DDH

Question 1

You are performing a routine newborn examination prior to discharge from hospital, and notice that the baby’s right hip is ‘clunky’. The baby otherwise examines normally.

Imp/DDx/Goals

Answer 1

Impression
- most likely DDH, common newborn presentation
- Due to ligamentous laxity +/- dysplasia of the hip, leads to instability of the hip joint and tendency for dislocation

Goals
- conduct thorough assessment and investigation to confirm the diagnosis
- provide appropriate management with referral to orthopaedics for consideration of conservative mx with harnessing, or surgical management (Depending on the severity)

Question 2

DDH - History

Answer 2

History:
- sx: none in this child but in older child look for painless limping/waddling on gait, may have activity related pain in older children
- risk factors: female gender, breech position at >34 weeks, family history, tight lower extremity swaddling
- complete paediatric history: growth, details of pregnancy, complications, feeding, etc

Question 3

DDH - Examination

Answer 3

Examination:
- General appearance + vital signs
- hip inspection: Galleazzi test (apparent femur difference), differences in leg creases (asymmetry)
- Hip examination: Ortolani (open = relocate) and Barlow (break = dislocate) - feeling for palpable clunk on dislocation/relocation
- Newborn screening assessment (full assessment for other abnormalities)

If child is already walking, looking for:
- limping gait
- trendelenburg sign and gait
- prominent GTs

Question 4

DDH - Investigations

Answer 4

Investigations:
- If no exam findings then consider conservative mx
- If positive ortolani vs barlow’s test then need immediate US

Depends on age;
- Ultrasound - preferred in infants from 6 weeks to 6 months
o if alpha angle > 60 then normal
o if alpha angle < 60 then for treatment
- X-Ray - for infants over the age of 6 months: looking for increased acetabular angle
o assess for the alpha angle

Question 5

DDH - Management

Answer 5

Management:
Goal is to maintain reduction of the hip. Management will depend on severity and patient age.
- likely referral to paeds orthodod if non-improving

Mild and less than 8wks:
- regular exam (most will spontaneously reduce)

Moderate/unstable/older than
- referall to paediatric orthopod to initiate appropriate treatment

Definitive treatments:
Conservative
- hip abduction orthosis (pavlik harness)
- closed reduction + spica casting

Surgical
- open reduction + spica casting
- osteomy (reshaping of acetabulum)

Supportive:
- require ongoing review to ensure appropriate development, and that the hip remains reduced and functional
- GP referral