Trinity University of Asia

St. Lukes College of Nursing

E. Rodriguez Sr. Avenue, Cathedral Heights, Quezon City, Philippines

Congenital Hip Dislocation

Definition: Is an abnormal formation in the hip joint in which the ball at the top of the thigh bone (femoral head) is not stable in the socket (acetabulum). Also, the ligaments of the hip joint may be loose and stretched. In here, although the hip is in the right place, the socket does not grow properly and is too shallow. If the socket is shallow, this may allow the ball to move from the position it should occupy. Furthermore, the head of the femur is usually dislocated post-superiorly. There is complete loss of contact between articular surface of femoral and head and acetabulum. Dislocation may either be partial or complete and may be either be unilateral or bilateral. May develop at any time during fetal life, infancy or childhood. Includes hip that are unstable, sublimated, dislocated, and have malformed acetabulum. Clinical Manifestation: Ortolanis Sign Barlows Sign Asymmetry of gluteal and thigh folds Limited hip abduction, as seen in flexion Alls/Galeazzis Sign Positive trendelenburg Sign (if child is weight bearing) Limping, toe walking, or waddling, duck-like gait

*The Ortolani and Barlow tests are most reliable from birth to 2-3 months of age. Other Signs and Symptoms:

Trinity University of Asia

St. Lukes College of Nursing

E. Rodriguez Sr. Avenue, Cathedral Heights, Quezon City, Philippines

Telescoping Sign-in older infant and child, the affected leg will be shorter than the other Dislocation Maneuvers (useful only in first three months of life) Thigh abduction Thigh extension Relocation Maneuvers Thigh flexion Thigh abduction

Treatment/Management: a) Range of motion exercises b) Orthosis (a force system, involving braces) c) Chiropractic medications for procedures of closed manipulations between 6-18months to reduce the dislocated hip joint d) Pain control e) Functional activities Age Less than 6 months More than 6 months More than 2 years old More than 3 years old More than 4 years old Management Pavlik harness Traction, closed reduction Open reduction: Anterolateral/Smith Petersen Approach Femoral shortening + Hip Spica Cast + Abduction Orthosis Pelvic Osteotomy

Management indicated for hip instability beyond 5 days:

Trinity University of Asia

St. Lukes College of Nursing

E. Rodriguez Sr. Avenue, Cathedral Heights, Quezon City, Philippines

Step 1: Pavlik Harness a) b) indicated as first-line if <6 months old start with harness trial for 3 4 weeks splints hips in flexed and abducted position ultrasound should demonstrate reduction at 3 weeks: Reduced: continue harness for more than 6 weeks Not reduced: Go to step 2

Step 2: Closed Reduction and Casting by Orthopedics. a) Removable protective Abduction Brace- used in children aged more than 6 months. b) Hip Spica casting for 12 weeks ( 6- 18months old) - Positioning confirmed by post-op MRI or CT scan c) Gradual reduction by traction - for approximately 3 weeks d) Abduction splint - Must be maintained if the radiographic evidence of residual dysplasia is still present. e) Plaster Treatment (Frog Cast) - Involves a large plaster around the lower body and both legs, with a hole cut to allow baby to pass urine and empty the bowels. Step 3: Surgical Management Surgical Open Reduction ( if hips are not reducible and is indicated for older children ) Indicated for refractory cases Requires multi-step procedures:

Trinity University of Asia

St. Lukes College of Nursing

E. Rodriguez Sr. Avenue, Cathedral Heights, Quezon City, Philippines

Tendon lengthening Clearing tissues obstructing relocation Tightening hip capsuled. Osteotomy if performed after age 18 month

Diagnostics: 1. Initial examination after birth 2. Radiographic examination/Hip X-ray (in infants than age 4 months and in children)>It is not reliable in early infancy because ossification of the femoral head does not normally take place until the third to six month of life.>evaluated with reference lines drawn over AP x-ray: Hilgenreiners Line.- horizontal line through tri-radiate cartilages) Perkins line- vertical line along lateral acetabulum) Shentons Line- femoral neck medial border; superior border of obturator foramen 3. CT scan is useful to assess the position of the femoral head relative to the acetabulum after closed reduction and casting. 4. Dynamic Hip Ultrasound for infants aged 1 -6 months diagnostic for congenital hip dislocation evaluates for subluxation and reducibility high false positive rate for <6 weeks old

Nursing Care:

Trinity University of Asia

St. Lukes College of Nursing

E. Rodriguez Sr. Avenue, Cathedral Heights, Quezon City, Philippines

1. Teach the parents how to maintain devices, provide nurturing activities to meet the infants need. 2. Prevent skin breakdown by putting undershirt under the chest straps of the pavlik harness and put knee socks under the foot and leg pieces to prevent the straps from rubbing the skin. 3. Check frequently for red areas under the straps and the clothing. 4. Gently massage healthy skin under the straps once a day to stimulate circulation. 5. Avoid lotions and powder they can cake and irritate the skin. * Complications of treatment may include a delay in walking if the child was placed in a body cast. The pavlik harness and other positioning devices may cause skin irritation, and a difference in leg length may remain. A growth disturbance of the upper thigh rarely occurs. The complications of surgical interventions can be re-dislocation and the severe form, osteonecrosis.

Trinity University of Asia

St. Lukes College of Nursing

E. Rodriguez Sr. Avenue, Cathedral Heights, Quezon City, Philippines

Pathophysiology:
Non Modifiable Factors: Gender: Female Birth order: Firstborn Race: Caucasians Family History Breech Positioning Large infant size Maternal hormone secretion

Modifiable Factors:
Delivery type: CS instead of NSD Postnatal Positioning

Acetabular Dysplasia

Femoral head dislocates from acetabulum

Congenital Hip Dislocation