What Does Hip Extension Look Like in Baby
Am Fam Dr.. 2006 Oct 15;74(8):1310-1316.
Patient data: See related handout on hip problems in infants.
Related Editorial
This article exemplifies the AAFP 2006 Annual Clinical Focus on caring for children and adolescents.
Article Sections
- Abstract
- Definitions
- Epidemiology and Etiology
- Physical Examination
- Radiographic Test
- Management
- References
Developmental dysplasia of the hip refers to a continuum of abnormalities in the immature hip that tin range from subtle dysplasia to dislocation. The identification of risk factors, including breech presentation and family history, should heighten a physician's suspicion of developmental dysplasia of the hip. Diagnosis is made past physical exam. Palpable hip instability, unequal leg lengths, and asymmetric thigh skinfolds may be present in newborns with a hip dislocation, whereas gait abnormalities and express hip abduction are more common in older children. The office of ultrasonography is controversial, just it generally is used to confirm diagnosis and assess hip development in one case handling is initiated. Bracing is commencement-line treatment in children younger than six months. Surgery is an option for children in whom nonoperative handling has failed and in children diagnosed later six months of historic period. It is important to diagnose developmental dysplasia of the hip early to better treatment results and to decrease the risk of complications.
The term developmental dysplasia of the hip (DDH) has replaced congenital dislocation of the hip because it more accurately reflects the total spectrum of abnormalities that affect the young hip. DDH can predispose a kid to premature degenerative changes and painful arthritis. Careful physical test is recommended as a screening tool; early diagnosis helps improve treatment results and decrease the risk of complications.
SORT: Key RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Risk factors for DDH should be identified in all children. | C | 12 |
| A conscientious physical examination is the basis for screening for DDH. | C | 12 |
| Ultrasonography should exist ordered for infants six weeks to vi months of historic period to analyze a clinical finding suggestive of DDH, appraise a high-run a risk babe, and monitor DDH as it is observed or treated. | C | 12 |
Definitions
- Abstract
- Definitions
- Epidemiology and Etiology
- Concrete Exam
- Radiographic Examination
- Management
- References
Hip dysplasia refers to an abnormality in the size, shape, orientation, or system of the femoral head, acetabulum, or both. Acetabular dysplasia is characterized past an immature, shallow acetabulum and can result in subluxation or dislocation of the femoral head. In a subluxed hip, the femoral caput is displaced from its normal position but still makes contact with a portion of the acetabulum. With a dislocated hip, at that place is no contact between the articular surface of the femoral caput and the acetabulum. An unstable hip is one that is reduced in the acetabulum but can be provoked to subluxate or dislocate. Teratologic hip dysplasia, which is exterior the telescopic of this discussion, refers to the more severe, stock-still dislocation that occurs prenatally, usually in those with genetic or neuromuscular disorders.
Epidemiology and Etiology
- Abstract
- Definitions
- Epidemiology and Etiology
- Physical Examination
- Radiographic Examination
- Direction
- References
The incidence of DDH is variable and depends on many factors. Approximately i in one,000 children is born with a dislocated hip, and 10 in i,000 may have hip subluxation.1–three Factors contributing to DDH include breech presentation, female person sex, positive family history, firstborn status, and oligohydramnios. Intrauterine position, sex, race, and positive family unit history are the most important risk factors.
A family history positive for DDH may exist plant in 12 to 33 percent of afflicted patients.4,v The run a risk of DDH for a child has been documented at 6 percentage when in that location is one afflicted sibling, 12 percent with one affected parent, and 36 percent if a parent and a sibling are affected.6 Lxxx percentage of children with DDH are females.seven This is postulated to be related to the effects of additional estrogen produced by the female person fetus, which increases ligamentous laxity.
The left hip is affected in 60 percent of children, the correct hip in 20 percentage, and both hips in xx percent.8 The left hip is more than commonly involved considering it is adducted confronting the mother's lumbosacral spine in the most common intrauterine position (i.e., left occiput inductive).
DDH occurs more than often in children who present in the breech position.9 Information technology is believed that in utero knee extension of the infant in the breech position results in sustained hamstring forces around the hip and contributes to subsequent hip instability. First-born children are affected twice as often equally subsequent siblings, presumably because of an unstretched uterus and tight abdominal structures in the mother. In utero postural deformities and oligohydramnios also are associated with DDH. For unknown reasons, DDH is less mutual in black persons.10
The postnatal extrauterine environment as well plays a role in DDH. The incidence of DDH is high in Native American cultures that apply swaddling, which forces the hips into adduction and extension.11
Physical Examination
- Abstruse
- Definitions
- Epidemiology and Etiology
- Concrete Test
- Radiographic Test
- Management
- References
No first-line method exists for diagnosing DDH during the newborn period. Even so, a conscientious physical examination is recommended as a screening tool, specially for loftier-risk infants.12 Evaluation of the hip begins with observation of both lower extremities.12 The diaper should be removed and the baby relaxed. Provocative dynamic tests, such as the Ortolani and Barlow maneuvers, should exist performed to assess its stability.13 Considering these tests often are hard to interpret, they should be performed routinely in children three months or younger.
Each hip must be examined separately. The child should be supine with the hips flexed to 90 degrees. The examiner should place his or her index and long fingers laterally over the child's greater trochanter with the thumb medially along the inner thigh most the groin crease. The examiner stabilizes the child'south pelvis by property the contralateral hip notwithstanding while the opposite hand examines the hip. The examiner should gently abduct the hip existence tested while simultaneously exerting an up force through the greater trochanter laterally (Figure one). The sensation of a palpable "clunk" is a positive Ortolani test and represents the reduction of a dislocated hip into the bony acetabulum.
Effigy 1.
Tests usually used to assess hip stability. (A) Ortolani maneuver. A gentle upward strength is applied while the hip is abducted. (B) Barlow maneuver. A gentle downward force is practical while the hip is adducted.
To perform the Barlow test, the pelvis is stabilized and the patient is positioned like to the Ortolani exam position. The difference is that the examiner adducts the child'southward hip and exerts a gentle downward force in an attempt to subluxate or dislocate an unstable hip posteriorly (Effigy 1). These tests generally are only useful in infants three months or younger. Thereafter, soft-tissue contractures limit the motion of the hip, fifty-fifty if information technology is confused.
In the offset few months of life, an unstable hip may be noted on physical exam. If the Ortolani or Barlow test is equivocal or inconclusive on examination at birth, the physician should have the newborn return for follow-up in two weeks.12
Asymmetric skinfolds or leg length inequality are mutual findings with unilateral hip dislocation (Figure 2), although asymmetric skinfolds are non specific to DDH. The Galeazzi sign is elicited by placing the child supine with both hips and knees flexed (Figure 3). An inequality in the height of the knees is a positive Galeazzi sign and usually is caused by hip dislocation or built femoral shortening. An baby with hip dislocation will develop limited hip abduction on the affected side by three months of age (Figure 4). Maximal abduction of the hips should be greater than 60 degrees, or a dislocated hip should be suspected.
Figure ii.
A 21–calendar month-old child with correct hip dislocation. Annotation the asymmetric skinfolds in the upper thigh.
Figure iii.
A positive Galeazzi sign in a seven-month-former girl with left hip dislocation. Note the apparent femoral shortening.
Effigy 4.
A three-year-old with a left hip dislocation. Note the express abduction.
Noting express abduction is especially important in identifying children with bilateral hip dislocations because the leg lengths (i.e., Galeazzi sign) are equal. In addition, in children who are walking, Trendelenburg'south symptom (a limp on the affected side) may exist the first sign of a dislocated hip. In children with established dislocations, the activeness of the gluteus medius in pulling the pelvis down in the stance phase is ineffective or weak considering of a lack of a stable fulcrum.
For a kid with a right hip dislocation, the pelvis drops on the opposite side (i.e., left), causing instability. To restore the stability and forestall falls to the left, the torso lurches to the right side and shifts the middle of gravity over the stance side (i.due east., correct hip). The top of the greater trochanter telescopes upward and mechanically hitches on the ilium to stabilize the articulation. This motion at every stance phase is called the Trendelenburg gait.14
Radiographic Examination
- Abstract
- Definitions
- Epidemiology and Etiology
- Physical Exam
- Radiographic Examination
- Management
- References
Radiographs of newborns with suspected DDH are of limited value considering the femoral heads do not ossify until iv to half-dozen months of age. Ultrasonography is the written report of option to evaluate for DDH in infants younger than vi months because it is capable of visualizing the cartilaginous beefcake of the femoral head and acetabulum.15–17 It is useful in identifying dysplasia of the cartilaginous portion of the acetabulum, confirming subluxation of the hip, and documenting reducibility and stability of the hip in the baby undergoing handling for known DDH. Ultrasonography is overly sensitive every bit a screening tool in the starting time six weeks of life, and in general should non be ordered until afterward that.18
Manifestly radiographs are useful after four to six months of age. Several reference lines and angles are useful in evaluating the anteroposterior radiograph of the infant's pelvis (Effigy 5). Hilgenreiner'south line is drawn horizontally through the triradiate cartilages of the pelvis. Perkin's line is drawn perpendicular to Hilgenreiner's line at the lateral edge of each acetabulum. The femoral head should lie inside the inferomedial quadrant formed by Hilgrenreiner's and Perkin's lines. In a dysplastic hip, the lateral border of the acetabulum may be hard to place, and the femoral head may lie in the superior or lateral quadrants.
Figure 5.
Anteroposterior radiograph of a seven-calendar month-old girl with left developmental dysplasia of the hip. (A) The horizontal line is Hilgenreiner's line, and the vertical lines are Perkin's lines. Note that the femoral caput on the right (normal) lies in the inferomedial quadrant formed past these lines. The left hip is dislocated; its femoral head lies in the superolateral quadrant. (B) Shenton'due south line is disrupted on the left (dislocated) hip.
Shenton's line is curvilinear. It is defined past the medial border of the femoral neck and the superior border of the obturator foramen. A suspension in Shenton'southward line suggests displacement of the femoral head from the bony acetabulum (Figure five).
The U.S. Preventive Services Task Force (USPSTF) recently concluded that evidence is insufficient to recommend routine screening for DDH in infants as a means to prevent adverse outcomes. Prove shows that screening leads to earlier identification of DDH; still, the USPSTF concluded that lx to lxxx percent of the newborn hips identified by concrete test and more than ninety per centum identified by ultrasonography as abnormal or equally suspicious for DDH resolve spontaneously and require no intervention.nineteen
Management
- Abstract
- Definitions
- Epidemiology and Etiology
- Physical Exam
- Radiographic Exam
- Management
- References
The goal of treatment in DDH is to reach and maintain reduction of the femoral head in the true acetabulum by closed or open ways. The before treatment is initiated, the greater the success and the lower the incidence of residual dysplasia and long-term complications.
Subluxation of the hip at birth often corrects spontaneously and may be observed for two weeks without handling. The double- or triple-diaper technique, which theoretically prevents hip adduction, has not demonstrated improved results when compared with no intervention at all. When subluxation persists beyond ii weeks of age, treatment is indicated and the advisable referral should be made.12
In newborns and infants up to six months of historic period, closed reduction and immobilization in a Pavlik harness is the treatment of selection (Figure 6). The Pavlik harness dynamically positions the hips in flexion and abduction while allowing motility. Avascular necrosis of the femoral caput has been reported with Pavlik harness treatment and may exist related to hyperabduction.20 In addition, hyperflexion has the potential to cause femoral nervus palsies.
Figure half-dozen.
A newborn with bilateral hip dislocations in a Pavlik harness. The harness prevents hip extension and adduction just allows flexion and abduction.
Reduction of the hip should exist confirmed past ultrasonography inside three weeks of harness placement. Treatment ordinarily is connected for at least half-dozen weeks total-time and half-dozen weeks role-time in immature infants, and perhaps longer in older children. The cease point of brace handling is a stable hip with normal imaging studies. If a dislocated hip is not reduced within three weeks, the harness should exist discontinued and an alternative treatment selected. This unremarkably involves closed reduction nether anesthesia with hip spica casting (Effigy 7).21
Effigy seven.
A four-month-old kid in a hip spica cast following bilateral closed reductions and adductor tenotomies.
The long-term results of Pavlik harness treatment (due east.g., nonoperative handling) bear witness a 95 percent success rate for acetabular dysplasia and subluxation.22,23 The success rate drops to eighty percent for frank dislocation.
In children older than six months, closed reduction nether general anesthesia and hip spica casting is the handling of choice. Postoperative computed tomography or magnetic resonance imaging should be used to confirm concentric reduction (Figure viii).24,25 Immobilization in the hip spica cast after closed reduction usually continues for at least 12 weeks after closed reduction.26
Effigy 8.
A postoperative computed tomography scan of a successful open reduction of a dislocated left hip.
If the hip is irreducible past closed ways, or a concentric reduction is not achieved, successful treatment requires open reduction.27 Open reduction of the hip in a kid with DDH involves lengthening tendons about the hip, removing obstacles to reduction, and tightening the hip capsule once reduction is obtained. Complications include femoral head osteonecrosis and redislocation.28 Surgery becomes more technically demanding in older children with established dislocations. Past 18 months, femoral osteotomies with or without pelvic osteotomies may be necessary to reconstruct and safely maintain the hip in a reduced position.
The goal of operative treatment of DDH is to normalize the hip joint to delay or prevent the premature onset of osteoarthritis. Intervention in early childhood, when remodeling potential is greater, provides the best opportunity for the development of a normal joint.29 Children with untreated hip dysplasia have been shown to develop premature degenerative changes by the fourth dimension they reach skeletal maturity, and develop painful arthritis in their thirties.thirty Children with hip dysplasia who are diagnosed in boyhood and undergo surgical treatment fare somewhat better but oftentimes require secondary procedures as adults for painful arthritis.31
Joint-preserving salvage osteotomies and total hip arthroplasty are surgical options once a child has achieved skeletal maturity. Both procedures have mixed long-term results and are inferior to surgical treatment initiated at before ages.32,33 Children in whom Pavlik harness treatment is initiated before six months of historic period have first-class results, although long-term studies are defective. The majority take no symptoms of arthritis, with mild radiographic abnormalities by skeletal maturity.34,35 A child with DDH usually requires long-term follow-up with radiographic evaluation until skeletal maturity is reached to ensure normal hip evolution.36–38
In general, the goal of the family physician in examining for DDH should be early diagnosis and referral. This is because treatment earlier in life, especially within the showtime half dozen months, is safer and more successful than treatment after the child is walking.
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REFERENCES
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20. Suzuki S, Kashiwagi N, Kasahara Y, Seto Y, Futami T. Avascular necrosis and the Pavlik harness. The incidence of avascular necrosis in iii types of congenital dislocation of the hip every bit classified by ultrasound. J Bone Articulation Surg Br. 1996;78:631–5.
21. Mubarak Southward, Garfin S, Vance R, McKinnon B, Sutherland D. Pitfalls in the use of the Pavlik harness for treatment of congenital dysplasia, subluxation, and dislocation of the hip. J Bone Articulation Surg Am. 1981;63:1239–48.
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24. Smith BG, Millis MB, Hey LA, Jaramillo D, Kasser JR. Postreduction computed tomography in developmental dislocation of the hip: part II: predictive value for outcome. J Pediatr Orthop. 1997;17:631–6.
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34. Fujioka F, Terayama One thousand, Sugimoto N, Tanikawa H. Long-term results of congenital dislocation of the hip treated with the Pavlik harness. J Pediatr Orthop. 1995;15:747–52.
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