Guideline 2.6 — Developmental Dysplasia of the Hip (DDH)

KEY TAKEAWAYS

DDH is a spectrum — from mild acetabular dysplasia and instability to frank dislocation — and early detection changes the outcome (a simple harness early vs surgery late).
Screen every newborn clinically: Ortolani (relocates a dislocated hip — a palpable "clunk") and Barlow (dislocates a dislocatable hip). A positive Ortolani (dislocated hip) is the most concerning finding.
After ~2–3 months, the maneuvers fade — limited/asymmetric hip abduction becomes the key sign (also asymmetric skin folds, a positive Galeazzi sign).
Know the risk factors: breech presentation (biggest), female sex, positive family history, firstborn; left hip most common.
Imaging: ultrasound before ~6 months (Graf), X-ray after ~4–6 months (once the femoral head ossifies) — for an abnormal exam or risk factors.
Treat with a Pavlik harness for a dislocated/persistently unstable hip in infants under ~6 months (high success) — but avoid excessive abduction (avascular necrosis risk).

1. Clinical Overview

Clinical Overview

Developmental dysplasia of the hip describes abnormal development of the relationship between the femoral head and the acetabulum, ranging from mild dysplasia/instability to subluxation and dislocation. It matters enormously because it is often silent, screenable, and dramatically more treatable when caught early — a Pavlik harness in the first months usually corrects what would otherwise require closed or open reduction, casting, or osteotomy later, with a lifetime risk of early osteoarthritis if missed. Screening is therefore woven into every newborn and well-child exam: instability maneuvers in the newborn period, then abduction assessment as the infant grows, backed by selective ultrasound for abnormal exams or risk factors.

2. Definitions

Term	Meaning
DDH	Abnormal femoral head–acetabulum development (dysplasia → subluxation → dislocation).
Ortolani maneuver	Abduction + anterior lift that relocates a dislocated hip (palpable clunk).
Barlow maneuver	Adduction + posterior pressure that dislocates a dislocatable hip.
Galeazzi sign	Apparent limb-length discrepancy (unequal knee heights with hips/knees flexed).
Graf classification	Ultrasound grading of acetabular morphology (alpha angle, coverage).
Pavlik harness	A device holding the hips flexed and abducted ("human position") to maintain reduction.

3. Pathophysiology & Risk Factors

Pathophysiology & Risk Factors

Mechanical and physiologic factors (ligamentous laxity, intrauterine positioning) lead to an unstable or poorly-covered femoral head; if the head isn't concentrically reduced, the acetabulum develops abnormally.
Physiologic laxity is normal in the first ~4–6 weeks and often resolves — hence caution about over-treating very early mild instability.

Risk factors: breech presentation (strongest), female sex, positive family history, firstborn/primiparity, oligohydramnios, and other "packaging" conditions (torticollis, metatarsus adductus); the left hip is most commonly affected; swaddling with hips extended/adducted increases risk.

4. Clinical Presentation & Screening

Clinical Presentation & Screening

Newborn period

Ortolani and Barlow maneuvers on every newborn exam:
Ortolani positive = dislocated hip that relocates (clunk) — the most concerning finding.
Barlow positive = dislocatable hip.
Mild laxity may be physiologic in the first weeks.

After ~2–3 months (maneuvers become unreliable)

Limited or asymmetric hip abduction — the key sign.
Asymmetric thigh/gluteal skin folds.
Positive Galeazzi sign (unequal knee heights) — suggests unilateral dislocation.
Leg-length discrepancy.

5. Diagnostic Approach

Diagnostic Approach

Universal clinical screening (Ortolani/Barlow, then abduction) at newborn and well-child exams.
Selective ultrasound (Graf) for an abnormal exam or risk factors — used before ~6 months (the femoral head isn't yet ossified). Often performed around ~4–6 weeks to avoid over-treating physiologic laxity. Assesses alpha angle and acetabular coverage.
Plain radiograph (AP pelvis ± frog-leg) for infants older than ~4–6 months (femoral head ossification) or when ultrasound is equivocal — assess acetabular index, Shenton's line, center-edge angle.
Referral to pediatric orthopedics for a positive Ortolani (dislocated hip), persistent instability, limited/asymmetric abduction, or an abnormal image.

6. Management (age- and severity-based)

Management (age- and severity-based)

Barlow-positive (dislocatable) / mild dysplasia: often observe for 4–6 weeks — many stabilize spontaneously — then re-examine ± ultrasound.
Ortolani-positive (dislocated) or persistent instability/dysplasia in infants <6 months: Pavlik harness (holds hips flexed + abducted) — success ~85–95%; monitor with ultrasound.
⚠️ Avoid excessive abduction — a major cause of avascular necrosis (AVN) of the femoral head (an iatrogenic complication); watch for femoral nerve palsy and skin issues.
Failure/irreducible hip: stop and reassess (harness failure predicts more complex disease).
Failed Pavlik / older (>6 months) / irreducible hip: closed reduction + spica cast (± adductor tenotomy, arthrogram).
Older (>~18 months) / failed closed reduction: open reduction ± pelvic/femoral osteotomy.

Sex	Risk factor	DDH per 1000 (Baylor Table 13-3)	Risk
Male	None	4.1	Low
	Family history	9.4	Low
	Breech	26	Medium
Female	None	19	Medium
	Family history	44	High
	Breech	120	High

Nursery practice (Baylor Ed. 33)

Incidence: about 1 in 200 for a shallow socket and 1 in 1000 for a dislocated hip. Surveillance continues at every health check until about 2 years, when gait matures.
Risk factors, quantified: breech after 34 weeks carries DDH in up to 23%, even after external cephalic version, and a transverse lie may also warrant surveillance. Females are affected more than 6 times as often. Other factors: firstborn, family history, crowding (LGA, multiples, fibroids), and tight swaddling with the legs extended.
Examination: perform Barlow with no downward pressure. The Ortolani is the most important sign. Limited abduction is generally not present before 3 months. Limit repeated examinations of an unstable hip.
Positive Ortolani, or limited or asymmetric abduction → paediatric orthopaedic consultation. Positive Barlow → serial examinations by the primary care provider or orthopaedics until the hip is stable.
Normal newborn exam but risk factors → outpatient hip ultrasound at 6 weeks if there was breech presentation after 34 weeks (either sex) or a first-degree relative with DDH. Imaging for family history alone is handled differently across guidelines (some reserve it for girls), so follow local policy.

Other "packaging" and limb findings to examine alongside the hips

Metatarsus adductus — the commonest congenital foot deformity (forefoot adducted, hindfoot neutral). A small percentage have hip dysplasia, so examine the hips carefully. More than 90% resolve without treatment.
Calcaneovalgus — hindfoot in extreme dorsiflexion with forefoot abduction; conservative care; typically resolves within 6 months.
Talipes equinovarus (clubfoot) — 1–2 per 1000. Idiopathic (commonest) is corrected in most cases by Ponseti serial casting and bracing, started within the first few weeks, so request orthopaedic consultation as an inpatient or arrange timely referral. Syndromic clubfoot (spina bifida, myotonic dystrophy, trisomy 18, connective tissue or neuromuscular disease) also needs orthopaedics. Positional clubfoot is a normal foot held in utero — it corrects easily with manipulation and resolves by 4–12 months.
Polydactyly — the commonest hand anomaly: 1 in 300 in Black and 1 in 3000 in white infants, autosomal dominant or recessive, isolated or syndromic. Most nursery cases are postaxial, pedunculated and boneless. Do not tie off with suture (infection, poor cosmetic result) — refer to paediatric surgery. If the digit contains bone, arrange orthopaedic follow-up for later removal.
Syndactyly — about 1 in 3000, sporadic or autosomal dominant; commonest between the 2nd and 3rd toes (more often in males), then the middle and ring fingers. Surgery is usual for the hand; for the toes, only if they are angulated.

7. Monitoring

Monitoring

Serial hip exam (instability early; abduction later) at well-child visits.
Ultrasound during Pavlik treatment (confirm and maintain reduction).
Watch for AVN, femoral nerve palsy, and skin breakdown on the harness.
Longer-term imaging to confirm normal acetabular development; monitor for residual dysplasia.

8. Complications

Complications

Untreated/late DDH: persistent dislocation, limp, leg-length discrepancy, pain, and early-onset osteoarthritis (with eventual need for reconstructive surgery).
Treatment-related: avascular necrosis (excessive abduction — iatrogenic), femoral nerve palsy, skin problems (Pavlik); redislocation; residual dysplasia (~20% after Pavlik).

9. Safety Warnings

Safety Warnings

⚠️ Screen every newborn (Ortolani/Barlow) — DDH is often silent.
⚠️ A positive Ortolani (dislocated hip) needs orthopedic referral.
⚠️ After ~3 months, check abduction — the maneuvers no longer work.
⚠️ Image for risk factors (breech, family history) even with a normal exam, per your guideline.
⚠️ Avoid excessive abduction in the Pavlik harness — AVN is iatrogenic.
⚠️ Avoid tight hip-extended swaddling — counsel "hip-healthy" swaddling.

10. Common Mistakes

Common Mistakes

Skipping/rushing the newborn hip exam.
Relying on Ortolani/Barlow after ~3 months (they've become negative).
Not imaging high-risk infants (breech, family history) per guideline.
Over-abducting in the Pavlik harness (AVN).
Over-treating physiologic laxity in the first weeks.
Missing limited/asymmetric abduction in older infants.
Not following for residual dysplasia after treatment.

11. Clinical Pearls

Clinical Pearls

💡 Ortolani relocates (in), Barlow dislocates (out) — and Ortolani-positive is the worrying one.
💡 After 3 months, think abduction (and Galeazzi), not clunks.
💡 Breech + female + family history + firstborn — the classic risk cluster; the left hip leads.
💡 Ultrasound before 6 months, X-ray after (ossification timing).
💡 The Pavlik works — but over-abduction causes AVN.
💡 Hip-healthy swaddling protects the hips.

12. Summary Table

Summary Table

Domain	Bottom line
Spectrum	Dysplasia → subluxation → dislocation
Newborn screen	Ortolani (relocates dislocated) + Barlow (dislocates dislocatable)
After ~3 months	Limited/asymmetric abduction, asymmetric folds, Galeazzi
Risk factors	Breech, female, family history, firstborn; left hip
Imaging	Ultrasound (Graf) <6 mo; X-ray >4–6 mo — for abnormal exam/risk factors
Treatment <6 mo	Pavlik harness (dislocated/persistently unstable); ~85–95% success
Older/failed	Closed reduction + spica; then open reduction ± osteotomy
Complications	Untreated → OA; treatment → AVN (over-abduction), residual dysplasia

13. Step-by-Step Bedside Algorithm

EVERY NEWBORN → hip exam: ORTOLANI (relocates dislocated) + BARLOW (dislocates dislocatable)
   + note RISK FACTORS (breech, female, family history, firstborn; left hip)
        │
        ▼
ORTOLANI-POSITIVE (dislocated) / persistent instability → REFER pediatric orthopedics
BARLOW-POSITIVE (dislocatable) / mild → OBSERVE 4–6 wks (many stabilize) → re-exam ± ultrasound
        │
        ▼
ABNORMAL EXAM or RISK FACTORS → IMAGING
   • ULTRASOUND (Graf) if <6 months (often ~4–6 wks)
   • X-RAY (AP pelvis) if >4–6 months (or equivocal US)
        │
        ▼
CONFIRMED DDH — treat by age/severity
   • <6 months, dislocated/persistently unstable → PAVLIK HARNESS (flex + abduct)
        → monitor with ultrasound; AVOID EXCESSIVE ABDUCTION (AVN); watch nerve/skin
        → failure/irreducible → reassess
   • failed Pavlik / >6 months / irreducible → CLOSED REDUCTION + SPICA CAST
   • >~18 months / failed closed → OPEN REDUCTION ± OSTEOTOMY
        │
        ▼
After ~3 months, screen by ABDUCTION/Galeazzi (maneuvers unreliable);
follow for residual dysplasia; counsel HIP-HEALTHY swaddling

14. References to Verify

Confirm each against the primary source before clinical or published use.

1.Screening/evaluation: AAP clinical report Evaluation and Referral for Developmental Dysplasia of the Hip in Infants. (Verify referral criteria.)
2.Maneuvers: Ortolani/Barlow technique and interpretation references. (Verify.)
3.Ultrasound: Graf classification and timing (<6 months; ~4–6 weeks). (Verify.)
4.Pavlik harness: success rates (~85–95%) and AVN/over-abduction risk. (Verify.)
5.Risk factors / swaddling: breech/family history/female associations and hip-healthy swaddling guidance. (Verify.)

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Chapter 2.6 — Developmental Dysplasia of the Hip (DDH)