Developmental Dysplasia of the Hip

Topic Overview

What is developmental dysplasia of the hip (DDH)?

Developmental dysplasia of the hip (DDH) is the name for a range of conditions of the hip. In mild cases, the ligaments and other soft tissues around the hip joint are not tight, and they allow the thighbone (femur) to move around more than normal in the hip socket. In more severe cases, the joint is loose enough to let the thighbone come partway out of the hip socket. This is called subluxation. Actual "dysplasia" is the most severe form of the condition. If a child has hip dysplasia, the socket is too shallow, more like a saucer than the deep cup that it should be. This allows the ball at the top of the thighbone (femoral head) to either partly or fully slip out of the socket (dislocate). DDH can affect one or both hip joints.

See pictures of normal hip anatomy in a child and a dislocated hip .

What causes DDH?

The exact cause of DDH is not known. But a number of risk factors can raise your child's chances of having DDH, including a family history of DDH and your baby's position in the womb and at birth.

What are the symptoms?

A baby with DDH may have:

• A hip joint that feels loose or slips out of place when examined.
• One leg that appears to be shorter than the other.
• Extra folds of skin on the inside of the thigh(s).
• A hip joint that moves differently than the other.

A child who is walking may:

• Walk on the toes of one foot with the heel up off the floor. The child walks this way because one leg is shorter than the other.
• Walk with a limp (or waddling gait if both hips are affected).

How is DDH diagnosed?

Usually, DDH is diagnosed during your newborn's physical examination. If your baby is older, DDH may be diagnosed during a well-baby checkup. But it may be more difficult to diagnose the condition in a baby older than 1 to 3 months, because the only outward sign may be less mobility or flexibility in the movement of the affected hip joint(s).

If the results of a physical examination are unclear, an imaging test such as an ultrasound or X-rays may be used to evaluate your child's hip joints.

How is it treated?

DDH is treated by moving your baby's upper thighbone into the hip socket and keeping it in place while the joint grows. A harness, called a Pavlik harness , is most often used to keep the joint in place in babies younger than 6 months. A hard cast, known as a spica cast , is used for older babies. Other forms of treatment, such as surgery or a brace, also may be needed.

Most children born with looseness (laxity) of the hips will not have problems. But a child will not outgrow severe DDH in which the hip sockets are too shallow. The condition requires treatment from a doctor to prevent possible permanent disability. You should not try to treat DDH on your own, such as by diapering a baby with 3 or 4 diapers at a time or by trying to put your baby's legs in certain positions. These are not effective treatments for DDH and may cause the joint to develop abnormally.

Frequently Asked Questions

Health Tools

Health Tools help you make wise health decisions or take action to improve your health.

	Actionsets are designed to help people take an active role in managing a health condition.
	Hip dysplasia: Caring for your child in a body (spica) cast

Symptoms

The signs of developmental dysplasia of the hip (DDH) vary depending on whether one or both hips are affected.

A newborn or infant with DDH may have:

• No obvious signs of a defect.
• Extra folds of skin on the inside of the thigh(s). But a newborn without this condition also may have these extra folds.
• Less mobility or flexibility in the movement of the hip joint(s).
• One leg that seems shorter than the other.
• Other physical deformities, especially of the feet.

In rare cases, DDH develops in the first few weeks or months after birth and signs may not be seen until your child starts to walk. Then your child may:

• Stand with one hip raised higher than the other because one leg is shorter than the other. The shorter leg is on the affected side. It seems shorter if the upper end of the thighbone has slipped up above its normal position in the hip socket.
• Walk on the toes of one foot with the heel up off the floor, attempting to make up for the difference in leg length.
• Walk with a limp (or a waddling gait if both hips are affected).
• Stand with a greater-than-normal inward curve (lordosis) of the lower back (lumbar area) if both hips are affected.

Children with untreated DDH may develop permanent deformities in their hips. Untreated DDH can also lead to hip joint degeneration, which is a sort of early "wearing out" of the socket. When the degeneration occurs in the cartilage that protects and cushions joints, it is known as osteoarthritis. Eventually the bones, which had been separated by the cartilage, rub against each other. This rubbing damages tissue and bone, and causes pain.

Exams and Tests

Developmental dysplasia of the hip (DDH) is usually diagnosed by a physical examination. A medical history and other tests also may be useful in diagnosing DDH.

All babies are examined for DDH at birth. Newborns who have risk factors for DDH, such as having foot, knee, or leg deformities, are examined very closely for the condition.

If a newborn's thighbone (femur) feels loose, the health professional usually will apply a Pavlik harness to hold the bone in place.

Your child's hips are also examined during regular well-child checkups. But a baby with DDH who is older than 1 to 3 months may have fewer visible signs, making it more difficult to detect. These babies may have only slightly less mobility or flexibility of the affected hip joint(s).

Imaging tests to diagnose DDH

Tests that show images of the hip joint are often done to help diagnose DDH if results from physical examinations are unclear. These tests are also used to monitor treatments for DDH.

Imaging tests used to diagnose and monitor DDH include:

• Ultrasound of the hip. This test provides the clearest images in babies younger than 5 months when the hip joints are still made of cartilage. Ultrasound can provide images to help a doctor identify the subtle signs of DDH that often aren't detected during a physical examination.
• Hip X-rays. These tests are most useful after a child is 4 to 6 months old. Before this age, a baby's bones are too soft to show up well on an X-ray.
• CT scans. These tests are mostly used to help doctors monitor treatment for DDH.

An orthopedic surgeon or a pediatric orthopedist usually confirms a diagnosis of and provides treatment for DDH. Your health professional will refer you to one of these specialists if he or she suspects your child has DDH.

Treatment Overview

Treatment for developmental dysplasia of the hip (DDH) focuses on moving your child's upper thighbone (femur) into its normal position and keeping it in place while the joint grows. The hip socket will not form and grow properly if the ball at the top of the thighbone (femoral head) does not fit snugly in the joint.

• Sometimes in babies with signs of DDH the thighbone and hip socket start to grow as they normally would, without treatment. But it is hard to predict whether this will happen.
• Hips that are fully dislocated or that can be dislocated easily by certain movements are usually treated as soon as they are detected.

Treatment for DDH usually includes one of the following:

• Pavlik harness. This device usually is tried first if your baby is younger than 6 months. The harness has fabric straps and fasteners that fit around your baby's chest, shoulders, and legs. The harness holds the baby's legs in a spread position, with the hips bent so that the thighs are out to the sides. Your doctor monitors the harness's effectiveness through regular examinations and imaging tests. The Pavlik harness successfully makes the hip normal about 90% of the time. But if your doctor doesn't see improvement in the hip after about 3 to 4 weeks, the harness is removed and other treatment options are explored.¹ See a picture of a Pavlik harness .
• Spica cast. This cast is made of plaster or fiberglass to form a hard covering over the waist, hips, and legs. To make it stronger, the cast may have a bar between the legs. See a picture of a spica cast with a bar and a photograph of a spica cast without a bar .

Other forms of treatment

• Braces and splints. Your child may wear a brace or splint as a first treatment for DDH instead of a Pavlik harness or spica cast. In some cases, a brace or splint follows another type of initial treatment, such as surgery. In these cases, the device is used to help support the hips and legs as they heal. In particular, children with DDH who also have other problems with their feet or knees may benefit from wearing a brace.
• Surgery. An osteotomy is surgery to correct a deformed thighbone or hip socket. This procedure repositions the thighbone, usually after cleaning the socket of fat deposits. If needed, surgery may include reshaping the socket or thighbone. After surgery, your child probably will need to wear a spica cast to position the hip joint until it completely heals.
• Physical therapy. An older child may need physical therapy exercises to restore movement of the legs and strengthen muscles after being in a spica cast.
• Traction. A very rarely used treatment for DDH, traction involves weights, pulleys, and ropes to gradually stretch and loosen the hip joint's muscles and tissues while holding the bones in their correct position. This allows doctors to place the ball at the top of the thighbone (femoral head) back into the hip socket. Traction may also help prevent problems with the blood supply to the joint. Typically, traction takes about 2 to 4 weeks. The treatment can be set up in a hospital or at home. Afterward, your child will probably wear a spica cast.

What to think about

If your child has had successful treatment for DDH, he or she will likely not have any further hip problems. But have your child examined regularly to make sure his or her hips continue to grow and develop normally.

The longer an unstable, dislocatable, or dislocated hip persists, the more likely it is to cause long-term problems that are difficult to treat. For this reason, it is important to diagnose and treat DDH early.

Follow-up medical checkups are very important for monitoring the effectiveness of treatment and preventing complications. For example, damage sometimes occurs to the blood supply of the femoral head from treatment. If not detected and treated early, this damage can lead to the destruction of bone cells (avascular osteonecrosis). The bone may then grow abnormally, become deformed, and later develop osteoarthritis.

Home Treatment

Basic home treatment for developmental dysplasia of the hip (DDH) focuses on interacting with your child and keeping him or her comfortable.

If your baby or child is wearing a harness, brace, or cast:

• Talk to your doctor about how to care for the device.
• Check your child's skin around the edges of the device for red areas or blisters. If you find any, contact your doctor for treatment.
• Don't put anything inside the device that might scratch or irritate your child's skin, which can lead to an infection. Also, don't apply ointments or creams to your child's skin without talking to your doctor first.
• Play with and hold your child as usual. In most cases, you should be able to interact with your child normally. You will have to adjust some activities, but keeping him or her stimulated and engaged is important. Simple measures, such as moving your child around to different places in your home throughout the day, can help. Also, keep a variety of toys within his or her reach.
• Take your child for short trips outside the home. He or she can still be safely placed in a carrier, stroller, or car seat. Depending on your child's leg positions, he or she may need a specially designed car seat. Ask your doctor about where to buy or rent one. Usually they are available through hospitals or medical supply houses.

Other home treatment depends on the precise medical intervention used.

Pavlik harness care

Do not remove the harness and do not adjust the straps for the first 3 to 4 weeks of treatment unless your doctor tells you to. The harness holds the joint in the correct position for normal development. Removing the harness may cause the thighbone to move out of position. Later in your child's treatment, the harness may be removed for short periods of time, such as for bathing or for cleaning the harness.

You can put your child's clothing on under the straps to prevent skin irritation. You can also pad the shoulder straps if needed.

Spica cast care

If the cast is made of plaster, turn your child at least every 2 hours for the first 24 to 48 hours to prevent uneven drying of the cast. Although you can use a fan to help the cast dry more quickly, don't use heat because the outside will dry before the inside and may burn your child. When you tap the cast and hear a hollow sound, it is dry.

While your child is in a spica cast :

• Tuck the baby's diaper inside the cast beginning at the child's rear and moving toward the front. Use a smaller size than you would normally and use only disposable diapers. Cut the adhesive tabs off the diaper so that they won't irritate your child's skin. Change the diaper as soon as possible after your child urinates or has a bowel movement. At night, add an extra smaller diaper, sanitary napkin, or adult incontinence pad inside the diaper.
• Place your child's clothing over the cast to prevent food or small toys from getting inside the cast.
• Don't move or lift your child by the bar between the legs.

Hip dysplasia: Caring for a child in a body (spica) cast

Traction care

• Make sure the weights are hanging freely.
• Check underneath your child for small toys or bits of food. These can irritate his or her skin.
• Bathe your child once a day.
• Find activities your child can safely do. For example, read to your child or play card games if your child is old enough. If your child is still a baby, you can help keep him or her calm and distracted during traction. Try talking, reading, and singing to keep the baby's attention. Touching and stroking the baby will also help.

Parental feelings and concerns

DDH is a defect in growth and development that is beyond your control. Remind yourself that you did not do anything to cause this condition. Understand that it takes time to manage the frequently shifting emotions that are common when your child is diagnosed with DDH. Also, it is important to have or to find a health professional with whom you feel comfortable talking about any concerns you may have.

Caring for a child with DDH is stressful for parents. Take time to care for yourself to reduce stress and to stay healthy. When you have the energy to function well, you are able to provide the best care for your child.

Other Places To Get Help

Organizations

Related Information

• Early Disease Detection
• Growth and Development, Ages 1 to 12 Months
• Growth and Development, Newborn
• Hip Problems, Age 11 and Younger
• Osteoarthritis

References

Citations

1. Rab GT (2006). Developmental dysplasia of the hip section of Pediatric orthopedic surgery. In HB Skinner, ed., Current Diagnosis and Treatment in Orthopedics, 4th ed., pp. 603-608. New York: Lange Medical Books/McGraw-Hill.

Other Works Consulted

• Shah SA, Stankovits LM (2006). Developmental dysplasia of the hip section of The hip. In FD Burg et al., eds., Current Pediatric Therapy, 18th ed., pp. 1018-1021. Philadelphia: Saunders Elsevier.

Credits