MENEJEMEN

FISIOTERAPI PADA
KASUS
CONGINETAL HIP
DISLOCATION

MENEJEMEN FT
PEDIATRI
 Conginetal Dislocation Of The Hip atau
yang sekarang disebugt Developmental
displasia of the Hip.

 Merupakan kelainan kongenital dimana

terjadi dislokasi pada panggul karena
acetabulum dan capur femur tidak berada
pada tempat seharusnya.
 ANATOMY OF THE HIP JOINT
 One of the most stable joints in the body .
 Hip joint is a multi axial ball and socket synovial joint designed for stability and weight
bearing.
 Movements at the joint include flexion, extension, abduction, adduction , medial and
lateral rotation and circumduction.

ARTICULAR SURFACES:
 Head of femur articulates with acetabulum of hip bone to form hip joint.
 Head of femur- more than half of a sphere, covered with a hyaline cartilage
 Acetabulum- lunate shape with a notch & fossa
 LIGAMENTS OF THE HIP JOINT

EXTRASCAPULAR:
 Iliofemoral
 Pubofemoral
 Ischiofemoral

INTRASCAPULAR
 Ligamentum teres
 Transverse ligament of the acetabulum.
 BLOOD SUPPLY

 Two circumflex femoral arteries (medial and lateral)

 They anastomoses at the base of the femoral neck to form a ring, from which
smaller arteries arise to the supply the joint itself.
 Foveal artery ( branch of the obturator artery)

NERVE SUPPLY
 Femoral nerve
 Obturator nerve
 Nerve to quadratus femoris
 Superior gluteal nerve
 Movement and muscles
 Flexion: Iliosoas, rectus femoris, Sartorius
 Extension: Gluteus Maximus, semimembranous,semitendinosus and biceps
femoris
 Abduction: Gluteus medius, gluteus minimus and the deep gluteals
(piriformis, gemelli etc.)
 Adduction: Adductors longus, brevis and magnus,pectineus and gracillis
 Lateral rotation: Biceps femoris, gluteus Maximus,  and the deep gluteals
(piriformis, gemelli etc.)
 Medial rotation: Gluteus medius and minimus, semitendinosus and
semimembranosus
 Embryonic dev.
 4-6weeks – the hip joint develops from the cartilaginous anlage
 7-8th week – acetabulum and head of femur are formed from the same primitive
mesenchymal cells
 11th week - complete development of the hip
 At late gestation, femoral head grows more rapidly than the acetabular cartilage.
 At birth, acetabulum is at its most shallow and most lax in order to maximize hip
ROM which facilitates delivery process
 After several weeks, acetabular cartilage develops faster than the femoral head,
which allows progressively more coverage.
 EPIDEMIOLOGI
 Bilateral > unilateral
 Perempuan > laki-laki = 8 : 1
 Kejadian meningkat pada :
 Ada riwayat keluarga
 Kebiasaan membedong bayi
 Bawaan dari kelainan kongenital lain, seperti: Congenital Muscular
Torticolis dan Congenital Metatarsus Adductus.
 ETIOLOGI
1. Genetik  Kelemahan Ligamen
2. Prenatal  Desakan Kembar ( caput femur janin msh blm terfiksasi
dengan baik terlepas dari acetabulum),Oligohidramnion
3. Persalianan Kesalahan proses persalinan, Bayi dengan
interpretasi bokong
4. Post Natal  Kebiasaan membedong (pembedongan erat membuat
kaki seharusnya fleksi menjadi, Gendongan bayi di sasa / punggung
dengan posisi kaki ekstensi
 CLASIFICATION

Typical Dysplasia
Developmental
(Congenital) Subluxation
Dysplasia of the Hip
Dislocation

Teratologic
 Typical  Dxiagnosa Awal normal  Patologi didapat
tanpa didapat syndrome dari kondisi genetic

 Teratologic  Didapat arthrogyposis atau syndrome selama

kehamilan
 Developmental Dysplasia of the Hip

1. Complete hip dislocation.

2. Partial hip subluxation.
3. Hip dysplasia (incomplete development).
TANDA DAN GEJALA

 CDH UNILATERAL :
 Keterbatasan Abduksi pd salah satu
hip
 Asimetri lipatan kulit
 Kemungkinan pemendekan salah
satu tungkai
 Pada palpasi, tronchanter mayor
lebih tinggi dibanding yang satu
 TANDA DAN GEJALA

 CDH BILATERAL :
 Wide perineum
 Peningkatan lumbar lordosis
Recommended
Not recommended
 CLINICAL FINDINGS
IN NEWBORNS
 Usually asymptomatic and must be screened by special maneuvers

1) Barlow test.
It is a provocative test that attempts to dislocate an unstable hip.
- Flexion ,adduction, posteriorly.
- “Clunk”
 Clinical Features : Neonates
BARLOW’S TEST ( bahar lo)
 Clinical Features : Neonates
BARLOW’S TEST
2) Ortolani test
It is a maneuver to reduce a recently dislocated hip.
 Flexion, abduction, anteriorly.
 We can`t use X-rays because the acetabulum and proximal femur are
cartilaginous and wont be shown on X-ray.
 US is the best method to Dx.
 Clinical Features : Neonates
ORTOLANI SIGN
 Clinical Features : Neonates
ORTOLANI SIGN
Clinical Manifestations
In infants:
 As the baby enters the 2nd and 3rd months of life, the soft tissues
begin to tighten and the Ortolani and Barlow tests are no longer
reliable.
 Shortening of the thigh, the Galeazzi sign , is best appreciated by
placing both hips in 90 degrees of flexion and comparing the height of
the knees, looking for asymmetry
 Asymmetry of thigh and gluteal skin folds.
 The most diagnostic sign is Ortolani’s limitation of abduction.
 Abduction less than 60 degrees is almost diagnostic.
 X-rays after the age of 3 months can be helpful esp. after the
appearance of the ossific nucleus of the femoral head
 US is 100% diagnostic.
 Limitation of Abduction
MOST RELIABLE SIGN
Galeazzi’s Sign
Asymmetric gluteal, thigh, labial folds
 In walking child
 In older children:
Complaints of limping, waddling (bilateral DDH), lumbar lordosis,
limitation of hip abduction, toe-walking, wide perineum, etc…
 Screening
 All neonates should have a clinical examination for hip instability
 Risk factors :
 breech presentation
 family history USG SCREENING
 torticollis
 oligohydramnios
 metatarsus adductus
 CLINICAL & USG

normal normal

normal ABnormal
ABnormal
F/U till maturity
REPEAT AT 6 WKS
ABnormal normal
Clinical & USG normal

REPEAT AT 3 & 6 WKS ABnormal

Closed / open reduction

 Birth to Six Months
 Triple-diaper technique
 Prevents hip adduction
 “Success” no different in some untreated
hips
 Pavilk harness (1944)
 Experienced staff*
 Very successful
 Allows free movement within confines of
restraints

*posterior straps for preventing add. NOT producing abd.

 Birth to Six Months
 Pavlik harness
 Indications
 Fully reducible hip*
 Child not attempting to stand
 Family
 Close regular follow-up (every 1-2 weeks)
 For imaging and adjustments
 Duration
 Childs age at hip stability + 3 months
 Pavlik Harness
 Failures
 Poor parent compliance
 Improper use by the physician
 Inadequate initial reduction
 Failure to recognize persistent dislocation
 Viere et al 1990
 Bilateral dislocation
 Absent Ortolani’s sign
 > 7weeks of age
 Pavlik Harness
 Complications
 Avascular necrosis
 Forced hip abduction
 Safe zone (abd/adduction and flexion/extension)
 Femoral nerve palsy
 Hyperflexion

*Be aware of Pavlik Harness Disease

*Follow until skeletal maturity
Von Rosens splint
 Splintage

 Held in a plaster Spica at 60 degrees of flexion, 40 degrees of abduction

and 20 degrees of internal rotation.
 After 6 weeks the Spica is changed and stability assessed
 If satisfactory, Spica retained for 6weeks, then abduction splint for
6months
 If concentric reduction is not achieved, open reduction is done.
 Birth - Six months
 Closed reduction + Spica
 Failure after 3 weeks of Pavlik trial
 Child 6 months to 2 years of age

 Closed or open reduction + adductor tenotomy

 If closed reduction fails then surgeon should be
prepared for an open procedure
 Closed reduction
 Force should be avoided
 Check for safe zone
 Post reduction:
 Spica change every six
weeks plus stability check
 Continue spica for 3-4
months
 Birth - Six months
 Closed reduction
 General anesthesia
 Arthrogram
 Safe zone - avoid AVN
 +/- adductor tenotomy
 Open reduction if concentric reduction not possible
 Usually teratogenic hips in this age group
 Open Reduction
 Medial approach
 Pectineus / adductor longus + brevis
 Cannot address simeoultaneous bony
work
 Antero -lateral
 Smith-peterson
 Sartorius / Tensor Fascia lata
 6 months - 4 years
 Present a more difficult problem
 Prolonged dislocation
 Contracted soft tissues
 6 - 18 months
 Closed reduction +/- adductor tenotomy
 Spica in human position of 100 degrees of flexion and about 55 degrees abduction
(3 months)
 Abduction Orthosis 4 wks full time/4 wks nighttime
 Open reduction (if closed fails)
 Capsulorraphy
 CT scan
 Spica for 6 wks followed by PT
 6 months - 4 years
 18 months - 4 years
 Closed reduction
 Reducibile - check arthrogram and medial dye pool
 Irreducible - Open reduction
 Open redcution
 Tight - femoral shortening
 Stable - +/- pelvic osteotomy
 Safe Zone
to 30 degrees from 20
maximum abduction

extended to below 90
degrees
without redislocation

Safe zone can be

improved
with adductor tenotomy
 Management of DDH – Guidelines

to 6 months 0 to 18 months 6 to 36 months 18 to 8 years 3

Pri, open
Pavliks Harness Pri. open reduction with
Traction reduction Femoral
Closed reduction shortening
Hip spica
weeks no 6
reduction
Arthrography
No reduction 1/3rd head>
visible

Open reduction
Pelvic osteotomy
 Femoral Shortening

 Schoenecker + Strecker 1984

 Traction vs. Femoral shortening
 56% AVN in traction group
 0% AVN in femoral shortening
 Pelvic Osteotomy

 Persistent instability + dysplasia after open reduction + femoral

shortening
 Requires concentric reduction of a reasonably spherical femoral
head
 Usually based on surgeon preference
 Salter and Pemberton 2 m/c in US
 Pelvic Osteotomy
 Volume changing
 Pemberton
 Hinges on triradiate
 Requires remodeling of “new” incongruity
 Provides more anterolateral coverage
 Dega’s
Pemberton
 Pelvic Osteotomy
 Redirecting
 Salter
 Osteotomy thru sciatic notch
 Hinge thru pubic symphysis
 Triple innominate
 Ganz
 Dial
 Pelvic Osteotomy
 Redirecting
 Salter
 Osteotomy thru sciatic notch
 Hinge thru pubic symphysis
 Triple innominate
 Ganz
 Dial
Salter Osteotomy
Salter Osteotomy
Salter Osteotomy
 Salvage or Shelf procedures
 Chiari
 Requires capsular metaplasia
 Pain - main indication
 Treatment of chronic hip pain in adolescents
Chiari Osteotomy
Chiari Osteotomy
Chiari Osteotomy
Chiari Osteotomy
Chiari Osteotomy
Avascular Necrosis
 Avascular Necrosis
 Most common
 Not part of the natural history of DDH
 Iatrogenic
 Etiology unknown
 Femoral head compression
 Injury to blood supply
 Excessive abduction
 Sullivan et al 1997
 Sig  blood flow w/ increasing abd angle
PEMERIKSAAN FISIOTERAPI
A. URUTAN MASALAH FISIOTERAPI
Kelemahan otot, gangguan pernafasan,tighness dan kontraktur

B. DIAGNOSA FISIOTERAPI
Gangguan gerak dan fungsi berkaitan dengan kelemahan otot, gangguan pernafasan,
tighness dan kontraktur karena DMP

IV. PERENCANAAN PROGRAM

 Jangka Pendek : fungsi fisiologis otot terjaga, kapasitas fungsi paru terjaga, tighness
berkurang / hilang, ROM bertambah/terjaga
 Jangka Panjang : Pasien dapat hidup dan bersosialisasi dengan kelainannya ( termasuk
alat bantu ) dan maintanence
INTERVENSI FISIOTERAPI
Metoda aktifitas dan latihan termasuk hydroterapi
 Breathing Exc
 Alat bantu
 Streatching