Version July 2025
INTRODUCTION —
Developmental dysplasia of the hip (DDH) describes a spectrum of conditions related to the development of the hip in infants and young children. It encompasses abnormal development of the acetabulum and proximal femur and mechanical instability of the hip joint (table 1).
Newborns often have physiologic laxity of the hip and immaturity of the acetabulum during the first few weeks of life. In most cases, the laxity resolves, and the acetabulum proceeds to develop normally. With assessment of risk factors, serial physical examination of the hips, and appropriate use of imaging studies, most children with pathologic hips can be correctly diagnosed and treated without long-term sequelae. (See "Developmental dysplasia of the hip: Treatment and outcome".)
Typical DDH, which generally occurs in otherwise healthy infants, will be the focus of this topic review. Hip dysplasia and instability also occur in association with other conditions. Teratologic hip dysplasia occurs in association with various syndromes (eg, Ehlers-Danlos syndrome, Down syndrome, arthrogryposis), and neuromuscular hip dysplasia occurs when there is weakness and/or spasticity in some or all of the hip muscle groups (eg, in spina bifida or cerebral palsy). The diagnosis and management of teratologic and neuromuscular hip dysplasia differ from the diagnosis and management of hip dysplasia in otherwise healthy infants.
The clinical features and diagnosis of DDH in otherwise healthy children will be reviewed here. The epidemiology, pathogenesis, treatment, and outcome are discussed separately. (See "Developmental dysplasia of the hip: Epidemiology and pathogenesis" and "Developmental dysplasia of the hip: Treatment and outcome".)
TERMINOLOGY —
The terminology for developmental problems of the hip has changed over time. "Developmental dysplasia of the hip" (DDH) is the preferred term [1]. "Developmental" is preferred to "congenital," since the condition is not always present or identifiable at birth and may develop during early childhood [2-4]. "Dysplasia" is preferred to "dislocation" because it includes a broader spectrum of changes in the shape and position of the femoral head and acetabulum. "Congenital hip dislocation" is an outdated term that was used at a time when most children were diagnosed after they began walking and the dislocation was assumed to be congenital.
Specific terms describing the position, stability, and shape of the hip are defined below (table 1):
●Dislocation – Complete loss of contact between the femoral head and the acetabulum.
●Subluxation – Femoral head is partially outside of the acetabulum but remains in contact.
●Dislocatable – Femoral head remains within the acetabulum at rest but can dislocate in other positions or with examination maneuvers. This is a hip with instability.
●Subluxatable – Femoral head remains within the acetabulum at rest but can be partially dislocated or subluxated with examination maneuvers. This is a hip with mild instability or laxity.
●Reducible – The hip is dislocated at rest, but the femoral head can be positioned into the acetabulum with manipulation (generally flexion and abduction).
●Dysplasia – Abnormality of the shape of the hip joint (usually shallowness of the acetabulum, involving the superior and anterior margins).
SCREENING —
Many organizations in North America, including the American Academy of Pediatrics, the American Academy of Orthopaedic Surgeons, and the Pediatric Orthopaedic Society of North America (POSNA) have published recommendations for screening for DDH. Clinical practice guidelines of all three organizations recommend clinical assessment (physical examination) for DDH at birth and every well-child visit until the child is walking normally [5-8]. Although POSNA acknowledges the lack of data to support routine newborn hip examination [6], it points to the value of early diagnosis in preventing long-term complications [9]. This is especially relevant given reports that missed diagnosis of DDH is a common cause for malpractice suits against pediatricians [10,11]. The United States Preventive Services Task Force no longer addresses screening for DDH [12].
We agree with published recommendations to conduct a hip examination on all newborn babies and include appropriate imaging for infants with risk factors for DDH, regardless of physical examination findings. (See 'Approach' below.)
Recommendations for screening newborn infants for DDH vary by health system. Some countries recommend ultrasound screening of all infants, whereas others recommend ultrasound screening of only those with selective risk factors [13-16]. The age at which the child is screened and the approach to screening (eg, clinical examination versus ultrasonography versus an approach based on risk stratification) also varies by health system [13,14,17].
Risk factors for DDH are discussed in more detail elsewhere. (See "Developmental dysplasia of the hip: Epidemiology and pathogenesis", section on 'Risk factors'.)
CLINICAL FEATURES —
DDH may be unilateral or bilateral; bilateral DDH occurs in as many as 37 percent of cases [18,19]. In patients with bilateral DDH, asymmetric features are not present [20].
The clinical features of DDH depend upon the age of the child and the severity of the abnormality (table 2). The spectrum of presentation in childhood ranges from hip instability on the newborn examination, to subtle limited abduction in the infant, to asymmetric gait in the toddler, to activity-related pain in the older child and adolescent. The earlier DDH is detected, the simpler and more effective the treatment and the better the long-term outcome [5,21]. (See "Developmental dysplasia of the hip: Treatment and outcome".)
Hip examination techniques and findings are described below. (See 'Age-specific hip examination techniques' below.)
Age-specific features — Asymmetric findings will not be present in bilateral cases.
Infants <3 months
●Hip instability
●Asymmetric leg creases
●Functional shortening of the femur (ie, positive Galeazzi test)
Infants ≥3 months
●Limited hip abduction
●Functional shortening of the femur
●Increased femoral anteversion
●Marked asymmetry of leg creases
●Positive Klisic test
Children who are walking
●Hyperlordosis
●Prominent greater trochanter
●Trendelenburg gait
●Trendelenburg sign
●Short leg limp with toe-heel gait and out-toeing
●Adduction contracture of the hip with compensatory genu valgum
Dysplasia without dislocation — Dysplasia without dislocation usually has no clinical findings and is asymptomatic until adolescence or early adulthood. It is often found only through diligent screening of risk factors, incidentally when radiographs are obtained for other concerns (eg, cystography (image 1) for evaluation of genitourinary concerns, abdominal radiography for evaluation of bowel obstruction), or assessment of activity-related hip pain in an adolescent or young adult.
Natural history — The natural history of untreated DDH depends upon the age of the patient and the severity of DDH [22-25].
●Newborn infants with hip instability – Most hip instability in newborns stabilizes soon after birth, as physiologic laxity decreases, and the femoral head and acetabulum grow. In observational studies, there is a high rate of resolution of neonatal hip instability without intervention [8,26-30]. In a cohort of 11,989 infants examined by a single examiner, 60 percent of hips that demonstrated instability on physical examination at birth stabilized in the first week of life, and nearly 90 percent stabilized by two months [26]. These hips were functionally and radiographically normal at 12 months of age. Similar results were reported in a study of routine ultrasonographic screening of more than 14,000 infants: 6 percent had abnormalities soon after birth, 90 percent of which became normal by nine weeks of age [30].
●Infants and young children with untreated hip dislocation – Infants and young children with untreated hip dislocation rarely show signs of pain or other limitations. Most children reach developmental milestones at the appropriate time, and a dislocated hip generally does not delay the age at which the child begins to walk.
A dislocated hip may function well for many years [25]. However, weakness in the hip abductor musculature may result in the classic Trendelenburg gait pattern, a truncal shift over the affected hip when any part of the foot is in contact with the ground and bearing weight. In unilateral dislocations, the patient will lean over only the affected side. In bilateral cases, patients will sway back and forth. Over time, there may be gradual progression of functional disability, pain, and accelerated degenerative hip disease. The risk of these sequelae is not well-defined but may be associated with the development of a false acetabulum. This occurs when the dislocated femoral head rubs a dent into the ilium that acts as a pseudoacetabulum [17].
Patients with unilateral dislocations may have leg length discrepancy, ipsilateral knee problems, scoliosis, and gait disturbance. Patients with bilateral dislocations may develop back pain (perhaps related to increased lumbar lordosis and increased trunk sway).
●Infants and children with hip dysplasia diagnosed incidentally by radiograph – Dysplasia in a reduced or subluxed hip may be diagnosed incidentally when radiographs are obtained for other reasons. The clinical course for patients with this presentation is variable. These hips are often asymptomatic in infants and young children, and radiographic abnormalities may improve with time, as the acetabulum still has excellent remodeling potential [17,31-33]. After school age, the likelihood of spontaneous improvement is low. Patients with persistent dysplasia without dislocation may remain asymptomatic for some time but may develop activity-related hip pain or premature degenerative joint disease in adolescence or young adulthood. This occurs as a result of increased cartilage contact stress at the anterior and lateral margins of the acetabulum. Pain may start soon after skeletal maturity, or, in females, during the first or second pregnancy or at menopause. Patients 40 to 60 years old who present with hip osteoarthritis are often found to have mild dysplasia as a contributing cause [22-25].
CLINICAL EVALUATION
Approach
●Routine hip examination – A hip examination should be performed on all newborn infants. Infants without risk factors for DDH, who have a normal newborn examination, should be reexamined at subsequent health supervision visits until the child is walking independently. Normal clinical examination at birth does not definitively exclude DDH (algorithm 1 and algorithm 2) [34].
●Risk factors for DDH – We recommend a screening ultrasound at four to six weeks of age for infants with risk factors for DDH, regardless of physical examination findings (algorithm 1). The American Academy of Pediatrics (AAP), the American Academy of Orthopaedic Surgeons (AAOS), and the Pediatric Orthopaedic Society of North America (POSNA) have all published recommendations for screening for DDH.
Each professional society uses a different set of overlapping criteria to define risk. The criteria we use are largely in line with theirs:
•Breech position any time during the pregnancy
•Positive family history
•Lower extremity swaddling that binds the hips in adduction
The AAOS states that breech position is a particularly strong risk factor for DDH.
Risk factors for DDH are discussed in more detail elsewhere. (See "Developmental dysplasia of the hip: Epidemiology and pathogenesis", section on 'Risk factors'.)
History — A thorough review of the child's prenatal, medical, and family history helps to identify risk factors for DDH and exclude other congenital or neuromuscular causes of hip instability. The most important risk factors are breech positioning at any time during the pregnancy (whether or not the infant is vertex at the time of delivery) [35], family history of DDH, and lower extremity swaddling with the hips bound in adduction [5].
The International Hip Dysplasia Institute provides a video demonstration of healthy swaddling on their website. Conditions that are associated with DDH but not proven to increase the risk of occurrence include torticollis, plagiocephaly, metatarsus adductus, clubfoot, being the firstborn infant, oligohydramnios, birthweight >4 kg, and multiple gestation pregnancy. (See "Developmental dysplasia of the hip: Epidemiology and pathogenesis", section on 'Risk factors'.)
Physical examination
Overview — We agree with professional society guidelines that recommend physical examination of the hip beginning in the newborn period and continuing at health supervision visits until approximately nine months of age and/or when the child is walking independently [5,6,8,36]. These societies include AAP, AAOS, POSNA, and the Canadian Task Force on DDH. (See 'Screening' above.)
The newborn examination and the office examinations at two to four weeks of age are particularly important for early detection of DDH.
General examination — The neurologic examination and examination of the spine and distal lower extremities are particularly important. This is where many of the abnormalities associated with DDH and other causes of hip instability are found.
●The neurologic examination should include evaluation of spontaneous movement of all four extremities and assessment of spasticity. (See "Neurologic examination of the newborn" and "Detailed neurologic assessment of infants and children".)
●The spine examination should include cervical range of motion (looking for torticollis (picture 1)) and cutaneous manifestations of spinal dysraphism (eg, dimples and hairy patches). (See "Myelomeningocele (spina bifida): Anatomy, clinical manifestations, and complications".)
●Examination of the extremities should include examination of the feet for metatarsus adductus (picture 2), which may be associated with DDH. (See "Approach to the child with in-toeing", section on 'Age <1 year: Metatarsus adductus'.)
Age-specific hip examination techniques — The most important aspects of the examination are hip instability in the young infant and range of motion in the older infant and child [5]. It is important to explain the hip examination to the caregivers as it is being performed and to document the results at each visit. (See 'Infants <3 months' below and 'Infants ≥3 months' below.)
Pertinent hip examination tests and maneuvers vary according to age (table 2).
Infants <3 months — In infants younger than three months, it is most important to evaluate the stability of the hips using the Ortolani maneuver [5]. The Barlow maneuver, Galeazzi test, and Klisic test also are useful.
Each hip should be examined individually for reducibility and instability (table 1) [26,37,38]. The infant should be on a stable surface in the supine position, with the hip flexed to 90° and in neutral rotation. The examination should occur when the infant is calm and not crying. The hips are best examined with all clothing and diapers removed from the lower extremities.
●Ortolani maneuver – The thigh is grasped loosely with the examiner's index and middle finger along the greater trochanter and the thumb on the inner thigh. From an adducted position, the hip is gently abducted with supination of the examiner's hand while lifting the greater trochanter anteriorly. Extreme abduction should be avoided because it decreases the sensitivity of the Ortolani maneuver. If the hip is dislocated, the Ortolani maneuver may reduce it and is accompanied by a palpable clunk (figure 1). A positive Ortolani maneuver assumes a dislocated hip that is reducible.
●Barlow maneuver – The hip is held in the same manner as for the Ortolani maneuver. The thigh is grasped loosely with the examiner's index and middle finger along the greater trochanter and the thumb on the inner thigh. The hip is gently adducted with pronation of the examiner's hand and, in a change from previous recommendations, no downward pressure is applied. The femoral head is palpated to detect moving out of the back of the acetabulum. The examiner should not attempt to forcefully dislocate the femoral head [5]. If the hip is dislocatable, posterior movement and a palpable clunk may be detected as the femoral head exits the acetabulum (the "jerk of exit") (figure 2) [5,26,37,38]. A subluxatable hip is characterized by a subtle sliding movement or a feeling of looseness, like a tennis ball moving in a soup bowl. A positive Barlow maneuver assumes a reduced hip that is subluxatable or dislocatable [5].
The "jerking" and/or "clunking" sensation of hip reduction and dislocation is distinct and different from the signs (eg, snapping, clicking, high pitch joint popping) of benign tendon or ligament snapping in and around the hip and knee. The term "hip click" is misleading and is best avoided; isolated hip clicks are not suggestive of DDH [39-41].
●Galeazzi test – The Galeazzi test assesses for functional shortening of one femur, which may indicate unilateral hip dislocation. Functional shortening of the femur occurs when the femurs are the same length, but because the femoral head is displaced cranially, the leg with the dislocated hip appears shorter and functions as a shorter limb. While asymmetric examination findings may be helpful to detect unilateral DDH, as many as 37 percent of DDH cases are bilateral [18], and lack of asymmetry does not exclude DDH.
The Galeazzi test is performed with the infant supine, hips flexed to 90°, knees flexed, and feet flat on a level surface and side by side, with the heels touching the buttocks. In this position, the knees are normally at the same level (figure 3). In unilateral dislocation, the head of the femur is displaced posteriorly, functionally shortening the thigh, and the ipsilateral knee will be lower than the other knee (figure 3).
●Skin fold asymmetry – Asymmetry in the position or number of the inguinal, thigh, or gluteal skin folds may be a clue to the diagnosis of unilateral DDH [42]. The increased folds are caused by "bunching" of the skin and muscle around a functionally shortened femur.
•Inguinal folds – Examine the inguinal folds with the infant supine and hips abducted (figure 4A).
•Thigh and gluteal folds – Examine the thigh folds with the infant supine and the hips in flexion and knees in extension (figure 4B).
●Klisic test – The Klisic test is performed by positioning the child supine on the examination table with the legs in a resting position of slight hip and knee flexion. The examiner places the index finger on the anterosuperior iliac spine and the middle finger on the greater trochanter. An imaginary line between these points passes through or above the umbilicus in a child without DDH (negative Klisic test). The line passes below the umbilicus if the hip is dislocated (positive Klisic test) because the greater trochanter is in a more superior position (figure 5).
The combination of the Barlow and Ortolani maneuvers has a high specificity (estimated to be approximately 98 to 99 percent) for detection of hip instability in an infant younger than three months [43]. The sensitivity varies depending upon the skill of the examiner and the number of examinations performed. The sensitivity in experienced hands ranges from 87 to 97 percent [44-48].
Infants ≥3 months — After three months of age, tests of hip instability are of little value because dislocated hips become irreducible and instability is no longer detected. The following examination findings are better indicators of DDH.
●Limitation of hip abduction – Normal range of hip abduction in a supine infant with the pelvis stabilized is >75°, and an angle <45° is abnormal (figure 6) [20].
●Galeazzi test – As described above for infants <3 months (figure 3). (See 'Infants <3 months' above.)
●Klisic test – As described above for infants <3 months (figure 5). (See 'Infants <3 months' above.)
●Skin fold asymmetry – As described above for infants <3 months (figure 4A and figure 4B).
●Increased hip internal rotation – Increased femoral anteversion is often associated with DDH and causes increased hip internal rotation [49]. Internal hip rotation is assessed with the patient lying prone on the examination table and the knees flexed; the lower leg is rotated away from the axis of the body (rotating the hip internally). The top panel of the figure (figure 7) demonstrates this maneuver and provides the normal ranges of hip rotation for age. (See "Approach to the child with in-toeing", section on 'Focused examination of the lower extremities'.)
Limitation of hip abduction is the most reliable sign of a dislocated hip in a child older than three months. In a 10-year prospective longitudinal study that included 2876 infants, unilateral limited hip abduction after eight weeks of age had a sensitivity of 78 percent and specificity of 93 percent in the detection of radiographically confirmed DDH [50]. In another review of 683 infants older than three months, unilateral limited hip abduction had a sensitivity of 69 percent and a specificity of 54 percent [51].
Signs of unilateral DDH include asymmetric abduction (decreased on the ipsilateral side compared with the contralateral side), apparent thigh-length discrepancy (as seen with the child in the supine position with the hips and knees extended), positive Galeazzi test (as seen with the child supine and the hips and knees flexed) (figure 3), positive Klisic test (figure 5), increased internal rotation of the hip, and asymmetric skin folds.
Signs of bilateral DDH include limited abduction of both hips, apparent widening of the perineum, bilateral positive Klisic tests, and short thigh segments (relative to the lengths of the arms and thorax) (figure 8).
Children who are walking — In walking-aged children, signs of DDH are primarily seen during walking or standing (table 2).
●Trendelenburg sign – The Trendelenburg sign is a pelvic tilt caused by the inability to maintain the pelvis horizontally while standing on the ipsilateral leg. It is evaluated with the Trendelenburg test (figure 9), which involves asking the patient to stand on one leg. In a positive Trendelenburg test, the patient will lean away from the affected hip.
●Trendelenburg gait – The Trendelenburg gait is characterized by a lurch over the affected leg. It is in the opposite direction of a positive Trendelenburg sign. Mechanically, the patient’s center of gravity is being moved over the hip joint to compensate for the weakness of the abductors. In unilateral DDH, the lurch is in one direction. In bilateral cases, the lurch is in both directions and appears as a "waddling" gait.
●Toe-walking – Toe-walking is caused by leg length discrepancy on the ipsilateral side. Because the affected limb is shortened due to the hip dislocation, the child may walk on their toes on that side to functionally lengthen the limb.
●Out-toeing – Out-toeing is seen when the child walks with the ipsilateral knee and toes pointed outward secondary to external rotation of the proximal femur.
●Hyperlordosis – Hyperlordosis is caused by superior and posterior displacement of the femoral heads and necks and is defined by a lumbar angle >40° (figure 8).
●Adduction contracture of the hip – An adduction contracture is seen on examination as any asymmetry of abduction between the two hips or bilateral abduction less than 45°. This contracture is likely caused by the dislocated hip holding the femur in a more adducted position and resulting in shortening of the muscle.
Signs of unilateral DDH include a positive Trendelenburg sign, toe walking, out-toeing, and the presence of a Trendelenburg gait.
Signs of bilateral DDH include hyperlordosis, bilateral Trendelenburg sign, and the presence of a Trendelenburg gait.
RADIOLOGIC EVALUATION
Indications for imaging — Indications for imaging include the following (algorithm 1 and algorithm 2):
●Hip ultrasound (see 'Ultrasonography' below)
•Obtain as soon as possible if hip examination is abnormal or inconclusive at any age <4 months
•Obtain at age six weeks if risk factors for DDH are present and hip examination is normal
●Pelvic radiograph (see 'Radiographs' below)
•Obtain as soon as possible if either:
-Hip examination is abnormal or inconclusive at any age ≥4 months
-Risk factors for DDH are present and hip ultrasound was not performed before age four months
•Obtain at age six months if breech position during pregnancy and ultrasound at six weeks of age was normal
Normal ultrasonography at six weeks of age does not necessarily predict the absence of dysplasia. In observational studies, 7 to 29 percent of infants with breech presentation and normal hip ultrasonography at six weeks of age had hip dysplasia on follow-up radiographs [52,53].
We recommend that infants with breech presentation during pregnancy who have a normal examination and normal imaging at six weeks of age receive radiographic imaging at six months of age to evaluate for hip dysplasia.
We recommend that infants with other risk factors for DDH who have normal examination and normal imaging at six weeks continue to be examined for signs of DDH (table 2) at subsequent health supervision visits until the child is walking independently.
Ultrasonography — Ultrasonography is the primary imaging technique used to assess the morphology and stability of the infant hip. It is an important adjunct to the clinical evaluation until four months of age [54-56].
The major drawback of ultrasonography is that accurate interpretation requires training and experience [57]. A systematic review of 28 studies found high variability and low reproducibility for all ultrasonographic dysplasia metrics [58].
Given regional variability in performance and interpretation of hip ultrasonography and thresholds for treatment, it is reasonable for clinicians to develop regional protocols in collaboration with a consulting pediatric orthopedic surgeon and pediatric radiologist [5].
Ultrasonographic criteria for DDH have been established for static imaging and dynamic imaging [56,59]. The combination of static and dynamic imaging permits evaluation of hip morphology, position, and stability.
Ultrasonographic findings consistent with DDH include:
●Static imaging – Static views are taken with the infant positioned in the lateral decubitus position and with the hips flexed at 30 to 45° [60]. In this position, the ossified ilium is viewed as a straight white line above the femoral head and superior acetabulum (image 2).
Another important parameter is the percentage of the femoral epiphysis that is covered by the acetabular roof (image 2). For infants older than four weeks of age, we consider coverage of >50 percent to be normal [61].
●Dynamic imaging – The dynamic technique uses axial and coronal images with real-time stress of the femoral head, similar to the instability test maneuvers [62]. Up to 4 to 6 mm of laxity is considered normal. Dynamic imaging is usually omitted when the hips are examined during treatment [59].
Radiographs — Radiographs may be helpful in the evaluation of DDH after four months of age [54,56]. Before that, radiographs have limited value because the femoral head and acetabulum are cartilaginous and unossified.
Infants that were in breech position during pregnancy and had a normal ultrasound at four to six weeks of age should have a radiograph at six months of age to evaluate for acetabular dysplasia [63-65].
Radiographs may also be helpful if there are concerns for other bony abnormalities (eg, congenital coxa vara, proximal femoral focal deficiency, and sacral agenesis). (See "Radiologic evaluation of the hip in infants, children, and adolescents", section on 'Imaging studies for specific clinical settings'.)
Hip radiographs in a newborn consist of a single anteroposterior (AP) view with the hips held in 20 to 30° flexion; the frog lateral view is unnecessary and increases radiation exposure.
AP radiographs in older infants are obtained with the hips in the neutral position [56]. Radiographic lines and angles are used to assess acetabular development and hip position.
Radiographic findings consistent with DDH include:
●Lateral and superior positioning of the ossified portion of the femoral head and neck (image 3 and figure 10A-B)
●Increased acetabular index (figure 11 and image 4); normal values for the acetabular index are as follows: <35° at birth, <25° at 1 year, <20° at 2 to 3 years, <15° at 6 to 7 years, <11 to 12° at 10 years, and <10° at 15 years [66]
●No ossification of the femoral nucleus by six months of age on the involved side (image 5) or asymmetric sizes of the femoral ossific nuclei (image 3)
DIAGNOSIS AND REFERRAL —
The diagnosis of DDH in infants is usually made by physical examination demonstrating hip instability, asymmetry (in unilateral cases), and/or limited abduction. Examination findings suggestive of DDH vary according to age (table 2). (See 'Age-specific hip examination techniques' above.)
Age-appropriate diagnostic imaging is obtained when any risk factors for DDH or signs of DDH on examination are present (algorithm 1 and algorithm 2). (See 'Indications for imaging' above.)
Children with any abnormal findings on imaging should be referred to an orthopedic surgeon who is experienced in the diagnosis and treatment of DDH. Our approach is generally consistent with recommendations from pediatric and orthopedic professional associations [5,8,56,59,67]. Local practices and preferences of the treating orthopedic surgeons may vary, particularly outside of the United States.
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Developmental dysplasia of the hip".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)
●Basics topic (see "Patient education: Developmental dysplasia of the hip (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Terminology – Developmental dysplasia of the hip (DDH) describes a spectrum of conditions related to the development of the hip in infants and young children. It encompasses abnormal development of the acetabulum and proximal femur, as well as mechanical instability of the hip joint (table 1). (See "Developmental dysplasia of the hip: Epidemiology and pathogenesis".)
●Hip examination – Hip examination should occur soon after birth and at every health supervision visit until the child is walking independently. The symptoms and signs of DDH vary with age and severity (table 2). (See 'Overview' above and 'Age-specific hip examination techniques' above.)
Physical examination techniques to detect hip instability in the newborn use abduction and elevation to feel for reducibility (the Ortolani maneuver) and gentle adduction without downward pressure to feel for dislocatability (the Barlow maneuver). The sensation of reducibility or dislocatability is distinct and best described as a "jerk" or "clunk." (See 'Infants <3 months' above.)
Assessment of hip abduction is used to evaluate for hip dysplasia in the older infant. (See 'Infants ≥3 months' above.)
Examination findings that are less specific for DDH include functional shortening of the femur, asymmetry of skin folds, and a positive Klisic test (figure 3 and figure 4A-B and figure 5).
●Screening ultrasound (if DDH risk factors present) – In infants with risk factors for DDH, we recommend obtaining a screening ultrasound of the hips at six weeks of age rather than relying on hip examination alone (Grade 1B). A higher proportion of these infants will have DDH than infants without risk factors, and the outcome of treatment is less favorable when initiated after four to six months of age. (See 'Screening' above and "Developmental dysplasia of the hip: Treatment and outcome", section on 'Age 6 to 18 months or failure of abduction splint'.)
Risk factors for DDH include:
•Breech position any time during the pregnancy
•Positive family history
•Lower extremity swaddling that binds the hips in adduction
●Diagnostic imaging – Diagnostic imaging is helpful in confirming physical examination findings, evaluating infants with risk factors, and making treatment decisions. During the first four months of life, ultrasonography is the primary imaging technique for assessing the morphology and stability of the hip because the cartilaginous and unossified femoral head and acetabulum are not visible on radiographs. (See 'Ultrasonography' above.)
After four months of life, radiographs are the primary imaging technique because they provide more detail. Ultrasound becomes less reliable when the femoral head and acetabulum have begun to ossify. (See 'Radiographs' above.)
●Diagnosis – The diagnosis of DDH in infants is usually made by physical examination that demonstrates hip instability, asymmetry (in unilateral cases), and/or limited abduction. Examination findings of DDH vary according to age (table 2). (See 'Diagnosis and referral' above.)
Age-appropriate diagnostic imaging is obtained when any risk factors for DDH or signs of DDH on examination are present (algorithm 1 and algorithm 2). (See 'Indications for imaging' above.)
Referral to an orthopedic surgeon – Children with any abnormal findings on imaging should be referred to an orthopedic surgeon who is experienced in the diagnosis and treatment of DDH.
