Developmental dysplasia of the hip: Clinical features and diagnosis
- Scott B Rosenfeld, MD
Scott B Rosenfeld, MD
- Assistant Professor of Pediatric Orthopaedic Surgery and Scoliosis
- Baylor College of Medicine
Developmental dysplasia of the hip (DDH) describes a spectrum of conditions related to the development of the hip in infants and young children. It encompasses abnormal development of the acetabulum and proximal femur and mechanical instability of the hip joint (table 1).
Newborns often have physiologic laxity of the hip and immaturity of the acetabulum during the first few weeks of life. In most cases, the laxity resolves, and the acetabulum proceeds to develop normally. With assessment of risk factors, serial physical examination of the hips, and appropriate use of imaging studies, most children with pathologic hips can be correctly diagnosed and treated without long-term sequelae. (See "Developmental dysplasia of the hip: Treatment and outcome".)
Typical DDH, which generally occurs in otherwise healthy infants, will be the focus of this topic review. Hip dysplasia and instability also occur in association with other conditions. Teratologic hip dysplasia occurs in association with various syndromes (eg, Ehlers-Danlos, Down syndrome, arthrogryposis), and neuromuscular hip dysplasia occurs when there is weakness and/or spasticity in some or all of the hip muscle groups (eg, in spina bifida or cerebral palsy). The diagnosis and management of teratologic and neuromuscular hip dysplasia differ from the diagnosis and management of hip dysplasia in otherwise healthy infants.
The clinical features and diagnosis of DDH in otherwise healthy children will be reviewed here. The epidemiology, pathogenesis, treatment, and outcome are discussed separately. (See "Developmental dysplasia of the hip: Epidemiology and pathogenesis" and "Developmental dysplasia of the hip: Treatment and outcome".)
The clinical features of DDH depend upon the age of the child and the severity of the abnormality (table 2). The spectrum of presentation ranges from instability on the newborn examination, to subtle limited abduction in the infant, to asymmetric gait in the toddler, to activity-related pain in the adolescent, to osteoarthritis in the adult. The earlier DDH is detected, the simpler and more effective the treatment and the better the long-term outcome [1,2]. (See "Developmental dysplasia of the hip: Treatment and outcome".)
- Weinstein SL, Mubarak SJ, Wenger DR. Developmental hip dysplasia and dislocation: Part II. Instr Course Lect 2004; 53:531.
- Shaw BA, Segal LS, SECTION ON ORTHOPAEDICS. Evaluation and Referral for Developmental Dysplasia of the Hip in Infants. Pediatrics 2016; 138.
- Lambeek AF, De Hundt M, Vlemmix F, et al. Risk of developmental dysplasia of the hip in breech presentation: the effect of successful external cephalic version. BJOG 2013; 120:607.
- American Academy of Orthopaedic Surgeons. Detection and nonoperative management of pediatric developmental dysplasia of the hip in infants up to six months of age. Evidence-based clinical practice guideline. September 2014. http://www.aaos.org/research/guidelines/DDHGuidelineFINAL.pdf.
- Schwend RM, Schoenecker P, Richards BS, et al. Screening the newborn for developmental dysplasia of the hip: now what do we do? J Pediatr Orthop 2007; 27:607.
- Patel H, Canadian Task Force on Preventive Health Care. Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns. CMAJ 2001; 164:1669.
- BARLOW TG. EARLY DIAGNOSIS AND TREATMENT OF CONGENITAL DISLOCATION OF THE HIP. Proc R Soc Med 1963; 56:804.
- Ortolani M. Congenital hip dysplasia in the light of early and very early diagnosis. Clin Orthop Relat Res 1976; :6.
- COLEMAN SS. Diagnosis of congenital dysplasia of the hip in the newborn infant. J Am Med Assoc 1956; 162:548.
- Bond CD, Hennrikus WL, DellaMaggiore ED. Prospective evaluation of newborn soft-tissue hip "clicks" with ultrasound. J Pediatr Orthop 1997; 17:199.
- Kane TP, Harvey JR, Richards RH, et al. Radiological outcome of innocent infant hip clicks. J Pediatr Orthop B 2003; 12:259.
- Dezateux C, Brown J, Arthur R, et al. Performance, treatment pathways, and effects of alternative policy options for screening for developmental dysplasia of the hip in the United Kingdom. Arch Dis Child 2003; 88:753.
- Baronciani D, Atti G, Andiloro F, et al. Screening for developmental dysplasia of the hip: from theory to practice. Collaborative Group DDH Project. Pediatrics 1997; 99:E5.
- Poul J, Bajerova J, Sommernitz M, et al. Early diagnosis of congenital dislocation of the hip. J Bone Joint Surg Br 1992; 74:695.
- Fulton MJ, Barer ML. Screening for congenital dislocation of the hip: an economic appraisal. Can Med Assoc J 1984; 130:1149.
- Burger BJ, Burger JD, Bos CF, et al. Neonatal screening and staggered early treatment for congenital dislocation or dysplasia of the hip. Lancet 1990; 336:1549.
- Groarke PJ, McLoughlin L, Whitla L, et al. Retrospective Multicenter Analysis of the Accuracy of Clinical Examination by Community Physicians in Diagnosing Developmental Dysplasia of the Hip. J Pediatr 2017; 181:163.
- Dunn PM. Perinatal observations on the etiology of congenital dislocation of the hip. Clin Orthop Relat Res 1976; :11.
- Ando M, Gotoh E. Significance of inguinal folds for diagnosis of congenital dislocation of the hip in infants aged three to four months. J Pediatr Orthop 1990; 10:331.
- Screening for the detection of congenital dislocation of the hip. Arch Dis Child 1986; 61:921.
- Novacheck TF. Developmental dysplasia of the hip. Pediatr Clin North Am 1996; 43:829.
- Choudry Q, Goyal R, Paton RW. Is limitation of hip abduction a useful clinical sign in the diagnosis of developmental dysplasia of the hip? Arch Dis Child 2013; 98:862.
- Castelein RM, Korte J. Limited hip abduction in the infant. J Pediatr Orthop 2001; 21:668.
- Sankar WN, Neubuerger CO, Moseley CF. Femoral anteversion in developmental dysplasia of the hip. J Pediatr Orthop 2009; 29:885.
- Loder RT, Skopelja EN. The epidemiology and demographics of hip dysplasia. ISRN Orthop 2011; 2011:238607.
- Wedge JH, Wasylenko MJ. The natural history of congenital dislocation of the hip: a critical review. Clin Orthop Relat Res 1978; :154.
- Wedge JH, Wasylenko MJ. The natural history of congenital disease of the hip. J Bone Joint Surg Br 1979; 61-B:334.
- Weinstein SL. Natural history of congenital hip dislocation (CDH) and hip dysplasia. Clin Orthop Relat Res 1987; :62.
- Crawford AH, Mehlman CT, Slovek RW. The fate of untreated developmental dislocation of the hip: long-term follow-up of eleven patients. J Pediatr Orthop 1999; 19:641.
- Bialik V, Bialik GM, Blazer S, et al. Developmental dysplasia of the hip: a new approach to incidence. Pediatrics 1999; 103:93.
- Castelein RM, Sauter AJ. Ultrasound screening for congenital dysplasia of the hip in newborns: its value. J Pediatr Orthop 1988; 8:666.
- Terjesen T, Holen KJ, Tegnander A. Hip abnormalities detected by ultrasound in clinically normal newborn infants. J Bone Joint Surg Br 1996; 78:636.
- Marks DS, Clegg J, al-Chalabi AN. Routine ultrasound screening for neonatal hip instability. Can it abolish late-presenting congenital dislocation of the hip? J Bone Joint Surg Br 1994; 76:534.
- Dezateux C, Rosendahl K. Developmental dysplasia of the hip. Lancet 2007; 369:1541.
- Harris NH, Lloyd-Roberts GC, Gallien R. Acetabular development in congenital dislocation of the hip. With special reference to the indications for acetabuloplasty and pelvic or femoral realignment osteotomy. J Bone Joint Surg Br 1975; 57:46.
- Schwend RM, Pratt WB, Fultz J. Untreated acetabular dysplasia of the hip in the Navajo. A 34 year case series followup. Clin Orthop Relat Res 1999; :108.
- Wood MK, Conboy V, Benson MK. Does early treatment by abduction splintage improve the development of dysplastic but stable neonatal hips? J Pediatr Orthop 2000; 20:302.
- Lehmann HP, Hinton R, Morello P, Santoli J. Developmental dysplasia of the hip practice guideline: technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics 2000; 105:E57.
- Elbourne D, Dezateux C, Arthur R, et al. Ultrasonography in the diagnosis and management of developmental hip dysplasia (UK Hip Trial): clinical and economic results of a multicentre randomised controlled trial. Lancet 2002; 360:2009.
- American College of Radiology. ACR Appropriateness Criteria. Developmental dylsplasia of the hip--child. www.acr.org/Quality-Safety/Appropriateness-Criteria (Accessed on August 21, 2012).
- Dias JJ, Thomas IH, Lamont AC, et al. The reliability of ultrasonographic assessment of neonatal hips. J Bone Joint Surg Br 1993; 75:479.
- American Institute of Ultrasound in Medicine, American College of Radiology. AIUM practice guideline for the performance of an ultrasound examination for detection and assessment of developmental dysplasia of the hip. J Ultrasound Med 2009; 28:114.
- Graf R. New possibilities for the diagnosis of congenital hip joint dislocation by ultrasonography. J Pediatr Orthop 1983; 3:354.
- Harcke HT, Pruszczynski B. Hip ultrasound for developmental dysplasia: the 50% rule. Pediatr Radiol 2017; 47:817.
- Harcke HT, Grissom LE. Performing dynamic sonography of the infant hip. AJR Am J Roentgenol 1990; 155:837.
- Hensinger RN. Standards in Pediatric Orthopedics: Tables, Charts, and Graphs Illustrating Growth, Lippincott Williams & Wilkins, Philadelphia 1986. p.68.
- Desai AA, Martus JE, Schoenecker J, Kan JH. Spica MRI after closed reduction for developmental dysplasia of the hip. Pediatr Radiol 2011; 41:525.
- Jaramillo D, Villegas-Medina O, Laor T, et al. Gadolinium-enhanced MR imaging of pediatric patients after reduction of dysplastic hips: assessment of femoral head position, factors impeding reduction, and femoral head ischemia. AJR Am J Roentgenol 1998; 170:1633.
- Mulpuri K, Song KM, Gross RH, et al. The American Academy of Orthopaedic Surgeons Evidence-Based Guideline on Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age. J Bone Joint Surg Am 2015; 97:1717.
- Pacana MJ, Hennrikus WL, Slough J, Curtin W. Ultrasound Examination for Infants Born Breech by Elective Cesarean Section With a Normal Hip Exam for Instability. J Pediatr Orthop 2017; 37:e15.
- Imrie M, Scott V, Stearns P, et al. Is ultrasound screening for DDH in babies born breech sufficient? J Child Orthop 2010; 4:3.
- Godley DR. Assessment, diagnosis, and treatment of developmental dysplasia of the hip. JAAPA 2013; 26:54.
- Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics 2006; 117:e557.
- US Preventive Services Task Force. Screening for developmental dysplasia of the hip: recommendation statement. Pediatrics 2006; 117:898.
- Mahan ST, Katz JN, Kim YJ. To screen or not to screen? A decision analysis of the utility of screening for developmental dysplasia of the hip. J Bone Joint Surg Am 2009; 91:1705.
- McAbee GN, Donn SM, Mendelson RA, et al. Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States. Pediatrics 2008; 122:e1282.
- CLINICAL FEATURES
- - Overview
- - General examination
- - Age-specific findings of DDH
- - Hip instability
- - Asymmetry
- - Range of motion
- - Klisic test
- - Bilateral dislocation
- - Dysplasia without dislocation
- Natural history
- DIAGNOSTIC IMAGING
- Plain radiographs
- Other imaging
- APPROACH TO DIAGNOSIS AND REFERRAL
- Positive Ortolani or limited/asymmetric abduction
- Positive Barlow
- Suboptimal or inconclusive examination
- Normal examination and risk factors
- Normal examination and no risk factors
- DIFFERENTIAL DIAGNOSIS
- SCREENING FOR DDH
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS