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Hips in Children.

DDH

Guidelines: NIPE 2020. 1

Timing of Scan

Born >= 34 weeks: At 4 to 6 weeks of age (not gestationally corrected).

Born <34 weeks: At 38 to 40 weeks gestationally corrected age.

Clinical Features

"Please note that observation of skin creases for symmetry is no longer part of the NIPE screen."

Indications

First-degree family history of hip problems in early life - this includes baby's parents or siblings who have had a hip problem that started as a baby or young child that needed treatment with a splint, harness or operation.

Breech presentation at or after 36 completed weeks of pregnancy , irrespective of presentation at birth or mode of delivery – this includes babies who have had a successful external cephalic version (ECV)

Breech presentation at the time of birth between 28 weeks gestation and term

All babies from a multiple pregnancy where any of the NIPE hip risk factors listed above are present should have a hip ultrasound. This is because if one of the babies meets the criteria of breech presentation described above during pregnancy, it may be difficult to accurately identify which baby was affected.

DDH Radiology = Graf 2

'Subluxed' = <50% bony coverage at rest. 'Capsular Laxity' = >50% bony coverage at rest but <50% on stress.

Graf Type Alpha Beta Notes
1a >60 <55 Mature hip, angular bony promontory
1b >60 <55 Mature hip, rounded bony promontory
2a 50-60 55-77 Physiologic Immaturity <3m
2b 50-60 55-77 Immaturity >3m
2c 43-49 55-77 Critical Hip, Subluxation
3 <43 Dislocated hip
4 <43 Dislocated hip, Inverted labrum

DDH & EDS 3 4

Only Type IV = Vascular and Type VI = Arthrochalasia are associated with hip dislocation in infancy.
Classical (Type I), Cardiac valvular (Type III) and hypermobility spectrum etc etc are not associates.

Type III = <1 in 1,000,000 Severe progressive AV or MV problems. Pectus and pes issues are common. AR
Type IV = 1 in 100,000 to 200,000. Get arterial rupture or dissection, and colon perforation <40y old. AD.
Type VI = 1 in 1,000,000. All get Bilateral CDH. and then more dislocatons. AD.

Irritable Hip

Kocher Criteria.5

Criteria are:
1. Non Weight Bearing
2. Temp >38.5
3. ESR > 40 [ or 2006 = CRP>20 ]
4. WCC > 12000

Each criterion counts as 1 point.

Scores are:
- 0 = Very low risk. Observation.
- 1 = 3% probability of septic arthritis. Consult.
- 2 = 40% probability of septic arthritis. Aspirate (if effusion)
- 3 = 93% probabiltiy of septic arthritis. Aspirate in Theatre / Washout.
- 4 = 99% probabiltiy of septic arthritis. Aspirate in Theatre / Washout.

References

  1. https://www.gov.uk/government/publications/newborn-and-infant-physical-examination-screening-standards/newborn-and-infant-physical-examination-screening-standards-valid-for-data-collected-from-1-april-2021 ↩

  2. https://my.statdx.com/document/developmental-hip-dysplasia/a4836bb1-d249-4c9e-bf22-0439316823d8?searchTerm=ddh&searchType=documents&category=All ↩

  3. Donald Basel. Ehlers-Danlos Syndrome Nelson Textbook of Pediatrics, Chapter 679, 3525-3531.e1 ↩

  4. 2017 International Classification of EDS. ↩

  5. https://pubmed.ncbi.nlm.nih.gov/10608376/ ↩