Developmental dysplasia of the hip

• What is developmental dysplasia of the hip (DDH)?


  Congenital abnormality of the hip joint

  Structural abnormality of joint -> instability & potential subluxation or dislocation

  Have potential to persist into adulthood -> weakness, recurrent subluxation/dislocation, abnormal gait & early degenerative changes
• Which hip is DDH more common in?


  Left hip

  BUT occurs bilaterally in 20% of cases
• What are the RFs of DDH?


  1st degree FHx

  Breech presentation

  Multiple pregnancy

  Firstborn child

  Prematurity

  Low amniotic fluid levels (oligohydramnios)
• What are the signs & symptoms of DDH?


  Infants

  • limited hip abducted (esp when hip flexed)
  • asymmetry of gluteal & thigh skinfolds
  • apparent limb length discrepancy

  Older children

  • Galeazzi sign -> unilateral femoral shortening
  • Walking difficulties or limp
  • Delayed walking
  • Waddling gait (bilateral cases)
• What are the DDx of DDH?


  Transient synovitis

  Septic arthritis

  Legg-Calve-Perthes disease

  Slipper Upper Femoral Epiphysis (SUFE)
• When is DDH screened for?


  Neonatal examination

  6-8 weeks

  (NIPE)
• What findings in NIPE examination may suggest DDH?


  Different leg lengths

  Restricted hip abduction on 1 side

  Significant bilateral restriction in abduction

  Difference in knee level when hips are flexed

  Clunking of the hips on special tests
• What special tests are used to check for DDH?


  Ortolani

  Barlow
• What is the Ortolani test?


  Baby on back with hips & knees flexed

  Palms placed on baby's knees with thumbs on the inner thigh & four fingers on outer thigh

  Gentle pressure used to abduct hips & apply pressure behind legs with fingers to see if the hips will dislocate anteriorly

  Clicking is common finding (normal)

  Clunking (indicates DDH, nedd USS)

  
• What is Barlow's test?


  Baby on back with hips adduction & flexed 90 degrees & knees bent @ 90 degrees

  Gentle downward pressure is placed on knees through femur to see if the femoral head will dislocate posteriorly

  Clicking -> common finding (normal)

  Clunking -> indicates DDH (needs USS)

  
• How is DDH diagnosed?


  Ultrasound of hips

  X-rays may be done in older children
• What is the management of DDH?


  Pavlik harness -> used to maintain hip in a flexed & abducted position for 6-12 weeks

  Surgery -> when harness fails or diagnosis made after 6 months of age -> after surgery, hip spica cast used to immobilise hip for prolonged period
• What is shown in the image?

  Pavlik Harness

  
• What are the possible complications of DDH?


  Degeneration of the hip joint & pain in lower back & hip

  Responsible for approx 1 in 3 hip replacements before 60 yrs