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Developmental dysplasia of the hip: Clinical features and

diagnosis
Author: Scott B Rosenfeld, MD
Section Editor: William A Phillips, MD
Deputy Editor: Mary M Torchia, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Sep 2019. | This topic last updated: May 23, 2019.

INTRODUCTION

Developmental dysplasia of the hip (DDH) describes a spectrum of conditions related to the
development of the hip in infants and young children. It encompasses abnormal development of the
acetabulum and proximal femur and mechanical instability of the hip joint (table 1).

Newborns often have physiologic laxity of the hip and immaturity of the acetabulum during the first
few weeks of life. In most cases, the laxity resolves, and the acetabulum proceeds to develop
normally. With assessment of risk factors, serial physical examination of the hips, and appropriate
use of imaging studies, most children with pathologic hips can be correctly diagnosed and treated
without long-term sequelae. (See "Developmental dysplasia of the hip: Treatment and outcome".)

Typical DDH, which generally occurs in otherwise healthy infants, will be the focus of this topic review.
Hip dysplasia and instability also occur in association with other conditions. Teratologic hip dysplasia
occurs in association with various syndromes (eg, Ehlers-Danlos, Down syndrome, arthrogryposis),
and neuromuscular hip dysplasia occurs when there is weakness and/or spasticity in some or all of
the hip muscle groups (eg, in spina bifida or cerebral palsy). The diagnosis and management of
teratologic and neuromuscular hip dysplasia differ from the diagnosis and management of hip
dysplasia in otherwise healthy infants.

The clinical features and diagnosis of DDH in otherwise healthy children will be reviewed here. The
epidemiology, pathogenesis, treatment, and outcome are discussed separately. (See "Developmental
dysplasia of the hip: Epidemiology and pathogenesis" and "Developmental dysplasia of the hip:
Treatment and outcome".)

CLINICAL FEATURES

The clinical features of DDH depend upon the age of the child and the severity of the abnormality
(table 2). The spectrum of presentation ranges from instability on the newborn examination, to subtle
limited abduction in the infant, to asymmetric gait in the toddler, to activity-related pain in the
adolescent, to osteoarthritis in the adult. The earlier DDH is detected, the simpler and more effective
the treatment and the better the long-term outcome [1,2]. (See "Developmental dysplasia of the hip:
Treatment and outcome".)

History — Thorough review of the child's medical and family history helps to identify risk factors for
DDH and exclude other congenital or neuromuscular causes of hip instability. The most important
risk factors are female sex, breech positioning at ≥34 weeks gestation (whether or not external
cephalic version is successful) [3], family history of DDH, and tight lower extremity swaddling [2].
Conditions that are associated with DDH, but are not proven to increase the risk of occurrence,
include torticollis, plagiocephaly, metatarsus adductus, clubfoot, being the firstborn infant,
oligohydramnios, birthweight >4 kg, and multiple gestation pregnancy. (See "Developmental dysplasia
of the hip: Epidemiology and pathogenesis", section on 'Risk factors'.)

Infants and young children with untreated hip dislocation rarely have pain or other limitations. Most
affected children begin to walk and reach other developmental milestones at the appropriate time.

Examination

Overview — We agree with professional society guidelines that recommend examination for DDH
beginning in the newborn period and continuing at health supervision visits until approximately nine
months of age and/or the child is walking independently [2-5]. The newborn examination and the
office examinations at two to four weeks of age are particularly important for early detection of DDH.

The pertinent examination findings of DDH vary according to age (table 2). The most important
aspects of the examination are hip instability in the young infant and range of motion in the older
infant and child [2]. It is important to explain the hip examination to the parents as it is being
performed and to document the results at each visit. (See 'Hip instability' below and 'Range of motion'
below.)

Examination for DDH at the newborn visit and at subsequent health supervision visits is
recommended by the American Academy of Pediatrics (AAP) [2], the American Academy of
Orthopaedic Surgeons [4], the Pediatric Orthopaedic Society of North America [5], and the Canadian
Task Force on DDH [6]. (See 'Screening for DDH' below.)

General examination — Important aspects of the general examination for DDH include the
neurologic examination and examination of the spine and distal lower extremities, looking for
abnormalities associated with DDH and other causes of hip instability.

● The neurologic examination should include evaluation of spontaneous movement of all four
extremities and assessment of spasticity. (See "Neurologic examination of the newborn" and
"Detailed neurologic assessment of infants and children".)

● The spine examination should include cervical range of motion (looking for torticollis (picture 1))
and cutaneous manifestations of spinal dysraphism (eg, dimples and hairy patches). (See
"Pathophysiology and clinical manifestations of myelomeningocele (spina bifida)".)

● Examination of the extremities should include examination of the feet for metatarsus adductus
(picture 2). (See "Lower extremity positional deformations", section on 'Metatarsus adductus'.)

Age-specific findings of DDH — The pertinent examination findings vary according to age (table
2):

● In infants younger than three months, it is most important to evaluate the stability of the hips
using the Ortolani maneuver [2]. The Barlow maneuver, the Galeazzi test (also called the Allis or
Perkins test), and the Klisic test also may be useful. Decreased abduction generally is not
present at this age. (See 'Hip instability' below and 'Asymmetry' below and 'Klisic test' below.)

● After three months of age, limited abduction, apparent thigh-length discrepancy (in unilateral
cases), and the Galeazzi (for unilateral cases) and Klisic tests are better indicators of DDH than
instability. By three months of age, tests of instability are of little value because unstable hips
have usually stabilized (the once-dislocatable hip stabilizes in the reduced position; the once-
reducible hip stabilizes in the dislocated position). (See 'Range of motion' below and 'Asymmetry'
below and 'Klisic test' below.)

● In walking-aged children with unilateral DDH, weakness of the hip abductors on the affected side
may be indicated by a positive Trendelenburg pelvic tilt test (inability to maintain the pelvis
horizontally while standing on the ipsilateral leg) (figure 1) and the presence of a Trendelenburg
lurch while walking. (See 'Asymmetry' below.)

Hip instability — Each hip should be examined individually for reducibility and instability (table 1)
[7-9]. The infant should be on a stable surface in the supine position, with the hip flexed to 90° and in
neutral rotation. The examination should occur when the infant is calm and not crying. The hips are
best examined with all clothing and diapers removed from the lower extremities.

● Ortolani maneuver – The thigh is grasped loosely with the examiner's index and middle finger
along the greater trochanter and the thumb on the inner thigh. From an adducted position, the hip
is gently abducted while lifting or pushing the trochanter anteriorly. Extreme abduction should be
avoided because it decreases the sensitivity of the Ortolani maneuver. If the hip is dislocated, the
Ortolani maneuver may reduce it and is accompanied by a palpable clunk. A positive Ortolani
maneuver assumes a dislocated hip that is reducible.

● Barlow maneuver – The hip is held in the same manner as for the Ortolani maneuver. The thigh is
grasped loosely with the examiner's index and middle finger along the greater trochanter and the
thumb on the inner thigh. The hip is gently adducted and, in a change from previous
recommendations, no downward pressure is applied, and the head is palpated to detect moving
out of the back of the acetabulum. The examiner should not attempt to forcefully dislocate the
femoral head [2]. If the hip is dislocatable, posterior movement and a palpable clunk may be
detected as the femoral head exits the acetabulum (the "jerk of exit") [2,7-9]. A subluxatable hip
is characterized by a subtle sliding movement or a feeling of looseness, like a tennis ball moving
in a soup bowl. A positive Barlow maneuver assumes a reduced hip that is subluxatable or
dislocatable [2].

The sensation of reduction or dislocation is distinct and best described as a "jerk" or "clunk." This
sensation is different from that of the high pitch benign joint popping, clicking, or snapping caused by
the snapping of tendons or ligaments in and around the hip and knee. The term "hip click" is
misleading and is best avoided; hip clicks are not suggestive of DDH [10,11].

The combination of the Barlow and Ortolani maneuvers has a high specificity (estimated to be
approximately 98 to 99 percent) in the detection of hip instability [12]. The sensitivity varies
depending upon the skill of the examiner, the number of examinations performed, and the diagnostic
standard (eg, ultrasonography, radiographs). Sensitivity is increased in experienced hands (ranging
from 87 to 97 percent) [13-17].

Asymmetry — Asymmetric examination findings may be helpful in unilateral DDH. However, as

many as 37 percent of cases are bilateral [18]. Lack of asymmetry does not exclude DDH and may
delay the diagnosis.

Apparent shortening of one femur is an important sign of unilateral dislocation and can be elicited
with the Galeazzi test. This is performed with the infant supine, hips flexed to 90°, knees flexed, and
feet flat on a level surface and side by side, with the heels in apposition to the buttocks. In this
position, the knees are normally at the same level. In unilateral dislocation, the head of the femur is
displaced posteriorly, functionally shortening the thigh, and the ipsilateral knee will be lower than the
other knee (figure 2). A positive Galeazzi test is not specific for DDH. Other causes of leg-length
discrepancy must be considered (eg, hemihypertrophy, femoral hypoplasia, coxa vara).

Asymmetry in the position or number of the inguinal, thigh, or gluteal skin folds (figure 3A-B) may be a
clue to the diagnosis of unilateral DDH. In the case of DDH, the increased folds are caused by
"bunching" of the skin and muscle around a functionally shortened femur. Asymmetric skin folds are
less helpful than other signs in predicting DDH. In a series of 105 children referred for asymmetric
skin folds, only two had pathologic DDH; both had a positive Galeazzi test and limited hip abduction
[19]. Asymmetric skin folds are sensitive but not specific for DDH, since skin fold asymmetry is
present in approximately 24 percent of all infants [20].

In the child who is walking, gait asymmetry may provide a clue to unilateral DDH. The abnormal gait is
usually caused by leg-length discrepancy, resulting in gait changes, such as toe-walking on the
affected side or vaulting over the longer contralateral leg [21]. A child with unilateral hip dislocation
will have a Trendelenburg lurch on the affected side (figure 1).

Range of motion — In a child older than two to three months, limitation of abduction (<45°) is the
most reliable sign of DDH. Normal range of motion in a supine infant with the pelvis stabilized is >75°
for abduction and at least 30° past the midline for adduction [22]. In a 10-year prospective
longitudinal study that included 2876 infants, unilateral limited hip abduction after eight weeks of age
had a sensitivity of 78 percent and specificity of 93 percent in the detection of radiographically
confirmed DDH [23]. In another review of 683 infants older than three months, unilateral limited hip
abduction had a sensitivity of 69 percent and a specificity of 54 percent [24]. Infants younger than
two to three months may have normal adduction because they have not had enough time to develop
an adduction contracture. (See "Developmental dysplasia of the hip: Epidemiology and pathogenesis",
section on 'Embryology and pathogenesis'.)

Patients with unilateral DDH may have increased internal rotation of the hip because increased
femoral anteversion is often associated with DDH [25]. Internal hip rotation is assessed with the
patient lying prone on the examination table and the knees flexed; the lower leg is rotated away from
the axis of the body (rotating the hip internally) (figure 4). (See "Approach to the child with in-toeing",
section on 'Focused neurologic examination'.)

Klisic test — A positive Klisic test is suggestive of DDH. The Klisic test is performed by placing the
index finger on the anterior-superior iliac spine and the middle finger on the greater trochanter. An
imaginary line between these points passes through or above the umbilicus in a child without DDH
(negative Klisic test). The line passes below the umbilicus if the hip is dislocated (positive Klisic test)
because the greater trochanter is in a more superior position (figure 5). The Klisic test may be
particularly helpful in bilateral dislocations when abduction is symmetrical and the Galeazzi sign is
negative (ie, the knees are at the same height), because the result is evaluated independently for each
side and does not rely on comparison with the contralateral limb.

Bilateral dislocation — Bilateral DDH occurs in as many as 37 percent of cases [18,26]. In infants
younger than three months, the tests for instability (ie, the Ortolani and Barlow maneuvers) may be
useful in detecting bilateral DDH. However, as DDH progresses, dislocated hips become irreducible
and instability is no longer detected. Findings related to symmetry (eg, Galeazzi sign, thigh folds) are
not helpful in bilateral dislocation [22]. (See "Developmental dysplasia of the hip: Epidemiology and
pathogenesis", section on 'Embryology and pathogenesis'.)

In children older than three months, the most important examination finding for bilateral dislocated
hips is symmetric limited abduction (<45°). Other signs may include widening of the perineum,
bilateral positive Klisic tests, and short thigh segments relative to the child's size (figure 6). Once the
child begins to walk, hyperlordosis and a waddling Trendelenburg gait are classic findings (table 2
and figure 1).

Dysplasia without dislocation — Dysplasia without dislocation usually has no clinical findings and
is asymptomatic until adolescence or early adulthood. It is often found only through diligent
screening of risk factors or incidentally when radiographs are obtained for other concerns (eg, an
abdominal radiograph for evaluation of bowel obstruction, cystography (image 1)) or for assessment
of activity-related hip pain in an adolescent or young adult.

Natural history — The natural history of untreated DDH depends upon the age of the patient and the
severity of DDH [27-30]. Most hip instability in newborns stabilizes soon after birth, as physiologic
laxity decreases and the femoral head and acetabulum grow. In observational studies, there is a high
rate of resolution of neonatal hip instability without intervention [4,7,31-34]. In a cohort of 11,989
infants examined by a single examiner, 60 percent of hips that demonstrated instability on physical
examination at birth stabilized in the first week of life, and nearly 90 percent stabilized by two months
[7]. These hips were functionally and radiographically normal at 12 months of age. Similar results
were reported in a study of routine ultrasonographic screening of more than 14,000 infants: 6 percent
had abnormalities soon after birth, 90 percent of which became normal by nine weeks of age [34].

Infants and young children with untreated hip dislocation rarely show signs of pain or other
limitations. Most children reach developmental milestones at the appropriate time. A dislocated hip
generally does not delay the age at which the child begins to walk. A dislocated hip may function well
for many years [30]. However, weakness in the hip abductor musculature may result in the classic
Trendelenburg gait pattern. Over time, there may be gradual progression of functional disability, pain,
and accelerated degenerative hip disease. The risk of these complications is not well-defined but may
be associated with the development of a false acetabulum [35]. Patients with unilateral dislocations
may have leg-length discrepancy, ipsilateral knee problems, scoliosis, and gait disturbance. Patients
with bilateral dislocations may develop back pain (perhaps related to increased lumbar lordosis).

Dysplasia in a reduced or subluxed hip may be diagnosed incidentally when radiographs are obtained
for other reasons. The clinical course for patients with this presentation is variable. These hips are
often asymptomatic in infants and young children, and radiographic abnormalities may improve with
time, as the acetabulum still has excellent remodeling potential [35-38]. After school age, the
likelihood of spontaneous improvement is low. Patients with persistent dysplasia without dislocation
may remain asymptomatic for some time but may develop activity-related hip pain or premature
degenerative joint disease in adolescence or young adulthood. This occurs as a result of increased
cartilage contact stress at the anterior and lateral margins of the acetabulum. Pain may start soon
after skeletal maturity, or, in females, during the first or second pregnancy, or at menopause. Patients
40 to 60 years old who present with hip osteoarthritis are often found to have mild dysplasia as a
contributing cause [27-30].

DIAGNOSTIC IMAGING

Ultrasonography — Ultrasonography is the primary imaging technique for assessing the morphology
and stability of the infant hip. It is an important adjunct to the clinical evaluation until four to six
months of age [39-41]. Ultrasonography can be helpful in confirming physical examination findings
and evaluating infants with risk factors who have normal examination findings. The major drawback
of ultrasonography is that accurate interpretation requires training and experience [42].

Ultrasonographic criteria for DDH have been established for static imaging (which includes coronal
and transverse planes) and dynamic imaging of the flexed hip with and without a modified Barlow
stress maneuver [41,43]. The combination of static and dynamic imaging permits evaluation of hip
morphology, position, and stability.

Static views include a coronal image with the infant in the lateral decubitus position and the hips
flexed at 30 to 45° [44]. In this position, the ossified ilium is viewed as a straight white line above the
femoral head and superior acetabulum (figure 7 and image 2). In practice, these images are often
oriented as if the baby is lying in the lateral position, with the ilium pointed to the left of the femoral
head, instead of above it. The alpha angle is measured from the lateral wall of the ilium and the bony
roof line. The beta angle is the angle formed by the lateral wall of the ilium and the cartilaginous roof
line. These angles are used to classify DDH according to the Graf system (figure 8) [44]. Another
important parameter is the percentage of the femoral epiphysis that is covered by the acetabular
roof. For infants younger than four months of age, we generally consider coverage of >50 percent to
be normal [45]. A systematic review of 28 studies found high variability and low reproducibility for all
ultrasonographic dysplasia metrics [46].

The dynamic technique uses axial and coronal images with real-time stress of the femoral head,
similar to the instability test maneuvers [47]. In the first few days of life, 4 to 6 mm of laxity is
considered normal. Dynamic imaging is usually omitted when the hips are examined during treatment
[43].

Radiographs — Radiographs may be helpful in the evaluation of DDH after four to six months of age
[39,41]. Before that, radiographs have limited value because the femoral head and acetabulum are
cartilaginous and unossified. However, they may be helpful if there are concerns for other bony
abnormalities (eg, congenital coxa vara, proximal femoral focal deficiency, and sacral agenesis) [41].
(See "Radiologic evaluation of the hip in infants, children, and adolescents", section on 'Imaging
studies for specific clinical settings'.)

When a hip radiograph is requested in a newborn, it should consist of a single anterior-posterior (AP)
view with the hips held in 20 to 30° flexion; the frog lateral view is unnecessary and increases
radiation exposure. The flexion is necessary to accommodate the physiologic flexion contracture of
the newborn hip.

After four to six months, when AP radiographs are obtained, the hips should be in the neutral position
[41]. Radiographic lines and angles are used to assess acetabular development and hip position.
Radiographic findings consistent with DDH include:

● Lateral and superior positioning of the ossified portion of the femoral head and neck (image 3
and figure 9A-B)

● Increased acetabular index (figure 10 and image 4); normal values for the acetabular index are as
follows: <35° at birth; <25° at 1 year; <20° at 2 to 3 years; <15° at 6 to 7 years; <11 to 12° at 10
years; and <10° at 15 years [48]

● Delayed appearance of the femoral ossific nucleus on the involved side or asymmetric sizes of
the femoral ossific nuclei (image 3)

Other imaging — Other imaging modalities, such as arthrography, computed tomography (CT), and
magnetic resonance imaging (MRI), are not useful in the diagnosis of DDH but may be used to
evaluate postsurgical reduction. Arthrography (injection of radiopaque contrast into the hip joint) and
three-dimensional imaging, such as MRI or CT, are frequently obtained to confirm successful
reduction and to determine the position of the femoral head within the acetabulum after casting.
Pediatric protocols that involve reduced doses of radiation should be used.
MRI is not typically used in the diagnostic evaluation of the young child with DDH, but its use is
becoming more common in the evaluation of postsurgical reduction [49]. Compared with CT, MRI
exposes the patient to no radiation and provides information about vascularity of the femoral head
[50]. It is also helpful for evaluating long-term sequelae of partially treated or untreated DDH, such as
labral tears and arthritis [50]. (See "Radiologic evaluation of the hip in infants, children, and
adolescents", section on 'Developmental dysplasia of the hip' and "Developmental dysplasia of the
hip: Treatment and outcome", section on 'Outcome'.)

DIAGNOSIS

The diagnosis of DDH in infants is usually made by physical examination demonstrating hip instability
(table 1), asymmetry (in unilateral cases), and/or limited abduction. Examination findings of DDH vary
according to age (table 2). (See 'Hip instability' above and 'Asymmetry' above and 'Range of motion'
above.)

Diagnostic imaging can be used to make the diagnosis in infants with inconclusive examination
findings. Diagnostic imaging also may be used to make the diagnosis in infants who have risk factors
and normal examination. (See 'Diagnostic imaging' above and 'Suboptimal or inconclusive
examination' below and 'Normal examination and risk factors' below.)

Ultrasonography generally is preferred for infants younger than four to six months of age and
radiography for infants older than four to six months. Ultrasonographic measurements (figure 7) are
used to classify DDH according to the Graf system (figure 8). Radiographic findings of DDH include
lateral and superior positioning of the ossified portion of the femoral head and neck (image 3 and
figure 9A-B), increased acetabular index (figure 10), and delayed appearance of the femoral ossific
nucleus on the involved side or asymmetric sizes of the femoral ossific nuclei. (See 'Ultrasonography'
above and 'Radiographs' above.)

APPROACH TO DIAGNOSIS AND REFERRAL

Our approach to diagnosis and referral for DDH varies with the clinical examination findings, the age
of the infant, and risk factors. It is generally consistent with the American Academy of Orthopaedic
Surgeons (AAOS) clinical practice guideline for the detection and nonoperative management of DDH
[4,51], the American Academy of Pediatrics (AAP) clinical practice guideline for early detection of
DDH [2], the American College of Radiology (ACR) Appropriateness Criteria for DDH [41], and the
American Institute of Ultrasound in Medicine guideline for detection and assessment of DDH [43].
Local practices and preferences of the treating orthopedic surgeons may vary, particularly outside of
the United States.

Positive Ortolani or limited/asymmetric abduction — For infants (of any age) with a positive Ortolani
maneuver (ie, a reducible dislocated hip) or limited or asymmetric abduction (ie, a nonreducible
dislocated hip), we suggest referral to an orthopedic surgeon who is experienced in the diagnosis and
treatment of DDH for further evaluation and management. Decisions regarding the imaging studies
can be deferred to the consultant, who may use a variety of studies during management and follow-
up.

Positive Barlow — For infants (of any age) with a positive Barlow maneuver (ie, a dislocatable or
subluxatable hip), we suggest hip surveillance (ie, serial follow-up examinations) to ensure the
development of hip stability. Hip surveillance may be performed by the primary care clinician or an
orthopedic surgeon who is experienced in the diagnosis and management of DDH according to local
practice and preference.

Suboptimal or inconclusive examination

● Newborn – If the newborn examination is suboptimal (eg, the infant is not relaxed enough for a
reliable assessment of motion and stability) or inconclusive (eg, no evidence of instability, but
with joint clicks or thigh asymmetry), the infant is re-examined at the next health supervision visit
(usually at two to four weeks of age).

● Two to four weeks – For two- to four-week-old infants with inconclusive examination (eg, no
evidence of instability, but with joint clicks or thigh asymmetry), we suggest referral to an
orthopedic surgeon who is experienced in the diagnosis and treatment of DDH for further
evaluation and management. Alternative courses of action, depending upon the level of
suspicion, include [2,43]:

• Ultrasonography at six to eight weeks (adjusted for prematurity), at which point "minor"
ultrasonographic abnormalities found in newborns should be resolved (see 'Ultrasonography'
above and 'Natural history' above)

• Continuing to follow clinically (see 'Examination' above)

● Four weeks and older – For infants four weeks and older with subtle or nonspecific findings, we
suggest imaging. We perform ultrasonography if the infant is younger than six months and
radiographs if the infant is older than six months of age. (See 'Diagnostic imaging' above.)

Normal examination and risk factors — Decisions regarding imaging of infants with normal physical
examination and risk factors for DDH are best made on a case-by-case basis [52]. The risk of
dislocation is greatly reduced if the newborn examination is normal [2].

We obtain imaging (by ultrasonography at four to six weeks of age [adjusted for prematurity]) for
infants with any of the following risk factors:

● Male and female infants with breech positioning at ≥34 weeks gestation (whether or not external
cephalic version was successful or was necessary)

● Family history of DDH (including hip replacement for dysplasia before age 40 years in a close
relative)

● History of clinical instability on examination

If ultrasonography is unavailable or a child with a risk factor presents at six months or older,
screening may be done with a radiograph of the hips and pelvis. (See 'Ultrasonography' above and
'Radiographs' above.)

The hips of infants with risk factors for DDH who have normal examination and normal imaging
studies at six weeks (ultrasonography) or four months (radiographs) should continue to be examined
at subsequent health supervision visits until the child is walking independently. The pertinent
examination findings vary depending on age (table 2). (See 'Examination' above and 'Age-specific
findings of DDH' above.)

Normal ultrasonography at six weeks of age is not necessarily predictive of absence of dysplasia. In a
retrospective study in a referral population, 29 percent of 131 infants with breech presentation and
normal hip ultrasonography at six weeks of age who returned for follow-up radiographs at an average
of five months of age had hip dysplasia on radiographs at four to six months of age [53]. This finding
suggests that infants with breech presentation require vigilant monitoring for signs of DDH (table 2)
until the child is walking normally.

Given regional variability in performance and interpretation of hip ultrasonography and thresholds for
treatment, it is reasonable for clinicians to develop regional protocols in collaboration with a
consulting pediatric orthopedic surgeon and pediatric radiologist [2].

Our strategy for selective screening with ultrasonography is consistent with the ACR Appropriateness
Criteria [41]. The 2016 AAP clinical practice guideline recommends that imaging before six months of
age be considered for male or female infants with suspicious or inconclusive physical examination or
normal hip examination and any of the following: history of breech presentation in the third trimester
(regardless of mode of delivery); positive family history; history of previous clinical instability or tight
lower extremity swaddling; or parental concern [2]. The 2014 AAOS clinical practice guideline
recommends imaging for infants with breech presentation, family history of DDH, or history of clinical
instability on examination [4]. (See "Developmental dysplasia of the hip: Epidemiology and
pathogenesis", section on 'Risk factors'.)

Normal examination and no risk factors — The hips of infants with normal examination should
continue to be examined for signs of DDH at subsequent health supervision visits. The pertinent
examination findings vary with age (table 2). (See 'Examination' above and 'Age-specific findings of
DDH' above.)

DIFFERENTIAL DIAGNOSIS

The major considerations in the differential diagnosis of DDH in infants include other causes of leg-
length discrepancy (in infants with a positive Galeazzi test (figure 2)), such as [54]:

● Proximal femoral focal deficiency, an uncommon congenital condition with a spectrum that
ranges from hypoplasia of the femoral head to congenital absence of all but the distal femoral
epiphysis (see "Radiologic evaluation of the hip in infants, children, and adolescents", section on
'Proximal femoral focal deficiency')

● Coxa vara, defined by an angle of less than 120° between the femoral neck and shaft, which
results in elevation of the greater trochanter (figure 11) (see "Radiologic evaluation of the hip in
infants, children, and adolescents", section on 'Developmental coxa vara')

● Hemihypertrophy or hemihyperplasia (eg, Beckwith-Wiedemann syndrome) (see "Beckwith-

Wiedemann syndrome")

● Sacral agenesis with limb deformity (see "Closed spinal dysraphism: Pathogenesis and types",
section on 'Caudal regression or sacral agenesis')

SCREENING FOR DDH

Recommendations for screening newborn infants for DDH vary from country to country. Some
countries recommend screening of all infants, whereas others recommend screening only those with
selective risk factors [55]. The age at which the child is screened and the approach to screening (eg,
clinical examination versus ultrasonography versus an approach based on risk stratification) also
varies from country to country [35,55].

The 2014 American Academy of Orthopaedic Surgeons clinical practice guideline recommends
against universal ultrasound screening of infants for DDH [4]. The Pediatric Orthopaedic Society of
North America (POSNA) acknowledges the lack of data to support screening [5] but points to the
value of early diagnosis in preventing long-term complications. POSNA recommends following the
American Academy of Pediatrics clinical practice guideline with clinical assessment for DDH at birth
and every well-child visit until the child is walking normally and selective imaging of infants with risk
factors [2]. This approach is supported by a decision analysis that recommends screening of all
infants with physical examination combined with selective use of ultrasound in infants that are high
risk [56]. This is especially relevant, given reports that missed diagnosis of DDH is a common cause
for malpractice suits against pediatricians [57]. The United States Preventive Services Task Force no
longer addresses screening for DDH [58].

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Developmental dysplasia of the hip".)

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● Basics topic (see "Patient education: Developmental dysplasia of the hip (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Developmental dysplasia of the hip (DDH) describes a spectrum of conditions related to the
development of the hip in infants and young children. It encompasses abnormal development of
the acetabulum and proximal femur, as well as mechanical instability of the hip joint (table 1).
(See "Developmental dysplasia of the hip: Epidemiology and pathogenesis", section on
'Terminology'.)
● Hip examination should occur soon after birth and at every health supervision visit until
approximately nine months of age and/or the child is walking independently. The symptoms and
signs of DDH vary with age and severity (table 2). (See 'Overview' above and 'Age-specific
findings of DDH' above.)

● Physical examination techniques to detect hip instability use abduction and elevation to feel for
reducibility (the Ortolani maneuver) and gentle adduction without downward pressure to feel for
dislocatability (the Barlow maneuver). The sensation of reducibility or dislocatability is distinct
and best described as a "jerk" or "clunk." Examination findings that are less specific for DDH
include asymmetry (of femur length, skin folds, or gait) and decreased hip abduction. (See 'Hip
instability' above and 'Asymmetry' above and 'Range of motion' above.)

● Diagnostic imaging is helpful in confirming physical examination findings, evaluating infants with
risk factors, and making treatment decisions. During the first four months of life, ultrasonography
is the primary imaging technique for assessing the morphology and stability of the hip.
Ultrasonographic measurements (figure 7) are used to classify DDH according to the Graf system
(figure 8). (See 'Ultrasonography' above.)

● The diagnosis of DDH in infants is usually made by physical examination demonstrating hip
instability, asymmetry (in unilateral cases), and/or limited abduction. Absence of asymmetry
does not exclude DDH because DDH is bilateral in as many as 37 percent of cases. Examination
findings of DDH vary according to age (table 2). Diagnostic imaging can be used to make the
diagnosis in infants with inconclusive examination findings. Diagnostic imaging also may be
used to make the diagnosis in infants who have risk factors and normal examination. (See
'Diagnosis' above.)

● Our approach to diagnosis of and referral for DDH varies with the examination findings, age of
the infant, and risk factors for DDH:

• For infants with a positive Ortolani maneuver or limited or asymmetric abduction, we

suggest referral to an orthopedic surgeon who is experienced in the diagnosis and treatment
of DDH. (See 'Positive Ortolani or limited/asymmetric abduction' above.)

• For infants with a positive Barlow maneuver, we suggest serial follow-up examinations by
the primary care clinician or an orthopedic surgeon who is experienced in the diagnosis and
treatment of DDH to ensure development of hip stability. (See 'Positive Barlow' above.)

• For newborns with suboptimal or inconclusive examination, we suggest re-examination at

the next health supervision visit. For infants two to four weeks of age with inconclusive
examination, we suggest referral to an orthopedic surgeon who is experienced in the
 diagnosis and treatment of DDH. For infants older than four weeks with inconclusive
examination, we suggest imaging. (See 'Suboptimal or inconclusive examination' above and
'Diagnostic imaging' above.)

• We obtain ultrasonography at four to six weeks (adjusted for prematurity) of age for infants
with normal examination and any of the following risk factors (see 'Normal examination and
risk factors' above):

- Breech positioning at ≥34 weeks gestation

- Family history of DDH (including hip replacement for dysplasia before age 40 years in a
close relative)

- History of clinical instability on examination

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REFERENCES

1. Weinstein SL, Mubarak SJ, Wenger DR. Developmental hip dysplasia and dislocation: Part II.
Instr Course Lect 2004; 53:531.

2. Shaw BA, Segal LS, SECTION ON ORTHOPAEDICS. Evaluation and Referral for Developmental
Dysplasia of the Hip in Infants. Pediatrics 2016; 138.

3. Lambeek AF, De Hundt M, Vlemmix F, et al. Risk of developmental dysplasia of the hip in breech
presentation: the effect of successful external cephalic version. BJOG 2013; 120:607.

4. American Academy of Orthopaedic Surgeons. Detection and nonoperative management of pedi

atric developmental dysplasia of the hip in infants up to six months of age. Evidence-based clini
cal practice guideline. September 2014. http://www.aaos.org/research/guidelines/DDHGuidelin
eFINAL.pdf.

5. Schwend RM, Schoenecker P, Richards BS, et al. Screening the newborn for developmental
dysplasia of the hip: now what do we do? J Pediatr Orthop 2007; 27:607.

6. Patel H, Canadian Task Force on Preventive Health Care. Preventive health care, 2001 update:
screening and management of developmental dysplasia of the hip in newborns. CMAJ 2001;
164:1669.
 7. BARLOW TG. EARLY DIAGNOSIS AND TREATMENT OF CONGENITAL DISLOCATION OF THE HIP.
Proc R Soc Med 1963; 56:804.

8. Ortolani M. Congenital hip dysplasia in the light of early and very early diagnosis. Clin Orthop
Relat Res 1976; :6.

9. COLEMAN SS. Diagnosis of congenital dysplasia of the hip in the newborn infant. J Am Med
Assoc 1956; 162:548.

10. Bond CD, Hennrikus WL, DellaMaggiore ED. Prospective evaluation of newborn soft-tissue hip
"clicks" with ultrasound. J Pediatr Orthop 1997; 17:199.

11. Kane TP, Harvey JR, Richards RH, et al. Radiological outcome of innocent infant hip clicks. J
Pediatr Orthop B 2003; 12:259.

12. Dezateux C, Brown J, Arthur R, et al. Performance, treatment pathways, and effects of
alternative policy options for screening for developmental dysplasia of the hip in the United
Kingdom. Arch Dis Child 2003; 88:753.

13. Baronciani D, Atti G, Andiloro F, et al. Screening for developmental dysplasia of the hip: from
theory to practice. Collaborative Group DDH Project. Pediatrics 1997; 99:E5.

14. Poul J, Bajerova J, Sommernitz M, et al. Early diagnosis of congenital dislocation of the hip. J
Bone Joint Surg Br 1992; 74:695.

15. Fulton MJ, Barer ML. Screening for congenital dislocation of the hip: an economic appraisal.
Can Med Assoc J 1984; 130:1149.

16. Burger BJ, Burger JD, Bos CF, et al. Neonatal screening and staggered early treatment for
congenital dislocation or dysplasia of the hip. Lancet 1990; 336:1549.

17. Groarke PJ, McLoughlin L, Whitla L, et al. Retrospective Multicenter Analysis of the Accuracy of
Clinical Examination by Community Physicians in Diagnosing Developmental Dysplasia of the
Hip. J Pediatr 2017; 181:163.

18. Dunn PM. Perinatal observations on the etiology of congenital dislocation of the hip. Clin Orthop
Relat Res 1976; :11.

19. Anderton MJ, Hastie GR, Paton RW. The positive predictive value of asymmetrical skin creases
in the diagnosis of pathological developmental dysplasia of the hip. Bone Joint J 2018; 100-
B:675.
20. Ando M, Gotoh E. Significance of inguinal folds for diagnosis of congenital dislocation of the hip
in infants aged three to four months. J Pediatr Orthop 1990; 10:331.

21. Screening for the detection of congenital dislocation of the hip. Arch Dis Child 1986; 61:921.

22. Novacheck TF. Developmental dysplasia of the hip. Pediatr Clin North Am 1996; 43:829.

23. Choudry Q, Goyal R, Paton RW. Is limitation of hip abduction a useful clinical sign in the
diagnosis of developmental dysplasia of the hip? Arch Dis Child 2013; 98:862.

24. Castelein RM, Korte J. Limited hip abduction in the infant. J Pediatr Orthop 2001; 21:668.

25. Sankar WN, Neubuerger CO, Moseley CF. Femoral anteversion in developmental dysplasia of the
hip. J Pediatr Orthop 2009; 29:885.

26. Loder RT, Skopelja EN. The epidemiology and demographics of hip dysplasia. ISRN Orthop 2011;
2011:238607.

27. Wedge JH, Wasylenko MJ. The natural history of congenital dislocation of the hip: a critical
review. Clin Orthop Relat Res 1978; :154.

28. Wedge JH, Wasylenko MJ. The natural history of congenital disease of the hip. J Bone Joint
Surg Br 1979; 61-B:334.

29. Weinstein SL. Natural history of congenital hip dislocation (CDH) and hip dysplasia. Clin Orthop
Relat Res 1987; :62.

30. Crawford AH, Mehlman CT, Slovek RW. The fate of untreated developmental dislocation of the
hip: long-term follow-up of eleven patients. J Pediatr Orthop 1999; 19:641.

31. Bialik V, Bialik GM, Blazer S, et al. Developmental dysplasia of the hip: a new approach to
incidence. Pediatrics 1999; 103:93.

32. Castelein RM, Sauter AJ. Ultrasound screening for congenital dysplasia of the hip in newborns:
its value. J Pediatr Orthop 1988; 8:666.

33. Terjesen T, Holen KJ, Tegnander A. Hip abnormalities detected by ultrasound in clinically normal
newborn infants. J Bone Joint Surg Br 1996; 78:636.

34. Marks DS, Clegg J, al-Chalabi AN. Routine ultrasound screening for neonatal hip instability. Can
it abolish late-presenting congenital dislocation of the hip? J Bone Joint Surg Br 1994; 76:534.

35. Dezateux C, Rosendahl K. Developmental dysplasia of the hip. Lancet 2007; 369:1541.
36. Harris NH, Lloyd-Roberts GC, Gallien R. Acetabular development in congenital dislocation of the
hip. With special reference to the indications for acetabuloplasty and pelvic or femoral
realignment osteotomy. J Bone Joint Surg Br 1975; 57:46.

37. Schwend RM, Pratt WB, Fultz J. Untreated acetabular dysplasia of the hip in the Navajo. A 34
year case series followup. Clin Orthop Relat Res 1999; :108.

38. Wood MK, Conboy V, Benson MK. Does early treatment by abduction splintage improve the
development of dysplastic but stable neonatal hips? J Pediatr Orthop 2000; 20:302.

39. Lehmann HP, Hinton R, Morello P, Santoli J. Developmental dysplasia of the hip practice
guideline: technical report. Committee on Quality Improvement, and Subcommittee on
Developmental Dysplasia of the Hip. Pediatrics 2000; 105:E57.

40. Elbourne D, Dezateux C, Arthur R, et al. Ultrasonography in the diagnosis and management of
developmental hip dysplasia (UK Hip Trial): clinical and economic results of a multicentre
randomised controlled trial. Lancet 2002; 360:2009.

41. American College of Radiology. ACR Appropriateness Criteria. Developmental dylsplasia of the
hip--child. www.acr.org/Quality-Safety/Appropriateness-Criteria (Accessed on August 21, 2012).

42. Dias JJ, Thomas IH, Lamont AC, et al. The reliability of ultrasonographic assessment of
neonatal hips. J Bone Joint Surg Br 1993; 75:479.

43. AIUM-ACR-SPR-SRU Practice Parameter for the Performance of an Ultrasound Examination for
Detection and Assessment of Developmental Dysplasia of the Hip. J Ultrasound Med 2018;
37:E1.

44. Graf R. New possibilities for the diagnosis of congenital hip joint dislocation by ultrasonography.
J Pediatr Orthop 1983; 3:354.

45. Harcke HT, Pruszczynski B. Hip ultrasound for developmental dysplasia: the 50% rule. Pediatr
Radiol 2017; 47:817.

46. Quader N, Schaeffer EK, Hodgson AJ, et al. A Systematic Review and Meta-analysis on the
Reproducibility of Ultrasound-based Metrics for Assessing Developmental Dysplasia of the Hip.
J Pediatr Orthop 2018; 38:e305.

47. Harcke HT, Grissom LE. Performing dynamic sonography of the infant hip. AJR Am J
Roentgenol 1990; 155:837.
 48. Hensinger RN. Standards in Pediatric Orthopedics: Tables, Charts, and Graphs Illustrating Growt
h, Lippincott Williams & Wilkins, Philadelphia 1986. p.68.

49. Desai AA, Martus JE, Schoenecker J, Kan JH. Spica MRI after closed reduction for
developmental dysplasia of the hip. Pediatr Radiol 2011; 41:525.

50. Jaramillo D, Villegas-Medina O, Laor T, et al. Gadolinium-enhanced MR imaging of pediatric

patients after reduction of dysplastic hips: assessment of femoral head position, factors
impeding reduction, and femoral head ischemia. AJR Am J Roentgenol 1998; 170:1633.

51. Mulpuri K, Song KM, Gross RH, et al. The American Academy of Orthopaedic Surgeons
Evidence-Based Guideline on Detection and Nonoperative Management of Pediatric
Developmental Dysplasia of the Hip in Infants up to Six Months of Age. J Bone Joint Surg Am
2015; 97:1717.

52. Pacana MJ, Hennrikus WL, Slough J, Curtin W. Ultrasound Examination for Infants Born Breech
by Elective Cesarean Section With a Normal Hip Exam for Instability. J Pediatr Orthop 2017;
37:e15.

53. Imrie M, Scott V, Stearns P, et al. Is ultrasound screening for DDH in babies born breech
sufficient? J Child Orthop 2010; 4:3.

54. Godley DR. Assessment, diagnosis, and treatment of developmental dysplasia of the hip. JAAPA
2013; 26:54.

55. Shipman SA, Helfand M, Moyer VA, Yawn BP. Screening for developmental dysplasia of the hip:
a systematic literature review for the US Preventive Services Task Force. Pediatrics 2006;
117:e557.

56. 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; 91:1705.

57. McAbee GN, Donn SM, Mendelson RA, et al. Medical diagnoses commonly associated with
pediatric malpractice lawsuits in the United States. Pediatrics 2008; 122:e1282.

58. United States Preventive Services Task Force. Developmental hip dysplasia: Screening. Availabl
e at: https://www.uspreventiveservicestaskforce.org/BrowseRec/InactiveTopic/224 (Accessed
on October 15, 2018).

Topic 6288 Version 24.0

GRAPHICS

Terminology for developmental dysplasia of the hip

Term Definition

Dysplasia Abnormality of the shape of the hip joint (usually shallowness of the acetabulum, involving the superior and
anterior margins).

Subluxatable/subluxable The femoral head is reduced (ie, within the acetabulum) at rest but can be partially dislocated or subluxated
with examination maneuvers. This is a hip with mild instability or laxity.

Dislocatable The femoral head is reduced at rest but can dislocate in other positions or with examination maneuvers. This
is a hip with instability.

Subluxation The femoral head is partially outside of the acetabulum but remains in contact with it.

Reducible The hip is dislocated at rest, but the femoral head can be positioned into the acetabulum with manipulation
(generally flexion and abduction).

Dislocation Complete loss of contact between the femoral head and the acetabulum.

Graphic 88588 Version 3.0

Clinical findings in infants and children with developmental dysplasia of the hip

Unilateral Bilateral*

Birth to 3 months of age

Hip instability ¶ (demonstrated by positive Ortolani or Barlow tests Δ) Yes Yes

Asymmetric leg creases (inguinal, gluteal, thigh, or popliteal) Yes No

Apparent shortening of femur (ie, positive Galeazzi sign Δ [also called Allis or Yes No
Perkins sign])

3 to 12 months of age

Limitation of hip abduction in 90° of flexion Yes Yes

Apparent shortening of the femur (ie, positive Galeazzi sign Δ [also called Allis Yes No
or Perkins sign])

Laterally rotated posture in prone position (ie, increased femoral anteversion) Yes Yes

Marked asymmetry of leg creases (inguinal, gluteal, thigh, or popliteal) Yes No

Klisic test ◊ Yes Yes

After the child begins to walk

Excessive lordosis No Yes

Prominent greater trochanter Yes Yes

Gluteus medius lurch (Trendelenburg gait) Yes Yes

Positive Trendelenburg sign Yes Yes

Short leg limp, with toe-heel gait and out-toeing Yes No

Increasing adduction contracture of the hip, with compensatory genu valgum Yes Yes

This table is intended for use in conjunction with UpToDate content on developmental dysplasia of the hip.

* Developmental dysplasia of the hip is bilateral in as many as 37% of cases.

¶ Hip instability is a diagnostic finding.
Δ Refer to UpToDate content on clinical features of developmental dysplasia of the hip for details regarding performance and interpretation of
examination maneuvers.
◊ The Klisic test is performed by placing the index finger on the anterior-superior iliac spine and the middle finger on the greater trochanter. An
imaginary line between these points passes through or above the umbilicus in a child without developmental dysplasia of the hip (negative Klisic
test). The line passes below the umbilicus if the hip is dislocated (positive Klisic test) because the greater trochanter is in a more superior
position.

Adapted from: The hip. In: Tachdjain MO. Clinical Pediatric Orthopedics. The Art of Diagnosis and Principles of Management. Appleton & Lange,
Stamford, CT 1997. p.167.

Graphic 77015 Version 6.0

Congenital muscular torticollis

(A) There is a fibrous mass in the right sternocleidomastoid muscle (arrow).

(B) Rotation toward the right is limited by the tightness in the right sternocleidomastoid
muscle.
(C) Rotation toward the left is normal.

Reproduced with permission from: MacDonald MG, Seshia MM, et al. Avery's Neonatology
Pathophysiology and Management of the Newborn, 6th ed, Lippincott Williams & Wilkins,
Philadelphia 2005. Copyright © 2005 Lippincott Williams & Wilkins.

Graphic 78313 Version 2.0

Metatarsus adductus (medial deviation of the forefoot)

Reproduced with permission from: Hart ES. Pediatric Orthopaedic Ailments. Department of Pediatric
Orthopaedics, Massachusetts General Hospital. Available at:
www2.massgeneral.org/ortho/pediatric_intoe.htm.

Graphic 57425 Version 2.0

Trendelenburg test

Normally, the pelvis stays level when a patient stands on one leg. When standing on the
affected leg, the pelvis tilts downward toward the unaffected side (as pictured in the
abnormal patient above) because of gluteal muscle weakness on the affected side (right
side in abnormal patient above).

Graphic 67453 Version 3.0

Galeazzi test

The patient is positioned as shown. The knee is lower on the affected side because of
posterior displacement in the developmentally dysplastic hip (arrow).

Graphic 63965 Version 2.0

Asymmetric inguinal folds

(A) Normal inguinal folds do not extend beyond the anal aperture (*).
(B) The inguinal fold on the right extends beyond the anal aperture, suggesting possible
developmental dysplasia of the right hip.
(C) The inguinal folds on both sides extend beyond the anal aperture, suggesting bilateral
developmental dysplasia of the hip.

Graphic 65835 Version 2.0

Asymmetric leg folds

Asymmetry of the thigh or popliteal creases is suggestive of developmental dysplasia of the hip
(DDH), with the abnormality on the side where the crease is most proximal. Asymmetry of the thigh
folds or popliteal creases is not helpful in cases of bilateral DDH.

Graphic 78543 Version 2.0

Normal hip rotation according to age (years)

Hip rotation is assessed with the child prone. The mean and normal range (two standard
deviations) for internal rotation (panel A) and external rotation (panel B) are depicted above.

Reproduced with permission from: Staheli LT. Lower limb. In: Fundamentals of Pediatric Orthopedics,
4 th ed, Lippincott Williams & Wilkins, Philadelphia 2008. Copyright © 2008 Lippincott Williams &
Wilkins. www.lww.com.

Graphic 71765 Version 11.0

The Klisic test for hip dislocation

The Klisic test is performed by placing the index finger on the anterior superior iliac spine and
the middle finger on the greater trochanter. An imaginary line between these two points should
point toward or above the umbilicus. The line will pass below the umbilicus if the hip is
dislocated.

Graphic 74071 Version 2.0

Clinical features of bilateral developmental dysplasia of the hips

Clinical features of bilateral developmental dysplasia of the hips include a wide perineum
(because of lateral displacement of the femoral heads and neck) and hyperlordosis (because of
superior and posterior displacement of the femoral heads and neck).

Graphic 86943 Version 1.0

Developmental dysplasia of the hip detected incidentally

Routine cystogram in this 2.2-year-old girl revealed disruption of Shenton line (dashed lines)
and acetabular dysplasia (arrow) of the right hip. Note normal Shenton line on the left.

Graphic 88828 Version 2.0

Ultrasonographic findings of the normal hip of an infant

(A) Diagrammatic representation of an ultrasonographic landmark of a normal right hip.

(B) Diagram demonstrating alpha and beta angles. The alpha angle is the angle formed by the ossified lateral wall of
the ilium (line 1 above) and the bony roof line (line 3 above). The beta angle is the angle formed by the ossified lateral
wall of the ilium (line 1 above) and the cartilaginous roof line (line 2 above).

Graphic 80478 Version 4.0

Ultrasound hip dysplasia

This coronal ultrasound image of the hip demonstrates that the femoral head is less than
50% covered by the bony acetabulum and that the alpha angle measures less than 60°.
Normally, the femoral head is greater than 50% covered by the acetabulum, and the alpha
angle measures greater than 60°. The alpha angle is formed by the acetabular roof and the
vertical cortex of the ilium.

Reproduced with permission from: Jeanne Chow, MD. Children's Hospital-Boston, Copyright © Jeanne
Chow, MD.

Graphic 56328 Version 6.0

Overview of the Graf hip classification types

Adapted from: Donaldson JS, Feinstein KA. Imaging of developmental dysplasia of the hip. Pediatr Clin North Am 1997;
44:591.

Graphic 56551 Version 6.0

Hip dysplasia radiograph

This frontal view of the pelvis demonstrates complete superolateral dislocation of the left femoral head (arrow). The
left acetabulum is shallow (asterisk). Note the smaller size of the femoral epiphysis on the dislocated left side. The
right hip is normal. The heart shape is a lead shield protecting the ovaries.

Courtesy of Scott B Rosenfeld, MD.

Graphic 79994 Version 5.0

Hilgenreiner and Perkins lines

Hilgenreiner line is a horizontal line through the upper margin of the radiolucent triradiate
cartilage. Perkins line is a vertical line drawn from the most lateral ossified margin of the
roof of the acetabulum and perpendicular to Hilgenreiner line. In the normal hip, the medial
end of the ossified upper femoral metaphysis lies medial to Perkins line and inferior to
Hilgenreiner line. In the subluxated hip, it lies lateral to Perkins line. In the dislocated hip, the
medial end of the ossific metaphysis of the femoral neck lies lateral to Perkins line and
superior to Hilgenreiner line.

DDH: developmental dysplasia of the hip.

Graphic 55366 Version 1.0

Shenton line

Shenton line as seen in an anteroposterior diagram of the hips. Shenton line is drawn from
the medial border of the femoral neck to the superior border of the obturator foramen. In the
normal right hip, it is a continuous contour, whereas in the hip with DDH (the left hip), it is
disrupted.

DDH: developmental dysplasia of the hip.

Graphic 82640 Version 4.0

Acetabular index

The acetabular index is the angle formed between Hilgenreiner line (a horizontal line
through the upper margin of the radiolucent triradiate cartilage) and a tangential line to the
lateral ossific margin of the roof of the acetabulum. The acetabular index changes with axial
and sagittal plane rotation of the pelvis and is helpful in measuring the development of the
osseous roof of the acetabulum. In the newborn, the acetabular index must be over 40° to
be significantly abnormal.

DDH: developmental dysplasia of the hip.

Graphic 74701 Version 3.0

Radiograph: Bilateral developmental dysplasia of the hips

Note that both femoral heads are displaced laterally and superiorly. The acetabular index (AI) is also
increased (>40°) bilaterally.

Courtesy of William Phillips, MD.

Graphic 86942 Version 2.0

Normal femur versus coxa vara

Normal femur (left) versus coxa vara (right). Coxa vara is defined by an angle of less than 120° between the
femoral neck and shaft. Coxa vara deformity elevates the greater trochanter.

Reproduced with permission from: LifeART. Copyright © 2011. Lippincott Williams & Wilkins. All rights reserved.

Graphic 59633 Version 2.0

Contributor Disclosures
Scott B Rosenfeld, MD Grant/Research/Clinical Trial Support: BSN Medical [DDH and femur fractures (Spica
casts)]. Speaker's Bureau: Orthopediatrics [Speaker honorarium]. William A Phillips, MD Nothing to
disclose Mary M Torchia, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.

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