Hips

Published on 03/06/2015 by admin

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CHAPTER 25 Hips

David Cartwright

Examination for congenital hip dysplasia and dislocation of the hip (now known as developmental dysplasia of the hip, DDH) is an important part of the assessment of normal newborns. This condition is more common in females.

Particular attention should also be paid to:

• breech presentations, especially those with extended legs

• babies with features of in-utero compression such as calcaneovalgus foot deformities, talipes equinovarus, asymmetry of lower jaw, marked head moulding

• babies from pregnancies with oligohydramnios.

Most information will be gained by performing the examination as soon as possible after birth. It must also be done again before discharge, and should be done whenever a baby in the first few months of life is seen, for whatever reason.

You are examining to determine four kinds of hips:

• dislocatable hip, reduced at rest

• dislocated hip, reducible by manipulation

• dislocated hip, not reducible (fixed dislocation).

Examination of the hips

1. Stand at the foot end of the cot.

2. Observe the position and spontaneous movements of the hips with the nappy removed.

A dislocated hip is held in a slightly adducted and flexed position.

3. Gently take the lower legs in your hands, with your thumbs pointing towards the knees.

Compare the lengths of the femurs by approximating the knees to the midline, without applying any backwards or forwards pressure, with the hips and the knees each flexed to 90°. The femur with a dislocated hip will appear shorter.

4. Flex the knees fully (i.e. calves on the thighs) and take the flexed legs in the palms of your hands, with your thumbs over the lower medial sides of the knee joints, and your 3rd and 4th fingers directed down the outsides of the legs towards the greater trochanters.

5. Without applying any backwards or forwards pressure, gently abduct both hips simultaneously (Ortolani’s manoeuvre).

— A normal hip will abduct fully, the thigh coming to rest on the bed.

— A dislocated, reducible hip will relocate the femoral head into the acetabular fossa during abduction. This action can be felt by the examiner as a clunk, and can often be seen by an observer.

— A dislocated, non-reducible hip will abduct to only about 45°.

6. Now you need to examine for the dislocatable hip (Barlow’s manoeuvre).

— Maintain abduction of each side in turn to stabilise the pelvis while examining the other hip.

— On the side to be examined, change your grip by moving your thumb higher up the medial thigh.

— At about 45° abduction, push back with your thumb, attempting to dislocate the femoral head. If the hip is dislocatable, a distinct movement (sometimes called a ‘clunk’) will be felt as the femoral head rides over the posterior edge of the acetabular fossa.

— Gently rock the femur between thumb and 3rd and 4th fingers to confirm dislocatability/reducibility.

Hip ultrasound

Some units use hip ultrasound to screen for congenital hip dysplasia. Others may use ultrasound in specific groups of babies (such as those born breech, those with an affected first-degree relative, or with other features of in-utero compression).

Treatment of hip problems

1. Dislocated, non-reducible hip — these require orthopaedic consultation. Advise the relevant paediatric/neonatal consultant first.

2. Dislocated, reducible and dislocatable hips — these may be observed for a few days in hospital. Advise the relevant paediatric consultant, who may wish to feel the hip early. If, by the time of discharge, the hip is still abnormal, it should have firmer splinting in a von Rosen splint, supervised by the orthopaedic department.

3. After discharge, a follow-up appointment should be made for all babies who have had abnormal hips in the neonatal period, for not more than 3 weeks following discharge. X-ray at 5–6 months old. Follow up until walking OK.

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