CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care Evaluation and Referral for Developmental Dysplasia of the Hip in Infants Brian A. Shaw, MD, FAAOS, FAAP, Lee S. Segal, MD, FAAOS, FAAP, SECTION ON ORTHOPAEDICS Developmental dysplasia of the hip (DDH) encompasses a wide spectrum abstract of clinical severity, from mild developmental abnormalities to frank dislocation. Clinical hip instability occurs in 1% to 2% of full-term infants, and up to 15% have hip instability or hip immaturity detectable by imaging studies. Hip dysplasia is the most common cause of hip arthritis in women younger than 40 years and accounts for 5% to 10% of all total hip replacements in the United States. Newborn and periodic screening have This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have been practiced for decades, because DDH is clinically silent during the fi rst fi led confl ict of interest statements with the American Academy year of life, can be treated more effectively if detected early, and can have of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of severe consequences if left untreated. However, screening programs and Pediatrics has neither solicited nor accepted any commercial techniques are not uniform, and there is little evidence-based literature to involvement in the development of the content of this publication. support current practice, leading to controversy. Recent literature shows Clinical reports from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external that many mild forms of DDH resolve without treatment, and there is a lack reviewers. However, clinical reports from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations of agreement on ultrasonographic diagnostic criteria for DDH as a disease or government agencies that they represent. versus developmental variations. The American Academy of Pediatrics has The guidance in this report does not indicate an exclusive course of not published any policy statements on DDH since its 2000 clinical practice treatment or serve as a standard of medical care. Variations, taking guideline and accompanying technical report. Developments since then into account individual circumstances, may be appropriate. include a controversial US Preventive Services Task Force “inconclusive” All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, determination regarding usefulness of DDH screening, several prospective revised, or retired at or before that time. studies supporting observation over treatment of minor ultrasonographic DOI: 10.1542/peds.2016-3107 hip variations, and a recent evidence-based clinical practice guideline PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). from the American Academy of Orthopaedic Surgeons on the detection Copyright © 2016 by the American Academy of Pediatrics and management of DDH in infants 0 to 6 months of age. The purpose of FINANCIAL DISCLOSURE: The authors have indicated they do not have this clinical report was to provide literature-based updated direction for a fi nancial relationship relevant to this article to disclose. the clinician in screening and referral for DDH, with the primary goal of FUNDED: No external funding. preventing and/or detecting a dislocated hip by 6 to 12 months of age in POTENTIAL CONFLICT OF INTEREST: The authors have indicated they an otherwise healthy child, understanding that no screening program have no potential confl icts of interest to disclose. has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain To cite: Shaw BA, Segal LS, AAP SECTION ON ORTHOPAEDICS. controversial. Evaluation and Referral for Developmental Dysplasia of the Hip in Infants. Pediatrics. 2016;138(6):e20163107 Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 6 , December 2016 :e 20163107 FROM THE AMERICAN ACADEMY OF PEDIATRICS INTRODUCTION primarily ultrasonography, have hip will fare poorly if it is unstable created uncertainty regarding and morphologically abnormal by Early diagnosis and treatment of whether minor degrees of anatomic 2 to 3 years of age. It is the opinion developmental dysplasia of the and physiologic variability are of the AAP that DDH fulfills most hip (DDH) is important to provide clinically significant or even screening criteria outlined by Wilson the best possible clinical outcome. abnormal, particularly in the first few and Jungner 4 and that screening DDH encompasses a spectrum of months of life. efforts are worthwhile to prevent a physical and imaging findings, from subluxated or dislocated hip by 6 to mild instability and developmental Normal development of the femoral 12 months of age. variations to frank dislocation. DDH head and acetabulum is codependent; is asymptomatic during infancy the head must be stable in the hip and early childhood, and, therefore, socket for both to form spherically The Ortolani maneuver, in screening of otherwise healthy and concentrically. If the head is which a subluxated or dislocated infants is performed to detect this loose in the acetabulum, or if either femoral head is reduced into uncommon condition. Traditional component is deficient, the entire the acetabulum with gentle hip methods of screening have included hip joint is at risk for developing abduction by the examiner, is the the newborn and periodic physical incongruence and lack of sphericity. most important clinical test for examination and selected use of Most authorities refer to looseness detecting newborn hip dysplasia. radiographic imaging. The American as instability or subluxation and Academy of Pediatrics (AAP) the actual physical deformity of the promotes screening as a primary femoral head and/or acetabulum INCIDENCE, RISK FACTORS, AND care function. However, screening as dysplasia, but some consider NATURAL HISTORY techniques and definitions of hip instability itself to be dysplasia. Incidence clinically important clinical findings Further, subluxation can be static (in are controversial, and despite which the femoral head is relatively The incidence of developmental abundant literature on the topic, uncovered without stress) or dislocation of the hip is quality evidence-based literature is dynamic (the hip partly comes out of approximately 1 in 1000 live births. lacking. the socket with stress). The Ortolani The incidence of the entire spectrum of DDH is undoubtedly higher but not The AAP last published a clinical maneuver, in which a subluxated or truly known because of the lack of practice guideline on DDH in dislocated femoral head is reduced a universal definition. Rosendahl 2000 titled “Early Detection of into the acetabulum with gentle et al 5 noted a prevalence of dysplastic Developmental Dysplasia of the hip abduction by the examiner, is but stable hips of 1.3% in the general Hip.” 1 The purpose of this clinical the most important clinical test for population. A study from the United report is to provide the pediatrician detecting newborn dysplasia. In Kingdom reported a 2% prevalence with updated information for DDH contrast, the Barlow maneuver, in of DDH in girls born in the breech screening, surveillance, and referral which a reduced femoral head is position. 6 based on recent literature, expert gently adducted until it becomes subluxated or dislocated, is a test opinion, policies, and position Risk Factors statements of the AAP and the of laxity or instability and has less Pediatric Orthopaedic Society of clinical significance than the Ortolani Important risk factors for DDH North America (POSNA), and the maneuver. In a practical sense, both include breech position, female sex, 2014 clinical practice guideline of the maneuvers are performed seamlessly incorrect lower-extremity swaddling, American Academy of Orthopaedic in the clinical assessment of an and positive family history. These Surgeons (AAOS). 1 – 3 infant’s hip. Mild instability and risk factors are thought to be morphologic differences at birth are additive. Other suggested findings, considered by some to be pathologic such as being the first born or having DEFINITIONS and by others to be normal torticollis, foot abnormalities, or developmental variants. oligohydramnios, have not been A contributing factor to the DDH proven to increase the risk of screening debate is lack of a uniform In summary, there is lack of universal “nonsyndromic” DDH. 3, 7 definition of DDH. DDH encompasses agreement on what measurable a spectrum of pathologic hip parameters at what age constitute Breech presentation may be the disorders in which hips are unstable, developmental variation versus most important single risk factor, subluxated, or dislocated and/ actual disease. Despite these with DDH reported in 2% to 27% or have malformed acetabula. 1 differences in definition, there is of boys and girls presenting in the However, imaging advancements, universal expert agreement that a breech position. 6, 8, 9 Frank breech Downloaded from www.aappublications.org/news by guest on September 27, 2021 e2 FROM THE AMERICAN ACADEMY OF PEDIATRICS presentation in a girl (sacral Traditional swaddling maintains the severe end of the disease spectrum presentation with hips flexed and hips