PEDIA PRELIMS

Congenital Hip Dysplasia and Birth Injuries

  • Birth injuries and congenital hip disorders discussed, focusing on congenital hip dislocation (dysplasia) and Developmental Dysplasia of the Hip (DDH).
  • Definitions
    • Congenital hip dislocation (dysplasia): misalignment of the hip at birth with improper formation & function of the hip socket; can include complete displacement of the femoral head from the acetabulum.
    • Developmental Dysplasia of the Hip (DDH): group of congenital abnormalities of the hip joints, including subluxation, dislocation, and preluxation. Subluxation is the most common type.
  • Epidemiology
    • Hip subluxation at birth: 1%1\%
    • Hip dysplasia in infants: 0.1%to0.3%0.1\% to 0.3\%
    • Girls affected more often than boys (about 9:1), usually unilateral though bilateral cases occur.
  • Etiology and risk factors
    • Unknown, but hypotheses include:
      1) Maternal estrogen causing ligament relaxation
      2) In utero hip/leg positioning (e.g., breech presentation)
      3) Genetic factors (family history)
    • Risk factors: breech presentation, female gender, family history (up to 1/3 cases have a positive history), firstborn, oligohydramnios.
    • Sibling risk: one affected sibling → 6%6\% risk; one affected parent → 12%12\%; both an affected sibling and parent → 36%36\%.
    • Left hip more commonly affected (in first-born girls, breech).
  • Breech position
    • Definition: fetus in longitudinal lie with buttocks or feet closest to cervix; occurs in 3$-$4\% of deliveries.
  • Pathophysiology progression
    • Preluxation (acetabular dysplasia): apparent delay in acetabular development; femoral head remains within acetabulum.
    • Subluxation: incomplete dislocation; femoral head remains in contact with acetabulum but capsule/ligaments torn, head partially displaced.
    • Dislocation: femoral head loses contact with acetabulum, displaced posteriorly and superiorly over fibrocartilaginous rim; left hip affected in about 60%60\% of cases; right 20%20\%; bilateral 20%20\%.
  • Anatomy quick reference
    • Acetabulum: large socket on lateral hip bone; articulates with femoral head to form hip joint.
    • Acetabulum formed by fusion of ilium, ischium, and pubis.
  • Assessment findings (clinical signs vary by age)
    • Gluteal fold asymmetry in prone position; excess gluteal folds in thigh.
    • Limited ROM and abduction on affected side.
    • Ortolani sign: hip click when flexed and abducted; click upon femoral head striking acetabulum.
    • Allis sign: affected limb shorter than the other.
    • Galeazzi sign: unequal femur length when compared.
    • Gait: waddling or limping with uneven weight distribution.
  • Laboratory and diagnostic studies
    • Early exam unreliable until ossification of femoral head (ages 3–6 months).
    • Ultrasonography: detects subluxations/dislocations; useful in infants.
    • CT/MRI: imaging modalities to assess position/reduction; used selectively.
    • Arthrography: confirms stability and evaluates reduction when X-rays are inconclusive.
    • X-rays: used in older infants/children after ossification.
  • Nursing management by age group
    • Neonate to 6 months:
    • Conservative reduction techniques (e.g., 3 diapers method or padding) to allow head of femur to reduce into acetabulum.
    • Pavlik harness: dynamic abduction brace; centers the femoral head in acetabulum; worn until stability is clinically and radiographically confirmed (typically 3–6 months before transitioning to an abduction brace).
    • Infant carried astride in mother’s hip position for stability.
    • 6 to 18 months:
    • Traction (skin/Bryant) for gradual reduction; followed by closed reduction with cast immobilization until joint is stable.
    • If hip not reducible: open reduction followed by Spica cast for 4–6 months, then transition to an abduction splint.
    • Spica cast details
    • Cast covers one or both legs up to the belly button; groin area open for toileting.
    • Open reduction indications
    • Refractory cases where reduction cannot be achieved with non-surgical means.
    • May involve tendon lengthening, clearing obstructive tissues, tightening hip capsule, possible osteotomy after age 1818 months.
    • Older child considerations
    • Correction more difficult due to secondary changes; surgical reduction required; successful reduction after 44 years is difficult; usually inadvisable after 66 years.
  • Specific nursing considerations and goals
    • Neurovascular assessment of affected limb; monitor color, temperature, mobility, sensation, capillary refill; report numbness/tingling.
    • Skin integrity and cast care: inspect under cast, keep skin clean and dry, ensure proper cast positioning, prevent skin breakdown.
    • Family education and psychosocial support; involve family in care; ensure device use is proper.
    • Mobility and activity planning: promote age-appropriate activities; assist with mobility aids as needed.
    • Positioning and skin care to prevent contractures; monitor for signs of cast complications (odor, pain, hotspots).
  • Related notes
    • Brachial plexus injuries (Erb-Duchenne and Klumpke) are discussed separately due to distinct etiologies and management.

Brachial Plexus Injury (Erb-Duchenne Palsy and Klumpke Palsy)

  • Etiology and mechanism
    • Injury to brachial plexus due to birth trauma (extreme lateral traction on head/neck during delivery of shoulders).
    • High birth weight, breech presentation, prolonged labor, vacuum/forceps delivery, twin pregnancy raise risk.
  • Anatomy and patterns
    • BPI involves C5–C8 and T1 nerve roots; upper injuries common (Erb’s palsy) affect shoulder abduction and external rotation and elbow flexion; lower injuries (Klumpke) affect hand movements; Horner’s syndrome can indicate avulsion injuries (sympathetic chain involvement).
  • Clinical manifestations
    • Erb’s palsy: shoulder adduction, internal rotation; elbow extension; forearm pronated; weak grasp; reduced reflexes.
    • Klumpke’s palsy: hand and forearm involvement; claw hand appearance possible.
  • Types of nerve injury (pattern)
    • Neurapraxia (stretch): nerve stretched but not torn; often recover within ~3 months; outside spinal cord.
    • Rupture: nerve torn outside spine; may require surgical repair.
    • Avulsion: nerve roots torn from spinal cord; cannot be directly repaired; nerve transfers may be needed; Horner’s syndrome possible.
  • Nerve injury specifics
    • Erb’s palsy: upper trunk (C5–C6, sometimes C7); weakness of shoulder and biceps.
    • Total plexus involvement: about 20$-$30\% of injuries; no movement at shoulder, arm, or hand.
    • Horner’s syndrome: approximately 10$-$20\%; signs include ptosis, miosis, anhidrosis; often indicates avulsion.
    • Klumpke’s palsy: lower roots (C8–T1); rare in babies; presents with hand weakness.
  • Interventions
    • Early physical therapy beginning around 3 weeks of age to prevent stiffness, atrophy, and shoulder dislocation.
    • Airplane splint: abducts shoulder with external rotation; used to protect nerves and support positioning.
    • Positioning and handling: avoid pulling on affected arm; support limb; dress/dress affected arm first; gentle handling and massage for sensation development.
    • Sensory stimulation and positioning to promote awareness of affected limb; graduated therapy over weeks to months.
  • Prognosis
    • Complete recovery