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The most common disorder affecting the hip in
children
Definition
 A progressive deformation of previously
normally formed structures during the
embryonic period
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Multifactorial :
-Mechanical Factors : all factors which tighten the space
available for the fetus in the uterus, like contracted pelvis
or tight unstretched uterine and abdominal musculature
which prevents free movement of the fetus.
-Hormonal Factors : maternal estrogens are increased before
delivery to relax the pelvic muscles , this leads to laxity of
the capsule and instability of the hip.
-Postnatal environmental Factors : some people have
traditional habits of wraping the babies in positions which do
not secure the femoral head inside the acetabulum
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At the time of birth , the joint capsule is distended and elastic.
After delivery the , the femoral head is loose within the joint
and free to fall out of the acetabulum . At this early stage the
shape of the head and acetabulum and soft tissues is very close
to normal , so if the head is maintained within the acetabulum
for few weeks , the joint will return to its normal configuration
and become stable.
If the dislocation is allowed to persist for long time, the bone
and soft tissues undergo adaptive changes , and the dislocation
is difficult to be reduced . The pathological changes may be in
the acetabulum (shallow acetabulum) , or the femoral head &
neck, capsule and ligamentum teres ( lax , redundant)
Congenital dislocation of the hip occurs in a posterolateral and
proximal direction
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New Born:
The mother may complain of asymmetric position of
lower limbs or lack of normal movement of one side
The most reliable methods for diagnosis are :
-Ortolani Test :(Reduction Test),if the hip is dislocated,
the femoral head can be returned into the acetabulum ,
by abducting the hips and pushing the thighs anteriorly
(+ve sign ).
-Barlow Test : ( Dislocation Test) , if the hip is unstable
( dislocatable) , it can be pushed posteriorly out of the
acetabulum after flexing and adducting the thigh
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Older Infants & Children :
-Limping during walking .
In case of bilateral hip dislocation , waddling gait .
-Shortening of affected lower limb, skin and
subcutaneous tissue are bunched up , extra skin folds
are observed
-Allis or Galeazi’s sign (shortening of affected thigh
when the knees are flexed ) .
-Telescoping or Pistoning test (with the hip flexed,
pushing the thigh posteriorly no resistance is
encountered )
-Trendlenburg test : ( if the patient is standing on the
affected side ,pelvic tilt is observed)
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LOOK :
External rotation attitude
 Lateralized contour
• Wide perineum
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( in bilateral )
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- Galeazzy sign
FEEL :
 Empty groin
 Weak Femoral pulse
Feel a Clunk
Not hear a click !
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Trendelenburgh: unilateral / bilateral
(waddling)
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Newborn :
In the first few days of life radiological diagnosis
is almost always negative
After the age of 6 months pathological changes are
evident :
- Shallow acetabulum ( Acetabulum Index),
avarage 22-27 deg.
- Short Neck (Increased angle of antivervsion)
- Shenton’s Line
- Shoemaker’s Line
- Lateral migration of trochanter
- Delayed ossification of the head
Obtain and Maintain concentric reduction
In an Atruamatic fashion
Without disrupting the blood supply
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Method depends on Age
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The earlier started, the easier the treatment
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The earlier started, the better the results
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Should be detected EARLY
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Birth to 6 months :
Pavlik harness or hip spica cast
6 months – 12 months :
closed reduction UGA and hip spica casts
12 months – 18 months :
possible closed / possible open reduction
Above 18 months :
open reduction and ? Acetabuloplasty
Above 2 years :
open reduction,acetabulplasty, and femoral
osteotomy
Above 8 years :
open reduction,acetabulplasty cutting three bones,
and femoral osteotomy
Most resolve spontaneously
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Observation
Pavlik harness
Double /triple diapers ??
Hip instability (dislocatable)
Established dislocation (reducible)
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Should be actively treated until hip is
normal clinically and radiographically
Pavlik harness
Hip Spica Cast
Other Devices
- Frejka pillow
- Craig
- Von Rosen splint
Soft abduction
splints:
Not good enough
Rigid abduction
splints:
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Initially non operative – closed reduction
Reduction under anesthesia and
immobilization in hip spica cast
Position:
Human
Avoid severe abduction
Avoid Frog position
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Must be stable and concentrically reduced
otherwise needs open reduction
Better Picture
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Possibly closed reduction !!
when hip stable and concentrically
reduced
Probably open reduction
when hip unstable or not concentrically
reduced
Arthrography guided:
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Open reduction
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And acetabulplasty
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And femoral shortening