CDH CONGENITAL DISLOCATION OF THE HIP

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CDHCONGENITAL DISLOCATION OF THE HIP

• Dr. ABDULMONEM ALSIDDIKY , MD , SSCO.
• Assistant Professor Consultant
• pediatric Ortho. Spinal Deformities
• KSU,KKUH
• Riyadh , Saudi Arabia

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Nomenclature

• CDH Congenital Dislocation of the Hip
• DDH Developmental Dysplasia of the Hip

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NORMAL PELVIS
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• Normal hip

• Dislocated hip

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Patterns of disease

• Dislocated
• Dislocatable
• Sublaxated
• Acetabular dysplasia

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Radiology

• After 6 months reliable

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Causes (multi factorial)
Unknown

• Hormonal
• Relaxin, oxytocin
• Familial
• Lig.laxity diseases
• Genetics
• Female 4 X male --- twins 40
• Mechanical
• Pre natal
• Post natal

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Mechanical causes

• Pre natal
• Breach , oligohydrominus , primigravida , twins
• (torticollis , metatarsus adductus )
• Post natal
• Swaddling , strapping

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Infants at risk

• Positive family history 10X
• A baby girl 4-6 X
• Breach presentation 5-10 X
• Torticollis CDH in 10-20 of cases
• Foot deformities
• Calcaneo-valgus and metatarsus adductus
• Knee deformities
• hyperextension and dislocation

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Infants at risk

• When risk factors are present
• The infant should be reviewed
• Clinically
• radiologically

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Clinical examination

• The infant should be
• quiet
• comfortable

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• Look
• External rotation
• Lateralized contour
• Shortening
• Asymmetrical skin folds
• Anterior posterior

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• Move
• Limited abduction

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• Special test
• Galiazzi
• Ortolani , Barlow test
• Trendelenburgh sign
• Limping ( waddling gait if bilateral)

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Special test
Galiazzi test
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Special test
Ortolani test
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Special test
Barlow test
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Special test
Trendelenburgh sign
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Screening programs

• Clinical screening proven to be effective
• Performed by trained personnel
• Must be dynamic
• Repeated with periodic examination
• U/S screening is controversial

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Investigations

• 0-3 months U/S
• gt 3months X-ray pelvis AP abduction

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U/S Screening

• Incidence of hip stability declines rapidly to
  50 within the first week of neonatal life.
• Better to delay U/S screening

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U/S - Problems

• Too sensitive
• Detects a lot of hip abnormalities, most of which
  would develop normally if left alone
• Operator-dependant

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Radiology

• Early infancy not reliable

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Radiology

• After 2-3 months more reliable

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Radiology

• After 2-3 months more reliable

39o
27o
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Radiology

• After 2-3 months more reliable

Von Rosen view
in
out
in
out
out
in
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Radiology

• After 2-3 months more reliable

out
in
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Radiology

• After 6 months reliable

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Radiology

• After 6 months reliable

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Treatment - Aims

• Obtain concentric reduction
• Maintain concentric reduction
• In a non-traumatic fashion
• Without disrupting the blood supply to femoral
  head

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Treatment

• Method depends on age
• The earlier started, the easier it is
• The earlier started, the better the results are
• Should be detected EARLY

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Treatment

• Birth 6m
• Pavlik harness or hip spica
• 6-12 m
• Closed reduction under GA and hip spica
• 12 - 18 m
• Open reduction
• 18 24 m
• Open reduction and Acetabuloplasty
• 2-8 years
• Open reduction, Acetabuloplasty, and femoral
  shortening
• Above 8 years
• Open reduction, Acetabuloplasty cutting all three
  pelvic bones, and femoral shortening

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Treatment Neonatal hip instability

• Most resolve spontaneously
• Can initially wait
• Avoid adduction swaddle
• Apply double diapers to bring back!!
• See at 2weeks of age

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Treatment Neonatal hip instability

• Unstable at 2 weeks
• Double / Triple diapers inadequate
• Gives illusion that patient is in treatment
  while wasting valuable time

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Treatment Neonatal hip instability

• Unstable at 2 weeks
• Pavlik Harness
• Dynamic, effective, safe

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Treatment 6-12 m

• Initially non-operative closed reduction UGA and
  immobilization in hip spica cast
• Position
• Avoid sever abduction
• Avoid frog position
• Must obtain stable concentric reduction,
  otherwise needs surgery

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Treatment 6-12 m

• Possibly closed reduction
• Stable and concentric reduction
• Possibly open reduction
• Unstable or un-concentric reduction
• Arthrography-guided

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Treatment 6-12 m

• Possibly closed reduction
• Stable and concentric reduction
• Possibly open reduction
• Unstable or un-concentric reduction
• Arthrography-guided

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Treatment 6-12 m

• Arthrography-guided Closed Reduction

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Treatment 6-12 m

• Arthrography-guided Closed Reduction

Acceptable
Too lateralized
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Treatment 18-24 m

• Open reduction surgery
• Possibly Acetabuloplasty

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Treatment Above 2 years

• Open reduction, and
• Acetabuloplasty, and
• Femoral shortening

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Acetabuloplasties

• Many types

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Treatment

• Birth 6m
• Pavlik harness or hip spica
• 6-12 m
• Closed reduction under GA and hip spica
• 12 - 18 m
• Open reduction
• 18 24 m
• Open reduction and Acetabuloplasty
• 2-8 years
• Open reduction, Acetabuloplasty, and femoral
  shortening
• Above 8 years
• Open reduction, Acetabuloplasty cutting all three
  pelvic bones, and femoral shortening

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CDH - Summary

• Complex multi-factorial, endemic disease
• Health education and Drs. awareness
• Screening programs are needed
• Learning proper examination methods
• Identify at risk groups
• Efficient referral system
• Proper management by specialized Drs

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Examples
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THANKS