What is Development Dysplasia of the Hip (DDH)? #illumedati 2


Hi guys, it’s Medicine Mondays, and most of my posts recently have been focused on the post-match preparation for internship. Today, I’m going to switch gears for a second to talk about Development Dysplasia of the Hip (DDH). This was previously known as “Congenital Dislocation of the Hip” but that name has now fallen out of favor because it is a misnomer. So then, What is Development Dysplasia of the Hip (DDH)?

Stock Photo from: Pixabay

What is Developmental Dysplasia of the Hip (DDH)?

For those of you in medical field, you’ve probably heard about this under its old name “Congenital Dislocation of the Hip”, which is a misnomer. This particular disease entity while usually has signs present at birth, is actually primarily developmental in etiology.

DDH is the reason that the Barlow and Ortolani maneuvers are performed on all neonates and infants. In patients with DDH, the Barlow maneuver will dislocate the hip and then the Ortolani maneuver will relocate them with a usually audible “thunk” or a “clunk” sensation.

Quick trivia, Ortolani developed his maneuver in 1937 and Barlow tested his maneuver between 1957–1962.


Why are we talking about this today?

Well, this is a case of slight role reversal.

My wife and I are both physicians. While we were doing our fellowships in Baltimore, MD, my daughter was born in May (she turns 4 this month).  She was born healthy, but her hips were both dislocated at birth. This finding was very suggestive of Developmental Dysplasia of the Hip.

As first time parents (and physicians) we were of course very concerned, so you can imagine that I researched the crap out what it was. Even as a physician, it was difficult to find enough information to reassure me that “she was going to be ok.”

For this reason, I wanted to dedicate a post to this particular entity and try my best to explain it. I hope that I am able to reassure parents about what to expect.


Diagnosis

The diagnosis of DDH can be difficult sometimes. In my particular case, my daughter’s hips were dislocated at birth, so it wasn’t too difficult. She had the classic positive Barlow and Ortolani maneuvers as well. However, for some, the hips may only sublux and not completely dislocate, or be very mild. This is why the Barlow and Ortolani maneuvers are so important, and is an essential part of every single clinical examination in the neonate/infant stage.

Risk factors for DDH include:

First-born, female, family history, breech presentation, oligohydramnios

In my daughter’s case, she had all of those risk factors, except for oligohydramnios.

Other things to check for:

  • Different leg length
  • Uneven  thigh skin folds
  • Unilateral decreased mobility or flexibility
  • Gait disturbances including: limping, toe walking, or a waddling, duck-like gait

Confirmation

Diagnosis is usually confirmed with ultrasound in the neonate/infant stage. X-ray may be also used in children who develop signs slightly later in life.

Ultrasound is the preferred method and established criteria have been created. For those interested, there is a good article about normal measurements – Ultrasoundpaedia. I think talking about the alpha and beta angles here is outside the scope of this article. However, I may do a short follow-up post about it so parents can understand what the report means.


Treatment

Depending on the age of the patient, treatment varies. The main stay of treatment when diagnosed early is the Pavilk harness.

[Click link above or the picture itself for their video]


What does it do?

Much of this information is in the link above. However, the long and short of it is that it keeps the hips in their normal location. This allows the hip joint to grow normally. Remember, like I said above, it’s a Developmental Dysplasia. Babies are kept in this harness for 6-12 weeks for 24 hours a day, with only minimal time outside the harness for bathing. This allows the hips to develop normally. After this period, and depending on your physician, usually the time period becomes “at night” for another 4-6 weeks. There will be slight differences based on physician preference.

That’s all well and good from a medical standpoint and of course I understand most of all that anyways.

However, let’s approach it from a parent’s point of view now with my own answers.


Is it my fault? Did I do something to make this happen?

No. And… No.

DDH is a multifactorial disease and is developmental. It’s definitely not your fault.

It’s actually not an uncommon entity. However, because of the Pavlik harness and early diagnosis, most parents will never have heard of this entity before. If you met my daughter, you would never know she had DDH as kid with her running and jumping everywhere.

Is this uncomfortable for my baby?

It may look uncomfortable and all those pictures all over the internet don’t really help ease your fears.

However, in my experience, it’s not uncomfortable for the baby at all. To be honest, it may even be somewhat comforting for them. (see pictures below)

How do I change diapers?

While it may seem kind of awkward, you can change diapers with the Pavilk harness still on.

You should only ever need to undo the vertically oriented front straps. The first few times it’s a little difficult, but you’ll get the hang of it.

Luckily, there is a great video on at hipdysplasia.org called Pavlik Harness Tips.

Sometimes a strap may come undone, or the velcro may stop sticking or slip a little. I was a little concerned about this so I marked the where the straps velcro’d. Then, whenever my orthopedic surgeon adjusted the straps, I would mark the straps changes with a permanent marker, with a different color for each adjustment. This way, I always knew that the straps were exactly where they were supposed to be.

I did this at our first follow-up appointment with our orthopedic surgeon, and he thought it was a great idea.

How do I bathe my baby?

Neonates don’t get out much, so they probably don’t need to be bathed everyday anyways. However, for baths they will need to come out of the Pavlik harness completely. After bathed and dried, they should go right back in their harness though. Once again, it helps to have the front straps marked, like I said above to make sure the hips are in the appropriate position.

How do I clean the harness?

First things first. Do not take the harness off the baby.

Clean it by dampening it with plain water then applying some detergent and scrubbing with an old toothbrush.

However, accidents can happen. For this reason,you may want to consider buying a second harness and having your orthopedic surgeon adjust and reapply that one at the next visit.

Is my baby going to be ok?

I’m not your orthopedic surgeon and don’t know how your baby presented.

However, in general, babies that are diagnosed with DDH early on and are placed in a Pavlik harness early do very well. Like I said above, it’s a developmental dysplasia. If you give the hips a chance to develop normally, they’ll do pretty well.

Can my baby wear normal clothes?

Of course he/she can! However, it may not look exactly the way you want…

For example, my daughter has a bunch of tiny little dresses during her neonatal period. She was in a Pavlik harness from her 3rd day of birth. The harness might make the dresses or other cute outfits seem more bulky than you imagined. However, once she moved on to just wearing the harness part-time, then we were able to dress her up in whatever we wanted during the day. She just wore her normal jammies at night with the Pavlik harness.

What do I tell everyone?

Pavlik harnesses are readily visible to anyone who meets your baby, especially in the first few months when they are in the harness 24/7. It’s best to just come up with a short, rehearsed phrase about what it is.

Perhaps something like this:

“My baby is in a Pavlik harness to make sure her hip joints grow correctly.”

Can my baby still go to daycare?

This may vary depending on how comfortable daycare is. However, there shouldn’t be a problem as long as you teach them how to change baby’s diapers correctly and handle the harness correctly.


Follow-up

Follow-up after initially being placed in a Pavlik harness will occur every two weeks or so. After the timeline above of full-time wear, part-time wear, and then bed-time only wear, the Pavlik harness will eventually be stopped. After this follow-up X-rays are performed at around 9 and 12 months. If these x-rays demonstrate normal development of the hip socket then there is really no reason for further follow-up. However, in some instances your orthopedic surgeon may want follow-up x-rays annually.


What are the other treatments?

The other treatments are mostly for patients that are diagnosed later than 6 months. I don’t have personal experience with these treatment options myself, but I will list them here for completeness.

From 6 months to 2 years of age, the first option is closed reduction with spica cast. If this fails, then the next option is an open reduction with a spica cast.

For children older than 2, they will usually require various surgeries including pelvic and femoral osteotomies. Osteo = bone and otomy = hole, so an osteotomy is where the surgeon creates holes in the bone, for the purposes of reshaping. For more information, go to Osteotomy – hipdysplasia.org.


I hope my little blog post helps new parents get some reassurance and a better grasp of what to expect.

Here are a few pictures of my daughter when she was little:

[Click Images to Enlarge]

3 days old – No Harness yet

5 days old – Harness On

Sensei’s note: The harness is over her jammies here. In hindsight, it should have been underneath. You are allowed to have the harness on over “light clothing”, however, it is probably preferable to have it on the skin (or underneath thin knee high socks) to prevent any excess motion.

7 days old – Harness On

However, this time, the harness is better positioned underneath the thicker jammies.

1 Month Old – Harness On (under dress)

Like I said above, your baby can still wear all those cute clothes, but they may seem a little “bulky” because of the harness underneath.

2 Months Old – Harness On with just a onesie (it’s July, so it’s hot)

Here the harness is on underneath the thin clothes. Also, she has little leggings we made for her underneath the leg straps because they would rub sometimes.

You can also see the color from permanent markers on the straps from prior adjustments.

And here she is today:

Here’s a recent post of her going down a waterslide.

Like I said, you’d never know she had DDH as a baby unless I told you. We can thank early diagnosis and the Pavlik harness for that.


TL;DR

Developmental Dysplasia of the Hip (DDH) is a developmental disorder, not congenital.

Congenital Dislocation of the Hip is a misnomer (and shouldn’t be used anymore).

This disorder is not uncommon, but with the advent of the Pavlik harness and early diagnosis, its effects are seldom seen.

Above I tried to go over questions parents may have after the initial diagnosis.

 

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

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