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    Developmental dysplasia of the hip

    A new clinical report from the American Academy of Pediatrics presents state-of-the-art guidance for detecting and managing this common pelvic condition in infants.

     

    Risk factors

    The clinical report notes that most DDH occurs in children without risk factors and that “high risk” is a relative and controversial term. Among features that have been identified as risk factors for DDH, breech presentation in the third trimester and positive family history (including hip replacement in a close relative when aged 40 years or younger) may be the most important.1,2 Frank beech presentation in a girl has the highest risk, and breech position toward the end of pregnancy has greater importance than breech delivery.2,4

    Orthopedic referral and treatment

    There is strong support from available evidence for treating hip dislocation, identified by a positive Ortolani test result, and for initially observing milder early forms of dysplasia and instability (positive Barlow test result) with periodic physical examination and imaging if deemed appropriate. Presence of a positive Barlow test is not an indication for orthopedic referral. Infants with a positive Barlow test should be followed and only referred to an orthopedist if clinical instability persists.

    There is insufficient evidence for recommending treatment versus observation in a specific case of minor ultrasonographic variation. In this setting, the approach to care should be determined through shared decision making.

    Treatment for hip dislocation should be performed by an orthopedist whereas follow-up observation, when indicated, can be performed by the pediatrician or the orthopedist.

    Indications for referral to an orthopedic specialist are: 1) unstable (positive Ortolani test result) or dislocated hip on physical examination, and 2) limited or asymmetric hip abduction in a child aged 4 weeks or older. Relative indications for referral include presence of DDH risk factors, questionable findings on physical examination, and any pediatrician or parental concern.

    Imaging (ultrasonography or radiography) is not required for orthopedic referral. The clinical report notes that treatment of neonatal DDH is not an emergency, and it is not necessary to begin intervention before the child is released from the hospital.2 A newborn with a positive Ortolani test should be seen by an orthopedist within several weeks after hospital discharge. The AAOS guideline on DDH, which pertains to infants aged 6 months or younger, notes there is limited evidence supporting either immediate or delayed (2 to 9 weeks) brace treatment for hips with a positive instability exam.1

    Preventing DDH

    The clinical report cautions against tight swaddling of the lower extremities with the hips adducted, and notes that “safe” swaddling, which does not restrict hip motion, minimizes the risk of DDH.2 A video on safe swaddling is available at: bit.ly/healthy-swaddling-video. The 2016 clinical report also cites a position statement on swaddling and DDH issued by the AAP, the POSNA, the International Hip Dysplasia Institute, the AAOS, the US Bone and Joint Initiative (USBJI), and Shriners Hospitals for Children that promotes “hip-healthy swaddling” when parents decide to swaddle their infant.12

    Next: A guideline review for functional constipation

    The report also notes that there is no high-level evidence that milder forms of dysplasia can be prevented by screening and early treatment and that no screening program can completely eliminate the risk of late-presenting DDH needing treatment.

    Medicolegal risk

    Recognizing that practitioners are likely to be concerned about liability in cases of undetected or late-developing DDH and the potential for this concern to trigger overdiagnosis and overtreatment, the clinical report includes a discussion of medicolegal risk. Suggested strategies are summarized in Table 3.4

    REFERENCES

    1. American Academy of Orthopaedic Surgeons. Detection and nonoperative management of pediatric developmental dysplasia of the hip in infants up to six months of age. Evidence-based clinical practice guideline. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2014. Available at: http://www.aaos.org/research/guidelines/DDHGuidelineFINAL.pdf. Accessed May 17, 2017.

    2. Shaw BA, Segal LS; Section on Orthopaedics. Evaluation and referral for developmental dysplasia of the hip in infants. Pediatrics. 2016;138(6):e20163107.

    3. Schwend RM, Schoenecker P, Richards BS, Flynn JM, Vitale M; Pediatric Orthopaedic Society of North America. Screening the newborn for developmental dysplasia of the hip: now what do we do? J Pediatr Orthop. 2007;27(6):607-610.

    4. American Academy of Pediatrics. Clinical practice guideline: early detection of developmental dysplasia of the hip. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. Pediatrics. 2000;105(4 pt 1):896-905.

    5. Lehmann HP, Hinton R, Morello P, Santoli J. Developmental dysplasia of the hip practice guideline: technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics. 2000;105(4):e57.

    6. US Preventive Services Task Force. Screening for developmental dysplasia of the hip: recommendation statement. Pediatrics. 2006;117(3):898-902.

    7. Shaw BA, Segal LS. Report recommends changes in screening for developmental dysplasia of the hip. AAP News. Available at: http://www.aappublications.org/news/2016/11/21/DDH112116. Published November 21, 2016. Accessed May 17, 2017.

    8. Patel H; Canadian Task Force on Preventive Health Care. Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns. CMAJ. 2001;164(12):1669-1677.

    9. Rosenfeld SB. Developmental dysplasia of the hip: clinical features and diagnosis. UpToDate. Available at: https://www.uptodate.com/contents/developmentaldysplasia-of-the-hip-clinical-features-and-diagnosis. Updated February 15, 2017. Accessed May 17, 2017

    10. Dunn PM. Perinatal observations on the etiology of congenital dislocation of the hip. Clin Orthop Relat Res. 1976;(119):11-22. Available at: http://journals.lww.com/corr/Abstract/1976/09000/Perinatal_Observations_on_the_Etiology_of.4.aspx. Accessed May 17, 2017.

    11. Ando M, Gotoh E. Significance of inguinal folds for diagnosis of congenital dislocation of the hip in infants aged three to four months. J Pediatr Orthop. 1990;10(3):331-334.

    12. American Academy of Pediatrics (AAP), Pediatric Orthopaedic Society of North America (POSNA), International Hip Dysplasia Institute (IHDI), American Academy of Orthopaedic Surgeons (AAOS), US Bone and Joint Initiative (USBJI), Shriners Hospitals for Children. Position statement: Swaddling and developmental hip dysplasia. Rosemont, IL: Pediatric Orthopaedic Society of North America; 2015. Available at: https://posna.org/POSNA/media/Documents/Position Statements/SwaddlingPositionStatementApril2015.pdf. Accessed May 17, 2017.

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