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Updated: Dec 22 2021

Developmental Dysplasia of the Hip (DDH)

  • Snapshot
    • A 4-month old female was referred by a local clinic for evaluation of asymmetric thigh creases during routine checkup. Physical exam revealed that the left lower limb was shorter than the right and lay externally rotated. Hip abduction was limited to 30 degrees. Ortolani's test was positive. Radiographs revealed a superiorly displaced left proximal femoral metaphysis and a shallow, hypoplastic left acetabulum. The infant was treated in a Pavlik abduction harness for congenital hip dislocation.
  • Introduction
    • Most common orthopaedic disorder in newborns
    • Developmental dysplasia/dislocation of the hip (DDH)
      • A spectrum of conditions characterized by
        • varying displacement of the proximal femur from the acetabulum including
          • dislocation: complete loss of contact between acetabulum and femoral head
          • subluxation: femoral head partially outside acetabulum
          • subluxable: subluxed with exam maneuvers, mild instability or laxity
          • dysplasia: abnormality of the hip joint shape, usually shallowness
    • Results from
      • poor development of the acetabulum and hip
      • due to excessive uterine packing
      • which causes excessive stretching of the posterior hip capsule and adductor muscle contractures
    • Deformity will progress if it is not corrected
  • Etiology
    • Risk factors - the 4 F's
      • females
      • firstborns
      • fanny first (breech presentations)
      • family history of DDH
  • Presentation
    • Idenitfy through screening physical exam
      • asymmetric skin folds
      • limited hip abduction on affected side
      • Barlow's test
        • test of dislocation
        • applied to dislocatable (but not already dislocated) hips
        • flex and adduct hips, apply light pressure on knees, directing force posteriorly
        • test is positive if hip dislocates posteriorly
      • Ortolani's test
        • test of reduction (performed immediately after Barlow maneuver)
        • applied to an already dislocated hip
        • lay infant supine, flex hips and knees to 90 degrees, apply anterior pressure on the greater trochanters using index fingers, gently abduct the hips using thumbs
        • produces soft "clunk" with anterior relation of the femoral head into the acetabulum
      • Galeazzi's test
        • check if knees at unequal heights when the hips and knees are flexed
          • dislocated side will be lower
      • Trendelenburg sign in walking patients
        • a dip of the pelvis in the opposite side when the patient stands on the affected leg
        • Trendelenburg sign also seen in superior gluteal nerve injury
  • Imaging
    • Clinical exam
    • Ultrasound
    • Radiographs are unreliable until the patient is at least four months old
      • because of radiolucency of femoral head
  • Treatment
    • < 6 months old
      • Pavlik harness (abduction bracing)
        • keep hips flexed and abducted
        • do not abduct > 60 degrees (increased risk of AVN)
      • Can observe until up to 4 weeks of age to allow for spontaneous resolution without risk of jeopardizing future interventions
    • 6-18 months old
      • closed reduction and hip spica cast
    • >18 months old
      • open reduction followed by hip spica cast
  • Complications
    • Joint contractures
    • AVN of the femoral head
  • Prognosis
    • Better if treatment begins earlier
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