Hip Dysplasia Screening (DDH)
Why every baby's hips are checked at birth, 6–8 weeks, and 4 months — and why early detection matters.
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- Dr Jubal John, FRACP
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- medical guides
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Take-home
Developmental dysplasia of the hip (DDH) is a spectrum, from a shallow socket that settles on its own (common) to a fully dislocated hip (rare). As a useful rule of thumb: around 1–2% of babies have some degree of hip dysplasia needing bracing, and around 1 in 1,000 has a frank dislocation (Pregnancy Birth and Baby). That is why every baby’s hips are examined at birth, 6–8 weeks, and 4 months, and why babies with risk factors have an ultrasound at around 6 weeks. Early treatment, usually just a brace, is highly effective: around 85% of DDH cases respond to bracing, and around 95% of babies with DDH can be successfully treated overall.
What is developmental dysplasia of the hip?
The hip is a ball-and-socket joint. “Dysplasia” means the socket is shallower than it should be. DDH is a range of conditions, not a single diagnosis:
- Hip immaturity / mild dysplasia: shallow socket, hip is stable. Most resolve on their own.
- Hip instability: the ball can be pushed partly out of the socket but returns to it. Sometimes noted as “laxity” of hips.
- Subluxation: the ball sits partly out of socket.
- Dislocation: the ball is fully out of the socket.
How common is each?
The numbers in context
- Around 1–2% of babies have some degree of hip dysplasia detectable in the first weeks, this is the group that may benefit from a Pavlik harness or similar bracing.
- Around 1 in 1,000 newborns has a frank dislocation, these are the babies most likely to need closed reduction, casting, or surgery.
- DDH is more common on the left hip (the way most babies tuck into the pelvis in utero) and meaningfully more common in girls than boys.
Why the spread matters
Parents often hear “1 in 1,000” and think DDH is very rare. That number is correct for the most severe end, frank dislocation. The wider spectrum of hip dysplasia needing a brace is around 10 times more common (1–2% of babies). That is why universal clinical screening exists, and why the 6-week paediatrician review is not skippable.
Risk factors for DDH
Even though roughly 75% of DDH cases occur in babies with no risk factors (which is why every baby is examined), the following raise the risk significantly and trigger a 6-week hip ultrasound as standard practice:
Green — usually fine
Major risk factors: always prompt an ultrasound
- Breech position from 36 weeks onwards (or at birth): the single strongest risk factor for DDH, warranting routine 6-week ultrasound regardless of clinical examination.
- Family history: first-degree relative (parent or sibling) with DDH
- Suspicious newborn hip examination: positive Ortolani or Barlow test, asymmetry, restricted abduction
Amber — be alert
Contributing risk factors: ultrasound considered if more than one
- Female sex: about 4 in 5 DDH cases are in girls
- Firstborn: the uterus is tighter, limiting room to move
- Oligohydramnios (low amniotic fluid)
- Multiple pregnancy (twins, triplets)
- Large birth weight
- Other “packaging” problems: torticollis, plagiocephaly, positional talipes, congenital knee issues
Red — act now
Post-birth risk factors
- Tight swaddling with legs extended: significantly increases DDH risk. Use hip-healthy swaddling (legs free to flex up and out, sometimes called “M-position” or “frog-leg”). See Red Nose and the International Hip Dysplasia Institute for safe wrapping.
- Carrying in narrow baby carriers that hold legs straight down
A note on breech position
Breech position is by far the most important factor. Around 3–4% of babies present breech near term, so this is not unusual. If your baby was breech at any point from 36 weeks or at delivery, mention it to every clinician who examines your baby. A 6-week hip ultrasound should be booked as standard.
Victorian screening protocol
Universal screening in Victoria is clinical examination at three key time-points, plus ultrasound for the risk groups.
Watch closely — MCH Line 13 22 29 for advice
Birth (within 72 hours)
- Newborn examination by paediatrician or trained midwife
- Ortolani and Barlow manoeuvres to test hip stability
- Check of leg length, skin creases, and hip abduction
6–8 weeks
- Repeat hip examination at the paediatric 6-week check and at the MCH nurse review
- Hip ultrasound for all babies with major risk factors, typically at 4–6 weeks of age (earlier ultrasounds miss changes because hips are still developing)
4 months
- Check for limited or asymmetric hip abduction, from this age, the Ortolani/Barlow tests are less reliable, and ultrasound is no longer useful
- From 4–6 months, hip X-ray replaces ultrasound if any concern remains
6–12 months and beyond
- Continuing surveillance at routine MCH and paediatric reviews
- Once a baby is weight-bearing and walking, any asymmetry in gait or leg length is checked
Signs parents may notice
In the first months
What's worth mentioning at a review
- Asymmetric thigh or buttock creases: extra or uneven skin folds (common and often innocent, but worth a look)
- One leg appears shorter when knees are bent up (Galeazzi sign)
- Difficulty with nappy changes: one hip doesn’t open as wide when you try to spread the knees outward
- “Clicky” hips: a click you feel when moving the hip. Note: most clicks are benign (the Australian DDH eHandbook describes the spectrum), but all are checked.
- Different leg positions at rest, one leg turning outward more than the other
In older babies and toddlers
Late signs, late diagnosis is harder to treat
Any of these warrant a prompt assessment, because treatment after 6 months becomes progressively more complex:
- Delayed walking: not walking by 18 months
- Limping or waddling gait once walking begins
- Leg length difference: one leg clearly shorter
- Walking on tiptoe on one side (to compensate for the short leg)
- A new limp in a previously well child → same-day review
How treatment changes with age
Treatment depends on when DDH is diagnosed. Earlier is simpler and more effective, which is the whole point of screening.
Birth to about 6 months: Pavlik harness
Pavlik harness
- A soft fabric harness that holds the hips in a flexed, abducted position (the natural “frog-leg” that babies take when allowed to)
- Worn 23 hours a day for 6–12 weeks
- Allows gentle movement while keeping the ball in the socket
- Over 9 in 10 babies respond well when treatment starts before 6 months
- Regular ultrasound monitoring during treatment
- Clothing, car seats, and most daily activities carry on normally
6–18 months: closed reduction + spica cast
Closed reduction
- If the Pavlik harness hasn’t worked (or diagnosis is later), the hip is positioned back into the socket under a short general anaesthetic
- A plaster spica cast (chest to ankles) holds the position
- Cast changed every 6–12 weeks over around 3–4 months total
- A brace may be used afterwards
Over 18 months: open surgery
Open reduction
- After 18 months, the hip usually needs surgical repositioning
- May include bone reshaping (osteotomy) of the femur or pelvis
- Spica cast after surgery, longer recovery
- Outcomes are still good, but the intervention is more complex, which is why catching DDH in the first 6 months matters.
Supporting your baby during treatment
Pavlik harness practicalities
- Dress baby in loose clothing that opens at the front: bodysuits with press-studs work well
- Check the skin daily under the straps for any redness or rubbing
- Sponge bath only while the harness is on (no tub bath)
- Never adjust the straps yourself: your orthopaedic team will adjust at each visit
- A car seat fitted with wider leg openings may be needed, your hospital usually has loan options
- Baby can still feed, sleep in a standard cot (on the back), and be carried normally
Emotional support
- Normal bonding, skin-to-skin, tummy time and play all continue
- Consider joining a DDH support group. Healthy Hips Australia runs an active parent community
- Harness time feels long while you’re in it; in the context of a whole childhood, it is brief
- Photos each week help you see the progress, which can be hard to notice day-to-day
Long-term outlook
With early detection and treatment, the vast majority of children with DDH have completely normal hip function.
Outcomes with early treatment
- Over 9 in 10 babies treated before 6 months avoid surgery altogether
- Normal activity levels after treatment, running, jumping, sport
- Long-term X-ray follow-up until skeletal maturity is standard, to be sure the socket is developing well
- If DDH is caught late, outcomes are still generally good, but with a higher chance of needing surgery and a longer rehabilitation
Follow-up after treatment
Children treated for DDH need periodic hip X-rays until skeletal maturity (around age 14–16) to monitor socket development, even after a successful early Pavlik harness. This is routine orthopaedic surveillance, not a sign something is wrong.
Hip-healthy swaddling
One of the few modifiable factors is how babies are wrapped. The International Hip Dysplasia Institute, Red Nose Australia, and every paediatric orthopaedic society agree: the legs should be free to bend up and out at the hips inside a wrap or sleeping bag.
Arms can be snug (arms down for sleep safety until rolling starts) but legs always need room. Sleeping bags with a generous leg pouch are ideal. See Safe Sleep for the full Red Nose recommendations.
Common questions
“My baby has a hip click: does that mean DDH?”
Most clicks are benign and settle on their own. Hip clicks are common in newborn examinations and the Australian DDH eHandbook outlines when an ultrasound is warranted. Every click is examined, and a hip ultrasound is arranged if there is any doubt, but the majority turn out to be normal.
“My baby was breech: do we definitely need an ultrasound?”
Yes. As standard practice, breech presentation from 36 weeks or at birth triggers a 6-week hip ultrasound as standard, even if the newborn hip examination is normal. It is the single strongest risk factor.
“Will DDH cause pain for my baby?”
Untreated DDH is not painful in babies (which is why it can go undetected without screening). Pain can develop in older children or adults with untreated dysplasia, which is part of why early treatment matters.
“Is DDH caused by anything I did?”
No. DDH is about anatomy and positioning in the womb, not anything a mother did or didn’t do. Swaddling is the one post-birth factor, using hip-healthy wrapping is the only modifiable thing, and most families do this instinctively.
“My older child wasn’t screened like this: is the protocol new?”
Universal clinical screening at three time-points has been standard in Australia for many years, but the ultrasound for risk groups at 6 weeks became more widely adopted over the past decade. Today’s protocol is more sensitive than 10–15 years ago.
Key messages for parents
Important points to remember
- DDH is common across the spectrum (1–2 in 100): frank dislocation is rarer (1–2 in 1,000)
- Early detection via screening usually avoids surgery
- Treatment is most effective in the first 6 months
- Hip-healthy swaddling (legs free to flex up and out) is the one modifiable risk factor
- If your baby was breech, has a family history, or you notice asymmetry, speak up at every review