developmental dysplasia of the hip

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Developmental Dysplasia of the Hip

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“Developmental dysplasia of the hip”

Dysplasia Subluxation Dislocated

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The aim of treatment

A normal hip

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Natural history

Hip arthritis in early adulthood

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Early diagnosis

Treatment success highTreatment late cases

Less successfulMore surgeryMore complications

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How common is DDH?

Clinically unstable hips – 1 in 64 babies

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Scottish Needs Assessment Program Report July 1993

Number of late cases not reduced by neonatal screeningPossible increase in number of late presenting cases

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National Screening Committee recommendations

All babies must be screened by clinical examination Ultrasound if clinical abnormality or risk factorsClinically abnormal hips should be seen by a specialist

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National Screening Committee (cont.)

Second hip check before 8 weeksPersonal Child Health Record lists signs and symptoms

suggesting DDHIf DDH suspected, referral to someone with the

appropriate expertise

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Clinical examination “24-hour check”

Five points: History of risk factors Leg length difference Groin/buttock creases Range of abduction Tests of stability

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Point 1 – History of risk factors

Breech presentation Family history of DDHAbnormalities of the lower limbs, e.g. clubfootTorticollis

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Point 2 - Leg length differenceHips and knees flexedCheck level of knees – should be levelIf not level then refer

Point 3 - Labial or groin folds and buttock creases

(Reprinted from Jones: Hip Screening of the Newborn – A Practical Guide, 1998, with permission from Elsevier.)

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Move

Point 4 - Range of abductionPoint 5 - Tests of stability

BarlowOrtolani

Restricted abduction and asymmetrical groin folds

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Instability tests

In Out

Stable Normal Fixed dislocation

Unstable Barlow + Ortolani +

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Test one hip at a timeHip and knee flexedFinger on greater trochanterStabilise pelvisCompare sidesTake your time, be gentle

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MultidisciplinaryClinical tests

Barlow testAbnormal if femur moves Backwards relative to the fixed pelvisTest for a located but dislocatable hip

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Ortolani testPositive if greater trochanter moves forwards as hip locates Hip is Out, but can be reducedTests for a dislocated but reducible hip

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MultidisciplinaryBarlow & Ortolani

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Examining infants hips - can it do harm?

“Over enthusiastic or repeated clinical examination may provoke instability”

Take your time, be gentle

Lowry et al (2005) Archives of Diseases in Childhood 90 (6): 579-81

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Barlow positive Incidence?

• 15 to 20/1000 Barlow positive • Many resolve without treatment • Decision to treat may be delayed• Need careful watching

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Ortolani positive. Incidence?

• 1 to 2/1000 Ortolani positive• Most will need treatment• Some centres splint from birth • Careful follow up

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‘Teratologic' or fixed dislocation

• Dislocated irreducible hip• Dislocation before birth• Association with arthrogryposis or myelomeningocele • Surgery usually required

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‘Life-like’ model of a female newborn Barlow positive hipOrtolani positive hip Expensive and delicate ++

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MultidisciplinaryClinical examination “24-hour check”

Five points:

History of risk factorsLeg length differenceGroin/buttock creasesRange of abductionTests of stability

BarlowOrtolani

Questions?

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MultidisciplinaryThe unstableneonatal hip

• What happens to them?• Hip can become normal• Progress to subluxation • Progress to dislocation• Remain located but remain dysplastic

We cannot tell which will get better on their own - they need watched

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Controversies in DDH

• The natural history not completely understood • Effectiveness of treatment not clear• Screening – Who? How? When?• Why are we still missing so many?

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MultidisciplinaryClinical examination

• Not universally successful• Failed to eliminate late presentations• Dysplasia may not be detectable • Detection improves when performed by a limited number

of experienced examiners

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•Some are missed•Others present late•Importance of 6-week and 36-month checks•Late signs

–Limp–Leg length difference–Restricted abduction

Age 5 years: bilateraldislocations

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Hip screening with ultrasound

OptionsUniversal screeningScreening of high risk babies

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• Difficult to organise• High number of immature hips – rescan• Expensive• ?Cost effective• Conclusion – not proven, although some very impressive

results

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Selective U/Sscreening

• Only high risk and clinically abnormal hips• Consultant radiologists and dedicated sonographer• ? Effectiveness• Manageable

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X-ray examination

X-rays before 4 months of age unreliableVery important in older children for diagnosis and monitoring of treatment

Dislocation age 15 months.

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Asymmetric abduction

Leg length discrepancy

DDH must be excluded

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Abduction splint – Pavlik, von RosenMonitoring for hip development and complications

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MultidisciplinaryHow not to examine a baby’s hips!

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MultidisciplinaryThank you.

Any questions?

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Aim – to reduce incidence of hip arthritis

The Five points of the examination History of risk factors Leg length difference Groin/buttock creases Range of abduction Tests of stability