Clinical Review

Five-Day-Old Infant With Hip "Clunk"

Clinician Reviews. 2010 April;20(4):24-27

References

1. Karmazyn BK, Gunderman RB, Coley BD, et al; American College of Radiology. ACR appropriateness criteria on developmental dysplasia of the hip—child. J Am Coll Radiol. 2009;6(8):551-557.

2. American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. Clinical practice guideline: early detection of developmental dysplasia of the hip. Pediatrics. 2000;105(4 pt 1):896-905.

3. Mencio GA. Developmental dysplasia of the hip. In: Sponseller PD, ed. Orthopaedic Knowledge Update: Pediatrics–2. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2002:161-171.

4. Children’s Hospital at Westmead. Developmental dysplasia of the hip (DDH). www.chw.edu.au/parents/factsheets/developj.htm. Accessed March 26, 2010.

5. Graf R. Classification of hip joint dysplasia by means of sonography. Arch Orthop Trauma Surg. 1984; 102:248-255.

6. Weinstein SL. Developmental hip dysplasia and dislocation. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopaedics. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:905-956.

7. Aronsson DD, Goldberg MJ, Kling TF Jr, Roy DR. Developmental dysplasia of the hip. Pediatrics. 1994; 94(2 pt 1):201-208.

8. Guille JT, Pizzutillo PD, MacEwan GD. Developmental dysplasia of the hip from birth to six months. J Am Acad Orthop Surg. 2000;8(4):232-242.

9. Hart ES, Albright MB, Rebello GN, Grottkau BE. Developmental dysplasia of the hip: nursing implications and anticipatory guidelines for parents. Orthop Nurs. 2006;25(2):100-109.

10. Dogruel H, Atalar H, Yavus OY, Sayli U. Clinical examination versus ultrasonography in detecting developmental dysplasia of the hip. Int Orthop. 2008; 32(3):415-419.

11. Mahan ST, Katz JN, Kim YJ. To screen or not to screen? A decision analysis of the utility of screening for developmental dysplasia of the hip. J Bone Joint Surg Am. 2009;91(7);1705-1719.

12. Storer SK, Skaggs DL. Developmental dysplasia of the hip. Am Fam Physician. 2006;74(8):1310-1316.

13. Ortolani M. Congenital hip dysplasia in the light of early and very early diagnosis. Clin Orthop Relat Res. 1976;119(1):6-10.

14. Barlow TG. Congenital dislocation of the hip in the newborn. Proc R Soc Med. 1966;59(11 part 1):1103-1106.

15. Bond CD, Hennrikus WL, DellaMaggiore ED. Prospective evaluation of newborn soft-tissue “clicks” with ultrasound. J Pediatr Orthop. 1997;17(2):199-201.

16. Atalar H, Sayli U, Yavuz OY, et al. Indicators of successful use of the Pavlik harness in infants with developmental dysplasia of the hip. Int Orthop. 2007; 31(2):145-150.

17. Rampal V, Sabourin M, Erdeneshoo E, et al. Closed reduction with traction for developmental dysplasia of the hip in children aged between one and five years. J Bone Joint Surg Br. 2008;90-B(7):858-863.

18. Clarke NMP, Sakthivel K. The diagnosis and management of congenital dislocation of the hip. Paediatr Child Health. 2008;18(6):268-271.

19. Hassan FA. Compliance of parents with regard to Pavlik harness treatment in developmental dysplasia of the hip. J Pediatr Orthop. 2009;18(3):111-115.

Patient/Family Education
The Pavlik harness is most effective when a consistent support system exists to educate parents about the importance of the harness, its care and maintenance, and the consequences of failure. Close monitoring of the infant’s progress is also essential to promoting adherence. Application and removal of the harness should be demonstrated to the parent or caregiver, as well as diapering, dressing, and undressing the infant; they should then be encouraged to practice immediately in the clinic or office.

During visits for harness adjustment, the strap position should be marked with indelible ink, allowing parents to reapply the device correctly, should removal be required (eg, for bathing).⁹ Ten percent of parents reportedly find reapplying the harness difficult during the first weeks of use. Difficulty in dressing and carrying an infant in a harness, feet slipping out of the harness, and skin irritation have been reported by about one-third of parents.¹⁹

Treatment adherence and subsequent success with the Pavlik harness is reported greatest (95%) in patients whose parents engage in demonstrations of harness use and follow instructions precisely.¹⁹ By providing a contact name and office number and following up with a phone call a few days after the harness is first applied, clinicians can significantly decrease parents’ anxiety and increase overall compliance.⁹

Conclusion
Despite recent increased awareness of DDH and the importance of thorough screening programs, hip dysplasia continues to be a frequently missed diagnosis in pediatrics. It is often up to the primary care clinician to screen for, assess, and potentially diagnose DDH. Therefore, a thorough understanding of this condition can promote early detection and diagnosis, with less invasive treatment and a more favorable outcome.

A proper hip examination should be a standard component of all newborn and infant well-child examinations. If DDH is suspected, appropriate referral to a pediatric orthopedic surgeon must be made so that timely treatment can be initiated. Early use of the Pavlik harness is significantly easier than the invasive surgery and prolonged immobilization necessitated by a delayed diagnosis. Whatever the course of treatment required, it is important for clinicians to support the patient and family: training and anticipatory guidance are essential components of DDH management.