• Clinical science

Developmental dysplasia of the hip

Summary

Developmental dysplasia of the hip (DDH) refers to hip instability, subluxation/dislocation of the femoral head, and/or acetabular dysplasia in a developing hip joint. The etiology is not yet fully understood but a breech presentation and family history of DDH are the most important risk factors. The clinical features depend on the age of the child. During the first 6 months, the child will be asymptomatic but the hip can be easily dislocated, and a clunk is felt during a hip examination. As the child grows older, contractures develop and abduction of the hip becomes limited. Deformities and leg length discrepancies also develop. A patient with DDH is at increased risk of accelerated osteoarthritis. Since DDH is a common congenital abnormality, all newborns must be screened by physical examination for DDH. Additional screening with imaging is recommended for children with a family history of DDH, a history of breech presentation, and/or clinical features of DDH. Ultrasonography is the imaging modality of choice for infants younger than 4 months, whereas x-rays are used for older children. The goal of treatment is to reduce and maintain the femoral head into the acetabulum as early as possible to allow the hip joint to develop normally. A rigid harness is used in children younger than 6 months. Children 6–18 months of age should be treated with closed reduction, while children older than 18 months should be treated with open reduction. Following either closed or open reduction, the hip should be immobilized in a hip spica cast. The prognosis is not good if treatment is initiated after 6 months.

Epidemiology

  • Incidence: most common congenital abnormality of skeletal development [1]
    • Hip instability: 1 in 100 births
    • Dislocation: 1 in 1000 births
  • Sex: > (4–5:1) [2]
  • Racial/regional background [1]
    • High incidence in Native American, Eastern European, and Sami populations
    • Low incidence in Chinese and black populations

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Pathophysiology

Clinical features

Age Clinical features [3]
< 6 months
6–18 months
> 18 months

A positive Barlow sign shows that the reduced hip is subluxatable or dislocatable. A positive Ortolani sign shows that a dislocated hip is reducible.

Leg length discrepancy, Galeazzi sign, and/or asymmetrical gluteal folds may be absent in patients with bilateral DDH.

Diagnostics

Screening [4]

  • Physical examination must be performed at every well-baby visit for up to 6 months
  • Screening with imaging is recommended up to 6 months of age only if one or more of the following risk factors are present

Imaging [4]

  • Hip ultrasound: imaging of choice in all infants younger than 4 months
    • Alpha angle < 60°
    • Beta angle > 55°
  • Pelvic x-ray (in AP and frog leg lateral view): imaging of choice in infants older than 4 months (when cartilage begins to ossify)
    • Findings of hip dislocation
      • Interrupted Shenton's line
      • The ossified nucleus of the femoral head lies at or above Hilgenreiner line
      • The ossified nucleus of the femoral head lies at or lateral to Perkin line
    • Findings of acetabular dysplasia
      • Acetabular angle > 30° after 4 months
      • Center-edge angle < 19° in the age group 6–13 years, or < 25° in children older than 14 years
  • Arthrogram: indicated following closed reduction to ensure successful reduction (see “Treatment” below)
  • Hip CT: imaging of choice to follow up patients with a hip spica (see “Treatment” below)
  • Hip MRI: not used in the diagnosis of DDH

Ultrasound is the imaging technique of choice for diagnosis of DDH in infants less than 4 months while x-ray is the imaging modality of choice for infants older than 4 months.

Treatment

  • < 6 months
    • Pavlik harness (most commonly used splinting device) that maintains the hips in 90–100° of flexion and 50° of abduction [3]
    • Alternatives: rigid harnesses (e.g., von Rosen harness)
  • 6–18 months; or failure of bracing: closed reduction followed by immobilization with a hip spica cast [5]
  • > 18 months; or failure of closed reduction: surgical therapy (open reduction possibly with a pelvic/femoral osteotomy) followed by immobilization with a hip spica cast
  • Older adolescents or adults: total hip arthroplasty


Differential diagnoses

See “Differential diagnosis of pediatric hip pain.”

The differential diagnoses listed here are not exhaustive.

Complications

We list the most important complications. The selection is not exhaustive.

Prognosis

  • The outcomes of children with DDH who receive early treatment are generally good. [3]
  • The reappearance of a U shaped acetabular teardrop shadow (kohle's shadow) after reduction is an indicator of good hip function.
  • Factors associated with a poor prognosis [5]
    • Late initiation of treatment (especially after 6 months)
    • Need for open reduction
    • Failure of a first-line treatment
    • Possibly, bilateral hip dislocation
  • 1. Loder RT, Skopelja EN. The epidemiology and demographics of hip dysplasia. ISRN Orthop. 2011; 238607. doi: 10.5402/2011/238607.
  • 2. Ortiz-Neira CL, Paolucci EO, Donnon T. A meta-analysis of common risk factors associated with the diagnosis of developmental dysplasia of the hip in newborns. Eur J Radiol. 2012; 81(3): pp. e344–e351. doi: 10.1016/j.ejrad.2011.11.003.
  • 3. Kotlarsky P. Developmental dysplasia of the hip: What has changed in the last 20 years?. World Journal of Orthopedics. 2015; 6(11): p. 886. doi: 10.5312/wjo.v6.i11.886.
  • 4. Mulpuri K, Song KM, Gross RH, et al. Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age: Evidence-based Clinical Practice Guideline. J Am Acad Orthop Surg. 2015; 23(3): pp. 202–205. doi: 10.5435/JAAOS-D-15-00006.
  • 5. Sewell MD, Rosendahl K, Eastwood DM. Developmental dysplasia of the hip. BMJ. 2009; 339(nov24 2): pp. b4454–b4454. doi: 10.1136/bmj.b4454.
last updated 11/07/2020
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