Developmental Dysplasia of the Hip (DDH) – Modern Study Review
High-Yield Summary
Developmental Dysplasia of the Hip (DDH) is a spectrum of hip joint abnormalities ranging from mild acetabular dysplasia to frank dislocation, primarily affecting infants and young children. Early diagnosis is critical to prevent long-term morbidity such as gait abnormalities, pain, and early osteoarthritis. Physical examination maneuvers in the newborn period, combined with imaging, guide timely intervention. Understanding the evolving clinical signs through infancy and childhood is essential for effective screening and management.
Key Diagnostic Findings
Anatomy
- Hip joint: Ball-and-socket joint formed by the femoral head and acetabulum.
- Greater Trochanter (GT): Important landmark for clinical lines (Klisic’s, Nelaton’s).
- Acetabular development: Dependent on concentric reduction of the femoral head.
Clinical Presentation
| Age Group | Key Findings | Notes |
|---|---|---|
| Newborn | – Asymmetric hip abduction | Most sensitive early sign |
| – Ortolani test: Reduction of dislocated hip | Positive test indicates reducible dislocation | |
| – Barlow test: Provocative dislocation | Positive test indicates unstable hip | |
| – Both signs may disappear within 4 weeks | 60% Barlow-positive hips stabilize within 1 week; 88% within 2 months | |
| Infant (Later) | – Persistent asymmetric abduction | Suggests ongoing dysplasia or subluxation |
| – Galeazzi sign: Unequal knee height when hips and knees flexed | Indicates femoral shortening or dislocation | |
| – Klisic’s line: GT to ASIS line deviation | GT is high in dislocated hip | |
| – Nelaton’s line: GT position relative to ischial tuberosity-ASIS line | GT lies cephalad in dislocation | |
| Child (Much Later) | – Painless limp | Indicates chronic hip instability or dysplasia |
| – Hyperlordosis | Compensation for hip instability | |
| – Trendelenburg gait | Weakness of hip abductors | |
| – Toe walking | Secondary to hip instability or contracture |
Imaging
- Ultrasound: Gold standard for infants <6 months; dynamic and static assessment of hip stability and morphology.
- X-rays: Used after 4-6 months when ossification centers appear; assess acetabular index, Shenton’s line, femoral head position.
Classification Systems
- Graf Classification (Ultrasound): Modern standard for infant hip dysplasia, grades hips from Type I (normal) to Type IV (dislocated).
- Ortolani-Barlow: Clinical classification of hip stability in newborns.
- Acetabular Index (Radiographic): Angle >30° after 6 months suggests dysplasia.
Current Gold Standard Treatment
Non-operative
- Pavlik Harness: First-line for infants <6 months with reducible hips (Ortolani positive). Maintains hip in flexion and abduction to promote concentric reduction.
- Closed reduction and spica casting: For infants 6-18 months failing harness or with unstable hips.
Operative
- Open reduction: Indicated if closed reduction fails or in late-presenting cases (>18 months).
- Osteotomies (e.g., Salter, Pemberton, or Dega): To correct acetabular dysplasia and improve coverage.
- Combined procedures: Often required in older children to restore hip stability and function.
Modern Complications & Outcomes
Complications
| Complication | Description | Prevention/Management |
|---|---|---|
| Avascular necrosis (AVN) | Femoral head ischemia due to reduction maneuvers or casting | Gentle reduction, avoid excessive abduction |
| Residual dysplasia | Persistent acetabular insufficiency | Long-term monitoring, possible osteotomy |
| Re-dislocation | Failure of reduction or inadequate immobilization | Careful follow-up, possible revision surgery |
| Nerve injury | Sciatic or femoral nerve injury during surgery | Meticulous surgical technique |
Outcomes
- Early diagnosis and treatment yield excellent functional outcomes with normal gait and hip function.
- Delayed diagnosis increases risk of osteoarthritis and need for complex reconstructive surgery.
- Long-term follow-up is essential until skeletal maturity to monitor for residual dysplasia or degenerative changes.
Classic Clinical Notes
DDH-exam
Developmental Dysplasia of the Hip – Physical Findings
Newborn:
- Asymmetric abduction – key finding
- Ortolani – reduction maneuver of a dislocated hip
- Barlow – provocative dislocation of a reduced hip
- both these signs may disappear within a month?
- 60% of Barlow positive hips are stable within a week anyways
- 88% of Barlow positive hips are stable within two months
Later:
- Asymmetric abduction
- Galleazi sign
- Klisic’s sign – line from GT to ASIS should continue medially and pass towards the umbilicus; in the dislocated hip, the GT is high and the line passes under the umbilicus
- Nelaton’s line – line from ischial tuberosity to ASIS; the GT should lie caudal to this line; in the dislocated hip, the GT is high and lies cephalad to this line
Much Later:
- Painless limp
- Hyperlordosis
- Trendelenberg gait
- Toe walking
Last Updated on January 25, 2026 by orthonet
Leave a Reply
Want to join the discussion?Feel free to contribute!