Developmental Dysplasia of the Hips

Care for infant while wearing Pavlik harness

Assess skin 2-3 times daily for redness or breakdown under the straps Dress the child in a shirt and knee socks under the harness to protect the skin Apply diapers underneath the straps to keep the harness clean and dry Leave the harness on at all times, unless otherwise indicated by the HCP Avoid lotions and powders to prevent irritation and excessive moisture Lightly massage the skin under the straps every day to promote circulation Only apply 1 diaper at a time as wearing >2 diapers increases risk of incorrect hip placement Parents should not alter the strap placements at home as incorrect positioning can lead to damage to the nerves or vascular supply of the hip

What is DDH?

A spectrum of disorders related to abnormal development of the hip may occur at any time during fetal life, infancy, or childhood. A change in terminology from congenital hip dysplasia and congenital dislocation of the hip to DDH more properly reflects a variety of hip abnormalities in which there is a shallow acetabulum, subluxation, or dislocation.

Pavlik Harness Interventions

1) Since harness is not to be removed, sponge bath is recommended 2.) Put undershirt under chest straps and knee socks under foot and leg pieces to prevent skin irritation 3.) Check skin areas 2-3 times a day 4.) Gently massage skin under straps daily to stimulate circulation 5.) Avoid use of lotions and powders 6.) Place diapers under straps 7.) Pad shoulder straps as needed 8.) Tell parents to touch and hold child to express affection and reinforce security 9.) Discuss modification in bathing, dressing, and diapering with parent

Evaluation

1. Has the hip joint alignment been re-established 2. Have child's growth and development needs been met?

Predisposing factors of DDH- Mechanical Factors

Breech presentation, multiple fetus, oligohydramnios, and large infant size as well as swaddling where the hips are maintained in adduction and extension which in time may cause a dislocation

Pathophysiology of DDH

Cause of DDH is unclear but is likely multifactorial. Certain factors such as gender, birth order, family history, intrauterine position, joint laxity, and postnatal positioning are believed to affect the risk of DDH.

Predisposing factors of DDH- Genetic Factors

Entail a higher incidence of DDH in siblings of affected infants and an even greater incidence of recurrence if a sibling and one parent were affected.

16-18 Months

Gradual reduction by traction (bilateral Bryant's traction) Cast for immobilization Preliminary Traction

Idiopathic DDH

Infant is neurologically intact

Predisposing factors of DDH- Physiologic Factors

Maternal hormone secretion and intrauterine positioning

Teratologic DDH

Neuromuscular defect, such as arthrogryposis or myelodysplasia. The teratologic form usually occurs in utero and are much less common.

Older Child

Open reduction Hip spica case

Diagnosis

Predisposition A. Intrauterine position (breech) B. Gender (female) C. Hormonal imbalance (estrogen) D. Cultural and environmental influences- some cultures carry their children straddled against the hip joint, causing a decreased incidence (Far Eastern and African) cultures that wrap infants tightly in blankets or strap to boards have high incidence (Navajo Indian) Confirmation by x-ray

Manifestations in infants age <2-3 months

Presence of extra inguinal or thigh folds Laxity of the hip joint on the affected side. Hip laxity is tested through the Barlow and Ortolani maneuvers These signs disappear after 2-3 months due to development of muscle contractures

Interventions to help reduce risk of DDH development

Proper swaddling- infants should be swaddled with their hips bent up (flexion) and out (abduction), allowing room for hip movement Choosing infant carriers or car seats with wide bases- infant seats should allow for proper hip positioning in an abducted manner Avoid any positioning device, seat, or carrier that causes hip extension with the knees straight and together

Newborn to 6 months interventions

Reduced by manipulation Splinted with proximal femur centered in the acetabulum in position of flexion Pavlik harness- worn full-time for 3-6 months until hip stable for infants less than 3 months age Encourage normal growth and development by allowing child to perform appropriate activities Teach parents; reapply harness and rationale for maintaining abduction Teach parents to move child from one room to another for environmental change

Dislocation

The femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly over the fibrocartilaginous rim. The ligamentum teres is elongated and taut.

Sublaxation

The largest percentage of DDH, subluxation, implies incomplete dislocation of the hip. The femoral head remains in contact with the acetabulum, but a stretched capsule and ligamentum teres cause the head of the femur to be partially displaced. Pressure on the cartilaginous roof inhibits ossification and produces a flattening of the socket.

Acetabular Dysplasia

This is the mildest form of DDH, in which there is a delay in acetabular development evidenced by osseous hypoplasia of the acetabular roof that is oblique and shallow, although the cartilaginous roof is comparatively intact. The femoral head remains in the acetabulum.

Assessment

Uneven gluteal folds and thigh creases (deeper on affected side) Limited abduction of hip with pain, unequal knee height with thigh flexion Ortolani's sign ( seen in infants less than 4 weeks old) Shortened limb on affected side in older infant and child Delays in walking; limp, lordosis, and waddling gait with older child