Trendelenburg is a medical sign and indicates gluteal or hip abductor weakness. For people who have a weakness of the hip abductor system for any reason (such as congenital dislocation of the hip joint) when standing, if the leg on the healthy side is lifted from the ground, the hip on the healthy side turns downward, and the trunk of the patient deviates to the opposite side. The walking of these people is called Trendelenburg walking. These people frequently bend to the sides while walking.
Clinical Signs of Congenital Dislocation of The Hip Joint
Clinical symptoms in congenital dislocation of the hip joint are different at different ages.
Congenital dislocation of the hip joint at birth to the first 3 months of life
- The presence of additional folds in the groin and their asymmetry, although it may be seen in a normal child with signs of congenital dislocation of the hip joint, at least the presence of any type of additional folds in the groin and their asymmetry should alert the doctor to this He suspected the disease and performed a complete examination in this regard.
- Limitation in the abduction of the hip joint, which is especially noticeable from the first month onwards. Sometimes the mother finds out about this while changing the baby’s clothes and brings the child to the doctor.
- Ortolani Test: We perform this test while the baby is lying on his back, hip, and knee are bent. The doctor takes the lower limb with one hand so that the thumb is on the inner side and the other fingers are on the outer side of the thigh, and with the other hand, he stabilizes the pelvis. Abduction of the hip joint, while the fingers push up from the outside, causes the head to fit into the acetabulum. The feeling of fitting is noticeable to the doctor (click) and sometimes a sound is heard along with it.
In congenital dislocation of the hip joint from 3 months onwards
- Ertolani and Barlow’s tests are usually not positive during this period.
- Limitation of thigh abduction is the most important examination after three months of limitation of thigh abduction.
- Shortness in the lower limb of the affected side: so that if we bend the hip and knee joints, the knees are not aligned and level with each other, this test is known as the Alice test or Galzi test.
- The child’s walking is usually delayed and he limps while walking. In unilateral dislocation of the lower limb, the affected side is short and the child bends the trunk to the affected side when walking (Trendelenburg Gait). In bilateral dislocation, the child bends the trunk to each side while walking, which is called duck-like walking.
- Sometimes the child has a clear lumbar lordosis that attracts attention when standing and walking. This lordosis increase is more obvious in bilateral types.
- In bilateral dislocation of the hip joint, there is no asymmetry of the fold of the rump, but the perineum is wider than usual.
If a healthy person leans on one leg while standing and lifts the other leg off the ground, the contraction of the hip abductor muscles on the side the person is standing on will keep the pelvis in a horizontal position. In congenital dislocation of the hip joint, the abductor muscles of the hip joint become weaker on the side of the dislocation. The reason for this weakness is that in congenital dislocation of the hip joint, the head of the femur is moved up and causes the origin and insertion of the hip abductor muscles to be closer, and therefore the effective arm of the abductor’s muscles is shortened and the muscle loses its effectiveness to a large extent.
Now, if a child with congenital dislocation of the hip joint stands on the leg of the affected side (dislocated hip) and lifts the other leg off the ground, the abductor muscles of the affected side will not be able to keep the pelvis in a horizontal position, and in this case, the pelvis will turn to the side. healthy falls (becomes a Darmi angle) and the child compensates for this defect by transferring the body weight to the affected side and as a result, lends itself to the affected side. This condition is called positive Trendelenburg, so in this test, the hip is deflected towards the healthy hip and the child’s body is deflected toward the affected side. In addition to congenital dislocation of the hip joint, positive Trendelenburg is also evident in paralysis or weakness of the abductor and coxa vara muscles.
The symptoms of bilateral congenital dislocation of the hip joint, unlike unilateral dislocation, are not very obvious and are often diagnosed later. Limitation of hip joint abduction, the wideness of the perineum, duck-like gait, and increased lumbar lordosis are the characteristic symptoms of this type of sprain.
Pathology of congenital hip joint dislocation
Leaving the femoral head out of the acetabulum cavity causes hypoplasia of this cavity, while the anteversion of the femoral neck increases. The joint capsule becomes hypertrophied and thickened, and the muscles around the hip joint, especially the hip adductor and iliopsoas muscles, shorten.
Here it is well known that in the early stages of life when the aforementioned changes have not occurred, the head of the femur can be easily placed in the acetabulum cavity and keep it fixed, while the passage of time makes the dislocation treatment more difficult. The hip joint is congenital.
Etiology of congenital dislocation of the hip joint
Congenital dislocation of the hip joint, which is the most common joint dislocation, is far more common in girls than in boys (9 times). In half of the cases, the complication is seen bilaterally. The cause of congenital dislocation of the hip joint is not well known. Hereditary-racial and climatic factors are effective in its occurrence. Congenital dislocation of the hip joint is more common in certain parts of the world, and the reason is probably related to the way the baby is strapped in the first months of life. In countries such as Iran and Italy, where babies are swaddled, congenital dislocation of the hip joint is much more common than in countries such as China and Indochina, which do not use swaddling.
Being the first child in the family, female gender, white race, breech delivery, and other congenital anomalies such as torticollis and clubfoot are more associated with dysplasia caused by insufficient development of the hip joint. In such children, a careful examination of the newborn is necessary, and even if the examinations of these high-risk babies are normal, they need to undergo an ultrasound to check for congenital dislocation of the hip joint.
Some authors consider insufficient and shallow growth of the acetabular cavity and some joint capsule laxity as a result of the increase of some female sex hormones in the mother’s blood to be the cause of this complication. As long as the fetus is in the mother’s womb. The hip joint is in flexion and the head of the femur is in a fixed position in the acetabular cavity. Swaddling the baby puts the hip joint in extension and adduction after birth, which can cause dislocation of the hip joint in high-risk babies.
trendelenburg sign – treatment
First of all, we remind you once again of the need to diagnose the disease as soon as possible and treat it quickly in the initial stages. Although several babies with unstable joints recover on their own without treatment, nevertheless, all these patients should be treated after diagnosis, because the diagnosis of which child will recover by itself and which one will not. It is not possible.
An unstable hip, which is diagnosed from birth, becomes stable after 8-12 weeks by using the usual splint (about 95 percent) and after re-examination, if it is stable, the splint is put aside. These babies should be re-examined in the following months because a few of these patients may experience dislocation again in the following months.
In cases where the treatment in childhood is not successful, or in cases where the disease is not diagnosed until puberty, patients at the age of 30-40 years old refer for pain caused by pseudoarthrosis or back pain caused by scoliosis or lordosis. These patients should be treated as much as possible with non-surgical treatments (pharmaceutical and physiotherapy treatments) and in case of failure, total hip joint replacement should be performed.
So if have noticed yourself, a friend or a family member who has started to show any positive Trendelenburg Signs, book them in with one of our Physiotherapists or Exercise Physiologists so we can assess and develop a long term management program to not only improve function but improve quality of life.