Developmental dysplasia of the hip

Establish pregnancy and family risk before examining. Record breech timing and mode of delivery, first-degree relatives who required a harness or operation, oligohydramnios, multiple pregnancy, torticollis and foot deformity. Confirm whether NIPE screening and any indicated ultrasound occurred and obtain the actual result rather than parental recollection of normal. Ask about swaddling and carrying position. In an older infant, ask about asymmetrical crawling, leg length, standing and delayed or unusual gait.

Examine on a warm firm surface with the infant settled and nappy removed. Inspect spontaneous movement, leg length and resting hip position. Ortolani gently abducts and lifts the proximal femur to identify a dislocated head that reduces; Barlow assesses whether a centred head can be displaced posteriorly. Repeat forceful attempts can injure the hip and add no value. Compare abduction with hips flexed, perform Galeazzi knee-height assessment and examine spine, feet and neck.

Screening timing matters. The NIPE physical examination occurs within the newborn period and at six to eight weeks. Selective ultrasound is offered for defined risk factors and abnormal examination, commonly at four to six weeks so physiological laxity can settle without delaying treatment. A normal early examination does not cancel risk-factor imaging. Conversely, a normal ultrasound does not justify ignoring later limited abduction or gait asymmetry; re-examine and refer from the current findings.

Ultrasound shows femoral-head coverage, acetabular morphology and movement before ossification obscures the view. Static Graf measurements and dynamic stability should be interpreted by a trained service within its pathway. Mild immaturity may be observed with repeat scanning, while displacement or instability requires orthopaedic review. In an older infant, AP pelvis assesses Shenton line, acetabular index and ossific nucleus position. Additional views are selected by the surgeon rather than routinely forcing a frog-leg pose.

Pavlik harness is used early when the hip is reducible and appropriate for dynamic treatment. Flexion directs the head toward the acetabulum while straps permit controlled abduction; the family should not adjust straps unless trained. Review clinically and with ultrasound soon after application and at protocolled intervals. If the hip is not reduced promptly, abandon prolonged unsuccessful harness use because pressure against the acetabular rim increases osteonecrosis and posterior-wall damage.

When harness treatment fails or presentation is later, reduce under anaesthesia. Arthrogram demonstrates the cartilaginous head, labrum and medial dye pool and tests whether a stable safe zone exists. Adductor tenotomy may permit reduction, followed by a carefully moulded hip spica. CT or MRI can confirm position according to local radiation and anaesthetic practice. Open reduction removes soft-tissue obstacles when closed reduction is not concentric or stable.

Residual structural disease is treated according to age and anatomy. Femoral shortening or derotation reduces pressure and corrects version; pelvic procedures redirect or reshape acetabular coverage. A walking child with high dislocation needs a specialist plan balancing reduction, vascular risk, stiffness and later function rather than simply applying an infant pathway late. Bilateral disease can lack obvious asymmetry, so gait, lumbar posture and pelvic imaging must be interpreted together.

Follow development beyond removal of harness or cast. Check abduction, leg length, gait, skin and femoral-nerve function and obtain radiographs until acetabular development is convincingly normal. Teach hip-safe swaddling with flexion and room for abduction. Provide urgent return advice for reduced limb movement, cast soiling or tightness, colour change, swelling, pressure injury or fever. Shared decisions should include the possibility of later osteotomy despite apparently successful early reduction.