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Developmental Dysplasia
       of the Hip
Overview
 Introduction
 Normal Development of the Hip

 Etiology and Pathoanatomy

 Epidemiology and Diagnosis

 Ultrasound morphologic and dynamic
Introduction
   Developmental Dysplasia of the Hip
    • DDH - preferred term
    • Teratogenic hips
    • Subluxation
    • Dislocation-usually posterosuperior
      (reducible vs irreducible)
    • Dysplasia
Background
   Risk Factors
    •   1/1,000 born with dislocated hip
    •   10/10,000 born with subluxation or dysplasia
    •   80% Female
    •   First born children
    •   Family history (6% one affected child, 12% one affected
        parent, 36% one child + one parent)
    •   Oligohydramnios
    •   Breech (sustained hamstring forces)
    •   Native Americans (swaddling cultures)
    •   Left 60% (left occiput ant), Right 20%, both 20%
    •   Torticollis or LE deformity
Breech Presentation
Associated Conditions

Torticollis (15% have DDH)   Metatarsus Adductus
                             (1.5-10%have DDH)
Normal Development
   Embryonic
    • 7th week - acetabulum and hip formed
      from same mesenchymal cells
    • 11th week - complete separation
      between the two
    • Prox fem ossific nucleus - 4-7 months
Normal Hip
 Tight fit of head in
  acetabulum
 Transection of

  capsule
    • Still difficult to
      dislocate
    • Surface tension
Pathoanatomy
 Ranges from mild dysplasia --> frank
  dislocation
 Bony changes

    • Shallow acetabulum
    • Typically on acetabular side
    • Femoral anteversion
Pathoanatomy
   Soft tissue changes
    • Usually secondary to prolonged subluxation or
      dislocation
   Intraarticular
    • Labrum
          Inverted + adherent to capsule (closed reduction
           with inverted labrum assoc with increased
           Avascular Necrosis)
    • Ligamentum teres
          Hypertrophied + lengthened
    • Pulvinar
          Fibrofatty tissue migrating into acetabulum
Fatty Tissue (Pulvinar Thickens)
Teres ligament (elongated and thickened)
Docking the head
subluxated                       dislocated




             Labrum: Cartilaginous acetabular lip.
             Neolimbus: a ridge of thickened articular cartilage
Transverse ligament (hypertrophic)
Hourglass shape of the capsule
by the iliopsoas tendon
progressive




Shortened of pelvifemoral
muscles
Pathoanatomy
   Soft Tissue (Intraarticular)
    • Transverse acetabular ligament
         Contracted
    • Limbus
         Fibrous tissue formed from capsular tissue
          interposed between everted labrum and
          acetabular rim
   Extraarticular
    • Tight adductors (adductor longus)
    • Iliopsoas
Tough Reductions…
   Obstacles to
    reduction
    • Extraarticular
          Tight iliopsoas and
           adductors
    • Intraarticular
          Labrum
          Ligamentum teres
          Transverse acetabular
           ligament
          Pulvinar
          Redundant capsule
           (hourglass)
          +/- limbus
Etiology and Epidemiology
   Multifactorial
    • Genetics and Syndromes
        Ehler’s Danlos
        Arthrogryposis

        Larsen’s syndrome

    • Intrauterine environmental factors
        Teratogens
        Positioning (oligohydramnios)

    • Neurologic Disorders
          Spina Bifida
Diagnosis
   Newborn screening
    • Ortolani’s and Barlow’s maneuvers with
      a thorough history and physical
    • Warm, quiet environment with removal
      of diaper
    • Head to toe exam to detect any
      associated conditons (Torticollis,
      Ligamentous Laxity etc.)
    • Baseline Neuro and Spine Exam
Diagnosis
   Key physical
    findings
    • Asymmetry
          Limb length-
           Galeazzi
          Abduction ROM
          Skin folds
          Limp
          Waddilng gait /
           hyperlordosis -
           bilateral involvement
Ortolani’s Maneuver




* After 3 months of age tests become negative
Barlow’s Maneuver
CLINICAL PRESENTATION
          (THE NEONATE):

Ortolani’s or Barlow’s sign
 Sonographic morphology.
CLINICAL PRESENTATION (THE NEONATE):
CLINICAL PRESENTATION(THE NEONATE):

      Barlow           Ortolani




               clunk
CLINICAL PRESENTATION (THE INFANT):



    Limited Abduction    Galeazzi Sign




                                         Hips
                                         90degrees
CLINICAL PRESENTATION(THE INFANT):



Asymmetric Folds
CLINICAL PRESENTATION (THE INFANT):

recognize a.bilateral dislocation

                                  Klisic Test




                            Anterior superior
                            iliac spine
                            Greater
                            trochanter




              Normal                            Dislocation
CLINICAL PRESENTATION (THE WALKING CHILD):
Femoral Neck Anteversion
IMAGING STUDIES (ULTRASOUND)




    identify   a silent hip
IMAGING STUDIES(ULTRASOUND)
IMAGING STUDIES (ULTRASOUND)
 BASELINE: line of ilium which intersects
 the bony and the cartilaginous portions of
 the acetabulum.

15-29


                                              As the femoral head subluxates:
                                                              decreased ALPHA angle


                                                               increased BETA angle
IMAGING STUDIES (ULTRASOUND)
The Ultrasound ( before 3 mo. )



  Ilium                           Abductor M.
IMAGING STUDIES (ULTRASOUND)
Diagnosis
 Some cases still missed
 At risk groups should be further

  screened
 AAP

    • Recs further imaging (e.g. US) if exam
      is “inconclusive” AND
       First degree relative + female
       Breech

       Positive provocative maneuver (Ortolani or

        Barlow)
    • Referral to Orthopaedist
Imaging
   X-rays
    • Femoral head ossification center
         4 -7 months
   Ultrasound
    • Operator dependent
 CT
 MRI

 Arthrograms

    • Open vs closed reduction
Imaging
   Ultrasound
    • Introduced in 1978 for eval of DDH
    • Operator dependent
    • Useful in confirming subluxation,
      identifying dysplasia of cartilaginous
      acetabulum, documenting reducibility
    • Prox Femoral Ossification Center
      interferes
    • Requires a window in spica cast (avoid)
Ultrasound
Femoral head


Abductors


Ilium
Ultrasound
Femoral head


Abductors


Ilium
Ultrasound
Femoral head


Abductors


Ilium
Ultrasound
Femoral head


Abductors


Ilium
Ultrasound
Graf’s alpha
angle
Ultrasound
Graf’s alpha
angle


>60° = normal




*line w/ ilium
bisects head 50/50
Fig. 5-A:: Figs. 5-A, 5-B, and 5-C: Ultrasonography of the infant hip with use of the
dynamic technique. (Figures kindly provided by Prof. H. T. Harcke.)
Fig. 5-A: Photograph showing the position of the transducer used to obtain the
transverse flexion view. With the hip in this position of flexion and adduction, a posterior
push is analogous to the Barlow test.
Fig. 5-B:: A transverse flexion ultrasonographic view of a normal hip shows
the femoral head (F) remaining in contact with the ischium (arrows) during
movement. A = anterior, L = lateral, and P = posterior.
Fig. 5-C:: With instability and displacement, the femoral head moves laterally
and posteriorly. The laterally displaced head (F, open arrows) has no contact
with the ischium (solid arrows). Fibrofatty tissue (T) with increased echogenicity
fills the acetabulum. A = anterior, L = lateral, and P = posterior.

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Developmental Dysplasia of the Hip and Ultrasound

  • 2. Overview  Introduction  Normal Development of the Hip  Etiology and Pathoanatomy  Epidemiology and Diagnosis  Ultrasound morphologic and dynamic
  • 3. Introduction  Developmental Dysplasia of the Hip • DDH - preferred term • Teratogenic hips • Subluxation • Dislocation-usually posterosuperior (reducible vs irreducible) • Dysplasia
  • 4. Background  Risk Factors • 1/1,000 born with dislocated hip • 10/10,000 born with subluxation or dysplasia • 80% Female • First born children • Family history (6% one affected child, 12% one affected parent, 36% one child + one parent) • Oligohydramnios • Breech (sustained hamstring forces) • Native Americans (swaddling cultures) • Left 60% (left occiput ant), Right 20%, both 20% • Torticollis or LE deformity
  • 6. Associated Conditions Torticollis (15% have DDH) Metatarsus Adductus (1.5-10%have DDH)
  • 7. Normal Development  Embryonic • 7th week - acetabulum and hip formed from same mesenchymal cells • 11th week - complete separation between the two • Prox fem ossific nucleus - 4-7 months
  • 8. Normal Hip  Tight fit of head in acetabulum  Transection of capsule • Still difficult to dislocate • Surface tension
  • 9. Pathoanatomy  Ranges from mild dysplasia --> frank dislocation  Bony changes • Shallow acetabulum • Typically on acetabular side • Femoral anteversion
  • 10. Pathoanatomy  Soft tissue changes • Usually secondary to prolonged subluxation or dislocation  Intraarticular • Labrum  Inverted + adherent to capsule (closed reduction with inverted labrum assoc with increased Avascular Necrosis) • Ligamentum teres  Hypertrophied + lengthened • Pulvinar  Fibrofatty tissue migrating into acetabulum
  • 12. Teres ligament (elongated and thickened) Docking the head
  • 13. subluxated dislocated Labrum: Cartilaginous acetabular lip. Neolimbus: a ridge of thickened articular cartilage
  • 15. Hourglass shape of the capsule by the iliopsoas tendon
  • 17. Pathoanatomy  Soft Tissue (Intraarticular) • Transverse acetabular ligament  Contracted • Limbus  Fibrous tissue formed from capsular tissue interposed between everted labrum and acetabular rim  Extraarticular • Tight adductors (adductor longus) • Iliopsoas
  • 18. Tough Reductions…  Obstacles to reduction • Extraarticular  Tight iliopsoas and adductors • Intraarticular  Labrum  Ligamentum teres  Transverse acetabular ligament  Pulvinar  Redundant capsule (hourglass)  +/- limbus
  • 19. Etiology and Epidemiology  Multifactorial • Genetics and Syndromes  Ehler’s Danlos  Arthrogryposis  Larsen’s syndrome • Intrauterine environmental factors  Teratogens  Positioning (oligohydramnios) • Neurologic Disorders  Spina Bifida
  • 20. Diagnosis  Newborn screening • Ortolani’s and Barlow’s maneuvers with a thorough history and physical • Warm, quiet environment with removal of diaper • Head to toe exam to detect any associated conditons (Torticollis, Ligamentous Laxity etc.) • Baseline Neuro and Spine Exam
  • 21. Diagnosis  Key physical findings • Asymmetry  Limb length- Galeazzi  Abduction ROM  Skin folds  Limp  Waddilng gait / hyperlordosis - bilateral involvement
  • 22. Ortolani’s Maneuver * After 3 months of age tests become negative
  • 24. CLINICAL PRESENTATION (THE NEONATE): Ortolani’s or Barlow’s sign  Sonographic morphology.
  • 26. CLINICAL PRESENTATION(THE NEONATE): Barlow Ortolani clunk
  • 27. CLINICAL PRESENTATION (THE INFANT): Limited Abduction Galeazzi Sign Hips 90degrees
  • 29. CLINICAL PRESENTATION (THE INFANT): recognize a.bilateral dislocation Klisic Test Anterior superior iliac spine Greater trochanter Normal Dislocation
  • 30. CLINICAL PRESENTATION (THE WALKING CHILD):
  • 31.
  • 33. IMAGING STUDIES (ULTRASOUND) identify a silent hip
  • 35. IMAGING STUDIES (ULTRASOUND) BASELINE: line of ilium which intersects the bony and the cartilaginous portions of the acetabulum. 15-29 As the femoral head subluxates: decreased ALPHA angle increased BETA angle
  • 36. IMAGING STUDIES (ULTRASOUND) The Ultrasound ( before 3 mo. ) Ilium Abductor M.
  • 38. Diagnosis  Some cases still missed  At risk groups should be further screened  AAP • Recs further imaging (e.g. US) if exam is “inconclusive” AND  First degree relative + female  Breech  Positive provocative maneuver (Ortolani or Barlow) • Referral to Orthopaedist
  • 39. Imaging  X-rays • Femoral head ossification center  4 -7 months  Ultrasound • Operator dependent  CT  MRI  Arthrograms • Open vs closed reduction
  • 40. Imaging  Ultrasound • Introduced in 1978 for eval of DDH • Operator dependent • Useful in confirming subluxation, identifying dysplasia of cartilaginous acetabulum, documenting reducibility • Prox Femoral Ossification Center interferes • Requires a window in spica cast (avoid)
  • 46. Ultrasound Graf’s alpha angle >60° = normal *line w/ ilium bisects head 50/50
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  • 56. Fig. 5-A:: Figs. 5-A, 5-B, and 5-C: Ultrasonography of the infant hip with use of the dynamic technique. (Figures kindly provided by Prof. H. T. Harcke.) Fig. 5-A: Photograph showing the position of the transducer used to obtain the transverse flexion view. With the hip in this position of flexion and adduction, a posterior push is analogous to the Barlow test.
  • 57. Fig. 5-B:: A transverse flexion ultrasonographic view of a normal hip shows the femoral head (F) remaining in contact with the ischium (arrows) during movement. A = anterior, L = lateral, and P = posterior.
  • 58. Fig. 5-C:: With instability and displacement, the femoral head moves laterally and posteriorly. The laterally displaced head (F, open arrows) has no contact with the ischium (solid arrows). Fibrofatty tissue (T) with increased echogenicity fills the acetabulum. A = anterior, L = lateral, and P = posterior.