import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Infant Hip Examination (DDH) The infant hip examination for DDH is a core clinical skill. Examiners expect you to perform Barlow and Ortolani tests correctly, recognize the difference between hip clicks and clunks, understand the limitations of clinical examination, and know when to refer for ultrasound. The examination differs by age. ## Quick Reference One-Pager ## Introduction and Setup **Patient Requirements:** - Warm, quiet room (baby should be calm) - Naked from waist down, nappy removed - Flat, firm surface - Baby should be relaxed and not crying **Consent Script (to parent):** "I'm going to examine your baby's hips to check they are developing normally. I need to move the hips gently. This doesn't hurt, but babies sometimes don't like being examined. It's best done when they're calm." **Key Concepts:** - DDH is a spectrum: Dysplasia → Subluxable → Dislocatable → Dislocated - Clinical examination is most sensitive in first few weeks of life - Instability may resolve spontaneously (physiological laxity) or progress - Sensitivity of clinical exam decreases after 3 months ## Risk Factors (History) **Major Risk Factors:** 1. **Breech presentation** (especially extended breech): 2-4% risk of DDH 2. **Family history**: First-degree relative with DDH (10-fold increased risk) 3. **Female sex**: 4-8× more common than males (ligamentous laxity from maternal hormones) **Minor Risk Factors:** - Oligohydramnios (reduced fetal movement) - First-born child - High birth weight - Associated packaging disorders: - Congenital muscular torticollis (20% association) - Metatarsus adductus - Calcaneovalgus foot - Plagiocephaly **Screening Indication:** - Universal clinical screening at newborn and 6-week checks - Ultrasound screening if any major risk factor (breech, family history) regardless of clinical findings ## Look (Inspection) - **Leg position at rest**: External rotation, shortened appearance - **Apparent leg length**: Compare knee heights with hips and knees flexed (Galeazzi) - **Thigh skin creases**: Asymmetry (not specific but should be noted) - **Abduction**: Compare range visually before testing - **Movement**: Spontaneous movement of both legs - **Gluteal creases**: Asymmetry (not specific, may be normal) - **Popliteal creases**: Asymmetry - **Leg length**: Gross shortening visible - **Thigh contour**: Fullness laterally with dislocation **Skin Crease Asymmetry:** This is NOT a reliable sign of DDH - up to 30% of normal infants have asymmetric thigh creases. It should prompt careful examination but is NOT diagnostic. ## Barlow and Ortolani Tests **Clunk vs Click:** - **CLUNK** (significant): A palpable movement of the femoral head in or out of the acetabulum. This is what Barlow and Ortolani detect. Requires referral. - **CLICK** (usually benign): A snapping sound or sensation from soft tissues (ligamentum teres, fascia lata, tendons). Very common (up to 10% of newborns). No referral required unless other concerns. **Key distinction:** A clunk is felt (movement of bone), a click is heard/snapped (soft tissue). ## Additional Tests ## Examination by Age ## Imaging **Ultrasound (Graf Method):** - First-line investigation under 4-6 months - Indications: - Clinical instability (positive Barlow/Ortolani) - Risk factors (breech, family history) even with normal exam - Clinical concern (asymmetric creases, limited abduction) - Timing: 6 weeks (not at birth - physiological laxity gives false positives) **Graf Classification:** | Type | Alpha Angle | Beta Angle | Interpretation | |------|-------------|------------|----------------| | I | Greater than 60° | Less than 55° | Normal | | IIa | 50-59° | - | Immature (normal if under 3 months) | | IIb | 50-59° | - | Delayed ossification (over 3 months, abnormal) | | IIc | 43-49° | Less than 77° | Critical (unstable) | | D | 43-49° | Greater than 77° | Decentered (subluxed) | | III | Less than 43° | Greater than 77° | Dislocated | | IV | Less than 43° | Greater than 77° | Dislocated (labrum inverted) | **X-Ray:** - After 4-6 months when femoral head begins to ossify - Look for: Shenton's line, acetabular index, femoral head position ## Complete the Examination **Always state to the examiner:** "To complete my examination, I would like to: - Check for **associated conditions** (torticollis, foot deformities) - Review **risk factors** (breech, family history) - Arrange **ultrasound** if any clinical or risk factor concerns - Document findings clearly - Arrange **follow-up** at 6 weeks for repeat examination" ## Summary Presentation ## DDH Management Summary ## Key Points for Examiners