Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT

3. Cardiopulmonary

4. GI

5. GU

6. Orthopedics
--Common Orthopedic Findings
--Growing Pains - Commonly Asked Questions

DDH: Developmental Dysplasia of the Hips

(Formerly Congenital Hip Dislocation)

Key Point: A normal neonatal or early hip examination does not assure normal hip development. The hips must be examined carefully through one year of age.

Risk Factors for the development of DDH:

1. family history - if parent or sib has DDH, percentages much higher
2. female incidence > male 6:1 because of relaxin hormone in females.
3. small uterus, big baby, primiparous mother, oligohydramnios
4. abnormal limb or other orthopedic, neurological, or genetic abnormality

Incidence of DDH: 2/1000 births; dislocatable: 15 per 1000 (some of these end up dislocated)

Physical Findings of DDH birth to 4 months of age:

1. Leg length discrepancy as measured by distance from anterior iliac crest to medial malleolus.
- What is abnormal difference in length?  Not clear, but > 2 cm clearly abnormal; some authorities (Nelson s text) state that > 1 cm may be abnormal.

2. Visual Examination of folds: asymmetric buttock folds and anterior thigh folds may be consistent with DDH, but can be normal.  Asymmetric Popliteal creases suggest leg length difference, and are abnormal. (Can occur with other abnormalities than DDH)

3. Maneuvers to examine hips: 3 signs:

1. Galeazzi sign: knees flexed, feet flat on table. DDH: knee is lower on affected side           
2. Barlow s sign: hip is in joint.  Thumb is on adductor muscles medially, and 3rd and 4th fingers are on greater trochanter.  Move the hip laterally: normal hips will not dislocate, abnormal hips will. If dislocate: + Barlow s sign
   BARLOW: HIP-STABILITY TEST
3. Ortolani sign: hip is out of joint; by pushing on greater trochanter, femoral head is reduced into the hip socket as the hip is abducted. hip “clunks” back into socket.
   This can be palpable, visible, and even audible.  ORTOLANI = OUT
   Ortolani sign found only in neonates several weeks of age.

Physical Findings after 4 months of age:

1. Leg length abnormalities the same as younger babies.
2. Folds: same as with younger babies.
3. Maneuvers no longer effective.
4. Hip HAS LIMITED ABDUCTION.   

What is a hip click and what should we do about it?  This is a common physical finding, and can reflect tendon sheaths clicking over joints, or patellar movement. There is nothing we should do about a hip click.  It is a normal variant.

DIAGNOSIS OF DDH: Clinical, Ultrasound before 4 months of age, X-ray after 4 mos of age; CT scan of hip also reliable method of diagnosis.

TREATMENT OF DDH: Pavlik Harness - allows active hip motion fixes hip in flexion and abduction.  Traction and surgery is indicated in older children.  

Reviewed 10/01         

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004