Screening for Hips (Barlow and Ortolani), limbs joints, hands, feet-Infant

Summary of Recommendation and Evidence

Population	Recommendation	Grade (What's This?)
Screening of both Genders	This screening is recommended a best practice.	B

Overview

The term “congenital dislocation of the hip” has traditionally been used to describe abnormal infant hips that may progress to dislocation. “Developmental dysplasia of the hip,” the currently preferred term, denotes the same range of hip problems but also includes hips that are never documented to be dislocated but are poorly developed, as well as hips that are determined to be abnormal after the newborn period.

Epidemiology and Natural History

The incidence of hip dislocation in unscreened populations is estimated to be one to two cases per 1,000 children of European origin. The abnormality is rare in black Africans.

The most significant risk factor for hip dysplasia is a positive family history. In a recent British study, more than 20 percent of children who required treatment for developmental dysplasia of the hip had a positive family history for the disorder; 5.5 percent of those children had an apparently normal physical examination at birth.

Risk Factors

The AAP guideline states that the hip is at risk of dislocation in the 12th gestational week, in the 18th gestational week, in the final four weeks of gestation, when mechanical forces play a role, and in the postnatal period.

The incidence of DDH is higher in girls, perhaps because females are more susceptible than males to the maternal hormone relaxin, which may contribute to ligamentous laxity. The left hip is affected three times more often than the right hip, which may be related to the left occiput anterior position of most nonbreech infants.

ORTOLANI AND BARLOW MANEUVERS

The Ortolani and Barlow maneuvers have been the standard techniques for detecting hip instability in newborns. These maneuvers cannot be performed in a fussy, crying infant whose muscle activity may inhibit the movement of an unstable hip. For the examinations, the infant's hips are flexed to 90 degrees; the thumbs of the examiner are placed on the medial proximal thigh, and the long fingers are placed over the greater trochanter.

For the Ortolani maneuver, the contralateral hip is held still while the thigh of the hip being tested is abducted and gently pulled anteriorly. The sensation of instability in a positive Ortolani maneuver is the palpable and sometimes audible “clunk” of the femoral head moving over the posterior rim of the acetabulum and relocating in the cavity. The more poorly developed the acetabulum (and thus the more unstable the hip), the less pronounced the “clunk.” Consequently, the Ortolani maneuver must be performed very gently to avoid obscuring the sound of the femoral head passing over a poorly developed posterior acetabulum. Audible high-pitched “clicks” without a sensation of instability have no pathologic significance.

The Barlow maneuver is performed by adducting the hip while pushing the thigh posteriorly. If the hip goes out of the socket, it is called “dislocatable” and the test is termed “positive.” The dislocation is confirmed by performing the Ortolani maneuver to reduce or relocate the hip.

Clinical Screening Strategies

An infant can have a normal physical examination but a family history that is positive for hip dysplasia (i.e., the abnormality has occurred in an immediate family member such as a parent or sibling). In this instance, the physician should consider obtaining a radiograph of the pelvis when the child is three to five months old or performing an ultrasound examination when the child is four to six weeks of age.

In some situations (e.g., when any child has suspected hip abnormality in the newborn period), the absence of developmental dysplasia of the hip must be documented. Pelvic radiography after the appearance of the femoral nucleus of ossification is still the most well-accepted standard for judging the presence or absence of developmental dysplasia of the hip.

An algorithm for the evaluation of infant hips:-

Treatment

In the United States, developmental dysplasia of the hip in a newborn is generally treated by splinting with the Pavlik harness, a brace that places the hips in flexion and abduction. In Europe, excellent results have been reported for the use of abduction pillows as the initial mode of treatment.

Successful treatment of dysplasia in infancy does not guarantee long-term radiologic normality of the hips. Premature onset of symptomatic degenerative arthritis of the hip remains a possibility later in life.