Title: Author: Designation: Speciality / Division: Directorate: CLINICAL GUIDELINES ID TAG Developmental Dysplasia of hips Regional Guideline Mr Aidan Cosgrove Paediatric Orthopaedics Orthopaedic Orthopaedics Date: January 2014 Consulted upon: Approved by: Yes Regional guideline (see below) Review Date (Every 2 years or sooner if required): CG ID TAG January 2017 CG0290 Page 1 of 10
Title: Author(s) Ownership: Approval by: Operational Date: Key words: Reference No: SG 24/14 Regional Guidelines for Developmental Dysplasia of the Hip (DDH) Referral Mr Aidan Cosgrove, Consultant Orthopaedic Surgeon Tel: 90633146 Withers Wards, Musgrave Park Hospital Brian Barry, Director, Specialist Hospitals and Women s Health Child Health Governance Approval 24/01/14 Standards and Guidelines 10/9/14 date: Policy Committee 15/9/14 Executive Team Meeting 17/9/14 October 2014 DDH, dysplasia, hip, referral Version No. 1.0 Supercedes None Links to other policies Date Version Author Comments 20/11/2012 0.1 A Cosgrove Initial Draft Next Review: October 2017 14/03/2013 0.2 A Cosgrove Revised draft taking on comments following consultation with; Orthopaedic Consultants. Nurse led clinic leads. Dr C Beattie/ J McClean Public Health Consultants. PHA leads for Health visiting. Selection of Consultant Paediatricians, Paediatric Radiologist Group meeting, Paediatric Ultrasonographers. 16/08/2013 0.3 A Cosgrove Minor typographical corrections 18/9/2013 0.4 A Cosgrove Further editing Page 2 of 10
EQUALITY STATEMENT In line with duties under the equality legislation (Section 75 of the Northern Ireland Act 1998), Targeting Social Need Initiative, Disability discrimination and the Human Rights Act 1998, an initial screening exercise to ascertain if this policy should be subject to a full impact assessment has been carried out. The outcome of the Equality screening for this policy is: Major impact Minor impact No impact. SIGNATORIES (Policy Guidance should be signed off by the author of the policy and the identified responsible director). Author Date: October 2014 Director Date: October 2014 Page 3 of 10
Guidelines for Referral to Orthopaedic Service, Nurse-led clinics or Radiology Service for Developmental Dysplasia of Hip Nov 2012 Page 4 of 10
1. INTRODUCTION Developmental Dysplasia of the Hip (DDH) occurs in 5/1000 births. If untreated, it may results in a limp, and later in life pain and early onset of osteoarthropathy. The importance of surveillance is well recognised and physical examinations are carried out as part of the core programme of child health contacts (Healthy Child Healthy Futures, May 2010) i. The overall aim is to detect DDH by effectively screening all infants and early referral of all those identified as at risk or with abnormal clinical findings following examination. Screening for DDH will be completed as a component of the newborn physical examination within 72 hours, at 10-14 days by the health visitor, at 6-8 weeks by the General Practitioner and at the 14-16 week review by the health visitor. The physical examinations are included in the NICE clinical guidelines for the NHS ii : 1.2 Purpose This policy is to help those tasked with surveillance for DDH in infants. It is to serve as a guide to the relevant risk factors and clinical findings. To define which infants need to be referred for further assessment and which can follow the routine surveillance. It is aimed to place all the information in a single accessible document and to ensure a uniformity of management across the Province. 1.3 Objective The objective is to improve the access of those with risk factors and abnormal findings to prompt specialist assessment and early management as well as to reduce the number of those referred without appropriate risk factors or findings, which can introduce undue delays in treatment. 1.4 Monitoring The effectiveness of this policy shall be determined by the ongoing audit of developmental dysplasia of hip by the Paediatric Orthopaedic service. This will be with particular reference to the number of presenting in each age cohort and requiring treatment. 2. Risk Factors There are two important risk factors: A family history of hip dysplasia in early life, i.e. mother, father, brother or sister had a hip problem that started when they were a baby that needed treatment with a splint, harness or operation. A breech presentation at the time of delivery or after 36 weeks of gestation irrespective of mode of delivery. (A breech lie before 36 weeks with subsequent cephalic presentation at delivery is not a risk factor.) There are other lesser risk factors; i) Congential Talipes Equinovarus (CTEV; Rigid Clubfoot)- these should be under the care of the orthopaedic service from an early age and they will screen the hips. Page 4 of 10
Other moulding issues with the neonatal feet, such as Calcaneovalgus feet (foot pushed up towards shin) resolve quickly and are not a risk factor for DDH. ii) Torticollis- if any concern on hip examination should be referred. 3. Clinical examination Clinical examination relies on four tests: Ortolani s test Barlow s test Limitation of Abduction Leg length discrepancy In the neonate and young infant one is more likely to detect instability, so the Barlow s and Ortolani s test are particularly useful. After 6 weeks a dislocation is more likely to be established and can be more difficult to reduce, so the leg length discrepancy and increasing tightness of the adductor muscles is more likely to be evident. However, one should perform all four checks for every child. Asymmetric skin creases in isolation are not indicative of pathology as many otherwise normal children have differences in the creases. If clinical examination is otherwise normal, ie: no restriction of abduction at the hip, equal limb lengths, negative Barlow s and Ortolani s tests, onward referral is not indicated. The tests are detailed below, the tests for instability rely on the detection of abnormal movement rather than the production of sound. Although on occasion there may be an audible component to the tests the vast majority of clicks are innocent. Indeed most clicks arise from the knees. An isolated click with an otherwise normal exam does not require referral. With bilateral dislocations there is no normal hip for comparison. However instability or limitation of abduction may be demonstrated. The upward and outward displacement of both thighs may leave a wide perineal gap. Performing the Clinical exam prior to the examination of the infant ensure a warm environment, a firm surface and a contented baby; the infant should be undressed from the waist downwards and the nappy removed; the examiners hands should be warm, the examination gentle and the baby relaxed; Page 5 of 10
the infant lies on his/her back with legs towards the examiner and the hips adducted and fully flexed; the hips should be tested for instability one at a time; Ortolani s Test Ortolani s test is based on an attempt to reduce a dislocated hip. One places the hands on the infant s thighs with the knee between the thumb and the extended index and ring fingers. The knee is gently abducted away from the midline exerting gentle upward pressure with the fingertip on the greater trochanter at the upper outer aspect of the thigh. If the dislocated hip reduces towards the socket one will have a sensation of the femoral head translating or moving forwards. Ortolani described this sensation as a skid Page 6 of 10
Barlow s Test Barlow s test is based on an attempt to dislocate an unstable hip from its socket. With the knee cupped between the thumb and fingers and the hip flexed one pushes gently down on the knee whilst moving it medially trying to detect movement backwards of the hip from its socket. This movement is sometimes described as pistoning. Page 7 of 10
Leg length discrepancy Infants before walking age cannot fully straighten out their hips, this is because of the persistence of flexed position of the legs from the womb. Therefore one must assess for differences between the lengths of legs with the hips flexed. One needs to take care that the pelvis is flat against the examination surface and look for a difference of the prominence of the knees. Limitation of Abduction Page 8 of 10
Hip abduction is tested by moving the thighs away from the midline with the hips flexed. Limitation of abduction is defined as less than 60 degrees of abduction of a hip or asymmetry of abduction of greater than 20 degrees. 4. REFERRAL PATHWAY Patients with risk factor or abnormal findings may be referred to; Nurse Led Clinic at MPH Nurse Led Clinic at Altnagelvin In some units there may be direct access for Ultrasound Examination of hips eg UHD; RJMH; Southwest Hospital- those with abnormal findings can then be directed to the nurse led clinics or to Paediatric Orthopaedic Clinic RBHSC For those older infants were x-ray would be the primary investigation (ie >4-5 months) it may be more expedient to arrange x-rays locally Page 9 of 10
MATERNITY UNITS AND COMMUNITY STAFF PROTOCOL FOR NEONATES AND BABIES WHO NEED REFERRED FOR ORTHOPAEDIC ASSESSMENT. RISKS FACTORS FAMILY HISTORY Where sibling/parents/half sibling have been treated BREECH At time of delivery; vaginal or via caesarean section Breech after 36 weeks gestation CONGENITAL TALIPES EQUINOVARUS (CTEV RIGID CLUBFOOT) Refer to Musgrave Park/Altnagelvin. Hips will also be checked at these clinics ABNORMAL CLINICAL SIGNS THAT NEED REFERRED Positive Ortolani test Positive Barlow Test Restriction of abduction Defined as less than 60 degrees of abduction or asymmetry of abduction greater than 20 degrees Unequal leg length Clicks and unequal skin creases with an otherwise normal examination do not need referred. REFERRAL PATHWAYS FOR MATERNITY /COMMUNITY REFERRERS Patients with risk factors or abnormal clinical findings may be referred to Nurse led clinic Musgrave Park fax (02890903076) Nurse led clinic Altnagelvin fax (02871611418) RBHSC clinic fax( 02890632816) In some Maternity units /Community areas there may be direct access for Ultrasound Examination of hips i.e. UHD; RJMU; Mater and Erne maternity those with abnormal findings can be directed to the appropriate Nurse Led Clinic or to the Paediatric Orthopaedic service RBHSC or Altnagelvin. Page 10 of 10