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Primary care management and referral guideline Primary care management and referral guideline

Developmental Dysplasia of the Hip (DDH) – Management and referral guideline

Purpose

Primary care management and referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.

Introduction

  • Developmental dysplasia of the hip (DDH) results from abnormal development of the proximal femur and acetabulum, which may lead to mild hip instability or frank subluxation or dislocation.
  • Signs may present at birth or develop as the baby grows.
  • Hip instability occurs in about 1 in 100 babies and resolve spontaneously by aged 6 to 8 weeks in about half of cases.
  • The incidence of severe dysplasia is about 5 in 1000, and that of hip dislocation is around 1 in 1000.
  • Of DDH cases:
    • 80% occur in girls.
    • 65% involve the left hip.
    • 20% are bilateral.
  • Treatment for DDH is by splinting or surgical reduction and casting.
  • Missed or late‑diagnosed DDH may lead to a limp, premature hip joint degeneration, and back pain, amongst other complications.

Assessment

Look for limited hip abduction.

The most important sign of a dislocated or dysplastic hip is limited hip abduction when the hip is flexed to 90°.

Ask about risk factors for DDH.

Risk factors for DDH

  • Breech presentation, especially if vaginal delivery
  • Family history of DDH, especially if in a parent or sibling
  • Female (4 times more likely)
  • Large baby (> 4 kg)
  • Overdue by > 2 weeks
  • Reduced uterine volume e.g., oligohydramnios, first baby, multiple pregnancy – these babies may display other “packaging disorders”:
    • Plagiocephaly
    • Torticollis
    • Scoliosis
    • Foot deformities
  • Prolonged swaddling with legs in extension

Examine the hips at the first health assessment (0 to 4 weeks) and at each vaccination visit in infancy. The child must be relaxed, with nappy off to detect subtle differences in abduction.

  • Listen for clicks – these are often benign, but should prompt further evaluation.
    Clicks
    High-pitched “clicks” may be heard or felt at the end-range of passive hip motion. They are caused by ligaments moving over bony prominences and are not the same as the “clunk” of dislocation. If the hip is stable, and there is symmetrical full abduction bilaterally, no imaging is required. If there is any doubt, arrange imaging.
  • If aged < 3 months, perform hip stress (Barlow) and reduction (Ortolani) tests. If aged > 3 months, Ortolani and Barlow tests are more difficult.

    Hip stress (Barlow) test

    1. Place the infant supine. Stabilise the pelvis with one hand and hold the other thigh with the thumbs medially and the fingers resting on the greater trochanter.
    2. Flex the hips and knees to 90° and adduct the hip, then apply gentle posterior pressure to see if the femoral head moves out of the acetabulum.
    3. The test is positive if there is a palpable clunk or sensation of movement.
    4. If the femoral head can be made to slip out of the socket and back in again, the hip is classed as ‘dislocatable’ and unstable.

    For an image, see Figure 3 in American Family Physician – A Comprehensive Newborn Examination: Part 2. Skin, Trunk, Extremities, Neurologic.

    Video demonstration of Ortolani and Barlow tests:

    1. Open Royal Children’s Hospital Melbourne – Developmental Dysplasia of the Hip.
    2. Click Education Module, then Instability and Dislocation. The video runs for 3 minutes, 10 seconds.

    Reduction (Ortolani) test

    1. Place the infant supine and hold each thigh with the thumbs medially and the fingers resting on the greater trochanter.
    2. Flex hips and knees to 90° and gently abduct one hip – normally there is smooth abduction to almost 90°.
    3. If the hip is dislocated, the movement is usually impeded, but if pressure is applied to the greater trochanter there is a soft ‘clunk’ as the dislocation reduces, and then the hip abducts fully (the ‘jerk of entry’).
    4. If abduction stops halfway and there is no jerk of entry, there may be an irreducible dislocation.

    For an image, see Figure 3 in American Family Physician – A Comprehensive Newborn Examination: Part 2. Skin, Trunk, Extremities, Neurologic.

    Video demonstration of Ortolani and Barlow tests:

    1. Open Royal Children’s Hospital Melbourne – Developmental Dysplasia of the Hip.
    2. Click Education Module, then Instability and Dislocation. The video runs for 3 minutes, 10 seconds.
  • Look for other signs:
    • restricted hip abduction.

      Restricted hip abduction

      Limited unilateral hip abduction in flexion is the most sensitive sign associated with DDH in the older infant.

      Symmetrical reduction of hip abduction to less than 60° may indicate bilateral DDH (20% of cases).

    • leg length discrepancy.

      Leg length discrepancy

      To check leg length:

      • place the infant on a firm flat surface with a level pelvis.
      • flex both hips and knees, then assess the vertical level of the knees for asymmetry (modified Galeazzi test).

      For an image, see Figure 3 in American Family Physician – Developmental Dysplasia of the Hip.

    • asymmetrical thigh and gluteal skin folds.

      Asymmetrical thigh and gluteal skin folds

      • With the infant prone, check for asymmetrical thigh or gluteal folds.
      • Note that skin fold asymmetry is seen in 25% of normal infants, and in isolation does not constitute a diagnosis of DDH. It is significant in the presence of other positive signs.
      • Asymmetry may not be present in bilateral disease.

      For images, see International Hip Dysplasia Institute – Asymmetry.

  • If the child is walking, check for an abnormal gait.

    Abnormal gait

    • The affected hip may be externally rotated.
    • The child may limp or compensate by toe-walking on the affected side, or flexing the knee on the normal side.
    • Increased lumbar lordosis, prominent buttocks, or a waddling gait may indicate bilateral DDH.

Arrange appropriate imaging for:

Appropriate imaging

  • Use an imaging service experienced in paediatric radiology.
  • Type of imaging depends on age:
    • Aged 6 weeks to 6 months – ultrasound
    • Aged > 6 months – AP X‑ray pelvis, as ossification sufficient for joint definition
  • Ultrasound will report alpha angle, which relates to the formation of the acetabulum (dysplasia) and femoral head coverage with the degree of subluxation or dislocation. The amount of laxity may also be described, which correlates to instability1.
  • On ultrasound bony coverage > 50%, an acetabular alpha angle of > 60° and normal acetabular shape are considered normal.
  • babies aged 6 weeks if high risk for DDH, even if examination is normal (i.e., breech, other packaging disorders present, positive family history).
  • any infant or child with obviously abnormal examination i.e., hip dislocation, instability, reduced abduction, abnormal gait.
  • patients with persistently equivocal examination findings.

Management

If dislocation or dislocatable hip on Ortolani or Barlow tests, discuss with your local paediatric orthopaedic team or local paediatric team and refer for acute assessment.

If suspected DDH and patient aged < 6 months, manage according to ultrasound results:

  • If alpha angle ≥ 60°, consider normal hip and continue to check at each vaccination encounter.
  • If alpha angle < 60°, refer to your local paediatric orthopaedic service and mark your referral as urgent.

If suspected DDH, patient aged > 6 months, and:

  • abnormal X‑ray or examination (i.e., limited leg abduction, short leg or limp), Refer to your local paediatric orthopaedic service and mark your referral as urgent.
  • normal X‑ray and examination, continue to check at subsequent consultations and vaccination encounters.

Arrange follow up of splinted babies during treatment to ensure adherence with splinting and check for complications. Provide parent information from Children’s Health Queensland:

If any other concerns, discuss with your local paediatric orthopaedic team or your local paediatric team.

When to refer

  • If dislocation or dislocatable hip on Ortolani or Barlow tests, discuss with your local paediatric orthopaedic team or local paediatric team and refer for acute assessment
  • Refer to your local paediatric orthopaedic service and mark your referral as urgent if clinical suspicion of DDH and:
    • alpha angle < 60° on ultrasound.
    • abnormal X‑ray or examination.
  • If any other concerns, discuss with your local paediatric orthopaedic team or your local paediatric team.

Guideline approval and disclaimer

Guideline approval history
Version no. 1.0 Approval date 27/06/2019 Review date 01/06/2022

Disclaimer

The information contained in this GP referral and management guideline is intended for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect.
This guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from this guideline, taking into account individual circumstances may be appropriate.
This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for the following:
  • ●  Providing care within the context of locally available resources, expertise, and scope of practice.
  • ●  Supporting consumer rights and informed decision making in partnership with healthcare practitioners including the right to decline intervention or ongoing management.
  • ●  Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary.
  • ●  Ensuring informed consent is obtained prior to delivering care.
  • ●  Meeting all legislative requirements and professional standards.
  • ●  Applying standard precautions, and additional precautions as necessary, when delivering care.
  • ●  Documenting all care in accordance with mandatory and local requirements.
Children’s Health Queensland disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable.

Resources

For health professionals
Education

Further information

For families

Contact details

Hospital Switchboard
(Ask for the General Paediatric Registrar)
t: 07 3068 1111

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