Is a hip ultrasound recommended for a newborn baby born in a breech position to assess for potential hip dysplasia?

Hip Ultrasound for Breech Babies

Yes, hip ultrasound is strongly recommended for all newborns born in breech position—both males and females—to screen for developmental dysplasia of the hip (DDH), regardless of whether the physical examination is normal. 1

Who Needs Screening

• Female infants born breech require ultrasound screening as recommended by the American Academy of Pediatrics (AAP), given their significantly elevated risk for DDH 1
• Male infants born breech also require ultrasound screening according to AAP guidelines, despite lower overall risk compared to females 1
• Breech presentation is the single most important risk factor for hip dysplasia, with studies showing 27% of breech infants with clinically stable hips having abnormal ultrasounds at screening 2
• Normal physical examination does not eliminate the need for imaging in breech-born infants, as dysplasia can develop even with initially normal clinical findings 1, 3

Optimal Timing

• Schedule the ultrasound at 4-6 weeks of age (ideally around 6 weeks) as recommended by the AAP 1
• Do not perform ultrasound before 2 weeks of age due to high false-positive rates from physiologic hip laxity that often resolves spontaneously 1
• Ultrasound is the preferred imaging modality for infants under 4 months of age, as X-rays have limited value due to largely cartilaginous hip structures 1, 3

Critical Follow-Up Requirements

A single normal ultrasound at 6 weeks is insufficient to rule out DDH in breech infants. This is a crucial pitfall to avoid:

• 29% of breech infants with normal 6-week ultrasounds developed dysplasia requiring treatment by 4-6 months of age 2
• Obtain an AP pelvis radiograph at 4-6 months even if the initial ultrasound was normal, as radiographs become more reliable once sufficient ossification occurs 1, 2
• Continue routine hip physical examinations at all well-baby visits throughout the first year 1

What Constitutes Abnormal Findings

Look for these specific examination findings that warrant immediate orthopedic referral:

• Positive Ortolani test (relocatable hip) 1
• Positive Barlow test (dislocatable hip) 1
• Limited hip abduction (>10° asymmetry or symmetric abduction <60°) 2
• Asymmetric thigh folds in older infants 4
• Any hip instability or laxity on examination 1

Treatment Implications

• 84-95% of mildly abnormal hips (Graf type II) normalize by 3 months without treatment, which is why ultrasound timing matters 1
• Infants with abnormal ultrasounds at 6 weeks (approximately 27% of breech babies) require treatment, typically with Pavlik harness 2
• Delayed diagnosis beyond 6 months often requires surgical correction rather than non-invasive treatments, making early detection critical 1
• Overtreatment of physiologically immature hips can lead to avascular necrosis of the femoral head, so avoid treating before 2 weeks of age 3

Cost-Effectiveness Considerations

While some research suggests that universal ultrasound screening of all breech infants may lead to overdiagnosis 5, 6, the AAP guidelines prioritize early detection given that:

• Breech presentation carries the highest risk among all DDH risk factors 2, 7
• The consequences of missed diagnosis include early degenerative joint disease and lifelong disability 3, 4
• The risk of subsequent dysplasia is too high to discharge breech patients after clinical examination alone 2

Recommended Algorithm

1. Perform careful physical examination at birth by experienced examiner 1
2. Schedule hip ultrasound at 4-6 weeks of age for all breech-born infants 1
3. If ultrasound is normal: Obtain AP pelvis radiograph at 4-6 months to detect late-developing dysplasia 2
4. If ultrasound shows instability or dysplasia: Refer to pediatric orthopedics within 2-4 weeks for treatment 3
5. Continue clinical hip examinations at all well-baby visits throughout infancy 1, 4