Late diagnosis in congenital dislocation of the hip

In 1966-1975, congenital dislocation of the hip was diagnosed after the neonatal period in 115 children in Uusimaa county in southern Finland; the incidence was 0.76 per thousand liveborns. No decreasing tendency could be seen during the time of the investigation. In most children, the diagnosis was made during the first medical examination at the child welfare clinic at the average age of 3 months. The number of children diagnosed at walking age seemed to be decreasing. The numbers of boys and bilateral affections were smaller in this group than among cases diagnosed during the neonatal period. Dislocation was suspected in 23 per cent of the children even before the diagnosis was made. The reasons for the delay are given and discussed. In 1981, 66 per cent of the children were symptomless and no radiographic signs could be seen. Sixteen per cent of the children had minor residual signs with no need for follow-up, and in 18 per cent the outcome was still unclear.     

Late diagnosis in congenital dislocation of the hip

In 1966-1975, congenital dislocation of the hip was diagnosed after the neonatal period in 115 children in Uusimaa county in southern Finland; the incidence was 0.76 per thousand liveborns. No decreasing tendency could be seen during the time of the investigation. In most children, the diagnosis was made during the first medical examination at the child welfare clinic at the average age of 3 months. The number of children diagnosed at walking age seemed to be decreasing. The numbers of boys and bilateral affections were smaller in this group than among cases diagnosed during the neonatal period.

Dislocation was suspected in 23 per cent of the children even before the diagnosis was made. The reasons for the delay are given and discussed. In 1981, 66 per cent of the children were symptomless and no radiographic signs could be seen. Sixteen per cent of the children had minor residual signs with no need for follow-up, and in 18 per cent the outcome was still unclear.     

Nonsurgical correction of congenital auricular deformities

Congenital auricular deformities are found in 55.2 per cent of neonates at birth. When the deformities are not hypoplastic, nonsurgical correction is very easy and reliable. Lop ear and Stahl's ear respond well to the nonsurgical correction only during the neonatal period, while protruding ears and cryptotia respond until approximately 6 months of age. We noticed that there are variations in the time period for response to nonsurgical correction in the different types of auricular deformities. We have continually observed the natural changes in 1000 babies' auricular shapes from birth to 1 year of age. Lop ear and Stahl's ear were auricular deformities that appeared in 47 per cent of all newborn babies. Eighty-four per cent of these deformities disappeared spontaneously during the first year of life. They were present in 7 per cent of the 1000 babies at 1 year of age. On the other hand, the percentage of protruding ears increases from 0.4 per cent at birth to 5.5 per cent at 1 year of age. Our observations show that most of the protruding ears are acquired deformities. If a baby is placed in a supine position, the weight of the baby's head will fold the ear forward when the baby turns its head to one side; this is the mechanism presented as the probable cause for the acquired protruding ear.     

Pitfalls of early diagnosis and treatment of congenital dislocation of the hip joint

The efficiency of the routines for early diagnosis and treatment of congenital dislocation of the hip joint (CDH) practiced in the 1960s in the city of G?teborg were reviewed. Between 1961 and 1970 there were 65,875 live births in G?teborg. Eighty-five percent of the estimated number of cases of CDH were diagnosed during the first month of life. Of the children "missed" at the primary screening on the maternity wards, 75% (15/20) were premature babies and/or had been delivered during weekends. In all, 475 newborn children were judged to have unstable hips (dislocated or dislocatable hips), corresponding to an incidence of 7.2 per thousand live births. In 19 children, abduction treatment with braces commenced during the first 10 days of life failed to prevent dislocation. Eighteen of these children were treated primarily with a Frejka pillow and one with a von Rosen splint. A history of CDH among relatives was obtained in 47% of these 19 children including four of five children who had developed pathological hips after supplementary treatment with a hip spica cast and/or surgery. Radiological examination at the age of 1-4 months was helpful in revealing failure of early abduction treatment to prevent dislocation, which in most cases was difficult to detect by clinical examination at this early age.     

Correlation of fetal posture and congenital dislocation of the hip

A statistical study was carried out on the incidence of CDH associated with mechanical factors in the uterus, including congenital genu recurvatum. There were 72 cases of CDH among 6559 infants (1.1 per cent). The incidence of CDH was 0.7 per cent in cephalic presentation, 2 per cent in footling presentation and 20 per cent in single-breech presentation. In another series, CDH was found in six of seven infants with congenital genu recurvatum. These findings suggest that a fetal posture with the hip flexed and the knee extended predisposes to the development of CDH.     

Congenital dislocation of the knee

Congenital dislocations of the knee (CDK) are rare, occurring 40-80 times more rarely than congenital dislocation of the hip (CDH). In a multicentric study of the European Paediatric Orthopaedic Society, 56 cases of CDK were found in 46 babies. Many other malformations associated with CDK were noticed, and muscular abnormality was always found at the knee. According to the classification of Leveuf, three grades have to be considered: grade 3, or complete dislocation, was the most frequent. At birth, treatment consisted of physiotherapy with rigid splint. Twenty-four patients with CDK have been treated only by the conservative technique. Operations were performed according to the abnormalities of the extensor apparatus: a progressive release and lengthening of the quadricipital tendon was necessary in all cases. In all forms of treatment, the range of the knee flexion was 120 degrees. Only two children had a bad result because of unstable knees. Results were always better with conservative treatment.     

Congenital dislocation of the hip in Western Australia. A comparison of neonatally and postneonatally diagnosed cases

Speculation that neonatally diagnosed congenital dislocation of the hip (CDH) may have a different etiology from cases diagnosed in the postneonatal period has not been examined in Australia because insufficient data have been available. A population-based study of CDH in children up to the age of two years who were born in Western Australia (WA) in 1981, 1982, or 1983 is the subject of this report. Study material comprised cases of CDH from the WA Congenital Malformations Register and denominator data (all births in WA for 1981-1983) from the Health Department of WA. From this material, rates of CDH were calculated for each of the study variables of interest. The rate of CDH was low for babies born to aboriginal mothers, and it is postulated that this may have a cultural basis, possibly in infant carrying postures. Overall, the prevalence of CDH for 1981-1983 was 6.4 cases per 1000 births, with 4.2/1000 diagnosed in the neonatal period and 2.2/1000 in the postneonatal period. Epidemiologic differences were noted between infants diagnosed in the neonatal period and those diagnosed postneonatally; rates of neonatally diagnosed CDH were higher in first births, breech presentation, and postmature infants than were rates of postneonatally diagnosed cases. Bilateral dislocation was more common (45.3%) in neonatally diagnosed cases than in postneonatally diagnosed cases (23.3%). These findings tended to support the idea that the time of diagnosis may define two distinct entities in CDH.     

Twenty years of progress in congenital diaphragmatic hernia at the University of Florida

Over the past 20 years the clinical paradigms underlying the care of children with congenital diaphragmatic hernia (CDH) have undergone profound changes. The purpose of this work is to provide an historic review of research and clinical studies related to CDH at the University of Florida (UF) and Shands Children's Hospital during the chairmanship of Edward M. Copeland, III, M.D. and to present our current clinical results. During Dr Copeland's tenure survival for newborns symptomatic with CDH treated at UF/Shands Children's Hospital has improved from less than 20 per cent to 85 per cent. Clinical observations have suggested and research studies at UF using a fetal lamb model have confirmed that fetal distress can occur late in gestation, which may predispose infants with CDH to pulmonary hypertension. However, our patient experience has confirmed that the most significant cause of mortality in human infants is not pulmonary hypertension but iatrogenic injury to their hypoplastic lungs. Strict avoidance of barotrauma in these babies has been the most important clinical advance during these two decades. Significant clinical and research problems remain including defining optimal prenatal care, management of complications during the first few weeks of life, and development of strategies to accelerate lung growth. Dramatic improvements in survival have resulted in children who manifest a number of clinical problems that were not evident when most of these patients died early in infancy. Our experience at Shand's Children's Hospital/UF indicates that feeding problems, respiratory infections, and management of subtle or overt neurologic complications may become major issues for some of these survivors and their families.     

Pitfalls of early diagnosis and treatment of congenital dislocation of the hip joint

Summary The efficiency of the routines for early diagnosis and treatment of congenital dislocation of the hip joint (CDH) practiced in the 1960s in the city of Göteborg were reviewed. Between 1961 and 1970 there were 65 875 live births in Göteborg. Eighty-five percent of the estimated number of cases of CDH were diagnosed during the first month of life. Of the children missed at the primary screening on the maternity wards, 75% (15/20) were premature babies and/or had been delivered during weekends. In all, 475 newborn children were judged to have unstable hips (dislocated or dislocatable hips), corresponding to an incidence of 7.2 per thousand live births. In 19 children, abduction treatment with braces commenced during the first 10 days of life failed to prevent dislocation. Eighteen of these children were treated primarily with a Frejka pillow and one with a von Rosen splint. A history of CDH among relatives was obtained in 47% of these 19 children including four of five children who had developed pathological hips after supplementary treatment with a hip spica cast and/or surgery. Radiological examination at the age of 1–4 months was helpful in revealing failure of early abduction treatment to prevent dislocation, which in most cases was difficult to detect by clinical examination at this early age.     

Unsattsfa Ctory Results of Early Treatment of Infants with Unstable Hips at Birth

Among 19,864 infants born in Trondheim between 1 May 1969 and 31 December 1974 instability of the hip joint was diagnosed in 378 (19.03 per thousand live-born). All infants were treated with a Frejka cushion splint, usually for 3 months. In spite of this early treatment, 31 infants (8.2 per cent) developed subsequent signs of CDH. In 20 children the diagnosis of CDH was based solely on radiological criteria, while 11 children also displayed clinical abnormalities, mast often restricted abduction of the hip joint. The prenatal and perinatal condition of the 31 children, with persistent signs of CDH in spite of early treatment, was compared with that of the 347 children who showed no obvious signs of CDH. The former group of patients had a relatively high frequency of hip abnormalities in their families, and an increased frequency of breech presentation at birth, concomitant foot deformities and instability of the hip joint also on the eighth day after birth. It is suggested that infants with unsatisfactory results from the early treatment of unstable hips constitute a separate clinical entity and an especially severe form of CDH.     

Unsatisfactory results of early treatment of infants with unstable hips at birth

Among 19,864 infants born in Trondheim between 1 May 1969 and 31 December 1974 instability of the hip joint was diagnosed in 378 (19.03 per thousand live-born). All infants were treated with Frejka cushion splint, usually for 3 months. In spite of this early treatment, 31 infants (8.2 per cent) developed subsequent signs of CDH. In 20 children the diagnosis of CDH was based solely on radiological criteria, while 11 children also displayed clinical abnormalities, most often restricted abduction of the hip joint. The prenatal and perinatal condition of the 31 children, with persistent signs of CDH in spite of early treatment, was compared with that of the 347 children who showed no obvious signs of CDH. The former group of patients had a relatively high frequency of hip abnormalities in their families, and an increased frequency of breech presentation at birth, concomitant foot deformities and instability of the hip joint also on the eight day after birth. It is suggested that infants with unsatisfactory results from the early treatment of unstable hips constitute a separate clinical entity and an especially severe form of CDH.     

Late diagnosed congenital dislocation of the hip

During the years 1975 to 1979, 82 574 children from five counties in southeast Norway were live-born, 197 of whom were treated for late detected CDH. for an incidence of 2.4 per 1 000 live births, i.e., 0.4 promille dislocation. 0.6 promille subluxation, and 1.4 promille dysplasia of the acetabulum without dislocation. All the hips had been found stable at birth. Eighty-six percent were girls, and the left hip was affected in 48 percent, the right hip in 31 perent, and both hips in 21 percent. Only 6.5 percent were delivered in the breech position. This and the stability found neonatally may indicate an etiologic difference between neonatally and late diagnosed CDH.     

Late diagnosed congenital dislocation of the hip

During the years 1975 to 1979, 82,574 children from five counties in southeast Norway were live-born, 197 of whom were treated for late detected CDH, for an incidence of 2.4 per 1,000 live births, i.e., 0.4 promille dislocation, 0.6 promille subluxation, and 1.4 promille dysplasia of the acetabulum without dislocation. All the hips had been found stable at birth. Eighty-six percent were girls, and the left hip was affected in 48 percent, the right hip in 31 perent, and both hips in 21 percent. Only 6.5 percent were delivered in the breech position. This and the stability found neonatally may indicate an etiologic difference between neonatally and late diagnosed CDH.     

Ultrasound and neonatal hip screening. A prospective study of 'high risk' babies

We describe a simple, quick ultrasound screening test for CDH, and its use in a prospective study of babies with a 'high risk' factor, over one year from January 1987. From a birth population of 3,879, 812 hip scans were performed on 406 babies and 98 babies were abnormal. So far, there have been no late cases of CDH. Family history, breech malposition, and postural foot deformities were confirmed to be important risk factors, but babies with a simple click were equally at risk. Our early results indicate that a large proportion of the potential late cases are contained within our extended high-risk group.     

Prenatal diagnosis and natural history of the fetus with a congenital diaphragmatic hernia: initial clinical experience

To study the accuracy of prenatal diagnosis and define the natural history of fetal congenital diaphragmatic hernia (CDH), we reviewed experience with CDH at The University of California, San Francisco (UCSF) over the last three years. All nine babies born in our institution (inborns) and six of 11 babies referred from other hospitals after birth (outborns) died, an overall mortality of 75%. All had pulmonary hypoplasia. Forty percent had associated malformations or chromosomal abnormalities, a higher incidence than generally reported. Prenatal sonograms were available in all nine inborn cases. CDH was correctly diagnosed prospectively in only five, but could be recognized retrospectively in all nine cases using the sonographic criteria developed from the study. Polyhydramnios was present in all nine cases; in seven cases sonography was performed because the woman was large-for-dates clinically. There were no false positive interpretations, and when necessary the diagnosis was confirmed by amniography. All nine cases of CDH detected in utero died. Seven deteriorated so rapidly that surgical repair could not even be attempted. Two who had optimal care (maternal transport, immediate resuscitation and operation) died after repair despite maximal intensive care including vasodilator therapy. Despite the theoretical advantages of maternal transport to pediatric surgical specialty centers, a majority of fetuses with a prenatal diagnosis of CDH will die because their lungs are inadequate to support extra-uterine life even at term.     

Teratologic congenital dislocation of the hip. Report of two cases

The incidence of teratologic dislocation of the hip is about 0.04 per thousand. Teratologic CDH is usually described together with other anomalies, such as arthrogryposis. Quite different opinions about the diagnostic criteria are found in the literature; some of these are reviewed in this report. Two cases of teratologic CDH with no other anomalies are also reported. Computer tomography was used to confirm reduction in plaster when conventional radiologic examination gave ambiguous results.     

Prevention of congenital dislocation of the hip in the newborn

Routine examination and early treatment of any instability in the hips of newborns has recently been called into question after a period of universal agreement. The hips of 49,937 neonates were prospectively studied by a general hip screening. Every unstable hip--449 in 317 children--was immediately treated with a Von Rosen splint for a 3-month-period. Overall, satisfactory reduction of the incidence of established congenital dislocation of the hip (CDH) was achieved. Risk factors leading to unstable hips (sex, first birth, and breech birth) and the development of CDH (time of stabilization) were considered.     

Screening of children with congenital dislocation of the hip joint on the maternity wards in Sweden

In Sweden screening for congenital dislocation of the hip joint (CDH) on the maternity wards was commenced in the 1950s. Of the estimated number of cases with CDH approximately 50% are diagnosed on the maternity wards and 80% during the first 6 months of life. Of the children "missed" at the primary screening on the maternity wards a substantial number have been premature babies treated at the intensive care unit postpartum. X-ray examination at the age of 1.5-3 months has been a helpful tool to reveal failure of early abduction treatment, which has been difficult to detect by clinical examination. Children with neonatal hip instability and a family history of CDH seem to represent a subgroup with an increased risk of failure of primary treatment and may need prolonged abduction treatment. The von Rosen splint has proved to be a reliable brace if used properly. If abduction treatment is commenced already during the first few days of life the risk for avascular necrosis is very low--1%.     

No beneficial effects of joint distraction on early microscopical changes in osteoarthrotic knees

The rate of post-operative dislocation after primary total hip arthroplasty in 1739 cases was 3.3 per cent; 0.9 per cent being classified as recurrent dislocations. Malposition of the socket, limb shortening or any other single technical factors could not be demonstrated to be responsible for post-operative dislocation of the hip. A previous osteotomy predisposed for dislocation, but in no case was this dislocation classified as recurrent. Cases with a previous cervical-femoral fracture were significantly more commonly dislocated compared with coxarthrosis cases. This fact probably could be explained by a high rate of alcoholism in men and old age in women.     

A sonographic study of the morphology of the preterm neonatal hip

Preterm and low-birth-weight infants are reported to have an increased risk of late presentation of congenital dislocation of the hip (CDH). A sequential sonographic study of hip morphology was made of 82 live preterm infants. Eighty-two matched, term controls were scanned for comparison. The morphology of the hips was similar at birth. The increase in missed CDH cannot be explained in simple morphological terms. Abnormal birth sonograms resolved rapidly in the absence of clinical instability, casting doubt on the role of static sonographic appearances to predict the need for treatment in the immediate newborn period.