Patient Presentation
A 5-day-old male came to clinic for follow-up after discharge from the newborn nursery. He was a full-term baby whose mother had prenatal care and had an uneventful pregnancy and normal vaginal delivery.
He was breastfeeding well and his parents had several routine newborn infant questions.
The pertinent physical exam showed an alert, non-dysmorphic male with a weight of 3290 grams (50% – down 130 grams since birth), length of 48 cm (25%), and head circumference of 37 cm (90%).
On his examination he had a dislocatable left hip. The right hip was normal. The rest of his physical examination was normal.
The patient was referred to orthopaedics who confirmed the diagnosis of developmental dysplasia of the hips and placed him in a Pavlik harness to be taken off only when bathing.
The patient’s clinical course showed that at 5 weeks of age, he was re-evaluated and still had a dislocatable hip.
The radiologic evaluation at that time showed the left hip to be fairly well located when the patient wore the harness but there was still dysplasia of the left hip. It was decided to keep him in the harness constantly for the next 2 weeks and to re-evaluate him.
At 7 weeks of age, his hip was stable but repeated ultrasound showed continued dysplasia of the left hip. At 3 months of age his hip was completely stable on physical examination and was minimally dysplastic on ultrasound examination also.
The harness was discontinued and at 6 months of age he had a normal examination and was discharged from the orthopaedic service.
Figure 48 – Coronal ultrasound images of the left hip (left-sided image) and right hip (right-sided image) were obtained after 5 weeks of therapy in a Pavlik harness with the patient located in the Pavlik harness during the exam. The coronal view is meant to simulate an anterior-posterior radiograph of the hip. The images show the left hip to still be dysplastic with there still being a shallow acetabulum and decreased alpha angle even though the left hip appears fairly well located in the left acetabulum. The left hip alpha angle measured 45 degrees (normal is usually greater than 60 degrees). The right hip was normal in appearance.
Discussion
Developmental dysplasia of the hip (DDH) is a group of abnormalities regarding the improper alignment and growth of the femoral head and acetabulum.
Without tight alignment of the femoral head and acetabulum, the hip joint may grow abnormally.
It was previously called congenital dysplasia of the hip (CDH)but it has become clear that some children have normal hips at birth but are later found to have dysplasia.
Therefore DDH is the preferred term.
Most patients have no risk factors, but risk factors include female gender, family history of DDH, in utero postural deformities and breech positioning.
DDH can lead to pain, difficulty ambulating and degenerative joint disease including potentially avascular necrosis of the femoral head and growth arrest.
DDH is usually unilateral (75%).
Recently the U.S. Preventive Services Task Force (USPSTF) concluded that there is insufficient evidence to recommend routine screening for DDH to prevent adverse outcomes.
Evidence shows that screening leads to earlier identification of DDH, but that there is a high rate of spontaneous resolution (60 – 80 % of the newborn hips identified by physical examination and > 90% identified as suspicious or abnormal by ultrasonography).
The American Academy of Pediatrics recommends serial physical examination of the hips but not general ultrasound imaging of the hips. It also recommends ultrasound imaging of all female infants born in the breech position or with a family history of DDH and optional imaging of male infants born in the breech position.
As the femoral heads do not ossify until 4-6 months of age, plain radiographs are not useful in newborns. Hip ultrasonography can image the cartilagenous structures of the hip and therefore is the modality of choice for hip imaging in infants < 6 months.
Children are often treated non-surgically with devices that flex and abduct the hips into position. One commonly used method is the Pavlik harness which looks similar to a marionette puppet. The infant has straps around the chest and over the shoulders for support. The infant also has straps on the calves. The chest/shoulder and calve straps are connected by ‘strings’ (usually made out of the same strap-like material) which holds the hips in a flexed and abducted position.
Long-term Pavlik harness treatment results (e.g., nonoperative treatment) show a 95 percent success rate for acetabular dysplasia and subluxation, but the rate decreases to 80% for frank dislocation.
Surgical treatment is used for unsuccessful non-surgical treatment, severe disease or some patients diagnosed late.
Learning Point
Physical examination signs to look for DDH in an infant include:
- Beginning position: Patient lying supine with both hips flexed to 90° and holding flexed knees in the palm of the hands with thumbs along medial aspect of thigh and fingers along lateral aspect of thigh.
- Barlow maneuver – gentle force on the femur posteriorly to try to dislocate the hip posteriorly. If positive, the femoral head can be felt to clunk or slip out of position. Some people remember this maneuver as “Barlow = Back” or pushing the femoral head back.
- Ortolani maneuver – gentle abduction and lifting of the femur. If positive, the femoral head can be felt to clunk or slip over the posterior rim of the acetabulum back into position. Some people remember the maneuver as “Ortolani = Out” or replacing the “out” femoral head.
- Other physical examination signs that may indicate a possible DDH are:
- Galeazzi or Allis sign – heights of the knees are uneven when bilateral hips and knees are flexed with the feet flat on the table. The shorter side is the affected side because the shorter femoral segment.
- Posterior leg creases – the creases of the buttocks, femur and knees are assymmetric because of the shorter femoral segment on one side.
Older children can present with gait abnormalities and decreased hip abduction.
Questions for Further Discussion
1. What surgical operations are performed for DDH?
2. What congenital syndromes are associated with DDH?
Related Cases
- Disease
- Developmental Dysplasia of the Hip
Hip Injuries and Disorders
- Symptom/Presentation
- Specialty
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
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.
Mier RJ, Brower TD. Pediatric Orthopedics A Guide for the Primary Care Physician. Plenum Publishing Co. New York, NY. 1994;21-25.
American Academy of Pediatrics. Clinical practice guideline: early detection of developmental dysplasia of the hip. Pediatrics. 2000;105:896-905. Available from the Internet at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/4/896(rev. 4/2000, cited 3/5/07).
U.S. Preventive Services Task Force Recommendation Statement. Screening for Developmental Dysplasia of the Hip. Available from the Internet at http://www.ahrq.gov/clinic/uspstf06/hipdysp/hipdysrs.htm (rev. 3/2006, cited 3/5/07)
Storer SK, Skaggs DL. Developmental dysplasia of the hip. Am Fam Physician. 2006 Oct 15;74(8):1284-5.
ACGME Competencies Highlighted by Case
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.
7. All medical and invasive procedures considered essential for the area of practice are competency 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.
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.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
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
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Date
April 16, 2007
Pediatric Education 