Clinical Review

Five-Day-Old Infant With Hip "Clunk"

Clinician Reviews. 2010 April;20(4):24-27

References

1. Karmazyn BK, Gunderman RB, Coley BD, et al; American College of Radiology. ACR appropriateness criteria on developmental dysplasia of the hip—child. J Am Coll Radiol. 2009;6(8):551-557.

2. American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. Clinical practice guideline: early detection of developmental dysplasia of the hip. Pediatrics. 2000;105(4 pt 1):896-905.

3. Mencio GA. Developmental dysplasia of the hip. In: Sponseller PD, ed. Orthopaedic Knowledge Update: Pediatrics–2. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2002:161-171.

4. Children’s Hospital at Westmead. Developmental dysplasia of the hip (DDH). www.chw.edu.au/parents/factsheets/developj.htm. Accessed March 26, 2010.

5. Graf R. Classification of hip joint dysplasia by means of sonography. Arch Orthop Trauma Surg. 1984; 102:248-255.

6. Weinstein SL. Developmental hip dysplasia and dislocation. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopaedics. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:905-956.

7. Aronsson DD, Goldberg MJ, Kling TF Jr, Roy DR. Developmental dysplasia of the hip. Pediatrics. 1994; 94(2 pt 1):201-208.

8. Guille JT, Pizzutillo PD, MacEwan GD. Developmental dysplasia of the hip from birth to six months. J Am Acad Orthop Surg. 2000;8(4):232-242.

9. Hart ES, Albright MB, Rebello GN, Grottkau BE. Developmental dysplasia of the hip: nursing implications and anticipatory guidelines for parents. Orthop Nurs. 2006;25(2):100-109.

10. Dogruel H, Atalar H, Yavus OY, Sayli U. Clinical examination versus ultrasonography in detecting developmental dysplasia of the hip. Int Orthop. 2008; 32(3):415-419.

11. Mahan ST, Katz JN, Kim YJ. To screen or not to screen? A decision analysis of the utility of screening for developmental dysplasia of the hip. J Bone Joint Surg Am. 2009;91(7);1705-1719.

12. Storer SK, Skaggs DL. Developmental dysplasia of the hip. Am Fam Physician. 2006;74(8):1310-1316.

13. Ortolani M. Congenital hip dysplasia in the light of early and very early diagnosis. Clin Orthop Relat Res. 1976;119(1):6-10.

14. Barlow TG. Congenital dislocation of the hip in the newborn. Proc R Soc Med. 1966;59(11 part 1):1103-1106.

15. Bond CD, Hennrikus WL, DellaMaggiore ED. Prospective evaluation of newborn soft-tissue “clicks” with ultrasound. J Pediatr Orthop. 1997;17(2):199-201.

16. Atalar H, Sayli U, Yavuz OY, et al. Indicators of successful use of the Pavlik harness in infants with developmental dysplasia of the hip. Int Orthop. 2007; 31(2):145-150.

17. Rampal V, Sabourin M, Erdeneshoo E, et al. Closed reduction with traction for developmental dysplasia of the hip in children aged between one and five years. J Bone Joint Surg Br. 2008;90-B(7):858-863.

18. Clarke NMP, Sakthivel K. The diagnosis and management of congenital dislocation of the hip. Paediatr Child Health. 2008;18(6):268-271.

19. Hassan FA. Compliance of parents with regard to Pavlik harness treatment in developmental dysplasia of the hip. J Pediatr Orthop. 2009;18(3):111-115.

Known risk factors for a positive newborn screening are shown in the table.^9,10 It is often helpful for clinicians to remember the “4F” mnemonic associated with DDH: female, firstborn, foot first, and family history.⁹

There is also an increased risk for DDH in patients with other conditions that are associated with intrauterine crowding. These include congenital muscular torticollis, metatarsus adductus, and congenital dislocation of the knee.²

Physical Examination
All newborn infants should be screened for DDH as part of the initial physical examination, with ultrasonography recommended for infants deemed at high risk for DDH and for those with inconclusive results on examination.^1,10,11 Providers should be aware that the newborn hip examination requires a considerable amount of practice and expertise.

A thorough medical history should always be obtained first, including gestational age, presentation (breech vs vertex), type of delivery (cesarean vs vaginal), gender, birth order, family history of DDH, ligamentous laxity, or myopathy.⁸

The examining clinician begins by placing the infant on a firm, flat surface. The infant should be as relaxed as possible. Next, the clinician observes both lower extremities for asymmetric thigh or buttock skin folds. Bilateral DDH can be very difficult to diagnose on the basis of this examination due to the lack of asymmetry (hips will have symmetric abnormality).

The Galeazzi sign is elicited by placing the infant supine with the hips and knees flexed to 90°.¹² With the hips in neutral abduction, the provider should determine whether the knees are at the same height. Unequal knee heights—a positive result for the Galeazzi sign—suggest femoral shortening (apparent leg length discrepancy), which may be explained by a hip dislocation. If both hips are dislocated, a false-negative result will often occur, since both will appear short and there will be no discrepancy.^2,12

Among physical examination techniques, the Ortolani and Barlow maneuvers are considered most reliable to detect hip instability in newborns and infants younger than 6 months^2,13,14 (review Figures 1A and 1B). The Ortolani test is used to detect the sensation of the dislocated hip reducing into the acetabulum, and the Barlow test elicits the unstable hip dislocating.² A palpable and occasionally audible clunk is considered a positive result on the Barlow test and usually indicates a diagnosis of DDH.¹⁴ High-pitched clicks or snaps frequently occur with hip range-of-motion maneuvers and during Ortolani and Barlow testing. These sounds are often attributed to snapping of the iliotibial band over the greater trochanter and do not usually signify dysplasia.¹⁵

Because DDH is a dynamic and evolving process, the physical findings on clinical examination change significantly, depending on the age of the infant or child. As an infant approaches age 3 months, limited hip abduction (especially when asymmetric) is often the most reliable physical examination finding in patients with DDH.¹² After age 3 to 4 months, Ortolani and Barlow testing will often produce negative results as progressive soft tissue contractures evolve.

Once a child begins to walk, gait abnormalities (eg, a short-limbed or waddling gait pattern) may raise suspicion for a diagnosis of DDH.⁷ It has been recommended that evaluation for DDH be performed at each routine office examination until the child is 12 months of age.¹

Treatment
The Pavlik harness is considered first-line treatment for DDH in infants younger than 6 months. The harness is a dynamic splint that allows the infant to engage in a sphere of active motion that encourages stabilization and deepening of the socket. The harness is applied with the knees flexed to about 90° and the hips in about 70° of abduction and 100° to 110° of flexion (as shown in Figures 2A and 2B).⁹

The duration of treatment depends on the infant’s age at presentation and the severity of DDH. Progress is judged by serial examinations and dynamic ultrasounds. The harness is worn full-time until clinical and radiographic examinations both yield normal results. After six weeks of treatment, the hips are examined out of the harness, and a repeat ultrasound is usually obtained. If findings are normal, use of the harness is ordinarily discontinued. Some patients will require harness use for a longer period in cases of delayed development of the acetabulum and/or severe laxity of the ligaments.⁹

The Pavlik harness is successful more than 90% of the time in newborns with DDH.⁸ Success rates have been reported as greatest in infants younger than 8 weeks at the time of treatment initiation, those with only one affected hip, and those with less severe disease (Graf types II or III).¹⁶

If ultrasonography shows no improvement after two to three weeks, it is usually recommended that the harness be discontinued; most orthopedic surgeons will then proceed with a closed or open reduction and spica body casting. Similarly, when the diagnosis of DDH is delayed until after ages 6 to 8 months, a closed reduction under anesthesia and placement of a spica body cast is usually the recommended treatment to maintain the hip in the reduced position.^17,18 Some older children (ages 1 to 5 years) may require bracing, traction, open reduction, and/or femoral or pelvic osteotomy.^17,18 It is believed that undiagnosed, untreated DDH can lead to early-onset degenerative hip disease (arthritis).¹