Hip Ultrasound Screening for Breech Presentation Infants
Hip ultrasound should be performed at 4-6 weeks of age (not before 2 weeks) for all infants—both male and female—with a history of breech presentation in the third trimester, regardless of whether the physical examination is normal. 1
Optimal Timing for Screening
The American Academy of Pediatrics specifically recommends initial ultrasound screening at 4-6 weeks of age for high-risk infants, including those with breech presentation. 1
Ultrasound performed before 2 weeks of age should be avoided due to unacceptably high false-positive rates caused by physiologic hip laxity that resolves spontaneously. 1
The 4-6 week window balances early detection against the natural resolution of neonatal hip instability that occurs by 2 weeks in most infants. 1
Who Requires Screening
Both female AND male infants born in breech presentation require ultrasound screening, contrary to older recommendations that made screening optional for males. 1
This recommendation applies even when the Barlow and Ortolani tests are completely normal on physical examination. 1
Breech presentation is confirmed as the most important risk factor for developmental dysplasia of the hip (DDH), with research showing 27% of breech infants with clinically stable hips having abnormal screening ultrasounds. 2
Critical Follow-Up Requirements
A single normal ultrasound at 6 weeks is insufficient to rule out DDH in breech infants. The evidence reveals a concerning gap:
Among breech infants with normal 6-week ultrasounds, 29% subsequently developed dysplasia requiring treatment when evaluated at 4-6 months with radiographs. 2
Therefore, breech infants require longitudinal evaluation: ultrasound at 6 weeks AND an AP pelvis radiograph at 4-6 months of age, even if the initial ultrasound is normal. 2
This extended surveillance is necessary because breech presentation subjects the hip to abnormal mechanical forces that may manifest as delayed acetabular development. 2
Why Ultrasound at This Age
Ultrasound is the preferred imaging modality for infants under 4 months because the hip structures remain largely cartilaginous. 1
Radiographs have limited diagnostic value before 4-6 months due to delayed appearance of the femoral head ossific nucleus and cartilaginous acetabular margins. 1
After 4-6 months, radiographs become more reliable as ossification progresses, making them the appropriate modality for follow-up imaging. 1, 3
Important Caveats
Normal physical examination findings do not preclude the development of dysplastic hips, making imaging essential rather than optional. 3
Breech infants do show higher rates of spontaneous stabilization (80% vs 66% in non-breech infants) for mild ultrasound-detected instability, but this does not eliminate the need for screening. 4
For premature infants (born <37 weeks gestation), screening ultrasound timing does not need adjustment for gestational age—perform at 4-6 weeks chronological age, not corrected age. 5
Selective screening of high-risk infants (rather than universal screening) is the standard approach, as 84-95% of mildly abnormal hips normalize by 3 months without treatment. 1
Treatment Implications
Early detection through this screening protocol allows for non-invasive treatment with Pavlik harness, which has 91% success rates in infants under one year. 3
Delayed diagnosis beyond 6 months often necessitates surgical correction rather than simple bracing. 1
Untreated dysplasia leads to early degenerative joint disease and lifelong functional impairment. 3