What do you do about dislocated hips, scoliosis, and other joint deformities?

According to Bleck, 1984, the most common and serious structural change in children who have severe physical disabilities is dislocation or partial dislocation of the hip. This deformity is seldom present at birth but develops as the child grows older and experiences abnormal muscle pull from spastic muscles, femoral torsion, and the lack of bearing weight on the legs. As one set of muscles pulls the leg in one direction, the corresponding set of muscles fails to balance the pull; then, the femur (thigh bone) moves to a position away from the acetabulum (hip socket) until the femur has no shelf on which to sit.

Bleck noted that some children with cerebral palsy do experience osteoporosis (brittle bones) but it is almost always limited to children who have total body involvement, are dependent on wheelchairs, and spend much of their time lying down. The osteoporosis is overwhelmingly due to lack of weight bearing and proper stress on the bones.

Bleck's study also observed that dislocation of the hip is found almost exclusively in people who have total body involvement and are non-ambulatory. If a child learns to walk by the age of four or five, Bleck concludes, the probability of hip dislocation will be greatly reduced. Children who become household walkers and use assistive devices for partial weight bearing may retain the subluxation (partial dislocation) but they will not have totally dislocated hips. The ability to walk is a major influence on hip dislocation. Generally speaking, a person who has the combination of a flexion contracture of the hip due to iliopsoas spasticity and femoral torsion will have hips that dislocate if the person is non-ambulatory and spends the majority of time sitting or lying down. On the other hand, a person who is partially weight bearing is likely to have subluxation of the hips and a person who is fully weight bearing will have normally located hips.

Scrutton, 1984, adds that scoliosis is usually secondary to pelvic asymmetry. If one hip dislocates, the child does not have an even foundation for sitting and it is impossible to align the trunk over the hips. If the child attempts to align the trunk over the hips, the spine must compensate for the uneven foundation and curvature results. Pelvic symmetry seems to be important in preventing scoliosis. The factors important to preventing hip dislocation and thus pelvic asymmetry, are abduction (separating the legs), external rotation of the legs (keeping the knees from turning inward), and early weight bearing.

In summary, the best way to prevent hip dislocation, pelvic asymmetry, scoliosis, and brittle bones is to provide the child with many opportunities to bear weight on the legs in an aligned position. One orthopaedic surgeon recommended aligned weight bearing for all non-ambulatory students regardless of hip formation UNLESS pain is present. If the student is experiencing any pain or discomfort, surgery may be the only alternative.