C h a p t e r 4 3
Disorders of the Skeletal System: Trauma, Infections, Neoplasms, and Childhood Disorders
1103
of DDH. Thus, the hips of children presenting with con-
genital abnormalities should be examined carefully.
Early diagnosis of DDH is important because treat-
ment is easiest and most effective if begun during the first
6months of life. Also, repeated dislocations cause damage
to the femoral head and the acetabulum. In infants, signs
of DDH include asymmetry of the hip or gluteal folds,
shortening of the thigh so that one knee (on the affected
side) is higher than the other knee, and limited abduction
of the affected hip
63–67
(Fig. 43-20). The asymmetry of
gluteal folds is not definitive but indicates the need for
further evaluation. Physical examination remains the key
to the diagnosis of DDH. However, the U.S. Preventive
Services Task Force (USPSTF) recently concluded that
evidence was insufficient to recommend routine screen-
ing of asymptomatic infants as a means of preventing
adverse outcomes.
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This recommendation applies only
to infants who do not have obvious hip dislocation or
other abnormalities evident without screening.
Several examination techniques can be used to screen
for a dislocatable hip. Two provocative dynamic tests for
assessing hip stability in the newborn are the Ortolani
maneuver (for reducible dislocation) and the Barlow
maneuver (for the dislocatable hip)
8,63–65
(Fig. 43-21).
The Galeazzi test is a measurement of the length of
the femurs that is done by comparing the height at the
knees while they are flexed at 90 degrees. An inequal-
ity in the height of the knees is a positive Galeazzi sign
and is usually caused by hip dislocation or congenital
femoral shortening. This test is not useful in detecting
bilateral DDH because both leg lengths will be equal. In
an older child, instability of the hip may produce a delay
in standing or walking and eventually cause a character-
istic waddling gait. When the thumbs are placed over
the anterior iliac crest and the hands are placed over the
lateral pelvis in examination, the levels of the thumbs
are not even; the child is unable to elevate the opposite
side of the pelvis (positive Trendelenburg test).
Diagnosis of DDH is confirmed by ultrasonography
or radiography. Ultrasonography is used in infants with
high-risk factors (e.g., female infants born in the breech
position) or an abnormal result on examination.
63–67
Radiographs of newborns with suspected DDH are of
limited value because the femoral heads do not ossify
until 4 to 6 months of age. After 6 months of age, the
increasing ossification of the femur renders ultrasonog-
raphy less reliable, and radiographs are preferred.
Treatment of DDH should be individualized and
depends on whether the hip is subluxated or dislocated.
Subluxation of the hip at birth often resolves without
treatment and should be observed for 2 weeks. When sub-
luxation persists beyond this time, treatment may be indi-
cated and referral is recommended. The best results are
obtained if the treatment is begun before changes in the
hip structure (e.g., 2 to 3 months) prevent it from being
reduced by gentle manipulation or abduction devices.
The Pavlik harness is used on newborns (up to 6 months)
to maintain the femoral head in the acetabulum.
63
The
FIGURE 43-20.
Congenital dysplasia of the left hip with
shortening of the femur, as indicated by legs in abduction and
asymmetric gluteal and thigh folds (arrows).
Barlow Test
Ortolani Test
FIGURE 43-21.
Examination for developmental dysplasia of
the hip. In the newborn both hips should be able to be equally
flexed, abducted, and rotated without producing a “click.”
A diagnosis of developmental dysplasia of the hip may be
confirmed by the Ortolani “click” test (top), in which the involved
hip cannot be abducted as far as the opposite one, and there is
a “click” as the femoral head moves back into place. A positive
Barlow test (bottom) is not diagnostic of developmental dyplasia
of the hip, but indicates laxity and a dislocatable progressively,
and a need for the baby to be re-examined in the future.
A feeling of the head of the femur slipping out into the anterior
lip of the acetabulum, constitutes a positive Barlow sign.This
can be confirmed by abducting the hip by pressing with your
index and middle fingers back inward and feeling for movement
of the femoral head as it returns to the hip socket.
