of life, use of a positioning device gives high probability of successful development. 6 Complications occur if DDH is found after early infancy, may require surgery. 6

Imaging in Dx of DDH: 

Imaging in Dx of DDH Diagnostic ultrasound is the gold standard for diagnosis of DDH in an infant. 3,4 Advantages of US include ease of use, freedom from ionizing radiation, capacity to reveal non-bony structures, and capacity for evaluating the progress of therapy. 3 A recent study published in scholarly journal International Orthopedics proved the importance of ultrasound in diagnosis of DDH. 2 DUE TO TECHNICAL DIFFICULTY, NARRATION IS NOT INCLUDED IN THE NEXT SLIDE. OUR APOLOGIES. THE POINT = CLINICAL EXAM TESTS ARE NOT SPECIFIC ENOUGH TO RULE IN DDH AND HAVE MISSED ACTUAL CASES OF DDH CONFIRMED WITH ULTRASOUND. 

Imaging in Dx of DDH: 

Imaging in Dx of DDH Highlights of the study: 3,541 infants tested by clinical examination and ultrasound Measured against ultrasound as a standard, clinical examination showed 97% sensitivity and 13.68% specificity Cases of DDH were found with ultrasound that were negative upon clinical examination.

Ultrasound in Dx of DDH: 

Ultrasound in Dx of DDH Coronal view of the hip (similar to AP radiograph projection) Measurement of Graf angle ( α and β) 3

Ultrasound in Dx of DDH: 

Ultrasound in Dx of DDH Measurement of α (alpha) and β (beta) angles are assessed by ultrasound according to Graf method. Highlights 3 : Alpha of 60 degrees or more = mature hip Alpha of 50-59 degrees = immature Alpha of 49 degrees or less = pathologic development

Ultrasound in Dx of DDH: 

Ultrasound in Dx of DDH

Ultrasound in Dx of DDH: 

Ultrasound in Dx of DDH

Ultrasound in Dx of DDH: 

Ultrasound in Dx of DDH

Ultrasound in Dx of DDH: 

Ultrasound in Dx of DDH

Ultrasound in Dx of DDH: 

Ultrasound in Dx of DDH

Ultrasound in Dx of DDH: 

Ultrasound in Dx of DDH

Impact on Function: 

Impact on Function Gait – Child may be limited with normal hip motions required for phases of gait, therefore may compensate with a waddling motion or require external support. Standing – Child may be limited in ability to stand/balance due to malalignment of hip, therefore requiring external support.

Role of PT in Management4: 

Role of PT in Management 4 Strengthening for any secondary muscle atrophy (gluteal musculature, iliopsoas, quadriceps, hamstrings) Pavlik Harness – keeps femoral head in optimal position within acetabulum to promote proper growth and development. Developmental delays – may need reclining wheelchair or scooterboard due to spica cast or orthoses. Emphasize gait and standing activities – tilt table, walker, crutches…(depending on type of cast or braces used)

Role of Imaging in Management: 

Role of Imaging in Management Progress in acetabular growth while wearing Pavlik harness and during physical therapy treatment may be monitored using ultrasound. 1 Thus, ultrasound is not only useful for diagnosis, but is also beneficial in monitoring acetabular deepening throughout treatment.

Questions for Class: 

Questions for Class 1) What other radiographic view would you want to see in order to have a better understanding of this disorder and why? 2) What would be the benefits of using MRI to view this condition in as opposed to radiographs?

References: 

References 1. Atalar , H., Sayli , U., Yavuz , O., Uras , I., Dogruel , H. Indicators of successful use of the Pavlik harness in infants with developmental dysplasia of the hip. Int Orthop . 2007 ; 31(2): 145–150 2. Dogruel , H., Atalar , H., Yavuz , O., and Sayli , U Clinical examination versus ultrasonography in detecting developmental dysplasia of the hip. Int Orthop . 2011; 45(6): 553–557 3. Gunay , C., et al. Correlation of femoral head coverage and Graf α angle in infants being screened for developmental dysplasia of the hip. Int Orthop . 2009; 33(3): 761-764 4. Nichols L. Child Development Note Packet. University of St. Augustine for Health Sciences. 2005: 138-142. 5. Developmental Dysplasia of Hip (DDH). Orthopaedia Review. In: Orthopaedia – Collaborative Orthopaedic Knowledgeabase . Created Mar 05, 2010 19:26. Last modified Sep 27, 2011 23:32 ver.10. Retrieved 02-09-2012, from http://www.orthopaedia.com/x/R4HRAQ . 6. Developmental Dysplasia of the Hip. Medicine Plus. http://www.nlm.nih.gov/medlineplus/ency/article/000971.htm. Updated February 7, 2012. Retrieved February 9, 2012.