Guideline sources The following summarized guidelines for the evaluation and management of developmental dysplasia of the hip (DDH) are prepared by our editorial team based on guidelines from the American Academy of Orthopaedic Surgeons (AAOS 2022), the Dutch Orthopaedic Society (DOS 2022), the American College of Radiology (ACR 2019), the Pediatric Orthopaedic Society of North America (POSNA 2007), and the U.S. Preventive Services Task Force (USPSTF 2006). 1 2 3 4 5 Guidelines 1. Screening and diagnosis Indications for screening: As per AAOS 2022 guidelines, avoid obtaining universal ultrasound screening of newborn infants. D As per POSNA 2007 guidelines, perform physical examination for hip instability at birth, with periodic follow-up exams until the child is walking. E As per USPSTF 2006 guidelines, insufficient evidence to recommend routine screening for DDH in infants as a means to prevent adverse outcomes. I https://web.pathway.md/diseases/rec5R6XC2IWHO9t1Z 1/5 6/29/23, 10:10 PM Developmental dysplasia of the hip Pathway 2. Diagnostic investigations Hip ultrasound: As per AAOS 2022 guidelines: Obtain imaging before 6 months of age in pediatric patients with 1 of the following risk factors: breech presentation family history history of clinical instability. A Consider obtaining an ultrasound in pediatric patients < 6 weeks of age with a positive instability examination to guide the decision to initiate brace treatment. C As per ACR 2019 guidelines, obtain hip ultrasound as the initial imaging in pediatric patients < 4 months of age with physical findings of DDH at initial imaging. B Show 2 more As per POSNA 2007 guidelines, consider obtaining ultrasound as an adjunct in evaluation for patients at risk for hip dysplasia and/or when the diagnosis is in question. E Pelvic radiography: As per AAOS 2022 guidelines, consider obtaining an anterioposterior pelvis radiograph instead of an ultrasound for the assessment of DDH in pediatric patients beginning at 4 months of age. C As per ACR 2019 guidelines: Obtain pelvic XR as the initial imaging in pediatric patients 4-6 months of age with a concern for DDH at initial imaging. B Obtain pelvic XR as the initial imaging in pediatric patients > 6 months of age with a concern for DDH. B As per POSNA 2007 guidelines, consider obtaining a pelvic XR for the evaluation of pediatric patients 4-5 months of age, if high-quality ultrasound is not available. E 3. Medical management Observation: As per AAOS 2022 guidelines, consider offering observation without a brace in pediatric patients with a clinically stable hip with morphologic ultrasound imaging abnormalities. C As per DOS 2022 guidelines, offer initial observation in 3 months old patients with centered DDH. B 4. Nonpharmacologic interventions Hip abduction braces: As per AAOS 2022 guidelines, consider offering either immediate or delayed (2-9 weeks) brace treatment for hips with a positive instability exam. C As per DOS 2022 guidelines: https://web.pathway.md/diseases/rec5R6XC2IWHO9t1Z 2/5 6/29/23, 10:10 PM Developmental dysplasia of the hip Pathway Consider offering abduction treatment if the hip does not normalize after 6-12 weeks. C Discontinue the abduction device when the hip has normalized or when the child is 1 year old. B Splinting: As per AAOS 2022 guidelines, consider offering the von Rosen splint over Pavlik, Craig, or Frejka splints for the initial treatment of an unstable hip. C As per DOS 2022 guidelines, offer a Pavlik harness in < 6 months old patients with centered DDH on repeated ultrasound. Consider offering another abduction device in > 6 months old patients. E As per POSNA 2007 guidelines: Offer early treatment with a Pavlik harness or similarly effective orthosis in patients with DDH. E Offer splinting for hips not stabilized after flexion/abduction. E Closed reduction: offer closed reduction for hips not stabilized after flexion/abduction. E Hip spica cast: offer spica cast immobilization for hips not stabilized after flexion/abduction. E 5. Follow-up and surveillance Indications for referral: refer patients to an experienced orthopedic surgeon for confirmation of the suggested diagnosis. E Serial clinical and imaging assessment: As per AAOS 2022 guidelines: Consider re-examining patients previously screened as having a normal hip examination on subsequent visits before 6 months of age. C Obtain serial physical examinations and periodic imaging assessments (ultrasound or radiograph based on age) during the management of patients with unstable hips. B As per DOS 2022 guidelines, assess < 1-year-old patients with centered DDH in the outpatient clinic and with imaging every 6 weeks. E As per ACR 2019 guidelines, obtain hip ultrasound in pediatric patients < 6 months of age with a known diagnosis of DDH during nonoperative surveillance imaging in harness. B Clinical findings Patient demographics Past obstetric history Infants Breech presentation Musculoskeletal exam Asymmetric thigh skin folds Hamstring stretch sign Hip click Hip dislocation https://web.pathway.md/diseases/rec5R6XC2IWHO9t1Z 3/5 6/29/23, 10:10 PM Developmental dysplasia of the hip Pathway Leg length discrepancy Limited hip abduction in flexion Limping Lumbar hyperlordosis Waddling gait Barlow test Galeazzi test Ortolani test telescoping test Likelihood Ratios Pertinent positives The following findings increase the probability of developmental dysplasia of the hip in adults. 5 Finding LR+ Value Positive telescoping test 25.5 Positive Trendelenburg's sign 14 Presence of limping 13.6 Presence of hamstring stretch sign 5.9 Show 2 more Pertinent negatives The following findings decrease the probability of developmental dysplasia of the hip in adults. 5 Finding LR- Value Absence of limping 0.1 Absence of hamstring stretch sign 0.1 Absence of leg length discrepancy 0.2 Negative Trendelenburg's sign 0.2 Show 2 more References 1. AAOS. Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age. AAOS. 21 Mar 2022. Open 2. Richard M Schwend, Perry Schoenecker, B Stephens Richards et al. Screening the newborn for developmental dysplasia of the hip: now what do we do?. J Pediatr Orthop. 2007 Sep;27 6 607 10. Open 3. Christiaan J A van Bergen, Pieter Bas de Witte, Floor Willeboordse et al. Treatment of centered developmental dysplasia of the hip under the age of 1 year: an evidence-based clinical practice guideline Part 1. EFORT Open Rev. 2022 Jul 5;7 7 498 505. Open 4. US Preventive Services Task Force. Screening for developmental dysplasia of the hip: recommendation statement. Pediatrics. 2006 Mar;117 3 898 902. Open https://web.pathway.md/diseases/rec5R6XC2IWHO9t1Z 4/5 6/29/23, 10:10 PM Developmental dysplasia of the hip Pathway 5. Expert Panel on Pediatric Imaging:, Jie C Nguyen, Scott R Dorfman et al. ACR Appropriateness Criteria Developmental Dysplasia of the Hip-Child. J Am Coll Radiol. 2019 May;16 5S S94 S103. Open 6. Kremli MK, Khoshhal KI, Zamzam M et al. Evaluation of clinical signs and tests of congenital dysplasia of the hip. Ann Saudi Med. 2002 Jan-Mar;22 1 2 102 4. Open 7. French LM, Dietz FR. Screening for developmental dysplasia of the hip. Am Fam Physician. 1999 Jul;60 1 177 84, 187 8. Open https://web.pathway.md/diseases/rec5R6XC2IWHO9t1Z 5/5