1. بسم الله الرحمن الرحيم

2. CDH Congenital Dislocation of the Hip
Mamoun Kremli
Professor / Consultant Pediatric Orthopedics
College of Medicine & King Khalid University Hospital

3. CDH The most common disorder affecting the hip in children
Spectrum of diseases/abnormalities of the hip with different etiologies, pathologies, and natural histories affecting the proximal femur and acetabulum
Initial pathology is congenital, progresses if untreated.
Does not always result in dislocation.

4. CDH Definition
A progressive deformation of previously normally formed structures during the embryonic period
NOT A malformation arising during the period of organogenesis

5. CDH Nomenclature CDH Congenital Dislocation of the Hip
DDH Developmental Dysplasia of the Hip
CDH Congenital Dysplasia of the Hip
CHD Congenital Heart Disease !

6. CDH Spectrum Teratologic Hip : Fixed dislocation Occurrs prenatally
Often with other anomalies
Dislocated Hip : Completely out
May or may not be reducible
Subluxated Hip : Only partially in
Unstable Hip : Femoral head can be dislocated
Acetabular Dysplasia : Shallow Acetabulu
Head Subluxated or in place

7. Have underlying hip dysplasia
CDH Incidence
Hip Instability at Birth : 0.5 – 1 % of infants
Classic CDH : 0.1 % of infants
Mild Dysplasia : Substantial
Contributing to adult Osteoarthritis
Up to 50 % of Hip Arthritis in Ladies
Have underlying hip dysplasia

8. CDH Incidence Area Incidence per 1000 Canadian Indians 188.5 Hungary
28.7
Uppsala, Sweden 20
USA Caucaseans
Blacks
15.5
4.9
Malmo, Sweden
2.18
Chinese, Hong Kong
0.1
Bantus, Africa
among (16678)

9. CDH Etiology
Multi-factorial

10. CDH Etiology Physiologic Factors Ligament Laxity : Hormonal :
( Estrogen, Relaxin) Females
Familial hyper laxity :
mild - moderate - Ehler Danlos
ADD Picture of knee hyperextension

11. Genetic Factors Gender : Female Most studies: Twin studies:
CDH Etiology
Genetic Factors
Gender : Female
Most studies:
Females > 4-6 X than males
Twin studies:
Monozygotic 38 %
Dizygotic % (similar to siblings)

12. Family Incidence and Genetic Counselling
CDH Etiology
Family Incidence and Genetic Counselling
Affected
At risk
Risk
One sibling
Siblings
1 in 17
One parent
Children
1 in 8
One parent, one sibling
1 in 3
2nd degree relative
Nieces, nephews
1 in 100

13. CDH Etiology Mechanical Factors Prenatal : - Breech position
- Oligohydramnious
- Primigravida
- Cong. Knee recurvatum/dislocation
- Metatarsus adductus
- Torticollis
Postnatal : Swaddling / Strapping – Knees extended

14. CDH Etiology Mechanical Factors
Breech Presentation :
Normally 2 –4 %
CDH %
The Breech position In Utero
Extended knees and flexed hips

15. CDH Etiology Environmental & Mechanical Factors
Swaddling / strapping ( Mihad ):
Knees extended & Hips adducted
Proven experimentally
Proven statistically
American Indians.
Eskimos, and
Saudi Arabia
Mechanics
Hip adduction and extension

16. CDH Patients At Risk Positive Family History : increases risk 10X
A baby girl : increases risk 4-6 times
Breech Presentation : increases risk 5-10 X
Torticollis : CDH in % cases
Foot Deformities :
( calcaneovalgus & metatarsus adductus)
signs of intrauterine crowding
Knee Deformities :
( hyperextension & dislocation )
associated with Teratologic type

17. CDH Risk Factors When Risk Factors Are Present
The infant should be examined repeatedly
The hip should be imaged
( by U/S or X-ray )

18. CDH Neonatal Examination
The infant should be quiet and comfortable

19. CDH Neonatal Examination
LOOK :
External rotation attitude
Lateralized contour
Wide perineum
( in bilateral )

20. CDH Neonatal Examination
anterior
posterior
LOOK :
Asymmetric thigh folds

21. CDH Clinical Examination
Look :
Shortening ( not in neonates )
- in supine
- Galeazzy sign

22. CDH Neonatal Examination
FEEL :
Empty groin
Weak Femoral pulse

23. CDH Neonatal Examination
MOVE :
Hip instability
in early infancy
Limited hip abduction in flexion - later
(careful in bilateral)
if <600 on both sides:
request imaging

24. Cerebral palsy Clinical Assessment Hip Flexion Deformity
Thomas Test
SPECIAL :
Loss of fixed flexion deformity of hips
( early infancy )
Normally FFD
newborn o
at 6 weeks 19o
at 6 months 7o
FFD
Normal
No FFD
?CDH

25. CDH Neonatal Examination Ortolani
Feel a Clunk
Not hear a click !

26. CDH Neonatal Examination Barlow

27. CDH Neonatal Examination Ortolani / Barlow
clunk
Ortolani
Barlow

28. CDH Neonatal Examination Ortolani / Barlow

29. CDH Neonatal Examination Hamstring Stretch Sign
Flex hip and knee 900 each.
Keep hip flexed and gradually extend the knee
Normally a resistance is felt towards the end of knee extension
(caused by the hamstrings which are pulled from both ends)
In cases of CDH, no resistance is felt
(when the hip is dislocated, the origin of the hamstrings are not pulled by hip flexion)

30. CDH Neonatal Examination Hamstring Stretch Sign

31. CDH Clinical Examination
Neonate (up to 2-3 months) :
- Instability/ Ortolani-Barlow
- Thomas test
Infant ( > 2-3 months) :
- Limited abduction
- Shortening ( Galeazzi )
- Hamstring stretch sign
Toddler : Limited abduction
Walking : Trendelenburgh

32. CDH Clinical Examination

33. CDH Clinical Examination

34. CDH Clinical Examination The Walking Child
Trendelenburgh: unilateral / bilateral (waddling)

35. CDH Screening Program Clinical screening proven to be effective
Performed by Trained personnel
Must be DYNAMIC
with periodic examination till walking
Adjunctive use of U/S controversial

36. CDH Ultrasound Screening
Incidence of hip instability declines rapidly to 50 % within the first week of neonatal life
Better to delay U/S screening

37. CDH Ultrasound Screening
Early U/S screening not recommended
Delayed U/S screening :
- Older than 6 weeks
- Those at risk only - by
History
Clinical exam

38. CDH Ultrasound Referral
If hip normal : no need
If hip clearly unstable : no need
If suspicious : U/S appropriate
If at risk factors : U/S appropriate

39. CDH Ultrasound Too sensitive
detects a lot of hip anomalies most of which would develop normally
Operator dependant
Static Vs Dynamic

40. CDH Radiography Early infancy : not reliable
By 2-3 months of age : reliable
AP view - neutral position
- draw reference lines
- acetabular index - in early infancy
< 30o : normal
30o – 40o : questionable
> 40o : abnormal
Von Rosen view : 45o abduction

41. CDH Radiography

42. CDH Radiography

43. CDH Radiography

44. CDH Radiography in
out
out in
Von Rosen view

45. CDH Radiography
39o
27o

46. CDH Radiography
out in

47. CDH Treatment Aims
Obtain and Maintain concentric reduction
In an Atruamatic fashion
Without disrupting the blood supply

48. CDH Treatment
Method depends on Age
The earlier started, the easier the treatment
The earlier started, the better the results
Should be detected EARLY

49. CDH Treatment
Birth to 6 months :
Pavlik harness or hip spica cast
6 months – 12 months :
closed reduction UGA and hip spica casts
12 months – 18 months :
possible closed / possible open reduction
Above 18 months :
open reduction and ? Acetabuloplasty
Above 2 years :
open reduction,acetabulplasty, and femoral osteotomy
Above 8 years :
open reduction,acetabulplasty cutting three bones, and femoral osteotomy

50. CDH Treatment Hip instability in the neonatal period
Most resolve spontaneously
Observation
Pavlik harness
Double /triple diapers ??

51. CDH Treatment Hip instability in the neonatal period
Double / Triple Diapers
Often inadequate : therefore inappropriate
Gives illusion patient is in “treatment” while wasting valuable time
Most hip instability improves spontaneously in early infancy , giving this ineffective management credit

52. CDH Treatment Birth – 6 months
Hip instability (dislocatable)
Established dislocation (reducible)
Should be actively treated until hip is normal clinically and radiographically
Pavlik harness
Hip Spica Cast

53. CDH Treatment Birth – 6 months Pavlik harness

54. CDH Treatment Birth – 6 months
Other Devices
- Frejka pillow
- Craig
- Von Rosen splint
Soft abduction splints:
Not good enough
Rigid abduction splints:
Risk AVN

55. Initially non operative – closed reduction
CDH Treatment 6 – 12 months
Initially non operative – closed reduction
Reduction under anesthesia and immobilization in hip spica cast
Position:
Human
Avoid severe abduction
Avoid Frog position
Must be stable and concentrically reduced otherwise needs open reduction
Better Picture

56. Possibly closed reduction !!
CDH Treatment 12 – 18 months
Possibly closed reduction !!
when hip stable and concentrically reduced
Probably open reduction
when hip unstable or not concentrically reduced
Arthrography guided:

57. CDH Treatment Arthrography Closed Reduction
Too lateralized
Acceptable

58. CDH Treatment Above 18 months
Open reduction
? and acetabulplasty
? And femoral shortening – if high

59. CDH Treatment Above 3 years
Open reduction
And acetabulplasty
And femoral shortening

60. Redirectional Acetabuloplasty Salter’s
Add Picture with K wires

61. Need for a lot of improvement in cover
Pemberton’s
Need for a lot of improvement in cover

62. Triple Steel

63. CDH When Not to Treat ?! Bilateral High Posterior Dislocation
good function – not painful

64. CDH When Not to Treat ! وخيرٌ من بعض ِ الدواءِ الداءُ
Painful stiff left hip
Painful stiff right hip in adduction

65. CDH When Not to Treat ! وخيرٌ من بعض ِ الدواءِ الداءُ
Painful right hip & ankylosed left hip

66. Complex multi-factorial, endemic– treatable.
CDH Summary
Complex multi-factorial, endemic– treatable.
Dr’s awareness and health education.
Screening programs are needed.
Learning proper examination methods.
Identify at-risk groups.
repeat examination & imaging.
Efficient referral system.
Proper management in referral centers.