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New Treatments for Dislocation of the Hip (Developmental Dysplasia of the Hip) 

Developmental dysplasia of the hip, otherwise previously known as congenital dislocation of the hip. This occurs in probably about 1:1,000 kids will actually have a dislocation, although anywhere from 1:50 to 1:100 will actually have some instability of the hip at birth. So the vast majority of these kids tighten up over time and do very well.

Risk factors, if they were going to ask you; being female is a risk factor, if it’s your firstborn child and a real important clinical one; if there any other orthopedic abnormalities, you have to look at the hips. If this kid has a congenital torticollis, if this kid has a club foot, if this kid has a metatarsus adductus, anything else orthopedic going on, look real carefully at the hips.

Okay, let’s talk about the physical exam. The key test in the newborn period is the Ortalani and the Barlow. The Barlow is an attempt to dislocate a hip that’s in the socket, or sublux the hip that’s in a socket. You bring the legs up straight to 90 degrees, you force the hip down and try to slide it out. The Ortalani is trying to take a hip that is already out of the socket and relocate it. So you adduct the hip and you are trying to lift up on the femoral head.

Again, the key thing in the newborn exam is not the idea of a click or a clunk. If you feel a little click, a little snapping sensation, that’s probably a ligamentous snap that you are feeling and it has no clinical relevance whatsoever. They call the dislocation a clunk, but it’s not like anything you hear. It’s obviously not a low-pitched sound.

After about four months of age, if you were born with a dislocated hip and somebody missed it, you would have so much soft tissue contracture that you couldn’t do a Ortalani or Barlow anymore. You can’t get the femoral head to move anymore. So once you get older than that you have to look for other indirect signs, like limited abduction or asymmetric thigh folds.

Unfortunately about 20 - 30% of all newborns will have asymmetric thigh folds, so it’s not a very great test.

This is the better test. This is looking for limited abduction and if you see here - if you look at a vertical 90 degrees - this hip is going all the way out, abducting all the way out almost to the table. This one is only going about 45 degrees. This is a sign of soft tissue contracture at the level of the hip. So the key finding in someone older than four months of age is limited hip abduction.

Okay, treatment. This is the treatment for most kids. A Pavlik harness is placed under six months of age. This is usually enough to keep the hip in place. What it does is it actually forces the hip back into an Ortalani position. The hip is flexed, abducted and forced to stay in that position you would put him in to try and relocated that hip.

We usually use it, if you pick it up at birth, for about 6-8 weeks. The later you pick it up the longer you need to use it. If you miss it and they get out beyond 6-18 months, or 6-12 months especially, now you’ve got problems because of the soft tissue contractures. Often the Pavlik harness is not enough to allow you to pull that hip, that femoral head, back into position.

Often under a year of age, closed reduction is useful. You often don’t have to do an open surgical procedure but you may have to release the soft tissue contracture by releasing the adductors. Once you get beyond a year of age it can be a real pain in the neck to treat these things. By a year of age your acetabulum hasn’t formed properly, you may have a false acetabulum forming higher up on the side of the hip. You’ve got extreme shortening of the adductor tendons around that area and your femoral head will also be forming flattened. So kids who are beyond a year of age, once they start to walk, it’s a real problem.

Metatarsus adductus. This is a deviation of the forefoot medially. You’ll see this at birth. But you can see that as this foot is coming up, it’s all of a sudden taking a right turn here. It’s coming up but then moving in medially at the metatarsus. And it is probably in most cases a positioning defect, a packaging defect. It was a little tight in utero and everything got a little squished. And you will see is therefore in situations where the child is in an abnormal position. If they are in a breech position or a twin delivery where it’s a little more crowded.

Treatment; it depends again on whether it’s flexible. If it’s flexible you don’t have to do anything. We often tell the parents to go in and stretch it many times a day. That gives the parents, basically, something to do until it gets better on its own. It’s not going to hurt, but probably not helpful. Very rarely if you ever have a flexible foot that persists beyond a year, some people will try to cast it at that point.