Characteristics of children with hip displacement in cerebral palsy

Abstract

Background: Hip dislocation in children with cerebral palsy (CP) is a common and severe problem. The dislocation can be avoided, by screening and preventive treatment of children with hips at risk. The aim of this study was to analyse the characteristics of children with CP who develop hip displacement, in order to optimise a hip surveillance programme.

Methods: In a total population of children with CP a standardised clinical and radiological follow-up of the hips was carried out as a part of a hip prevention programme. The present study is based on 212 children followed until 9-16 years of age.

Results: Of the 212 children, 38 (18%) developed displacement with Migration Percentage (MP) >40% and further 19 (9%) MP between 33 and 39%. Mean age at first registration of hip displacement was 4 years, but some hips showed MP > 40% already at two years of age. The passive range of hip motion at the time of first registration of hip displacement did not differ significantly from the findings in hips without displacement. The risk of hip displacement varied according to CP-subtype, from 0% in children with pure ataxia to 79% in children with spastic tetraplegia. The risk of displacement (MP > 40%) was directly related to the level of gross motor function, classified according to the gross motor function classification system, GMFCS, from 0% in children in GMFCS level I to 64% in GMFCS level V.

Conclusion: Hip displacement in CP often occurs already at 2-3 years of age. Range of motion is a poor indicator of hips at risk. Thus early identification and early radiographic examination of children at risk is of great importance. The risk of hip displacement varies according to both CP-subtype and GMFCS. It is sometimes not possible to determine subtype before 4 years of age, and at present several definitions and classification systems are used. GMFCS is valid and reliable from 2 years of age, and it is internationally accepted. We recommend a hip surveillance programme for children with CP with radiographic examinations based on the child's age and GMFCS level.

Figure 1

Measurement of Migration Percentage (MP). MP = A/B × 100. On the right hip with a "Gothic arch" formation of the lateral margin, the midpoint of the arch is used as reference point.

Figure 2

Number of children related to age (years) at first registration of MP above 33% (yellow) and 40% (red).

Figure 3

Proportion of children (%) with MP < 33% (green), 33–39% (yellow) and > 40% (red) in relation to subdiagnosis.

Figure 4

Proportion of children (%) with MP < 33% (green), 33–39% (yellow) and > 40% (red) in relation to GMFCS level.