Pediatrics · Year 3 · from Pediatrics

Case 3: Developmental Dysplasia of the Hip

Patient Demographics

  • Age: 6-week-old female
  • Sex: Female

Chief Complaint

Newborn screening examination reveals hip abnormality.

History of Present Illness

A 6-week-old female infant is referred to orthopedics after her pediatrician noted an abnormal hip examination at the 1-month well-child visit. The infant was born at 39 weeks via cesarean delivery due to frank breech presentation. Birth weight was 3.2 kg. She is the first-born child. The parents report no concerns; the baby is feeding well and meeting developmental milestones. Family history reveals that the mother was treated for "hip problems" as an infant.

Physical Examination

  • Vital Signs: Weight 4.1 kg (50th percentile), Length 54 cm (50th percentile)
  • General: Alert, active infant in no distress
  • Hips - Right:
  • Ortolani maneuver: Negative (no clunk with abduction)
  • Barlow maneuver: Negative (hip stable with adduction)
  • Abduction: Symmetric with left
  • Hips - Left:
  • Ortolani maneuver: Positive - palpable clunk felt as femoral head reduces into acetabulum with hip abduction
  • Barlow maneuver: Positive - hip subluxes posteriorly with gentle posterior pressure during adduction
  • Abduction: Mildly limited compared to right
  • Extremities: Equal leg lengths, symmetric thigh folds
  • Neurologic: Normal tone, symmetric reflexes

Imaging Findings

  • Hip ultrasound (Graf method):
  • Right hip: Alpha angle 65 degrees (normal >60), beta angle 52 degrees - normal, mature hip
  • Left hip: Alpha angle 48 degrees (abnormal <60), beta angle 72 degrees - Graf Type IIc, indicating dysplasia with poor acetabular coverage; dynamic instability present

Diagnosis

Developmental dysplasia of the hip (DDH), left hip

Clinical Reasoning

This infant has multiple risk factors for DDH: female sex (4:1 female predominance), breech presentation (highest risk factor), first-born status, and positive family history. The positive Ortolani maneuver (reduction clunk) indicates that the hip is dislocated at rest but can be reduced with abduction. The positive Barlow maneuver indicates the hip is unstable and can be dislocated. Hip ultrasound is the appropriate imaging modality before 4-6 months of age (before femoral head ossification) and confirms dysplasia with poor acetabular coverage. Early diagnosis is critical because treatment at this age has excellent outcomes.

Management

  1. Pavlik harness: Immediate fitting; maintains hips in flexion (100-110 degrees) and abduction (50-70 degrees) to promote acetabular development
  2. Wearing schedule: Full-time wear (23 hours/day) for 6-12 weeks until hip is stable
  3. Follow-up: Weekly ultrasound and clinical examination for first 2-3 weeks to confirm reduction and monitor progress
  4. If Pavlik fails: Closed reduction under anesthesia with spica casting (typically if diagnosed after 6 months or harness unsuccessful)
  5. Prognosis: Excellent if treated before 6 months; >95% achieve normal hip development
  6. Screen siblings: Especially female siblings of affected children

Clinical Image

Image Description: Infant wearing a Pavlik harness, which maintains the hips in flexion and abduction to allow proper acetabular development in developmental dysplasia of the hip.

Source: Wikimedia Commons URL: https://commons.wikimedia.org/wiki/File:Pavlik_harness.jpg License: CC BY-SA 4.0

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