Multidisciplinary Developmental Dysplasia of the Hip Quality Education

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

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

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

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

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

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

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

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

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

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

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

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

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

Multidisciplinary Instability tests In Out Stable Normal Fixed dislocation Unstable Barlow + Ortolani + Quality Education for a Healthier Scotland

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

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

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

Barlow & Ortolani Quality Education for a Healthier Scotland Multidisciplinary

Examining infants hips - can it do harm? Multidisciplinary “Over enthusiastic or repeated clinical examination may provoke instability” Take your time, be gentle Lowry et al (2005) Archives of Diseases in Childhood 90 (6): 579 -81 Quality Education for a Healthier Scotland

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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