Developmental dysplasia of the hip (DDH) is an important newborn-related topic with some recent updates. The AAP published an updated clinical report on DDH in Dec for the first time in 16 years. The report highlighted the "primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial."
Materials for this week:
- Case and discussion
- AAP Clinical Report – Evaluation and Referral for Developmental Dysplasia of the Hip 2016
- Developmental Dysplasia of the Hip – Pediatrics in Review article 2012 (see really helpful figures in this article)
- International Hip Dysplasia Institute Videos of Ortolani and Barlow; AAP Section on Orthopedics video showing positive Ortolani and Barlow
- What are the primary risk factors for DDH? Female gender (up to 75% of DDH), family history, and breech presentation. As of the updated guideline, there is now also a risk factor noted for tight swaddling with legs adducted and extended. (Preferred safe swaddling is flexed and abducted hip position).
- Who should we screen for DDH? All children should receive routine clinical evaluation of their hips at each scheduled health supervision visit. Based on consensus (due to the lack of clinical studies), children who have equivocal findings on exam, or increased risk factors for DDH (and normal exam findings) should have imaging.
- What physical exam techniques should be used? Look for asymmetry* of the thigh or gluteal folds or limb length discrepancy (*if hip dysplasia is bilateral, we can't compare sides) while supine with the hips and knees in straight-leg position, and then with the hips and knees in flexed position. Galeazzi sign is unequal knee height when legs are flexed. Then we use Ortolani maneuver- newest guidelines say Ortolani has best predictive value and Barlow may not be necessary and/or harmful if too much pressure is applied. If Barlow is used, it should be gentle pressure applied while adducting the hip after performing Ortolani. The Ortolani and Barlow maneuvers are really most reliable in the first 6 weeks up to 12 weeks, as the hip laxity decreases with time. After that, we use observation of skin folds and hip movement. Limited hip abduction or asymmetric hip abduction after the neonatal period (4 weeks) should be referred.
- What imaging do we use to screen? Ultrasound at age 6 weeks-6 months, or plain xrays at 4-6 months. There are more false positives with early ultrasound and many children with more subtle findings may be watched.
- What constitutes a positive screen? Based on consensus, children who have unstable hips on exam, or abnormal findings on radiographic evaluation, should be referred to an orthopedist. Infants who have only hip clicks do not require further imaging or referral.