CASE

PRESENTATION
New guidelines
for DDH

Dr. MANAR
AHMED
PHC-NGHA

 Female infant,2 mos, presents to

well baby clinic for vacc.
During exam :
There was abn. posturing of LLs at hips

`e mild tenderness
The Ortolani and Barlow tests were
performed, but not conclusive
U\S of both hips was requested

Hip U\S
Mildly displaced left femoral head
with respect to the left
acetabulum without any evidence
of joint effusion, and
findings likely to represent mild
severity left DDH.

AP Neutral, Frog Leg

Lateral
Increased sloping of the left acetabular roof
which shows relatively small size and
associated with small depression just lateral
to it (likely to represent pseudoacetabulum).
The left Shenton line is disrupted with
appearance of mild lateral subluxation of the
left hip.
Features are likely to represent left
developmental hip dysplasia, for clinical
correlation and further evaluation by
ultrasound.

Definition
Developmental dysplasia of the hip (DDH)
, formerly known as congenital dislocation
of the hip, encompasses a wide spectrum
of hip problems, from subtle hip instability
in the newborn, to subluxation,
dislocation, and acetabular dysplasia
(abnormal socket growth).

Incidence
Incidence of DDH is approximately 2 to 4 per
1000 live births,
Prevalence rates of 1.5 in 1000 in whites and
somewhat lower in blacks.

Risk factors
Risk factors include
female sex (4- to 8-fold increased risk)
family history of DDH
firstborn status
large infant size, and
Breech presentation
history of oligohydramnios.
Because of the normal left occiput anterior
position in utero, which places the left hip against
the mother's spine and limits its abduction, DDH
is 3 times more common in the left hip than in the
right.

Pathogenesis
The foundation of these problems is that the ball of the hip joint
does not remain tightly within the socket.
If the ball lies outside the confines of the socket it is called a
dislocation.
If it is in the socket but is able to be pushed out of the socket it is
either subluxatable or dislocatable.
If the femoral head does not stay securely within the confines of
the socket, the hip joint cannot develop normally.
If the ball is out of the socket for any length of time, the femoral
head becomes deformed and the socket remains shallow.
Ultimately, the deformed hip joint can lead to the development of
arthritis in either adolescence or early adulthood.
Since DDH can be associated with packaging inside the uterus
(breech); other congenital anomalies of the foot (metatarsus
adductus or hooked foot), knee (subluxation), or neck (wry neck or
torticollis) can be associated with dislocation of the hip.

Ultimate results
The natural history of DDH depends on the type
and degree of abnormality.
Most DDH identified in the newborn period
represents laxity and immaturity; 60% to 80% of
DDH identified by physical examination and 90%
identified by ultrasound resolve spontaneously.

Treatment
Treatment depends on the age at detection.
Most children between birth and 6 months of age can
be treated with a Pavlik harness.
The soft harness helps guide the hip and hold it in the
optimum position and it is not removed until the hip
becomes stable. (approximately 6 weeks) Once stability
is achieved and documented by ultrasound, the harness
is slowly weaned over several weeks. (wearing during
nap and night time)
Once the harness is removed the child is followed until
the hip is normal clinically and by x-ray to make sure
the socket develops normally.
Oftentimes further bracing and sometimes surgery is
necessary to stimulate and or correct socket
development.

Treatment
Children between the ages of 6 to 12 months (under
walking age) are usually treated with a closed reduction
of the hip.
This is done in the operating room under anesthesia.
Once asleep, dye is put into the hip joint and the femoral
head is guided into the socket manually.
Once in position, a spica (body) cast is applied to hold the
hip in position.
The hip is usually held in this cast for 3 months,
sometimes requiring a change of the cast after the first 6
weeks.
Once the cast is removed the child is followed until the
hip is normal clinically and by x-ray to make sure the
socket develops normally.
Oftentimes further bracing and sometimes surgery is
necessary to stimulate and or correct socket
development.

Treatment
Children between the ages of 12 to 18 months (above walking
age) may be treated with either a closed reduction or an open
reduction (surgery).
If surgery is required, the joint is opened, the femoral head is
placed into the socket, and the hip capsule (lining) is tightened.
The repair of the joint is protected in a rigid body cast for
approximately 6 weeks.
In children older than 18 months of age, open reduction is usually
the treatment of choice.
In addition it is often necessary to help the socket develop
surgically by making a cut in the pelvis bone.
Sometimes it is also necessary to cut the femur bone to shorten
(and sometimes rotate) it to allow the ball to be placed into the
socket without undo pressure on it.
These additional surgeries help guide development of the hip
joint; correcting the shallow socket and abnormal rotation of the
femur bone.
Once again a cast is used to hold the repair for about 6 weeks.

American Academy of
Pediatrics guidelines for DDH
screening

The American Academy of Pediatrics

recommends clinical hip evaluation at every
newborn well-baby visit, starting at 1 to 2
weeks, then at 2, 4, 6, 9, and 12 months.
Diagnosis depends on physical examination
and radiography or ultrasound.
Clues to DDH include risk factors, asymmetric
thigh skin folds, and thigh shortening

American Academy of
Pediatrics guidelines for DDH
screening

The Ortolani and Barlow tests are

performed for screening.

The Ortolani test causes a "clunk" to be

detected when the displaced femoral head
slips into the acetabulum.
The Barlow test can elicit a dislocation
followed by reduction and identifies some
unstable hips missed by the Ortolani test.

American Academy of
Pediatrics guidelines for DDH
screening

In children older than 3 months, these tests

are less likely to have positive results.
Limitation of hip abduction, asymmetric skin
folds and shortened thigh are more useful.
Once a child is walking, a typical limp and
toe-walking on the affected side are also
indications of DDH.

American Academy of Pediatrics

guidelines for DDH screening
In bilateral DDH, a waddling gait may be present,
increased lumbar lordosis, prominent buttocks
Radiographs are of limited value in the first month
because the femoral head is composed of cartilage.
By 4 to 6 months, radiographs are more reliable and
should be performed in the neutral position, with
dislocation or subluxation of the femoral head
recognized by evaluation of the ossific nucleus of
the femoral head and metaphysis to the acetabulum.
Radiographic examination is made by visual
assessment.

American Academy of
Pediatrics guidelines for DDH
screening

There is no established role for radiographs in

routine screening for DDH, but screening may
be considered in infants at risk for DDH after 6
weeks of age.
Ultrasound was introduced by Graf in the
coronal plane, and the North American
standard for hip ultrasound recommends a
coronal view in Graf format and a transverse
view with the hip flexed and without modified
Barlow stress maneuver.

American Academy of
Pediatrics guidelines for DDH
Hips are classifiedscreening
by Graf as:
type 1, requiring no treatment or follow-up;
type 2, requiring no treatment but requiring follow-up
(subtypes are a, b, c, and d);
type 3, with low displacement, requiring immediate
treatment; and
type 4, with high displacement, requiring immediate
treatment.

The American Academy of Pediatrics recommends hip

ultrasound for girl infants born in breech position and
optional imaging for boys born in breech position or
girls with a positive DDH family history.
Some infants with risk factors, most notably, a family
history of hip dysplasia and/or breach presentation at
delivery, are recommended for hip imaging routinely
at 6 weeks of age even in the face of a normal
physical exam.

American Academy of
Pediatrics guidelines for DDH
screening

Routine screening of all infants by ultrasound is not

recommended.
Selected ultrasound screening with positive physical
examination findings has been shown to reduce
abduction splinting and cost.
Computed tomography is primarily used for follow-up
after surgery and not for diagnosis of DDH.
Magnetic resonance imaging may be used in complex
dislocations with suspected avascular necrosis.
Arthrography is used to evaluate lateral displacement
of the femoral head after closed reduction

American Academy of
Pediatrics guidelines for DDH
screening

All neonates should receive generalized

physical evaluation; neonatal screening
has reduced late presentation of DDH.
There is agreement that dislocated hips
should be treated and stable "clicking"
hips should be followed.

American Academy of
Pediatrics guidelines for DDH
screening
The management of hips with unstable (lax but
displaced) hips remains controversial, with some
advocating early treatment and others
recommending follow-up.
Physical examination, but not routine
radiography, ultrasound, or other radiologic
tests, are indicated for screening all children for
DDH.

Conclusion
Formerly known as congenital dislocation of the hip, DDH
encompasses a variety of hip joint abnormalities including
abnormal acetabular shape (dysplasia) and unstable
positioning or displacement from the femoral head
Early Detection of DDHReducesComplications
Late detection could lead to early degenerative changes
in adulthood possibly resulting in the need for joint
replacement.
The key is to catch these kids early and try to avoid
surgery through physical exam. screening and selective
use of ultrasound for infants with a positive physical
exam. or risk factors for hip dysplasia.

Conclusion
The USPSTF was concerned about the high risk
for complications and problems with surgical
treatments. However, if you don't pick up these
kids early, instead of just using a harness (like
you often can early on), it can evolve into a
surgical problem
The hope is that the criteria will send out the
message that ultrasound is the screening
modality of choice for evaluation of DDH in
children younger than four months

References
American Academy of Pediatrics web
site
medscape