• DDH ranges from mild acetabular dysplasia with a stable hip through more severe forms of dysplasia, often associated with neonatal hip instability, to established hip dysplasia with/without later subluxation or dislocation 
• Delayed diagnosis requires more complex treatment and has a less successful outcome than dysplasia diagnosed early
• Screening for DDH is part of the newborn and infant physical examination (NIPE)

• Family history of first degree relative with DDH
• Breech presentation during pregnancy
• Hip abnormality on clinical examination
• Structural foot abnormality – congenital calcaneovalgus, fixed talipes equinovarus
• Significant intrauterine moulding – congenital torticollis, congenital plagiocephaly
• Birth weight >5 kg
• Oligohydramnios
• Multiple pregnancy
• Prematurity
• Neuromuscular disorders

• All babies are offered a NIPE to be completed by aged 72 hr, to include: 
  
  • questions to the parents to identify risk factors for DDH and a thorough examination for hip abnormalities
    
    • ask parents: “Is there anyone in the baby’s close family, i.e. mother, father, brother or sister, who has had a hip problem that started when they were a baby or young child and that needed treatment with a splint, harness or operation?”
  • Ortolani and Barlow tests, to detect an unstable hip, or hip that is dislocated or subluxed but reducible
    
    • will not detect an irreducible hip, which is best detected by identifying limited abduction of the flexed hip

Observe for

• Symmetry of leg length
• Level of knees when hips and knees are both flexed

Manipulation

• Barlow test (left) and Ortolani test (right) (see Figure 1) 
• When examining hip stabilise pelvis on opposite side
• Can legs be fully abducted

Barlow test (right hip)

• Hip adducted and flexed to 90°
• Hold distal thigh and push posteriorly on hip joint 
• Test is positive when the femoral head felt to slide posteriorly as it dislocates

Ortolani test (left hip)

• Stabilise pelvis and examine each hip separately 
• In a baby with limited hip abduction in flexion, hip is flexed to 90° and gently abducted while examiner’s finger lifts the greater trochanter
• Test is positive when the femoral head is felt to locate into the acetabulum

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• Enhanced screening is done through ultrasound of the hips 
• NIPE guidelines include specific criteria for referral for enhanced screening and the timescale in which this should occur 
• Individual trusts may add local criteria to supplement national criteria
• SCREEN POSITIVE result is an abnormal clinical hip examination (with/without risk factors) or NIPE hip risk factors

Abnormal examination defined as:

• Difference in leg length 
• Knees at different levels when hips and knees bilaterally flexed 
• Difficulty abducting hip to 90° 
• Palpable ‘clunk’ when undertaking Ortolani or Barlow manoeuvre 

NIPE hip risk factors:

• Family history of first degree relative with hip problems in early life, unless DDH has definitely been excluded
• Breech presentation at ≥36 completed weeks of pregnancy, irrespective of presentation at delivery or mode of delivery, or
• Breech presentation at the time of birth between 28 weeks’ gestation and term
• In the case of a multiple birth, if any baby falls into either category, all babies in this pregnancy to have ultrasound examination

Additional local criteria for referral may include:

• Significant moulding
• Congenital torticollis, congenital plagiocephaly
• Structural foot deformity
• Congenital calcaneovalgus
• Fixed talipes equinovarus
• Check your local referral criteria 

Screen negative − no risk factors on history and normal examination

• No further intervention needed
• Inform parents and document findings 
• These babies will be rechecked at their 6–8 week check

Screen positive – (risk factors or abnormal examination as detailed above)

• Inform parents of findings and plan for further investigation
• Document findings and plan
• Request outpatient hip ultrasound to be performed in accordance with NIPE guidance
• For babies born <34⁺⁰ weeks’ gestation, hip ultrasound should be undertaken 38−40 weeks’ corrected age
• For babies born ≥34⁺⁰, hip ultrasound scan should be undertaken at aged 4−6 weeks
• Departments to have system in place to review all hip scan results and inform parents as they are reported
  
  • babies with normal hip scan require no further action and will be re-examined at their 6–8 week check babies with abnormal hip scan require a specialist assessment
• An outcome decision for all babies should have been made by aged 6 weeks for babies born ≥34⁺⁰, and by 40⁺⁰ weeks’ corrected age for babies born <34⁺⁰ weeks

Dislocated/dislocatable/unstable hip – positive Ortolani or Barlow test or limited hip abduction

• Review by middle grade or consultant to confirm diagnosis
• Inform parents of findings and plan for further investigation and management
• Document findings and plan
• Urgent referral required 
• Check local policy regarding referral to physiotherapy/orthopaedic team and ultrasound. Service may be provided locally or referral to a tertiary centre paediatric orthopaedic team may be required