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developmental dysplasia of the hip, congenital dislocation of hip
Developmental dysplasia of the hip (DDH) was formerly referred to as congenital dislocation of hip. Now that the condititon is better understood, the former term is preferred to reflect the facts that
The cause of DDH is both
It has been estimated that only 1 in 100 newborn infants have clinically unstable hips (subluxatable - the ball of the hip is able to be moved around loosely in the hip joint joint - or dislocatable - the ball of the hip is able to be actually slid in and out of joint with a "clunk" that can be felt), whereas only one in 800 to 1,000 of newborn infants eventually experience a true dislocation whereby the ball of the hip lies outside the socket.
If an abnormal hip remains untreated, the child will develop the long-term complications, including:
For this reason, your baby's doctor will carefully examine the hips at every visit. She will perform several tests and inspect the hip area carefully for subtle signs of either hip instability or dislocation.
The examination in the newborn nursery is the critical screening tool to detect loose, dislocatable, and dislocated hips. Up to about 4 to 6 months of age, the Barlow and Ortolani maneuvers done at routine well-baby examinations are most important. Around 6 months of age, a parent might notice differences in the range of motion of the hip with some difficulty with diapering. Perhaps a parent or the doctor might notice a leg length difference or an asymmetric appearance of the two legs (asymmetric skinfolds). The importance of frequent, routine screening hip examinations until walking age by an experienced physician cannot be overemphasized.
A common concern is the presence of hip clicks in infants. Hip clicks per se are usually not due to actual or potential dislocation and are secondary to normal snapping of the tendons and other factors analagous to popping in the normal ankle or cracking knuckles.
Once a child is walking, gait abnormality related to leg length difference is the hallmark for identifying an abnormal hip. Asymmetric intoeing or outtoeing is the clue - one foot points in or out significantly more than the other. If the hip abnormality still remains undiagnosed, pain or more noticeable gait asymmetry ultimately draws attention to the hip as the child becomes older.
In older or walking children, complaints of limping, waddling, increased lumbar lordosis ("swayback"), toe walking, and leg-length discrepancy may indicate an unrecognized DDH, and should obviously be brought to your doctor's attention.
If an unstable hip is recognized at birth, treatment consists of maintaining the position of the hip in flexion (knee up towards the head) and abduction (knee away from the centerline) for about 1-2 months. The Pavlik harness is the most widely used device, but the Frejka splint and some other devices are also used. The device chosen for treatment maintains proper position of the femoral head and allows for "tightening up" of the ligamentous structures as well as for stimulation of normal formation of the hip socket. The treatment must be continued until the hip is stable and xrays or ultrasound examinations are normal.
From 1-6 months, true dislocations may develop. As a consequence, treatment is directed toward reduction of the femoral head into the socket (acetabulum), usually with the Pavlik harness or similar device. The harness pushes the femoral head toward the socket, and usually, relocation of the femoral head will occur within 3-4 wk. The Pavlik harness is approximately 95% successful in dysplastic or subluxated hips and 80% successful in true dislocations. Triple diapering is frowned upon now because it promotes hip extension, which is not a good position for normal hip development. If a spontaneous reduction does not occur by splinting, then a surgical closed reduction (manipulation under anesthesia) is done.
In the older infant from 6-18 Mo, surgical closed reduction (manipulation under general anesthesia) is the major method of treatment.
After 18 mo of age, the progressive deformities become so severe that major open surgical intervention is necessary to realign the hip.