How Common Is Developmental Dysplasia of the Hip in Infants With Breech Presentation?

Patient Presentation
A 1-week-old female came to clinic for her health supervision visit. Breastfeeding was going well and mild clinical jaundice had resolved. The past medical history showed a full-term female with no prenatal risk factors who had been born by Cesarean section for breech presentation. The family history was negative for orthopaedic issues.

The pertinent physical exam showed an alert infant. Her weight was 3.26 kg (50%), length of 48% (50%) and head circumference of 35 cm (90%). Her examination was notable for erythema toxicum neonatorum on her cheeks and a normal hip examination. The diagnosis of a healthy female was made and routine parent education was given. The physician did schedule a screening hip ultrasound because of the breech delivery. The patient’s clinical course at 1 month found her to be in good health with growth parameters consistent with birth. The radiologic evaluation of a hip ultrasound showed developmental dysplasia of the left hip. The patient was sent to Orthopaedics who placed her in a Pavlik harness. At her 2 month check up she was doing well with only minimal intermittent skin irritation from the harness.

Case Image

Figure 115 – Coronal views from a hip ultrasound exam show a normal right hip (above) with the right femoral head well centered in the right acetabulum and a dysplastic left hip (below) with the left femoral head displaced laterally out of the shallow left acetabulum.

Discussion
Developmental dysplasia of the hip (DDH) includes several abnormalities where the femoral head and the acetabulum are not aligned normally or grow abnormally. This includes hips that are dislocatable, dislocated, dysplastic and subluxed. The natural history and pathophysiology are poorly understood.

Screening can lead to earlier identification, but there are high rates of spontaneous resolution in the newborn period that require no intervention. Resolution rates are 60-80% if identified by physical examination and 90% resolve if identified by ultrasound examination in studies. Physical examination screening includes the Barlow and Ortolani examinations. Barlow examination is the adducting of a flexed hip with posterior force to identify a dislocatable hip. Ortolani examination is the abducting of a flexed hip with anterior force to relocate a dislocated hip. Some people remember Barlow is “back” (gentle force to push the femoral head backward) and Ortolani is “out” (the femoral head is out of place and is realigned with the gentle anterior force). These maneuvers can be difficult to perform in a manner that provides consistent accuracy. A review of other physical examination signs can be found here.

Ultrasound examination is another screening and diagnostic technique. In some studies ultrasound has a high false-positive rates which could lead to unnecessary treatment and followup. It is felt that this is due to operator dependence. In other studies ultrasound has high rates of intraobserver and inter-observer reliability. Screening recommendations differ by different professional groups and can be found at the National Guideline Clearinghouse link in the To Learn More section below.

DDH treatment includes abduction devices such as the most commonly used Pavlik harness or less commonly a hip spica cast. Surgical procedures which are even less common involve reduction of the femoral head into the acetabulum and potentially other procedures on the acetabulum, femur or hip adductor tendons. If DDH is left untreated problems such as pain, osteoarthritis, leg length discrepancies, and gait abnormalities may occur. Even if treated there still exists the possibility of hip deformity and osteoarthritis in later life.

Learning Point
DDH incidence is between 1.5-20 per 1000 births. Of patients identified with DDH only 10-27% have risk factors for DDH other than female gender. Risk factors include:

  • *Breech delivery
  • *Family history of DDH
  • *Female gender
  • Congenital anomalies
  • Interuterine postural deformities
  • Oligohydramnios
  • Primiparity
  • High birth weight

*These are the most consistent risk factors for DDH.

Risks for clinical hip instability or DDH are:

  • Breech females – 84 per 1000
  • Family history positive females – 24 per 1000
  • Breech males – 18 per 1000
  • Females without risk factors – 14 per 1000
  • Males without risk factors – 3 per 1000

Questions for Further Discussion
1. What is the Graf classification?
2. What are indications for surgical intervention for DDH?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Hips Injuries and Disorders
and at Pediatric Common Questions, Quick Answers for this topic: Developmental Dysplasia of the Hips

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Lehmann HP, Hinton R, Morello P, Santoli J. Developmental dysplasia of the hip practice guideline: technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics. 2000 Apr;105(4):E57.

Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for Developmental Dysplasia of the Hip: A Systematic Literature Review for the US Preventive Services Task Force. Pediatrics 2006;117;e557

US Preventive Services Task Force. Screening for Developmental Dysplasia of the Hip: Recommendation Statement. Pediatrics. 2006:117(3); 898 -902.

Mahan ST, Kasser JR. Does Swaddling Influence Developmental Dysplasia of the Hip? Pediatrics. 2008;121(1);177-178.

Fox AE, Paton RW. The relationship between mode of delivery and developmental dysplasia of the hip in breech infants: a four-year prospective cohort study. J Bone Joint Surg Br. 2010 Dec;92(12):1695-9.

American Academy of Orthopaedic Surgeons. Developmental Dislocation (Dysplasia) of the Hip (DDH). Developmental Dislocation (Dysplasia) of the Hip (DDH)
Available from the Internet at http://orthoinfo.aaos.org/topic.cfm?topic=a00347 (rev. 10/13, cited 6/17/14).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Causes Proteinuria?

    Patient Presentation
    A 16-year-old female came to clinic because of 2 days of dysuria. She was having some increased frequency and also pain with urination. She wasn’t sure if the pain began with the bladder contracting or when her urine stream touched her genital area. She denied fever, chills, nausea, emesis, constipation or pain with defecation. She also denied previous bladder infections or sexual activity. The family history was negative for renal disease or hearing problems. The social history showed her to be a cross-country runner who had increased her mileage the past week by almost 50%. The review of systems was negative.

    The pertinent physical exam showed a healthy female with no distress. Her blood pressure was 106/62, pulse of 68 and respiratory rate of 16. She was afebrile and her growth parameters showed a weight of 25%, and height of 75%, consistent with previous measurements. Her abdomen examination was negative including no suprapubic or costovertebral angle tenderness. Genitourinary examination revealed diffuse erythema of the vaginal area and perineum.

    The diagnosis of skin irritation due to contact with sweat and clothing friction was made. The patient was advised to change into clean clothing often, not tuck her shirt into her pants to help keep moisture away from the genital area and to use sports lubrication products to decrease the friction from her clothing. Because a bladder infection could not be fully ruled-out a laboratory evaluation of a urine dip was done and showed a specific gravity of 1.015, 2+ protein and negative leukocyte esterase and blood. Because of the protein, the physician reviewed her chart more closely and saw normal blood pressure readings and also a BUN and creatinine that were normal during an emergency room visit for head trauma The physician thought that the proteinuria was most likely due to the increase in exercise. The patient’s clinical course over the next few weeks found none to 1+ protein in the urine, and which resolved after the cross-country season finished.

    Discussion
    Proteinuria occurs relatively often in pediatric practice with 5-15% of school children having transient proteinuria, the most common cause. However, proteinuria can be a sign of kidney disease. Therefore, it is important to evaluate the proteinuria in light of the clinical situation. A good history and physical examination along with a full urinalysis and/or BUN and creatinine, or urine protein/creatinine ratio may be all that is necessary. Another patient with edema, hypertension or hematuria needs a fuller evaluation and treatment. Proteinuria is usually categorized into three groups to assist with evaluation and treatment and they include: transient, orthostatic or persistent.

    Transient means just that. It occurs only during the inciting problem and remits afterwards. It generally is < 2+ on a dipstick. Proteinuria due to fevers usually resolves in 10-14 days, and exercise induced proteinuria remits within 48 hours of the exercise.

    Orthostatic (postural) proteinuria is proteinuria that occurs in the upright position only. It can be intermittent or persistent. It is the most common cause of asymptomatic proteinuria in children especially adolescents. Protein excretion in the recumbent position is < 4 mg/m2/hr and in the upright or ambulatory position is 2-4 times this amount.

    Persistent asymptomatic isolated proteinuria occurs in children and laboratory and clinical testing is otherwise normal. The protein is monitored every 6-12 months and if protein is rising then renal biopsy may be indicated. Glomerular diseases all have proteinuria. One of the most common in children is nephrotic syndrome due to minimal change disease. Nephrotic syndrome has the following characteristics: proteinuria, hypoalbuminemia, hypercholesterolemia and edema.

    An urine dipstick is often used to interpret proteinuria. The amounts of protein are shown here:

    Trace = 10-20 mg/dL
    1+ = 30 mg/dL
    2+ = 100 mg/dL
    3+ = 300 mg/dL
    4+ = 1000-2000 mg/dL

    “A urine sample is positive for protein if the dipstick is [> or =] 1+ on a urine sample with a specific gravity of [ 1.015, the dipstick must be [> or =] 2+ to be considered positive.”

    Learning Point
    The differential diagnosis of proteinuria includes:

    • Transient proteinuria
      • Cold exposure
      • Congestive heart failure
      • Epinephrine administration
      • Exercise
      • Fever
      • Seizures
      • Serum sickness
    • Orthostatic
    • Persistent asymptomatic isolated proteinuria
      • Glomerular disease
        • Nephrotic syndrome, minimal change
        • Alport syndrome
        • Glomerulonephritis
          • Membranoproliferative
          • Post-infectious
        • Henoch-Schonlein purpura
        • HIV-associated nephropathy
        • IgA nephropathy
        • Sickle cell anemia
        • Systemic lupus erythematosus, nephritis
        • Vasculitis
      • Tubulointerstitial disease
        • Fanconi anemia
          • Dent’s disease
        • Interstitial nephritis
        • Ischemia
        • Reflux nephropathy
        • Renal dys- or hypoplasia
        • Medications
          • Aminoglycosides
          • Lithium
          • Penicillin

    Questions for Further Discussion
    1. What are indications for renal biopsy with proteinuria?
    2. What are causes of falsely-positive proteinuria on dipstick?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Urine and Urination and Kidney Diseases.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Ariceta G. Clinical practice: Proteinuria. Eur J Pediatr. 2011 Jan;170(1):15-20.

    Hladunewich MA, Schaefer F. Proteinuria in special populations: pregnant women and children. Adv Chronic Kidney Dis. 2011 Jul;18(4):267-72.

    Kaplan BS, Pradhan M. Urinalysis interpretation for pediatricians. Pediatr Ann. 2013 Mar;42(3):45-51.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Causes Abdominal Distention?

    Patient Presentation
    A 10-year-old male came to the emergency room with a several day history of abdominal distension and generalized abdominal pain. The patient and family could provide few details but the pain was located periumbilically, occurred only during the day and would come and go. He occasionally felt nauseous but had no emesis. He denied any fever, chills, upper respiratory illnesses or urinary symptoms. He was unsure when his last bowel movement was. He had a history of constipation where his bowel movements were large enough to block up the toilet. He said that this didn’t feel like the pain he had with his appendicitis 1 year previously. The past medical history was positive for being underimmunized and having an appendectomy 1 year previously. The social history revealed financial difficulties. The mother also had a lower intellect with some difficulties with daily activities.

    The pertinent physical exam showed a well-appearing male with normal vital signs. His weight was 10% and height was 75%. His abdomen was moderately distended. He had normal bowel sounds in all quadrants. Palpation found no fluid wave or organomegaly. He had palpable loops of bowel from the left lower quadrant that followed the colon upwards and into the right abdomen. Palpation of the colonic loops reproduced the main. He denied costovertebral angle or suprapubic tenderness. There was no guarding or rebound. Genitourinary examination was normal and on the rectal examination he had a large rectal vault with stool that was guaiac negative. The diagnosis of constipation was made, but because of the recent abdominal surgery a radiograph was taken. The radiologic evaluation showed stool throughout the colon with no air fluid levels, confirming the diagnosis. The patient was given an enema in the emergency room with some production of stool. The social worker in the emergency room helped to get polyethylene glycol (MiralaxTM) from the hospital pharmacy to take home. She also helped them make an appointment in a local clinic for constipation followup and well child care. The mother refused help with transportation to the appointment, but was willing to have the social worker contact the clinic social worker who might be able to help with the family’s social needs.

    Case Image

    Figure 114 – Supine view of the abdomen demonstrates a moderate amount of stool throughout the colon from the cecum to the rectum.

    Discussion
    Constipation generally is defined as infrequent or painful defecation. It often is due to passing large hard stool infrequently which causes painful defecation and then withholding behaviors. As stool withholding continues, the rectum dilates and gradually accommodates with the normal defecation urge disappearing. Chronic rectal distension results in both loss of rectal sensitivity, and loss of urge to defecate, which can lead to encopresis. Abdominal distention because of stool retention occurs frequently. Treatment includes colonic evacuation, establishing regular bowel habits, eating a balanced diet with dietary fiber and laxatives to keep the stool soft and help promote the normal motility patterns. MiraLax is polyethylene glycol, an osmotic laxative often used to help with bowel evacuation and as a maintenance medication. The dose when used as a maintenance medication is 0.5 -1 gram/kg/day divided BID. The dose can be titrated to have one soft stool per day. The differential diagnosis of constipation can be reviewed here.

    Abdominal distention is caused by some type of abdominal obstruction or space-occupying lesion that blocks or impinges on the intestinal lumen. This leads to failure of the intestinal contents to pass through the intestinal tract. Proximal to the obstruction is swallowed air and abdominal contents and secretions. The abdominal contents cannot move distal to the obstruction causing no flatus and bowel movements. If the obstruction is high in the gastrointestinal tract (generally proximal to the jejenum) then emesis is common and there will be little abdominal distention because there is no air and contents moving further into the distal tract. If the obstruction is low, then there is more of a reservoir to hold the accumulated material causing abdominal distention. Emesis is less common with distal obstructions. Fluid loss and electrolyte abnormalities secondary to emesis, dehydration, intestinal stasis, and bowel edema all can lead to bacterial invasion into the bowel wall. This accompanied with increasing intraluminal pressures can cause abnormal intestinal tract vascular flow, ischemia, necrosis and perforation of the viscous.

    Abdominal pain often, but not always, accompanies abdominal distention. The causes of abdominal pain include many others that are considered medical reasons such as abdominal migraine, pelvic inflammatory disease, etc. These can be reviewed here.

    Learning Point
    The differential diagnosis of abdominal distention includes:

    • Anatomical
      • Annular pancreas
      • Antral web
      • Duplications
      • Hirschsprung disease
      • Incarcerated inguinal or umbilical hernia
      • Imperforate anus
      • Jejunal and ileal atresia
      • Meckel diverticulum
      • Persistent cloaca
    • Neonatal
      • Meconium ileus
      • Meconium plug
      • Necrotizing enterocolitis
    • Infectious/Inflammatory
      • Appendicitis
      • Ileus
      • Intussception
      • Perforated viscus
      • Organomegaly
      • Sepsis
    • Other
      • Adhesions
      • Ascites
      • Constipation
      • Colonic pseudoobstruction syndrome
      • Mass/Tumor
      • Trauma with mass, such as hematoma
      • Pregnancy

    The differential diagnosis of proximal gastrointestinal obstructions includes:

    • Bezoar
    • Duodenal atresia
    • Esophageal atresia
    • Malrotation and midgut volvulus
    • Pyloric stenosis
    • Tracheoesophageal fistula

    Questions for Further Discussion
    1. What are the indications for a surgical consultation for abdominal distention?
    2. How is intestinal obstruction evaluated?
    3. How is intestinal ileus treated?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Abdominal Pain and Constipation

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1376-79.

    Jackson PG, Raiji MT. Evaluation and management of intestinal obstruction. Am Fam Physician. 2011 Jan 15;83(2):159-65.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    July 21, 2014