Developmental Dysplasia of the Hip

1. Developmental Dysplasia of the Hip

2. “Developmental dysplasia of the hip” Dislocated Dysplasia Subluxation

3. The aim of treatment A normal hip

4. Natural history • Hip arthritis in early adulthood

5. Early diagnosis • Treatment success high • Treatment late cases • Less successful • More surgery • More complications

6. How common is DDH? • Clinically unstable hips – 1 in 64 babies

7. Scottish Needs Assessment Program Report July 1993 • Number of late cases not reduced by neonatal screening • Possible increase in number of late presenting cases

8. National Screening Committee recommendations • All babies must be screened by clinical examination • Ultrasound if clinical abnormality or risk factors • Clinically abnormal hips should be seenby aspecialist

9. 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

10. Clinical examination “24-hour check” • Five points: • History of risk factors • Leg length difference • Groin/buttock creases • Range of abduction • Tests of stability

11. Point 1 – History of risk factors • Breech presentation • Family history of DDH • Abnormalities of the lower limbs, e.g. clubfoot • Torticollis

12. Look • 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.)

13. Move • Point 4 - Range of abduction • Point 5 - Tests of stability • Barlow • Ortolani Restricted abduction and asymmetrical groin folds

14. Instability tests

15. Resting position • Test one hip at a time • Hip and knee flexed • Finger on greater trochanter • Stabilise pelvis • Compare sides • Take your time, be gentle

16. Clinical tests • Barlow test • Abnormal if femur movesBackwards relative to the fixed pelvis • Test for a located but dislocatable hip

17. Clinical tests 2 • Ortolani test • Positive if greater trochanter moves forwards as hip locates • Hip is Out, but can be reduced • Tests for a dislocated but reducible hip

18. Barlow & Ortolani

19. 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

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

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

22. ‘Teratologic' or fixed dislocation • Dislocated irreducible hip • Dislocation before birth • Association with arthrogryposis or myelomeningocele • Surgery usually required

23. Baby Hippy • ‘Life-like’ model of a female newborn • Barlow positive hip • Ortolani positive hip • Expensive and delicate ++

24. Clinical examination “24-hour check” • Five points: History of risk factors Leg length difference Groin/buttock creases Range of abduction Tests of stability • Barlow • Ortolani Questions?

25. The 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

26. 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?

27. Clinical 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

28. Missed? • 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: bilateral dislocations

29. Hip screening with ultrasound • Options • Universal screening • Screening of high risk babies

30. Universal U/Sscreening • Difficult to organise • High number of immature hips – rescan • Expensive • ?Cost effective • Conclusion – not proven, although some very impressive results

31. Selective U/Sscreening • Only high risk and clinically abnormal hips • Consultant radiologists and dedicated sonographer • ? Effectiveness • Manageable

32. 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.

33. Late signs of DDH • Asymmetric abduction • Leg length discrepancy DDH must be excluded

34. Treatment • Abduction splint – Pavlik, von Rosen • Monitoring for hip development and complications

35. How not to examine a baby’s hips!

36. Thank you. Any questions?

37. Summary • 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