Developmental dysplasia of hip
DDH encompasses a spectrum of conditions where the femoral head has an abnormal relationship with the acetabulum, leading to hip instability.
Associated Factors
- Physiological hip laxity in newborns (usually resolves within weeks with normal acetabular development).
- Risk factors:
- Breech position (especially after 34 weeks)
- Female sex, first-born
- Family history of DDH
- Oligohydramnios
- Intrauterine “packaging deformities” (e.g., torticollis, metatarsus adductus, plagiocephaly)
- Neuromuscular conditions (e.g., cerebral palsy, spina bifida)
- Excessive swaddling with legs extended
Clinical Presentation
Pathways to GP Consultation
| Trigger for Visit | Parental Concerns | Clinical Notes |
|---|---|---|
| Routine check abnormality | Maternal & Child Health Nurse notes mention a “click,” limited abduction, or asymmetry | Parent seeks clarification, referral, or imaging |
| Risk-factor follow-up | Breech birth, family history, packaging deformities | “We just want to make sure the hips are okay” |
| Parental observation | “Something looks wrong” during nappy changes or mobility | Common in late-presenting cases |
| Delayed motor milestones | Not rolling, sitting, or walking on time | Often accompanies other gross motor concerns |
| Abnormal gait | Limping, waddling, toe-walking, frequent falls | Classic toddler presentation |
| Second opinion after bracing | Concerns about harness fit, pressure sores, or persistent instability | Reassurance & coordination with orthopaedics needed |
Age-Specific Parental Concerns & Clinical Signs
| Age Group | Parental Worries | Clinical Findings |
|---|---|---|
| Newborn (0-3 mo) | – “I heard a click in the hip.” – “The nurse said the hips felt loose.” – “He was breech—does that mean bad hips?” | Positive Ortolani/Barlow test |
| Early infant (3-6 mo) | – “I can’t spread her legs for nappy changes.” – “One leg seems shorter.” – “Skin creases don’t match.” | Limited abduction, asymmetric thigh/gluteal creases, Galeazzi sign |
| Late infant (6-12 mo) | – “He isn’t crawling/pulling to stand.” – “She favors one leg.” – “Hip ultrasound was borderline—do we need another?” | Delayed milestones, unequal weight-bearing, abnormal imaging |
| Toddler (>12 mo) | – “She waddles when walking.” – “He limps after a few steps.” – “She falls a lot.” | Trendelenburg gait, leg-length discrepancy |
| Any age | – “Will this cause arthritis later?” – “Is the brace hurting?” – “Will she need surgery?” | Long-term disability concerns, brace-related issues |
Diagnosis
Clinical Examination
- Neonates (<3 mo):
- Ortolani maneuver (“click of entry” – reduces dislocated hip)
- Barlow maneuver (“click of exit” – dislocates unstable hip)
- Infants (3-12 mo):
- Limited hip abduction (most sensitive sign once contractures develop)
- Asymmetric thigh/gluteal creases
- Leg-length discrepancy (Galeazzi sign)
- Walking age (>1 yr):
- Trendelenburg gait (abductor weakness)
- Pelvic obliquity, lumbar lordosis (bilateral cases)
- Toe-walking (compensation for leg shortening)
Investigations
- Ultrasound (if <4-6 mo): Preferred due to cartilaginous femoral head.
- Indicated for high-risk infants or abnormal exam.
- X-ray (if >6 mo): Assesses bony acetabular development.
Management
Non-Operative
- Pavlik harness (if <6 mo): Maintains hip reduction.
- Contraindicated in teratologic dislocations or neuromuscular disorders.
- Closed reduction + spica casting (6-18 mo): If Pavlik fails.
Operative
- Open reduction + spica casting (>18 mo).
- Femoral/pelvic osteotomy (older children).
Complications if Untreated
- Chronic pain, early osteoarthritis
- Gait abnormalities (limping, Trendelenburg)
- Leg-length discrepancy
- Secondary issues (knee problems, scoliosis, back pain)
Barlows Manoevre
- try and dislocate the flexed hip with a postero-lateral movement of the proximal femur = ‘click of exit’
Ortolani
- Then to feel the movement of the reduction of the dislocated hip back into the acetabulum by moving the femoral head anteriorly whilst the hip is abducted =’click of entry’
