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.
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
- 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.
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
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.
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.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
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
Pediatric Education 