quality education for a healthier scotland multidisciplinary developmental dysplasia of the hip

Quality Education for a Healthier Scotland

Multidisciplinary

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 high

Treatment late cases

Less successful

More surgery

More 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 screening

Possible 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 factors

Clinically abnormal hips should be seen by a specialist


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National Screening Committee (cont.)

Second hip check before 8 weeks

Personal Child Health Record lists signs and symptoms suggesting DDH

If 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 DDH

Abnormalities of the lower limbs, e.g. clubfoot

Torticollis


MultidisciplinaryLook

Point 2 - Leg length difference

Hips and knees flexed

Check level of knees – should be level

If 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 abduction

Point 5 - Tests of stability

Barlow

Ortolani

Restricted abduction and asymmetrical groin folds


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Instability tests

In Out

Stable Normal Fixed dislocation

Unstable Barlow + Ortolani +


MultidisciplinaryResting position

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


MultidisciplinaryClinical tests

Barlow test

Abnormal if femur moves Backwards relative to the fixed pelvis

Test for a located but dislocatable hip


MultidisciplinaryClinical tests 2

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


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


MultidisciplinaryBaby Hippy

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


MultidisciplinaryClinical examination “24-hour check”

Five points:

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

BarlowOrtolani

Questions?


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?


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


MultidisciplinaryMissed?

•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

Options

Universal screening

Screening of high risk babies


MultidisciplinaryUniversal U/Sscreening

• 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 unreliable

Very important in older children for diagnosis and monitoring of treatment

Dislocation age 15 months.


MultidisciplinaryLate signs of DDH

Asymmetric abduction

Leg length discrepancy

DDH must be excluded


MultidisciplinaryTreatment

Abduction splint – Pavlik, von Rosen

Monitoring for hip development and complications


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How not to examine a baby’s hips!


MultidisciplinaryThank you.

Any questions?


MultidisciplinarySummary

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

quality education for a healthier scotland multidisciplinary developmental dysplasia of the hip

Documents

quality education

dislocatable hip slide

normal hip slide

gentle slide

specialist slide

early adulthood slide

hip screening

clubfoot torticollis