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Developmental dysplasia of the hip (DDH)
DDH is checked by clinical examination at every visit in the first year: until 3 months the Barlow and Ortolani tests, and later limited abduction; imaging is ultrasound up to 4–6 months and X-ray thereafter, and early treatment is the Pavlik harness.
Why it matters in the exam
Questions ask who is at risk (breech presentation in the third trimester, family history, female sex, first-born, oligohydramnios and "tight" swaddling with straight hips), which test suits the age and what the treatment is. Per AAP 2016, selective ultrasound is done at 6 weeks for infants with breech presentation, family history or an unstable hip on examination — and not before 4–6 weeks, because physiological laxity causes false-positive findings.
Examination findings change with age. Barlow shows a dislocatable hip (posterior push in adduction), and Ortolani shows a dislocated hip that reduces (a "clunk" on abduction) — both disappear after about 3 months. From that age the key sign is limited hip abduction, together with the Galeazzi sign (a lower knee on the dislocated side) and leg shortening. Asymmetric skin folds are not specific. A child who starts walking with a limp or a waddling gait — DDH that was missed.
Treatment depends on age: under 6 months a Pavlik harness that holds the hip in flexion and abduction; at 6–18 months closed reduction under anaesthesia and a spica cast; and after 18 months usually open reduction. The important complication of treatment is avascular necrosis of the femoral head. The later the diagnosis, the more complex the treatment and the worse the outcome.
Key points
- Risk: breech, family history, female, first-born.
- Until 3 months Barlow and Ortolani; later limited abduction.
- Ultrasound at 6 weeks; X-ray after 4–6 months.
- Under 6 months — Pavlik harness.
- The key complication: avascular necrosis of the femoral head.
Summary table
| Age | Key sign | Imaging | Treatment |
|---|---|---|---|
| Birth to 3 months | Barlow and Ortolani | Ultrasound at 6 weeks by risk or finding | Pavlik harness if the hip is unstable or dysplastic |
| 3–6 months | Limited abduction, Galeazzi | Ultrasound | Pavlik harness |
| 6–18 months | Limited abduction, leg shortening | Pelvic X-ray (the femoral head ossifies) | Closed reduction and spica cast |
| Over 18 months | Limp, waddling gait, Trendelenburg | Pelvic X-ray | Open reduction, sometimes osteotomy |
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Sources
- AAP Clinical Report: Evaluation and Referral for Developmental Dysplasia of the Hip in Infants, 2016 — Physical examination and selective ultrasound
- AAOS Appropriate Use Criteria / Clinical Practice Guideline: Detection and Nonoperative Management of Pediatric DDH in Infants up to Six Months of Age, 2014 (reaffirmed) — Imaging and Pavlik harness
- Nelson Textbook of Pediatrics, 22nd edition (2024) — Developmental Dysplasia of the Hip
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.