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Treatment of Congenital Dislocation of the Hip
TREATMENT OF CONGENITAL DISLOCATION OF THE HIP
W. J.
SCHNUTE,
M.D.*
IN 1946, Dr. E. L. Compere and I described a method of treatment of congenital· dislocation of the hip. At intervals we plan to review our series of patients with congenital dislocations of the hip and report our observations and any changes in the treatment that may become necessary. Early diagnosis and early treatment of a congenitally dislocated hip certainly has a direct relationship to the end result. The children in this series have all been under 4 years of age; but, unfortunately, only one child has been younger than 1 year at the beginning of treatment. The basic plan of treatment of these children has been the gentle manipulative reduction of the dislocated hip with the patient under general anesthesia. Gentleness in this manipulation cannot be overemphasized. Forceful mlJ,nipulation can only cause irreparable damage to the hip joint. The danger of additional injury to the shaft of the femur and to the epiphyseal cartilages of the femur and pelvis is always present. Under light anesthesia sufficient relaxation is obtained with gentle traction to permit reduction of the simple congenital dislocation of the hlp. . Traction on the extremity is continu~d fqr five to ten minutes. It is important not to hurry this phase of the reduction. The hip is then flexed above 90 degrees, adducted across the pelvis, and abducted into the frog-leg position of 90 degrees or more abduction, 90 degrees external rotation and 90 degrees flexion of the knee. In most cases the reduction of the hip can be felt by the surgeon and an audible snap heard. This reduction can also be checked by a simple clinical test. If the hip is reduced and held in the frog-leg position, it will not be possible to extend the knee completely; if the attempted reduction has failed, the knee will completely extend with ease. A double, long leg plaster spica (Fig. 28) is applied and kept on for three or four months. Postreduction x-rays are necessary without exception. At the end of three or four months the cast is ehanged, and a double hip spica cast is applied to hold the hips in wide abduction and internal rotation. This cast is worn for six to eight weeks and is then removed, following which bilateral long leg casts with a wide spreader bar (Fig. 29, 30) to maintain abduction and internal rotation are applied and continued for six weeks. At this time active hip motion is begun. Rigid shank shoes fitted with a spreader bar of a length permitting maximum abduction and internal rotation of the hips, similar in con-
* Associate in Bone and Joint Surgery, Northwestern University Medical School; Attending Orthopedic Surgeon, Wesley Memorial, Chicago Memorial, and Children's Memorial Hospitals, Chicago. 59
60
W. J. SCHNUTE
Fig. 28.-Frog-leg cast, which is maintaining wide abduction and external rotation of the hips.
Fig. 29.-Long leg casts with spreader bar, maintaining wide abduction of the hips which in this stage are held in internal rotation. Motion of the hips is begun.
TREATMENT OF COGENITAL DISLOCATION OF HIP
61
Fig. 3O.-Spreader bar attached to high top shoes, maintaining wide abduction and internal rotation of the hips but permitting greater freedom of movement of the hips and knees, and also permitting periods of activity without support.
struction to the Denis Browne splints, are to be made ready to replace the abduction casts. The abduction boot splints are worn for six to eight weeks day and night and removed only for bathing. The interval of freedom from the splints is slowly increased over the next six months-at the end of which time the splints are worn only at night, and they are continued at night for one or two years or as long as necessary to develop a deep, adequate acetabulum. The aim of the prolonged support of the hips in wide abduction and internal rotation is to develop and deepen the acetabulum by constant active pressure from the head. This has been accomplished in these patients. A simple congenital dislocation was mentioned in a previous paragraph. This type of dislocation is in contrast to the dislocated hip associated with arthrogryposis multiplex congenita or multiple other deformities such as a congenital shortening of the femur, absent sacrum, or multiple deformities of the lumbar spine with neurological changes in the lower extremities. The reduction of these types of dislocations and the maintenance of the reduction is difficult and frequently disappointing.
Fig. 31.-0riginal x-rays of the pelvis in internal rotation and external rotation, taken March 9, 1945, showing the bilateral dislocated hips and the shallow oblique acetabula.
Fig. 32.-X-rays, taken May 23, 1946, showing complete reduction of both hips with the appearance of deep, adequate acetabula. 62
'l'Hli:A'l'MEN'l' OF CONGENI'l'AL DISLOCATION 0]<' HIP
63
Fig. 33.-0riginal x-rays, taken July 18, 1944, at age of I! years, showing unilateral congenital dislocation of the hip and also a shallow oblique acetabulum.
Fig. 34.-X-rays, taken June 12, 1948, showing complete reduction of the hip. Acetabulum compares favorably in depth to the normal hip. Clinically, gait was normal; leg length was equal; and Trendelenburg was negative.
64
w.
J. SCHNUTE
Occasionally reduction of the dislocation has not been possible at the first attempt; but after a week of relaxation in a cast holding a frog-leg }!>osition, a second attempt is usually successful. In: one of the patients in this series, four gentle manipulations were carried out before reduction was obtained.
W. J.
SCHNUTE,
M.D.*
IN 1946, Dr. E. L. Compere and I described a method of treatment of congenital· dislocation of the hip. At intervals we plan to review our series of patients with congenital dislocations of the hip and report our observations and any changes in the treatment that may become necessary. Early diagnosis and early treatment of a congenitally dislocated hip certainly has a direct relationship to the end result. The children in this series have all been under 4 years of age; but, unfortunately, only one child has been younger than 1 year at the beginning of treatment. The basic plan of treatment of these children has been the gentle manipulative reduction of the dislocated hip with the patient under general anesthesia. Gentleness in this manipulation cannot be overemphasized. Forceful mlJ,nipulation can only cause irreparable damage to the hip joint. The danger of additional injury to the shaft of the femur and to the epiphyseal cartilages of the femur and pelvis is always present. Under light anesthesia sufficient relaxation is obtained with gentle traction to permit reduction of the simple congenital dislocation of the hlp. . Traction on the extremity is continu~d fqr five to ten minutes. It is important not to hurry this phase of the reduction. The hip is then flexed above 90 degrees, adducted across the pelvis, and abducted into the frog-leg position of 90 degrees or more abduction, 90 degrees external rotation and 90 degrees flexion of the knee. In most cases the reduction of the hip can be felt by the surgeon and an audible snap heard. This reduction can also be checked by a simple clinical test. If the hip is reduced and held in the frog-leg position, it will not be possible to extend the knee completely; if the attempted reduction has failed, the knee will completely extend with ease. A double, long leg plaster spica (Fig. 28) is applied and kept on for three or four months. Postreduction x-rays are necessary without exception. At the end of three or four months the cast is ehanged, and a double hip spica cast is applied to hold the hips in wide abduction and internal rotation. This cast is worn for six to eight weeks and is then removed, following which bilateral long leg casts with a wide spreader bar (Fig. 29, 30) to maintain abduction and internal rotation are applied and continued for six weeks. At this time active hip motion is begun. Rigid shank shoes fitted with a spreader bar of a length permitting maximum abduction and internal rotation of the hips, similar in con-
* Associate in Bone and Joint Surgery, Northwestern University Medical School; Attending Orthopedic Surgeon, Wesley Memorial, Chicago Memorial, and Children's Memorial Hospitals, Chicago. 59
60
W. J. SCHNUTE
Fig. 28.-Frog-leg cast, which is maintaining wide abduction and external rotation of the hips.
Fig. 29.-Long leg casts with spreader bar, maintaining wide abduction of the hips which in this stage are held in internal rotation. Motion of the hips is begun.
TREATMENT OF COGENITAL DISLOCATION OF HIP
61
Fig. 3O.-Spreader bar attached to high top shoes, maintaining wide abduction and internal rotation of the hips but permitting greater freedom of movement of the hips and knees, and also permitting periods of activity without support.
struction to the Denis Browne splints, are to be made ready to replace the abduction casts. The abduction boot splints are worn for six to eight weeks day and night and removed only for bathing. The interval of freedom from the splints is slowly increased over the next six months-at the end of which time the splints are worn only at night, and they are continued at night for one or two years or as long as necessary to develop a deep, adequate acetabulum. The aim of the prolonged support of the hips in wide abduction and internal rotation is to develop and deepen the acetabulum by constant active pressure from the head. This has been accomplished in these patients. A simple congenital dislocation was mentioned in a previous paragraph. This type of dislocation is in contrast to the dislocated hip associated with arthrogryposis multiplex congenita or multiple other deformities such as a congenital shortening of the femur, absent sacrum, or multiple deformities of the lumbar spine with neurological changes in the lower extremities. The reduction of these types of dislocations and the maintenance of the reduction is difficult and frequently disappointing.
Fig. 31.-0riginal x-rays of the pelvis in internal rotation and external rotation, taken March 9, 1945, showing the bilateral dislocated hips and the shallow oblique acetabula.
Fig. 32.-X-rays, taken May 23, 1946, showing complete reduction of both hips with the appearance of deep, adequate acetabula. 62
'l'Hli:A'l'MEN'l' OF CONGENI'l'AL DISLOCATION 0]<' HIP
63
Fig. 33.-0riginal x-rays, taken July 18, 1944, at age of I! years, showing unilateral congenital dislocation of the hip and also a shallow oblique acetabulum.
Fig. 34.-X-rays, taken June 12, 1948, showing complete reduction of the hip. Acetabulum compares favorably in depth to the normal hip. Clinically, gait was normal; leg length was equal; and Trendelenburg was negative.
64
w.
J. SCHNUTE
Occasionally reduction of the dislocation has not been possible at the first attempt; but after a week of relaxation in a cast holding a frog-leg }!>osition, a second attempt is usually successful. In: one of the patients in this series, four gentle manipulations were carried out before reduction was obtained.