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\%
Hip dysplasia in infants: 0.1\% to 0.3\%
Girls affected more often than boys (about 9:1), usually unilateral though bilateral cases occur.
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\% risk; one affected parent → 12\%; both an affected sibling and parent → 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\% of cases; right 20\%; bilateral 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 18 months.
Older child considerations
Correction more difficult due to secondary changes; surgical reduction required; successful reduction after 4 years is difficult; usually inadvisable after 6 years.
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.