CONFIRMING DIAGNOSIS A positive Ortolani’s or Trendelenburg’s sign confirms DDH. To elicit Ortolani’s sign, place the infant on his back, with his hip flexed and abducted. Adducting the hip while pressing the femur downward will dislocate the hip. Then, abducting the hip while moving the femur upward will move the femoral head over the acetabular rim. If you hear a click or feel a jerk as the femoral head moves, the test is positive. This sign indicates subluxation in a neonate younger than 1 month and subluxation or complete dislocation in an older infant.
To elicit Trendelenburg’s sign, have the child rest his weight on the side of the dislocation and lift his other knee. His pelvis drops on the normal side because of weak abductor muscles in the affected hip. However, when the child stands with his weight on the normal side and lifts the other knee, the pelvis remains horizontal.
Ultrasound of the hip reveals hip deformity. X-rays show the location of the femur head and a shallow acetabulum. Magnetic resonance imaging may also be used to assess reduction.
Treatment
The earlier the infant receives treatment, the better his chances are for normal development. Treatment varies with the patient’s age. In infants younger than 3 months, treatment includes gentle manipulation to reduce the dislocation, followed by holding the hips in a flexed and abducted position with a splint-brace or harness to maintain the reduction. The infant must wear this apparatus continuously for 2 to 3 months and then use a night splint for another month so the joint capsule can tighten and stabilize in correct alignment.
If treatment doesn’t begin until after age 3 months, it may include bilateral skin traction (in infants) or skeletal traction (in children who have started walking) in an attempt to reduce the dislocation by gradually abducting the hips. In Bryant’s traction, or divarication traction, both extremities are placed in traction, even if only one is affected, to help maintain immobilization. This type of traction is used in children who are younger than 3 years and weigh less than 35 lb (16 kg). The length of treatment is 2 to 3 weeks.
If traction fails, gentle closed reduction under general anesthetic can further abduct the hips; the child is then placed in a spica cast for 4 to 6 months. If closed treatment fails, open reduction, followed by immobilization in a spica cast for an average of 6 months, or osteotomy may be considered.
In the child age 2 to 5 years, treatment is difficult and includes skeletal traction and subcutaneous adductor tenotomy. Treatment begun after age 5 rarely restores satisfactory hip function.
Special considerations
The child who must wear a splint, brace, or body cast needs special personal care that requires parent education.
❑ Teach parents how to correctly splint or brace the hips, as ordered. Stress the need for frequent checkups.
❑ Listen sympathetically to the parents’ expressions of anxiety and fear. Explain possible causes of developmental hip dislocation, and give reassurance that early, prompt treatment will probably result in complete correction.
❑ During the child’s first few days in a cast or splint-brace, he may be prone to irritability due to the unaccustomed restricted movement. Encourage his parents to stay with him as much as possible and to calm and reassure him.
❑ Assure parents that the child will adjust to this restriction and return to normal sleeping, eating, and playing behavior in a few days.
❑ Instruct parents to remove braces and splints while bathing the infant but to replace them immediately afterward. Stress good hygiene; parents should bathe and change the child frequently and wash his perineum with warm water and soap at each diaper change.
If treatment requires a spica cast:
❑ When transferring the child immediately after casting, use your palms to avoid making dents in the cast. Such dents predispose the patient to pressure sores. Remember that the cast needs 24 to 48 hours to dry naturally. Don’t use heat to make it dry faster because heat also makes it more fragile.
❑ Immediately after the cast is applied, use a plastic sheet to protect it from moisture around the perineum and buttocks. Cut the sheet into strips long enough to cover the outside of the cast, and tuck them about a finger length beneath the cast edges. Using overlapping strips of tape, tack the corner of each petal to the outside of the cast. Remove the plastic under the cast every 4 hours; then wash, dry, and retuck it. Disposable diapers folded lengthwise over the perineum may also be used.
❑ Position the child either on a Bradford frame elevated on blocks, with a bedpan under the frame, or on pillows to support the child’s legs. Be sure to keep the cast dry, and change the child’s diapers often.
❑ Turn the child every 2 hours during the day and every 4 hours at night. Check color, sensation, and motion of the infant’s legs and feet. Be sure to examine all his toes. Notify the physician of dusky, cool, or numb toes.
❑ Check the cast daily for odors, which may herald infection.
❑ If the child complains of itching, he may benefit from diphenhydramine, or you may aim a hair dryer set on cool at the cast edges to relieve itching. Don’t scratch or probe under the cast. Investigate any persistent itching.
❑ Provide adequate nutrition, and maintain adequate fluid intake to avoid renal calculi and constipation, both complications of inactivity.
❑ Provide adequate stimuli to promote growth and development.
❑ Tell parents to watch for signs that the child is outgrowing the cast (cyanosis, cool extremities, or pain).
❑ Tell parents that treatment may be prolonged and requires patience.
The patient in Bryant’s traction may be cared for at home if the parents are taught traction application and maintenance.
❑ Encourage the parents to cuddle and hold the child and encourage him to interact with siblings and friends.
❑ Maintain skin integrity and check circulation at least every 2 hours.
❑ Feed the child carefully to avoid aspiration and choking.
❑ Refer the child and his parents to a child life specialist to ensure continued developmental progress.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
Other Book Chapters Related to Developmental problems
Read excerpts from these other book chapters related to Developmental problems:
Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Developmental problems
» Next page: Developmental Delay (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
