Referrals pathways for Regional Paediatric model
Developmental dysplasia of the hip (DDH), formerly congenital dysplasia of the hip, occurs in 2-4% of births. Early recognition and management is important to prevent long-term morbidity, and surveillance should be undertaken by general practitioners and maternal and child health nurses.DDH should be considered in any of the following at risk populations (also refer to the BHS hip screening flowsheet):
- breech delivery
- foot abnormalities at birth
- family history of DDH (first degree relative)
Examination should be perfomed on all newborns prior to discharge, although ongoing monitoring remains important even if initial examination was normal given the potential for DDH to appear after birth. Examination should involve:
- Ortolani & Barlow test (dislocatable or dislocated hips are concerning, 'clicking' less so)
- Hip abduction (with hips flexed to 90 degrees - limited or asymmetrical is concerning)
- Galleazi test (supine with hips and knees flexed to 90 degrees – asymmetry of knee height is concerning)
- Note that asymmetric thigh or hip creases alone are not a reliable sign of DDH.
Also refer to the BHS hip screening flowsheet.
For further education regarding examination for DDH, please see the RCH Orthopaedic Department DDH Education Resource.
- DDH surveillance should be undertaken by general practitioners and maternal and child health nurses given DDH can develop after birth, even after normal initial examination and/or scans.
- Clinical examination and ultrasound are required for exclusion of 'at risk' hips - do not rely on one of these alone.
- Hip ultrasound should be performed in any at risk baby at 6 weeks post due date - only those with dislocatable hips on examination should undergo earlier ultrasound.
- Hip x-ray is only suitable for those older than 6 months of age.
- Immature hips on ultrasound can undergo repeat ultrasound if they are low grade (Graf type 1b or 2a) and there are no clinical abnormalities detected, however if they are persistently immature, of higher grade (Graf 2b, 3 or 4) or clinically unstable, referral to the paediatric DDH clinic is recommended.
- Clinical examination and ultrasound are required for exclusion of DDH in 'at risk' hips - do not rely on one of these alone.
- Refer to the BHS hip screening flowsheet to determine those requiring ultrasound.
- Hip ultrasound should be performed for any 'at risk' baby at 6-8 weeks post due date (only those with dislocated hips on examination should undergo earlier ultrasound).
- Immature hips or mild dysplasia (Graf type 1b or 2a) on initial ultrasound can undergo repeat ultrasound in 6-8 weeks if they are clinically stable.
- Persistently immature, higher grade (Graf 2b, 3 or 4) or clinically unstable hips require referral to the paediatric DDH clinic.
- Hip x-ray is only useful for children 6 months or older, ultrasound is preferred prior to this.
- Bracing of the hip by a qualified orthopaedic team (orthopaedic surgeon and/or advanced practice physiotherapist with an orthotist) should be undertaken for any persistently immature or dysplastic hips.
- Surgery is reserved for those in whom bracing is not effective, or when a diagnosis is delayed with significant abnormalities.
- Observation is appropriate for low grade (Graf 1b or 2a) dysplasia or mild immaturity.
- Paediatric Hip Clinic - BHS
- BHS runs a specific paediatric DDH clinic for concerns of possible or proven DDH. This clinic is more appropriate than general paediatric services for DDH.
- Barwon DDH/club foot clinic
- Geelong has a long standing paediatric DDH clinic for the more serious DDH cases, however initial referral to the BHS paediatric hip clinic is advisable initially.
- A referral to paediatric outpatient services is only appropriate when there are multiple abnormalities associated with DDH, not for DDH alone.
- Further resources
- Further education on hip examination can be obtained through the RCH Orthopaedic Department DDH Education Resource