20 January 2011
Dr Nidham Oda
CASE
A young mother brings her 8 weeks old girl to your GP clinic because one of the
nurses found asymmetrical hip creases. Take further History, Physical Examination,
advised on the Management.
DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)
HISTORY
I understand that your child has an asymmetrical hip
I want to ask a few questions about that
That you yourself detect this creases or the nurse
Have you noticed any asymmetry while changing nappies
Is your child moving her legs or both hips normally
Is she crying if she moves one of her legs or when changing nappy
Are you concerned
How is your baby in general
Is she feeding well
Is she putting on weight
Does she have any vomit
Is she wetting nappies normally
How about her poos or bowel motions, any change, diarrhoea?
Does she have any cough at all
Is the child your first child?
Was she full-term or premature?
Was she delivered normally or by operation? by SC (a risk factor)
Why by SC?breech presentation (another risk factor)
Was there any problem after delivery, did she stay long in the post delivery room
Does anyone in the family suffers from hip problems
How about you? Any problems after delivery, are you coping well with your child
after SC?
PHYSICAL EXAMINATION
General Appearance
Vital Signs
Growth parameters I want to check his blue book
Quick exam of the chestlung, heart, abdomen
Move to the hip
Remove nappy, look for the asymmetry
Screening test to aid which patient needs further investigation Ortolani test
(dislocating the hip, full abduction) & Barlow test (relocating the hip, adduction)
positive if there is click or clung sounds.
Flex both knees 90 degrees, do full abduction (Ortolani)
Opposite movement, relocate the head (Barlow)
Ortolani Test (steps 1-5) Ortolani test is performed by abducting the infants hip and
assessing for a clicking sound. This test is used to detect the posterior dislocation of
the hip. A positive Ortolanis sign is noted when a clicking or distinctive clunk is
heard when femoral head re-enters the acetabulum. Ortolani maneuver is performed
before 2-3 months of age. The maneuver is done in early infancy because after 2-3
months the development of soft tissue contracture prevents the hip from being
relocated, thus, no clicking or clunking sound will be assessed in children with
congenital hip dysplasia.
Barlow Test (steps 6 and 7) Barlow test is performed by bringing the thigh towards
the midline of the body. Feeling of femoral head slipping out of the socket
postolaterally, is considered as a positive Barlows sign.
The Ortolani test is then used to confirm that the hip is actually dislocated.
Procedure
1. Lay the infant in a supine position and flex the knee to 90 degrees at the hips.
Proper position of the infant ensures accurate results.
2. Hold the infants pelvis with one hand to stabilize it during manipulation.
3. Using the other hand, place the middle fingers over the great trochanter of the
femur and the thumb on the internal side of the thigh over the lesser trochanter.
Placing the fingers in this manner allows easy abduction of the hips.
4. Slowly and gently abduct the hips while applying pressure over the greater
trochanter. The femur is pulled forward while the greater trochanter is used as a
fulcrum.
5. Listen for a clicking or clunking sound while performing step number four.
Normally, no sound is heard. A clicking or clunking sound is a positive Ortolanis
sign and it happens when the femoral head is re-entering the acetabulum.
6. With the fingers in the same position, assess the infant for Barlows sign. Hold the
hips and knees at 90 degree flexion while exerting a backward pressure (down and
laterally).
7. Slowly and gently adduct (bringing the thigh towards the midline) the hip. Note
any feeling of the femoral head slipping. Normally, the hip joint is stable. The
feeling of the femoral head slipping out of the socket postolaterally is a positive
Barlows sign.
EXPLANATION
Your daugr hmight have Developmental Dysplasia of the Hip which needs to be
confirmed. The only way to confirm at this age is by doing ultrasound, diagnostic up
to the age of 9 months, afterwards diagnosis by X-ray.
DDH is a condition in which there is underdevelopment of the femoral head.
The head of the femoral is smaller than normal, easily dislocated.
Exact cause unknown.
Usually is developmental, she is born with it.
Risk factors is more common:
- who are born by Caesarian Section or
- Breech delivery or
- premature
- baby girl or
- with a first family history
MANAGEMENT
Needs to be treated, if untreated will lead to:
- Delayed walking
- Limp when walk
- Shortening of the leg
- May develop early osteoarthritis changes in the head
Treatment depends on the age:
Very young, very good time, easily treated with a splint
Abduction splint (within the first 6 months) Pavlik harness
After 3-18 months Hip spica (from belly button to the leg for a few months)
After 18 months prefer surgery
Despite early treatment some cases progress to acetabular dysplasia
(underdevelopment of the roof of the hip joint) and to premature osteoarthritis. Thus
a follow-up X-ray of the pelvis during teenage years should be considered for anyone
with a history of DDH
Table 65.2 Comparison of important causes of hip pain in children
Transient
DDH
Perthes'
SCFE
synovitis
Age (years) 0 - 4
4-8
4-8
10 - 15
Limp
Pain
Septic
arthritis
Any
Won't
walk
+++
+
+
+
All,
Limited
especially
Abduction and All,
Abduction
All
movement
abduction and IR
especially IR
IR
Subchondral AP may be
No diagnostic
fracture
normal
value in neonatal
Plain X-ray
Normal
Dense head Frog lateral
period (use
Pebble stone view shows
ultrasound)
epiphysis
slip
