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Hip Dysplasia
A malformation of the hip joint that is present at birth. Genetic
factors likely play a role in this disorder. Features include hip dislocation, asymmetry of leg
positions, asymmetric fat folds, and diminished movement on the affected side. Some
children will exhibit little or no features and must be diagnosed by physical examination
of the hip joints.
Information about of Hip Dysplasia
Hip Dysplasia is an abnormal formation of the hip joint in which the ball at the top of
the thighbone (femoral head) is not stable in the socket (acetabulum). Also, the ligaments
of the hip joint may be loose and stretched. The degree of instability or looseness
varies. A baby born with DDH may have the ball of his or her hip loosely in the socket,
the looseness may worsen as the child grows and becomes more active, or the ball may be
completely dislocated at birth.
Left untreated, DDH or hip dysplasia leads to pain and osteoarthritis by early
adulthood. It may cause legs of different lengths or a "duck-like" walk and
decreased agility. DDH has a familial tendency. It usually affects the left hip and is
predominant in:
- Girls.
- First born children.
- Babies born in the breech position (especially with feet up by the shoulders). The
American Academy of Pediatrics now recommends ultrasound screening of all female, breech
babies.
Although hip dysplasia is usually noted in the newborn exam, treatment is easier and
safer the earlier the diagnosis is made. Hips found normal at birth can be found abnormal
later, but this is rare. Pediatricians screen for DDH at a newborn’s first exam and
at every well-baby checkup thereafter. Otherwise, the condition may not be noticed until a
child begins to walk – by which time treatment is more complicated and uncertain.
Symptoms of Hip Dysplasia
Although some dislocated hips show no signs, contact a doctor if your baby has:
- Legs of different lengths.
- Uneven thigh skin folds.
- Less mobility or flexibility on one side.
In children who have begun to walk, limping, toe walking and a waddling
"duck-like" gait are also signs.
In addition to visual clues, doctors use careful physical examination tests to check
for subtle signs of hip instability or dislocation in babies, such as listening and
feeling for "clunks." Hip X-rays also may be helpful in older infants and
children.
Treatment methods depend upon the child’s age.
Causes of Hip Dysplasia
Clinical studies show a familial tendency toward hip dysplasia, with more females
affected than males. This disorder is found in many cultures around the world. However,
statistics show that the Native American population has a high incidence of hip
dislocation. This has been documented to be due to the common practice of swaddling and
using cradleboards for restraining the infants. This places the infant's hips into extreme
adduction (brought together). The incidence of congenital hip dysplasia is also higher in
infants born by caesarian and breech position births. Evidence also shows a greater chance
of this hip abnormality in the first born compared to the second or third child. Hormonal
changes within the mother during pregnancy, resulting in increased ligament laxity, is
thought to possibly cross over to the placenta and cause the baby to have lax ligaments
while still in the womb. Other symptoms of complete dislocation include a shortening of
the leg and limited ability to abduct the leg.
Diagnosis of Hip Dysplasia
Because the abnormalities of this hip problem often vary, a thorough physical
examination is necessary for an accurate diagnosis of congenital hip dysplasia. The hip
disorder can be diagnosed by moving the hip to determine if the head of the femur is
moving in and out of the hip joint. One specific method, called the Ortolani test, begins
with each of the examiners hands around the infant's knees, with the second and third
fingers pointing down the child's thigh. With the legs abducted (moved apart), the
examiner may be able to discern a distinct clicking sound with motion. If symptoms are
present with a noted increase in abduction, the test is considered positive for hip joint
instability. It is important to note this test is only valid a few weeks after birth.
The Barlow method is another test performed with the infant's hip brought together with
knees in full bent position. The examiner's middle finger is placed over the outside of
the hipbone while the thumb is placed on the inner side of the knee. The hip is abducted
to where it can be felt if the hip is sliding out and then back in the joint. In older
babies, if there is a lack of range of motion in one hip or even both hips, it is possible
that the movement is blocked because the hip has dislocated and the muscles have
contracted in that position. Also in older infants, hip dislocation is evident if one leg
looks shorter than the other.
X-ray films can be helpful in detecting abnormal findings of the hip joint. X rays may
also be helpful in finding the proper positioning of the hip joint for treatments of
casting. Ultrasound has been noted as a safe and effective tool for the diagnosis of
congenital hip dysplasia. Ultrasound has advantages over x rays, as several positions are
noted during the ultrasound procedure. This is in contrast to only one position observed
during the x ray.
Treatment of Hip Dysplasia
The objective of treatment is to replace the head of the femur into the acetabulum and,
by applying constant pressure, to enlarge and deepen the socket. In the past,
stabilization was achieved by placing rolled cotton diapers or a pillow between the
thighs, thereby keeping the knees in a frog like position. More recently the Pavlik
harness and von Rosen splint are commonly used in infants up to the age of six months. A
stiff shell cast may be used, which achieves the same purpose, spreading the legs apart
and forcing the head of the femur into the acetabulum. In some cases, in older children
between six to 18 months, surgery may be necessary to reposition the joint. Also at this
age, the use of closed manipulation may be applied successfully, by moving the leg around
manually to replace joint. Operations are not only performed to reduce the dislocation of
the hip, but also to repair a defect in the acetabulum. A cast is applied after the
operation to hold the head of the femur in the correct position. The use of a home
traction program is now more common. However, after the age of eight years, surgical
procedures are primarily done for pain reduction measures only. Total hip surgeries may be
inevitable later in adulthood.
Alternative treatment of Hip Dysplasia
Nonsurgical treatments include exercise programs, orthosis (a force system, often
involving braces), and medications. A physical therapist may develop a program that
includes strengthening, range-of-motion exercises, pain control, and functional
activities. Chiropractic medicine may be helpful, especially the procedures of closed
manipulations, to reduce the dislocated hip joint.
Prognosis
Unless corrected soon after birth, abnormal stresses cause malformation of the
developing femur, with a characteristic limp or waddling gait. If cases of congenital hip
dysplasia go untreated, the child will have difficulty walking , which could result in
life-long pain. In addition, if this condition goes untreated, the abnormal hip
positioning will force the acetabulum to locate to another position to accommodate the
displaced femur.
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 may help prevent strain on
the hip joints. Early diagnosis remains an important part of prevention of congenital hip
dysplasia.
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