Developmental Dysplasia of the Hip (DDH) - Past Notes PDF

Developmental (Congenital) Dysplasia DDHof the Hip.  Spectrum of diseases  (DDH) describes a spectrum of disorders related to abnormal development of the hip that may occur at any time during fetal life, infancy, and childhood.  Initial pathology is congenital, but Progres...

Developmental (Congenital) Dysplasia DDHof the Hip.  Spectrum of diseases  (DDH) describes a spectrum of disorders related to abnormal development of the hip that may occur at any time during fetal life, infancy, and childhood.  Initial pathology is congenital, but Progresses (becomes worse) if not treated  Does not always result in dislocation incidance  1-1.5% per 1000 live birth  17% to 23% of infant with DDH are born breech  Girls are more affected 80%  Positive family hx in approx. 12-33%  4fs : frank breech , female gender, family hx , first born  Left hip Breech presentations Full Breech Frank Breech Footling Breech …………  Additionalrisk factors for DDH include  oligohydramnios,  hip asymmetry,  and other musculoskeletal conditions including torticollis  and metatarsus adductus or foot deformities  Pathophysiology The cause of DDH is unknown, but certain factors such as  female gender  first pregnancy,  family history,  breech intrauterine position,  high birth weight,  joint laxity,  postnatal positioning are believed to affect the risk of DDH.  Predisposing factors associated with DDH  physiologic factors, including maternal hormone secretion and intrauterine positioning  mechanical factors, which involve breech presentation, multiple fetuses, oligohydramnios, and large infant size, as well as continued maintenance of the hips in adduction and extension that with time can cause dislocation  genetic factors, which include a higher incidence of DDH in siblings of affected infants and even greater incidence of recurrence if a sibling and one parent were affected. Etiology Mechanical factors-Postnatal:  Swaddling / strapping hips adducted and extended, and knees extended  Developmental Dysplasia of the Hip and Infant Care Practices  A striking relationship exists between the development of dislocation and methods of handling infants.  Among cultures with the highest incidence of dislocation (Navajo Indians and Canadian Natives [formerly referred to as Eskimos]), newly born infants are tightly wrapped in blankets or other swaddling material or are strapped to cradle boards.  In cultures where mothers carry infants on their backs or hip in a widely abduction straddle position, such as the Far East and Africa, the disorder is virtually unknown. Degrees of DDH 10  Categories…………3  Acetabular dysplasia : mildest form , delay in acetabular development evidenced by osseous hypoplasia of the acetabular roof that is oblique & shallow – no sublaxation or dislocation.  Sublaxation: largest form – incomplete dislocation. Femoral head remain in contact with the acetabulum, but a streched capsule &ligamentum teres- head partially displaced-flatten socket.  Dislocation : most sever form. Femoral head loses contact with the acetabulum – displaced posteriorly & superiorly. Diagnostic Evaluation  The diagnosis of DDH should be made in the newborn period if possible, since treatment initiated before 2 months of age achieves the highest rate of success.  Inthe newborn period, hip dysplasia usually appears as hip joint laxity rather than outright dislocation.  Subluxation and the tendency to dislocate can be demonstrated by the Ortolani and Barlow tests. Clinical Features : Neonates BARLOW’S TEST ( bahar lo) Clinical Features : Neonates BARLOW’S TEST ( bahar lo) Clinical Features : Neonates ORTOLANI SIGN Ortolani and Barlow Test Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc., an 16 imprint of Elsevier Inc. NURSING ALERT  TheBarlow and Ortolani maneuvers should be performed only by an experienced clinician to prevent an injury to the infant’s hips  TheOrtolani and Barlow maneuvers are most reliable from birth to 4 weeks of age ……..  Adduction ‫ تقريب‬contractures develop at about 6 to 10 weeks of age, and the Ortolani sign disappears.  After this time, the most sensitive test is limited hip abduction ‫( ابعاد‬Fig. 34-38, B).  Other signs are shortening of the thigh on the affected side (Galeazzi sign) (Fig. 34-38, C)  asymmetricthigh and gluteal folds (Fig. 34-38, A), and broadening of the perineum (in bilateral hip dislocations). Galeazzi Sign Copyright © 2015, 2011, 2007, 2003, 1999 by Mosby, Inc., an 19 imprint of Elsevier Inc. Galeazzi’s Sign  …….. Asymmetric gluteal, thigh, labial folds Limitation of Abduction MOST RELIABLE SIGN  ………….  In the older infant and child, the affected leg appears shorter than the other.  In both unilateral and bilateral dislocations the greater trochanter is prominent and appears above a line from the anterosuperior iliac spine to the tuberosity of the ischium.  There may be telescoping or piston mobility, meaning that the head of the femur can be felt to move up and down in the buttock when the extended thigh is pushed first toward the child’s head and then pulled distally  …………  Instability of the hip on weight bearing produces a characteristic waddling gait and marked lumbar lordosis in bilateral hip dislocations.  When the child stands first on one foot and then on the other (holding onto a chair, rail, or someone’s hand), bearing weight on the affected hip, the pelvis tilts downward on the normal side instead of upward as it would with normal stability (positive Trendelenburg sign)  …………..  Radiographic examination in early infancy is not reliable because ossification of the femoral head does not normally take place until 4 to 6 months of life.  However, the cartilaginous femoral head can be visualized directly by ultrasonography.  Universal newborn screening with ultrasonography has been proposed; however, numerous studies reveal this approach has a high rate of false-positives and subsequent overtreatment.  Therefore, ultrasonography is considered an adjunct to the physical examination  Therapeutic Management Newborn to 6 Months :-  The hip joint is maintained, by dynamic splinting, in a safe position with the proximal femur centered in the acetabulum in a degree of flexion.  A variety of abduction devices are available; of these, the Pavlik harness is the most widely used, and with time, motion, and gravity, the hip works into a more abducted, reduced position (Fig. 34-39). Treatment: Neonatal -6months  Pavlik Harness  Dynamic, effective, safe  Keeps hips abducted and flexed – for 6 weeks-12wk  Worn continuously …………  The harness does not rigidly immobilize the hip but acts to prevent hip extension and adduction.  The Pavlik harness is worn continuously until the hip is stable on both clinical and ultrasound examination, usually within 6 to 12 weeks.  It is highly effective when the follow-up care is adequate, and the parents follow instructions in its use 6 to 24 Months  In this age-group, the Pavlik harness has a low success rate.  Therefore surgical treatment with a closed reduction is recommended, and the child is placed in a spica cast for approximately 12 weeks.  If the hip is not reducible, a surgical open reduction may be necessary.  A hip abduction orthosis may be used after spica casting in order to maintain the hip in an appropriate, stable position and further promote hip development  Older Child  Correction of the hip deformity in the older child is inherently more difficult than in the preceding age-groups because secondary adaptive changes and other etiologic factors (such as juvenile arthritis or cerebral palsy) complicate the condition.  Operative reduction, which may involve preoperative traction, tenotomy of contracted muscles, and pelvic osteotomy procedures designed to construct an acetabular roof, often combined with proximal femoral osteotomy, is usually required. ………….  Aftercast removal, range-of-motion exercises help restore movement.  Other rehabilitation measures may include muscle strengthening, a period of crutch or walker use, and gait training. Nursing Care Management  Early detection of DDH in the newborn.  During the infant assessment process and routine nurturing activities, the nurse inspects the hips and extremities for any deviations from normal.  The ambulatory child who displays a limp or waddling gait is also referred for evaluation.  Nonambulatory children with cerebral palsy or spina bifida should be assessed for evidence of hip problems as well ……….  Themajor nursing challenges in the care of an infant or child in a cast or other device are related to maintenance of the device and adaptation of nurturing activities to meet the child’s needs.  Generally,treatment and follow-up care of these children are carried out in an outpatient setting. Pavlic harness care  Parents should be instructed not to adjust the harness.  Skin care is an important aspect of the care of an infant in a Pavlik harness. instructions for preventing skin breakdown are stressed: Check frequently (at least two to three times per day) for red areas under the straps and at skin folds. Gently massage healthy skin under the straps once a day to stimulate circulation. In general, avoid lotions and powders because they can cake and irritate the skin. Always place the diaper under the straps  Cast care  Casts offer more challenging nursing and caregiver problems, since they cannot be removed for routine care and bathing.  Care of an infant or small child with a cast requires nursing innovation to reduce irritation and to maintain cleanliness of both the child and the cast, particularly in the diaper area.  Confinement in a cast or orthotic device should not exclude children from family activities. They can be held astride the lap for comfort and transported to areas of activity.  The child may be allowed to walk in a cast or orthotic device. An adapted wheelchair or stroller can offer mobility to an older infant or child Nsg care management  Detect  Follow –up care  Pavlic- harness : may not remove during bathing , not allow to adjust the harness ,skin care ( check 2-3 time per day for red area under the strap , gently massage healthy skin once a day , avoid lotion & powder , place diaper under the strap.  Cast care Complications.  Avascular necrosis of the femoral head  Redislocation  Residual subluxation  Acetabular dysplasia  Postoperative complications (wound infections)