Congenital dislocation of the hip

When a child is born it is almost immediately put through a number medical tests to check out the health of the child. You know the routine, count the fingers and toes. One of the myriad of initial tests is to check that the formation of the hip joint is going the way nature intended it. Whilst this is being done it can look as if the doctor is trying to rotate the child’s hips to touch each other.

This bizarre flexibility test on a fresh new human being is performed to test for Congenital Dislocation of the Hip (CDH).

The other names are just as long winded: Development dysplasia of the hip or Developmental Dislocation of the Hip Joint (DDH).

Congenital Dislocation of the Hip

CDH simply put is when the ball and socket joint of the hip is malformed. The dislocation occurs while forming in the uterus and ranges in severity. The most severe being complete bilateral dislocation down to ‘clicky’ hip(s), this is when the socket is a touch shallow and the joints click or thunk when moved. The statistics quote that in 1 to 1.5 of 1000 live births are born with CDH. When there are aggressive screening systems in place it can jump as high as 5 in every 1000. There are a number of risk factors that are associated with the probable birth of a child with CDH:

• Female (80% of cases)
• Breech Birth (may account for 25% - 45% of CDH)
• First Born
• Genetic History
• Down's Syndrome

Treatment

Once CDH is diagnosed then a treatment regime is begun. The diagnosis is not always easy as some cases are ‘silent’, having no symptoms and only an ultrasound will pick it up. The treatment regime has changed quite a lot over the past thirty years. Before then many cases went undiagnosed only to have the hip collapse later in life usually in the early to mid twenties.

As a parent there are some symptoms you should be on the look out for:

• Legs of different lengths.
• Uneven thigh skin folds.
• Less mobility or flexibility on one side.
• Toddler who walks with a limp, waddling gait or toe walking.

The methods of treatment begin as non invasive but become more so if unsuccessful.

To begin the legs are placed in devices to keep the legs apart and turned outward in what is called the frog leg position. It holds the hips in the correct position so they form into the natural position. There are a number of orthotics that complete this task, the most common being the Palvik Harness. Although some of these harnesses become an issue for the older child who is becoming more active and able to remove the harness thus it has an age limit of about 18 months.

If the hips have not moved into the correct position then the doctors move onto more invasive techniques. Traction is the next step, the weights pulling the hips back into place. The traction can be combined with closed and/or open reductions.

Reductions are almost the most invasive treatment and are reserved for the most severe cases.

A closed reduction is when the patient is put under general anesthetic and whilst in that relaxed state the leg is manually wrenched into position. It is then held in place with the use of plaster casts or orthotics in the frog leg position.

The open reduction is only used if all other treatments have failed or if the child is older and CDH has only just been detected. Open reductions are major surgical interventions, when the joint is opened to align the hip into the correct position, sometimes using bone grafts and pins to build a socket. The child can then spend time in traction or plaster. The surgery invariably leaves dramatic scarring.

Prognosis

With any luck the hips should corrected before the child has reached two years of age. This when some of the really nasty complications set in including malformation of the developing femur, with a characteristic limp or waddling gait. In general children who are born with CDH and are treated quickly and grow in to adulthood with few problems; although leg length discrepancies may continue. If it goes untreated the child will have difficulty walking, which could result in life-long pain.

Personal Case Study

You might be wondering why I have written this write up, it is not a life threatening or particularly gross medical condition. The interest in CDH is purely personal, I make no bones about that. One thing I found lacking in the many articles that I combed through was personal accounts and information regarding the prognosis of adults with severe cases of CDH. It was here that I thought I would add a personal touch. The following is my personal experience with CDH.

I was my mother's first child and breech birth and I was born with bilateral top of the line in severity CDH. The resulting first two years of my life consisted of braces, plaster casts and a number of operations. My mother talks about it this time with regret - she rarely took me out because she found the stares of people at this child in a frog leg plaster too hard to bear. My earliest memory is of a hospital ward, I think that memory saddens my mother a lot.

My left hip was well and truly repaired by the time I was two but the right is another story. I endured almost triple the amount of operations on the right leg and I was six before it was properly aligned. That means I spent three years walking on a dislocated hip, (I walked late at two years). When it was finally put in place I was left with one leg shorter than the other and multiple scars that have been reopened a number of times. The right hip has a low shallow socket and malformed head of the femur, on bad days you can hear it click in and out of joint as you walk beside me. This has given me an uneven gait, a femur full of titanium and arthritis since I was sixteen. My long term prognosis is a hip replacement as I head towards forty.

My gamy leg has been a bane and good fortune and has shaped me into the person I am. I am restricted in what I can do in many ways but this makes me more likely not to let dicky hips get in the way of my life. I would not trade the scars or pain for anything, I would not be me with out them.