#177: Hip, Hip… Oh No! Developmental Dysplasia of the Hip

May 13, 2026 | By Sydney Engel

Audio

Hip, hip, hooray – it’s time to click into developmental dysplasia of the hip! In this episode, the Cribsiders break down how to spot hips that slip, slide, or simply don’t sit right in the socket. From mastering your Ortolani to knowing when to harness the moment (hello, Pavlik), we’ve got you covered from newborn exam to walking woes. Tune in for can’t-miss pearls that will keep your hip exams on point and your clinical skills in alignment.

Hip Dysplasia Pearls

1. A careful hip exam (in which the infant is relaxed and unclothed) at every visit until walking is the most important tool for detecting DDH.
2. The Ortolani maneuver (a “clunk” with reduction) is the most reliable sign of a dislocated but reducible hip – don’t over-rely on the more subtle Barlow.
3. Any breech positioning in the 3rd trimester warrants a screening hip ultrasound at 6–8 weeks, even if the physical exam is normal.
4. Use ultrasound in infants <6 months (before ossification) and x-ray after 6 months when the femoral head becomes visible.
5. Most infants treated early with a harness develop normal hips, while delayed diagnosis increases the likelihood of surgery and long-term complications.

Developmental Hip Dysplasia Notes 

Pathophysiology

• Abnormal relationship between the ball and the socket of the hip
• Spectrum of disease – includes a) a hip that is in the socket but moves out, b) a hip out of the socket that can be relocated, and c) a hip that is unable to be relocated into the socket
• Typically not painful for the child

Risk factors

• Feet first (i.e., breech position, includes any time in 3^rd trimester) – 4-6x increased risk (JAMA, 2025)
• First born
• Female
• Family history
• Newborn positioning also matters – avoid tight swaddling of lower extremities

Exam

• A high quality exam is the most important step for detection and diagnosis!
• Should be done every visit until walking
• Infant should be relaxed and unclothed during exam
• All infants:
  • Abduction: Look for symmetry
  • Gluteal/thigh crease symmetry
• Younger infant:
  • Ortolani: Most essential
  • Barlow: More subtle/difficult to detect
  • Expert tip: If the Ortolani or Barlow test is positive in an infant >6 weeks, it is reasonable to refer to orthopedics prior to/while awaiting imaging
• Older infant:
  • Galeazzi
  • Crawling patterns
  • Expert tip: Have a low threshold to x-ray for any abnormal findings including atypical crawling/walking

Source: International Hip Dysplasia Institute 

Imaging

• Ultrasound: Should be obtained at 6-8 weeks for all infants with history of breech positioning in the 3^rd trimester, as well as for any abnormal exam findings at <6 months
• X-ray (AP and frog-leg): Consider at 6-12 months for a patient with history of breech positioning, as well as for abnormal exam findings after 6 months

Treatment

Treatment typically follows a stepwise approach, which includes:

• Pavlik harness:
  • First step for DDH in a younger infant (usually <6 mo) with a stable hip but an abnormal alpha angle on ultrasound (angle created by lines along the bony acetabulum and the ilium)
  • Weekly monitoring ultrasounds for the first few weeks
  • Typically takes about 3 weeks for hip to reduce
  • Standard course is full-time use for ~6 weeks after the hip is reduced and stable, followed by a weaning process that varies by clinician
  • Baby should be able to move and kick without pain – evaluate immediately for any changes in movement
• Rigid hip abduction brace: May be attempted prior to surgical reduction when there is inadequate reduction with Pavlik harness
• Closed reduction: Often indicated when diagnosed after 6 months. Performed in the OR – hip is manipulated into reduced position and then cast is applied. Cast is typically worn for 3 months.
• Open reduction: Often indicated for babies >12 months

Follow up

• Children treated early with harnessing typically go on to have normal hips
• Children with a history of surgical reduction should have routine follow up through skeletal maturity to monitor for proximal femoral growth disturbances
• Monitor for progress towards walking – most babies do figure out how to walk within 6-8 weeks of spica cast removal

Links

• Hip Dysplasia Institute
• DDH Clinical Guidelines 

Goal

Listeners will be able to recognize risk factors and exam findings of developmental dysplasia of the hip and counsel families on appropriate screening, imaging, and stepwise management options.

Learning Objectives

After listening to this episode listeners will…  

1. Explain the pathophysiology and spectrum of developmental dysplasia of the hip.
2. Identify key risk factors for DDH, including breech positioning, female sex, family history, and first-born status.
3. Describe the components of a high-quality hip exam in infants, including the use of Ortolani and Barlow maneuvers and age-specific exam findings.
4. Identify appropriate indications for imaging in DDH, including when to obtain ultrasound versus x-ray based on age and clinical findings.
5. Explain the stepwise management of DDH, including the role of Pavlik harness, bracing, and surgical interventions based on patient age and response to treatment.

Disclosures

Dr. Fornari reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Engel S, Fornari E, Chiu C, Masur S. “#177 Hip, Hip… Oh No! Developmental Dysplasia of the Hip”. The Cribsiders Podcast. https:/www.thecribsiders.com/ May 13th, 2026.