Developmental dysplasia of the hip

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Developmental dysplasia of the hip (DDH) denotes aberrant development of the hip joint and results from an abnormal relationship of the femoral head to the acetabulum. There is a clear female predominance, and it usually occurs from ligamentous laxity and~~/or~~ abnormal position in utero. Therefore, it is more common with oligohydramniotic pregnancies. This article describes the commonly used radiographic measurements and lines involved in DDH.

Epidemiology

The reported incidence varies between 1.5 and 20 per 1000 births ¹, with the majority (60-80%) of abnormal hips resolving spontaneously within 2-8 weeks ¹ (so-called immature hip).

Risk factors include ^1,4:

female gender (M:F ratio ~1:8)
family history
breech presentation
oligohydramnios

Clinical presentation

DDH is usually suspected in the early neonatal period due to the widespread adoption of clinical examination (including Ortolani test, Barlow ~~maneuvers~~manoeuvres, Galeazzi sign). The diagnosis is then usually confirmed with ultrasound, although the role of ultrasound in screening is controversial ^1,3.

Radiographic features

Ultrasound is the modality of choice prior to ossification of the proximal femoral epiphysis. Once there is a significant ossification then x-ray examination is required.

For some reason, the left hip is said to be more frequently affected ⁴. One-third of cases ~~are~~is affected bilaterally ⁵.

Ultrasound

Ultrasound is the test of choice in the infant (<6 months) as the proximal femoral epiphysis has not yet significantly ossified. Additionally, it has the advantage of being a real-time dynamic examination allowing the stability of the hip to be assessed with stress views.

~~A number of~~Some values are used to 'objectively' assess morphology.

Alpha angle

The alpha angle is formed by the acetabular roof to the vertical cortex of the ilium. This is a similar measurement as that of the acetabular angle (see below). The normal value is greater than or equal to 60º.

Beta angle

The beta angle is formed by the vertical cortex of the ilium and the triangular labral fibrocartilage (echogenic triangle). The normal value is less than 77º ⁶ but is only useful in assessing immature hips when combined with the alpha angle (see the sonographic classification of developmental hip dysplasia).

Bony coverage

The percentage of the femoral epiphysis covered by the acetabular roof. A value of greater than 58% is considered normal.

Plain radiograph

The key to plain film assessment is looking for symmetry and defining the relationship of the proximal femur to the developing pelvis. The ossification of the superior femoral epiphyses should be symmetric. Delay of ossification is a sign of DDH.

Hilgenreiner line

Hilgenreiner line is drawn horizontally through the inferior aspect of both triradiate cartilages. It should be horizontal but is mainly used as a reference for Perkin line and measurement of the acetabular angle.

Perkin line

Perkin line is drawn perpendicular to Hilgenreiner line, intersecting the lateral most aspect of the acetabular roof. The upper femoral epiphysis should be seen in the inferomedial quadrant (i.e. below Hilgenreiner line, and medial to Perkin line)

Acetabular angle

The acetabular angle is formed by the intersection between a line drawn tangential to the acetabular roof and Hilgenreiner line, forming an acute angle. It should be approximately 30 degrees at birth and progressively reduce with the maturation of the joint.

Shenton line

Shenton line is drawn along the inferior border of the superior pubic ramus and should continue laterally along the inferomedial aspect of the proximal femur as a smooth line. If there is a superolateral migration of the proximal femur due to DDH then this line will be discontinuous.

Treatment and prognosis

Management options include:

Pavlik harness: usually for younger patients (less than 6six months of age)
closed reduction: usually for older patients
open reduction (ORIF): much older patient or if closed reduction not successful

-<p><strong>Developmental dysplasia of the hip (DDH)</strong> denotes aberrant development of the hip joint and results from an abnormal relationship of the femoral head to the acetabulum. There is a clear female predominance and it usually occurs from ligamentous laxity and/or abnormal position in utero. Therefore, it is more common with <a href="/articles/oligohydramnios">oligohydramniotic</a> pregnancies. This article describes the commonly used radiographic measurements and lines involved in DDH.</p><h4>Epidemiology</h4><p>The reported incidence varies between 1.5 and 20 per 1000 births <sup>1</sup>, with the majority (60-80%) of abnormal hips resolving spontaneously within 2-8 weeks <sup>1</sup> (so-called immature hip).</p><p>Risk factors include <sup>1,4</sup>:</p><ul>
+<p><strong>Developmental dysplasia of the hip (DDH)</strong> denotes aberrant development of the hip joint and results from an abnormal relationship of the femoral head to the acetabulum. There is a clear female predominance, and it usually occurs from ligamentous laxity and abnormal position in utero. Therefore, it is more common with <a href="/articles/oligohydramnios">oligohydramniotic</a> pregnancies. This article describes the commonly used radiographic measurements and lines involved in DDH.</p><h4>Epidemiology</h4><p>The reported incidence varies between 1.5 and 20 per 1000 births <sup>1</sup>, with the majority (60-80%) of abnormal hips resolving spontaneously within 2-8 weeks <sup>1</sup> (so-called immature hip).</p><p>Risk factors include <sup>1,4</sup>:</p><ul>
-</ul><h4>Clinical presentation</h4><p>DDH is usually suspected in the early neonatal period due to the widespread adoption of clinical examination (including Ortolani test, Barlow maneuvers, Galeazzi sign). The diagnosis is then usually confirmed with ultrasound, although the role of ultrasound in screening is controversial <sup>1,3</sup>.</p><h4>Radiographic features</h4><p>Ultrasound is the modality of choice prior to ossification of the proximal femoral epiphysis. Once there is a significant ossification then x-ray examination is required.</p><p>For some reason, the left hip is said to be more frequently affected <sup>4</sup>. One-third of cases are affected bilaterally <sup>5</sup>.</p><h5>Ultrasound</h5><p>Ultrasound is the test of choice in the infant (<6 months) as the proximal femoral epiphysis has not yet significantly ossified. Additionally it has the advantage of being a real-time dynamic examination allowing the stability of the hip to be assessed with stress views.</p><p>A number of values are used to 'objectively' assess morphology.</p><h6>Alpha angle</h6><p>The <a href="/articles/alpha-angle-1">alpha angle</a> is formed by the acetabular roof to the vertical cortex of the ilium. This is a similar measurement as that of the acetabular angle (see below). The normal value is greater than or equal to 60º.</p><h6>Beta angle</h6><p>The <a href="/articles/beta-angle-ddh">beta angle</a> is formed by the vertical cortex of the ilium and the triangular labral fibrocartilage (echogenic triangle). The normal value is less than 77º <sup>6</sup> but is only useful in assessing immature hips when combined with the alpha angle (see <a href="/articles/graf-method-for-ultrasound-classification-of-developmental-dysplasia-of-the-hip">sonographic classification of developmental hip dysplasia</a>).</p><h6>Bony coverage</h6><p>The percentage of the femoral epiphysis covered by the acetabular roof. A value of greater than 58% is considered normal.</p><h5>Plain radiograph</h5><p>The key to plain film assessment is looking for symmetry and defining the relationship of the proximal femur to the developing pelvis. The ossification of the superior femoral epiphyses should be symmetric. Delay of ossification is a sign of DDH.</p><h6>Hilgenreiner line</h6><p><a href="/articles/hilgenreiner-line">Hilgenreiner line</a> is drawn horizontally through the inferior aspect of both <a href="/articles/triradiate-cartilage">triradiate cartilages</a>. It should be horizontal but is mainly used as a reference for Perkin line and measurement of the acetabular angle.</p><h6>Perkin line</h6><p><a href="/articles/perkin-line">Perkin line</a> is drawn perpendicular to <a href="/cases/hilgenreiner-s-line">Hilgenreiner line</a>, intersecting the lateral most aspect of the acetabular roof. The upper femoral epiphysis should be seen in the inferomedial quadrant (i.e below Hilgenreiner line, and medial to Perkin line)</p><h6>Acetabular angle</h6><p>The <a href="/articles/acetabular-angle">acetabular angle</a> is formed by the intersection between a line drawn tangential to the acetabular roof and Hilgenreiner line, forming an acute angle. It should be approximately 30 degrees at birth and progressively reduce with maturation of the joint.</p><h6>Shenton line</h6><p><a href="/articles/shenton-line">Shenton line</a> is drawn along the inferior border of the superior pubic ramus and should continue laterally along the inferomedial aspect of the proximal femur as a smooth line. If there is superolateral migration of the proximal femur due to DDH then this line will be discontinuous.</p><h4>Treatment and prognosis</h4><p>Management options include:</p><ul>
~~-<li>Pavlik harness: usually for younger patients (less than 6 months of age)</li>~~
+</ul><h4>Clinical presentation</h4><p>DDH is usually suspected in the early neonatal period due to the widespread adoption of clinical examination (including Ortolani test, Barlow manoeuvres, Galeazzi sign). The diagnosis is then usually confirmed with ultrasound, although the role of ultrasound in screening is controversial <sup>1,3</sup>.</p><h4>Radiographic features</h4><p>Ultrasound is the modality of choice prior to ossification of the proximal femoral epiphysis. Once there is a significant ossification then x-ray examination is required.</p><p>For some reason, the left hip is said to be more frequently affected <sup>4</sup>. One-third of cases is affected bilaterally <sup>5</sup>.</p><h5>Ultrasound</h5><p>Ultrasound is the test of choice in the infant (<6 months) as the proximal femoral epiphysis has not yet significantly ossified. Additionally, it has the advantage of being a real-time dynamic examination allowing the stability of the hip to be assessed with stress views.</p><p>Some values are used to 'objectively' assess morphology.</p><h6>Alpha angle</h6><p>The <a href="/articles/alpha-angle-1">alpha angle</a> is formed by the acetabular roof to the vertical cortex of the ilium. This is a similar measurement as that of the acetabular angle (see below). The normal value is greater than or equal to 60º.</p><h6>Beta angle</h6><p>The <a href="/articles/beta-angle-ddh">beta angle</a> is formed by the vertical cortex of the ilium and the triangular labral fibrocartilage (echogenic triangle). The normal value is less than 77º <sup>6</sup> but is only useful in assessing immature hips when combined with the alpha angle (see the <a href="/articles/graf-method-for-ultrasound-classification-of-developmental-dysplasia-of-the-hip">sonographic classification of developmental hip dysplasia</a>).</p><h6>Bony coverage</h6><p>The percentage of the femoral epiphysis covered by the acetabular roof. A value of greater than 58% is considered normal.</p><h5>Plain radiograph</h5><p>The key to plain film assessment is looking for symmetry and defining the relationship of the proximal femur to the developing pelvis. The ossification of the superior femoral epiphyses should be symmetric. Delay of ossification is a sign of DDH.</p><h6>Hilgenreiner line</h6><p><a href="/articles/hilgenreiner-line">Hilgenreiner line</a> is drawn horizontally through the inferior aspect of both <a href="/articles/triradiate-cartilage">triradiate cartilages</a>. It should be horizontal but is mainly used as a reference for Perkin line and measurement of the acetabular angle.</p><h6>Perkin line</h6><p><a href="/articles/perkin-line">Perkin line</a> is drawn perpendicular to <a href="/cases/hilgenreiner-s-line">Hilgenreiner line</a>, intersecting the lateral most aspect of the acetabular roof. The upper femoral epiphysis should be seen in the inferomedial quadrant (i.e. below Hilgenreiner line, and medial to Perkin line)</p><h6>Acetabular angle</h6><p>The <a href="/articles/acetabular-angle">acetabular angle</a> is formed by the intersection between a line drawn tangential to the acetabular roof and Hilgenreiner line, forming an acute angle. It should be approximately 30 degrees at birth and progressively reduce with the maturation of the joint.</p><h6>Shenton line</h6><p><a href="/articles/shenton-line">Shenton line</a> is drawn along the inferior border of the superior pubic ramus and should continue laterally along the inferomedial aspect of the proximal femur as a smooth line. If there is a superolateral migration of the proximal femur due to DDH then this line will be discontinuous.</p><h4>Treatment and prognosis</h4><p>Management options include:</p><ul>
+<li>Pavlik harness: usually for younger patients (less than six months of age)</li>

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