Developmental dysplasia of the hip in neonates

Please note that some guidelines may be passed their review date. The review process is currently paused. It is recommended that you also refer to more contemporaneous evidence.

Developmental dysplasia of the hip (DDH) is the preferred term for the disease previously referred to as congenital dislocation of the hip since it recognises that presentation can follow a normal examination of the hips in the newborn period. Some facts:

• Highest risk in breech presentation and positive family history.
• Prevalence is higher in firstborn and females.
• DDH refers to a spectrum of disorders of hip instability producing subluxation or dislocation and imaging features of poor acetabular development.
• Early detection is vital. If DDH is left untreated the hip joint develops abnormally and surgical reduction is required. By contrast, early conservative management with splinting (for example, Denis-Browne splint) or Pavlik harness allows the hip joint to develop normally and avoids the need for surgery in most cases.

Pathogenic factors for DDH

Developmental hip dysplasia may be caused by:

• abnormal rotation of the developing hip during the first trimester
• neuromuscular disease, especially in the second trimester
• abnormal mechanical forces such as oligohydramnios, breech presentation (particularly frank breech), in the third trimester
• female infants (who are more susceptible to the maternal hormone relaxin)
• postnatal mechanical forces associated with swaddling or wrapping (African infants strapped to their mothers' backs with hips abducted have a very low incidence of DDH).

Screening algorithm

• All newborn infants should have the Ortolani and Barlow tests performed by a trained examiner as part of the routine newborn examination.
• Unfortunately, infants who are unwell after birth and who require admission to neonatal intensive or special care units often have this important part of their newborn examination omitted.
• It must always be documented that the examination has been performed both in the infant's medical record and child health record.
• Infants in whom the examiner is uncertain of the findings should be re-examined by a more experienced clinician prior to discharge.
• Inexperienced examiners who are unsure whether what they are feeling is a 'click' (which can be a common finding caused by ligaments moving over bony prominences) or a 'clunk' are advised to enlist expert help.
• Infants in whom either test is positive should be assessed by an experienced clinician prior to discharge and fitted with a splint/harness. In the absence of an experienced clinician at your health service, referral to an orthopaedic specialist is desirable. Ultrasound can help confirm the clinical signs and assist in monitoring the response to treatment.
• The longer the hip is left in abnormal position the more the anatomy changes, developing abnormalities of the proximal femur and acetabulum. After 18 months, both bones may need surgical correction to provide joint congruity and stability.
• Since DDH can develop over time, all infants (both high and low risk) with normal newborn examinations should have their hips regularly re-examined during the first year of life

High-risk infants may need ultrasound

High-risk infants in whom examination is normal should have ultrasonography performed at about six to 12 weeks after birth or at six to eight weeks corrected age if born prematurely.

High risk infants include:

• family history of DDH (one or more first-degree relative or two or more second-degree relatives)
• breech presentation
• neuromuscular disease such as arthrogryposis or spina bifida
• low liquor volume
• birthweight over 5 kg.