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
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
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
29. CLINICAL PRESENTATION (THE INFANT):
recognize a.bilateral dislocation
Klisic Test
Anterior superior
iliac spine
Greater
trochanter
Normal Dislocation
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
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)
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.
