Diagnosis and Referral Pathway for DDH
This DDH Diagnosis Pathway is appropriate for metropolitan regions and also for remote regions that lack access to reliable hip ultrasonography. For patients with certain risk factors and a normal examination the Guidelines of the American Academy of Pediatrics state, “…imaging with an ultrasonographic examination at 6 weeks of age or a radiograph of the pelvis at 4 months of age is recommended.” Therefore, these guidelines substitute the use of radiographs when ultrasound studies may be unavailable or unreliable. This practice should allow non-surgical treatment of most cases of hip dislocation that cannot be detected by clinical examination in the newborn period.
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The DDH Diagnosis Pathway was approved by the Medical Advisory Board of the International Hip Dysplasia Institute in December 2015 after being developed and implemented by the St. Luke’s Health System of Idaho. This system of hospitals provides healthcare services for a wide region of the Northwest United States including remote regions and indigenous people. The accompanying PowerPoint presentation explains the basis for development and implementation. This includes a program for quality assessment and documentation of performance with outcome metrics. For more information, please contact IHDI.
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Examination of the newborn includes the Ortolani and Barlow method. Hip clicks and asymmetrical folds are discussed in the older age group.
The Ortolani method is an examination method that identifies a dislocated hip that can be reduced into the socket (acetabulum). Ortolani described the feeling of reduction as a “Hip Click” but the translation from Italian was interpreted a sound instead of a sensation of the hip moving over the edge of the socket when it re-located. After the age of six weeks, this sensation is rarely detectable and should not be confused with snapping that is common and can occur in stable hips when ligaments in and around the hip create clicking noises. When the Ortolani test is positive because the hip is dislocated, treatment is recommended to keep the hip in the socket until stability has been established
The Barlow method is an examinaiton method that identifies a loose hip that can be pushed out of the socket with gentle pressure. Approximately 80% of “Barlow Positive” hips will resolve spontaneously in the first few weeks of life. Early treatment may be recommended when the hip is “dislocatable” but minor degrees of instability can be treated with multiple diapers followed by an Ultrasound Study at approximately six weeks of age.
A Chan, et.al. Acta Paediatr. 90:836, 2001; and NR Boree and Clarke JBJS 76B:525, 1994
The video clips you will find here have been abstracted from a 21 min video entitled ‘Examination of the newborn’, which was produced for the ‘Skills Center’ (Ferdighetssenteret) by the University of Oslo Photo and Video Service in 2003. This video, which is available on loan from the Skills Center for medical students at The University of Oslo, was the result of a term project by medical students Robert Bentehaugen and Anders Lippert. Filming was done by Christian Nissen and Bjorn Ohnstad, and editing was by Christian Nissen, Robert Bentehaugen, and Anders Lippert. The pediatrician/neonatologist, professor Thor Willy Ruud Hansen, has also written the text which accompanies the clips.
Examination After Age 3 Months – Limited Abduction
In this older age group, the most common finding is limited abduction of the hip. After the age of three months hip dislocation may be fixed and may not be detected by the Ortolani or Barlow methods that are used to examine newborn infants. For this reason the “hip click” described by Ortolani is rarely meaningful after the age of 6-8 weeks. Careful examination with the pelvis level is necessary. Bilateral hip dislocations may be more difficult to identify because they are symmetrically tight. The mother may indicate that it is difficult to apply diapers when both hips are dislocated or she may notice a difference when only one hip is dislocated. The Left hip of the six-month old child shown above is dislocated. Note limited abduction
Limb Length Difference
Difference in thigh lengths may be caused by unilateral hip dislocation. This is detected by the Allis or Galeazzi test. In this test, the hips are flexed and the length of the thighs are compared to see if the knee heights are equal. This is difficult to determine in infants because the pelvis must be perfectly level.
Asymmetrical Buttock Creases
Asymmetrical gluteal creases may be a sign of unilateral hip dysplasia. Thigh folds that are asymmetrical rarely indicate hip dysplasia unless they are associated with uneven gluteal creases.
Conditions that Mimic Hip Dysplasia
- Benign Hip Click
- Asymmetrical Hip Abduction Contracture
- Adductor Muscle Tightness
- Congenital Coxa Vara
- Congenital Short Femur