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Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10

CLINICAL GUIDELINE

Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH)


Document Registration Number: HNEH CG 10_10
Sites where Guideline applies Target audience All HNE Health sites General Practitioners, Paediatricians, Medical Officers, Midwives, Child and Family Health Nurses, Physiotherapists. This document provides guidance to clinicians regarding the screening, assessment and management of Developmental Dysplasia of the Hip Developmental Dysplasia of the Hip, Hip Screening, No

Description

Keywords Replaces Existing Guideline?

Related documents (Policies, Australian Standards, Codes of Conduct, legislation etc)


American Academy of Paediatrics (2000) Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip. Pediatrics, 105(4), 896-905. Royal Prince Alfred Hospital (2004) RPA Newborn Care Guidelines: Developmental Dysplasia of the Hip. Downloaded from http://www.sswahs.nsw.gov.au/rpa/neonatal on 10/01/10. National Health and Medical Research Council (2002) Child Health Screening and Surveillance: A critical review of the evidence. Report prepared by Centre for Community Child Health, Royal Childrens Hospital Melbourne. Downloaded from www.nhmrc.gov.au The Royal Childrens Hospital Melbourne (2008). Developmental Dysplasia of the Hip: Education Module DVD. Victorian Department of Education and Early Childhood Development Norfolk and Norwich University Hospital (2006). Trust Guideline for Developmental Dysplasia of the Hip (DDH). Accessed online at www.nnuh.nhs.uk on 11/05/2010 Paediatric & Neonatal Physiotherapy Department, Royal North Shore Hospital (2007). Application of Pavlik Harness Guidelines. Obtained from Barbara Lucas, Physiotherapist, Royal North Shore Hospital.

Position responsible for Guideline Governance Guideline Contact Officer Contact Details Date authorised Authorising body Date for review TRIM number

Professor Eric Ho Head of Paediatric Orthopaedics Jenny Martin, Director Allied Health, Kaleidoscope 4921 3700 22 October 2010 Children, Young People and Families Network December 2012 10/26-1-13

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Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10

DEVELOPMENTAL DYSPLASIA OF THE HIP CLINICAL PRACTICE GUIDELINE SUMMARY

Developmental Dysplasia of the Hip (DDH) is a common orthopaedic condition affecting the hip of infants. This document sets out recommendations, based on current best practice evidence, regarding the screening, assessment and management of DDH and is relevant to Child and Family Health Nurses, General Practitioners, Medical Officers, Midwives, Paediatricians and Physiotherapists. The aim of this document is to assist with the early identification of DDH, as the earlier an abnormality of the infant hip is detected, the simpler and more effective the treatment will be. Vital points to note regarding the screening and management of DDH include:

All newborns should undergo a hip examination, including the Barlow and Ortolani tests, following birth, prior to discharge from hospital. High risk infants should be booked for an Ultrasound at 6 weeks of age. This includes all breech presentations and those with a family history (parent or sibling) of DDH. Referral should be made to GP to ensure follow up of ultrasound. See full guideline for risk factor and referral pathway information. If an examiner is unsure of the stability of an infants hip/s, re-examination by an experienced clinician should be sought. Hip examination should occur at birth, 6-8 weeks and 6 months of age, as per to the childs Personal Health Record (Blue book). At risk infants should undergo hip examination at all well consultations. Any child with a dislocatable hip should be referred immediately to an Orthopaedic Surgeon or Paediatrician. Concerns regarding an infants hips should be acted on immediately delays in treatment may have adverse effects on the outcomes for the infant.

CLINICAL PATHWAYS to assist in the clinical decision making process are provided within this guideline: Examination at birth prior to discharge from hospital page 9 Child and Family Health Nurse Checks page 10 General Practitioner Review page 11

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Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10

CONTENTS
Introduction Situation Background Assessment Recommendation
Main Message Risk Factors Physical Examination Clinical Pathways Examination at birth prior to discharge from hospital Child and Family Health Nurse Checks General Practitioner Review Physiotherapy management of DDH using a brace/harness Resources 3 4 4 4 4 6 6 7

9 10 11 12 13 14 14 14 15

Implementation Plan Evaluation Plan Consultation with Key Stakeholders References


9 Appendices Appendix A: Neonatal Hip Instability Form Appendix B: Parent Handout: Caring for your child in a Pavlik Harness

16 17

Introduction
Definition Developmental Dysplasia of the Hip (DDH) is a condition that affects the neonatal and infant hip joint. DDH is a term used to describe a spectrum of abnormalities affecting the relationship of the femoral head to the acetabulum.2 These may include an immature hip, a hip with mild acetabular dysplasia, a hip that is dislocatable, a hip that is subluxated, or a hip that is frankly dislocated.3 In many circumstances, symptoms of DDH may be present at birth, however will resolve within the first weeks of life4. Alternatively, the hip may be stable at birth and develop an abnormality; hence the use of the term Developmental Dysplasia of the Hip (DDH), rather than Congenital Dysplasia of the Hip (CDH), as this condition was previously known. Incidence Although there are some inconsistencies in the literature regarding incidence of DDH, it is generally accepted that approximately: 1 in 100 infants will be identified as having some hip instability at birth3,4 1-2 in 1000 infants will be born with a dislocated hip3,4

Given the spectrum of DDH, each case may present with differing symptoms, severity and response to treatment.

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Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10 Importance of Early Identification and Intervention It is widely recognised that the earlier an abnormality of the infant hip is detected, the simpler and more effective the treatment will be1. Although formal evidence supporting the effectiveness of routine screening for DDH is minimal6, the American Academy of Pediatrics recognises that implementation of a surveillance and screening program for the early detection of DDH will minimise the number of late presentation cases1. Concerns exist regarding the treatment of infant hips where diagnosis has not been confirmed or has been misdiagnosed. Well-trained clinicians, irrespective of profession, are much more effective at identifying true symptoms of DDH than those who have less training and experience3,4,7. This highlights the importance of widespread education among clinicians regarding physical examination of the hip.

Situation
Across HNE Health, assessment and management of DDH is currently being undertaken by clinicians from various disciplines, however there is currently no formal guideline in place to guide clinicians in this process and ensure that all patients are provided with equitable services across our area health service. Data collected over the past 10 years shows that late presentation cases of DDH continue to occur, suggesting that current practices are not efficient in all circumstances, calling for clear guidelines in regard to roles and responsibilities of clinicians in the screening, assessment and management of DDH. Hence, this guideline provides a framework by which roles and responsibilities of clinicians regarding the screening, assessment and management of DDH are clearly identified and resources to facilitate this process provided.

Background
There is currently no formal guideline in place within the HNE Health regarding the screening, assessment and management of DDH. Other organisations, both national and international, have published recommended guidelines, and the need for clear screening processes has been evidenced within the literature. The current guideline has been developed based on existing guidelines and evidence currently available within the literature.

Assessment
Based on current evidence, and an identified need within the current workforce regarding clear guidelines for management of DDH, this document is comprised of the following: Information regarding the purpose of the guideline and background information Information regarding risk factors and physical examination related to DDH Clinical Pathways Physiotherapy management of DDH using a brace/harness Resources Appendices

The document has been developed in conjunction with, and reviewed by key stakeholders from across various disciplines and locations within the HNE Health.

Recommendation
The following clinical practice guideline should guide the practice of all clinicians within HNE Health involved in the screening, assessment and management of Developmental Dysplasia of the Hip.

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Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10

GLOSSARY and DEFINITIONS


Listed of acronyms and terms with their definitions Acronym or Term
DDH

Definition
Developmental dysplasia of the hip (DDH) is a condition that affects the neonatal and infant hip joint. DDH is a term used to describe a spectrum of abnormalities affecting the relationship of the femoral head to the acetabulum.3 These may include an immature hip, a hip with mild acetabular dysplasia, a hip that is dislocatable, a hip that is subluxated, or a hip that is frankly dislocated.4 Variables or characteristics that increase the likelihood of an individual developing a particular disease or condition Process by which a clinician carries out hands-on investigation of the patients body to check for signs of disease or condition Documentation tool utilised within some HNE Health facilities to assist with identification of risk factors, appropriate examination and clear documentation of findings. Lying face upwards Lying face downwards In which the fetus is positioned in utero with buttocks and legs facing downwards In which a family member of the patient has a known history of the condition being investigated Condition in pregnancy characterised by a deficiency in amniotic fluid Condition characterised by asymmetrical distortion, or flattening, of one side of the skull A shortening in the muscles of the neck, causing head to tilt to one side Permission obtained from patient or caregiver prior to examination or treatment of that patient Occurs when there is an interruption in the blood supply to the femoral head, causing cellular death

Risk Factors Physical Examination Hip Instability Form

Supine Prone Breech Presentation Family History Oligohydramnios Plagiocephaly Torticollis Consent Avascular Necrosis of the Hip

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Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10

GUIDELINE
MAIN MESSAGE The purpose of this document is to provide guidance to clinicians regarding the screening, assessment and management of Developmental Dysplasia of the Hip (DDH) across Hunter New England Area Health Service. This guideline is designed for use with the full-term infant with no obvious neuromuscular or orthopaedic condition. Clinicians are encouraged to monitor for hip instability in all babies when medically stable, including pre-term infants1. This guideline provides: recommended clinical pathways for screening and assessment of the hips at birth prior to discharge from hospital, at child and family health nurse consultations and general practitioner reviews. an overview of risk factors for DDH recommended procedure for the physical examination of the hips procedures for the treatment of DDH using a pavlik harness. This guideline reflects what is currently recognised as best practice within the literature regarding the management of DDH. It should be used as a guide in assisting clinicians when making management decisions, however each child should be individually evaluated and a clinical decision made according to that childs specific situation. Practice Alert: This guideline is not designed as an educational tool. All clinicians involved in the screening, assessment and management of DDH require training regarding examination and/or management of this condition. Training should be received from experienced colleagues or sought from a tertiary hospital. Recommended educational resources can be found on page 13 of this document.

RISK FACTORS Risk factors play an important role in the identification of DDH. Infants with significant or multiple risk factors are considerably more likely to develop DDH than children without those risk factors, and as such, risk factors provide important information when making decisions regarding the management of an infants hip/s. Risk Factors associated with DDH include1,11: Breech Presentation Family History of DDH (especially if in parent or sibling) Female Baby (DDH is four times more likely to occur in a female infant) Large Baby (>4kg) Overdue > 42 weeks Oligohydramnios Associated with Plagiocephaly, Torticollis and foot deformities First born baby or multiple pregnancies The left hip is affected in 75% of cases, due to the position of the hip in relation to the mothers spine in utero. Risk factors such as oligohydramnios, large or overdue baby and first born or multiple pregnancies increase the risk of DDH as they are associated with decreased intrauterine space. The most significant risk factors for DDH are breech presentation and family history.1 The American Association of Pediatrics recommends routine ultrasound screening at 6 weeks of age for female babies born in the breech position, with optional screening for breech males, as well as females with a family history of DDH1.

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Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10 Practice Alert: Within Hunter New England Area Health Services, routine ultrasound screening at 6 weeks of age should be offered to: 1. All breech presentations 2. Children with a family history (parent or sibling) with DDH If there are 4 or more risk factors present, regardless of what those risk factors are, it is recommended that the infant is closely monitored for DDH with the option of ultrasound screening. PHYSICAL EXAMINATION Physical examination is crucial in initial identification of DDH. The following is a general overview of the procedure for physical examination of the infant hips. Please note that the reliability of physical examination changes as the child grows, therefore examination techniques vary depending on the age of the child. Prior to physical examination, the examiner should5: Gain consent from the parent/guardian Ensure a warm, quiet environment for the examination to occur Ensure the infant is well, relaxed and fed Remove clothing from the lower limbs Place the child on a firm, flat examination surface Birth to 3 months of age Ortolani Test (reduction test) The Ortolani is performed with the newborn supine and the examiners index and middle fingers placed along the greater trochanter with the thumb placed along the inner thigh. The hip is flexed to 90 but not more, and the leg is held in neutral rotation. The hip is gently abducted while lifting the leg anteriorly. With this maneuver, a clunk is felt as the dislocated femoral head reduces into the acetabulum5 Barlow Test (stress test) The Barlow provocative test is performed with the newborn positioned supine and the hips flexed to 90. The leg is then gently adducted while posteriorly directed pressure is placed on the knee. A palpable clunk or sensation of movement is felt as the femoral head exits the acetabulum posteriorly. This is a positive Barlow sign 5 After 3 months of age, the Ortolani and Barlow tests may be unreliable5, therefore additional means of examination, used in combination with the Ortolani and Barlow tests, are necessary. The screening techniques described below may also be used with infants 0-3 months of age. Older Infants (> 3 months of age) Check for restricted abduction at the hips Limited abduction is the most sensitive sign associated with DDH in the older infant.1 With the infant in supine, on a firm, flat surface with pelvis stabilised and hips and knees at 90, abduct and adduct the hips to check for restricted range of motion. This manoeuvre should be performed gradually and may need to be repeated a number of times, to ensure an accurate result is obtained. Normal range of motion at the hip is abduction to 60 or more, with range less than this suggestive of DDH.12 Check for leg length discrepancy Total leg length discrepancy should be assessed in prone with hips and knees extended, as well as assessing for leg length discrepancy using the Galeazzi Test. This test should be conducted with the infant in supine, on a firm, flat surface with the pelvis stabilised and level. Hips are flexed to 90 and placed in neutral adduction/abduction, with knees in flexion. In this position, the vertical level of the knees can be assessed for asymmetry5. Check for asymmetrical thigh and gluteal skin folds With the infant in prone, check for asymmetrical thigh or gluteal folds. Note that asymmetrical skin folds alone do not constitute a diagnosis of DDH1, however this information can be used in combination with other physical signs during assessment. In children who are walking, a limp may be present or the child may toe-walk on the affected side. If DDH is present in both hips, increased lumbar lordosis, prominent buttocks, or a waddling gait may be present9. Version One December 2010 Page 7

Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10

Practice Alert: Abnormal development of the acetabulum cannot be determined by physical examination, but requires imaging techniques to be identified. For this reason, it is important to consider risk factors, not solely results of the physical examination, when making decisions regarding management of the infants hip/s.

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Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10 CLINICAL PATHWAY: EXAMINATION FOLLOWING BIRTH PRIOR TO DISCHARGE FROM HOSPITAL
PHYSICAL EXAMINATION By Medical Practitioner, Midwife or other (according to hospital policy)

Neonatal Hip Instability form completed and placed in infants PHR / result and plan clearly documented in PHR OUTCOME

Normal Hip/s

Breech presentation and/or family history

Unsure

Dislocatable Hip/s

Routine follow up by GP and CFHN as per infants PHR

Prior to discharge: Book ULTRASOUND for 6 weeks of age

Refer to ORTHOPAEDIC SURGEON or PAEDIATRICIAN or GP

Immediate referral to ORTHOPAEDIC SURGEON or PAEDIATRICIAN Contact above for instruction re: timely and suitable followup

Refer to ORTHOPAEDIC SURGEON or PAEDIATRICIAN or GP

Prior to discharge: Book ULTRASOUND for 6 weeks of age

Figure 1 Clinical Pathway: Examination at birth and pathway for discharge from Hospital

All infants should have a hip examination prior to being discharged from hospital following birth. This examination may be conducted by clinicians from various disciplines, as per institutional policy. Findings of this examination, including risk factors, should be documented according to organisational documentation requirements. The neonatal hip instability form should be completed and placed in the infants Personal Health Record (PHR). This form will identify potential risk factors in the infant, assist in ensuring appropriate physical examination is carried out and document referral process if applicable. (See Appendix 1 for sample and how to obtain this form) A normal hip is classified as one that does not present with hip instability, when significant risk factors are not present (see page 5 of this document for details regarding risk factors). Further referral is not required for these infants. Routine examination of the infants hips will be conducted by the child and family health nurse and/or GP at 1-4 week, 6-8 week and at 6 month Child Health Checks, in accordance with schedule in the infants Personal Health Record (PHR). For a breech presentation or if there is a family history (sibling or parent history) of DDH, an Ultrasound should be booked for when the infant is 6 weeks of age. It is recommended that this ultrasound is booked and the family provided with the appointment details prior to discharge from hospital. A referral to the Orthopaedic Surgeon, Paediatrician or GP should be made prior to discharge for all babies born in the breech position or with a family history of DDH, to ensure ultrasound results are followed up and the hip/s are monitored appropriately. If, following physical examination of the hip, the examiner is unsure of hip stability, a referral should be made prior to discharge to the Orthopaedic Surgeon, Paediatrician or GP to ensure the hip/s are monitored appropriately. If the infant has dislocatable hip/s at birth, immediate contact and referral should be made prior to discharge to the Orthopaedic Specialist or Paediatrician to confirm diagnosis and ensure that treatment is commenced. The child may then be referred for treatment via a brace/harness (physiotherapy or an alternative discipline may manage brace/harness treatment in each area). Version One December 2010 Page 9

Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10 CLINICAL PATHWAY: CHILD AND FAMILY HEALTH NURSE FOLLOW UP CHECKS

PHYSICAL EXAMINATION (within 1-4 weeks of discharge)

Findings documented in PHR

OUTCOME

Normal Hip/s

Risk Factors Present

Dislocatable Hip/s OR Unsure

Check hips at 6 weeks and 6 months as per infant PHR

Refer to GP (if prior referral to Orthopaedic Specialist, Paediatrician or GP has not been made)

Immeadiate referral to GP Referral to Paed Physio (if available) Review hips at each CFHN visit

Figure 2 Clinical Pathway: Child and Family Health Nurse Child Health Checks for DDH

All infants should have had a hip examination following birth prior to discharge from hospital, and the neonatal hip instability form (see appendix 1) completed and added to the infants Personal Health Record (PHR). This form will provide information regarding risk factors and the stability of the hip at birth. All infants who were a breech presentation, as well as those with a family history of DDH (parent or sibling) or if the child has significant risk factors (see page 5 of this document for details regarding risk factors) a referral should have been made to the Orthopaedic Surgeon, Paediatrician or GP for the hip/s to be monitored. If these risk factors are present and a referral has not been made, the Child and Family Health Nurse should make a referral to the General Practitioner. The Child and Family Health Nurse is encouraged to monitor the hip/s of those children with significant risk factors on a more regular basis than the PHR suggests for the general population, ideally at each well consultation. If the hip examination identifies that the infant has normal hips, the hips should be monitored at 6-8 weeks and 6 months according to the PHR schedule of the child health checks. Note that physical examination of the hip changes when the infant reaches 3 months of age see page 6 of this booklet for details regarding physical examination. If the physical examination identifies dislocatable hip/s or you are unsure of hip stability, an urgent referral should be made to the GP (and Paediatric Physiotherapist if available) to ensure that the child is referred on to Orthopaedic Surgeon or Paediatrician for appropriate management of the hip. When referring to the GP, a clinical note template is available on CHIME to assist in ensuring the child is reviewed by the GP in a timely manner. For those children with physical signs of DDH, it is recommended that physical examination of the hip be carried out by the Child and Family Health Nurse at all well consultations until the child is walking.

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Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10 CLINICAL PATHWAY: GENERAL PRACTITIONER REVIEW
Referral received from CFHN or Hospital Practitioner

PHYSICAL EXAMINATION (within 2 weeks of referral) OUTCOME

Normal Hip/s

Monitor hips as per infants PHR

Breech presentation OR Family History OR Unsure AGE

Dislocatable Hip/s

Refer for ULTRASOUND or XRAY (according to age brackets on this pathway)

6 weeks to 5 months

> 5 months

Refer for ULTRASOUND

Refer for XRAY

Immediate referral to ORTHOPAEDIC SURGEON or PAEDIATRICIAN Contact above for instruction re: timely and suitable followup

Figure 3 Clinical Pathway: Review and management of DDH by the General Practitioner

Review of the infant hips should occur within 2 weeks of referral. The timeframe in which DDH is identified and treatment begun can have a significant influence on the overall outcome for the infant with DDH. Physical examination should be conducted and risk factors noted. It is recommended that all babies born in the breech position, as well as those with a family history (parent or sibling) of DDH, undergo ultrasound screening at 6 weeks of age the General Practitioner should ensure that this ultrasound has been booked and follow up on results as recommended in the ultrasound report. If physical examination shows normal hips, and there are no significant risk factors present, it is recommended that hips be monitored as per the infants Personal Health Record until the child is walking. If the child was a breech presentation, has a family history (Parent or sibling with DDH) or the practitioner is unsure of hip stability, the child should be referred for imaging. If the child is 6 weeks to 5 months of age, Ultrasound (US) is generally the most appropriate imaging technique9. If the child is 5 months or greater, Xray is generally the most appropriate imaging technique (between 4 and 6 months, US and X-ray are equally effective diagnostic tools1). Note that if the child has significant risk factors, and has already undergone an ultrasound with normal results, further imaging is not necessary unless physical signs are present, or the clinician feels the significance of the risk factors (for example, extensive family history) warrants further investigations. If physical examination shows dislocatable hip/s, immediate contact and referral should be made to an Orthopaedic Surgeon / Paediatrician. Referral for an ultrasound/xray to confirm diagnosis should also be made. Once diagnosis is confirmed by Orthopaedic Surgeon / Paediatrician, the child may be referred for treatment via a brace/harness (generally this requires referral to physiotherapy, however in some areas other disciplines manage brace/harness treatment).

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Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10 PHYSIOTHERAPY MANAGEMENT OF DDH USING A BRACE / HARNESS Children who are diagnosed with DDH in the first 6 months of life may be treated with the application of a hip brace. In the HNE Health the Pavlik Harness is generally utilised for this purpose, however other braces, such as the Dennis-Browne brace may also be used. This document will focus on the process of treatment using a Pavlik Harness. Physiotherapists who receive a referral for an infant below 6 months of age with suspected or diagnosed DDH should review the risk factors of the infant and carry out a physical examination of the hip/s. Application of a pavlik harness should only occur if diagnosis has been confirmed by an Orthopaedic Surgeon or treating Paediatrician. The harness should be applied as soon as possible following confirmation of diagnosis6. Application of the Pavlik Harness10: Fitting the Harness 1. 2. 3. 4. 5. 6. With clothing removed, the baby is laid on top of the harness in supine Shoulder and chest straps are adjusted and velcroed into position Leg straps are adjusted and velcroed into position The optimal hip position within the brace is hip flexion approximately 90 and hip abduction greater than or equal to 60 Check to ensure room for growth at the straps a finger should be able to be comfortably inserted behind each strap. Reapply clothing over the harness

The harness should be kept on at all times, with weekly physiotherapy appointments to remove the harness, bathe the baby and re-apply a clean harness. Skin integrity should be checked at each weekly appointment. Duration of treatment using the harness should be determined in consultation with the Orthopaedic Surgeon. On completion of treatment using the pavlik harness, even if symptoms of DDH have resolved, the physiotherapist should ensure that the child has an appointment with the Orthopaedic Surgeon to review the hip/s once the child is walking. Parent Education It is the responsibility of the Physiotherapist to ensure that parents understand the care instructions for the pavlik harness. The following instructions are of particular importance: The harness must be kept on at all times, unless instructed by the Orthopaedic Surgeon to be removed For this reason, the baby must be sponged bathed with a damp cloth Skin care should be discussed and parents shown those areas that need to be checked regularly for signs of pressure Parents must not change the position of the harness only the Physiotherapist or Orthopaedic Surgeon should change this position

A parent handout should be provided to all parents with a child placed in a pavlik harness. Appendix 2 of this document provides a parental handout on caring for a child in a pavlik harness. Follow Up The physiotherapist should: Ensure the parents have weekly Physiotherapy appointments for a bath / change of harness Ensure the parents have a follow-up appointment with the Orthopaedic Specialist Ensure the parents have contact details of the Physiotherapist

Practice Alert: Avascular necrosis has been identified as a risk associated with application of a Pavlik harness5. Parents should be informed of the risks associated with this treatment.

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Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10 RESOURCES Below is a list of suggested resources that may assist clinicians in the assessment and management of the child with DDH.

Online Training Package An online education package is currently being developed. Check HNE Health intranet sites for availability of this package.

Developmental Dysplasia of the Hip: Learning Resource. Royal Childrens Hospital, Melbourne. This 30 minute 3D animated audiovisual learning package explores the pathology and incidence of DDH, and provides a step-by-step guide to physical examination of the hip. This resource can be accessed via the HNE Intranet through other useful links, or at http://www.education.vic.gov.au/ecsmanagement/matchildhealth/learndevelop/hipdysplasia.htm

Developmental Dysplasia of the Hip Parent Fact Sheet A parent fact sheet regarding DDH can be downloaded from: http://www.chw.edu.au/parents/factsheets/pdf/developmental_dysplasia_of_the_hip.pdf

Child Health Screening and Surveillance: A critical review of the evidence Report prepared by Centre for Community Child Health, Royal Childrens Hospital Melbourne for the National Health and Medical Research Council (NHMRC) Discussion paper reviewing current recommended practices regarding the assessment and management of DDH

Simulation hippy dolls available at a number of sites across HNE Health Baby hippy dolls, that simulate the symptoms of DDH in the infant, enabling clinicians to practice examination techniques are available at many sites across the area health service. Maitland Hospital Paediatric Medicine Department Manning Base Hospital Paediatric Physiotherapy Department Tamworth Hospital Paediatric Physiotherapy Department John Hunter Childrens Hospital Paediatric Physiotherapy Department, Obstetrics and Gynaecology Physiotherapy Department, Paediatric Orthopaedic Department

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Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10

IMPLEMENTATION PLAN
The clinical practice guideline will be formatted into a user-friendly resource booklet and made available on the Kaleidoscope website. Clinical Pathways will be individually downloadable to enable clinicians to print these off and have readily available to refer to within the workplace. The guideline will be presented at JHH Grand Rounds in March, 2011, teleconferenced across HNE Health. During this presentation, staff will be informed where guideline can be accessed, and encouraged to begin using guideline to guide practice immediately. Key stakeholders from each discipline across the area will be involved in the distribution of this document among their colleagues, and feedback will be sought from all those utilising the document 3 months following implementation. A copy of the clinical practice guideline, along with a laminated copy of the Clinical Pathway: General Practitioner Review will be forwarded to all General Practitioners within the HNE Health, according to contact details supplied by General Practice Divisions across the area. The guideline will also be made available to General Practitioners via GP Division internet sites. An online learning package regarding DDH, accessible to HNE HEALTH employees via Mylink will include a link to the clinical guideline. Clinicians who wish be recognised as having completed this education module will be required to complete an online quiz. This quiz will reflect processes outlined within the clinical practice guideline and ensure that clinicians have read and understand their role within these guidelines. Key contacts at Rural Referral Hospital sites will be encouraged to develop local protocols to ensure appropriate implementation across the area health service. This will be facilitated by key stakeholders within each area. Following implementation and review of the guideline, key stakeholders across the North Coast Area Health Service will be approached regarding implementation of this guideline within the North Coast Area Health Service.

EVALUATION PLAN
This guideline will be evaluated by the following methods: Feedback from Key Stakeholders will be sought 3 months following the implementation in the form of a questionnaire. Questionnaires will be distributed via email to clinicians from medicine, midwifery, child and family health nursing and physiotherapy. Key stakeholders will be asked to forward this questionnaire to colleagues involved in the screening, assessment and management of DDH. Data regarding late presentation cases will continue to be collected. This data can be used in a comparative analysis with data collected prior to the implementation of this guideline to investigate possible impact of the clinical practice guideline on early identification and treatment. Paediatric Physiotherapy and Orthopaedic Departments at the John Hunter Childrens Hospital will be responsible for the review of this data in December, 2011. Questionnaires will be sent via mail/fax to General Practitioners regarding the use of the guideline among this population.

CONSULATION WITH KEY STAKEHOLDERS


The following key stakeholders have been involved in the development of this guideline: Prof Eric Ho, Paediatric Orthopaedic Surgeon, John Hunter Childrens Hospital Dr Lynette Reece, Orthopaedic Surgeon, Maitland Hospital Dr Sandeep Tewari, Orthopaedic Surgeon, John Hunter Childrens Hospital Dr Vishal Kapoor, Staff Specialist Paediatrician, Tamworth Base Hospital Dr Keith Howard, Paediatrician, Maitland Jenny Martin, Head of Allied Health, John Hunter Childrens Hospital Denise WongSee, Acting Head of Allied Health, John Hunter Childrens Hospital December 2010 Page 14

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Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10 Christine Smith, Physiotherapist, John Hunter Hospital Carolyn Matthews, Paediatric Physiotherapist, John Hunter Childrens Hospital Kristen Finlay-Jones, Obstetrics and Gynaecology Physiotherapist, John Hunter Hospital Claire Doherty, Physiotherapist, Tamworth Base Hospital Heather Scott, Paediatric Physiotherapist, Manning Base Hospital, Taree Eileen Guest, Child & Family Health Nurse, Newcastle Jennifer Reed, Child & Family Health Nurse, Maitland Louise Austin, Northern Child Health Network Luke Wakely, Physiotherapist, Tamworth.

REFERENCES
1. American Academy of Paediatrics (2000) Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip. Pediatrics, 105(4), 896-905. 2. Royal Prince Alfred Hospital (2004) RPA Newborn Care Guidelines: Developmental Dysplasia of the Hip. Downloaded from http://www.sswahs.nsw.gov.au/rpa/neonatal on 10/01/10. 3. Mahan, ST, Katz, JN & Kim, YJ (2009). To Screen or Not to Screen? A decision analysis of the utility of screening for developmental dysplasia of the hip, Journal Bone and Joint Surgery Am, 91, 17051719. Accessed online at www.ejbjs.org on 03/01/10 4. National Health and Medical Research Council (2002) Child Health Screening and Surveillance: A critical review of the evidence. Report prepared by Centre for Community Child Health, Royal Childrens Hospital Melbourne. Downloaded from www.nhmrc.gov.au 5. The Royal Childrens Hospital Melbourne (2008). Developmental Dysplasia of the Hip: Education Module DVD. Victorian Department of Education and Early Childhood Development 6. Norfolk and Norwich University Hospital (2006). Trust Guideline for Developmental Dysplasia of the Hip (DDH). Accessed online at www.nnuh.nhs.uk on 11/05/2010 7. Shipman, SA, Helfand, M, Moyer, VA & Yawn, BP (2006). Screening for Developmental Dysplasia of the Hip: A systematic review for the US preventive service task force. Pediatrics, 117, 557-576. 8. United States Preventive Services Task Force (2006). Screening for developmental dysplasia of the hip: recommendation statement. National Guideline Clearinghouse, accessed online at www.guideline.gov on 23/02/2010. 9. Karmazyn, DK, Funderman, R, Coley BD, Blatt, ER, Bulas D, Fordham L, Podberesky DJ, Prince JS, Paidas C, Rodriguez W, Expert Panel on pediatric Imiaging. ACR Appropriateness Criteria developmental dysplasia of the hipchild. Accessed online at www.guideline.gov on 23/02/2010. 10. Paediatric & Neonatal Physiotherapy Department, Royal North Shore Hospital (2007). Application of Pavlik Harness Guidelines. Obtained from Barbara Lucas, Physiotherapist, Royal North Shore Hospital. 11. Chan, McCaul, Cundy, Hann Byron-Scott (1997) Perinatal risk factors for developmental dysplasia of the hip, Arch Dis Childhood, 76 (2), 94-100. 12. Walsh, J (2010) Developmental Dysplasia of the Hip, Paediatric & Child Health, 9, 24-26. 13. Verbal consultation with the three primary Paediatric Orthopaedic Surgeons within HNE HEALTH at time of development of this guideline: Dr Lynette Reece, Orthopaedic Surgeon, Maitland District Hospital Prof Eric Ho, Paediatric Orthopaedic Surgeon, John Hunter Childrens Hospital Dr Sandeep Tewari, Orthopaedic Surgeon, John Hunter Childrens Hospital and Manning Base Hospital

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Appendix A: Neonatal Hip Instability Form


Front of form:

Back of form:

The above form can be altered to suit individual organisations and printed onto pads so that the form is easily accessible within both inpatient and outpatient settings. To alter and order copies of the Hip Instability Form, please contact: Rachel Hogan SALMAT Ph: 0409 928 104 rachel.hogan@salmat.com.au Version One December 2010 Page 16

Appendix B

Screening, Assessment and Management of Developmental Dysplasia of the Hip (DDH) HNEH CG 10_10

DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)

CARING FOR YOUR CHILD IN A PAVLIK HARNESS


Caring for your child in a pavlik harness Your Physiotherapist will fit and adjust the harness. Do not remove the harness or adjust the straps. The harness has been fitted in the best position to enable development of the hip joint, and adjusting this may impact on the treatment process. Bathing As the harness cannot be removed, you will need to bathe your baby with a damp cloth. Weekly Physiotherapy appointments will be required so that you can bathe your baby, and a clean harness can be applied. Clothing Disposable nappies work well underneath the harness and help to keep it dry. Clothing may need to be slightly larger than your baby previously required. Skin Care You should check your babys skin daily for any rubbing or chafing. Soft fleecy material can be applied to any areas that are rubbing (your physiotherapist can provide you with this). Skin creases should be checked daily, and a barrier cream such as zinc and castor oil used if irritation occurs. Excessive use of creams or powders is not recommended. Positioning Extensive movement of the legs, such as kicking is not recommended within the harness and should not be encouraged. Continue to encourage tummy time and play during your babys awake times. If you are having difficulty positioning your baby for feeding, speak to your physiotherapist about alternative options. Physiotherapist Name: __________________ Phone Number: ________________________ Follow-up appointments: Date: __________________ Time: __________ Date: __________________ Time: __________ Date: __________________ Time: __________ In older children, or if hip bracing is not effective, surgical intervention, followed by the application of a hip spica plaster may be required to stabilise the hip joint. It is the responsibility of the parent to ensure a followup appointment with the Orthopaedic Specialist has been booked

What is DDH? DDH is a condition that affects the formation of the hip joint in infants. It is usually detected by physical examination in the days following birth. How common is it? Around 1-2 in every 1000 babies will be diagnosed with DDH. It is more common in girls than boys, and is more likely if there is a family history of DDH or the child was carried in the breech position. First babies, large babies and those with another condition such as torticollis have an increased chance of developing DDH. What treatment is required? Children diagnosed within the first months of life are generally treated using a hip brace. This brace positions the hip in the most ideal position to allow the hip joint, and surrounding tissues, to develop. The later a child is diagnosed, the longer this brace may need to be worn. Complications In a small number of children, blood supply to the hip joint may be disrupted. This is called avascular necrosis and does not usually become evident until the child is older and walking. Will further treatment be required? Most hips will stabilise and no further treatment will be required.

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