Developmental dysplasia of the hip: Nursing

DEVELOPMENTAL DYSPLASIA OF THE HIP
	KEY POINTS	NOTES
DEFINITION	Socket or acetabulum and the femoral head are misaligned, resulting in an unstable hip joint
PHYSIOLOGY	Hip joint Function to support body weight & provide mobility Ball and socket synovial joint Femur head sits and rotates within the acetabulum of the pelvis Bottom of acetabulum, the ligamentum teres attaches to the fovea capitis Helps with joint stability during flexion and abduction Embryonic development Mesoderm separated by a cleft distinguishing the acetabulum and the femoral head Proper development requires the femoral head to stay within the acetabulum By the 11th week of gestation Hip joint is recognizable
CAUSES AND RISK FACTORS	Causes Unknown Risk factors Too much mechanical force applied against a fetal thigh Breech position Multiple gestations Macrosomia Oligohydramnios Congenital musculoskeletal deformities Family history of developmental dysplasia of the hip joint Biological female sex Improper swaddling
PATHOPHYSIOLOGY	During development Femoral head dislocates out of the acetabulum Both structures grow out of proportion to one another Unable to form a stable joint Three types Dysplasia Femur head is in a shallow acetabulum, and dislocates on exam Subluxation Femur head is loose in acetabulum but doesn't dislocate on exam Dislocation No contact between femoral head and acetabulum Complications Atrophy of muscles around hip Avascular necrosis of the femoral head Early osteoarthritis
SIGNS AND SYMPTOMS	Neonates Laxity of hip ligaments Infant Shortened leg on affected side Asymmetric gluteal or thigh skin folds Child Abnormal gait Limp
DIAGNOSIS	History Physical assessment Age <6 months Barlow & Ortolani maneuvers Age 6 months Hip abduction test Older children Trendelenburg test Diagnostic imaging
TREATMENT	Age < 6 months Abduction splint, Pavlik harness Worn 23 hours per day for at least 6 weeks Age > 6 months Closed reduction under sedation Surgical open reduction Spica cast
MANAGEMENT OF CARE	Goals of care Provide postoperative care Emotional support Ensure cast is drying evenly Petal cast edges to soften Neurovascular and skin assessment Ensure proper chest expansion and breathing Assist with cast removal when needed Emotionally support caregivers Report to HCP Respiratory distress Vomiting after feeding Signs or symptoms of neurovascular compromise Absence of distal pulses Poor capillary refill Cool, pale, or discolored skin Decreased foot movement or sensation
PATIENT AND FAMILY TEACHING	Explain condition, plan of care, and safe medication administration Discharge preparation Ensure car seat accommodates cast Teach repositioning for skin care Neurovascular assessment Cast care Keep clean and dry Cover with plastic bag during bathing and eating Double diapering If cast is soiled Wipe w/ clean cloth Cleanse skin underneath cast Do not insert objects into cast Notify HCP Skin is blue Loss of sensation Can't wiggle toes Object stuck in cast

Questions

USMLE® Step 1 style questions USMLE

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The nurse in the pediatric medical unit is preparing to discharge a client with a history of developmental dysplasia of the hip in a spica cast. Which step(s) should the nurse explain to the caregivers to prevent skin breakdown in their child? Drag potential steps to the box on the right. Choose only the step(s) that is/are appropriate.

Developmental dysplasia of the hip is a condition where the socket or acetabulum and the femoral head are misaligned, resulting in an unstable hip joint. Typically, the condition is present at birth, but sometimes it appears later as the bones develop over time.Now, let’s go over some anatomy and physiology. The hip joint is also called the acetabulofemoral joint. The main function of the hip joint is to support the weight of the body while providing mobility. It is a ball and socket synovial joint, where the ball-shaped head of the femur sits and rotates within the acetabulum of the pelvis, which is a cup-shaped socket. At the bottom of the acetabulum, known as the acetabular fossa, arises a ligament called the ligamentum teres, that attaches to the fovea capitis, which is a depression found on the tip of the femoral head. This ligament helps with joint stability, especially during hip flexion and abduction.

Now, during embryonic development, the mesoderm is separated by a cleft to distinguish the acetabulum and the femoral head by the 7th week of pregnancy. The proper development of a hip joint requires that the femoral head stays fitted within the acetabulum, so that they both grow together keeping their sizes and shapes proportional. Finally, by the 11th week, the hip joint is fully recognizable. All right, now the exact causes of developmental dysplasia of the hip are unknown, but there are several risk factors. One of these is too much mechanical force being applied against a fetal thigh, which can cause the femoral head to slip out of the acetabulum. This can happen when a baby is lying in a breech position within the uterus. This sort of mechanical force can also occur with multiple gestations, macrosomic or large babies or with oligohydramnios, where there is not enough amniotic fluid to expand the uterine cavity.

Additionally, having congenital musculoskeletal deformities increases the risk for developmental dysplasia of the hip. Other risk factors include family history of developmental dysplasia of the hip joint, and being assigned female at birth. A final important risk factor is being improperly swaddled, so the infant’s legs are wrapped tightly in an extended position, instead of wrapped loosely so the legs can move freely.Developmental dysplasia begins during development, when the femoral head dislocates out of the acetabulum. As a result, they grow out of proportion to one another and are unable to form a stable joint. Moving on to pathology, the three main types of developmental dysplasia of the hip include dysplasia, where the head of the femur is in a shallow acetabulum, and it will dislocate on physical exam; subluxation, which is when the head of the femur is loose in the acetabulum, but it will not dislocate on physical exam; and dislocation, where there is no contact between the femoral head and acetabulum.

In addition, the acetabular structures will start hypertrophying within the acetabular fossa like the ligamentum teres and the transverse ligament. In other words, the socket becomes “more shallow”, making for a poor fit for the femoral head.In terms of complications, if the dislocation continues, the muscles around the hip will begin to atrophy. Less common complications include avascular necrosis of the femoral head, which results from reduced blood supply, femoral nerve palsy, and early osteoarthritis. Clinical manifestations of developmental dysplasia of the hip may differ according to the baby’s age. In neonates, the only sign might be laxity of the ligaments around the hip. An infant may present with a shortened leg on the affected side, as well as asymmetric gluteal or thigh skin folds. Ambulatory children often present with an abnormal gait or limp. The diagnosis of developmental dysplasia of the hip starts with the client's history and physical assessment. Babies up to 6 months of age are usually tested with the Barlow and Ortolani maneuvers.

The Barlow maneuver consists of adducting the hip while holding the knee straight, and when this pops the femoral head out of the socket, this raises suspicion of hip dysplasia. The Ortolani maneuver consists of flexing the baby’s hip at 90°, and then gently abducting it. If the femoral head was out of the socket, the Ortolani maneuver will cause it to slip back into the acetabulum, which will feel and sound like a clunk. After the age of 6 months, the hip abduction test can be used. The test begins with the hips flexed to 90° and then the thighs are gradually abducted. Normally the thighs can be abducted to 70° from the midline. In developmental dysplasia of the hip, abduction is under 45° because of muscle shortening in the affected hips. For older children, a Trendelenburg test can be performed, which is where the child is asked to stand on one leg for 30 seconds without leaning. A negative test is when the pelvis stays level, or rises, and positive when the pelvis drops toward the unsupported side. Finally, imaging tests can be used to confirm the diagnosis, by assessing the position of the femoral head and the structure of the acetabulum.

Developmental dysplasia of the hip: Nursing

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