Edit concept Question Editor Create issue ticket

Congenital Hip Dysplasia

Congenital Hip Dislocation

Congenital hip dysplasia describes a medical condition characterized by an abnormal development of the hip joint.


Presentation

Congenital hip dysplasia is frequently asymptomatic. This is why screening procedures are extremely important, especially after birth. Signs and symptoms that may be present include increase in the range of motion of the hip, abnormalities in the development of motor function (for example, when walking, crawling or sitting), externally rotated lower extremities and an asymmetric distribution of folds on the buttocks and the legs. This is usually visualized after close examination and extension of the lower extremities.

Difficulty Walking
  • Depending on the severity of the situation, this could result in pain, osteoarthritis, difficulty walking or an inability to walk. It can also contribute to a marked deterioration in a person's basic quality of life.[health.howstuffworks.com]
Limited Mobility
  • These include a breech position in the womb, especially if your baby had maintained the breech position with straight legs (called the extended breech position) due to limited mobility in the womb.[singhealth.com.sg]
Hip Pain
  • pain, antalgic gait(painful), scoliosis, back pain, or need for THR occur[quizlet.com]
  • Previously treated and subtle disease may predispose to hip joint degeneration and hip pain.[drmclawhorn.com]
  • The first sign of hip dysplasia in an adolescent or young adult is typically hip pain and/or a limp. This is usually in the groin area. Often there is a sensation of catching, snapping or popping in addition to pain with activities.[hipdysplasia.org]
  • If your child or teenager has hip pain, you may also wish to visit our page, Hip Pain in Teens and Children – Q & A. Back in the Game Patient Stories Specialized Centers, Departments and Services:[hss.edu]
  • As the disease progresses, hip pain and activity limitations worsen. For this reason, early diagnosis and consideration of different treatment options is important.[ortho.wustl.edu]
Limited Hip Abduction
  • Infants: After 2 to 3 months, soft tissues tighten and specific physical findings include limited hip abduction, thigh shortening (Galeazzi or Allis sign), and asymmetry of gluteal or thigh folds.[now.aapmr.org]
  • […] between femoral head and acetabulum, rendering the dislocation irreversible w/o surgery Contraction of the bup adductors limiting hip abduction II.[faculty.washington.edu]
Positive Ortolani Sign
  • This is a positive Ortolani sign. The Barlow provocative test is performed with the newborn positioned supine and the hips flexed to 90 . The leg is then gently adducted while posteriorly directed pressure is placed on the knee.[pediatrics.aappublications.org]
Impulsivity
  • Moreover, the angular impulse of the hip flexors was significantly reduced in the patient group.[ncbi.nlm.nih.gov]
Waddling Gait
  • Ambulatory children: Often present after a leg-length discrepancy, limp, or waddling gait is noticed. These children will have a positive Trendelenburg sign, with a shortened femur on the affected side.[now.aapmr.org]
  • A congenital hip dislocation results in limping or waddling gait immediately after the child begins to walk.[doctor-kolesow.ru]
  • gait Imaging Findings Ultrasound may be performed with measurement of the alpha angle (greater than 60degress considered normal) and beta angle (less than 55 degrees considered normal) Conventional radiography – using a standing or supine AP view of[learningradiology.com]
  • Symptoms may include a distinct waddling gait, one hip lower than the other, a limp, and walking on tiptoe.[betterhealth.vic.gov.au]
Abnormal Gait
  • A walking child may present with abnormal gait signs, including any of the following 2 : Limp. Waddling gait. Hyperlordosis. Positive Trendelenburg sign.[now.aapmr.org]

Workup

The physical exam is extremely important in screening children right after birth. This is usually done by performing the Barlow and Ortolani tests. The Barlow technique consists of hip flexion to a 90-degree direction followed by adduction. The physician then places his hands on the knee and presses in the posterior direction. In this way, dislocated hips can be identified. On the other hand, in the Ortolani technique, the physician also flexes the hip up to 90 degrees but, instead of performing an adduction procedure, he abducts. He subsequently places his fingers over the hip and exerts pressure on the trochanter. A hip that is dislocated can be relocated using this procedure. The examinations should be conducted on a solid surface and each hip should be individually tested.

Screening for congenital hip dysplasia has considerably improved after the introduction of ultrasonography. Nonetheless, it remains unclear if all children should be screened with this imaging modality. Screening with ultrasonography can result in false positive findings, leading to an overdiagnosis of the condition. Furthermore, not all patients with congenital hip dysplasia are caught early, even with ultrasound [9].

Despite the fact that studies have not shown a definite relationship between ultrasonography and correct diagnosis of congenital hip dysplasia in high-risk infants, medical professionals recommend its use in the assessment of children with possible hip abnormalities [10]. Ultrasonography is especially useful during the monitoring phase of treatment by closed reduction.

During imaging acquisition, the patient is placed in the normal position with complete relaxation of the hips or while standing at a 65-degree angle relative to the x-ray plate. In the first case, an anteroposterior image is taken, while in the second case, a view with a false profile is acquired. When hip dysplasia is suspected, the radiographer can take another image while the hip is abducted and internally rotated. This can determine if the joint is reducible and give a better picture of the anatomic relationship between the femur and the joint.

Computed tomography (CT scan) can further aid in the diagnosis and management. It allows the full visualization of the hip joint and can determine the degree of anteversion of the femur and posterior coverage of the acetabulum. Magnetic resonance imaging (MRI) can also be helpful in identifying the soft tissue and the bony structures around the hip.

When congenital hip dysplasia is diagnosed, arthrography can be employed to determine the overall dynamic stability of the joint [11]. It is performed under anesthesia through the injection of a dye within the hip, followed by a fluoroscopic examination. Arthrography usually accompanies closed reduction of the hip although it is sometimes performed independently. It is also sometimes used in combination with MRI to identify labral tears.

Treatment

Treatment of congenital hip dysplasia varies depending on the severity of the condition and the time of diagnosis. If it is caught early, non-surgical interventions are usually employed. Nonetheless, severe cases or late diagnosis may necessitate surgery.

Non-surgical methods of treatment generally include placement of a Pavlik harness for up to 1 or two months. A Pavlik harness is a special device that can keep the hip in the right position. The baby can still move his legs freely and without compromising diaper access [12].

Surgical treatment, on the other hand, takes place if other methods have not succeeded. When the child is 6 months, the surgeon may perform an open procedure, whereby the thighbone is shortened and the head of the femur is correctly placed within the hip joint [13].

Prognosis

Prognosis of congenital hip dysplasia is excellent when the condition is identified early and treated accordingly. Usually, invasive surgical treatment and complications do not occur. In fact, up to 90% of all cases of congenital hip dysplasia can be treated with excellent outcomes [8].

Results of surgical intervention vary considerably. Some cases of congenital hip dysplasia may require only one intervention but others may necessitate several procedures. Untreated congenital hip dysplasia can also lead to arthritis with severe complications in adulthood.

Children who are successfully treated may require frequent monitoring as the condition is sometimes known to reoccur when growth is substantial.

Etiology

The etiological mechanisms underlying the disease remain unknown but several factors are thought to be involved. Native Americans and Laplanders are at a much higher risk of acquiring the disease than other ethnic groups. On the other hand, Southern Chinese and Africans have an extremely low prevalence of congenital hip dysplasia. Genetics can also play a prominent role. Individuals with a family history of congenital hip dysplasia are ten times more likely to acquire the disease than control subjects [2].

Other factors can also play a critical role. About 80% of all individuals with congenital hip dysplasia are girls and 20% of cases have undergone birth in the breech position. This contrasts with 2 to 4% of individuals in the overall population [3].

Musculoskeletal disorders are sometimes involved in the disease processes that eventually lead to the development of congenital hip dysplasia, especially metatarsus adductus, and torticollis. In addition, oligohydramnios increases the risk of congenital hip dysplasia. Because the left hip is usually positioned against the sacrum of the mother, it is much more commonly involved than the right hip. When the mothers swaddle the baby, the hips may be forcibly adducted, increasing the risk of developing the condition. It is now known that this habit may be related to cultural factors [4].

Congenital hip dysplasia can also be accompanied by other neuromuscular conditions such as Larsen syndrome, myelomeningocele, arthrogryposis and cerebral palsy.

Epidemiology

Estimates of congenital hip dysplasia in the United Kingdom range from one to two cases for every 1,000 live births. Within developed countries, this value varies between 1.5 and 20 cases for every 1,000 births [5] [6]. Congenital hip dysplasia falls within a broad spectrum of normal variations in the anatomy, making diagnostic criteria difficult to define and complicating in the process the estimation of prevalence. With the advance of newer screening and diagnostic modalities such as ultrasound imaging, the prevalence of congenital hip dysplasia has considerably increased. This can be attributed to an overdiagnosis of the condition.

Congenital hip dysplasia is much more frequent in girls with a risk that is 4 times greater than boys. It is usually diagnosed after birth within the space of a few months. Incidence is greater among white people than the African-Americans in the United States and is normally associated with the breech position or delivery near or at term.

Sex distribution
Age distribution

Pathophysiology

The hip normally develops in the first few months following birth. It is a ball-and-socket joint and can only develop normally when the femoral head and the acetabulum are well aligned and are in proper positioning. Congenital hip dysplasia results when the femoral head and the acetabulum are present in the wrong position, leading occasionally to the development of a false acetabulum, particularly in severe conditions. Congenital hip dysplasia that is untreated can ultimately result in arthritis. Nonetheless, this occurs very infrequently and can only take place after several decades [7].

Prevention

There are no preventive measures for congenital hip dysplasia. Regular screening at birth is extremely important and may prevent serious complications associated with the condition.

Summary

Congenital hip dysplasia (CHD) is a medical disorder in which there is abnormal development of the hip joint especially in the relationship between the head of the femur and the acetabulum. The causative mechanisms remain unknown but both genetic and environmental factors are thought to be involved. The condition is strongly associated which ethnicity and gender. For example, Native Americans are at a much higher risk of acquiring the condition than individuals from a southern Chinese or African background [1]. In addition, girls are four times more likely to develop congenital hip dysplasia than boys. It is also associated with breech position during delivery and with other neuromuscular abnormalities such as torticollis and metatarsus adductus. Congenital hip dysplasia can accompany Larsen syndrome, myelomeningocele, and cerebral palsy. Patients usually present asymptomatically but certain signs and symptoms can be evident. In particular, there are abnormalities in motor function and children may exhibit externally rotated hips.

The physical exam plays an important role for screening and diagnostic purposes. In particular, the Barlow and Ortolani techniques are employed to detect any early sign for subluxation in the hip joints. Ultrasonography can also be utilized, although it is usually reserved for children known to be at a much higher risk for the condition. Widespread use of ultrasound may result in an overdiagnosis of the condition, especially that hip dysplasia presents over a wide spectrum that can sometimes be a normal variation of the condition.

Treatment is most commonly non-surgical when the condition is caught early. Children are placed in a Pavlik harness for 1 or 2 months. This is a device that holds the hip joint in the correct position, while simultaneously allowing free movement of the legs along with full access to the diaper area. Surgery is usually performed after 6 months through an open procedure, whereby there is full access to the hip joint, permitting the surgeon to shorten the thigh bone and reposition the head of the femur within the acetabulum.

Prognosis of congenital hip dysplasia is excellent when it is caught early and treatment is promptly delivered. More than 90% of patients can fully recover. Nonetheless, untreated hip dysplasia can lead to arthritis and complications in adulthood, including abnormalities in joint and lower extremity anatomy, in addition to severe pain.

Patient Information

Congenital hip dysplasia refers to a medical condition, in which the hip joint abnormally develops, leading to serious complications during growth and later in adulthood. The underlying mechanisms are not well understood, but it is thought that a combination of genetic and environmental factors contribute to its development. Native Americans and Laplanders are, particularly at risk. On the other hand, Africans and Southern Chinese have the lowest rates in the world. Other risk factors include female gender and babies born in a breech position. In fact, females are four times more likely to develop congenital hip dysplasia than males.

Patients are usually asymptomatic, hence the importance of screening right after birth and in the early developmental period. The physical exam is of prominent importance for screening newborns. Ultrasound can also be used, especially for children known to be at a much more elevated risk.

Congenital hip dysplasia is treated most commonly non-surgically, especially if it is diagnosed early. The baby is placed in a special device, that gradually allows a repositioning of the head of the long bone of the thigh within the cavity of the hip joint. This treatment can last from one to two months and has excellent results. Very severe cases or late diagnosis may sometimes necessitate surgical treatment. In this procedure, the surgeon opens the skin and the underlying tissue to completely expose the hip, and subsequently shortens the thigh bone and repositions it within the joint in the correct place.

Prognosis of congenital hip dysplasia is excellent, especially if diagnosis and treatment are delivered promptly. More than 90% of patients can expect a complete resolution of the problem.

References

Article

  1. Bialik V, Bialik GM, Blazer S, et al. Developmental dysplasia of the hip: a new approach to incidence. Pediatrics. 1999; 103:93-99.
  2. Bjerkreim I, Arseth PH. Congenital dislocation of the hip in Norway. Late diagnosis CDH in the years 1970 to 1974. Acta Paediatr Scand. 1978; 67(3):329-32.
  3. Carter CO, Wilkinson JA. Genetic and environmental factors in the etiology of congenital dislocation of the hip. Clin Orthop Relat Res. 1964; 33:119-28
  4. Kutlu A, Memik R, Mutlu M, et al. Congenital dislocation of the hip and its relation to swaddling used in Turkey. J Pediatr Orthop. 1992;12(5):598-602.
  5. Patel H, Canadian Task Force on Preventive Health Care. Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns. CMAJ. 2001; 164:1669-1677.
  6. Eastwood DM. Neonatal hip screening. Lancet. 2003; 361:595-597.
  7. Wedge JH, Wasylenko MJ. The natural history of congenital disease of the hip. J Bone Joint Surg Br. 1979; 61-B:334-338.
  8. Storer SK, Skaggs DL. Am Fam Physician. 2006;74(8):1310-1316.
  9. Hernandez RJ, Cornell RG, Hensinger RN. Ultrasound diagnosis of neonatal congenital dislocation of the hip. A decision analysis assessment. J Bone Joint Surg Br. 1994;76(4):539-43.
  10. Clarke NM, Clegg J, Al-Chalabi AN. Ultrasound screening of hips at risk for CDH. Failure to reduce the incidence of late cases. J Bone Joint Surg Br. 1989;71(1):9-12.
  11. Henle P, Tannast M, Siebenrock KA. [Imaging in developmental dysplasia of the hip] [German]. Orthopade. 2008 May 23.
  12. Imrie M, Scott V, Stearns P, et al. Is ultrasound screening for DDH in babies born breech sufficient? J Child Orthop. 2010;4:3-8.
  13. Vitale MG, Skaggs DL. Developmental dysplasia of the hip from six months to four years of age. J Am Acad Orthop Surg. 2001; 9:401-411.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2019-07-11 20:35