DDH primarily affects firstborn females who are delivered in the breech position

A 23-year-old female presented to our clinic for a checkup. Although she did not complain of any particular symptom, she related how she had surgery for hip problems at a young age. She was the firstborn, and she was delivered in the breech position. Her grandmother had similar problems. The clinical examination demonstrated that she had a large scar on the anterior aspect of her upper thigh; a decreased range of movement of the hip into flexion; and abduction of the right hip and, to a lesser degree, the left hip.

Imaging Findings
On the A-P pelvis view, the most important findings are about the hips, particularly the right hip. A marked reduction in the superior hip-joint space is accompanied by subchondral sclerosis, the formation of a large subchondral cyst, and the formation of osteophytes on the lateral femur. About the left hip, the acetabulum laterally has a rather unusual appearance, with a bony excrescence extending laterally. The hip joint is well preserved. However, the femoral head is noted to be slightly uncovered (using the center edge angle of Wiberg.)¹

Diagnosis
This patient has developmental dysplasia of the hip (DDH) with surgical intervention using an osteotomy technique. The right hip has developed severe degenerative joint disease.

DDH is a condition that affects particularly firstborn females delivered in the breech position. Many other factors exist, such as a family history or neuromuscular disorders such as paraplegia. DDH is a common condition that affects the Caucasian population. However, up to 60% of those with DDH have no known risk factors.

The clinical examination of the newborn should consist of Ortolani’s and Barlow’s orthopedic tests, which should be performed in the first few days after birth to determine the presence of instability about the hip. In an older child, Galeazzi’s test—another orthopedic test designed to determine the cause of leg-length inequality—may be performed. During the clinical examination of a patient with DDH, as well as for leg-length inequality, decreased abduction of the hip may be noted, as well as asymmetry of the gluteal folds, particularly in a newborn.

In terms of imaging, in the newborn, the best imaging modality to start with is ultrasound of the hips to determine the position of the capital femoral epiphysis and the developing acetabulum.² Later in the baby’s development (from the age of 6 months normally), the ossification of the capital femoral epiphysis allows for radiography to be used to assess the developing hip. The early findings of DDH on radiographs include a small or absent capital femoral epiphysis, verticalization of the acetabulum, and lateral displacement of the femur. However, not all of these signs may be present, and they will be most apparent after the age of 6 months. This is, therefore, why ultrasound is the best imaging modality in the first few months to evaluate the baby, make the diagnosis, treat the baby appropriately, and assess the developing hip. If the condition goes undetected for several months, the treatment options become much more limited and difficult.

Treatment
In the first few days to few weeks after birth, if the diagnosis of DDH is made, the baby is usually placed in a harness to encourage the hips to be in flexion, abduction, and external rotation. The harness is known as a Pavlik harness, and the baby is usually obliged to wear it for 23 out of 24 hours of the day for several weeks, during which time ultrasound should be performed regularly to determine the hip joint’s development. If the condition is not detected early, then the young child may be subjected to the harness, although by the age of 6 months and older the harness’ effectiveness is vastly diminished or surgical options are considered. Surgery is usually reserved for children when they are older and better able to tolerate the general anesthetic. It consists of various procedures, one of which includes inserting part of the iliac crest to the region of the lateral acetabulum to build up the acetabulum and increase the coverage of the hip joint.

The importance of early detection is vital, since if the condition is left unchecked, patients may develop early severe degenerative joint disease of the hip.

In terms of chiropractic management of DDH in the older patient, particular attention should be paid to the hip joints and the lumbopelvic region. Chiropractic manipulation for fixations about the hips, mobilization, and distraction techniques may be used, with muscle work with the hip taken in to abduction and external rotation. The entire lower limb should be addressed bilaterally. A small number of studies have been published to date demonstrating the efficacy of particular techniques, but further work needs to be performed to develop these protocols to be more helpful for the practicing chiropractor.³

In this patient, gentle mobilization about both hips was performed, as well as soft-tissue work to the muscles about the hip articulations. A full spine approach with modification of the chiropractic techniques, including drop techniques and biomechanical blocking, was used to treat the lumbar spine and pelvis. The physical examination performed after four treatments noted an increase in the range of motion about both hips.

Michelle A Wessely, BSc (chiropractic), DC, DACBR, is head of radiology and head of clinical research at Institut Franco-Europeen de Chiropratique, Ivry-Sur-Seine, France. Contact her at mwessely@ifec.net.

References
1. Yochum T, Rowe L. Chapter 10: Measurements in Skeletal Radiology. In: Essentials of Skeletal Radiology. Lippincott, Williams and Wilkins. 2005:197–256.

2. Fenoll B. Le depistage clinique et echographie de la luxation congenitale de la hanche [Guidelines for improving the screening of developmental dysplasia of the hip]. Arch de Pediatrie. 2006;13(6): 699–702.

3. Diez F. Chiropractic management of patients with bilateral congenital hip dislocation with chronic low back and leg pain. JMPT. 2004;27(4):E6.