Cdh

1. CDH
CONGENITAL DISLOCATION OF THE
HIP
Dr. ABDULMONEM ALSIDDIKY , MD , SSCO.
Assistant Professor & Consultant
pediatric Ortho.& Spinal Deformities
KSU,KKUH
Riyadh , Saudi Arabia

2. Nomenclature
 CDH : Congenital Dislocation of the Hip
 DDH : Developmental Dysplasia of the Hip

3. NORMAL PELVIS

4. Normal hip Dislocated hip

5. Patterns of disease
 Dislocated
 Dislocatable
 Sublaxated
 Acetabular dysplasia

6. Radiology
 After 6 months: reliable

8. Causes (multi factorial)
 Hormonal
 Relaxin, oxytocin
 Familial
 Lig.laxity diseases
 Genetics
 Female 4 X male --- twins 40%
 Mechanical
 Pre natal
 Post natal

9. Mechanical causes
 Pre natal
 Breach , oligohydrominus , primigravida , twins
 (torticollis , metatarsus adductus )
 Post natal
 Swaddling , strapping

11. Infants at risk
 Positive family history: 10X
 A baby girl: 4-6 X
 Breach presentation: 5-10 X
 Torticollis: CDH in 10-20% of cases
 Foot deformities:
 Calcaneo-valgus and metatarsus adductus
 Knee deformities:
 hyperextension and dislocation

12. Infants at risk
When risk factors are present
 The infant should be reviewed
 Clinically
 radiologically

13. Clinical examination
 The infant should be
 quiet
 comfortable

14.  Look:
 External rotation
 Lateralized contour
 Shortening
 Asymmetrical skin folds
 Anterior – posterior

16.  Move
 Limited abduction

17.  Special test
 Galiazzi
 Ortolani , Barlow test
 Trendelenburgh sign
 Limping ( waddling gait if bilateral)

18. Special test
Galiazzi test

19. Special test
Ortolani test

20. Special test
Barlow test

21. Special test
Trendelenburgh sign

22. Screening programs
 Clinical screening proven to be effective
 Performed by trained personnel
 Must be dynamic
 Repeated with periodic examination
 U/S screening is controversial

23. Investigations
 0-3 months U/S
 > 3months X-ray pelvis AP + abduction

24. U/S Screening
 Incidence of hip stability declines rapidly to
50% within the first week of neonatal life.
 Better to delay U/S screening

25. U/S - Problems
 Too sensitive:
 Detects a lot of hip abnormalities, most of which
would develop normally if left alone
 Operator-dependant

26. Radiology
 Early infancy: not reliable

27. Radiology
 After 2-3 months: more reliable

28. Radiology
 After 2-3 months: more reliable
27o 39o

29. Radiology
 After 2-3 months: more reliable
in out
in out
Von Rosen view
in out

30. Radiology
 After 2-3 months: more reliable
in out

31. Radiology
 After 6 months: reliable

32. Radiology
 After 6 months: reliable

33. Treatment - Aims
 Obtain concentric reduction
 Maintain concentric reduction
 In a non-traumatic fashion
 Without disrupting the blood supply to
femoral head

34. Treatment
 Method depends on age
 The earlier started, the easier it is
 The earlier started, the better the results are
 Should be detected EARLY

35. Treatment
 Birth – 6m
 Pavlik harness or hip spica
 6-12 m:
 Closed reduction under GA and hip spica
 12 - 18 m:
 Open reduction
 18 – 24 m:
 Open reduction and Acetabuloplasty
 2-8 years:
 Open reduction, Acetabuloplasty, and femoral shortening
 Above 8 years:
 Open reduction, Acetabuloplasty cutting all three pelvic bones, and
femoral shortening

36. Treatment: Neonatal hip instability
 Most resolve spontaneously
 Can initially wait
 Avoid adduction swaddle
 Apply double diapers – to bring back!!
 See at 2weeks of age

37. Treatment: Neonatal hip instability
Unstable at 2 weeks:
 Double / Triple diapers: inadequate
 Gives illusion that patient is “in treatment” while
wasting valuable time

38. Treatment: Neonatal hip instability
Unstable at 2 weeks:
 Pavlik Harness
 Dynamic, effective, safe

39. Treatment: 6-12 m
 Initially non-operative closed reduction UGA and
immobilization in hip spica cast
 Position:
 Avoid sever abduction
 Avoid frog position
 Must obtain stable concentric reduction,
otherwise needs surgery

40. Treatment: 6-12 m
 Possibly closed reduction
 Stable and concentric reduction
 Possibly open reduction
 Unstable or un-concentric reduction
 Arthrography-guided

41. Treatment: 6-12 m
 Arthrography-guided Closed Reduction

42. Treatment: 6-12 m
Arthrography-guided Closed Reduction
Too lateralized Acceptable

43. Treatment: 18-24 m
 Open reduction – surgery
 Possibly: Acetabuloplasty

44. Treatment: Above 2 years
 Open reduction, and
 Acetabuloplasty, and
 Femoral shortening

45. Acetabuloplasties
 Many types

47. Treatment
 Birth – 6m
 Pavlik harness or hip spica
 6-12 m:
 Closed reduction under GA and hip spica
 12 - 18 m:
 Open reduction
 18 – 24 m:
 Open reduction and Acetabuloplasty
 2-8 years:
 Open reduction, Acetabuloplasty, and femoral shortening
 Above 8 years:
 Open reduction, Acetabuloplasty cutting all three pelvic bones, and
femoral shortening

48. CDH - Summary
 Complex multi-factorial, endemic disease
 Health education and Drs. awareness
 Screening programs are needed
 Learning proper examination methods
 Identify at risk groups
 Efficient referral system
 Proper management by specialized Drs

51. Examples