Congenital Hip Dislocation

A dislocation of the hip in newborns. The condition may also be referred to as congenital hip dysplasia. A hip dislocation is where the ball joint at the top of the leg is not sitting in the correct position in the hip joint. The problem is usually picked up through routine examinations following birth. The condition tends to be more common in girls and babies born in the breech position. Epidemiology: Classic Congenital Hip Dislocation a. Incidence Hip subluxation at birth: 1% Hip dysplasia in infants: 0.1 to 0.3%

b. Girls 9 times more often affected than boys c. Usually unilateral, but bilateral is common. Risk Factors a. Breech Presentation b. Female gender c. Family History (positive in up to one third of cases) One affected sibling: 6% risk One affected parent: 12% risk One affected sibling and one affected parent: 36%

d. Firstborn e. Oligohydramnios Types a. Classic Congenital Hip Dislocation b. Congenital Abduction Contracture of the Hip

c. Teratologic Congenital Hip Dislocation 1. Severe, prenatal fixed dislocation 2. Associated with genetic and neuromuscular disordersses.

Associated Conditions Symptoms In congenital dislocation, the earliest sign may be a clicking sound when the newborns legs are pushed apart. If the condition goes undetected at the newborn stage, eventually the affected leg will look shorter than the other one, skin folds in the thighs will appear uneven, and the child will have less flexibility on the affected side. When he starts to walk, hell probably limp, walk on his toes, or waddle like a duck. Signs: Classic Congenital Hip Dislocation 1. Dislocation and Relocation maneuvers 1. Useful only in first 3 months of life 2. Repeat in 2 weeks if equivocal 3. Tests Ortolani Test (relocate hip into acetabulum) Barlow's Test (attempt to sublux unstable hip) Congenital Torticollis Breech Presentation in utero First degree relative with hip dysplasia history Clubfoot The cause of this problem is still unknown.

2. Pelvis symmetry Galeazzi's Sign (compare the 2 femur lengths) Observe for asymmetric skin folds

Diagnosis A careful physical examination of a newborn usually detects hip dislocation. In older infants and children, hip x-rays can confirm the diagnosis. Treatment: The treatment of hip dysplasia depends on the age of the child. The goal of treatment is to properly position the hip joint ("reduce" the hip). Once an adequate reduction is obtained, the doctor will hold the hip in that reduced position and allow the body to adapt to the new position. The younger the child, the better capacity to adapt the hip, and the better chance of full recovery. Over time, the body becomes less accommodating to repositioning of the hip joint. While treatment of hip dysplasia varies for each individual baby, a general outline follows: Birth to 6 months Generally in newborns, a hip dysplasia will reduce with the use of a special brace called a Pavlik harness. This brace holds the baby's hips in a position that keeps the joint reduced. Over time, the body adapts to the correct position, and the hip joint begins normal formation. About 90% of newborns with hip dysplasia treated in a Pavlik harness will recover fully. Many doctors will not initiate Pavlik harness treatment for several weeks after birth. 6 months to 1 year In older babies, Pavlik harness treatment may not be successful. In this case, your orthopedic surgeon will place the child under general anesthesia. This usually allows the hip to assume the proper position. Once in this position, the child will be placed in a spica cast. The cast is similar to the Pavlik harness, but allows less movement. This is needed in older children to better maintain position of the hip joint. Over age 1 year

Children older than one year old often need surgery to reduce the hip joint into proper position. The body can form scar tissue that prevents the hip from assuming its proper position, and surgery is needed to properly position the hip joint. Once this is done, the child will have a spica cast to hold the hip in the proper position. Screening Screening for congenital hip dislocation is done once the newborn baby is born. The hospital staff does a number of reflex exercises to check that all of the babys reactions are normal. There are two ways that congenital hip dislocation can be detected through the Ortolani maneuver and the Barlow maneuver. In order to do the Ortolani maneuver it is recommended the examiner put the newborn baby in a position in which the contralateral hip is held still while the thigh of the hip being tested is abducted and gently pulled anteriorly. If a sound of a "clunk" of the femoral head moving over the acetabulum it is normal but the less likely the examiner hears the "clunk" sound that means the acetabulum was not fully developed. The next method that can be used is called the Barlow maneuver it is done by adducting the hip while pushing the thigh posteriorly. If the hip goes out of the socket it means it is dislocated and the newborn has a congenital hip dislocation. They examine the baby by laying the baby on its back and separating their two legs apart if a clicking sound can be heard then that means that the baby may have this condition. It is highly recommended that these maneuvers be done when a baby is not fussy because the baby may inhibit hip movement. There can also be another way to detect congenital hip dislocation and it is called the tonic labyrinthine reflex (TLR). It is a reflex that is present in newborn babies. It is suggested that in order to do this reflex exercise the head is tilting back which causes the babys back to become stiffened, the legs are straightened and pushed together with the toes to point, and the arms bent at the elbows and wrists. Also the hands will be put into a fist or the fingers will be curled. If this reflex is present past the newborn stage the person may have an abnormal extension pattern.

Rehabilitation Hip dislocation rehabilitation can take anywhere from two to three months, depending on that patient. Complications to nearby nerves and blood vessels can cause loss of blood supply to the bone, also known as osteonecrosis. The protective cartilage on the bone can also be disturbed from this type of injury. For this reason, it is important for patients to contact a physician and get treatment immediately following injury. The first step to recovering from a hip dislocation is reduction. This refers to putting the bones back into their intended positions. Normally, this is done by a physician while the patient is under a sedative. Other times, a surgical procedure is required to reduce the hip bones back into their natural state. Next, rest, ice, and take anti-inflammatory medication to reduce swelling at the hip Weight bearing is allowed for the type one posterior dislocation, but should only be done as pain allows and patient is comfortable. Within 57 days of the injury occurrence, patients may perform passive range of motion exercises to increase flexibility. A walking aid should be used until the patient is comfortable with both weight bearing and range of motion.

Management: Classic Congenital Hip Dislocation a. Management indicated for hip instability beyond 5 days b. Step 1: Pavlik Harness 1. Indicated as first-line if age <6 months 2. Start with harness trial for 3-4 weeks 3. Splints hips in flexed and abducted position 4. Long-term effect: 95% (80% if frank dislocation) 5. Ultrasound should demonstrate reduction at 3 weeks Reduced: Continue harness for >6 weeks Not Reduced: Go to Step 2

c. Step 2: Closed Reduction and Casting by Orthopedics 1. Indications 2. Attempted closed reduction under arthrogram 3. Hip Spica Casting for 12 weeks 4. Positioning confirmed by post-op MRI or CT d. Step 3: Surgical Open reduction 1. Indicated in refractory cases 2. Requires multi-step procedure 3. Complicated by re-disclocation, osteonecrosis Prognosis Delayed treatment risks worse outcomes Monitor children with imaging until skeleton mature

Complications Premature arthritis of the hip as early as late teen Prevention Prevention includes proper prenatal care to determine the position of the baby in the womb. This may be helpful in preparing for possible breech births associated with hip

problems. Avoiding excessive and prolonged infant hip adduction, or forcing the legs in a straight position close together for periods of time (as in swaddling) may help prevent strain on the hip joints. Early diagnosis remains an important part of prevention of congenital hip dysplasia. Anatomy In hip dislocation, the ball at the top of the thighbone (femoral head) does not sit securely in the socket (acetabulum) of the hip joint. Surrounding ligaments may also be loose and stretched. The ball may be loose in the socket or completely outside of it. Pathophysiology a. Femoral head dislocates from acetabulum b. Results from Acetabular Dysplasia (shallow acetabulum) Results in subluxed, dislocated or unstable hip Remainder are right (20%) and bilateral (20%) c. Left hip is affected in 60% of cases