CONGENITAL

 

CONGENITAL DISLOCATION OF HIP

Introduction:

          Developmental dysplasia op hip (DDH) is a congenital or acquired deformation or misalignment of the hip.  It is also known as congenital dislocation of hip (CDH) or hip displacement.

 

Definition:

          Developmental dysplasia of hip refers to a variety of conditions in which the head of femur and acetabulum cavity are improperly aligned and the femur head lies outside the hip socket or acetebulum cavity.

 

Types:-

1.      Uni-lateral

2.     Bi – lateral

 

1.     Uni-lateral:-

In unilateral dysplasia only one joint shows deformity.

 

2.     Bi-lateral:-

If both hip joints are affected it is bilateral dysplasia.

 

DEGREES OF DEVELOPMENT DYSPLASIA OF HIP

There are three degrees of developmental dysplasia of hip:-

1.      Acetabulam dysplasia or pre-luxation.

2.     Sub-luxation

3.     Complete dislocation or luxation.

 

1.     Acetabulam dysplasia or pre-luxation.

          This is the mid least form in which the acetebulum cavity or hip socket is too shallow or deformed.

          The femur head remains in contact with the acetabulum cavity but it is displaced.

 

2.     Sub-luxation

It accounts for largest percentage of congenital hip dysplasia, sub-luxation means incomplete dislocation of hip.

The femur head remains in contact with the acetebulum cavity but it is displaced.

 

3.     Complete dislocation or luxation.

In this type, there is no contact between the head of femur and acetebulum cavity.

This is complete loss of contact between the femur head and acetebulum.

Patho-physiology

Ø  Hip displacement is the result of either laxity of the supporting capsule or an abnormal acetebulum.

Ø A dislocatable hip is the one that can be manually displaced with stress but returns to acetebulum when stress is removed.

Ø A sub-luxated hip is the one in which the femor head remains in contact with the acetebulum.

Ø A hip is unstable when the tight fit between femur head and acetebulum is lost and femur head is able to partially dislocate.

 

Clinical Features

Infants

Ø Shortening of leg

Ø Asymmetry of legs

Ø Asymmetry of gluteral folds of skin, when infant is placed in prone position.

Ø Limited range of motion in affected hip.

Ø Apparently short femur on affected side.

Ø After 3 months of age the affected leg may turn out ward (or) become shorter than other leg.

 

 

Clinical features in older children

Ø Unequal length of legs

Ø Gait abnormalities such as toe walking.

Ø Gulleazzi sign is seen it is demonstrated by placing the both hips at 90⁰ of fiexion and comparing the height of knees and looking for asymmetry.

 

Etiology

Ø Developmental dysplasia of hip occurs in 1-2/1000 live births.

Ø It is eight times more common in females than males.

Ø Bilateral involvement is present in about 50% of the cases.

 

Diagnosis:-

1.      Barlow’s test

2.     Ortolani’s test

3.     Ultra sound and x-ray

 

 

 

Developmental dysplasia of the hip: It includes physiological mechanical and genetic factors

 

i]  Physiological factor:

 

Ø It  includes maternal hormone estrogen, the production of which is increased towards the end of pregnancy leading to greater pelvic laxity of mother.

Ø Increased estrogen effects the feotal joints.

Ø Female infants react more to estrogen, hence the defect is more common in girls.

 

ii] Mechanical factor:

 

Ø Mechanical factor includes abnormal intra uterine position of the fetus, breech presentation and large size of fetus.

 

iii]  Genetic factor:

 

Ø It contributes to developmental dysplasia of hip includes a positive family history.

 

Management

       i.            For newborns and infants younger than 6 months.

1.     Promoting normal growth and development

2.     Maintaining correct position of hip.

3.     Maintaining physical mobility.

4.     Protecting skin from irritation

5.     Providing optimum nutrition

6.     Parental support and education

 

i)                  For new borns and infants younger than 6 months:-

Ø  New born hip that are Barlow positive (reduced but dislocatable) ortolani positive (dislocated but disreducible) should be treated with a parlik harness as soon as diagnosed.

Ø Other braces are available (von-rosen splint, frejka, pillow) the pelvic harness is most common device.

Ø Maintaining the hip in a pavlik harness on a full time basis of 6 weeks, hip resolves 95% in cases.

Ø The anterior straps of the harness should be set to maintain hips in flexion and posterior straps maintain abduction.

Ø After 6 months of age, the failure rate of palvik harness is 50% because it is difficult to maintain the increasingly active and erawling infant in harness.

i)                  Promoting normal growth and development

Ø The nurse must make the parents accept the child who is immobilized for treatment of hip dysplasia may not develop gross motor skill.

Ø The family should provide opportunities to the child to develop and practice motor skills.

 

ii)                Maintain correct position of hip

Ø The parents must be explained the purpose of splint and its proper use.

Ø Parents must be informed about the time for which the splint is to be worn.

Ø Parents must be taught how to keep hip of the child in abduction, which splints are removed for physical care.

 

iii)             Maintain physical mobility

Ø The nurse can help the family explore alternatives to assist with reclining back etc.

Ø Provide opportunities to the child when they can use their arms and uncasted leg.

 

iv)             Protect skin from irritation

Ø For a baby in pavlik harness, skin irritation occurs whenever the straps of harness touch the skin, so caregivers should take following measures.

Ø Daily skin should be washed with mild soap and dried thoroughly.

Ø Care givers should not use locations.

 

v)               Provide optimum nutrition

Ø Fluid intake by the child should be encouraged.

Ø Provide adequate amount of well balanced diet, high in protein content and low in calories.

 

vi)             Educate and support the parents

Ø Parents should be taught, correct use of harness and brace.

Ø Parents need to be taught, about the signs of pressure due to cost

 

Complications

Ø Bracing device may cause skin irritation.

Ø Differences in the lengths of the legs may persist despite appropriate treatment.

Ø Untreated hip dysplasia will lead to arthritis and deterioration of the hip which can be severely debilitating.

 

 

SUMMARY

 

          Congenital hip dislocation (CHD) occurs when a child is born with an unstable hip.  Its caused by abnormal formation of the hip joint during their early stages of fetal development.  Another name for this condition is “Developmental Dysplasia of hip”.  This instability worsens as your child grows.