Developmental Dysplasia of the Hip.
Last updated Wednesday, February 09, 2005
AboutBasics of developmental dysplasia of the hip Developmental dysplasia of the hip (DDH) describes abnormal formation
of the hip, which can occur before birth (during growth of the fetus),
or after birth (during early childhood).Facts and myths One of the most widely held misconceptions is that developmental
dysplasia of the hip can be effectively treated at home with double or
triple diapers. This method does not work, and often delays the early
(and therefore higher chance of success) implementation of treatments
that have proven benefits.Prognosis In 90% of cases, developmental dysplasia of the hip (DDH) resolves without consequence.
In 10% of cases, there may be long term problems, including pain, stiffness and arthritis. Lethality Developmental dysplasia of the hip is non-lethal.Pain If untreated, developmental dysplasia of the hip may cause pain, which
can be so severe that it prevents the affected individual from walking.Debilitation The pain, stiffness and arthritis that can result from untreated
developmental dysplasia of the hip can be very debilitating. One
outcome may be loss of the ability to walk and confinement to a wheel
chair.Daily activities Untreated, individuals with developmental dysplasia of the hip may
become confined to a wheel chair because of hip pain, stiffness and
arthritis, which will significantly impact activities of daily living.
The goals of treatment are to restore full function of the hip, so
that they can live a normal life without any physical impairments. Diet There is no evidence that diet plays any role in causing or curing developmental dysplasia of the hip.Relationships Since there is a potential for hip pain, stiffness and arthritis, which
may ultimately lead to loss of the ability to walk and confinement to a
wheel chair, developmental dysplasia of the hip can significantly
impact social relationships.Other impacts Stiffness and dislocation of the hip can be disfiguring by altering the
way an individual walks, for example, by producing a waddling gait. The
scars from surgery to correct the condition can be disfiguring as well.Incidence The two most important risk factors for developmental dysplasia of the
hip (DDH) are a family history of the condition, and breech position of
the child during pregnancy. In addition, it seems to occur more
frequently in first born girls, and less frequently in individuals of
African descent.Communicability DDH is not contagious.Injury & trauma risk factors DDH is not likely to result from injury or trauma.Anatomy The hip is a ball and socket joint. The ball swivels in the socket to
allow for universal or multiplanar motion in every direction (unlike
for example the knee joint, which moves essentially in one plane,
bending and straightening in one direction only). The socket comes from
the pelvis, and is known as the acetabulum. The ball comes from the
femur, or thigh-bone, and is known as the femoral head.Initial symptoms Developmental dysplasia of the hip is asymptomatic in childhood,
which is why it can be missed and which is why babies are screened for
it. The first sign is usually a "clunk" or reduced range of motion of
the hip manipulation or physical examination.
One of the first signs that there is a problem perceived by parents
is a waddle when the child begins to walk. The child tilts over to the
side of the dislocated hip when that leg is planted on the ground and
the unaffected leg is swinging. Progression As the child gets older, for example toward the end of the first
decade of life, pain becomes a feature of the developmental dysplasia
of the hip. When the hip is manipulated during a physical examination,
there is typically reduced range of motion of the hip.
Untreated, developmental dysplasia of the hip may worsen throughout
an individual's life. Treated, developmental dysplasia of the hip has
the potential to recur or get worse until maturity, which is why we
follow the children we treat until they are mature. Causes The hip is a ball and socket joint. In developmental dysplasia of the
hip, the socket (known as the acetabulum of the pelvis) is too shallow.
This may result in uneven distribution of force across the hip.
Alternatively, the socket may be so shallow that the ball (known as the
head of the femur, or thigh-bone) can dislocate. In both cases, the
result is initially a waddling gait, and eventually hip pain,
stiffness, and arthritis.Diagnosis The physical examination, performed by a pediatrician or an
orthopaedic surgeon, is the best method to diagnose developmental
dysplasia of the hip.
Other aids to diagnosis include ultrasound examination of the hips
during the first six months of life (much of the hip is made of
cartilage and can't be seen well on X-ray), and X-ray examination of
the pelvis after six months of age (when the bones are sufficiently
developed that they can be seen well on X-ray). Treatment Treatment for developmental dysplasia of the hip is dependent upon age.
In the first six months of age, the standard of care is a Pavlik
harness, which holds the hips bent up and out but allows for motion as
the child kicks the legs. Between six and eighteen months, the hip is
examined under general anesthesia. If it can be held safely, the child
is placed in a spica cast (a body cast that holds the hip in the
optimal position to promote proper growth of the socket, or acetabulum,
and ball, or femoral head). If the hip is unstable, it is surgically
opened and any obstacles to reduction (tissues which might be filling
up the acetabulum or in another way preventing the femoral head from
sitting properly in the acetabulum) are cleared; the child then is
placed in a spica cast. After eighteen months of age, it is necessary
to cut the pelvis or the femur to better align the acetabulum and the
femoral so that they can develop normally.Self-management No self-management methods have been shown to work in treating developmental dysplasia of the hip.Health care team The pediatrician often makes the initial diagnosis. The orthopaedic
surgeon confirms the diagnosis, provides education on the condition,
and treats the condition until resolution. Along the way, other health
care professionals may be involved as deemed necessary by the type of
intervention selected and the type of outcome. For example, nurses
perform preoperative and postoperative management, such as learning how
to care for a spica cast.Medications There are no specific medications for developmental dysplasia of the hip.Surgery Surgery can help treat DDH.
After six months of age, surgery is recommended for treatment of
developmental dysplasia of the hip. Between six and eighteen months,
the child is taken to the operating room and the hip is examined under
general anesthesia. If it can be held safely, the child is placed in a
spica cast (a body cast that holds the hip in the optimal position to
promote proper growth of the socket, or acetabulum, and ball, or
femoral head). If the hip is unstable, it is surgically opened and any
obstacles to reduction (tissues which might be filling up the
acetabulum or in another way preventing the femoral head from sitting
properly in the acetabulum) are cleared; the child then is placed in a
spica cast.
After eighteen months of age, it is necessary to cut the pelvis or
the femur to better align the acetabulum and the femoral so that they
can develop normally. The cut bones often require internal fixation, or
the placement of steel implants such as pins or plates, to hold them in
their new position while they heal, and these implants have to be
removed in a second operation. Splints or braces During the first six months of life, the standard of care is
application of a Pavlik harness, which is named after the
Czechoslovakian doctor who devised it. This looks like a parachute, and
is easy on the child and the parents. It holds the hips in a flexed
(bent up toward the chest) and abducted (held out to the sides, which
puts the ball, or femoral head, centered or in an optimal position to
induce the socket, or acetabulum, to develop normally.Alternative remedies There are no alternative remedies that have scientifically proven benefits for developmental dysplasia of the hip.Long-term management Children with developmental dyplasia of the hip must be followed by
their orthopaedic surgeon until maturity, because the condition can
recur or "come back" despite successful treatment as long as the
skeleton is still growing.Condition research One area of interest for us at Children's Hospital and Regional Medical Center
is the optimal type of osteotomy (cutting of the pelvis or femur) to
treat developmental dysplasia of the hip. There are several ways the
pelvis can be cut to better align, or redirect, the acetabulum in order
to promote normal developmental of the hip. We would like to find out
which of the various surgical methods has the best result so that we
can provide that to our patients.
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