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## Complete Summary

#### GUIDELINE TITLE

Developmental dysplasia of the hip.

#### BIBLIOGRAPHIC SOURCE(S)

Gunderman R, Strain JD, Cohen HL, Fordham L, McAlister WH, Slovis TL,
Smith WL, Tosi L, Expert Panel on Pediatric Imaging. Developmental
dysplasia of the hip. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2005. 8 p. \[38 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Babcock DS, Hernandez RJ,
Kushner DC, Cohen HL, Gelfand MJ, McAlister WH, Parker BR, Royal SA,
Slovis TL, Smith WL, Strain JD, Strife JL, Tosi L. Developmental
dysplasia of the hip. American College of Radiology. ACR Appropriateness
Criteria. Radiology 2000 Jun;215(Suppl):819-27.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Developmental dysplasia of the hip (DDH)

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Family Practice\
Pediatrics\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
developmental dysplasia of the hip (DDH)

#### TARGET POPULATION

-   All infants in the United States

-   Infants at high risk of developmental dysplasia of the hip (DDH)

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  X-ray, bilateral hips, anteroposterior (AP) view

2.  Ultrasound (US), bilateral hips

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1 to 9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Developmental Dysplasia of the Hip (DDH)**

**Variant 1: Patient \<4 months of age, positive physical findings
(Ortolani or Barlow maneuvers).**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  US, bilateral hips   8                   Prefer to wait until the patient
                                           is at least 2 weeks of age to
                                           perform the US.

  X-ray, bilateral     3                    
  hips, AP view                            

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: Patient \<4 months of age, equivocal physical findings.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  US, bilateral hips   8                   Prefer to wait until the patient
                                           is at least 2 weeks of age to
                                           perform the US.

  X-ray, bilateral     2                    
  hips, AP view                            

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: Patient \<4 months of age, breech presentation or positive
family history. Without physical findings.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  US, bilateral hips   5                   Prefer to wait until the patient
                                           is at least 2 weeks of age to
                                           perform the US.

  X-ray, bilateral     2                    
  hips, AP view                            

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 4: Patient 4 months of age or older. Clinically suspicious for
DDH (limited abduction or abnormal gait.)**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, bilateral     8                    
  hips, AP view                            

  US, bilateral hips   3                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 5: Clinically suspicious for teratogenic dysplasia.**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, bilateral     8                    
  hips, AP view                            

  US, bilateral hips   5                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Definition**

Developmental dysplasia of the hip (DDH), formerly known as congenital
dislocation of the hip, comprises a spectrum of abnormalities that
affect the infant hip, including abnormal acetabular shape (dysplasia)
and malposition of the femoral head ranging from mild subluxability to
fixed dislocation.

**Incidence**

DDH affects 1.5 per 1,000 of the American Caucasian population; it less
frequently affects African Americans. It is four to eight times more
common in females. It is also more common in patients with a family
history of DDH, in first-borns, in women with oligohydramnios, and in
large infants. It is three times more common in the left hip than the
right, likely due to the normal left occiput anterior position in utero,
which places the left hip against the mother\'s spine and limits its
abduction.

**Etiology**

The origin and pathogenesis of DDH are probably multifactorial. Abnormal
laxity of the ligaments and hip capsule is seen in patients and families
with DDH. The maternal hormone relaxin may also be a factor. Mechanical
factors of reduced in utero space and movement restriction are thought
to be causative in conditions such as oligohydramnios and being first
born. Extreme hip flexion with knee extension, as in breech position,
tends to promote femoral head dislocation and leads to shortening and
contracture of the iliopsoas muscle.

**Natural History**

DDH has a bimodal clinical presentation, in the early neonatal period
and late, at approximately 2 to 3 months of age. The acetabulum seems to
be particularly susceptible to remodeling during the first 6 weeks of
postnatal life. The laxity and instability common in newborns may
resolve spontaneously in the first month after birth, as in 80% of the
cases, or progress to subluxation or dislocation.

**Diagnosis**

The diagnosis of DDH may be made by clinical examination or by imaging
methods such as radiography or ultrasound (US). The timing and the
selection of patients requiring imaging evaluation are controversial.

**Clinical Evaluation**

The clinical evaluation of the hips for DDH should be performed at each
well-baby visit. The American Academy of Pediatrics recommends a
well-baby visit at 1-2 weeks, and at 2, 4, 6, 9, and 12 months of age.
As part of the clinical evaluation, it is important to elicit risk
factors for DDH. Examination findings suggesting DDH include a positive
Ortolani or Barlow test, asymmetric skin folds, and shortening of the
thigh observed on the dislocated side. The Ortolani test consists of
abducting and gently lifting the flexed thigh and pushing the greater
trochanter anteriorly; this test is designed to enable the already
dislocated hip to be detected by causing the femoral head to slip into
the acetabulum; a \"clunk\" should be felt or heard. The second test,
introduced by Barlow, consists of a gentle maneuver, with the thumb of
one hand placed over the femoral neck and the fingers placed over the
greater trochanter to try to 1) gently abduct the thigh and dislocate
the femoral head posteriorly, and then 2) gently lift the thigh upward
while abducting the leg with the fingers over the greater trochanter,
endeavoring to relocate the femoral head in its socket. The Barlow test
aims to elicit a dislocation followed by reduction and identifies
unstable hips missed by the Ortolani test. Both tests are designed to
detect instability between the femoral head and acetabulum, indicating
ligamentous or capsular laxity.

In children older than 3 months of age, these tests are less likely to
be positive. In the over 3-month age group, limitation of hip abduction
and extra thigh folds secondary to shortening are more useful clinical
signs of DDH. Once a child is walking, there is a typical limp and the
child often toe-walks on the affected side. If both hips are dislocated,
increased lumbar lordosis, prominent buttocks, and a waddling gait
pattern are present. The physical exam may reveal a stable \"clicking\"
hip, that is, a hip with no laxity but with a \"click\" elicited by the
physical exam. The sensitivity and specificity of the clinical
examination depend on the expertise of the evaluator. Effectiveness of
clinical screening varies, depending on whether an orthopedic surgeon,
experienced pediatrician, or intern performs the examination.

**Radiographic Evaluation**

In the first month of life, when the femoral heads are composed entirely
of cartilage, radiographs are of limited value unless a dislocation is
present. Instability may be undetectable, and evaluation of acetabular
development is influenced by the infant\'s position at the time the
x-ray is taken. By 4 to 6 months of age, radiographs become more
reliable. They are readily available and relatively low in cost.
Radiographs may be performed on patients with neuromuscular disorders,
myelodysplasia, or arthrogryposis (teratologic dislocation) to assess
other bony abnormalities.

Radiography of the pelvis should be obtained with hips in neutral
position. The von Rosen view, with legs at 45-degree angle, abduction,
and thighs internally rotated, may be helpful in accentuating a
dislocated hip that may not be apparent on routine views. Frog-leg view
may be obtained to assess reduction when neutral view is abnormal.

Dislocation or subluxation of the femoral head can be recognized by
evaluating the relationship of the ossific nucleus of the femoral head
and metaphysis to the acetabulum. The nucleus of the femoral head
ossifies at approximately 4 months (50^th^ percentile), with a normal
range of 2 to 8 months. The ossified femoral head nucleus allows easy
evaluation of the relationship of the femoral head to the acetabulum.
However, if the nucleus of the femoral head is not ossified, its
position can be estimated. In addition to evaluating the relationship of
the ossific nucleus of the femoral head, the relationship of the
proximal femoral metaphysis to the acetabulum must also be evaluated.
The medial gap \-- that is, the distance between the most medial portion
of proximal femur and a line drawn perpendicular to the lateral edge of
the acetabulum \-- should not exceed 5 mm. Shenton\'s, Hilgenreiner\'s,
and Perkin\'s lines provide an assessment of the lateral migration of
the femoral head and neck. Shenton\'s line runs from the top of the
obturator foramen and the medial femoral neck to the lesser trochanter,
and should be a smooth curve. The proximal femoral metaphysis should not
be lateral to Perkin\'s line, drawn through the superolateral corner of
the acetabulum. It should also not be superior to Hilgenreiner\'s line,
drawn through the triradiate cartilage.

As the child grows, adaptive changes of the hip joint and femur become
more evident on routine radiography. In DDH, the roof of the acetabulum
is vertically oriented, and often there is a delay in the appearance and
growth of the ossific nucleus of the femoral head, as compared to the
normal hip.

The radiographic evaluation consists predominantly of a visual
assessment; however, measurement of the acetabular index is an objective
parameter that may be used in the diagnosis and follow-up of patients
with DDH. The 95% tolerance interval for intraobserver variability is
8.35 degrees, with interobserver variability exceeding intraobserver
variability; this measurement error casts doubt on the reliability of
the acetabular index based on a single reading.

**Ultrasound Evaluation**

A high-frequency linear array transducer should be used for US
evaluation of the hip. Two methods have emerged: an acetabular
morphology method proposed by Graf and a dynamic stress technique.

In 1980, Graf described a method of static US imaging in the coronal
plane. In normal hips, the round, hypoechoic, speckled femoral head lies
centered in the acetabulum. The Graf method is based on a single coronal
image. The position of the femoral head, appearance of the bony
acetabulum, configuration of the cartilaginous acetabular rim, position
of the cartilaginous labrum, and shape and echogenicity of the
cartilaginous roof are all assessed, and a visual assessment of the hip
is made. An important adjunct in the evaluation of the hips by this
method is the alpha angle. This angle is obtained by drawing a line
along the lateral aspect of the ilium and another line from the lower
iliac margin in the acetabular fossa to the lateral edge of the bony
acetabular roof.

Graf developed a morphologic and geometric hip classification scheme
(types I-IV) using an alpha angle, which measures the osseous acetabular
roof angle, and a beta angle, which defines the position of the
echogenic fibrocartilaginous acetabular labrum. The hips are categorized
according to the following classification:

-   Type I hips are normal and require no treatment and no follow-up,
    the alpha angle is greater than 60 degrees.

-   Type II hips are further subdivided into subtypes: IIa, IIb, IIc,
    and subtype D. In subtype IIa, seen in infants less than 3 months of
    age, the hip is normally located, but the bony acetabulum is
    immature (the alpha angle is between 50-59 degrees). These patients
    require no treatment but should be closely observed clinically and
    with US until they meet type I criteria, there is a small risk of
    delayed displacement or acetabular dysplasia in this group;
    therefore, follow-up is advised.

-   Type III hips (low displacement) and type IV hips (high
    displacement) are usually very apparent clinically, and both require
    immediate treatment, the beta angle should be less than 55 degrees.

Harcke and Grissom, and others developed the dynamic or real-time
method, which attempts to visualize the Barlow and Ortolani maneuvers on
US. This technique is performed in both the coronal and transverse
planes, with and without stress. The modified Barlow maneuver is
performed by holding the knee with the hip flexed 90 degrees and in
adduction. The femur is pushed (pistoned) posteriorly.

In 1993, at a meeting at the Alfred I. duPont Institute, Wilmington,
Delaware, a North American standard for hip US was agreed upon which
combines the two techniques. The standard consists of 1) a coronal view
in the Graf format and 2) a transverse view with the hip flexed, with
and without modified Barlow stress maneuver.

One study assessed the reliability of US assessment of neonatal hips.
Five experienced observers commented on 62 scans of good quality
selected at random. The mean kappa value was \< 0.3 for the agreement of
the shape of the triangular cartilage, the bony modeling, the shape of
the promontory, and four other parameters. There was also very
unsatisfactory agreement with regard to the beta and alpha angles
described by Graf. The intraobserver variability was assessed with
similar results: a kappa of \< 0.67 and significant differences in the
values of the alpha and beta angles were found.

The alpha angle is important when using the Graf technique; it separates
intermediate type IIa hips (alpha angle=50°-59°), which require
follow-up, from normal hips (alpha angle [\>]{.underline} 60°). The
difference between two measurements obtained several months apart on the
same films was 2.3º (SD=10°). The large standard deviation results in a
wide interval, approximately 40°, within which two separate measurements
in the same patient could fall. Other authors have reported similar
findings regarding the reliability of US. This measurement error limits
the usefulness of US measurements in following children undergoing
treatment.

**Other Imaging Modalities**

Computed tomography (CT) and magnetic resonance imaging (MRI) may be
used to evaluate DDH in patients with casts, late presentations, complex
hip dislocations, or avascular necrosis. The primary use of CT in DDH is
for follow-up purposes rather than for initial diagnosis. MRI may be
used in complex dislocations and suspected avascular necrosis. Positive
contrast arthrography is not indicated in the typical case, but may be
performed when concentric reduction is questionable or difficult to
maintain.

**Timing of Evaluation**

The goal of a screening program is to detect all patients with DDH early
on, when therapy is most effective and noninvasive, and to eliminate
those patients without DDH, in whom unnecessary treatment may be costly
and harmful. Delayed diagnosis increases the risk of complications, and
infants diagnosed after 6 months often require surgical correction. Two
types of screening can be performed: generalized screening in which all
neonates are evaluated, and selective screening in which only those at
high risk are evaluated.

**Generalized Screening**

*Clinical Evaluation*

Currently, every neonate undergoes a routine physical examination that
includes evaluation of the hips for stability. Despite neonatal physical
examination screening programs, late presentation of DDH has not been
eliminated. The incidence of late diagnosis with screening remains
within the same range as that of late diagnosis without screening,
albeit at the lower margin. However, it seems beyond debate that these
tests for dislocation and dislocatability are far from accurate in
identifying future cases of unequivocal dislocation of the hip.

*Radiographic Evaluation*

Radiographic evaluation during the first month of life is of limited
value, because the hip may not be subluxed or dislocated at the time
films are obtained, and secondary bony acetabular signs may not be
present. However, radiographic screening at 3 months of age has been
successfully implemented.

*Ultrasound Evaluation*

The major objectives of adding US to the evaluation of patients with DDH
are to reduce the incidence of late diagnosis and to reduce the number
of hips being treated. In one study, US evaluation of every neonate
resulted in no late diagnosis of DDH. Others, however, have documented
an increase in the number of treated hips and no difference in the
incidence of late diagnosis of DDH. Another study reported a similar
increase in the number of treated patients.

**Selective Screening**

*Clinical Evaluation*

All infants should be evaluated by physical examination at well-baby
visits during the first year of life. A normal physical examination does
not preclude the development of a dysplastic hip in an infant.
Therefore, imaging (by radiography or US) should be performed despite a
normal physical exam in all infants at risk. Because instability often
resolves spontaneously by 2 weeks of age, evaluation for instability
should not take place before then.

*Radiographic Evaluation*

By 6 weeks of age, radiographic changes in the acetabulum and lateral
displacement of the femoral neck and metaphysis can be recognized. A
radiographic screening program can be successfully implemented for
infants at 4 months of age who were clinically normal at the neonatal
exam but are considered to be at risk for DDH.

*Ultrasound Evaluation*

When US is used to evaluate high-risk infants, a not statistically
significant trend toward a reduction in the number of late dislocations
is observed, because DDH is diagnosed late in patients with no risk
factors or abnormal clinical exam. Regarding the impact of US on the
number of hips treated in high-risk patients, the results depend on the
timing and frequency of examination. Resolution of US abnormalities
occurs in approximately 50% of patients found initially to have major
laxity on US. Of US abnormalities found using the Graf methodology, 96%
spontaneously resolve. If US is used once during the newborn period and
therapy is instituted on the basis of the US findings, the number of
treated hips is substantially higher than if ultrasound is not used. The
alternative approach of frequent monitoring of a group of high-risk
patients requires significant resources. In addition, if a normal US
were initially performed at 6 weeks of age rather than at birth, the
number of lax hips requiring follow-up examinations would be
significantly reduced. Therefore, US evaluation of high-risk patients
should be performed at approximately six weeks of age.

In one study, patients were treated on the basis of their clinical
findings, not the US results. The authors concluded that newborn infants
who appear normal on clinical examination but whose US findings are
abnormal or suggestive of DDH do not need treatment from birth; most of
these infants\' hips \"settle\" spontaneously; that is, the laxity
resolves.

The routine use of US in screening all neonates and infants cannot be
recommended. A prospective, randomized, controlled trial of over 15,000
infants showed no significant difference in the rates of detection in
infants screened with US versus those screened with high-quality serial
physical examinations. A systematic review of US screening for DDH found
that, compared to clinical screening, US screening may increase
treatment rates, but is also associated with shorter and less invasive
treatment. The authors concluded that evidence is lacking either for or
against general US screening of newborns for DDH.

Evidence-based medicine reviews have suggested that US evaluation should
be regarded as the technique of choice for evaluating high-risk infants
(especially breech presentation and positive family history), clarifying
equivocal physical examination findings, and monitoring treatment in
infants with DDH.

In a 33-center study by the United Kingdom Hip Trial, the use of US
examinations in infants with clinically detected hip instability allowed
a reduction in abduction splinting and was not associated with an
increase in abnormal hip development, higher rates of surgical
treatment, or significantly increased healthcare costs. In a 10-year
prospective study of 34,723 British infants, 2,578 with clinical
instability or risk factors were imaged with US. Instability was present
in 77, of whom only 31% had a risk factor. The authors concluded that
selective US examination may be justified for infants with clinical
instability, family history of DDH, breech presentation, and postural
foot deformity. In an Irish study of 52,893 infants, US examination was
performed on 5,485 infants who had a first-degree relative with DDH,
breech presentation, or a persistent \"click\" in an otherwise stable
hip. Eighteen (.33%) were found to have dislocated hips, and 153 (2.78%)
were found to have dysplastic hips. Based on the finding that 3.2/1,000
infants required treatment, the authors conclude that US screening in
infants with such risk factors is worthwhile.

**Treatment**

Early treatment results in improved outcome. Although there is agreement
in the literature that patients with displacement should be treated and
that those with stable \"clicking\" hips should be followed clinically,
there is some disagreement regarding the treatment of patients with
unstable (lax, but not displaced) hips. Some advocate early treatment
for every patient with instability. Others prefer clinical observation,
because a significant number of these patients (80%) progress
spontaneously to clinically normal status.

**Abbreviations**

-   AP, anteroposterior

-   US, ultrasound

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation
and early diagnosis of developmental dysplasia of the hip (DDH)

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Gunderman R, Strain JD, Cohen HL, Fordham L, McAlister WH, Slovis TL,
Smith WL, Tosi L, Expert Panel on Pediatric Imaging. Developmental
dysplasia of the hip. \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2005. 8 p. \[38 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1999 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Pediatric Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Richard Gunderman, MD, PhD; John D. Strain, MD; Harris
L. Cohen, MD; Lynn Fordham, MD; William H. McAlister, MD; Thomas L.
Slovis, MD; Wilbur L. Smith, MD; Laura Tosi, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Babcock DS, Hernandez RJ,
Kushner DC, Cohen HL, Gelfand MJ, McAlister WH, Parker BR, Royal SA,
Slovis TL, Smith WL, Strain JD, Strife JL, Tosi L. Developmental
dysplasia of the hip. American College of Radiology. ACR Appropriateness
Criteria. Radiology 2000 Jun;215(Suppl):819-27.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricImaging/DevelopmentalDysplasiaoftheHipChildDoc1.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on March 29, 2006.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008