Assessment protocol and importance of Orthotic Management of Congenital Dislocation of Hip

This presentation will cover details about congenital dislocation of hip including pathology to orthotics management. it will cover details about assessment of CDH/DDH along with orthotics management.

1. Assessment protocol and importance of
Orthotic Management of Congenital
Dislocation of Hip
Poly Ghosh
L
ecturer (P&O)
NI
LD, Kolkata
1

2. Introduction
•Disturbance of the normal anatomy of the hip, either
a complete dislocation of the head of the femur
from the acetabulum or a partial displacement
(subluxation) from the socket.
•The term "developmental dysplasia" has recently
supplanted "congenital dislocation" as the accepted
name of this condition
2
Specht EE: Congenital dislocation of the hip (Medical
Progress). West J Med 124:18-28, Jan 1976

3. Pathophysiology
•DDH is a gradually progressive disorder associated with distinct
anatomical changes, many of which are intially reversible.
•In normal hip at birth, there is a tight fit between the femoral head
and the acetabulum.The femoral head is held in the acetabulum by
the surface tension created by the synovial fluid.
•In DDH, this tight fit is lost and femoral head spontaneously slides
into and out of the acetabulum.
3
Pediatric orthopaedics: core knowledge in orthopaedics by
John P. Dormans, MD

4. Most abnormalities in DDH are on acetabular side.
 Changes on the femoral side are secondary to anteversion and pressure
changes on the head from the acetabulum or illium associated with subluxation
or dislocation.
At birth, the pathological findings in DDH range from mild capsular laxity to
severe dysplastic changes.
The most common pathological change is a hypertrophied ridge of
acetabular cartilage in the superior, posterior, and inferior aspect of the
acetabulum


4
Pediatric orthopaedics: core knowledge in orthopaedics by John P.
Dormans, MD

5. •If the hip remains dislocated, the acetabular roof becomes
progressively more oblique, the concavity gradually flattens
and presents a convex surface, and the medial wall of the
acetabulum thickens.
•In adults, the fully dislocated femoral head may lie well
above the acetabular margin in a markedly thickened hip
capsule, the so called high- riding dislocation.
5
Pediatric orthopaedics: core knowledge in orthopaedics by John P.
Dormans, MD

6. Etiology
Genetic : studies have found that families in which more
than one child has a dislocated hip is 22to 50 per 1000 live
births, which is at least 10 times the usual risk for
dislocation.
Hormonal: Relaxin hormone.
Mechanical: Breech position
6

7. Incidence
•There is a marked geographical
and racial variation in the
incidence of DDH.
•These differences may be
caused by enviornmental
factors, such as child-rearing
practices, rather than genetic
predisposition.
7
Asia and Africa<native American and
eastern European
Pediatric orthopaedics: core knowledge in orthopaedics
by John P. Dormans, MD

8. Presentation of CDH
1.Intrauterine dislocation in early foetal life
2.Congenital dislocation of the hip secondary to intrauterine
neuromuscular or muscular abnormalities
3.Congenital dislocation of the hip due to capsular laxity
8

9. Grade of CDH
9

10. Cont…….
GRADE I
•Head of the femur
located within
acetabulum
•Dislocation is posterior
or postero-superior lip
of acetabulum
•Labrum is stretched and
everted,acetabulum
elliptical
•Dislocation is not
complete in the hips but
restrained by the capsule
and ligamentum teres
GRADE II
•Partial or complete
dislocation at rest
•Labrum is more
everted
•Capsule more stretched
and ligamentum teres
longer
•Acetabulum shallower
than normal
•Head of femur slightly
more elliptical and
reduced in size
10
GRADE III
•Head of femur
dislocated upward and
backwards beyond
the labrum
•Acetabulum shallow
and poorly developed
•Head of femur small,
elliptical often pitted
anddiscoloured

11. On observation
 In early childhood:-
1.How the parents are carrying baby?
2.Asymmetric folds
3.Restricted abduction in hip flexion
 In older childhood :-
1.Shortening of the affected leg
2.Scoliosis
3.Lumbar lordosis
4.Wider perineum
5.gait
11

12. Physical Examination
12
Examination in the maternity ward, or within the first few days of
life.
Include
Taking the history,
To assess the risk factors and
Antecedents,
Test –
Ortolani Test
Barlow Test
Hip examinations on newborns should therefore be performed
routinely, and this practice should be emphasized while the
newborn is still in the maternity ward. It should also be part of the
outpatient follow-up over children's first weeks and months of life.

13. Ortolani Test
13
•The child is placed on its back
with the hip flexed at right
angle and the knees flexed.
•Starting with the knees
together , the hips are slowly
abducted
•If one of them is dislocated,
somewhere in 90 degrees arc
of abduction , the head of the
femur slips back into
acetabulum with a visible and
palpable movement(click)

14. First Method (Dislocated)
•Child is placed on its back with the
leg pointing towards the examiner.
•The hip flexed at right angle and
knee fully flexed.
•The middle of the each finger is
placed over the GT
•The thumb of each hand is placed
at inner side of thigh
•Hips are abducted, if sign is +ve,
femoral head is felt to slip into the
acetabulum.
Second method
(Dislocatable)
•With the hip a little flexed,
pressure is applied outwards and
towards the examination couch
with the thumb on the inner side
of the thigh
•Femoral head may be felt to slip
out of acetabulum and to return
back again when the pressure is
released.
14
Barlow Test

15. 15

16. •Between three and six months of age,
 uncommon
to find children with a positive Ortolani sign in this
age group.
•The examiner should also bear in mind that if
children present “cracking noises at the time of
undergoing the physical examination, this may not
be due to an unstable or dislocated hip.
16

17. •Infant
•Unilateral cases
•Limited hip abduction
•Galeazzi sign-
•Asymmetry of thigh and gluteal skin folds
•Affected hip lying more flexed and adducted
.
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Pediatric orthopaedics: core knowledge in
orthopaedics by John P. Dormans, MD

18. •Bilateral cases
•Displaced head of the
femur sometimes
papated
•With hip extended, GT
felt more prominent
•Telescoping may be
elicited when the femur
is moved up and down
in its long axis
•Klisic test
18

19. •Walking child
•Limp, waddling gait, or a limb length
discrepancy
•Trendelenburg sign is positive.
•Limited abduction.
•Galeazzi sign positive
•Telescopy sign is positive-
•Excessive lordosis due to hip flexion
contracture.
•Wider perineum
•In bilateral dislocations clinical findings
are waddling gait and hyperlordosis of
the lumbar spine.
19
Bilateral involvement

20. Clinical presentation
 In early childhood:-
 not very clear until child
start to walk
Asymmetry in the buttock or
thigh fold
Limited hip movements
A click in every times the
hip is moved.
20
In older child:-
1.walking- Delayed or
limping(U/L) or Waddling
(B/L)
2.Postural Changes- Scoliosis,
Lordosis

21. Investigation
•Ultrasound
•Primary Imaging modality for infants younger that 6
months
•It can be used both for diagnosis and to monitor treatment
•Static technique of Graf
21
Pediatric orthopaedics: core knowledge in orthopaedics by John P.
Dormans, MD

22. Radiographs
•Recommended after 6 months when
proximal femoral epiphysis ossifies.
•An anterior posterior view of the
pelvis can be interpreted through
several classic lines drawn on it.
•Below the age of 1 year:-difficult to
diagnose as ossification is not
complete .
•In older child:-
Epiphysis of the head of the femur
appears small
Epiphysis- displaced upward and
laterally
Acetabulam- Shallow
22
Pediatric orthopaedics: core knowledge in
orthopaedics by John P. Dormans, MD

23. •Acetabular index
•In a new born- 40 degree
•In 4months – 25 degree
•Centre- edge angle of wiberg.
•6-13 years: >19 degree
•14 years: >25 degree
•Radiographs of the hip in abduction and
internal rotation should also be obtained
because these views shows whether the
hip is reducible
•Broken shentons line-
23

24. CT or Magnetic resonance imaging
•Used for diagnosis and evaluation of DDH and for
the documentation of femoral head acetabular
relationships after closed and open reduction.
24
Pediatric orthopaedics: core knowledge in orthopaedics by John P.
Dormans, MD

25. Classification Systems
•Graf Classifications (Ultrasound-based)
•Tonnis Classification (Radiographic)
25

26. Graf introduced
 two angles as a
guide to evaluation: Alpha
 angle
(angle between the lateral
acetabular epiphysis and
 triadiate
cartilage and the lateral margin of
the ilium)
 
The normal value is greater than or
equal to 60 degrees. and
 Beta angle (angle between the
lateral border of the
 ilium and a
line joining the lateral acetabular
epiphysis
 and labrum).
The normal value is less than 77
degrees, but is only useful in
assessing immature hips when
combined with the alpha angle
26
Pediatric orthopaedics: core knowledge in orthopaedics by John P.
Dormans, MD

27. Ultrasound classification of DDH
•Graf proposed an ultrasound classification system for
infant hips (Developmental Dysplasia of the Hip
(DDH) combining both alpha and beta angles. There
are a number of additional subdivisions, which are
often not used clinically.
 
•As a general rule, the alpha angle determines the type
and in some instances the beta angle is used to
determine subtype.
 
27

28. Cont…
•Type I : alpha angle > 60 degrees
 (normal)
• Type Ia : beta angle < 55 degrees
Type Ib
 : beta angle > 55 degrees
Type II 
•Type IIa : alpha angle 50 - 59 degrees
•Type IIb
 : alpha angle 50 - 59 degrees 
•Type IIc
•alpha angle 43 - 49 degrees
•beta angle < 77 degrees
28

29. •Type III 
: alpha angle < 43 degreestype IIIa and IIIb
distinguished on the grounds of structural alteration of the
cartilaginous roof
•Type IV alpha angle < 43 degrees
•dislocated with labrum interposed between femoral head and
acetabulum
•Type D ("about to decenter") alpha angle 43 - 49 degrees
•Beta angle > 77 degrees
29

30. •The hip is classified into 4 types and several
subtypes according to various factors:
•In their simplest form, type I hips are normal, type
II hips are either immature or somewhat abnormal,
type III hips are subluxated, and type IV hips are
dislocated.
30
Pediatric orthopedics: core knowledge in orthopedics by John P.
Dorman's, MD

31. Tonnis classification
•Tönnis is classification is based upon
the location of the femoral ossific
nucleus according to the SMA line
(Line between the superolateral
margins of both acetabuli) and
Perkin’s line (a perpendicular line
from the superolateral margin of the
acetabulum to the SMA-line).
•Grade I: femoral ossification center is
medial to the P-line.
•Grade II: the ossification center
islateral to the P-line but below the
SMA-line.
•Grade III: the ossification center is on
or near the SMA-line.
•Grade IV: the ossification center is
above the SMAline 7
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Pediatric orthopaedics: core knowledge in orthopaedics by John P.
Dormans, MD

32. 32

33. •No immediate treatment is indicated for
Dislocatable hip
•Splinting
•Surgical –sometimes in neonate, release of tight
adductor and illiopsoas tendon
•Teratologic type- tenotomy and operative reduction
of the dislocation
•Continued splint for atleast 6months
33
Treatment

34. Goal of treatment
•To attain a concentric reduction of the hip
•To produce normal acetabular and femoral head
development.
•To avoid complications of treatment, including stiffness,
infection, and avascular necrosis(AVN) of the femoral head
•To avoid unnecessary patient and parental hardship (i.e.,
physical, emotional, financial).
34
AAOS Atlas of orthoses and assistive devices by John D. Hsu, John W.
Michael, John R. fisk

35. 35

36. Splinting
1.Frejka pillow
2.Pavlic harness
3.Tubingen hip orthosis
4.Von rosen splint
5.Illfeld orthosis
6.Semirigid Plastazote Hip Abduction Orthoses
7.Camp Dynamic Hip Abduction Orthosis
36

37. Positioning in splinting
•Flexion, abduction and lateral rotation- more easy
to maintain with splintage
•Extension, adduction and medial rotation
•Capsule become tight
37

38. Timing with splinting
•Child must remain in the splint continuously and
should only be taken out to test stability or adjust
the splint whilst the hip is kept in abduction
•Hip should not forced into excessive abduction
•A max. 50 degree and preferably less than 45
degrees of abduction and 90degrees of flexion
•Unless the capsule is very lax
38

39. Frejka pillow
•A soft abduction pillow in
infants
•To maintain abduction of the hip
•Due to its soft nature infant
could easily overcome the
abduction pressure
•The most recent version consist
of a 9*9*3/4 inches foam pillow
that is placed around child’s
buttocks, much like a diaper, and
secured in a cloth harness and
straps.
39
AAOS Atlas of orthoses and assistive devices by
John D. Hsu, John W. Michael, John R. fisk

40. Complications related to frejka pillow
•Even with much firmer construction, infants were not held in
adequate abduction or flexion to allow the femoral head to
be directed toward the triradiate cartilage.
•It has been reported to be a cause of AVN.
•It is a passive positioning device and does not allow active
motion.
40
AAOS Atlas of orthoses and assistive
devices by John D. Hsu, John W. Michael,
John R. fisk

41. Pavlik harness
•Gold standard for the treatment of
hip dysplasia.
•Success rates with the pavlik
harness are reported to be 90% to
100% for the treatment of hip
subluxation or dysplasia and 80%
to 95% for the treatment of
dislocated hip.
•Infants upto the age of 8mnths
having dysplastic, subluxated or
dislocated hips
41
AAOS Atlas of orthoses and assistive devices by John D. Hsu, John W.
Michael, John R. fisk

42. Pavlik
Harness-
design
42

43. Principle
•When appropriately applied, the harness prevents
adduction and extension of the hip while allowing
further flexion, abduction, and rotation. This
position and motion are designed to aid the gentle,
spontaneous reduction of the dislocated hip and
acetabular development of the dysplastic hip.
43
AAOS Atlas of orthoses and assistive
devices by John D. Hsu, John W. Michael,
John R. fisk

44. Complications
•Pavlik harness disease
•Skin irritation
•Femoral nerve palsy
•Inferior dislocation of hip
•AVN of femoral head
44
Pes cavus caused due to pavlik harness
AAOS Atlas of orthoses and assistive
devices by John D. Hsu, John W. Michael,
John R. fisk

45. Tubingen hip orthosis
•Update of the traditional pavlik
design.
•Dysplastic
•Hip without instability (iia, iib,
iic stable on the graf scale
• It provides hip flexion beyond
90 degrees and abduction
•Offers the advantage of leaving
the knee and ankle joints free.
•Allows the hip to be positioned
in 90 to 110 degrees of flexion
and 45 to 55 degrees of
abduction
45

46. Von rosen splint
•The von rosen splint consists of a plastic frame that
is easily shaped to conform to the child’s body.
46
Shaped across shoulder
Around waist
To adjust hip flexion and abduction

47. Limitations
•Orthosis requires continues attention and must be
checked frequently to assure appropriate positioning
is maintained and complications are being avoided.
•Its is a passive positioning device and does not
allow active motion.
47
AAOS Atlas of orthoses and
assistive devices by John D. Hsu,
John W. Michael, John R. fisk

48. Iifeld splint
Consist of 2 thigh bands
connected by a crossbar with
universal joints.
A waist to hold the device on
more securely.
Since the length of the cross bar is
adjustable, abduction and to some
extend flexion can be controlled.
It’s major use is in post operative
maintence of abduction.
48

49. Semirigid Plastazote Hip Abduction Orthoses
•These devices offer a possible option for the infant who
has a persistent Ortolani-positive hip after 3 to 4 weeks in
a Pavlik and offers the advantages of avoiding both
general anesthesia and a spica cast
49
Orthotics and prosthetics in rehabilitation,second edition,
Michelle M. Lusardi, PT, Phd

50. Camp Dynamic Hip Abduction Orthosis
•Late-diagnosed developmental
dysplasia of the hip.
•It is recommended to support hip
maturation after successful
reduction.
•The orthosis fixes the hip joint in
90-degree of flexion and 60
degrees of abduction.
50

51. When to stop using splint
•Clinical and radiological examination confirms hip
stable and concentrically reduced.
•Once adduction is regained- hip is stable
51

52. Risk factors for success of splinting
52

53. 53
Prctice of
paediatric
orthopaedics,
Lynn T. staheli

54. Preliminary Traction
•When femoral head is not reducible with orthosis skin
traction is preferred.
•The skin is wrapped with a webril and the traction applied
to the thighs and across the slightly bent knee.
•Not more than 4 to 5 lb. of skin traction are used.
•X-rays should be taken once a week and if no improvement
is seen then pin traction is used.
54
Pediatric Orthopaedics by Lovell and
winter

55. •Pin traction should be continued till femoral head is
below the level of acetabular level to avoid
avascular necrosis.
55
Pediatric
Orthopaedics by
Lovell and winter

56. Close reduction
Once femoral head is
pulled below acetabular
level, attempt of closed
reduction is done under
general anesthesia.
After reduction most
stable and safe position of
reduction is found.
56
Pediatric Orthopaedics by Lovell and
winter

57. Open reduction
•Key steps during open reduction includes removal
of the ligamentum teres and the fibrofatty pulvinar
with division of the transverse acetabular ligament
and the iliopsoas tendon to allow the femoral head
to seat deeply into the dysplastic, shallow
acetabulum.
57
Pediatric orthopaedics: core knowledge
in orthopaedics by John P. Dormans, MD

58. Treatment for children older than 2 years
•More challenging.
•In a child older than 2 years, open reduction is
usually necessary.
58
Pediatric orthopaedics: core knowledge
in orthopaedics by John P. Dormans, MD

59. Sequele and complications
•Residual acetabular dysplasia
•Avascular necrosis
59
Pediatric orthopaedics: core knowledge
in orthopaedics by John P. Dormans, MD

60. Follow up
•Clinical assessment should be made at 3 months intervals
until walking is established
•Radiography
•Arthrography- congruity on movement of the hip will reveal
any instability
60

61. Conclusion
•An age-inappropriate orthosis, either according to its indication or
its inappropriate size, and biomechanically unsuitable, is one of the
factors that contribute to a poor prognosis
•The regular follow-up of the treatment of congenital hip dislocation
allows the early detection and management of the various
complications.
•Success for the treatment of ddh relies on early detection and
management.
•All neonates should have a clinical examination for the hip
instability.
•Care should be taken to avoid complications
61

62. References
Pediatric orthopaedics: core knowledge in orthopaedics by John
P. Dormans, MD
AAOS Atlas of orthoses and assistive devices by John D. Hsu,
John W. Michael, John R. fisk
Pediatric Orthopaedics by Lovell and winter.
Orthotics and prosthetics in rehabilitation,second edition,
Michelle M. Lusardi, PT, Phd
Prctice of paediatric orthopaedics,Lynn T. staheli
Journal of Bone and Joint Survery Vol. 63-A, No. 8, pp. 1239-
1248, October1981.) Copyrighted 1981 by the Journal of Bone
and Joint Surgery, Inc. Printed in U.S.A.
Developmental Dysplasia of the Hip from Birth to Six Months.
Guilleet al, JAAOS, 1999.
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63. 63