Developmental Dysplasia of the Hip Clinical Presentation

Updated: May 08, 2017
  • Author: Junichi Tamai, MD; Chief Editor: William L Jaffe, MD  more...
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Presentation

Physical Examination

Early clinical manifestations of developmental dysplasia of the hip (DDH) are identified during examination of the newborn. The classic examination finding is revealed with the Ortolani maneuver, in which a palpable "clunk" is present when the hip is directed in and out of the acetabulum and over the neolimbus. A high-pitched "click" (as opposed to a clunk) in all likelihood has little association with acetabular pathology. [27, 28] Ortolani originally described this clunk as occurring with either subluxation or reduction of the hip (in or out of the acetabulum). More commonly, the Ortolani sign is referred to as a clunk felt when the hip reduces into the acetabulum, with the hip in abduction.

To perform this maneuver correctly, the patient must be relaxed. Only one hip is examined at a time. The examiner's thumb is placed over the patient's inner thigh, and the index finger is gently placed over the greater trochanter. The hip is abducted, and gentle pressure is placed over the greater trochanter. In the presence of DDH, a "clunk," similar to that noted in turning a light switch on or off, is felt when the hip is reduced. The Ortolani maneuver should be performed gently, in such a way that the fingertips do not blanch. [29]

Barlow described another test for DDH that is performed with the hips in an adducted position, in which slight gentle posterior pressure is applied to the hips. A "clunk" should be felt as the hip subluxates out of the acetabulum. [22]

The clinical examination for late DDH (age 3-6 months) is quite different. At this point, the hip, if dislocated, is often dislocated in a fixed position. [13] The Galeazzi sign is a classic identifier of unilateral hip dislocation (see the image below). This is performed with the patient lying supine and the hips and knees flexed. The examination should demonstrate that one leg appears shorter than the other. Although this finding is usually due to hip dislocation, it is important to realize that any limb-length discrepancy results in a positive Galeazzi sign.

Galeazzi sign is classic identifier of unilateral Galeazzi sign is classic identifier of unilateral hip dislocation. Patient lies supine, with hips and knees flexed. Examination should demonstrate that one leg appears shorter than other. Although this appearance is usually due to hip dislocation, it is important to realize that any limb-length discrepancy results in positive Galeazzi sign.

Additional physical examination findings for late dislocation include asymmetry of the gluteal thigh or labral skin folds, decreased abduction on the affected side, standing or walking with external rotation, and leg-length inequality. [30]

Bilateral dislocation of the hip, especially at a later age, can be quite difficult to diagnose. This condition often manifests as a waddling gait with hyperlordosis. Many of the aforementioned clues suggesting a unilateral dislocated hip are absent, such as the Galeazzi sign, asymmetric thigh and skin folds, or asymmetrically decreased abduction. Careful examination is needed, and a high level of suspicion is important.

Any limp in a child should be considered abnormal. The diagnosis can be quite variable, but an underlying etiology must always be pursued.

Of primary importance is making the diagnosis of hip dislocation or dysplasia. Once this diagnosis is made, the patient should be examined to make sure that there is no underlying medical or neuromuscular disorder. Proximal femoral focal deficiency can masquerade as hip dysplasia and often manifests similarly. Because the femoral head does not ossify, the radiographic appearance also may be deceiving. Other neuromuscular disorders can manifest as dysplasia later in life, such as Charcot-Marie-Tooth disease.

Using expected-value decision analysis, Mahan et al found that the screening strategy associated with the highest probability of having a nonarthritic hip at the age of 60 years was to screen all neonates for hip dysplasia with a physical examination and to use ultrasonography selectively for high-risk infants. [31] The expected value of a favorable hip outcome was 0.9590 for screening all neonates with physical examination and selective use of ultrasonography, 0.9586 for screening all neonates with physical examination and ultrasonography, and 0.9578 for no screening.

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Complications

Numerous possible complications can occur, including redislocation, stiffness of the hip, infection, blood loss, and, possibly the most devastating, avascular necrosis of the femoral head. The rate of femoral head necrosis varies substantially; depending on the study, it may be anywhere from 0% to 73%. Numerous studies demonstrate that extreme abduction, especially when combined with extension and internal rotation, results in a higher rate of avascular necrosis. [32, 33, 34]

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