# Developmental Dysplasia of the Hip Referral - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: AAP Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip 2016 - Verified date: 2026-08 ## Verified against - AAP Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip 2016 ## Treatment metadata - No drug therapy required (Urgent Orthopaedic Referral) ## Complete treatment card ```text DEVELOPMENTAL DYSPLASIA OF THE HIP REFERRAL Sources: AAP Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip 2016 Review status: REVIEWED against the source listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (1) - How it looks changes with age: mild instability and limited abduction in infancy, a limping gait in the toddler, hip pain in the teen years, and osteoarthritis in adulthood [groin pain · hip pain · limp] SIGNS - what you find (10) - The Barlow and Ortolani maneuvers can pick up hip instability or dislocation - On Ortolani testing a felt jerk or clunk signals a dislocated hip, whereas an isolated click without instability is not significant - During Barlow's maneuver, the examiner may feel a distinct clunk when the femoral head slips out of the socket - In experienced hands these maneuvers are 87 to 97 percent sensitive and 98 to 99 percent specific - Uneven hip position or an unequal number of gluteal skin folds can suggest dysplasia, though this is also a normal variant in 27 percent of unaffected infants - The Galeazzi sign compares apparent knee height with both hips and knees flexed and the feet flat on the table - In older infants, abduction under 75 degrees or adduction past 30 degrees beyond midline suggests dysplasia - A Trendelenburg limp, exaggerated lower-back curve, toe walking, uneven leg lengths, or early hip arthritis can also point to dysplasia once past the newborn period [limp] - On a dislocated hip the Klisic line runs from the trochanter and iliac spine down to below the navel instead of at or above it - After about 4 months the joint capsule tightens, so Barlow and Ortolani testing may no longer be positive and limited abduction becomes the key finding TESTS (12) - Screening protocols call for imaging the hip - sonography around six weeks old, or a plain film by four months old - in at-risk girls - Cross-sectional imaging is mainly used once the hip has already been reduced and placed in a cast, to check its position - Because the femoral head ossific nucleus usually only appears between 4 and 6 months, x-ray becomes the preferred study over ultrasound past that age - A normal hip x-ray at 4 months reliably rules out dysplasia even in an at-risk child - On ultrasound the key measurement is femoral head coverage by the socket of at least 50 percent, with an alpha angle over 60 degrees considered normal - The Graf alpha angle, between the bony socket and the ilium, is normally greater than 60 degrees - The Graf beta angle, between the labrum and the ilium, is normally under 55 degrees - On x-ray, the Hilgenreiner line should pass above the femoral head - The Perkin line should run lateral to the femoral head, which should sit medial to it - Any break in the smooth Shenton line arc from the femoral neck to the obturator foramen signals an abnormality - The acetabular index should read under 35 degrees at birth and under 25 degrees by age one - The Wiberg center-edge angle, reliable only after age 5, should measure over 20 degrees IF NOT THIS - what else fits (4) - Proximal femoral focal deficiency is another cause of leg length inequality - A femoral neck fracture is another cause of leg length inequality - Coxa vara is another cause of leg length inequality - A prior joint infection leaving residual damage is another cause of leg length inequality Source StatPearls "Developmental Dysplasia of the Hip" - disease-level clinical article Status traced to the source above 1. NO DRUG THERAPY REQUIRED (URGENT ORTHOPAEDIC REFERRAL) [1st line] Adult Urgent paediatric orthopaedic referral. Hip ultrasound under 6 months, X-ray over 6 months. No medicine treats this and none is needed. - Urgent referral Peds Urgent referral to pediatric orthopedics for hip ultrasound (if <6 months) or X-ray (if >6 months). No routine pharmacotherapy Source AAP Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip 2016 Why Structural orthopaedic condition requiring urgent specialist referral for harness bracing; routine pharmacotherapy is not indicated. Caution URGENT ORTHOPEDIC REFERRAL: Early diagnosis (<6 weeks) allows non-surgical treatment with Pavlik harness with >90% success. The screening maneuvers are Barlow (dislocates unstable hip) and Ortolani (reduces dislocated hip). The risk factors are female sex, breech presentation, family history of DDH, and swaddling with legs extended. 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