Developmental Dysplasia of Hip (DDH) or Congenital Dislocation of Hip (CDH)

Developmental dysplasia of hip (DDH) - previously known as Congenital dislocation of hip (CDH) - Physiotherapy case presentation with treatment.

1. Presented by - Neetu Bargayary Roll no – UF-181-361-0036 Registration no - 18095356

2. INTRODUCTION DDH is defined as ‘a spectrum of disease ranging from minor dysplasia (inadequate development) of the hip to subluxation of the joint to complete dislocation’. Previously referred to as "congenital dislocation of the hip (CDH)," the term developmental is preferred since not all cases are present or identified at birth.

3. EPIDEMIOLOGY 1 per 1000 live births Unilateral CDH is more common (B/L:unilateral = 1:3) Left hip affected in 67% cases Family history present in 20% Incidence of breech 30-50% More common in first borns – due to smaller uterus More common in females (M:F = 1:5) Most common congenital disorder in western countries. It is uncommon in India & some other Asian countries, because of the culture of mother carrying the child on the side of her waist with the hip of the child abducted.

4. ETIOLOGY Primarily, due to hip dysplasia. Risk Factors: Heriditary predisposition to joint laxity Hormone induced joint laxity in females Breech malpositioning

5. Any physical limitation (intra uterine growth restriction) like LGA (large for gestational age), oligohydramnios , twins, etc Post maturity (post term pregnancy) is a risk factor Caesarean section Tight swaddling in the adducted and extended position Foot deformities (including postural).

6. ANATOMY The hip joint is a ball and socket joint (a type of synovial joint): The femoral head (ball) fits into the acetabulum (socket) It allows 3 degrees of freedom: flexion/extension, abduction/adduction & medial/lateral rotation.

7. It’s primary function is to support the weight of the HAT (head, arms & trunk) The joint is stabilized by the surrounding joint capsule and ligaments. THE JOINT CAPSULE :

8. THE LIGAMENTS : Iliofemoral Ligament: Strongest, Y- shaped, & prevent hyperextension of the hip joint. Pubofemoral Ligament: Triangular in shape, prevent excessive abduction and extension. Ischiofemoral Ligament: Prevents hyperextension & holds the femoral head in the acetabulum .

9. THE MUSCLES :

10. ARTERIAL SUPPLY :

11. NERVE SUPPLY:

12. PATHOLOGY At birth, the hip is mostly made up of a flexible cartilage, which is slowly replaced by bone as we grow, until adulthood. The femoral head & acetabulum put pressure on each other to form a closed pack joint. But in DDH there will be dysplasia (inadequate development) of the hip (particularly the acetabulum ) by birth, infancy or childhood. Various anatomical & mechanical changes in DDH are: Shallow acetabulum Femoral head is dislocated upwards & laterally. Its epiphysis is small & ossifies late.

13. Femoral neck could be shortened & excessively anteverted (twist/rotates inwards) Normal femoral torsion (angle of twist) = 15 to 20° The pelvis is usually tilted forwards (anterior pelic tilt), it is small & atrofied . There is lordosis .

14. Capsule is loose & elongated & could be hourglass shaped Stretched/ hypertropied ligamentum teres Limbus (labrum of acetabulum ) may be folded The space btw the acetabulum and the femoral head is filled with fibro fatty tissue ( Pulvinar ) Muscles of the hip, especially the adductors, undergo adaptive shortening.

15. CLINICAL FEATURES Clinical features vary in infants (early childhood), children & adults. IN INFANTS (below 1 year olds): Limited ROM of the affected hip (decreased abduction & external rotation) Increased internal rotation Asymmetric creases (skin folds) of groin, thigh & glutei (buttock fold is higher on the affected side) in U/L cases In B/L cases, the perineum is widened & the buttocks are broad & flat

16. IN EARLY CHILDHOOD & ADOLESCENTS (above 1 year olds): All the features found in infants, plus: Increased lumbar lordosis Clicking sound with hip movements Femoral artery is more prominently felt Unilateral or B/L shortening of leg Child walks with a ‘peculiar gait’ though there is no pain Trendelenberg gait in unilateral cases Waddling or sailor’s gait in B/L cases

17. IN ADULTS: DDH in adults shows all the features seen in adolescents. In addition, patient will have features of secondary osteoarthritis: Pain Stiffness Limp Crepitus Restricted movements

18. DIAGNOSIS Diagnosis of DDH is done by a physical exam &/or diagnostic imaging procedures. PHYSICAL EXAMINATION: 1) Barlow test ( upto 6 months) First part: Patient will be in supine position Therapist faces towards the patient & flexes both knees & hips to 90° Followed by slow adduction of the hip Mild pressure is then applied on the knee while pushing the femoral head towards the acetabulum , resulting in dislocation of the head posteriorly with an audible or palpable click

19. Second part: Similar to Ortolani’s sign/test 2) Ortolani’s test (3-9 months) The hip is taken into abduction, along with application of gentle traction (pulling forward) on the femoral head If the femoral head slips forward into the acetabulum with a click, the test is positive, indicating that the hip was dislocated.

20. 3) Galeazzi sign or Allis test (3 months to 2 years) Test for unilateral DDH The child lies supine with the knees & hips flexed to 90° A positive test is indicated if one knee is higher than the other

21. 4) Skin fold test of thigh & 5) Skin fold test of glutei region Creases of the B/L thigh & glutei are symmetrical in normal hip Asymmetrical in unilateral DDH 6) Trendelenberg sign/test The patient stands on normal limb first, followed by affected limb with the contralateral leg raised off the ground When standing on the normal limb there will be hiking of opposite hip but incase of standing on the affected limb there will be pelvis drop on the opposite side indicating impairment of abductors due to DDH

22. DIAGNOSTIC IMAGING: 1) Ultrasonography Helps in early diagnosis of DDH at birth Imaging choice during the first few months of life (less than 4 months) when the ossification centre of the femoral head is yet to appear. 2) Radiography Imaging of choice in infants > 4months when the femoral ossification centre is visisble

23. In infants (below 1 year old), since the epiphysis of the femoral head is not ossified, it is difficult to diagnose a dislocated hip. Von Rosen’s view, also called AIR view (X-ray taken with hip abducted & internally rotated) may help to identify dislocated hip.

24. In children & adolescents , x-ray of pelvis show important features: Perkin’s line – A vertical line drawn at the outer border of the acetabulum Hilgenreiner’s line – A horizontal line drawn at the level of triradiate cartilage Broken Shenton’s line - A line from the medial neck of the femur should continue in an unbroken curve to follow the superior margin of the obturator foramen. Acetabular index/roof angle – Normal value is less than or equal to 30°

25. CEA (center edge angle) of Weiberg – It's formed by 2 lines One line drawn from the center of the femoral head to the outer edge of the acetabular roof, and Another vertical line drawn through the center of the femoral head. Normal value is 15-30° In DDH, CEA will be less than 15°

26. TREATMENT Aim - To reduce (realign) the femoral head into the acetabulum & maintain it until the hip becomes clinically stable & a ‘round’ acetabulum covers it The methods of treatment varies in different age groups Upto 6 months of age Treated CONSERVATIVE LY: Application of splints (for 2-3 months) such as Von Rosen splint or Pavlik harness (below image), positioned in hip flexion & abduction, facilitates reduction PHYSIOTHERAPY

27. 6 months to 2 years of age NON-OPERATIVE : closed manipulation under general anaesthesia & maintained in a: Gallow’s traction (given for 4-6 weeks) POP hip spica (given for 6 weeks) Hip spica may cause contracture of hip adductors in some cases. Then, Adductor tenotomy is required OPERATIVE : Open reduction is opted incase the conservative method, fails. PHYSIOTHERAPY

28. 2 to 8 years of age Treated SURGICAL LY : Open reduction followed by pelvic ( acetabular reconstruction) or femoral osteotomy (femoral shortening) Acetabular reconstruction may be performed at the same time with femoral shortening or later . Salter’s osteotomy (a pelvic surgery that treats hip dysplasia in young children by rotating the pelvic bone to improve its position on top of the femoral head) is preferred by most surgeons PHYSIOTHERAPY

29. Above 8 years of age NO TREATMENT ( until development of secondary OA) in of B/L DDH cases due to: Poor treatment results SURGERY : Incase of unilateral cases open reduction with osteotomy may be required THR is considered once adulthood is reached or when the secondary OA develops Sometimes, arthrodesis (fusion with surgical pins, plates & screws) of the hip is also done. PHYSIOTHERAPY

30. CASE STUDY DEMOGRAPHIC DATA Name- Ms Amena Age- 1 year, 10 months old Sex- Female Occupation- Nil Communication- Bengali Referral doctor- Dr. Surya Udai Singh (Dept. of Orthopedics & Joint Replacement) Date of assessment- 1/4/24 SUBJECTIVE ASSESSMENT Chief complain – Child’s parents complains of baby Amena not being able to walk independently History of present illness – A 1 year, 10 months old female child, Amena , presented to OPD with complains of not being able to walk independently & balance instability

31. Past medical history – A 1 year 10 months old female child, Amena , presented to the hospital with complains of not being able to walk independently with shortening of left LL (2cm LLD) Left hip closed reduction + one & a half hip spica application under GA A dductor percutaneous tenotomy

32. Surgical history – No significant history Pain history – no pain (vas score = 0 ) Family history – No significant history Mother’s antenatal history – Decreased fetal movements Birth history – 2 nd child of a non- consanguinous marriage LSCS (indication from previous LSCS) Weight -3kg Cried immediately, no NICU admission Born with B/L CTEV for which she was on P onseti casting (6 weeks), P onseti bracing or FAO –foot ankle orthosis or CTEV (23 hours for 3 months, which is now worn at nighttime only) Developmental history – Delayed milestones according to parents Can cruise – holding some support

33. OBJECTIVE ASSESSMENT On observation Body built – mesomorphic Posture – while standing Head & Neck – central Shoulder , Elbow & UE – same leveled on both sides Chest – normal Back & Spine – aligned, no exagerrated lumbar lordosis ASIS – same leveled Patella – same leveled Calf – wasted Foot – stands on toe Pattern of movement – normal Type of ventilation – spontaneous respiration Pattern of breathing – normal Skin changes – absent Gait – tip toe walking (with support)

34. On palpation Edema – palpable swelling in left gluteal region Warmth – normal body temperature (38°c), afebrile Tenderness – absent On examination Vital signs – stable Consiousness – alert Higher cortical function - Intact Speech – normal Hearing – normal Vision – normal Cranial nerves – intact Sensory – intact Contracture/deformity – CTEV (night bracing) Involuntary movements – absent Coordination – good Muscle wasting – present at calf muscles

35. Muscle tone: UL – normal LL - hypotone Reflexes: Biceps (C5) - intact Triceps (C7)- intact Brachioradialis (C6)- intact Quadriceps (L4)- diminished Plantar flexion (S1)- absent Plantar – flexed Abdominal – N/A Muscle power at hip Right hip – grade 5 Left hip – grade 4 (adductors are greatly affected) Dorsiflexors –weak

36. ROM at hip: Balance: HIP RIGHT LEFT Flexion 120-135 130° 130° Extension (0-30°) 20° 20° Abduction (45-50°) 50 ° 40 ° Adduction (20-30°) 40° 50° Internal rotation (<70°) 50° 70° External rotation (>20°) 70° 50° BALANCE STATIC DYNAMIC Sitting Good Good Standing Fair Poor

37. Auscultation – B/L BVS Dyspnea - absent Cough - absenr Hand function – good Assistive devices – none Investigations - X-ray shows dislocation at left hip Physiotherapy special test – Galeazzi sign or Allis test = + ve Skin fold test of thigh & glutei region = + ve Trendelenberg sign/test =+ ve Physiotherapy diagnosis – Developmental dysplasia of hip Physiotherapy management – Physiotherapy Aims : To strengthen weak muscles To maintain & improve ROM To reduce muscle wasting To improve balance & gait To make the patient functionally independent

38. DURING IMMOBILIZATION (lasts for 6 weeks with hip spica ) AROM of unaffected limb Isometrics of quads , hamstrings & g luteal muscles Active & resistive ankle toe movements DURING MOBILIZATION Active & resistive ankle toe movements Calf stretches Isometrics to gluteal , quad & hamsstring muscles AROM at the hip & knee Relaxed passive adduction Passive stretching Prone lying (tummy time) Weight bearing activities like Quadruped kneeling Encouraged crawling Knee standing Knee walking Physiotherapy Management :

39. Balance training Reaching activities using balls/toys, etc Supine Quadruped Kneeling Sitting Standing Sit-to-stands Gym ball exercises Gait training Waking – straight, sideways, tandem waking, obstacle walking Stair climbing on stepper Gradual squatting & cross leg sitting by 6th week of mobilization