Symposium: Surgery & orthopaedics

The diagnosis and

management of congenital
dislocation of the hip
NMP Clarke
K Sakthivel

Abstract
Congenital dislocation of the hip (CDH) or developmental dysplasia of the
hip (DDH) is a common condition that encompasses a spectrum of pathology affecting the neonatal hip. Clinical signs of instability may be difficult to detect at birth using the Barlow Ortolani test. A clear imperative
is to make an early diagnosis since delay after 3 months is synonymous
with the necessity for surgery and also leads to a compromised prognosis. There is considerable controversy about clinical screening for DDH or
ultrasound screening, either comprehensive or selective. Risk factors
such as breech presentation, oligohydramnios and talipes are well
known and there is some evidence that selective screening for these babies with ultrasound may assist diagnosis. The incidence of neonatal hip
instability is around 1520 per 1000 live births but that of established
dislocation 12 per 1000 live births in unscreened cohorts. The usual
early treatment is with the Pavlik harness but after 3 months, surgery
either an open or closed reduction is necessary and in some surgically
untreated children, secondary procedures such as pelvic osteotomy are
necessary.

Keywords arthrogram; harness; hip dysplasia; osteotomy; screening

programme

a Schematic representation of the ultrasound image in 1b.

b Ultrasound image from developmental dysplasia of the hip
screening, showing that the hip is located in the acetabulum.

Introduction

Figure 1

Congenital dislocation of the hip (CDH) or developmental dysplasia of the hip (DDH) (as it is now more commonly known)
is defined as deformation of the hip joint, which is present at
birth or which develops during the first few months of life.
This is because the femoral head may be partly or completely
displaced from the acetabulum. Figure 1 shows that the hip is
normally located in the acetabulum. This clinical spectrum also
includes secondary joint dysplasia whether instability or dislocation persist or not.
The relatively newer term DDH, is now more widely used
because it takes into account that the pathology may develop
with the growth and altered development of the hip.1 The primary pathology, however, is due to hip instability, which, if left
untreated, leads to hip dysplasia of varying severity.

There is a wide variety of pathological changes such as flattening or inversion of the labrum and capsular structures (limbus)
along with hypoplasia of the capital femoral ossific nucleus
which can develop from the primary hip instability. Associations
with other neuromuscular conditions and other syndromes have
been documented and these are collectively called teratologic
dislocations.

Incidence
The incidence of neonatal hip instability is between 15 and 20
per 1000 live births. However, the incidence of frank hip dislocation is 1 to 2 per 1000. These numbers prove the theory that most
patients with neonatal hip instability settle favourably in the first
few weeks of life.
There is a higher preponderance in the left hip of the first
born female baby. Factors like a positive family history, breech
presentation and oligohydramnios increase the predisposition by
a factor of 10.

NMP Clarke ChM FRCS FRCSEd is at Southampton General Hospital,

Southampton University Hospitals NHS Trust, Hampshire SO16 6YD, UK.
K Sakthivel FRCSEd FRCS(T&O) is Southampton General Hospital,
Southampton University Hospitals NHS Trust, Hampshire SO16 6YD, UK.

PAEDIATRICS AND CHILD HEALTH 18:6

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2008 Elsevier Ltd. All rights reserved.

Symposium: Surgery & orthopaedics

however, a huge cost implication with this type of screening and,

therefore, it is unlikely to be accepted in the UK.
Ultrasound examination forms a major part of the screening
and diagnosing of DDH in newborn babies. In the past decade
or two, ultrasound examination has been increasingly used as
a secondary screening tool. It helps to assess the cartilaginous
femoral head and acetabular morphology. There are two methods of ultrasound examination widely described in the literature.
The first, the Graf method,6 relies on static screening and calculation of the alpha and beta angles to define acetabular dysplasia.
The second, the Clarke and Harcke method,7 relies on a more
dynamic study of the whole hip joint and its instability is better diagnosed with this method. The algorithm in Figure 3 gives
guidance on the authors preferred screening choice.

Screening
Early diagnosis of this condition is vital as the prognosis of
the hip in such a situation depends on the time of initiation of
appropriate treatment. It is very difficult to identify the signs and
symptoms of DDH in a newborn. Hence, it is paramount that a
screening programme is in place to identify the condition early to
enable the initiation of treatment (see Figure 2).
Currently all newborn babies are subject to an examination
of the hip by either a paediatrician or other trained personnel.
The neonatal examination should involve the time-tested Ortolani and Barlow tests.2,3 The Ortolani test identifies the clunk of
reduction of the hip on abduction. The Barlow test proactively
induces the displacement of the femoral head from the acetabular socket. These tests were meant to identify all cases of DDH
to enable us to administer early effective splintage. However, as
these tests are very subjective, the results depend on the experience of the examiner. Recently, there has been growing concern
that the number of missed cases is on the increase.
As there are significant implications in treating late presenting established cases of DDH, a robust screening programme is
recommended.
After about 6 weeks of age the secondary signs of instability
develop. Restriction of abduction becomes more pronounced and
the development of asymmetric thigh creases and limb length discrepancy becomes more obvious. When the child starts to walk a
limp is noted. Commonly, in late presentation cases, the parents
tend to complain of abnormal limb posture and this has to be
taken seriously and a thorough investigation is warranted. A total
of 20% of children with DDH will not have stood up or walked by
18 months compared with just 5% of the normal population.4
After an initial examination in the neonatal period there are
two types of screening programme: a general screening programme where all newborn babies in the health district are subject to an ultrasound examination; and a more selective screening
programme where only babies with a positive clinical examination or a positive risk factor are subjected to an ultrasound
examination. However, there is wide variation in treatment policies and outcomes, making guidelines for clinical screening very
controversial.5 Universal screening is reported to be effective and
has abolished late cases and subsequent hip dysplasia. There is,

Management
The management of DDH strongly depends on the time of diagnosis. The earlier the diagnosis usually means the better the
prognosis. The management can be divided, for the sake of better understanding, into age at diagnosis4,8:
03 months
312 months
1224 months
Over 24 months
03 months
These babies are usually picked from the screening programme
and have the best prognosis. Delayed diagnosis, beyond 3
months, is almost synonymous with surgical intervention.
Treatment at this stage involves the use of an abduction device.
The Von Rosen splint is a fixed abduction device and, although
it holds the hip in abduction, there is significant concern about
the risk of avascular necrosis (AVN) of the cartilaginous femoral head due to contact pressure. As a consequence of this

Neonatal examination by paediatricians

Normal hips

Normal hips
with risk factors

Abnormal hips

No ortho
follow-up

USS screening
clinic 6 weeks

Double nappies
USS clinic 2 weeks

Normal hips

Discharge

Figure 2 A clinical photograph of a baby being screened in one of our

clinics.

PAEDIATRICS AND CHILD HEALTH 18:6

Dysplastic hip

Relocatable

Fixed

Pavlik

Surgery ??

Figure 3 Flowchart giving guidance on the authors preferred screening

choice.

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2008 Elsevier Ltd. All rights reserved.

Symposium: Surgery & orthopaedics

complication the Pavlik harness is more widely used. The popularity of this harness has increased as it dynamically relocates
the head. The various straps in the harness prevent the hips
abducting beyond the midline as well as maintaining flexion
between 90 and 100 degrees. The hips in the harness need to
be closely monitored. Ultrasound has been shown to be very
effective in monitoring the hips during the treatment period
with successful outcomes in 90% of cases where the treatment
started before 6 weeks. However, in patients where the hips are
rigid and do not respond early to treatment, the harness will
need to be abandoned within 23 weeks due to risk of developing AVN. After 6 weeks of continuous usage when the hip is
successfully relocated, the harness should be slowly weaned
away for the next 6 weeks. The use of the harness during nighttime after this is recommended for a further 6-week period.
Radiological follow-up of the development of the hips is continued as the child grows. Figure 4 shows an algorithm for early
management of DDH.

Treatment plan

Pavlik harness for 6 weeks

References
1 Klisic PJ. Congenital dislocation of the hip: a misleading term.
J Bone Joint Surg 1989; 71B: 136.
2 Barlow TG. Early diagnosis and treatment of congenital dislocation
of the hip. J Bone Joint Surg 1962; 44B: 292310.
3 Ortolani M. Un segno poco noto e sua importanza per la diagnosis
precoce di prelussazione congenital dellanca. Pediatria Napoli
1937; 45: 129136.
4 Clarke NMP. Congenital dislocation of the hip. Curr Orthop 2004;
18: 25661.
5 Leck I. An epidemiological assessment of neonatal screening for
dislocation of the hip. J R Coll Physicians Lond 1986; 20: 5662.
6 Graf R. New possibilities for the diagnosis of congenital hip joint
dislocation by ultrasonography. J Pediatr Orthop 1983; 3: 3549.
7 Clarke NMP, Harcke HT, McHugh P, et al. Real time ultrasound in
the diagnosis of congenital dislocation and dysplasia of the hip.
J Bone Joint Surg 1985; 67B: 406412.

Weekly ultrasound

Persists

Resolve

Abandon harness
(? in 2/3 weeks)

Start weaning
after 6 weeks

Regular follow-up
Figure 4 Algorithm for early management of developmental dysplasia
of the hip.

PAEDIATRICS AND CHILD HEALTH 18:6

Pavlik harness
Arthrogram, closed/open reduction
Open reduction
Open reduction + femoral shortening

After 24 months
Diagnosis at this stage requires surgical treatment. It involves
open reduction, which is usually augmented with femoral shortening to decrease the joint pressure, minimising the risk of AVN.
The upper age limit for such treatment lies between 6 and 8 years.
Dislocations after this age are best left as such and, contrary to
past belief, these hips function better.

Initial examination/screening

Discharge

03 months
312 months
1224 months
24 months +

baby to a period of traction prior to this surgical treatment. Other

forms of traction like Hoop traction and serial abduction traction
have all been outdated.
Following an adductor tenotomy and an arthrogram under a
general anaesthetic, the quality of the reduction is assessed. A
concentric reduction can be treated in a spica cast for 3 months.
However, an eccentric reduction necessitates an open reduction.
The baby is then placed in a spica cast for 6 weeks. The spica is
changed every 6 weeks under an anaesthetic and the stability of
the hip is studied on each plaster change. The plan of treatment
is better illustrated in Table 1.
Following closed reduction there is a 60% chance (40% following open reduction) of requiring a secondary procedure usually to address acetabular dysplasia. Complications of treatment
include early displacement and avascular necrosis. An immediate postoperative computed tomography is performed to confirm
hip location. Avascular necrosis rates in the literature vary from
5 to 20%. Prognosis varies with the stage of avascular necrosis10
and can only be ascertained with regular follow-up.

1224 months
Diagnosis at this age means surgical treatment. This may involve
either closed or open reduction. It is not unusual to subject the

Abnormal

Initial treatment plan

Table 1

312 months
These babies have either been diagnosed late (and hence missed
the screening programme) or have had unsuccessful treatment
with the harness. The management of these babies invites a
widespread debate. One group of surgeons advocate early aggressive treatment, which includes arthrogram, adductor tenotomy
and surgical reduction (which may be closed or open). Another
group of surgeons advise the delay of open reduction until there
is radiological evidence of an ossific nucleus in the femoral head.
This coincides with the development of an anastomotic blood
supply within the femoral head, which may reduce the chances
of AVN following treatment.9

Normal

Age at diagnosis

270

2008 Elsevier Ltd. All rights reserved.

Symposium: Surgery & orthopaedics

8 Oxford textbook of orthopaedics and trauma. The Oxford University

Press; 2002.
9 Segal LS, Boal DK, Borthwick L, et al. Avascular necrosis after
treatment of DDH: the protective influence of the ossific nucleus.
J Pediatr Orthop 1999; 19: 17781.
10 Kalamchi A, MacEwan GD. Avascular necrosis following treatment
of congenital dislocation of the hip. J Bone Joint Surg 1980; 62A:
87688.

PAEDIATRICS AND CHILD HEALTH 18:6

Practice points
DDH continues to present late despite clinical screening
programmes
The efficacy of screening is still debatable
Ultrasound is useful in the early management of DDH

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2008 Elsevier Ltd. All rights reserved.