Hip dysplasia

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Updated by: Allison Duey-Holtz
Updated on: 8/2/17

Definition

Developmental abnormalities involving the relationship between the femoral head and the acetabulum

Diagnosis/symptoms

Signs and symptoms

Anatomic characteristics/exam findings:

• Birth to 4 months:
  • Asymmetric frog hip abduction
  • Positive Barlow or Ortolani
  • Positive Galleazi
• 6 months and older:
  • Asymmetric frog hip abduction
  • Positive Galleazi
  • Abnormal gait with unilateral toe walking or hyperlordosis

Hip “click” in isolation without other positive exam findings is not directly indicative of hip dysplasia; as opposed to the “clunk” sensation of positive Barlow and Ortolani Asymmetric thigh folds alone are not good predictors of hip dysplasia in absence of other positive exam findings

• Risk factors:
  • Female
  • Breech presentation
  • Family history of DDH
  • Inappropriate swaddling

DDH is present in 1 per 100 live births, whereas dislocation at birth is present in approximately 1 per 1,000 infants

• Children who have normal findings should continue to have their hips examined at each of the recommended health supervision visits until a normal gait is demonstrated

Causes

• Improper relative positioning of femoral head to pelvic acetabulum leads to dysplastic development.
• Laxity is expected in infants up to 6 weeks of life give they are born with inherent hip laxity due to systemically retained maternal estrogen and in order to allow delivery.

Treatment

Birth to 4-6 months (depending on patient size and tolerance): Pavlik Harness

>6 months to 2 years: Rhino hip abduction orthosis

>2 years: likely requires surgical intervention

Pending improvement with bracing; may require open or closed reduction with subsequent spica casting.

Referring provider's initial evaluation and management:

Diagnosis:

Differential diagnosis

• Spasticity/adductor muscle tightness or contracture
• Benign hip click
• Congenital coxa vara
• Congenital short femur

Diagnostic tests

• Birth to 6 months:
  Dynamic hip ultrasound
• 6 months and older:
  AP/frog lateral pelvis X-ray

Babies with breech presentation who have normal ultrasounds at 6 weeks of life should have a pelvis X-ray at 6 months of age given risk of late onset DDH.

When to initiate referral/ consider refer to Orthopedic Clinic:

• If positive risk factors with no abnormal exam findings; recommend dynamic hip ultrasound at 6 weeks of life
  • If ultrasound is normal, no referral required
  • Recommend AP/frog lateral pelvis X-ray at 6 months if breech

• If positive clinical exam findings; refer to orthopedics:
  • If positive Barlow or Ortolani; do not need ultrasound prior to appointment.
  • If other other exam findings noted; order ultrasound (if pt <6 months) or pelvis X-ray (if pt >6 months) prior to appointment

What can referring provider send to Orthopedic Clinic?

1. Using Epic

• Please complete the external referral order

In order to help triage our patients and maximize the visit, the following information would be helpful include with your referral order:

• Urgency of the referral
• What is the key question you would like answered?

Note: Our office will call to schedule the appointment with the patient.

2. Not using Epic external referral order:

• In order to help triage our patients maximize the visit time, please fax the above information to (414) 607-5288
• It would also be helpful to include:
• Chief complaint, onset, frequency
• Recent progress notes
• Labs and imaging results
• Other Diagnoses
• Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient's problems.

Specialist's workup will likely include:

After referral to Ortho Clinic:

• Clinical exam:
  • Evaluate for hip abduction
  • Positive Barlow or Ortolani
  • Positive Galleazi

• Education to families on:
  • Patient education: Hip healthy swaddling