Quality Education for a Healthier Scotland Multidisciplinary Developmental Dysplasia of the Hip

Quality Education for a Healthier Scotland Multidisciplinary “Developmental dysplasia of the hip” Dysplasia Subluxation Dislocated

Quality Education for a Healthier Scotland Multidisciplinary The aim of treatment A normal hip

Quality Education for a Healthier Scotland Multidisciplinary Natural history Hip arthritis in early adulthood

Quality Education for a Healthier Scotland Multidisciplinary Early diagnosis Treatment success high Treatment late cases Less successful More surgery More complications

Quality Education for a Healthier Scotland Multidisciplinary How common is DDH? Clinically unstable hips – 1 in 64 babies

Quality Education for a Healthier Scotland Multidisciplinary Scottish Needs Assessment Program Report July 1993 Number of late cases not reduced by neonatal screening Possible increase in number of late presenting cases

Quality Education for a Healthier Scotland Multidisciplinary National Screening Committee recommendations All babies must be screened by clinical examination Ultrasound if clinical abnormality or risk factors Clinically abnormal hips should be seen by a specialist

Quality Education for a Healthier Scotland Multidisciplinary National Screening Committee (cont.) Second hip check before 8 weeks Personal Child Health Record lists signs and symptoms suggesting DDH If DDH suspected, referral to someone with the appropriate expertise

Quality Education for a Healthier Scotland Multidisciplinary Clinical examination “24-hour check” Five points: History of risk factors Leg length difference Groin/buttock creases Range of abduction Tests of stability

Quality Education for a Healthier Scotland Multidisciplinary Point 1 – History of risk factors Breech presentation Family history of DDH Abnormalities of the lower limbs, e.g. clubfoot Torticollis

Quality Education for a Healthier Scotland Multidisciplinary Look Point 2 - Leg length difference Hips and knees flexed Check level of knees – should be level If not level then refer Point 3 - Labial or groin folds and buttock creases (Reprinted from Jones: Hip Screening of the Newborn – A Practical Guide, 1998, with permission from Elsevier.)

Quality Education for a Healthier Scotland Multidisciplinary Move Point 4 - Range of abduction Point 5 - Tests of stability Barlow Ortolani Restricted abduction and asymmetrical groin folds

Quality Education for a Healthier Scotland Multidisciplinary Instability tests InOut StableNormalFixed dislocation UnstableBarlow +Ortolani +

Quality Education for a Healthier Scotland Multidisciplinary Resting position Test one hip at a time Hip and knee flexed Finger on greater trochanter Stabilise pelvis Compare sides Take your time, be gentle

Quality Education for a Healthier Scotland Multidisciplinary Clinical tests Barlow test Abnormal if femur moves Backwards relative to the fixed pelvis Test for a located but dislocatable hip

Quality Education for a Healthier Scotland Multidisciplinary Clinical tests 2 Ortolani test Positive if greater trochanter moves forwards as hip locates Hip is Out, but can be reduced Tests for a dislocated but reducible hip

Quality Education for a Healthier Scotland Multidisciplinary Barlow & Ortolani

Quality Education for a Healthier Scotland Multidisciplinary Examining infants hips - can it do harm? “Over enthusiastic or repeated clinical examination may provoke instability” Take your time, be gentle Lowry et al (2005) Archives of Diseases in Childhood 90 (6):

Quality Education for a Healthier Scotland Multidisciplinary Barlow positive Incidence? 15 to 20/1000 Barlow positive Many resolve without treatment Decision to treat may be delayed Need careful watching

Quality Education for a Healthier Scotland Multidisciplinary Ortolani positive. Incidence? 1 to 2/1000 Ortolani positive Most will need treatment Some centres splint from birth Careful follow up

Quality Education for a Healthier Scotland Multidisciplinary ‘ Teratologic' or fixed dislocation Dislocated irreducible hip Dislocation before birth Association with arthrogryposis or myelomeningocele Surgery usually required

Quality Education for a Healthier Scotland Multidisciplinary Baby Hippy ‘ Life-like’ model of a female newborn Barlow positive hip Ortolani positive hip Expensive and delicate ++

Quality Education for a Healthier Scotland Multidisciplinary Clinical examination “24-hour check” Five points: History of risk factors Leg length difference Groin/buttock creases Range of abduction Tests of stability Barlow Ortolani Questions?

Quality Education for a Healthier Scotland Multidisciplinary The unstable neonatal hip What happens to them? Hip can become normal Progress to subluxation Progress to dislocation Remain located but remain dysplastic We cannot tell which will get better on their own - they need watched

Quality Education for a Healthier Scotland Multidisciplinary Controversies in DDH The natural history not completely understood Effectiveness of treatment not clear Screening – Who? How? When? Why are we still missing so many?

Quality Education for a Healthier Scotland Multidisciplinary Clinical examination Not universally successful Failed to eliminate late presentations Dysplasia may not be detectable Detection improves when performed by a limited number of experienced examiners

Quality Education for a Healthier Scotland Multidisciplinary Missed? Some are missed Others present late Importance of 6-week and 36- month checks Late signs –Limp –Leg length difference –Restricted abduction Age 5 years: bilateral dislocations

Quality Education for a Healthier Scotland Multidisciplinary Hip screening with ultrasound Options Universal screening Screening of high risk babies

Quality Education for a Healthier Scotland Multidisciplinary Universal U/S screening Difficult to organise High number of immature hips – rescan Expensive ?Cost effective Conclusion – not proven, although some very impressive results

Quality Education for a Healthier Scotland Multidisciplinary Selective U/S screening Only high risk and clinically abnormal hips Consultant radiologists and dedicated sonographer ? Effectiveness Manageable

Quality Education for a Healthier Scotland Multidisciplinary X-ray examination X-rays before 4 months of age unreliable Very important in older children for diagnosis and monitoring of treatment Dislocation age 15 months.

Quality Education for a Healthier Scotland Multidisciplinary Late signs of DDH Asymmetric abduction Leg length discrepancy DDH must be excluded

Quality Education for a Healthier Scotland Multidisciplinary Treatment Abduction splint – Pavlik, von Rosen Monitoring for hip development and complications

Quality Education for a Healthier Scotland Multidisciplinary How not to examine a baby’s hips!

Quality Education for a Healthier Scotland Multidisciplinary Thank you. Any questions?

Quality Education for a Healthier Scotland Multidisciplinary Summary Aim – to reduce incidence of hip arthritis The Five points of the examination History of risk factors Leg length difference Groin/buttock creases Range of abduction Tests of stability