How to Recognize Hip Dysplasia
Hip dysplasia recognition depends critically on the patient's age, with specific physical examination maneuvers and clinical signs varying from infancy through adulthood.
Recognition in Newborns and Infants (Birth to 3 Months)
The Ortolani and Barlow maneuvers are the most reliable diagnostic tools during the first 3 months of life 1, 2.
- Ortolani test: Detects a dislocated hip that can be reduced back into the acetabulum with hip abduction 1, 3
- Barlow test: Identifies a hip that can be dislocated posteriorly out of the acetabulum with adduction and posterior pressure 1, 3
- These provocative maneuvers are highly specific but have poor sensitivity compared to ultrasound, meaning a negative exam does not rule out dysplasia 4
Important caveat: 60-80% of abnormalities identified by physical examination and >90% identified by ultrasound spontaneously normalize at follow-up, so not all early findings represent true pathology 1.
Recognition in Older Infants (3+ Months)
After 3 months of age, limitation of hip abduction becomes the single most important clinical finding 2, 3.
- The Ortolani and Barlow maneuvers lose sensitivity after 3 months as the hip becomes more stable 2
- Limited hip abduction (inability to abduct the hip to 75-80 degrees with the hip flexed to 90 degrees) is the key finding 1, 2
- Asymmetric skin folds in the gluteal and thigh regions suggest unilateral dysplasia 1, 2
- Leg length discrepancy with shortening of the affected side (Galeazzi sign when hips and knees are flexed) 1, 5
- Wide perineum may be observed in bilateral hip dislocation 2
Recognition in Adolescents and Young Adults
Adolescents and young adults typically present with insidious onset hip pain rather than physical examination findings 6.
- Pain location: Most commonly in the groin or lateral hip in a C-shaped distribution around the inguinal crease 6
- Delayed diagnosis is common: Patients typically see multiple providers and have prolonged pain before accurate diagnosis 6
- Physical examination: May show limited hip abduction and internal rotation 6
- Radiographic evaluation is essential for diagnosis in this age group, as clinical examination alone is insufficient 6
Recognition in Adults
Adults with untreated hip dysplasia present with early degenerative joint disease and hip pain 7.
- Untreated subluxation and dislocation inevitably lead to early degenerative joint disease 7, 1
- DDH causes up to one-third of all total hip arthroplasties in patients under 60 years old 7, 1
- Preoperative radiographic evaluation should assess degree of acetabular dysplasia, subluxation/dislocation, degenerative changes, and limb length discrepancy 7
High-Risk Populations Requiring Heightened Surveillance
Female gender is the single strongest risk factor with a relative risk of 5.36 4.
Additional risk factors include:
- Breech presentation (relative risk 3.8) 1, 4
- Positive family history (relative risk 2.35) 1, 4
- Left hip involvement (3 times more common than right) 1
- Oligohydramnios (relative risk 1.75) 4
- Firstborn status 1, 5
- Skeletal pathologies (relative risk 2.04) 4
Screening Algorithm
All newborns should undergo hip screening physical examination at every well-baby visit (2 weeks, 2 months, 4 months, 6 months, 9 months, and 1 year) 1, 3.
- Selective ultrasound screening (not universal) should be performed after 2 weeks of age for infants with risk factors or inconclusive physical examination findings 1
- Ultrasound is preferred for infants under 4-6 months of age 1, 3
- Radiographs become more reliable after 4-6 months when ossification centers develop 1, 3
Critical pitfall: A normal neonatal screening examination does not guarantee normal hip development, as dysplasia can develop later 1, 3. This is why repeated examinations throughout the first year are essential.