Infant hip in developmental dysplasia: Facts to consider for a successful diagnostic ultrasound examination

Eugenio O. Gerscovich, MD


evelopmental dysplasia of the hip (DDH) is a deformity of the acetabulum of a variable degree. This is indicative of delayed modeling, which is referred to as “immaturity”. It is associated with a femoral head which is shallow in location (subluxed) or frankly displaced out of the acetabulum (dislocated). “Instability” indicates joint laxity which allows a non-displaced femoral head to become subluxed or dislocated when under stress and which can be provoked by the examiner. Instability is in general associated with acetabular immaturity, but not necessarily. Proper growth and development of the acetabulum is due to the presence of the femoral head in adequate contact and without stress within it. In other words, the acetabulum needs the femoral head for its development. DDH is the result of the disruption of this relationship. It is estimated that in 98% of the cases it results from a late intrauterine event of a previously well formed hip due to persistent forces. In 2% of cases it results from an early intrauterine event secondary to a congenital neuromuscular disorder. The term used for the latter type of hip is “teratologic”. In a
Dr. Gerscovich is in the Department of Radiology at The University of California-Davis Medical Center’s Ambulatory Care Center in Sacramento, CA.

small number of cases DDH occurs later, beyond the neonatal period, despite initial normal clinical, and sometimes normal ultrasound, examinations.1 The hip develops from a single block of mesoderm, and at the beginning of the fetal period (8 weeks since conception) all the structures of the joint are already in place (figure 1).2 At birth, the acetabulum has a smaller bony component and a larger cartilaginous one,3 and the femoral head coverage by the acetabulum is less than at any other time during the fetal or postnatal periods.4 This situation results in a 6-week postnatal period in which the acetabulum is highly susceptible to modeling; it is slightly less susceptible from 6 to 12 weeks and very slightly susceptible after 16 weeks. If the femoral head is in a normal position within the acetabulum the end result will be a normal hip. This is the key period for treatment of DDH. If the femoral head is in an abnormal relationship and this is not corrected, the end result will be a permanently dysplastic hip. Early diagnosis is, therefore, pivotal. However, it is important to know that with minor ultrasound findings, 78% of the hips will spontaneously become normal by the fourth week and 90% by the ninth week.5 Therefore, a conservative attitude in the interpretation of the ultrasound findings is warranted. The consideration of some facts should help us understand, in a particular case, the possibilities of a successful ultrasound examination and a positive diagnosis.

Patient’s age at the time of the examination
The first problem encountered in examination of the infant hip is technical and related to visualization of the structures. The femoral head begins ossifying between the second and eighth month of life in males, and earlier in females (figure 2). On ultrasound, visualization of the neovascularity of the future ossification center begins weeks before the radiological findings. As the size of the ossification center progressively enlarges it will, at some point, obscure the deeper acetabulum, making ultrasound examination impossible. The age of occurrence of this event is variable, mostly occurring in the second semester of life. If the patient is in that age range we might attempt the ultrasound examination first and move on to a radiograph in case of failure. Some authors are more

FIGURE 1. Ultrasound of a hip in a 20-week fetus. I = ilium, A = acetabulum, FH = femoral head, FS = femoral shaft.



from: Gerscovich EO: A radiologist’s guide to the imaging in the diagnosis and treatment of developmental dysplasia of the hip. Raven Press. (B) Severe oligohydramnios: The fetal body (arrows) and internal organs (B = bladder. Similarly. APPLIED RADIOLOGY. and Blacks have been found to have deeper acetabula at birth. Skeletal Radiol 26:386-397. and Norway 16. Newborns with a risk factor by history but with a normal physical examination can wait for 4 to 6 weeks. the normal instability of the hip of the first weeks of life will be avoided. mothers traditionally swaddle their C FIGURE 4. with permission. Austria 6. environment. Axial view of a hip with an ossification center (arrow) in the femoral head in a 3-month-old female infant. Chinese and Black Africans have a negligible incidence. 1993).57%. it results in a palpable “clunk” (reprinted. physical examination as applied to real-time sonography and radiology. (A) Normal amount: A lower extremity (arrow) is surrounded by amniotic fluid (AF) without undue tension and with freedom of movement.B) Barlow’s maneuver. B FIGURE 3. For example.7%. A B dogmatic and recommend ultrasound only up to 4 months of age.6 per thousand newborns. A newborn with an abnormal physical examination will benefit from the ultrasound examination if performed promptly within the first 2 weeks of life. Australia reports a 1% incidence. and season of the year Articles from different countries report a different incidence of DDH in all of its forms. Physical examination. The difference is most likely genetic. with radiography thereafter. Poland 3. In: Wenger DR. from: Wenger DR: Developmental dysplasia of the hip. On the other hand. When the dislocatable femoral head passes over the posterior labrum. but American Blacks are affected.9%. with permission. given time. March 1999 19 . I. p = placenta) are compressed. Influence of the amount of amniotic fluid in the normal development of the fetal hip and body in the second trimester of pregnancy. New York.6 The second problem is deciding the timing of the ultrasound examination on the basis of the clinical history and results of physical examination. The fetal limbs are in extreme forced positions and cannot be visualized. (C) Barlow’s maneuver performed on the left hip of a patient (reprinted. diagram.7 Race. Israel 5. pp 256-296. Rang M (eds): The Art and Practice of Children’s Orthopaedics.A FIGURE 2. whereas for indigenous North Americans and Lapps it can be as high as 25 to 50 per thousand. 1997). General considerations. This maneuver attempts to dislocate an unstable hip. many of the morphologically immature hips will progress towards normality. Additionally. In this way. (A. environmental factors cannot be ignored.9%. The reported average of hip dislocation is 0. It is interesting to note that in the group with a high incidence.9%. Netherlands 3.

B) Ortolani’s maneuver. which are placed in hyperflexion and/or hyperextension for prolonged periods of time (figure 3). Additionally. When ample space is not available.15 However.10 A B Familial DDH Cases of families with several members involved by DDH are well known. from: Gerscovich EO: A radiologist’s guide to the imaging in the diagnosis and treatment of developmental dysplasia of the hip.14 This is thought to be possibly related to an increased level of circulating estrogen observed in affected newborns. from: Wenger DR: Developmental dysplasia of the hip. whereas only 2 to 4% of deliveries are in the breech presentation. For example. Similarly. In: Wenger DR. Sixty percent of patients with DDH occur in primiparous mothers. (A.16 C FIGURE 5.9 There is a higher incidence of DDH in Central Europe and in the South American Andean countries. both result in unphysiological hyperextension of the hips. the risk for those with a positive maternal history but a presentation other than breech is 1 in 25. with permission. thus affecting the development of the acetabulum. to which females are more sensitive. This is observed in 30 to 50% of patients with DDH. in Japan after the institution of a national program to discourage the swaddling of infants.infants with the hips in extension. 1993). in the groups with a low incidence of the problem. and 36% if both a sibling and a parent are. oligohydramnios severely restricts motion and places stress on the extremities. This is thought to be responsible for the increased incidence of left hip involvement that is seen in 80% of these patients. 1997). diagram. has been reported. On the contrary.11 The risk of DDH for a female fetus in breech presentation with a maternal history of the disease is 1 in 15. This is as valid for the proper development of the extremities as for the lungs. in the range of 1. New York. A higher winter incidence of DDH. with permission. first pregnancies find unstretched maternal abdominal and uterine walls which also may limit free movement. pp 256-296. There is a reported familial incidence in 20% of patients.12 A newborn with a sibling affected by the dysplasia carries a risk of 6%. Intrauterine mechanical restriction: way of delivery The development of a fetus requires enough room to move freely without inordinate tension applied. 20 APPLIED RADIOLOGY. the incidence of DDH dropped from 3. I. physical examination as applied to real-time sonography and radiology. representing another possible causative factor. which is more natural. (C) Ortolani’s maneuver performed on the left hip of a patient (reprinted. Physical examination. Skeletal Radiol 26:386-397. Rang M (eds): The Art and Practice of Children’s Orthopedics. abnormalities such as DDH can develop. or strap them to a cradle board. March 1999 . When the dislocated femoral head passes over the posterior labrum. Raven Press.13 Fetal sex DDH is from 4 to 8 times more frequent in females than in males.8 On the same venue. elevated levels of estrogens were not confirmed by other researchers.5% as compared to that of summer (1%). Estrogenic action results in the blockage of maturation of collagen. This maneuver attempts to reduce a dislocated hip.2%. mothers carry their infants against their waist with the children’s legs in flexion and abduction. the pregnancy hormone relaxin has been found in variable levels in newborns with DDH. Breech presentation results in increased tension and hyperflexion of the hips due to their location within the inelastic maternal pelvis and the impossibility of free active motion. 12% if one parent is affected. Most fetuses in breech presentation lie with the left lower extremity on the maternal spine which forces its adduction and limits its motion. it results in a palpable “clunk” (reprinted. General considerations.5 to 0.

20 The mode of delivery. does not seem to affect the likelihood of DDH. March 1999 21 . T = triradiate cartilage. spina bifida. G = gluteus muscles. (B) Coronal view.17. generalized joint laxity. Shaded area = ultrasound beam path.A B FIGURE 6. 1997). corresponding diagram. as well as other syndromes.14 Also. vaginal or by Cesarean section. Sonogram of the left hip in a newborn boy. it has been seen with scoliosis.l9 Twin fetuses have a similar incidence of DDH to that of singletons. CA = cartilaginous acetabulum. BA = bony acetabulum. head and facial deformities. arrow = labrum. hitachi obsoletely Physical examination We might receive a referral for ultrasound on the basis of abnormal physical findings. M= medial (reprinted. and cardiac and renal abnormalities (due to secondary oligohydramnios). IS = ischium. physical examination as applied to real-time sonography and radiology.21 Musculoskeletal and other abnormalities DDH has an association with other postural and non-postural musculoskeletal abnormalities. IL = ilium. I. On observation. It is found in 2% of patients with club foot and metatarsus varus and in 20% of those with torticollis. (A) A coronal view oriented to be in anatomic position to match the diagram in figure 6B. S = superior. arthrogryposis multiplex. myelodysplasia. an infant with a dislocated hip might show a shortened lower limb and redundant skin folds in APPLIED RADIOLOGY. FH = femoral head. sacral agenesis. Bilateral involvement is described in 25%. from: Gerscovich EO: A radiologist’s guide to the imaging in the diagnosis and treatment of developmental dysplasia of the hip. with permission. General considerations.18 High birth weight also is associated with an increased incidence of DDH. Skeletal Radiol 26:386397.

technique. Both findings are secondary to an upward displacement of the dislocated femoral head. Sonogram of a subluxed hip in a 10-day-old female. acetabular coverage of femoral head. (A) Coronal view with acetabular angles: alpha [A] = 32°. March 1999 . These findings are more likely to be seen in older infants. not in the newborn. study of older children. I = ilium. T = triradiate cartilage. corresponding diagram. Skeletal Radiol 26:447-456. Skeletal Radiol 26:447-456. I = ischium. It should be noted that a mild displacement of a few millime- A B FIGURE 8. a gentle posterior push. acetabular cartilage thickness. II. study of older children. M = medial. technique. With the limb in adduction. beta [B] = 77°. BA = bony acetabulum. Ultrasonography: anatomy. acetabular angle measurements.A B FIGURE 7. P = pubis. is made. Sonogram of the left hip in a newborn boy (same patient as in figure 6). 22 APPLIED RADIOLOGY. M = medial (reprinted. 1997). from: Gerscovich EO: A radiologist’s guide to the imaging in the diagnosis and treatment of developmental dysplasia of the hip. II. A = anterior. acetabular coverage of femoral head. attempts to dislocate a well placed femoral head (figure 4). P = pubis. screening of newborns. from: Gerscovich EO: A radiologist’s guide to the imaging in the diagnosis and treatment of developmental dysplasia of the hip. acetabular angle measurements. three-dimensional technique. acetabular cartilage thickness. (B) Axial view. FH = femoral head. When positive (subluxable or dislocatable hips). FH = femoral head. Coronal section in the “standard plane” of a normal hip. Ultrasonography: anatomy. we refer to the hip as “unstable”. (B) Axial view with the femoral head in contact with the acetabulum. M= medial. 1997). the thigh due to an apparent excess of skin.22 By performing different maneuvers we may find a limitation of abduction on the affected side as compared to the opposite side. L = lateral. with permission. performed with hip and knee flexion. The Barlow’s maneuver. with permission. IS = ischium. Beta angle = 49° = superior. screening of newborns. Alpha angle = 67°. three-dimensional technique. oriented in the way the ultrasound equipment displays it. A = anterior (reprinted. S = superior. like a piston. (A) An axial view oriented to be in anatomic position to match the diagram in figure 7B. FIGURE 9. Shaded area = ultrasound beam path.

Sonogram of a dislocated hip in a 1.14 The described maneuvers have been incorporated into the ultrasound examination. While the extremity is being abducted. This is achieved by slightly rotating the transducer. On the basis of the results. IS = ischium. It is performed with flexion of the hip and knee. A = anterior (reprinted. S = superior. ters is normal in the first 2 weeks of life due to circulating humoral factors. 1997). from: Gerscovich EO: A radiologist’s guide to the imaging in the diagnosis and treatment of developmental dysplasia of the hip. and their specificity has been found to be from 84. Ultrasonography: anatomy. three-dimensional technique. ranging from 10 to 34. improving their sensitivity and specificity. (B) Axial view. acetabular cartilage thickness. an anterior and sustained push to the thigh is applied from the posterior aspect. Skeletal Radiol 26:447-456. screening of newborns. Its key is to correctly identify this “standard plane”. Clinically.24 Ultrasound examination The anatomy of the infant hip is illustrated in figures 6 and 7. we refer to the dislocated hip as “reducible” or “non-reducible”. Occasionally. we might find a positive finding on ultrasound. technique. study of older children. In general.4%. with permission. and has no pathological significance. For that.5-month-old female.23 False negative results of the Ortolani’s maneuver can occur in newborns with extreme capsular laxity in which the dislocated femoral head can be fully abducted without actually reducing it. The final step is to obtain a sharp definition of the lower end of the bony acetabulum. M = medial. acetabular angle measurements. trapping the femoral head outside the acetabulum. It also can occur in older infants with a longstanding dislocation in which the hip muscles become contracted and shortened. acetabular coverage of femoral head. attempting to relocate the posteriorly dislocated femoral head. Two techniques for the ultrasound examination of this area are widely in use. The first reported technique is based on the morphology of the acetabulum. March 1999 23 . P = pubis. II. The Ortolani’s maneuver attempts to reduce a dislocated hip (figure 5). IL = ilium. If these A B FIGURE 10. The femoral head has lost contact with the acetabulum.3 to 99%. instability is found in 1 to 3% of all newborns. though. this finding results from joint capsule and tendon stretch- hitachi left behind APPLIED RADIOLOGY. H = femoral head. Both use a lateral approach with the infant supine or in the lateral decubitus position. we have to place the iliac bone parallel to the surface of the transducer. (A) Coronal view. It should be noted that the sensitivity of the clinical Ortolani’s and Barlow’s maneuvers has been reported by several authors. This is achieved by gently sliding the transducer in the anteroposterior direction. It was described by Graf in 198025 and consists of a single coronal image through the deepest portion of the acetabulum (figure 8). At our institution we sometimes get referrals because of audible high pitch “clicks” observed during the performance of the described clinical and snapping.

In this technique the position of the femoral head is not considered. The smaller the angle the less the cartilaginous coverage due to a better acetabular bony containment of the femoral head. it takes into consideration the position of the femoral head. Described by Morin et al in 1985. Sonographically. or a combination of the two. When finding a dislocated hip. subluxed. Axial views of a normal hip in a 2-month-old infant with no femoral head displacement during stress (Barlow’s maneuver). respectively. The second ultrasound technique used in the diagnosis of DDH is dynamic and was described by Harcke et al in 1984. from 50 to 60 degrees is considered physiologic before 3 months of age.27 A third method. (B) The hip under stress. The examination is performed in the coronal. Stress views and angle measurements are optional. On the above 24 APPLIED RADIOLOGY. An angle of 60 degrees or more is normal. This measurement is indicative of the acetabular cartilaginous roof coverage and is secondary in significance to the alpha angle. Ultrasonography: anatomy. It is calculated by the equation (d/D) × 100. acetabular cartilage thickness. including its cartilaginous portion and labrum. AC = 50%. screening of newborns. with permission. is based on the measurement of the acetabular coverage of the femoral head (figure 12). The recommended protocol of a “dynamic standard minimum examination” asks for the patient to be placed in a supine or lateral decubitus position. Figures 9 and 10 are examples of a subluxed and a dislocated hip. three-dimensional technique. mild instability is found in all newborns for the first few days. March 1999 . based on the premise that its position (normal. from: Gerscovich EO: A radiologist’s guide to the imaging in the diagnosis and treatment of developmental dysplasia of the hip. 1997). with spontaneous resolution in normal cases. (A) The relaxed hip. which is complementary to the other two described above. However. (A) A newborn male with a normal hip. AC = 27%. we should be in view of the entire acetabulum. acetabular coverage of femoral head. B FIGURE 11. similar to Graf’s technique. it incorporates the Barlow’s maneuver in both imaging planes in trying to demonstrate instability (subluxable. study of older children. Acetabular coverage (AC) of the femoral head. (B) A 10-day-old female with a subluxed hip. dislocatable hips) (figure 11). and images are obtained with and without stress. as recommended at a symposium on the subject held in Maryland in 1993. parameters are obtained correctly. the Ortolani’s maneuver should be performed to check for reducibility. D = femoral head diameter. Skeletal Radiol 26:447-456. technique.26 This technique incorporates the use of real time. Scanning is performed in the coronal plane with the hips extended or flexed. M = medial (reprinted. and axial planes. A second angle (beta) is drawn between the iliac line and a line drawn from the labrum to the transition point between the iliac bone and the bony acetabulum. d = segment of femoral head covered by the acetabulum. acetabular angle measurements. or dislocated) will be reflected by the morphology of the evaluated acetabulum. On the described image. Values under 50 degrees are abnormal at any age. In the axial plane the thighs are in 90 degrees flexion. but needs to be followed for observation. S = superior. First. the slope of the acetabulum (alpha angle) is measured with respect to the iliac line. Second. Graf’s classification of DDH is based on these 2 angles. II.28 this maneuver is based on the radiographic migration percentage (MP). Different institutions use one method or the other. two key points differentiate it from Graf’s.A B A FIGURE 12.

LopezMoratalla M. AR 12. An acetabular coverage of the femoral head of 58% or more is normal. Forst J. Von Deimling U. 17. 1995. 1988. Renshaw TS: Pediatric Orthopedics. 1990. 27. Rossig S: Ultrasound hip joint screening in newborn infants. 18. 7. Yamamuro T. 1984. Pediatrics 94:47-52. pp 63-88. WB Saunders. 1987. Williams & Wilkins. Klinische Padiatrie 210:115-119. Clegg J. Pediatrics 94:201-208. Hennrikus WL. 1970. Wilson PD. Clin Symp 31:3-31. 1994. Tillmann B: Embryonic development of the hip joint. Harcke HT. Hensinger RN: Congenital dislocation of the hip. 2. Baltimore. Ishida K: Recent advances in the prevention. 9. 19. 1979. 1994. 11. we can see if more than half of the femoral head is covered by the acetabulum. 21. 1988. Heller KD: Pathogenetic relevance of the pregnancy hormone relaxin to inborn hip instability. hitachi flowing colors APPLIED RADIOLOGY. 24. Tolo VT. Clin Orthop 225:62-76. Bond CD. Wood B: Hip and thigh. Andren L. Forst C. Borglin NE: A disorder of oestrogen metabolism as a causal factor of congenital dislocation of the hip. Semin Ultrasound CT MR 15:256-263. Tachdjian MO: Pediatric Orthopedics. ed 2. Bouklas P. Lie RT: Ultrasound in the early diagnosis of congenital dislocation of the hip: the significance of hip stability versus acetabular morphology. Ceballos T. The less the coverage the more immature the acetabulum. DeRosa GP. 1960. Marks DS. Lee MS. 15. Intermediate values are indeterminate. 1985. Finally. Clarke NM. MacEwen GD: The infant hip: Real-time US assessment of acetabular development. 29. D is the maximum diameter of the femoral head. et al: Examination of the infant hip with real-time ultrasonography. and below 33% is abnormal (subluxation). DellaMaggiore ED: Prospective evaluation of newborn soft-tissue hip “clicks” with ultrasound. Z Orthop Ihre Grenzgeb 128:338-340. 4. which tells us a normal hip is present. Ruhmann O. 8. 1997. Is twin pregnancy a risk factor for dysplasia? 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