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20 January 2011

Dr Nidham Oda
CASE
A young mother brings her 8 weeks old girl to your GP clinic because one of the
nurses found asymmetrical hip creases. Take further History, Physical Examination,
advised on the Management.

DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)
HISTORY
I understand that your child has an asymmetrical hip
I want to ask a few questions about that
That you yourself detect this creases or the nurse
Have you noticed any asymmetry while changing nappies
Is your child moving her legs or both hips normally
Is she crying if she moves one of her legs or when changing nappy
Are you concerned
How is your baby in general
Is she feeding well
Is she putting on weight
Does she have any vomit
Is she wetting nappies normally
How about her poos or bowel motions, any change, diarrhoea?
Does she have any cough at all
Is the child your first child?
Was she full-term or premature?
Was she delivered normally or by operation? …by SC (a risk factor)
Why by SC?…breech presentation (another risk factor)
Was there any problem after delivery, did she stay long in the post delivery room
Does anyone in the family suffers from hip problems
How about you? Any problems after delivery, are you coping well with your child
after SC?
PHYSICAL EXAMINATION
General Appearance
Vital Signs
Growth parameters  I want to check his blue book
Quick exam of the chest…lung, heart, abdomen
Move to the hip
Remove nappy, look for the asymmetry
Screening test to aid which patient needs further investigation  Ortolani test
(dislocating the hip, full abduction) & Barlow test (relocating the hip, adduction) 
positive if there is click or clung sounds.
Flex both knees 90 degrees, do full abduction (Ortolani)
Opposite movement, relocate the head (Barlow)

Ortolani Test (steps 1-5) Ortolani test is performed by abducting the infant’s hip and assessing for a clicking sound. Feeling of femoral head slipping out of the socket postolaterally. is considered as a positive Barlow’s sign. 4. 2. Procedure 1. The Ortolani test is then used to confirm that the hip is actually dislocated. This test is used to detect the posterior dislocation of the hip. Lay the infant in a supine position and flex the knee to 90 degrees at the hips. thus. 3. Normally. A clicking or clunking sound is a positive Ortolani’s . Slowly and gently abduct the hips while applying pressure over the greater trochanter. Proper position of the infant ensures accurate results. The maneuver is done in early infancy because after 2-3 months the development of soft tissue contracture prevents the hip from being relocated. place the middle fingers over the great trochanter of the femur and the thumb on the internal side of the thigh over the lesser trochanter. Placing the fingers in this manner allows easy abduction of the hips. 5. A positive Ortolani’s sign is noted when a clicking or distinctive “clunk” is heard when femoral head re-enters the acetabulum. no clicking or clunking sound will be assessed in children with congenital hip dysplasia. no sound is heard. Barlow Test (steps 6 and 7) Barlow test is performed by bringing the thigh towards the midline of the body. The femur is pulled forward while the greater trochanter is used as a fulcrum. Hold the infant’s pelvis with one hand to stabilize it during manipulation. Listen for a clicking or clunking sound while performing step number four. Ortolani maneuver is performed before 2-3 months of age. Using the other hand.

Hold the hips and knees at 90 degree flexion while exerting a backward pressure (down and laterally). Normally. easily dislocated. Slowly and gently adduct (bringing the thigh towards the midline) the hip.Shortening of the leg . if untreated will lead to: . EXPLANATION Your daugr hmight have Developmental Dysplasia of the Hip which needs to be confirmed.baby girl or . diagnostic up to the age of 9 months. 7.premature .Breech delivery or .who are born by Caesarian Section or . Exact cause unknown. The only way to confirm at this age is by doing ultrasound. Risk factors is more common: . With the fingers in the same position. Usually is developmental. the hip joint is stable. 6.sign and it happens when the femoral head is re-entering the acetabulum. easily treated with a splint Abduction splint (within the first 6 months)  Pavlik harness After 3-18 months  Hip spica (from belly button to the leg for a few months) After 18 months  prefer surgery Despite early treatment some cases progress to acetabular dysplasia (underdevelopment of the ‘roof’ of the hip joint) and to premature osteoarthritis. Note any feeling of the femoral head slipping. she is born with it. assess the infant for Barlow’s sign. afterwards diagnosis by X-ray.with a first family history MANAGEMENT Needs to be treated.Delayed walking . DDH is a condition in which there is underdevelopment of the femoral head. Thus a follow-up X-ray of the pelvis during teenage years should be considered for anyone with a history of DDH .Limp when walk .May develop early osteoarthritis changes in the head Treatment depends on the age: Very young. The feeling of the femoral head slipping out of the socket postolaterally is a positive Barlow’s sign. very good time. The head of the femoral is smaller than normal.

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Table 65. Limited especially Abduction and All. Abduction All movement abduction and IR especially IR IR • Subchondral • AP may be • No diagnostic fracture normal value in neonatal Plain X-ray • Normal • Dense head • Frog lateral period (use • Pebble stone view shows ultrasound) epiphysis slip .2 Comparison of important causes of hip pain in children Transient DDH Perthes' SCFE synovitis Age (years) 0 .4 4-8 4-8 10 .15 Limp + Pain - + + + Septic arthritis Any Won't walk +++ + + + All.