DEVELOPMENTAL DYSPLASIA OF

THE HIP
(DDH)
TIM V
IH/RR/YD/PF

INTRODUCTION
Developmental Dysplasia of the Hip is a term
to comprise a spectrum of disorders including
acetabular dysplasia without displacement,
subluxation, and dislocation, and also
teratological forms of malarticulation leading
to dislocation are also included.
DDH is caused by many factor, most of them
involves intrauterine condition and the factor
that involves extrauterine condition are
postnatal instability
Solomon L, Warwick D, Nayagam S. Apley's system of orthopaedics and fractures.
Ninth ed. London: Hodder Arnold Company; 2010.

INCIDENCE
Incidence by finding
Dislocation (1.4/1000 births)
Clinical finding (2.3/100 births)
Ultrasound abnormality (8/100 births)
Girls : Boys (7 : 1)
Left Hip > Right Hip
Bilateral in 1 of 5 cases

Low incidences: Blacks and Asians

High incidences: Whites and Native
americans

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier Inc; 2008.
Solomon L, Warwick D, Nayagam S. Apley's system of orthopaedics and fractures. Ninth ed.
London: Hodder Arnold Company; 2010.

ETIOLOGY
Ligamentous laxity (often inherited)
Prenatal positioning : Breech position
(especially footing)
Postnatal positioning (hip swaddled
in extension)
Primary acetabular dysplasia
(unlikely)
Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier
Inc; 2008.

Prenatal Positioning
Double breech position (low incidence)
Single footing breech (2% incidence)
Frank breech (20% incidence)

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier
Inc; 2008.

Postnatal Positioning
Wrap their newborn babies in a hipextended position Native
American

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier Inc;
2008.

Pathophysiology
Normal hip joint develops well in utero,
maintained in acute flexion
If passively extended in presence of joint
laxity
Dislocate and subsequently relocate
- Dislocatable : within the first 2 months
- If maintain in extension position
secondary changes : abnormal
develompment of acetabulum, increase
femoral neck anteversion, hyperthropy of
elongated capsule, contracture and shortening
of hip crossing muscle
Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier Inc;
Persistent dislocate2008.

Pathophysiology

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier
Inc; 2008.

Pathophysiology

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier
Inc; 2008.

Pathophysiology

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier

Clinical features
During infancy
clinically silent only apparent on USG
examination
Barlows and Ortolanis test may
positive
Other clinical indicator may absent
including loss of abduction

Solomon L, Warwick D, Nayagam S. Apley's system of orthopaedics and fractures. Ninth

ed. London: Hodder Arnold Company; 2010.

 Children
May asymptomatic
Sometimes trendelenburg sign positive
Leg length may be assymetrical
Restricted movement changed center
of rotation

Solomon L, Warwick D, Nayagam S. Apley's system of orthopaedics and fractures. Ninth

ed. London: Hodder Arnold Company; 2010.

 Young adult
Pain over lateral side of hip muscle
fatigue/segmental overload on the edge
of acetabulum
Some experience sharp pain in the
groin labral tear/detachment

Solomon L, Warwick D, Nayagam S. Apley's system of orthopaedics and

fractures. Ninth ed. London: Hodder Arnold Company; 2010.

 Older adults
Most people with mild acetabular
dsyplasia are asymptomatic
Present with features of secondary OA

Solomon L, Warwick D, Nayagam S. Apley's system of orthopaedics and

fractures. Ninth ed. London: Hodder Arnold Company; 2010.

Barlows test
To subluxate/dislocate
femoral head from
within acetabulum.
The hip is adducted
and a gentle push is
applied to slide the
hip posteriorly with
examiner's fingers are
positioned over the
greater trochanter.
Positive the hip will
be felt to slide out of
the acetabulum.
Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York:
Elsevier Inc; 2008.

Ortolani test
Reverse of the Barlow test
to reduce a dislocated
hip.
Grasps the child's thigh
between the thumb and
index finger and, with the
fourth and fifth fingers, lifts
the greater trochanter
while simultaneously
abducting the hip.
Positive femoral head
will slip into the socket with
a delicate clunk that is
palpable but not audible
(repeat 4-5 times).
Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York:
Elsevier Inc; 2008.

Galeazzi test

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier Inc;
2008.

Trendelenburg gait
Affected side appears
shorter than the
normal extremity,
child toe-walks on the
affected side.
With each step, the
pelvis drops as the
dislocated hip
adducts, and the child
leans over the
dislocated hip.
Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier
Inc; 2008.

Radiography
X-Ray Imaging (>6 months)
Pelvis in neutral position in relation to
the examination table, the lower
limbs held in neutral rotation and
slight flexion
In older children who are walking, a
weight bearing AP radiograph with
the hips in neutral position (patellae
facing directly forward) is the
Herring
JA. Tachdjian's view
pediatric orthopaedics. Fourth ed. New York: Elsevier Inc;
optimum
2008.

Reference lines and angles of AP

radiograph of pelvis

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier Inc;
2008.

 Center-edge angle of
Wilberg
Angle between
Perkins line and a
line drawn from
lateral lip of
acetabulum through
the center of the
femoral head
Measure in older
children
Increase with age
Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier Inc;
2008.

Severin Classification System of

DDH

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier Inc;
2008.

MRI
Excellent anatomic visualisation but
expensive and need sedation
Kashiwagis MRI based classification
Group 1: sharp acetabular rim all
reducible with pavlik harness
Group 2: rounded acetabular rim
some could be reduced with pavlik
harness
Group 3: inverted acetabular rim
none reducible with pavlik harness
Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier
Inc; 2008.

Screening Criteria
All neonates clinical examnation for
hip instability
Clinical examination + USG :
Firstborn
Female
Breech presentation
Oligohydramnions
Metatarsus adductus
Torticollis
Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier
Inc; 2008.

Management
Birth to Six Months

Journal of the American Academy of Orthopaedic Surgeons,2000.

Pavlik Harness
The transverse
chest strap placed
below the nipple
line.
Hip flexed 120
posterior straps
should not produce
forced abduction.

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier Inc;
2008.

Management Age 6 to 18 months

Journal of the American Academy of Orthopaedic Surgeons,2000.

.

Management Age 18 to 48 months

Journal of the American Academy of Orthopaedic Surgeons,2000.

.

Complication
Avascular Necrosis
Avascular necrosis occurs when
excessive presure is aplied for an
extended time to the femoral head,
occluding its vascular perfusion.

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier Inc; 2008.

THANK YOU

Klisic test (Infant)

Place middle finger on
greater trochanter and
index on SIAS
Normal: imaginary line
drawn between the two
fingers point to
umbilicus
Dislocated: trochanter
is elevated, imaginary
line project halfway
between umbilicus and
pubis
Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier Inc;
2008.

Wynne-Davies Criteria for

Ligamentous Laxity

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier Inc; 2008.

Reference lines and angles of AP

radiograph of pelvis
Horizontal line of
Hielgenliner

Drawn between upper ends of tri-radiate

cartilage of the acetabulum.

Vertical line of
Perkins

Drawn from the lateral edge of the acetabulum

vertical to horizontal line.
Normal hip: the ossification center of the
femoral hip lower medial quadrant. Dislocated
hip: upper lateral quadrant.

Acetabular index

Angle between horizontal line of hilgenreiner

and the line between the two edges of the
acetabulum. Normal hip 20-30, dilocated or
dysplastic hip 30

Shentons line

Semicircle between femoral neck and inner

margin of pubis, in dislocated hip this line is
broken

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier Inc; 2008.

 Infant <6mo hip composed

primarily by cartilage
Ultrasonography show cartilage very
well

Herring JA. Tachdjian's pediatric orthopaedics. Fourth ed. New York: Elsevier Inc;
2008.