Paeds · rheumatology-musculoskeletal-and-sports
Developmental dysplasia of the hip
Also known as DDH · congenital hip dislocation · congenital dislocation of the hip · CDH · hip dysplasia · Ortolani positive hip · Graf classification · Pavlik harness · acetabular dysplasia
A fellowship approach to developmental dysplasia of the hip: the Ortolani and Barlow manoeuvres in the newborn, the Graf ultrasound angles that grade the infant hip, the Pavlik harness that reduces it, and the late-presenting toddler whose painless limp and short leg declare a hip that screening missed.
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Target exams
Red flags
- A positive Ortolani or Barlow test in the newborn is a clunk of true instability, not a benign soft-tissue click, and it demands hip ultrasound and orthopaedic referral
- Breech presentation, regardless of sex, mandates ultrasound screening of the hips by six weeks of age under current selective-screening guidance
- Loss of hip abduction in an infant beyond three months is the single most reliable bedside sign of an established dysplastic hip
- A toddler with a painless limp, a short leg, and a toe-walking gait has late-presenting dysplasia until a pelvis radiograph proves otherwise
- A Pavlik harness that has not reduced the hip within three weeks must be abandoned, because continued forced abduction causes avascular necrosis of the femoral head
- Untreated or undertreated dysplasia silently progresses to early osteoarthritis of the hip by the fourth or fifth decade
Life stages
Care settings
Clinical exam formats
Board mappings
- Musculoskeletal medicine - perform the newborn hip examination (Ortolani and Barlow) and recognise developmental dysplasia of the hip
- Neonatology and the newborn - risk factors for DDH and the timing of hip ultrasound
- Growth and Development - normal motor milestones and their deviations
- Musculoskeletal medicine - the Graf ultrasound classification and the age-stratified management of DDH
- Orthopaedics - the Pavlik harness, closed and open reduction, and the prevention of avascular necrosis
- Renewed curriculum for first-year trainees from 2027 - Learning goal 6: Clinical management - essential general paediatrics
- Musculoskeletal 10-12
- Neonatal and infant problems 10-12
- Clinical Applications
- Short Cases
- Long Cases
- 10. Musculoskeletal - developmental dysplasia of the hip and the newborn hip examination
- 1. Neonates and infants with DDH screening and early management
- 4. Professional skills and knowledge: Patient management
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- Video
- General Pediatrics Content Outline - D19 Rheumatology or Orthopedics
- General Pediatrics Content Outline - Universal Task 3: Physical Examination
- General Pediatrics Content Outline - Universal Task 5: Patient Management
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Medical Knowledge 2: Conditions common in pediatric primary care
- Systems-Based Practice 2: Coordinated acute and chronic care
- Medical Expert
- Pediatrics: Foundations EPA #5 - Performing a focused physical examination
- Pediatrics: Rheumatology and musculoskeletal applied domain
A six-week-old girl born in the breech position has a soft clunk on the left Ortolani test, her ultrasound shows a Graf type III hip with an alpha angle of forty degrees, and a Pavlik harness is fitted and checked at three weeks to confirm reduction. A three-month-old boy with a normal newborn examination now has asymmetric thigh folds and limited left abduction, and his ultrasound reveals a shallow acetabulum with an alpha angle of fifty-two degrees, a Graf type IIb hip that has declared after the neonatal screen. A two-year-old girl who was never screened walks in with a painless left-sided limp, a short left leg, and a left hip that shifts upward and outward on the radiograph, a late-presenting dislocation that now needs an open reduction. The task in each is to screen at the right age, to image with the right modality, and to match the treatment to the age of the child. [2] [10]
Hold the pathway as five moves. Screen with Ortolani and Barlow in every newborn, because the clunk found in the first weeks is the hip that a harness can still cure. Image the at-risk infant with ultrasound and the older child with a pelvis radiograph, because ultrasound sees cartilage that the radiograph cannot. Grade the hip with the Graf alpha angle before six months and the International Hip Dysplasia Institute grade after, because the grade sets the treatment. Harness the reducible infant hip in a Pavlik, and check reduction at three weeks, because the unreduced harness causes avascular necrosis. Refer every clunk, every failed harness, and every late presentation to orthopaedics, because the window for a simple cure closes with each month of delay. [2] [7]
Overview & Definition
Developmental dysplasia of the hip describes a spectrum of abnormal development of the hip joint that is present at or soon after birth. At the mild end sits a capsular laxity that allows the femoral head to sublux, and at the severe end sits a fixed dislocation in which the head has migrated completely out of the acetabulum and come to rest against the ilium. The older name, congenital dislocation of the hip, has fallen from favour because the condition is not always present at birth and because the spectrum includes dysplasia without dislocation. [2]
The clinical importance of the condition comes from what an untreated dysplastic hip does to the adult. A shallow acetabulum and an unstable head fail to distribute load, the cartilage wears, and the joint develops osteoarthritis by the fourth or fifth decade. A dislocated hip that is never reduced leaves the child with a short leg, a limp, and a restricted, painful joint through childhood. The whole enterprise of newborn screening exists because the hip found and treated in the first months of life recovers almost completely, while the hip found in the toddler needs surgery and never quite returns to normal. [5] [10]
The fellowship candidate holds the condition as a time-sensitive problem. The neonate with a clunk is the prize, because a Pavlik harness worn for a few weeks will usually restore a normal hip. The infant with limited abduction is still salvageable with a harness or a closed reduction. The toddler with a limp has crossed into surgical territory, and the adolescent with residual dysplasia is managed to delay arthritis, not to cure it. The age at which the hip is found is the single strongest determinant of the outcome. [2] [11]
References11ShowHide
- [1]Graf R. The diagnosis of congenital hip-joint dislocation by the ultrasonic Combound treatment. Archives of Orthopaedic and Traumatic Surgery, 1980.PMID 7458597
- [2]Guille JT, Pizzutillo PD, MacEwen GD. Development dysplasia of the hip from birth to six months. Journal of the American Academy of Orthopaedic Surgeons, 2000.PMID 10951112
- [3]Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics, 2006.PMID 16510634
- [4]Shorter D, Hong T, Osborn DA. Screening programmes for developmental dysplasia of the hip in newborn infants. Cochrane Database of Systematic Reviews, 2011.PMID 21901691
- [5]Perry DC, Paton RW. Knowing your click from your clunk: is the current screening for developmental dysplasia of the hip fit for purpose? The Bone and Joint Journal, 2019.PMID 30813794
- [6]Narayanan U, Mulpuri K, Sankar WN, Clarke NM, Hosalkar H, Price CT, et al. Reliability of a New Radiographic Classification for Developmental Dysplasia of the Hip. Journal of Pediatric Orthopaedics, 2015.PMID 25264556
- [7]Tibrewal S, Gulati V, Ramachandran M. The Pavlik method: a systematic review of current concepts. Journal of Pediatric Orthopaedics Part B, 2013.PMID 23995089
- [8]Peled E, Bialik V, Katzman A, Eidelman M, Norman D. Treatment of Graf's ultrasound class III and IV hips using Pavlik's method. Clinical Orthopaedics and Related Research, 2008.PMID 18288557
- [9]Bilgili F, Sağlam Y, Göksan SB, et al. Treatment of Graf Type IIa Hip Dysplasia: A Cut-off Value for Decision Making. Balkan Medical Journal, 2018.PMID 29966996
- [10]Terjesen T, Horn J. Have Changes in Treatment of Late-detected Developmental Dysplasia of the Hip During the Last Decades Led to Better Radiographic Outcome? Clinical Orthopaedics and Related Research, 2016.PMID 26290341
- [11]Dwan K, Kirkham J, Paton RW, Morley E, Newton AW, Perry DC. Splinting for the non-operative management of developmental dysplasia of the hip (DDH) in children under six months of age. Cochrane Database of Systematic Reviews, 2022.PMID 36214650