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Unscreened w/ risk factor(s): breech presentation, FHx, or hx clinical hip instability
Clinically unstable hip exam Clinicians could obtain an imaging study before age 6 mo in infants w/ clinical hip instability hx [M] as a risk factor1 - Imaging options:2 US @ age 2-6 wk or x-ray @ age 4 mo. For infants age 4-6 mo: AP pelvis x-ray might be preferred3 to US [L]. In infants <6 wk old w/ clinical instability, clinicians might obtain US to guide decision on whether to initiate brace tx [L]; sequential US might aid determining when to initiate brace tx for infants up to 8 wk old [L]
- Brace timing:4 Clinicians might consider either immediate or delayed (eg, by 2-9wk) brace tx [L]
- Brace type: von Rosen splint might be used over Pavlik, Craig, or Frejka splints as initial tx5 [L] for unstable hip
- Brace monitoring:6 Serial physical exams & periodic imaging (US or x-ray, based on age6) [L]
Footnotes 1 Risks. Evidence didn’t support these as DDH risk factors: gender, foot abnormalities, oligohydramnios, torticollis. This guideline is not intended to address teratologic hip abnormalities or hip abnormalities assoc w/ neuromuscular, genetic, or acquired complex musculoskeletal or developmental abnormalities.
2 Imaging. US btwn age 2-6 wk or an AP pelvis x-ray @ age 4 mo [M] have been studied, though optimal age for imaging is unknown.
3 X-ray. Evidence didn’t distinguish children based on NL vs abnl physical exam or w/ vs w/o DDH risk factors. Radiographs expose pts to ionizing radiation.
4 Timing. For infants w/ hip instability on exam, evidence is conflicting about whether observation vs immediate bracing results in better outcomes; studies didn’t differentiate btwn dislocated vs dislocatable hips.
5 Braces. Rigid braces may have high higher resolution rates vs nonrigid braces. Nineteen percent (19%) of rigid-brace pts had skin irritation. All bracing has potential for AVN risk; relative risk btwn rigid vs soft unknown. Listed braces were studied; similar fixed-position braces may or may not work as well as those listed.
6 Monitoring brace. Re-exams & re-imaging might change tx plan/duration. Studies evaluated US @ age 2-6 wk or x-ray @ age 4 mo. In general, for infants age 4-6 mo, AP pelvis x-ray might be preferred to US [L]. Optimal timing/frequency of imaging unknown.
Clinicians could obtain an imaging study before age 6 mo in infants w/ breech presentation1 and/or (+)FHx2 [M] as risk factors3 - Imaging options: US btwn age 2-6 wk or an AP pelvis x-ray @ age 4 mo [M] have been studied, though optimal age4 for imaging is unknown. For infants age 4-6 mo, AP pelvis x-ray might be preferred5 to US [L]
- Surveillance. For infants w/ previously NL physical exam: Clinicians might re-examine on subsequent visits6 up to age 6 mo [L]
Footnotes 1 Breech. Meta-analyses support breech “presentation” as the risk factor (vs breech delivery, breech position in 3rd trimester, etc); no literature supports any particular duration of breech positioning.
2 FHx was variously defined in studies, ranging from DDH per se to unspecified hip disorders/problems, and from 1st-deg relatives to any relative, however distant.
3 Risks. Evidence didn’t support these as DDH risk factors: gender, foot abnormalities, oligohydramnios, torticollis. This guideline is not intended to address teratologic hip abnormalities or hip abnormalities assoc w/ neuromuscular, genetic, or acquired complex musculoskeletal or developmental abnormalities.
4 Optimal screening age for infants w/ risk factors is unknown; studies evaluated US @ age 2-6 wk or x-ray @ age 4 mo.
5 X-ray. Evidence didn’t distinguish children based on NL vs abnl physical exam or w/ vs w/o DDH risk factors. Radiographs expose pts to ionizing radiation.
6 No literature defines optimal f/u frequency/duration; literature didn’t address screening of children up to walking age, when findings (eg, abnl gait) may allow additional DDH detection.
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Unscreened w/o risk factors (no breech presentation, FHx, hx clinical hip instability)
There’s moderate evidence to NOT screen all1 newborn infants [M]; universal screening has potential to result in over-tx - Surveillance. For infants w/ previously NL physical exam: Clinicians might re-examine on subsequent visits2 up to age 6 mo [L]
Footnotes 1 This guideline is not intended to address teratologic hip abnormalities or hip abnormalities assoc w/ neuromuscular, genetic, or acquired complex musculoskeletal or developmental abnormalities.
2 No literature defines optimal f/u frequency/duration; literature didn’t address screening of children up to walking age, when findings (eg, abnl gait) may allow additional DDH detection.
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Previously clinically screened
Clinically unstable hip exam Sequential US might aid determining when to initiate brace tx for infants up to 8 wk old [L]. If on brace tx, serial physical exams & periodic imaging might be done [L] - Imaging options:1 US @ age 2-6 wk or x-ray @ age 4 mo. For infants age 4-6 mo: AP pelvis x-ray might be preferred2 to US [L]
- Brace timing:3 Clinicians might consider either immediate or delayed (eg, by 2-9wk) brace tx [L]
- Brace type: von Rosen splint might be used over Pavlik, Craig, or Frejka splints as initial tx4 [L] for unstable hip
- Brace monitoring:5 Serial physical exams & periodic imaging (US or x-ray, based on age5) [L]
Footnotes 1 Imaging. US btwn age 2-6 wk or an AP pelvis x-ray @ age 4 mo [M] have been studied, though optimal age for imaging is unknown.
2 X-ray. Evidence didn’t distinguish children based on NL vs abnl physical exam or w/ vs w/o DDH risk factors. Radiographs expose pts to ionizing radiation.
3 Timing. For infants w/ hip instability on exam, evidence is conflicting about whether observation vs immediate bracing results in better outcomes; studies didn’t differentiate btwn dislocated vs dislocatable hips.
4 Braces. Rigid braces may high higher resolution rates vs nonrigid braces. Nineteen percent (19%) of rigid-brace pts had skin irritation. All bracing has potential for AVN risk; relative risk btwn rigid vs soft unknown. Listed braces were studied; similar fixed-position braces may or may not work as well as those listed.
5 Monitoring brace. Re-exams & re-imaging might change tx plan/duration. Studies evaluated US @ age 2-6 wk or x-ray @ age 4 mo. In general, for infants age 4-6 mo, AP pelvis x-ray might be preferred to US [L]. Optimal timing/frequency of imaging unknown.
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