Developmental Dysplasia of the Hip Screening
2
Audio Transcript Auto-generated
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Hi, this is Melanie.
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I'm working with jess and Jessica and Jessica today and
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we're presenting on developmental dysplasia of the hip screening.
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So we start with a definition and in the literature
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it's hard to um really define it because the definitions
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are different.
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It ranges anywhere from just mild hip instability to a
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full dislocation of the hip.
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The key thing to remember throughout this presentation is early
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diagnosis and treatment provide the best possible clinical outcome.
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And with the least amount of intervention.
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The prevalence of this Hip Dysplasia is occurs in about
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1-2% of full term infants and Up to 15% of
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that instability is detectable by uh imaging studies.
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It's the most common disorder for Children.
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Hip disorder.
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There's about one in 100 infants that have in hip
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instability and the true dislocation rate is seen in about
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one in 1000 births.
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It's much higher, six times higher in females than males
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and the left hip is more affected than the right.
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Some of the risk factors include breach positioning in utero
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and in fact this is the most important risk factor
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for um developmental dysplasia.
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Of the hip Breaches seen in 2-27% of boys and
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girls. And the Frank Breech position in girls carries the
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highest risk.
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The number two uh risk factor is a positive family
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history in a first degree relative, which increases the Infants
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Risk by 12 times.
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It can also be associated with other uh things like
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torta cola's from in utero positioning.
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If there's any clinical instability, that's a risk factor.
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Of course females more than males and firstborn tend to
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be more affected.
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As you can imagine, getting that pelvis opened the first
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time for birth.
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The prolonged abnormal post natal positioning in some cultural groups
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of tight swaddling can be a respect er as well.
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So genetic implications, the biggest one is that um there's
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12 times more risk for having hip dysplasia in offspring
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if the first degree relative also has hip dysplasia.
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And now we'll move on to screening.
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This is Jessica frank.
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I'm gonna take over screening some of our physical findings
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that we're going to find in babies that have hip
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dysplasia are going to be unequal thigh, skin creases or
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gluteal folds.
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Um So you're gonna look for asymmetry in the skin
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creases, um limited abduction, so difficulty taking moving the leg
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away from the body obviously, or abducting the hip, um
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difficulty diapering and leg length discrepancies.
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Um If the baby is walking, you're going to see
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a disturbed gait or abnormal gait um and they may
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have some pain when they walk as well.
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Our two maneuvers are the Barlow and Ortolani maneuvers are
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Barlow maneuver is gonna, you're gonna start with the knees
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flexed and brought to the midline while you apply gentle
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downward pressure.
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Um If you feel a clunk then you have a
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positive Barlow um sign um The Ortolani maneuver is done
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by abducting the hips.
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So you with the knees bent out.
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So you're gonna have the baby in a frog position
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and you're gonna push up posterior early with the fingers
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to try to pop a hip into the sockets, you're
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relocating, you're trying to relocate the femoral head.
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If you feel a clunk their um then you have
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relocated the hip and so they have hip instability.
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Um And then our gal Yossi test is you have
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your baby um laying on the back and you look
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at the knee height difference.
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So um just another way to think about measuring leg
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lengths. Um The limitations of these maneuvers sensitivity of these
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maneuvers depends on the experience of the examiner.
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If your clinician is really experienced, your sensitivity is going
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to be about 87 and 97%, but if you have
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an inexperienced clinician um that sensitivity does go down.
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Um The Barlow exam alone is not recommended to be
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performed alone.
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You want to perform it with the Ortolani exam so
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that you have a higher specificity Um which is about
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98-99%. In the detection of hip instability.
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Um maneuvers alone detect 54% of developmental dysplasia of the
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hip and they are more sensitive in infants that are
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less than three months old because their tissues are soft
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and they haven't developed contractors yet.
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Um severely dislocated hip.
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You may not actually have a positive Barlow or Ortolani
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because you the hip is dislocated and you cannot relocate
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it so there's no clunking that's happening and then it's
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it's already outside of the hip socket.
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So um you won't feel the clunk of it dislocating.
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So that's something to keep in mind with people that
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have or with babies that have higher um Risk factors
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they may have a negative Barlow and Ortolani sign, but
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that doesn't mean that there isn't an issue.
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Um The most sensitive exam for um Children that are
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greater than three months is a symmetric diminished hip abduction.
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So if you are able to abduct one of their
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hips more easily than the other.
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Um And this is where the diapering comes in.
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Um You want to take a look at that leg
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length discrepancy.
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You wanna take a look for leg length discrepancies and
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maybe an asymmetry in the thigh folds.
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Um To check for dysplasia of the hip.
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Um If you have a walking child they will have
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some disturbed gait.
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So um sometimes they may tilt their trunk towards the
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effective hit um when weight bearing or if both of
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their hips are unstable, they may have a waddling gait
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where the trump tilts side to side um alternating depending
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on the hip that is bearing weight.
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Mhm. So if you have a positive screen or if
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you have some high suspicion about hip dysplasia, you're gonna
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do some diagnostic testing um ultrasound of the hips uh
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for infants six weeks to six months of age.
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Um With one of those significant risk factors is going
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to be a good idea because that's going to increase
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the identification of hip dysplasia.
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Um However we are not going to ultrasound every baby
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for hip dysplasia because it is not recommended.
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Um If our baby is greater than four months of
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age, you're also going to get a x ray of
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the interior pelvis.
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Yeah. This Jessica cook.
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I'm gonna go ahead and pick up here at treatment
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and follow up.
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Um So if our baby is found to have a
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Barlow positive exam, um it's okay to actually observe this
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baby, make sure you re examine their hips at every
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visit. Um If they happen to have an Ortolani positive
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exam or an order, Lonnie and Barlow positive exam, we're
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going to refer to orthopedics.
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Um The other factors to refer to orthopedics include um
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The risk factors we already mentioned, LTD hip abduction or
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asymmetric hip abduction after four weeks of age.
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Or if there's anything questionable on our exam or if
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our parents have caregivers have any concerns were also going
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to refer to or.
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So The important thing is to catch this early um
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because if you see here based on their age from
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0-6 months um if we catch it, then they'll simply
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just need a havoc harness, which Ortho will provide.
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Um And it's basically a really soft flexible harness that
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the baby will use.
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Um it has a 90% effective successful rate using this
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harness. Um however, if the patient does have an order
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on a positive exam, this harness has a 21-37% failure
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rate. Um So they would need the oilfield harness um
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Which is more restrictive and less flexible.
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Um so that is the difference in that um 6-18
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months of age, um they will end up meeting a
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closed reduction surgery with a hip spica cast um over
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12-18 months of age, Or 12-18 months of age.
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And up.
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They will require an open hip reduction and then greater
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than two years, they'll continue to still need an open
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hip reduction.
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Um But this will include possibly a memorial shortening osteo
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to me 3-8 years and open hip with or without
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for moral shortening Osteo to me.
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But they'll also need possibly a pelvic osteo to me
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and then greater to eight years of age.
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If it's still not caught, they could end up with
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an open hip production um with possible arthur a plaster
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later in life.
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So this is extremely important um as far as early
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diagnostic and treatment, moving on the complications.
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Um So there's delayed treatment um which affects normal growth
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of that hip joint, having that continue to stay outside
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that socket definitely will cause lifelong complications.
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Some of these can include residual dysplasia, limited range of
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motion, unstable gait pain.
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Um Some scoliosis with low back pain, possibly early degenerative
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changes. Um And then women younger than 45-10% of them
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may need a total hip replacement.
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Um Hip arthritis could result and then possibly um osteoarthritis.
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Now we'll move on to anticipatory guidance.
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So we definitely want to teach our parents and caregivers
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to avoid tight swaddling of those lower extremities um making
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those legs um stay in a midline position.
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We want to remind them to allow the hips to
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have the freedom of flexing and abducting during their squabbling.
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Um That way they can move their hips and also
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flex their knees.
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We also want to tell our parents and caregivers to
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report any range of motion or neurovascular changes that they
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might see.
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And then if there are requiring a brace or a
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cast, we want to also emphasize the importance of still
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holding and cuddling the baby.
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Last but not least.
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We're going to talk about some levels of strength of
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evidence. So keep in mind when you're looking up guidelines
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for this type of screening, there is going to be
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a different scene with the United States preventative Task force
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versus the American Academy American Academy of Pediatrics.
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Um So some of the screening and surveillance recommendations vary.
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For instance with the American Academy of Pediatrics.
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Um They recommend that all newborn infants are screened on
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exam at every well visit until 6 to 9 months
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of age and the use of ultrasound or X ray
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or an X ray um for those with abnormal findings
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or risk factors is implemented.
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Whereas the United States preventative Task force um does not
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recommend any kind of hip screening um labeling it an
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eye for insufficient um insufficient evidence for this type of
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recommendation. So it's something to keep in mind um when
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you are presented with a patient that does have this
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kind of exam, finding that based on where you get
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your recommendations, they are going to vary.
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Um And last but not least, we'll show you some
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of our references.
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Feel free to use some of these two reference um
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in your practice and thank you so much for watching.