Developmental Dysplasia of Hip

Introduction

If your child has been diagnosed with developmental dysplasia of the hip — usually shortened to DDH — you are probably reading this in the early days after the diagnosis, when there is a lot of new information to take in. This guide is written for you. It explains what DDH is, why it happens, how it is treated at different ages, what recovery looks like, and what follow-up your child is likely to need over the coming years.

The most important thing to know at the start is that DDH is treatable, and that the outlook for children diagnosed early is generally very good. Treatment is matched to your child’s age, the severity of the dysplasia, and how the hip responds. Some children need only a soft harness for a few weeks. Others need a procedure under anaesthesia or, in older children, surgery to reshape the hip socket. Across all of these paths, the goal is the same: to give the hip joint the best possible chance to grow into a stable, normal-functioning hip.

Because DDH care is age-dependent and unfolds over months or years, this article is organised to help you understand both the immediate decisions in front of you and the longer arc of follow-up that will continue as your child grows.

What Is Developmental Dysplasia of the Hip?

The hip is a ball-and-socket joint. The rounded top of the thigh bone (the femoral head, or “ball”) sits inside a cup-shaped part of the pelvis (the acetabulum, or “socket”). In a normal hip, the ball fits deeply and snugly into the socket, and the two grow together during infancy and childhood.

In developmental dysplasia of the hip, this fit is not quite right. The term covers a spectrum:

• Mild dysplasia — the socket is a little shallow, but the ball is in place.
• Hip instability — the ball is in the socket but can be pushed partly out on examination.
• Subluxation — the ball sits partly outside the socket.
• Dislocation — the ball is fully out of the socket.

The word “developmental” is important. DDH is not always present at birth in its most obvious form. Some hips look normal at first and then become unstable or shallow over the first weeks and months of life. This is why hip checks are repeated during routine baby visits, and why a hip that was “fine” at the newborn check can still develop a problem later.

DDH usually affects one hip more often than both, and the left hip is more commonly involved than the right. It is more common in girls than in boys.

Causes and Risk Factors

There is no single cause of DDH. It is generally understood as the result of several factors working together — some involving the baby’s position in the womb, some involving genetics, and some involving the natural looseness of an infant’s ligaments.

Factors that increase the likelihood of DDH include:

• Female sex. Girls are several times more likely than boys to be affected, in part because they are more sensitive to the hormones that loosen ligaments during late pregnancy.
• Breech position in the womb, especially in the last trimester. The hips of a breech baby are often folded in a way that puts pressure on the developing joint.
• Family history of DDH in a parent or sibling.
• First-born babies, where the uterus has not stretched from a previous pregnancy and space is tighter.
• Low amniotic fluid (oligohydramnios), which also restricts space.
• Tight swaddling with the legs straight and pressed together, which can keep the hips in an unfavourable position after birth.

It is important to be clear that nothing a parent did or did not do during pregnancy “caused” DDH. The condition reflects how the joint developed, not parenting choices. The one practical point parents are often counselled about is hip-safe swaddling — allowing the baby’s hips to bend and spread freely rather than being tightly wrapped straight.

Signs That Lead to a DDH Diagnosis

Most children with DDH are identified in one of two ways: through routine newborn and infant hip examination, or because a parent or doctor notices something different about the hip as the child grows. If you are reading this after a diagnosis, you will already be familiar with whichever route led you here. This section is meant to give context for what doctors look at, and to help parents of children who present later understand why the diagnosis was made.

In newborns and young infants

• A hip “clunk” or “click” felt during examination.
• Uneven skin folds at the groin or behind the thigh.
• Limited ability to spread one leg out to the side (limited abduction).
• An apparent difference in leg length when the knees are bent.

In older babies and toddlers

• Delayed walking, or walking with an uneven pattern.
• A limp or a “waddling” gait when both hips are affected.
• Walking on the toes on one side.
• One leg appearing shorter than the other.

DDH in infants is generally painless. Pain tends to appear only much later if untreated dysplasia leads to joint damage in adolescence or adulthood. The absence of pain is one reason routine screening matters so much: a baby with DDH will not cry or complain, and the condition can otherwise be easy to miss.

How DDH Is Diagnosed

Diagnosis combines a careful physical examination with imaging.

Physical examination

Two classic manoeuvres are used in newborns:

• The Ortolani test, in which the examiner gently lifts and spreads the hip to see whether a dislocated ball can be moved back into the socket.
• The Barlow test, in which gentle pressure is applied to see whether a hip that is “in” can be pushed “out.”

In older infants, the joint stiffens and these tests become less useful. Examiners then look more at hip abduction (how far the hips can spread), thigh fold symmetry, and apparent leg length.

Imaging

• Ultrasound is the imaging method of choice for babies under about six months. At this age, much of the hip is still made of cartilage, and ultrasound shows the soft structures well without using radiation.
• X-ray becomes more useful from around four to six months onwards, when the femoral head begins to ossify (turn into bone) and shows up clearly on plain films.
• MRI or CT is sometimes used after surgery or in more complex cases to assess hip position inside a cast.

The American Academy of Pediatrics and the American Academy of Orthopaedic Surgeons both recommend that infants with risk factors — particularly breech-positioned girls and babies with a family history — receive imaging even when the physical examination is normal, because some cases are missed on examination alone.

An Overview of Treatment by Age

DDH treatment is strongly age-dependent. The same hip looks very different at three months, nine months, and three years, and the treatment that fits an infant is not appropriate for a toddler. Broadly, treatment follows this pattern:

• Birth to around 6 months: non-surgical treatment with a harness or brace is the usual first step.
• Around 6 to 18 months: closed reduction under anaesthesia with a hip spica cast, sometimes preceded by traction, is commonly used when bracing has not worked or the child presents later.
• Around 18 months and older: open reduction (surgery to put the hip back in place) is more often needed, sometimes combined with bone-reshaping procedures (osteotomy).
• Older children and adolescents: more complex bony surgery may be needed to correct residual dysplasia.

These age bands overlap and are not rigid. The treating team will make recommendations based on your child’s specific hip, response to earlier treatment, and overall health.

Non-Surgical Treatment

The Pavlik harness

For babies diagnosed in the first few months of life, the Pavlik harness is the most widely used treatment. It is a soft cloth harness with shoulder straps and stirrups that hold the hips in a flexed and slightly spread-out position. In this position, the ball of the hip is pushed gently into the socket, and the socket is encouraged to deepen as the joint grows.

Key points about Pavlik harness treatment:

• It is usually worn full-time at first — including during sleep, feeding, and nappy changes — for several weeks.
• The doctor adjusts the straps as the baby grows, and checks the hips by examination and ultrasound at regular intervals.
• Treatment typically continues for several weeks to a few months, with a gradual reduction in wear time as the hip stabilises.
• Parents are taught how to handle, bathe, and dress the baby with the harness on. Skin care under the straps is important.

When started early, Pavlik harness treatment is successful in the majority of stable and reducible hips. Success is less likely if the hip is fully dislocated and cannot be reduced into the socket, or if treatment is started after about four to six months of age. If the harness has not produced a stable hip after a few weeks of correct use, doctors generally move on to the next step rather than continuing indefinitely, because prolonged unsuccessful Pavlik use can put the femoral head at risk.

Abduction braces

For some babies — for example, those who have outgrown the Pavlik harness, those with milder dysplasia, or those who need ongoing support after a procedure — a more rigid abduction brace may be used. These braces hold the hips in a wider position and are usually worn for a defined number of months while the socket continues to mature.

Procedures and Surgery

When non-surgical treatment is not appropriate — either because the hip is too dislocated to begin with, the harness has not worked, or the child is too old — doctors move to procedures performed under general anaesthesia.

Closed reduction and hip spica cast

A closed reduction is a procedure in which the surgeon manipulates the hip back into the socket without making a large cut. It is typically used in babies from about six to eighteen months old, although the exact age range varies.

Steps usually include:

• The child is given general anaesthesia.
• The surgeon gently moves the leg through specific positions to guide the femoral head into the socket.
• Imaging (often a hip arthrogram, where a small amount of contrast is injected to outline the joint) is used to confirm the hip is well seated.
• A hip spica cast — a cast that wraps around the lower trunk and one or both legs — is applied to hold the hip in the corrected position.

The spica cast is usually worn for several weeks, often with one cast change under anaesthesia. After the cast is removed, the child commonly transitions to an abduction brace for several more months while the socket continues to deepen.

Open reduction

An open reduction is a surgical procedure in which the surgeon makes an incision over the hip to remove or release tissue that is blocking the femoral head from sitting properly in the socket. It is used when closed reduction is not successful or when the child is too old for closed reduction to be likely to work — usually from around 18 months onwards, though the threshold varies.

During open reduction, the surgeon may:

• Release a tight muscle or tendon that is pulling the hip out of position.
• Remove tissue inside the socket that is preventing the femoral head from sitting deeply.
• Tighten the joint capsule to help hold the hip in place.

Open reduction is generally followed by a hip spica cast.

Bone-reshaping surgery (osteotomy)

In older children, or when the bony shape of the socket or the upper thigh bone is too abnormal to be corrected by soft-tissue surgery alone, doctors may add a bone procedure called an osteotomy. The bone is cut and repositioned so that the socket better covers the ball or the angle of the thigh bone better matches the socket.

The two main types are:

• Pelvic osteotomy — the pelvis is cut and reshaped to improve coverage of the femoral head by the socket. Several specific techniques exist (such as Salter, Pemberton, Dega, and triple osteotomies), each suited to particular ages and patterns of dysplasia.
• Femoral osteotomy — the upper thigh bone is cut and realigned, typically to reduce excessive angle or rotation. Plates and screws hold the bone in place while it heals; these are often removed in a later, smaller operation.

In some children, pelvic and femoral osteotomies are combined in a single operation. The decision depends on the shape of the hip on imaging, the child’s age, and the surgeon’s assessment.

A note on minimally invasive techniques

Parents sometimes ask whether DDH can be corrected with arthroscopy or robotic surgery. In children, these approaches are not the standard tools for correcting dysplasia or dislocation. Hip arthroscopy plays a more established role in older adolescents and adults with residual dysplasia or related conditions, not in the primary treatment of childhood DDH.

Living with a Hip Spica Cast

For many families, the spica cast is the most demanding part of treatment. The cast is large, the baby or toddler cannot bend at the hips, and daily routines need to change for several weeks.

Practical things to expect and prepare for:

• Nappy care. The cast has an opening for nappy changes. Smaller nappies tucked inside a larger outer nappy, frequent changes, and careful cleaning all help keep the cast dry and prevent skin problems.
• Skin checks. Skin at the edges of the cast can become red or sore. Parents are taught to check the edges daily and to watch for any unusual smell, drainage, or discomfort.
• Feeding. Older babies and toddlers may need to be fed in a slightly reclined position. Bottle and breastfeeding positions can be adapted.
• Sleep. A firm, supportive surface helps. Pillows or wedges can be used to change position as advised.
• Travel. Standard car seats often do not fit around a spica cast. Special spica-compatible car seats or travel vests may be needed. Plan this before the cast is applied.
• Activities. Babies and toddlers in casts can still play, be carried, and interact normally. Floor time on a blanket, age-appropriate toys, and being held are all important for development.

Recovery from DDH treatment is gradual and is paced by the hip’s healing, not by a fixed timetable. What follows is a general picture; your child’s surgeon will give you specifics.

After a Pavlik harness

Once the harness is no longer needed, most babies move easily back into normal positions and developmental milestones such as rolling, sitting, and crawling. Follow-up ultrasound or X-ray is used to confirm that the hip is continuing to develop normally.

After closed or open reduction

• In the cast (weeks): the hip is held in position while the soft tissues heal around the corrected joint.
• After cast removal: the hip and leg will look thinner because of muscle loss, and the joint will be stiff. This is expected. Movement returns gradually over several weeks as the child uses the leg again.
• Bracing phase: an abduction brace is often worn for several more months, sometimes only at night by the end of treatment.
• Walking: children who were already walking before surgery typically need a few weeks to relearn balance and rebuild strength. Many do this through normal play rather than formal physiotherapy, although physiotherapy may be added if progress is slow.

After osteotomy

Recovery is longer because the bone needs to heal. Weight-bearing restrictions and follow-up imaging are used to confirm that the bone has united before normal activity is resumed. Internal hardware (plates and screws) is often removed in a smaller, planned operation months later.

Long-Term Follow-Up

DDH is not a condition that ends when the cast comes off or the brace is put away. The hip continues to grow throughout childhood, and follow-up is used to make sure that growth is healthy.

Long-term follow-up typically includes:

• Periodic clinical reviews with the paediatric orthopaedic surgeon.
• X-rays of the hips at intervals, often yearly or every couple of years, depending on how the hip is developing.
• Watching for residual dysplasia — a socket that remains a little shallow even after successful early treatment.
• Continuing follow-up until skeletal maturity (the end of growth), so that any late changes can be picked up and addressed.

Some children who appear fully corrected in early childhood are found, on later X-rays, to have a hip that has not finished developing as expected. Identifying this in childhood or adolescence is important because it is easier to address at that stage than after adult joint changes have set in.

Risks and Complications

Every treatment carries some risk. The most important risks specific to DDH treatment are:

• Avascular necrosis of the femoral head. This is when the blood supply to the ball of the hip is disturbed, which can affect its growth. It is uncommon but is a recognised risk of any treatment that forces the hip into a corrected position, including the Pavlik harness, closed reduction, and open reduction. The risk is one of the reasons doctors do not push the harness for too long without progress, and one of the reasons imaging is used carefully during reduction.
• Recurrent dislocation or residual dysplasia. The hip may slip out again, or may remain shallow even after the ball is in place. Either may require further treatment.
• Stiffness or limited movement. Some loss of range of motion is common immediately after a cast and usually improves with time.
• Leg length difference. A small difference between the two legs can persist, especially after late-diagnosed unilateral DDH. Small differences usually do not cause functional problems; larger ones may need attention as the child grows.
• Skin problems from harnesses, braces, or casts — usually preventable with careful daily care.
• Surgical risks common to any operation: bleeding, infection, anaesthesia-related risks, and the need for further surgery.

The paediatric orthopaedic team will go through the specific risks of your child’s recommended treatment with you before consent.

Outlook and Life After DDH Treatment

The outlook for children with DDH depends mainly on how early the condition was identified and how the hip has responded to treatment. Children diagnosed and treated in the first few months of life generally do very well, with hips that develop normally and full participation in walking, running, sports, and other physical activities. Children diagnosed later may still do well but tend to need more intensive treatment, and the chance of some residual change in the hip is higher.

Untreated or late-treated DDH is a leading cause of early adult hip arthritis. This is the reason behind so much emphasis on early diagnosis and on long-term follow-up: addressing problems in childhood and adolescence is generally far better tolerated than addressing them after adult joint damage has occurred.

For most families, by the time the child reaches school age, DDH has become a part of the medical history rather than a part of daily life — with the exception of scheduled follow-up appointments. Even so, it is worth keeping records of treatments, surgeries, and imaging, because they remain relevant if any hip symptoms appear later in life.

How to Think About Choosing a Surgeon and Centre

Because DDH care can span years and may involve more than one procedure, continuity with a paediatric orthopaedic team matters. Things parents commonly look at when choosing a centre include:

• Specific experience in paediatric hip disorders, including the age range of your child.
• Familiarity with the full range of treatments — bracing, closed reduction, open reduction, and osteotomy — so that a child whose needs change is not steered into a single technique.
• Availability of paediatric anaesthesia and paediatric imaging.
• Clear communication about what each step involves, what alternatives exist, and what follow-up will be required.
• A good working relationship between the family and the team, including the ability to ask questions and get clear answers.

Meeting more than one specialist before committing to surgery is a reasonable step, particularly for older children or complex cases where there is real choice between approaches.

Supporting Your Child Through Treatment

Children, especially young ones, take many cues from their parents. A few practical things tend to help:

• Use simple, honest language appropriate to the child’s age. For toddlers, “the doctor is going to help your hip grow strong” is often enough.
• Keep routines as normal as possible during bracing or cast time — meals, songs, books, and play.
• Allow yourself support. Caring for a baby in a harness, or a toddler in a spica cast, is physically and emotionally demanding. Asking family and friends for specific help (a meal, an hour of company, a school run) is reasonable.
• Connect with other parents if that helps you. Many find that hearing from families a few months ahead in the same journey is reassuring.

Frequently Asked Questions

Did I do something during pregnancy that caused this?

No. DDH is influenced by factors such as the baby’s position in the womb, family history, and natural ligament looseness in infants. It is not caused by anything a parent did or did not do during pregnancy.

If my child has DDH, will the next baby have it too?

Having one child with DDH does increase the chance of DDH in siblings, though most siblings will not be affected. Future babies are typically screened more carefully, including with hip ultrasound, regardless of how they look on examination.

Can DDH be treated without surgery?

Yes — in many cases, particularly when DDH is identified in the first few months of life, a Pavlik harness or brace is enough. Surgery becomes more likely when the diagnosis is late or when bracing has not worked.

How long will my baby need to wear the harness?

This varies. Many babies wear the harness full-time for several weeks and then taper to part-time wear for a few more weeks or months, guided by examination and ultrasound. The treating team will plan and adjust this as the hip responds.

Will my child be able to walk normally?

Most children with treated DDH walk normally and participate fully in physical activities. The chance of completely normal hip development is highest when treatment starts early.

Will my child be able to play sports?

Children who have had successful DDH treatment are generally able to take part in sports and active play, often without any restrictions. Specific advice may be given after recent surgery while bone or soft tissues are still healing.

Will my child need a hip replacement later?

Most children treated successfully in infancy or early childhood do not. The risk of needing a joint replacement in adulthood is higher when DDH was untreated, treated very late, or left the hip with residual dysplasia despite treatment. This is one of the reasons long-term follow-up is important.

What about baby carriers and swaddling?

Hip-healthy positioning — allowing the hips to bend and spread, rather than being held tightly straight — is recommended for all babies, and especially for those at risk of or being treated for DDH. The orthopaedic team will give specific guidance during treatment.

How often will follow-up be needed?

This depends on age, treatment, and how the hip is developing. After active treatment ends, follow-up visits and X-rays typically continue at intervals through childhood and adolescence, ending around skeletal maturity.

Conclusion

Developmental dysplasia of the hip is a treatable condition, and the great majority of children diagnosed in time grow up to walk, run, and play like any other child. The treatment path depends on your child’s age and the specific hip: a harness in infancy, a procedure with a cast in older babies, surgery and sometimes bone reshaping in older children. What ties all of these together is the same goal — a stable, well-formed hip that will serve your child for a lifetime.

Equally important is the long view. DDH care does not end when the harness comes off or the cast is removed; periodic follow-up through childhood and adolescence is part of giving the hip the best possible chance to develop normally. Understanding this from the beginning makes the journey feel less like a series of separate events and more like a single, well-coordinated plan for your child’s hip health.