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Presentations of Hip DysplasiaNeonatal Hip DysplasiaIdeally, DDH is detected by routine history and physical exam in the neonatal period. Questions to the parents regarding risk factors can be important. Clinical screening is the gold standard for diagnosis with dynamic hip examinations carried out at birth and at subsequent pediatrician visits throughout childhood. The Ortolani test and Barlow maneuver should be done at each exam. The Ortolani Test: The examiner’s hands are placed over the child’s knees with his/her thumbs on the medial thigh and the fingers placing a gentle upward stress on the lateral thigh and greater trochanter area. With slow abduction, a dislocated and reducible hip will reduce with a described palpable “clunk.” The Barlow Maneuver is done by guiding the hips into mild adduction and applying a slight forward pressure with the thumb. If the hip is unstable, the femoral head will slip over the posterior rim of the acetabulum, again producing a palpable sensation of subluxation or dislocation. In Infants, the Degree of Instability Can Be Described As:
Hip Dysplasia Presentations in the Infant 2 Months or OlderAfter 2-3 months of age, the Ortolani test and Barlow maneuvers are less sensitive but several other physical exam findings become more apparent:
Hip Dysplasia Presentations in the Walking Child
Hip Dysplasia Presentations in Preadolescents and Adolescents
Other Possible Late Presentations
How Is Hip Dysplasia Evaluated?Children under 6 months of age: Beyond clinical screening exams, US (ultrasound) is the preferred technique. Though US screening of all infants is not advised, infants with identified risk factors or questionable exams should be routinely screened. With a normal exam, screening US should be delayed until at least 4-6 weeks, when hip maturation improves exam specificity. US is also used to document reduction and follow the improvement or maturity of a dysplastic hip following treatment. Children 6 months of age or older: Plain radiographic evaluation is used. On an AP radiograph, lines which localize the femoral head in relationship to the acetabulum-- Hilgenreiner’s, Perkin’s, and the acetabular index--can be drawn and measured. The proximal femoral metaphysis should lie medial to Perkin’s line, within the inner and lower quadrant of the resulting grid. In the dysplastic hip, the normal acetabular index (around 25 to 27 degrees) is increased. Other findings include disruption of Shenton’s line, delay in epiphyseal ossification and/or a widened or delayed “teardrop” appearance. Plain radiographs and measurements are also used to follow hip development and maturation. How Is Hip Dysplasia Treated?Once DDH is identified, prompt referral to a pediatric orthopedist is suggested. Birth to 6 months: Immature, stable hips (Barlow negative) that become normal do not need treatment. Hips that are Barlow positive at birth may also become stable in the first 3 weeks of life; therefore, treatment may be delayed. In both cases, close follow-up and routine physical exams are required, plus a later US to document normal hip stability and development. With an unstable, Ortolani positive hip, early treatment is required. Reduced hips are positioned in flexion and mild abduction to stimulate normal joint development, most commonly performed via the Pavlik harness, a dynamic brace which positions the thighs to allow and maintain hip reduction. Infants are followed bi-weekly for strap adjustment. Progress is monitored and reduction verified with subsequent US evaluations. Pavlik treatment continues until US parameters have normalized and the hip stabilized on exam, on average 2-3 months later. Follow-up through skeletal maturity is then emphasized. 6 months to 1-2 years: Children who present at this time or fail to stabilize with the Pavlik harness require genera anesthesia, followed by closed or open hip reduction and spica casting. Over 2 years of age: Older children may require extensive open surgical reductions with possible femoral and pelvic osteotomies (cutting and realigning the bones), followed by a spica cast. Outcomes of TreatmentTreatment success depends on the child’s age and the success of repositioning. Many cases treated in the first 6 months of life with a Pavlik harness recover and develop normally with no long-term problems. The older the child or less successful the reduction, the greater the possible need for repeated surgeries or eventual hip arthritis and subsequent replacements later in life. You Might Also Be Interested In
Pavlik HarnessDoes your child wear a pavlik harness? This Helping Hand can aid you in day to day activities with your child in a pavlik harness.
Blog Hip Dysplasia in Children: Causes, Symptoms and TreatmentFor parents, a diagnosis of Developmental Dysplasia of the Hip (DDH) brings a wide range of emotions and responses. Parents want to understand not only the condition, but what the future holds for their child after diagnosis. Which clinical finding suggests developmental dysplasia of the hip in an infant?Early clinical manifestations of developmental dysplasia of the hip (DDH) are identified during examination of the newborn. The classic examination finding is revealed with the Ortolani maneuver, in which a palpable "clunk" is present when the hip is directed in and out of the acetabulum and over the neolimbus.
Which finding would the nurse see when assessing a newborn for developmental dysplasia of the hip?Hip Dysplasia Presentations in the Infant 2 Months or Older
Tight hip adductors/decreased hip abduction. Asymmetric thigh or gluteal folds. The space between the legs may look wider than normal.
Which concern would be a priority for the nurse caring for an infant born with exstrophy of the bladder?The primary goal when caring for a child with bladder exstrophy is to: preserve normal kidney function. develop adequate bladder function and promote urinary continence.
What procedure should a nurse use when elevating the head of an infant in a spica cast?Using the bedpan
Elevate your child's head and shoulders with pillows when he/she is placed on the bedpan. This will help prevent urine from running backward and inside the cast. A gauze or cloth pad or a small folded towel placed on the back rim of a bedpan will absorb any moisture and help keep the cast dry.
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Which is the priority intervention for the infant with developmental dysplasia of the hip?
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