Diagnostic Imaging Pathways - Paediatric, Hip Developmental Dysplasia
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This pathway provides guidance on the screening imaging of paediatric patients to exclude developmental dysplasia of the hips.
Date reviewed: March 2017
Date of next review: March 2020
Published: July 2017
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Teaching Points
Teaching Points
- Developmental dysplasia of the hip (DDH) is the most common hip pathology noted in infants and delayed diagnosis may lead to early development of osteoarthritis in addition to abnormal or painful gait
- Early diagnosis and treatment is critical to provide the best possible functional outcome
- Risk factors that predispose to DDH include
- Family history
- Associated congenital orthopaedic conditions
- Female sex
- Breech presentation
- High birth weight
- Ultrasonography is the initial investigation of choice if risk factors are present and screening is indicated
- Ultrasonography is recommended as an adjunct to the clinical evaluation by a properly trained health care provider
- Ultrasonography is best delayed until at least 3-4 weeks post term to avoid false positives
- Plain films of the hip are indicated after 6 months of age
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Risk Factors for Developmental Dysplasia of the Hip
- Although most patients with developmental dysplasia of the hip have no risk factors, screening based on risk factors has been proposed to limit over diagnosis 1, 2
- Risk factors that predispose to DDH include; 2
- Female
- Breech presentation
- Family history
- Associated congenital orthopaedic conditions
- Oligohydramnios
- High birth weight
- First born
- A meta-analysis found that the most significant risk factors associated with DDH included: those presenting in the breech position during delivery (common odds ratio {OR} of 5.7 and 95% confidence interval {CI} of 4.4-7.4), being female (OR 3.8, 95% CI 3.0-4.6), clicking hips at clinical examination (OR 8.6, 95% CI 4.5-16.6) and having a family history of DDH (OR 4.8, 95% CI 2.8-8.2) 2, 3
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Ultrasound
- Uses and features
- Effective non-invasive way to image the cartilaginous hip joint that involves no exposure to radiation 1, 4
- The cartilage and the hip can be visualized while assessing the stability of the hip and the morphologic features of the acetabulum 4-7
- Indications for its use vary but in general it is used in children under 4-6 months of age who have signs of hip instability on examination
- Graf's standardised morphology criteria are commonly used 5,7
- Studies indicate that ultrasonography is more sensitive than physical examination in detecting developmental dysplasia of the hip 5, 8
- Limitations
- Hip ultrasound is best delayed until at least 3-4 weeks post term because of physiological immaturity evident on early US which may lead to false positive results. 1, 9 Whilst it is ideal to delay ultrasound until at least 3-4 weeks post term, if the hip is clinically dislocated or is frankly unstable then earlier orthopaedic referral should be sought
- Accurate results in hip sonography requires training and experience 5
- Ultrasonography used as a screening tool in some centres has reduced the number of infants who require surgical treatment at the expense of more infants being treated with abduction splinting 10-12
- Universal ultrasonography screening of newborn infants is not recommended 9
- Recent studies have suggested that targeted ultrasound to infants at high risk of hip dysplasia did not significantly increase the rate of treatment but also did not significantly reduce the rate of late detected dysplasia or surgery 10
- The screening of children for developmental dysplasia of the hip is a controversial topic. Clinical methods of screening when performed by experienced clinicians have a reasonably high sensitivity and specificity for detecting DDH 1, 10, 13-16
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Plain Radiography
- Plain radiography is less reliable in the first few months of life when the femoral head is composed mainly of cartilage 9
- It becomes a more reliable method of investigating for DDH in children aged between 4 and 6 months as the ossification center of the femoral head appears 5, 9
- The relationships of the femoral head and proximal femoral metaphysis to the acetabulum are an important part of evaluating for DDH
- A single AP pelvic view is usually sufficient but a frog view should be done to assess reducibility if subluxation or dislocation is noted 9
- The use of the acetabular index and other objective means are used to evaluate for DDH, although the sensitivity and specificity of some of these are uncertain. However, these measurements are only one part of the radiographic assessment used to gauge hip dysplasia 17, 18
References
References
Date of literature search: February 2017
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- LeBa TB, Carmichael KD, Patton AG, Morris RP, Swischuk LE. Ultrasound for Infants at Risk for Developmental Dysplasia of the Hip. Orthopedics. 2015;38(8):e722-6. (Level III evidence). View the reference
- Ortiz-Neira CL, Paolucci EO, Donnon T. A meta-analysis of common risk factors associated with the diagnosis of developmental dysplasia of the hip in newborns. Eur J Radiol. 2012;81(3):e344-51. (Level I evidence). View the reference
- de Hundt M, Vlemmix F, Bais JM, Hutton EK, de Groot CJ, Mol BW, et al. Risk factors for developmental dysplasia of the hip: a meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2012;165(1):8-17. (Review article). View the reference
- Clarke NM, Harcke HT, McHugh P, Lee MS, Borns PF, MacEwen GD. Real-time ultrasound in the diagnosis of congenital dislocation and dysplasia of the hip. J Bone Joint Surg Br. 1985;67(3):406-12. (Level III evidence). View the reference
- Clinical practice guideline: early detection of developmental dysplasia of the hip. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. American Academy of Pediatrics. Pediatrics. 2000;105(4 Pt 1):896-905. (Guideline). View the reference
- Graf R. The diagnosis of congenital hip-joint dislocation by the ultrasonic Combound treatment. Arch Orthop Trauma Surg. 1980;97(2):117-33. (Review article). View the reference
- Graf R. Fundamentals of sonographic diagnosis of infant hip dysplasia. J Pediatr Orthop. 1984;4(6):735-40. (Level III evidence). View the reference
- Carmichael KD, Longo A, Yngve D, Hernandez JA, Swischuk L. The use of ultrasound to determine timing of Pavlik harness discontinuation in treatment of developmental dysplasia of the hip. Orthopedics. 2008;31(10):(Level II evidence). View the reference
- Kotlarsky P, Haber R, Bialik V, Eidelman M. Developmental dysplasia of the hip: What has changed in the last 20 years? World J Orthop. 2015;6(11):886-901. (Review article). View the reference
- Shorter D, Hong T, Osborn DA. Cochrane Review: Screening programmes for developmental dysplasia of the hip in newborn infants. Evid Based Child Health. 2013;8(1):11-54. (Level I evidence). View the reference
- Patel H. Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns. CMAJ. 2001;164(12):1669-77. (Evidence based recommendations). View the reference
- Rosendahl K, Markestad T, Lie RT. Ultrasound screening for developmental dysplasia of the hip in the neonate: the effect on treatment rate and prevalence of late cases. Pediatrics. 1994;94(1):47-52. (Level II evidence). View the reference
- Duppe H, Danielsson LG. Screening of neonatal instability and of developmental dislocation of the hip. A survey of 132,601 living newborn infants between 1956 and 1999 J Bone Joint Surg Br. 2002;84(6):878-. (Level III evidence). View the reference
- Krikler SJ, Dwyer NS. Comparison of results of two approaches to hip screening in infants. J Bone Joint Surg Br. 1992;74(5):701-3. (Level III evidence). View the reference
- Macnicol MF. Results of a 25-year screening programme for neonatal hip instability. J Bone Joint Surg Br. 1990;72(6):1057-60. (Level III evidence). View the reference
- Bialik V, Fishman J, Katzir J, Zeltzer M. Clinical Assessment of Hip Instability in the Newborn by an Orthopedic Surgeon and a Pediatrician. Journal of Pediatric Orthopaedics. 1986;6(6):703. (Level IV evidence). View the reference
- Kay RM, Watts HG, Dorey FJ. Variability in the assessment of acetabular index. J Pediatr Orthop. 1997;17(2):170-3. (Level III evidence). View the reference
- Spatz DK, Reiger M, Klaumann M, Miller F, Stanton RP, Lipton GE. Measurement of acetabular index intraobserver and interobserver variation. J Pediatr Orthop. 1997;17(2):174-5. (Level III evidence). View the reference
Information for Consumers
Information for Consumers
Information from this website |
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Consent to Procedure or Treatment Radiation Risks of X-rays and Scans |
Radiation Risk of Medical Imaging for Adults and Children Children's (Paediatric) Hip Ultrasound for DHH Children's (Paediatric) X-ray Examination Making Your Child's Test or Procedure Less Stressful |
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