Hip Dysplasia (DDH)
Understanding Developmental Dysplasia of the Hip
Developmental dysplasia of the hip (DDH) is when the ball shaped part of the end of the thighbone and the socket do not fit correctly together. There are varying levels of hip dysplasia, from mild to severe.
If the ball (femoral head) is not held correctly in place, the socket (acetabulum) may be more shallow than usual. Sometimes this makes the joint less stable and the ball may slide in and out of the socket. This is called a dislocatable or ‘subluxatable’ hip. If the ball loses contact with the socket and stays outside the joint it is called a dislocated hip. One or both hips may be affected.
About 1 or 2 in every 1,000 babies has a hip problem needing treatment. In fact, many more babies (about 6%) will have immature hips that will get better without treatment. With DDH, the problem persists, needing early diagnosis to help reduce the severity and length of time needed for treatment.
For a guide to Baby Hip Development please download our BMA (British Medical Association) award winning FREE Baby Hip Health leaflet for more detailed information.
DDH can happen to any baby but some factors make the condition more likely.
The two most important risk factors are:
• a baby born by breech or who was in the breech position in the last three months of pregnancy
• a close family history of DDH or hip problems that came on in early childhood.
• DDH is more common in first pregnancies and in baby girls
In more than half of cases, however, there is no identified risk factor and the cause is unknown.
Things that could hinder normal hip development are; tight swaddling or spending long periods of time in car seats. Anything that pulls the hips straight or restricts their natural movement should be avoided.
How is DDH Detected?
ALL babies’ hips are checked at birth and at 6-8 weeks as part of a national screening programme called the Newborn Infant Physical Examination (NIPE). The baby’s hips are gently manipulated to see if they are correctly in joint by tests known as the Ortolani and Barlow Tests.
Even if the physical examination is normal NHS guidelines say that your baby’s hips will have an ultrasound examination within 6 weeks if the following applies:
• there is a history of early childhood hip problems in your family or
• your baby was in the breech position: around 36 weeks of pregnancy even if the baby turned for head first delivery.
• born before 36 weeks in a breech position.
• in a multiple birth, if any of the babies is in either of the groups above, every baby should have an ultrasound examination.
The physical examination is not 100% accurate as this only detects hip instability at the time of the examination. This means that some babies might appear to be normal at the tests but develop problems later or that DDH has not been picked up at the initial examination. As routine hip examinations finish after the 6-8 week check, family members are best placed to identify a problem.
Early diagnosis gives the best chance for effective treatment. The condition becomes more difficult to treat as child gets older and there is a risk of developing arthritis of the hip at a young age.
Possible signs of DDH include;
• Deep unequal creases in the buttocks or thighs
• When changing a nappy one leg does not seem to move outwards as fully as the other or both legs seem restricted
• The child drags a leg when crawling
• One leg looks longer than the other
• A limp (if one leg is affected) or a ‘waddle’ if both hips are affected
The child is unlikely to feel pain even if displaying these symptoms.
How is DDH Treated?
From birth to six months, babies with developmental dysplasia of the hip are usually fitted with a special fabric harness, the most common types being the Pavlik harness or the Van Rosen Splint. The type of harness will vary, depending the treating hospital. Studies have shown that the best time for this treatment is between the ages of 6 to 12 weeks. The harness needs to be worn for several weeks and in most cases this will correct the condition.
For more information about the Pavlik harness please download The Parents’ Guide to caring for a child in a Pavlik Harness.
Regular check-ups and ultrasound scans are necessary to check the fit of the harness and the progress of treatment.
For some children, when a splint has not worked or DDH is not diagnosed until after six months old, surgery may be required.
The BMA ‘Highly Commended’ Steps publication Hip Surgery and Spica Cast Care explains the different procedures that may be required and gives practical advice about life with a spica cast. The booklet also includes information about communicating with doctors, going into hospital, cast and wound care and practical hints and tips. Steps have also produced a guide to help parents and carers prepare themselves and their child for a hospital admission.
The accompanying DVD’s…
Offer helpful advice on day to day life in a spica cast. Further film clips on caring for an older child in hip spica can be found on our YouTube Channel.
Steps has compiled a list of items and equipment recommended by other DDH parents that may be useful when caring for a child in a hip spica cast.
DDH our story – keeping it in the family
When Eva was born, I was aware of Hip Dysplasia or Congenital Hip Dysplasia as it was known when I had my treatment and diagnosis, back in the 1980s. However, I wasn’t concerned about passing it on. I knew that my Dad’s cousin had had a daughter who had been in ‘froggy plaster’ as a child, just like I had, but who wasn’t as badly affected as me. I was aware it may be ‘in the family’. Still, I was shocked when, at 2 days old, Eva had her new born check and a simple ‘clunk’ during a routine manipulation changed our world.
Eva in her Van Rosen Splint
The lady doing the checks on Eva was a physio, so within what seemed like minutes, she was fitted with a little harness, not a Pavlik as in most cases, but a Van Rosen splint which does a very similar job. Things weren’t too bad with the harness. I struggled a little to breastfeed, given the new contraption and my painful caesarean scar, but I managed. Something at the back of my mind, however, told me that the 95% success rate of the harness wouldn’t apply to us.
I was finally diagnosed with hip dysplasia as a 14 month old, following months of my mum trying to convince doctors that something was not right with my legs. I underwent a closed reduction and spent a whole year in spica cast. Despite this, I soon learned to walk and all seemed normal, until I was 6 and my x rays showed that my hip was not forming properly and I would need further surgery. I had what I suspect was a Salter/ Pemberton osteotomy at the age of 7 and returned to spica, for 6 months.
Since then, I have gone on to swim competitively, race in triathlons, get my degree and PhD, perform environmental research in difficult terrain across Africa and have two children. Which brings me back to Eva; her DDH was bilateral (in both hips) and very severe, although Graph measurements and alpha angles were still a foreign language to me then. Her right hip progressed well in harness and she wore it for nearly 6 months, by which time, her left hip was still severely dysplastic and it was obvious an operation would be needed.
She had her open reduction in 2013, followed by 5 months in spica cast with a broomstick. It was tough, my relationship had broken down and I was left as a single mother, struggling to get out of the house and unable to afford the car seat I needed to go and access help from family an hour’s drive away. At that time, the Steps grant was not enough to cover the seat and I relied on local help to get the seat and other vital supplies to keep me going. Steps were there on the phone when I needed a chat and some reassurance. Eva was sweet natured and tolerant of the cast, although putting her under anaesthetic was a horrible experience, which she fought with terrified desperation every time. I will never forget the look of betrayal in her 7 month old eyes as I held the mask over her face and watched her go ‘under’.
The time flew and she came out of cast a week before her first birthday in August. She took her first steps on Christmas Eve, a cliché, but the best gift I could have hoped for. In May 2014, her sister Islay was born. Due to our family history, she was scanned at 6 weeks despite a clear new born check. Her hip dysplasia was picked up and she spent 12 weeks in a splint before being discharged from orthopaedic care, fully fixed.
Our story would have ended there but further yearly x rays showed Eva’s hip slowly growing, but sadly, not well enough. In March 2017, she had her latest and hopefully last surgery – a Salter osteotomy at the age of 4 and 6 weeks in spica cast. It was tougher in some ways, but easier in others. I knew what to expect. I knew it would soon be over and I knew how to prepare her and explain what was going on. She literally skipped into theatre and held her own mask this time, joking about unicorns until she passed out.
Getting ready for surgery
Eva Following a Salter osteotomy
Eva is out of cast now and walked as soon as it was removed. The following day, I took her to the hospital park and she climbed the climbing frame. The physios had to stop her jumping on the bed so she could have her first session. Less than a week after cast removal, she entered her school sports day; walking the races, holding her teacher’s hand and getting cheered on by her friends. The prognosis is good, her hip is well shaped and functioning. It Is unlikely she will need any more surgery, but if she does, she will cope and so will I.
Both girls, happy and healthy following DDH treatment
My hip is also bearing up well. A recent arthrogram (an MRI scan with dye in the joint to see a more accurate picture) shows a good amount of cartilage and a well rounded femoral head. I get pain, especially at night, but it is manageable. I can’t run any more, but I have learnt to row and my team are currently first in the North England Rowing Sunday league. Some people will be comforted by this story, others horrified but the research all shows that 95% of DDH cases, picked up early, can be treated successfully in a splint or harness. A few may need further surgery, but the overwhelming majority will only need a small operation and not the major surgery myself and my eldest daughter faced. We are currently participants in a research study into the genetics and inheritability of DDH and hope the study will help understanding and improve diagnosis and treatment of the condition.
My experience with Steps led me to apply for a job with the organisation and nearly 2 years later, I am still here; writing publications on familiar subjects, such as spica casts and getting your child ready for surgery and not so familiar topics, such as leg length difference, rare bone growth disorders, clubfoot and a guide for families facing amputation. I am supported by a fantastic medical board, who guide me on all my publications and by the wonderful relationship I have with NHS orthopaedic consultants, physiotherapists and many more specialist nurses and practitioners who make the high quality of the work we do possible.