CONGENITAL HIP DISLOCATION

INTRODUCTION Congenital hip dysplasia is a condition of abnormal development of the hip resulting in hip joint instability and potential dislocation of the thigh bone from the socket in the pelvis. This condition has been in the early 200s been termed developmental hip dysplasia, because it often develops over the first few weeks, months or years of life. Congenital hip dysplasia is a disorder in children that is either present at birth or shortly thereafter. During gestation, the infants hip should be developing with the head of the thigh bone (femur) sitting perfectly centered in its shallow socket (acetabulum). The acetabulum should cover the head of the femur as if it were a ball sitting inside of a cup. In the event of congenital hip dysplasia, the development of the acetabulum in an infant allows the femoral head to ride upward out of the joint socket, especially when the infant begins to walk.

PATHOPHYSIOLOGY
Developmental dysplasia of the hip (DDH) involves abnormal growth of the hip. Ligamentous laxity is also believed to be associated with hip dysplasia, although this association is less clear. DDH is not part of the classic description of disorders that are associated with significant ligamentous laxity, such as Ehlers-Danlos syndrome or Marfan syndrome. Children often have ligamentous laxity at birth, yet their hips are not usually unstable; in fact, it takes a great deal of effort to dislocate a child's hip. Therefore, more than just ligamentous laxity may be required to result in DDH. At birth, white children tend to have a shallow acetabulum. This may provide a susceptible period in which abnormal positioning or a brief period of ligamentous laxity may result in hip instability. However, this characteristic is not as true for children of black descent, who have a lower rate of DDH. Predisposing Factors: Female newborn Breech birth

Family history of congenital hip dislocation First Born Oligohydramnios (lack of intra-uterine fluid)

Femoral head dislocates from acetabulum

Results in Acetabular Dysplasia (Shallow acetabulum)

Results in subluxed, dislocated or unstable hip)

Left hip is affected in 60% of cases

Remainder are right (20%) and bilateral (20%)

CAUSES AND SYMPTOMS The cause is not clear although there are some factors that are known to contribute to the chance of the baby being born with CDH. Hormonal changes within the mother during pregnancy result in increased ligament looseness or laxity and are thought to possibly cross over the placenta and cause the baby to have lax ligaments while still in the womb. Other symptoms include shortening of the leg and limited ability to abduct the leg or move it forward.

Certain clinical signs have been identified that are helpful in the evaluation of newborns and infants for possible CHD, which include the following: limited abduction of the flexed hip, due to shortening and contraction of the hip adductors;

increase in depth or asymmetry of the inguinal or thigh skinfolds; shortening of one leg;

Allis' or Galeazzi's sign -- lower position of knee of the affected side when knees and hips are flexed, due to location of femoral head posterior to acetabulum in this position;

Ortolani's "jerk" sign ("clunk of entry" or reduction sign); Barlow's test ("clunk of exit" or dislocation sign);

telescoping or pistoning action of thighs, due to lack of containment of femoral head with acetabulum; Trendelenburg's test -- drop of normal hip when child, standing on both feet, elevates unaffected limb and bears weight on affected side, due to weakness of hip abductors; and

waddling type of gait.

DIAGNOSTIC EVALUATION OF DEVELOPMENTAL DYSPLASIA OF THE HIP Assessment: DDH is often not detected at the initial examination after birth; thus all infants should be carefully monitored for hip dysplasia at follow-up visits throughout the first year of life. X-Ray: Radiographic examination in early infancy is not reliable because ossification of the femoral head does not normally take place until the third to sixth month of life. Ultrasound: The cartilaginous head can be visualized directly with highresolution ultrasonography. The ultrasonographic examination can detect slight subluxations and dislocations as well as monitor progress over time.

In older infants and children Radiographic examination is useful in confirming the diagnosis. An upward slope in the roof of the acetabulum (the acetabular angle) greater than 40 degrees with upward and outward displacement of the femoral head is a frequent finding in older children. A CT scan may be useful to assess the position of the femoral head relative to the acetabulum following closed reduction and casting. 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 1 Year of Age 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. The success of treatment depends on the age of the child, and the adequacy of the reduction. In a newborn infant with a good reduction, there is a very good chance of full recovery. When treatment begins at older ages, the chance of full recovery decreases. Children who have persistent hip dysplasia have a chance of developing pain and early hip arthritis later in life. Surgery to cut and realign the bones (hip osteotomy), or a hip replacement, may be needed later in life. BRYANTS TRACTION Another way of correcting congenital hip dysplasia is by doing Bryants Traction. This is a kind of traction applied to the lower leg with the force pulling vertically, employed especially in fractures of the femur in infants and young children. Described by Bryant in 1873. NURSING CARE PLAN DEVELOPMENTAL DYSPLASIA OF THE HIP Nursing diagnosis 1: Impaired physical mobility R/T dislocation of hip, and presence of splint or cast Interventions 1. Maintain the correct position of the hip. 2. Explain the components and purposes of splint or cast. 3. Enhance play and using the upper portion of the body. 4. Teach walking with cast 5. Support the casted limp and avoid pressure on heels Nursing diagnosis 2: Potential for injury, neurovascular impairment R/T compression by cast. Interventions 1. Watch for signs of compression 2. Observe pedal pulse and ability to move fingers

3. Ask for tingling, numbness, pain, or burning sensation 4. Assess for tightness by inserting finger between cast and skin Nursing diagnosis 3: Knowledge deficit of parent regarding home care: Interventions 1. Teach how to care of the child 2. Inform parents of different treatment procedures 3. Involve parent in care of the child 4. Stress the importance of regular follow up