Physiotherapy in Developmental Dysplasia of Hip for undergraduate students

1. DR. SREERAJ S R

2. Sreeraj S R
Introduction
• https://www.youtube.com/watch?v=69kWyAsSMRE&ab_channel=Childre
n%27sHospitalColorado
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Definition
• Partial or complete displacement of the femoral head from the acetabular
cavity since birth.
• Also known as a congenital hip dislocation
• Risk factors
• Breech Presentation
• Family History of DDH (especially if in parent or sibling)
• Female Baby (4 times more likely to occur in a female infant)
• Large Baby (> 4 kg)
• Overdue pregnancy (> 42 weeks)
• Oligohydramnios (< amniotic fluid volume)
• Associated with Plagiocephaly, Torticollis and foot deformities
• First born baby or multiple pregnancies (twins or triplets etc.)
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• The most significant risk factors for DDH are breech presentation and
family history.
• The American Association of Paediatrics recommends routine ultrasound
screening at six weeks to six months of age for female babies considered
high risk:
• breech presentation in the third trimester;
• family history of DDH or a personal history of instability;
• history of incorrect tight lower extremity swaddling; or
• whose caregivers are anxious
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Incidence
• Approximately 1.0 – 9.2 per 1000 infants are born with a dislocated hip in
India.
• The incidence of sonographically abnormal hips is 7.5% and the hip
dislocation rate is 1 in 1000.
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Etiology
• Genetic: Dysplastic trait found in families.
• Hormonal: Hormone induced joint laxity.
• Mechanical: Faulty intrauterine positions, particularly in the first-born.
• Primary: Acetabular dysplasia.
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Pathology
• Acetabulum: There could be a primary acetabular dysplasia and the acetabulum is shallow.
• Head of femur: Ossification is delayed. The dislocated head of femoral head appears flat on its
posterior and medial aspect.
• Neck of femur: Shortening and ante version.
• Pelvis: Usually tilted forwards, small and atrophied and may be more vertical than normal.
• Capsule: Shows hourglass constriction, one containing head and the other containing the
acetabulum and the constriction between them being produced by the iliopsoas tendon which
crosses the capsule at this level.
• Ligaments: ligamentum teres thickens and elongates, transverse acetabular ligament
hypertrophies.
• Muscle: The pelvifemoral group, adductors, hamstrings, graciliss, sartorius, TFL, pectineus and
rectus femoris shorten, and the pelvitrochanteric group, obturators, quadrates femoris and psoas
tendon become functionally stretched and elongated and therefore incompetent.
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Physical Examination
• Prior to physical examination, the examiner should;
• Gain consent from the parent/guardian
• Ensure a warm, quiet environment for the examination to occur
• Ensure the infant is well, relaxed and fed
• Remove clothing from the lower limbs
• Place the child on a firm, flat examination surface
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Birth to 3 months of age
• Following classification is used:
• Loose hip: joint elements are positioned in satisfactory relation and we
are not able to do a manual dislocation, but there is a significant
stretching of soft tissues and ligaments, and the separation of the
femoral head from the acetabulum.
• Luxable hip: such hip where we can do a manual dislocation.
• Luxated hip: the head of the femur is out of the acetabulum, and
repositioning is performed with Ortolani maneuver.
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Birth to 3 months of age
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• Barlow maneuver
• The Ortolani maneuver

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Older Infants (> 3 months of age)
• Following classification is used:
• Displastic hip: joint bodies are in a satisfactory relationship, but
acetabulum is shallow with a steep roof.
• Subluxated hip: the head of the femur is only in partial contact with
the outer part of the acetabulum.
• Luxated hip: the head of the femur is located outside the acetabulum
in the soft tissues.
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Older Infants (> 3 months of age)
• Check for asymmetric skin folds or leg length discrepancy in case of
unilateral hip dislocation.
• Check for restricted abduction at the hips.
• Infant in supine, with pelvis stabilised and hips and knees at 90˚, abduct
and adduct the hips gradually and repeatedly.
• Limited abduction is the most sensitive sign associated with DDH in the
older infant with range < 600 is suggestive of DDH.
• A positive Galeazzi sign is elicited by laying the child supine and flexing
both hips and knees. A positive sign is indicated by an inequality in the
height of the knees.
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• The conservative treatments is mainly about reconstructing and maintain
the proper anatomical position is the hip joint.
• This treatment is based on eliminating the resistance of the contorted
adductor muscles of the hip joint.
• The position of the child’s hip joints in most of the instruments
corresponds to the natural position of the lower limbs i.e. the flexion in
the joint of approximately 100° and the abduction to 50°
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• Children who are diagnosed with DDH in the first 6 months of life may be
treated with the application of a hip brace.
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Application of the Pavlik Harness
1. With clothing removed, the baby is laid on top of the harness in supine
2. Shoulder and chest straps are adjusted and velcroed into position
3. Leg straps are adjusted and velcroed into position
4. The optimal hip position within the brace is hip flexion approximately
90° and hip abduction greater than or equal to 60°
5. Check to ensure room for growth at the straps – a finger should be able
to be comfortably inserted behind each strap.
6. Reapply clothing over the harness.
• https://www.youtube.com/watch?v=C0WbnQwS920&ab_channel=IHDIOnline
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Application of the Pavlik Harness
• The harness should always be kept on, with weekly physiotherapy
appointments to remove the harness, bathe the baby and re-apply a clean
harness.
• Skin integrity should be checked at each weekly appointment.
• Duration of treatment using the harness should be determined in
consultation with the Orthopaedic Surgeon.
• On completion of treatment using the Pavlik harness, even if symptoms of
DDH have resolved, the physiotherapist should ensure that the child has
an appointment with the Orthopaedic Surgeon to review the hip/s once
the child is walking.
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Parent Education
• It is the responsibility of the Physiotherapist to ensure that parents understand
the care instructions for the Pavlik harness.
• The following instructions are of particular importance:
1. The harness must always be kept on
2. The baby can be sponged bathed
3. Skin care should be discussed and parents shown those areas that need to
be checked regularly for signs of pressure
4. Parents must not change the position of the harness – only the
Physiotherapist or Orthopaedic Surgeon should change this position
5. A parent handout should be provided to all parents with a child placed in a
Pavlik harness.
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Complications
1. Femoral nerve palsy was reported to be 2.5% in a large case series.
• Higher body mass index and older age were found to be risk factors correlated with
the occurrence of femoral nerve palsy.
• Removing the harness or adjusting it to take pressure off the nerve usually works to
resolve the nerve palsy.
2. Skin breakdown (dermatitis), especially in the groin, behind the knee, on the
shoulder, or on the leg
3. Bone breakdown because of decreased blood supply (avascular necrosis)
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Murnaghan ML et al (2011)

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The Physical Therapy goals
• Rebuilding the mobility of the hips with dysplasia;
• Strengthening the hypotonic muscles of the affected members;
• Rebalancing the pelvis muscles to correct the asymmetry;
• Increasing the passive and active stability of hip joints;
• Facilitating the quality acquisition of motor elements in the next stage of
development;
• Preventing future articular and periarticular sequelae.
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The Physical Therapy program
• The Swedish massage was used for decontracting and strengthening the hip muscles (lateral
rotator group; gluteus maximus; gluteus minimus; and gluteus medius), and for the
paravertebral muscles.
• It sliding, friction, kneading, tapotement, the infant being in prone position, their choice being
made according to the aims of the massage.
• The postural correction can be done from the prone and supine positions, the legs performing
an external rotation and abduction, with flexed knees. The duration of these exercises can be
10 seconds each, with 3 repetitions.
• The passive mobilizations consisted in slow movements of external rotation, abduction, and
extension applying light tensions at the end. Circular tractions can also apply to the hips with
dysplasia.
• The active mobilizations consisted in facilitating the recovery reactions on a gym ball from
prone and supine positions. The aim of these movements was to strengthen the hip muscles,
and the entire body, thus aiding the next stage of development.
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• Vojta method
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Hip-Healthy Swaddling
• Improper swaddling may lead to hip dysplasia.
• When in the womb the baby’s legs are in a fetal position with the legs
bent up and across each other.
• Sudden straightening of the legs to a standing position can loosen the
joints and damage the soft cartilage of the socket.
• Proper swaddling: Video
• https://www.youtube.com/watch?time_continue=345&v=LLqfRQdUP7k&
feature=emb_logo&ab_channel=IHDIOnline
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References
1. Developmental Dysplasia of the Hip in Infants: A Clinical Report from the AAP on Evaluation and Referral [Internet]. [cited 2020 Sep 28]. Available from:
https://www.aafp.org/afp/2017/0801/afp20170801p196.pdf
2. Agarwal A, Gupta N. Risk factors and diagnosis of developmental dysplasia of hip in children. J Clin Orthop Trauma. 2012;3(1):10-14.
doi:10.1016/j.jcot.2011.11.001
3. Bhalvani C, Madhuri V. Ultrasound Profile of Hips of South Indian Infants. Indianpediatrics.net [Internet]. 2011 [cited 2020 Sep 25];48:475–7. Available from:
https://www.indianpediatrics.net/june2011/june-475-477.htm
4. Screening, assessment and management of DEVELOPMENTAL DYSPLASIA OF THE HIP Clinical Practice Guideline Resource Manual [Internet]. [cited 2020 Sep
25]. Available from: http://www.nchn.org.au/docs/Man-DDH.pdf
5. Gavrankapetanović I, Papović A. Developmental Dysplasia of the Hip in Childhood – Etiology, Diagnostics and Conservative Treatment. Developmental
Diseases of the Hip - Diagnosis and Management [Internet]. 2017 Apr 12 [cited 2020 Sep 28]; Available from: https://tinyurl.com/y27ax759
6. Noordin S, Umer M, Hafeez K, Nawaz H. Developmental dysplasia of the hip. Orthop Rev (Pavia). 2010;2(2):e19. doi:10.4081/or.2010.e19
7. Murnaghan ML, Browne RH, Sucato DJ, Birch J. Femoral nerve palsy in Pavlik harness treatment for developmental dysplasia of the hip. J Bone Joint Surg Am.
2011;93(5):493-499. doi:10.2106/JBJS.J.01210
8. Edyta P, Bartłomiej W, Paweł W, Anna Z, Dominika C. Physiothreapeutic treatments in infants with congenital hip dysplasia. Journal of Education, Health and
Sport. 2018;8(6):37-44. eISNN 2391-8306. DOI http://dx.doi.org/10.5281/zenodo.1251127
9. Pavlik Harness Treatment for Children [Internet]. 2020 [cited 2020 Sep 25]. Available from: https://tinyurl.com/y6equmv7
10. Marinela R. Early Physical Therapy Intervention in Infant Hip Dysplasia. Procedia - Social and Behavioral Sciences. 2013 Apr;76:729–33.
11. Hip-Healthy Swaddling [Internet]. Hipdysplasia.org. 2018 [cited 2020 Sep 28]. Available from: https://tinyurl.com/y3kdzoo2
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