Diagnostic and Treatment Approaches for Hip Pathology in Children

Initial Evaluation and Diagnosis

Initial imaging should be age-appropriate, with ultrasound for infants under 4 months and radiographs for older children, to accurately diagnose hip pathologies and guide appropriate treatment 1, 2
The American College of Radiology recommends that clinical examination should be performed at each well-baby visit 2

Developmental Dysplasia of the Hip (DDH) affects 1.5 in 1,000 of the American Caucasian population, 4-8 times more common in females 2
Risk factors for DDH include family history, firstborn status, large infant size, oligohydramnios, and breech presentation 2
60-80% of abnormalities identified on physical examination and >90% identified on ultrasound resolve spontaneously 2
Untreated subluxed and dislocated hips can lead to early degenerative joint disease and impaired function 2

For infants <3 months: Ortolani and Barlow tests are most useful 2
For children >3 months: Limitation of hip abduction and asymmetric thigh folds are more useful clinical signs 2
In walking children: Look for typical limp, toe-walking on affected side, increased lumbar lordosis, prominent buttocks, and waddling gait if bilateral 2

Radiographs become more reliable by 4-6 months of age when sufficient ossification has occurred 1, 2
Selective ultrasound screening recommended at 4-6 weeks for high-risk infants 1
The earliest recommended timing for ultrasound is 2 weeks of age, as hip instability often resolves spontaneously by this time 1

Limited evidence supports use of the von Rosen splint over Pavlik, Craig, or Frejka splints during initial hip instability treatment 3
Serial physical examinations and periodic imaging assessments are recommended throughout treatment 3
For stable hips with ultrasound abnormalities, observation without bracing may be appropriate 3

Initial evaluation with limited tibial/fibula radiographs is suggested for walking children with nonlocalized limp 4
MRI is highly sensitive for detecting soft-tissue, cartilage, and bony pathology, including stress reactions/fractures 4
Ultrasound has limited field of view but is useful for evaluating joint effusions and soft-tissue fluid collections 4

Spiral tibial fractures are the most common fractures in children <4 years presenting with nonlocalized limp 4
Other causes include osteochondritis, apophysitis, osteonecrosis, and tumors 5
Toddler's fracture (nondisplaced oblique distal tibial fracture) may go unrecognized on initial radiographs 5

When hip infection is suspected, urgent evaluation is necessary 5
Bone scan is reported to have high sensitivity for diagnosis of osteomyelitis 5
MRI should be performed when a tumor is suspected as it is sensitive for evaluation of bone marrow and soft-tissue extension 5

For infants undergoing treatment with abduction devices, serial imaging is recommended to monitor progress 1
After successful treatment, transition to radiographic monitoring typically occurs at 4-6 months of age 1
If initial evaluation is negative and symptoms persist or worsen, follow-up clinical reassessment and further imaging evaluation may be necessary 4

Negative radiographs do not completely exclude the possibility of a nondisplaced fracture 5
Ultrasound has high sensitivity but can lead to overdiagnosis and overtreatment if performed too early (before 2 weeks of age) 1
Pain due to hip pathology can be referred elsewhere in the lower extremity (thigh, knee, buttock), leading to misdiagnosis 5
Normal results on physical examination do not preclude the development of a dysplastic hip in an infant 6

Closed reduction is successful in 91% of cases in infants up to one year of age, but success depends on achieving concentric reduction without obstacles, according to the American Academy of Orthopaedic Surgeons 7
Obtain complete blood count, platelet count, platelet function study, and von Willebrand screen before any surgical intervention, as recommended by the American Academy of Pediatrics 8

Screen for easy bruising or bleeding history, as children with developmental conditions may have undiagnosed coagulopathies, as noted by the American Academy of Pediatrics 8

Prompt orthopedic evaluation within 2-4 weeks is appropriate to prevent further acetabular underdevelopment, according to the American Academy of Orthopaedic Surgeons 7