DEVELOPMENTAL
DYSPLASIA OF HIP
DEPARTMENT OF ORTHOPAEDICS
AFMC, PUNE
ARMED FORCES MEDICAL COLLEGE, PUNE
The clinical presentation of developmental dysplasia of the hip varies according to the age of the
child
Careful clinical examination is required especially in newborns (<6 months old) because
radiographs are not always reliable in making the diagnosis of developmental dysplasia
The infant should be calm, relaxed, and pacified during the examination, and only one hip should
be examined at a time.
Clinical features
ARMED FORCES MEDICAL COLLEGE, PUNE
IN NEONATES
DDH in the neonate is diagnosed by eliciting Ortolani or Barlow sign
The hip is adducted, and a gentle push is applied to slide the hip posteriorly. The examiner’s
fingers are positioned over the greater trochanter, and the trochanter is allowed to move
laterally.
In a positive test,the hip will be felt to slide out of the acetabulum. As the examiner relaxes
the proximal push, the hip can be felt to slip back into the acetabulum.
ARMED FORCES MEDICAL COLLEGE, PUNE
BARLOW TEST
Ortolani test
ARMED FORCES MEDICAL COLLEGE, PUNE
Ortolani test is the reverse of the Barlow test
In this the examiner attempts to reduce a dislocated hip
The examiner grasps the child’s thigh between the thumb and the index finger and, with the fourth and
fifth fingers, lifts the greater trochanter while simultaneously abducting the hip.
When the test result is positive, the femoral head will slip into the socket with a delicate “clunk” that is
palpable but not audible.
Patients who had negative clinical examination results during the neonatal period present at an older
age with dysplasia and hence follow should be done in patient with high risk
ARMED FORCES MEDICAL COLLEGE, PUNE
ORTOLANI’S TEST
IN INFANT
Progression from instability to dislocation during the newborn period is a gradual process.
ARMED FORCES MEDICAL COLLEGE, PUNE
Few may develop an irreducible dislocation within a few weeks, whereas in others the hip
dislocation remains reducible until they are 5 or 6 months old
When the hip is no longer reducible, specific physical findings appear, including
limited abduction
shortening of the thigh
proximal location of the greater trochanter
asymmetry of the thigh folds
pistoning of the hip
The limitation of abduction, which is the most reliable sign of a dislocated hip, is best appreciated by
ARMED FORCES MEDICAL COLLEGE, PUNE
abducting both hips simultaneously with the child on a firm surface
Shortening of the thigh - examined by placing both hips in 90 degrees of flexion and
comparing the height of the knees, looking for asymmetry
ARMED FORCES MEDICAL COLLEGE, PUNE
GALEAZZI TEST
Because the thigh is foreshortened, there will be more thigh folds on the affected
side than on the normal side
ARMED FORCES MEDICAL COLLEGE, PUNE
KLISIC TEST
ARMED FORCES MEDICAL COLLEGE, PUNE
Useful in bilateral dislocation
In this the examiner places the third finger over the greater trochanter and the index finger on the
anterior superior iliac spine.
An imaginary line drawn between the fingers should point to the umbilicus. When the hip is dislocated,
the more proximal greater trochanter causes the line to point approximately halfway between the
umbilicus and the pubis
IN WALKING CHILD
ARMED FORCES MEDICAL COLLEGE, PUNE
Shortening of limb
Abductor lurch or Trendelenburg gait - With each step, the pelvis drops as the
dislocated hip adducts, and the child leans over the dislocated hip
Wadling gait in bilateral cases
Excessive lordosis due flexion contracture of hip
Trendelenburg sign
ARMED FORCES MEDICAL COLLEGE, PUNE
Trendelenburg sign
ARMED FORCES MEDICAL COLLEGE, PUNE
Excessive lumbar lordosis
Radiographic evaluation
ARMED FORCES MEDICAL COLLEGE, PUNE
Plain radiography of the pelvis usually demonstrates a frankly dislocated hip in individuals of
any age.
In newborns with typical DDH, however, the unstable hip may appear radiographically
normal
Several classic radiographic lines are helpful when evaluating the immature hip
The Hilgenreiner line is a line through the triradiate cartilage
The Perkin line is drawn at the lateral margin of the acetabulum, is perpendicular to the
ARMED FORCES MEDICAL COLLEGE, PUNE
Hilgenreiner line.
The Shenton line is a curved line that begins at the lesser trochanter, goes up the femoral
neck, and connects with a line along the inner margin of the pubis.
In a normal hip, the medial beak of the femoral metaphysis lies in the lower, inner
ARMED FORCES MEDICAL COLLEGE, PUNE
quadrant produced by the juncture of the Perkin and Hilgenreiner lines and the
Shenton line is smooth
In the dislocated hip, the metaphysis lies lateral to the Perkin line and the Shenton
line is broken
Acetabular index
angle formed by the juncture of the Hilgenreiner line and a line drawn along the acetabular
surface
ARMED FORCES MEDICAL COLLEGE, PUNE
In normal newborns, the acetabular index averages 27.5 degrees.
At 6 months of age, the mean is 23.5 degrees.
By 2 years of age, the index usually decreases to 20 degrees.
Thirty degrees is considered the upper limit of normal
Lateral center- edge angle
lateral center–edge angle is formed at the juncture of the Perkin line with a line that connects the lateral
margin of the acetabulum to the center of the femoral head.
ARMED FORCES MEDICAL COLLEGE, PUNE
It is a useful measure of hip position
In children who are 6 to 13 years old, an angle of more than 19 degrees and in children who are 14 years
old and older, an angle of more than 25 degrees is considered normal
Normal range 25 – 40 degrees ,reduced in case of DDH
Anterior center edge angle
Anterior center edge angle is measured in false-profile radiographic view hip
ARMED FORCES MEDICAL COLLEGE, PUNE
Helps to determine extent of anterior coverage of femoral head
the mean value is 32.8 degrees, with a range of 17.7 to 53.6 degrees
ARMED FORCES MEDICAL COLLEGE, PUNE
Acetabular tear drop - The teardrop usually appears between 6 and 24 months of age in
a normal hip and later in a dislocated hip
When the hip is dislocated or subluxated, the acetabular portion of the teardrop loses its
convexity, and the teardrop is wider from the superior to the inferior directions.
ARMED FORCES MEDICAL COLLEGE, PUNE
Acetabular index of depth to width - in which the depth of the central portion of the
acetabulum is divided by the width of the acetabular opening, with normal being more than
38%.
Femoral head extrusion index - represents the percentage of the femoral head that lies outside
of the acetabulum.
Ultrasonography
ARMED FORCES MEDICAL COLLEGE, PUNE
Ultrasonography useful in studying anatomy of the hip and the relationship of the femoral head
and the acetabulum
A lateral imaging technique with the transducer placed over the greater trochanter is
recommended
Graf ultrasound classification system for DDH is based on the angles formed by the sonographic
structures of the hip
“baseline” is the line of the ilium as it intersects the bony and cartilaginous portions of the
acetabulum.
The “inclination line” is the line along the margin of the cartilaginous acetabulum.
The third line is the “acetabular roofline” along the bony roof .
ARMED FORCES MEDICAL COLLEGE, PUNE
The intersection of the roofline and the baseline forms the alpha angle, whereas the intersection of the
inclination line and the baseline forms the beta angle.
A smaller alpha angle indicates a shallower bony acetabulum. A smaller beta angle indicates a better
cartilaginous acetabulum.
The femoral head subluxates, the alpha angle decreases, and the beta angle increases
In simplest form GRAF classification - class I hips are normal, class II hips are either immature or
somewhat abnormal, class III hips are subluxated, and class IV hips are dislocated
ARMED FORCES MEDICAL COLLEGE, PUNE
ARMED FORCES MEDICAL COLLEGE, PUNE
ARMED FORCES MEDICAL COLLEGE, PUNE
ARMED FORCES MEDICAL COLLEGE, PUNE
Arthrography
In infants or young patients with missed DDH, arthrography is typically performed intraoperatively at the time
ARMED FORCES MEDICAL COLLEGE, PUNE
of reduction to assess the anatomy of the hip and impediments to reduction
While performing a reconstructive osteotomy, the arthrogram helps to demonstrate the best position of the
femur to obtain concentric reduction of the hip and thus helps in planning correction
In the normal hip, the free border of the labrum is easily seen as a sharp “thorn” overlying the femoral head .A
recess of joint capsule overlies this thorn and medial pooling less than 5mm
ARMED FORCES MEDICAL COLLEGE, PUNE
In a child with DDH, when the hip is in the dislocated position, the acetabular edge is seen,
and the capsule is enlarged as it extends over the femoral head. The capsule is constricted at its
ARMED FORCES MEDICAL COLLEGE, PUNE
middle portion into an hourglass shape by the iliopsoas tendon
Athrogram following poor reduction
ARMED FORCES MEDICAL COLLEGE, PUNE
MRI
It is not commonly used because of the expense involved and the need for sedation
ARMED FORCES MEDICAL COLLEGE, PUNE
MRI findings include the widening of the iliac bone, the lateral drift of the superior and posterior
portions of the acetabular floor, the overgrowth of the acetabular cartilage, and the convexity of the
posterior portion of the acetabular cartilage
MRI with gadolinium-contrast arthrography is an important tool for the evaluation of the adolescent
patient with hip dysplasia for the evaluation of the condition of the labrum and the articular cartilage of
the hip joint.
Disruption and tears of the labrum, cartilage delamination, and articular cartilage loss can be identified
ARMED FORCES MEDICAL COLLEGE, PUNE
Computed tomography
ARMED FORCES MEDICAL COLLEGE, PUNE
In infants, plain films in cast have been used to evaluate the postreduction hip, but CT provides
superior information
In addition to assessing the quality of reduction, the degree of dysplasia can also be ascertained
In patients where pelvic osteotomy is planned, CT scan aids in planning reconstruction especially in
localizing the location and magnitude of acetabular deficiency
Normally postioned hip hip after closed reduction
ARMED FORCES MEDICAL COLLEGE, PUNE
ARMED FORCES MEDICAL COLLEGE, PUNE
NCCT showing dislocated hip
NCCT showing normal and dysplastic acetabulum
ARMED FORCES MEDICAL COLLEGE, PUNE
