DYSPLASIA

• Developmental dysplasia of the hip


  Infantile hip instability, dislocation, or shallowness of the hip socket
• Developmental dysplasia of the hip


  • Usually detected at birth or during infancy and early development
  • Most common disorder affecting the hip joint in children younger than age 3 years
  • Can be unilateral or bilateral
• Degrees of hip dysplasia


  • Subluxtable - Head of femur is loose in socket, can be moved but won't dislocate
  • Dislocatable - Femoral head can be pushed out of socket
  • Dislocated - Femoral head lies totally outside acetabulum (most severe)
• The practitioner must consider the degree of dysplasia and the child's age when determining the treatment choice
• Pathophysiology


  • Genetic component predisposes developing hip to mechanical forces, causing femoral head to move outside acetabulum
  • Prenatal factors like breech positioning and postnatal factors like swaddling play a role
  • Excessive/abnormal joint movement during birth can cause dislocation
  • Displacement of bones can damage joint structures
  • Disruption of blood flow can lead to ischemic necrosis
  • Pathologic changes are reversible if treated early
• Risk factors


  • Mechanical factors like breech positioning, oligohydramnios, and postnatal positioning
  • Multiple gestation pregnancy
  • Genetic factors like family history
  • Generalized ligament laxity
  • Female sex
  • Birth weight greater than 4 kg
  • Firstborn child
• The disorder is almost six times more common in females than males
• The left hip is more commonly affected than the right hip due to positioning in utero
• DDH is associated with other congenital conditions like torticollis, plagiocephaly, metatarsus adductus, clubfoot, and other lower limb deformities
• DDH may be more common in term infants than preterm infants less than 36 weeks' gestation
• Complications


  • Degenerative hip changes
  • Neurovascular injury related to surgery
  • Abnormal acetabular development
  • Lordosis
  • Joint malformation
  • Back pain in bilateral hip dislocation
  • Sciatic nerve injury (paralysis)
  • Avascular necrosis of femoral head
  • Soft-tissue damage
  • Unstable gait, pain with ambulation, functional scoliosis, valgus deformity of ipsilateral knee, hip osteoarthritis, lower back pain if untreated
  • Permanent disability
  • Delayed ambulation
  • Growth disturbance of proximal femur (rare)
• Age factor


  DDH screening should be initiated in newborn period and continue until about age 9 months or when child can walk independently. Early detection is crucial at ages 2 and 4 weeks.
• History


  • Breech delivery
  • Family history (first-degree relative)
  • Family history of ligamentous laxity
• Physical findings


  • Asymmetrical thigh or gluteal folds
  • Decreased mobility or flexibility on one side
  • Limited abduction on dislocated side (typically in children older than age 3 months)
  • Uneven level of knees
  • Swaying, limping, or toe walking due to uncorrected bilateral dysplasia
  • Leg length discrepancies, shortening of affected limb
  • Positive Ortolani, Barlow, or Trendelenburg signs
• Ortolani, Barlow, and Trendelenburg signs


  Positive signs confirm DDH. Ortolani and Barlow are used up to age 6 months, Trendelenburg is used in children older than age 4 years.
• Diagnostic tests


  • Radiography (not useful in children younger than 6 months)
  • Ultrasonography (used in infants younger than 6 months with positive instability exam)
  • Sonography and MRI (reveal laxity, subluxation, dislocation, reducibility)
  • Hip arthrography (helps decide treatment approach)
• Treatment goal


  Obtain and maintain concentric reduction (alignment) of the hip
• Treatment by age


  • Infants younger than 6 months: Bracing with Pavlik harness, von Rosen splint, or semirigid orthosis
  • Children older than 6 months or if bracing ineffective: Closed reduction, hip spica cast
  • Children older than 24 months or if previous treatment ineffective: Open reduction, femoral shortening, pelvic/femoral osteotomy
• The younger a child with DDH begins treatment, the more effective and greater improved the outcome. Treatment after age 5 years rarely restores satisfactory hip function.
• Medications


  • Acetaminophen for pain
• No dietary restrictions
• Activity as tolerated
• Nursing interventions


  • Provide reassurance and encourage family involvement
  • Assist with application of harness/splint
  • Inspect skin for breakdown
  • Keep infant/child dry, frequent diaper changes
  • Turn infant/child every 2 hours, pad bony prominences
  • Complete fall risk assessment, implement precautions
  • Provide appropriate cast care
  • Ensure proper traction alignment
  • Provide pin-site care if skeletal traction
  • Administer medications, monitor effects
  • Provide diversional activities for child in spica cast/traction
  • Teach family how to manage harness/brace at home
  • Consult OT to assist with daily activities
  • Collaborate with PT to promote ROM exercises
  • Encourage family to verbalize questions/concerns, provide support
• Care for infant or child with developmental dysplasia of the hip


  1. Turn the infant or child every 2 hours, as indicated, padding bone prominences

  2. Complete a pediatric fall risk assessment using an approved screening tool, and implement necessary precautions

  3. Provide appropriate cast care

  4. Ensure proper traction alignment

  5. Provide pin-site care, as ordered, if skeletal traction is used

  6. Administer prescribed medications and monitor their effects

  7. Provide diversional activities for an older child who requires a spica cast or skeletal traction

  8. Teach the family how to manage the Pavlik harness or postoperative abduction brace at home

  9. Consult with occupational therapy to assist with daily activities

  10. Collaborate with physical therapy to promote range-of-motion exercises, as tolerated

  11. Encourage the family to verbalize questions, feelings, and concerns. Actively listen, and answer questions honestly

  12. Provide encouragement and support for both the child and family, as appropriate

  13. Consult with a child life specialist to provide age-appropriate distractions and support

  14. Collaborate with social services to provide counseling, community resources, and support

  15. Consult with care management to ensure that all home-going needs are met prior to discharge
• Associated Nursing Procedures


  • Alignment and pressure-reducing device application
  • Assessment techniques
  • Cast application, pediatric
  • Cast assessment and management, pediatric
  • Cast removal, assisting, pediatric
  • Fall prevention, pediatric
  • Hip arthroplasty postprocedure care
  • Hip spica cast care, pediatric
  • Intake and output measurement, pediatric
  • Pain assessment, pediatric
  • Pain management
  • Postoperative care
  • Preoperative care, pediatric
  • Pressure injury prevention
  • Pulse assessment, pediatric
  • Skeletal pin site care, pediatric
  • Skeletal traction management, pediatric
  • Skin care, neonate
  • Traction, care of patient
• Patient and Family Teaching

  • Disease; diagnosis; treatment, including use of a splint, harness, cast, traction, or surgery; and prognosis, including the fact that the use of a harness is 95% effective when used before a child is 6 months old
  • Prescribed medications, including drug names; dosages; indications for use; frequency, route, and duration of administration; expected results; potential adverse effects; and signs and symptoms of toxicity
  • Proper application of a harness, including the need to leave two fingerbreadths of space between the chest and strap and to use the harness for the specified number of hours each day, usually 24 hours per day
  • Need for a follow-up examination every 3 weeks to adjust the straps to accommodate the child's growth and possible need for ultrasound examination every 2 to 3 weeks after initiating a harness to evaluate effectiveness
  • Use of casting or traction, including the type and duration of therapy
  • Need for meticulous skin care to prevent skin breakdown
  • Appropriate diversional activities if the child requires long-term spica casting or traction
  • Technique for performing neurovascular checks of the affected extremity, including the signs and symptoms of changes in peripheral vascular status due to compression, such as pallor, cool extremities, and pain
  • Necessary modifications or adjustments to routine skin and diaper care if the infant is in a harness
  • Need to interact with the infant or child to foster appropriate growth and development
  • Importance of close monitoring
  • Possible need for additional surgeries in the future
• Discharge Planning


  1. Assess the child's (if appropriate) and the parents' or caregiver's understanding of the diagnosis, treatment regimen, need for follow-up care, and warning signs or potential problems that require medical attention

  2. Explain the importance of scheduling and attending all follow-up appointments

  3. Confirm transportation arrangements for initial follow-up appointments

  4. Ensure that the parents or caregivers understand the treatment regimen, including the purpose and desired effect of each medication, the dosage and how to administer it, and potential adverse effects

  5. Ensure that the parents or caregivers are able to obtain the prescribed medications. Ensure that the child (if appropriate) and the parents or caregivers have the name and contact information of someone to call if they encounter a problem

  6. Document the discharge planning evaluation in the child's medical record. Record those who were involved in planning and teaching, their understanding of the teaching, and any need for follow-up teaching
• Related Patient Teaching Handouts

  • Developmental dysplasia of the hip
  • Developmental Dysplasia of the Hip Discharge Instructions, Child
  • Hip Abduction Brace
• Resources


  • American Academy of Orthopaedic Surgeons: www.aaos.org
  • American Academy of Pediatrics: www.aap.org
  • American Orthopaedic Association: www.aoassn.org
  • National Library of Medicine—MedlinePlus: www.medlineplus.gov