Developmental Dysplasia of the

Hip
 This refers to a spectrum of disorders of the hip that may
be present at birth or develop during childhood. The hip
may be completely dislocated with the femoral head
outside of the acetabulum or subluxated with the femoral
head partially outside the acetabulum.

 DDH can lead to premature degenerative joint disease,

impaired walking and pain.
 What is the incidence?

Hip instability can be detected in 1:100 babies;

actual dislocation 1-2:1000 children
DDH is detected in 1 in 5000 infants at 18 months
of age
20% bilateral involvement. When unilateral, left is
3 times more often affected than right because in
normal fetal positioning it is forced into adduction
against the mother’s sacrum.
 Risk Factors

Breech Presentation (Girls 12%; Boys 3%): 7x

higher than non-breech
Females 4 times more common than males
Positive family history: Risk of recurrence in
subsequent children 6% with one affected child;
12% with one affected parent; 36% with affected
parent and child
Crowded intrauterine environment (Oligo, LGA, 1st
born, multiple gestation)
 Clinical Features

Hip instability – Barlow and Ortoloni Test

• Asymmetry Skin Fold Test
 Decreased range of Motion- An infant lying supine
should have hip abduction of >75% and adduction of 30%
past the midline. An infant >3 mo with < 45% abduction
is a sign of DDH.
Dislocation- Klisic test can be used to detect
dislocation, especially after 3 months. Place index
finger on anterior superior iliac spine & the middle
finger on the great trochanter. An imaginary line
between these 2 points should point towards or above
the umbilicus. If dislocated will point below.
Abnormal Gait-
 Bilateral DDH is very difficult to diagnose but may be
evident once a child begins to walk with hyperlordosis,
a waddling Trendelenburg gait, and unilateral toe-
walking.
 How to diagnose DDH
 Physical Exam
*Barlow and Ortoloni Test
*Galeazzi and Skin folds tes
*Decreased ROM (including limited abduction),
abnormal gait
•Ultrasound
*Assesses the morphology and stability of the hip (static
and dynamic imaging) until infant is 3-5 months of age. US
is more accurate after 4 weeks of life. Accurate
interpretation requires training and experience
Radiographs: More valuable after 4-6 months of age
when the ossification center develops in the femoral head.
 Who do you screen or refer for DDH
 Newborn: If positive Ortolani/BarlowRefer to Peds Ortho. Do
not order US. Treatment decisions are not based on US but PE
findings. If soft signs (asymmetry of creases, hip clicks), then re-
exam at 2 weeks.
 2 week: If positive Ortolani/BarlowRefer to Peds Ortho. If
other signs/ suspicion for DDH present then refer to Peds Ortho or
perform US at 1 month. If hips normal continue routine screening
at WCC.
 Breech: AAP recommends all girls should be screened by US at 6
weeks or Radiograph at 4-6 mo (risk 120/1000); Consider screening
all breech boys (risk 26/1000).
 + FHX: Consider screening girls by US at 6 weeks or Radiograph at
4 months (risk 44/1000), boys with family history risk (9.4/1000)
should follow periodic schedule unless positive findings.
 Risk Factors

• Gender (Female)
• Breech position (foot first; Complete breech)
• First born children
• Family history
• Oligohydramnios
 Treatment for DDH
 0-6 months:
 abduction splinting (ie-Pavlik harness, Aberdeen splint,
von Rosen splint). The pavlik harness prevents hip
extension and adduction and permits flexion and
abduction.
 Treatment usually last up to 2-3 weeks; discontinued
after 3 weeks if the dislocated hip is not reduced
Possible Complications:
•Femoral nerve compression
• Brachial plexus palsy
• Knee sublaxation
• Skin breakdown
• Residual acetabular dysplasia
• Avascular necrosis of the femoral head
 6-18 months: Closed or open reduction in OR under
anesthesia is usually necessary for infants 6 months or
older. This is followed by 3-4 months of spica casting
changed at 6 week intervals to maintain hip in position.

 18 months and older: Open reduction in OR under

anesthesia is usually necessary for children 18 months or
older. This is followed by 3-4 months of spica casting
changed at 6 week intervals to maintain hip in position.
Risks for long-term problems such as failure of
treatment, residual dysplasia, and avascular necrosis of
the femoral head are greater the older the patient is at
treatment.
CASE 1:

2 week old baby girl here for her weight check.

Birth hx is significant for breech presentation
necessitating a c/s. No further complications.
PE in newborn nursery was documented as stable
hips. What are important features of your
physical exam today? What follow-up is
important?
 Residents should discuss performing hip
examination at each well child check including
Galeazzi test, range of motion testing (including
abduction), Barlow & Ortolani maneuvers (until
8-12 weeks), evaluating skin folds, & gait (when
weight bearing)
 Musculoskeletal Trauma
Contusion Sprain Strain
• Soft tissue injury
• Injury to ligaments and
produced by blunt force • Injury to muscles or
tendons that surround a
such as a kick or a fall, tendon from overuse,
Definition causing small blood
joint. It is caused by a
overstretching, or
thrusting motion or
vessels to rupture and excessive stress.
hyperextension of a joint
bleed into soft tissues

• Swelling
• Limited joint ROM near • Pain
• Pain
injury • Redness or bruising
• Bruising
Clinical • Bluish discoloration • Limited motion
• Limited ability to move
Manifestation • Swelling & pain • Muscle spasms
joint
• Injured muscle may feel • Swelling
• Hearing/feeling a “pop”
weak & stiff • Muscle weakness
during time of injury
• Rest, ice compression, &
evaluation
• Limb immobilization
• Cryotherapy immediately
w/ rest • NSAIDs
after injury
• Ice compression • Protection
• Exercise
Management • Evaluation for first 24 • Rest
• Elevate affected part 15-
hrs (minor) • Ice compression
25cm above heart level to
• Evaluation for first 48 • Evaluation
help venous & lymphatic
hrs (severe)
drainage until swelling goes
down