History

Fact Explanation
Asymptomatic Most Developmental Dysplasia of the Hip (DDH) are asymptomatic and detected by neonatal screening.
Asymmetry of skin folds around the hip With shortening of the affected limb the skin folds become asymmetrical.
Limp or waddling gait If untreated developmental dysplasia of the hip can lead to permanent gait abnormalities.
Shortening of the affected leg Once the head of the femur undergoes necrosis the affected limb becomes shorter than the other.
Limited abduction of the hip After one month of age the ligaments around the hip joint thickens leading to limited abduction of the hip. [1]
References
  1. KLIEGMAN Robert M., STANTON Bonita F., ST GEME III Joseph W., SCHOR Nina F., BEHRMAN Richard E. Nelson Textbook of Pediatrics. . 19th Edition. London. Elsevier . 2011. Chapter 670.1

Examination

Fact Explanation
Barlow's manoeuvre This checks whether the hip can be dislocated posteriorly out of the acetabulum.
Ortolani's manoeuvre Once the Barlow’s test is positive, this manoevoure checks whether the hip can be relocated back into the acetabulum on abduction which gives a palpable “clunk.” [1] Both of these tests should be done in all neonates and are repeated at routine surveillance at 8 weeks of age, before the definitive diagnosis of DDH is made. These tests becomes less reliable when the newborn is more than one month old, because of the tightened soft tissues around the hip joint. Developmental dysplasia of the hip: a spectrum of abnormality. [2]
Limited hip abduction This becomes a more reliable sign once the child is more than one month old. [3,4]
Galeazzi sign This is the shortening of the thigh of the affected limb. This can be appreciated by flexing both hips to 90 degrees and comparing the height of the knees, looking for asymmetry. This is positive in unilateral DDH. [5]
Klisic test In this test the examiner places the 3rd finger over the greater trochanter and the index finger of the same hand on the anterior superior iliac spine. An imaginary line joining the two fingers should point to the umbilicus. If the hip is dislocated, the trochanter is elevated, and the line projects halfway between the umbilicus and the pubis. [6]
References
  1. WEINSTEIN SL. Developmental hip dysplasia and dislocation. In: Morrissy RT, Weinstein SL, editors. Lovell and Winter's pediatric orthopaedics. 4th ed. Philadelphia: Lippincott–Raven; 1996. p. 903-43.
  2. HARCKE HT. Pediatrics. 1999 Jan; 103:152
  3. TACHDJIAN MO. Congenital dysplasia of the hip. In: Tachdjian MO, editor. Pediatric orthopedics. 2nd ed. Vol 1. Philadelphia: WB Saunders; 1990. p. 297-526
  4. MOONEY Mooney JF, EMANS JB. Review Developmental dislocation of the hip: a clinical overview. Pediatr Rev. 1995 Aug; 16(8):299-303; quiz 304
  5. LIU R, LI Y, BAI C, SONG Q, WANG K. Effect of preoperative limb-length discrepancy on abductor strength after total hip arthroplasty in patients with developmental dysplasia of the hip. Arch Orthop Trauma Surg. Dec 3 2013
  6. KLIEGMAN Robert M., STANTON Bonita F., ST GEME III Joseph W., SCHOR Nina F., BEHRMAN Richard E. Nelson Textbook of Pediatrics. 19th Edition. London. Elsevier . 2011. Chapter 670.1

Differential Diagnoses

Fact Explanation
Septic arthritis [1] The child will have pseudo paralysis of the limb and will refuse to walk. The child might have fever.
Osteomyelitis Localized pain and limp due to pain are presenting features.
Transient synovitis [1] This is a painful condition. So the child will have a painful limp. Usually pain is self limiting. [1]
Neuromuscular Eg: Cerebral palsy Cerebral palsy and other neuromuscular conditions will lead to an abnormal gait. Eg: waddling gait or circumductive gait.
Juvenile idiopathic arthritis (JIA) JIA patients will have a charasteristic salmon pink color evanescent rash which appears with fever.
Perthes disease [1] Once acute it produces a painful limp. This is common in 3-10 years age group.
Slipped upper femoral epiphysis (SUFE) Acute SUFE is painful and chronic SUFE is painless
Avascular necrosis of the femoral head This painful condition most commonly occurs in 11-16 years age group.
Malignant disease, e.g. leukaemia This can produce bone pain and there by painful limping. [2]
References
  1. PERRY Daniel C. Evaluating the child who presents with an acute limp BMJ 2010; 341
  2. KLIEGMAN Robert M., STANTON Bonita F., ST GEME III Joseph W., SCHOR Nina F., BEHRMAN Richard E. Nelson Textbook of Pediatrics. 19th Edition. London. Elsevier . 2011. Chapter 670.1
  3. De ANGELIS, BUSCONI Nicola A., BRIAN D. Assessment and Differential Diagnosis of the Painful Hip. Clinical orthopeadics and related research. 406, January 2003, pp 11-18

Investigations - for Diagnosis

Fact Explanation
Ultra Sound Scan (USS) of the hip USS of the hip helps in quantifying the degree of dysplasia and whether there is subluxation or dislocation. USS of the hip joint is considered a superior method for the early diagnosis of DDH . [1]
X Ray of the hip joint When the proximal femoral epiphysis ossifies, by 4-6 months of age, an anteroposterior (AP) view of the pelvis helps to determine whether the normal anatomy is altered or not. Radiographs is less costly, and less operator dependent than an ultrasound examination.
MRI or CT scan of the hip These investigations provide more detailed information of the joint if the USS findings are inconclusive. Since CT and MRI can give more accurate information, the surgery can be planned based on that information. [2]
Arthrogram Though this will provide more detailed information of the joint this investigation is not routinely done.
References
  1. SZOKE N, KUHL L, HEINRICHS J. Ultrasound examination in the diagnosis of congenital hip dysplasia of newborns. J Pediatr Orthop. 1988 Jan-Feb; 8(1):12-6
  2. WAKABAYASHI K, WADA I, HORIUCHI O, MIZUTANI J, TSUCHIYA D, OTSUKA T. MRI findings in residual hip dysplasia. J Pediatr Orthop. Jun 2011;31(4):381-7

Investigations - Followup

Fact Explanation
USS of the hip Once a splint is put the progression should be monitored by USS, in children less than 4 months of age. [1]
X-ray of the hip This also helps to evaluate the success of the corrective splinting or the surgery. In children who are more than 4-5 months of age X-ray of the hip is superior to the USS. [2]
References
  1. BIALIK V, WIENER F, BENDERLY A (1992) Ultrasonography and screening in developmental displacement of the hip. J Pediatr Orthop B 1:51–54.
  2. Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip. PEDIATRICS Vol. 105. April 1, 2000. pp. 896 -905

Investigations - Screening/Staging

Fact Explanation
Ultrasound screening The above two manoeuvres might fail to detect DDH in where there is only a mildly shallow acetabulum. Ultrasound Scan (USS) of the hip is performed not to miss those neonates. Although practiced in some centers and it is highly specific in detecting DDH USS is expensive and has a high rate of false positives [1,2] and is not routinely recommended. [3] Routine USS of the hip in infants with a positive family history or breech presentation is in a value of detection of DDH. The conditions leading to a tighter intrauterine space like oligohydramnios and large birth weight which consequently, lessen the room for normal fetal motion may be associated with DDH. [4]
References
  1. HERNANDEZ RJ, CORNELL RG, HENSINGER RN. Ultrasound diagnosis of neonatal congenital dislocation of the hip. A decision analysis assessment. J Bone Joint Surg Br. Jul 1994;76(4):539-43.
  2. Congenital dislocation of the hip: to screen or not to screen. Dwyer NS. Arch Dis Child. 1987 Jun; 62(6):635-7.
  3. PATON RW, SRINIVASAN MS, SHAH B, HOLLIS S. Ultrasound screening for hips at risk in developmental dysplasia. Is it worth it?. J Bone Joint Surg Br. Mar 1999;81(2):255-8.
  4. KLIEGMAN Robert M., STANTON Bonita F., ST GEME III Joseph W., SCHOR Nina F., BEHRMAN Richard E. Nelson Textbook of Pediatrics. 19th Edition. London. Elsevier . 2011. Chapter 670.1

Management - General Measures

Fact Explanation
Watchful waiting till the spontaneous resolution This gives 90-97% success rates. [1]
References
  1. BIALIK V, BIALIK GM, BLAZER S, SUJOV P, WIENER F, BERANT M. Developmental dysplasia of the hip: a new approach to incidence. Pediatrics. 1999 Jan; 103(1):93-9

Management - Specific Treatments

Fact Explanation
Craig splint This is a positioning device, and puts the hips in abduction.
Pavlik harness This is a restraining device and applied to infants as soon as the diagnosis is made. This is applied for several months. These devices should be carefully monitored as ischemic necrosis of the head of the hip is a possible complication. [1] Since the success rates of Pavlik harness becomes less with aging once the child is more than 6months old it should not be used. [2] Patients with bilateral DDH are more likely to experience failure in treatment with Pavlik harness than the others. [3] Avascular necrosis of the hip is known to be higher with the use of Pavlik harness. [4]
Plaster hip spica If the hip has not stabilised or when the diagnosis is made later in life, hip abduction using traction and a further period of splinting is done using a plaster hip spica.
Open reduction and derotation femoral osteotomy On failure of the above conservative measures surgical correction will be indicated. Once the diagnosis is made when the child is more than 2years of age open reduction is considered the first choice in management. [5] A varus osteotomy is known to alter the mechanical axis of the lower extremity and this might result in genu valgum deformity of the knee. [6]
References
  1. VIERE RG, BIRCH JG, HERRING JA, ROACH JW, JOHNSTON CE. Use of the Pavlik harness in congenital dislocation of the hip. An analysis of failures of treatment. J Bone Joint Surg Am. Feb 1990;72(2):238-44
  2. WEINSTEIN SL. Developmental hip dysplasia and dislocation. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter's Pediatric Orthopaedics. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001:905-35
  3. VIERE RG, BIRCH JG, HERRING JA, ROACH JW, JOHNSTON CE. Use of the Pavlik harness in congenital dislocation of the hip. An analysis of failures of treatment. J Bone Joint Surg Am. 1990 Feb; 72(2):238-44.
  4. SUZUKI S, KASHIWAGI N, KASAHARA Y, SETO Y, FUTAMI T. Avascular necrosis and the Pavlik harness. The incidence of avascular necrosis in three types of congenital dislocation of the hip as classified by ultrasound. J Bone Joint Surg Br. 1996 Jul; 78(4):631-5
  5. HUSEYIN Arslan, AHMET Kapukaya, SERDAR Necmioğlu. Is varus osteotomy necessary in one-stage treatment of developmental dislocation of the hip in older children?. J Child Orthop. Nov 2007: 1: 291-297
  6. SUDA H, HATTORI T, IWATA H (1995) Varus derotation osteotomy for persistent dysplasia in congenital dislocation of the hip. J Bone Joint Surg (Br) 77:756–61