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Developmental dysplasia of the hip (DDH)

    • What is developmental dysplasia of the hip (DDH)?

      Hip dysplasia

      Developmental dysplasia of the hip (DDH), formerly known as congenital dislocation of the hip, is a condition where the hip joint is not properly formed in babies and young children.

      The hip joint connects the thigh bone (femur) to the pelvis. The top of the thigh bone is rounded like a ball, and sits inside the cup-shaped hip socket hence the hip joint is known as a ball-and-socket joint.

      In babies and children with DDH, the hip socket is too shallow. As a result, the top of the thigh bone is not securely held and may slip out or dislocate. DDH is more likely to occur in the left hip (due to the position of the foetus in the mother’s womb) but in some patients both hips may be affected.

      Early diagnosis and treatment can help to prevent joint complications that may result in difficulty walking. Left untreated, DDH will result in pain, and a higher likelihood of developing osteoarthritis of the hip which can lead to a knock-on effect on the spine. In some cases, DDH may require surgical intervention.

      Types of DDH

      DDH can vary, ranging from mild to severe, and may be categorised as:

      • Subluxable, in which the head of the thigh bone is loose within the hip socket but has not dislocated.
      • Dislocatable, where the head of the thigh bone sits within the hip socket but is easily pushed out during a physical examination.
      • Dislocated, in which the head of the thigh bone is completely out of the hip socket.
    • It is unclear what causes DDH, however it is known to be more common among:

      • Girls, due to circulating female hormones produced by the foetus, bringing about the ligamentous laxity
      • First-born children
      • Babies who were in breech position before birth (with the head pointing upwards instead of downwards)
      • Family history
      • Oligohydramnios (low levels of amniotic fluid)

      To help detect DDH early, some experts recommend ultrasound screening for all female babies who were in breech position.

    • Common signs of DDH in babies include:

      • Legs that are of different lengths
      • Uneven folds or creases of skin on the thigh or near the buttocks
      • Abnormal leg movement

      Among older children, signs may include:

      • Delayed ability to sit or walk
      • Impaired or reduced mobility or flexibility on one side
      • Leaning to one side while standing or walking
      • Limping or waddling while walking
      • Walking on toes
    • Hip dysplasia prevention massage

      Newborn babies who are considered as being at high risk for DDH may be checked using ultrasound, while older infants and young children may have their hips X-rayed. This will allow the doctor to clearly see if the child has DDH.

      The doctor will need to perform a hip examination to check for abnormalities in the range and movement of the hip in question. In newborns, some specific tests may be performed to ascertain this.

    • Treatment for DDH varies, and includes non-surgical and surgical options. The treatment, if detected early, may take months, and follow-up monitoring is recommended as the child grows.

      Non-surgical Treatment

      Non-surgical options such as a harness or brace can be instituted when DDH is detected early and reducible.

      Newborns

      For newborns, a brace known as a Pavlik harness is used to keep the thighbone in its correct position within the hip socket. This allows the joint to mould around the femoral head. The harness must be used under the advisement of a trained doctor with frequent monitoring. In the meantime, parents will be taught how to manage daily activities such as cleaning, changing of diapers and feeding while the baby is wearing the harness.

      Older than 6 months

      For children who are older than 6 months, or in those whom the use of the harness has failed, a closed reduction and cast may be required. In a closed reduction, the baby’s thigh bone is gently moved into its proper position while the child is under anaesthetic, and a cast (also known as a spica cast) is applied to hold the bones in place. Parents will be taught how to perform the usual tasks of baby care while maintaining the integrity of the cast.

      6 months - 18 months

      Closed reduction with a body cast is also used to treat DDH in older children. However, they may need to undergo a procedure known as skin traction in which the soft tissues are stretched in preparation for the bones to be positioned.

      Surgical Treatment

      If a closed reduction is not successful in correcting the DDH, surgery may be advised. There are different types of surgical procedures depending on the age of the patient and the severity of the condition. These range from Open Surgical reduction and casting to procedures which require osteotomy (making cuts in the bone) in order to alter the bony architecture.

    • Cases in which the diagnosis is delayed or left untreated can lead to complications such as pain, difficulty walking and the eventual onset of osteoarthritis or damage to the soft cartilage surrounding the hip joint socket (hip labral tear).

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