What is the recommended screening protocol for Developmental Dysplasia of the Hip (DDH) in infants?

Recommended Screening Protocol for Developmental Dysplasia of the Hip (DDH) in Infants

All infants should undergo clinical evaluation for DDH at each well-baby visit during the first year of life, with selective imaging for high-risk infants or those with abnormal physical examination findings. 1

Clinical Screening Protocol

Physical Examination

• Perform at all well-baby visits (recommended at 1-2 weeks, 2,4,6,9, and 12 months of age) 1
• Key examination techniques:
  • Ortolani test: Abduct and gently lift the flexed thigh while pushing the greater trochanter anteriorly to detect if a dislocated hip can be reduced (listen/feel for a "clunk")
  • Barlow test: Gently adduct the thigh to attempt to dislocate the femoral head posteriorly, then abduct while lifting to relocate it
  • After 3 months of age, focus on:
    • Limited hip abduction
    • Asymmetric thigh folds
    • Apparent shortening of the affected limb

Risk Factor Assessment

Identify infants with higher DDH risk:

• Female gender (4-8 times more common than in males) 1
• Breech presentation
• Positive family history of DDH
• Firstborn status
• Large infant size
• History of oligohydramnios

Imaging Protocol

Ultrasound Screening

• Timing: After 2 weeks of age (to avoid false positives from normal neonatal laxity) 1
• Selective screening recommended for:
  • Female infants born in breech position (mandatory) 1
  • Male infants born in breech position (optional) 1
  • Female infants with positive family history (optional) 1
  • Infants with inconclusive or abnormal physical examination findings 1
  • Infants with other risk factors (e.g., foot deformities) 1

Radiographic Evaluation

• Not recommended for generalized screening 1
• Appropriate after 4 months of age when ossification centers of femoral heads are typically present 1
• Indicated for:
  • Follow-up of previously identified DDH
  • Evaluation of infants >4 months with risk factors who had normal early examinations

Management Algorithm Based on Findings

1. Normal physical examination, no risk factors:

   • Continue routine clinical screening at well-baby visits
   • No imaging required

2. Normal physical examination with risk factors:

   • Ultrasound at 6 weeks of age 1
   • If normal ultrasound: routine follow-up
   • If abnormal ultrasound: refer to orthopedic specialist

3. Abnormal/equivocal physical examination:

   • Ultrasound evaluation (after 2 weeks of age) 1
   • If positive: refer to orthopedic specialist
   • If negative: follow-up examination at next well-baby visit

4. Positive Ortolani or Barlow test:

   • Ultrasound confirmation 1
   • Refer to orthopedic specialist for treatment consideration

Common Pitfalls and Caveats

• Physical examination alone has limited sensitivity; serial examinations are necessary 2
• False-positive rates are high in the first 2 weeks of life due to normal neonatal laxity 1
• Despite normal newborn examinations, late-onset DDH can occur in approximately 1 in 5000 infants 3
• Universal ultrasound screening is not recommended due to high rates of overdiagnosis and unnecessary treatment 1
• Treatment decisions should not be made based on imaging alone before 2 weeks of age 1
• Delayed diagnosis (after 6 months) often requires more invasive surgical intervention 1, 4

The goal of screening is early detection when treatment is most effective and least invasive. Despite screening programs, late presentation of DDH has not been completely eliminated, emphasizing the importance of continued vigilance throughout the first year of life 1.