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Abstract

Developmental hip dysplasia is an abnormality of the hip joint which is associated with an unstable or dislocatable hip. During infancy, hips should be screened to determine whether they are stable, unstable or dislocated. In Australia, this screening is often performed by nurses using physical assessment. Physical examination includes a number of assessments which seek to identify underlying abnormalities in hip joint anatomy and function. This scoping review outlines the physical assessments used by nurses in the screening and surveillance of developmental hip dysplasia. A review of the literature identified 15 (N = 15; 100%) sources of evidence, which included original research articles (n = 6; 40%), expert opinion pieces (n = 2; 13.3%) and practice guidelines (n = 7; 46.7%). There were 18 physical assessments identified as being used by nurses in the screening process for developmental hip dysplasia. However, it is apparent that high quality research is required to examine the timing, specificity and sensitivity of the physical assessments identified.

Keywords

infant developmental dysplasia of the hip hip dislocation congenital

Introduction

Developmental dysplasia of the hip (DDH) describes a spectrum of abnormalities in which the femoral head and acetabulum are not in alignment, grow abnormally or a combination of both (Committee on Quality Improvement, 2000; Shipman et al., 2006). These abnormalities can occur in utero, in the perinatal period, or during infancy and early childhood as a result of both genetic and environmental factors (Committee on Quality Improvement, 2000). The use of physical assessment to detect DDH in infancy and early childhood is a long standing practice used by health professionals internationally (Barlow, 1962; Ortolani, 1937).

Routine screening of newborns for DDH began in Sweden in 1948 (Barlow, 1962). The importance of this initial screening assessment is well-documented in literature and is reflected in international guidelines and recommendations for DDH screening (Canadian Task Force on Preventitive Health Care, 2001; Committee on Quality Improvement, 2000; International Hip Dysplasia Institute, 2015; Public Health England, 2021). Early screening, and therefore early diagnosis, in most circumstances leads to less invasive treatment over a shorter duration (Williams, 2018). Long term prognosis for treated DDH is good, without diagnosis and treatment the long-term impacts can include pain, decreased function and eventually arthritis (Williams, 2018).

There is no international agreement on the appropriate physical examination, or timing and frequency of screening for DDH throughout early infancy and childhood (Sewell et al., 2009; Shorter et al., 2011). Internationally, recommendations for DDH screening ranges from physical examination to universal ultrasonography of the hip joint (Williams, 2018). Physical examination includes a number of assessments which seek to identify underlying abnormalities in hip joint anatomy and function (Williams, 2018). These abnormalities manifest as differences in movements, appearance of the limb and provocative tests (Williams, 2018). Universal ultrasonography is recommended for DDH screening in European countries, while targeted ultrasonography of infants with a positive physical examination is used in Australia, America and Canada (Canadian Task Force on Preventitive Health Care, 2001; Committee on Quality Improvement, 2000; International Hip Dysplasia Institute, 2015; Public Health England, 2021; Williams, 2018).

In Australia, recommendations for DDH screening are that infants receive a newborn DDH screening assessment and additional assessments at universal child health checks; timing of hip assessment at these universal health checks varies between states (Government of South Australia, 2017; New South Wales Health, 2011). In Australia, universal child health checks are most frequently completed by Child Health Nurses at home visits, in child centres and clinic environments. Thus, in Australia, nurses are often the first clinician to assess an infant’s hip for DDH.

Through undertaking a preliminary search of the literature, it was identified that there are inconsistencies in recommended assessments used in the screening process for DDH (Wright et al., 2018). There appears to be a paucity of information on the approaches to physical assessment that are used by nurses in the ongoing screening and surveillance of all children and infants. This provided the rationale for a detailed search of current literature to determine the types of assessments that are used and recommended for nurses when screening for DDH.

Aim

To gain a thorough understanding of the research area by identifying and appraising all available peer-reviewed literature, policy documents, expert opinions, case studies and commentaries in order to capture all physical assessment techniques used by nurses when screening for DDH.

The objectives of this scoping review are to document and thematically collate the physical assessments used by nurses who screen for DDH; understand the recommendations associated with these physical assessments; and clarify what gaps exist in the literature and policy in regard to the recommended physical assessments, accuracy of physical assessments and recommended timing of physical assessment when nurses and midwives screen for DDH.

The research questions posed for the scoping review were two-fold; (1) What physical assessments do nurses use to screen for DDH in children and infants? and (2) What physical assessments for the practice guidelines, if any, recommend when screening for DDH in children and infants?

Materials and methods

Approach

This scoping review follows the methodologically rigorous six-stage framework outlined by Arksey and O’Malley (2005). A scoping review approach was determined the best approach to this review as it enabled the rapid mapping of literature and key concepts underpinning this area of research, and to identify the main sources and types of evidence available (Arksey and O’Malley, 2005). Arksey and O’Malley’s (2005) framework supports identification of primary and secondary sources of literature related to the research questions, including quantitative and qualitative research, opinion articles and international policies and guidelines. This six-stage framework supports a rigorous scoping review process that is transparent and replicable, therefore, increasing the reliability of the review findings. However, the sixth stage which focusses on consultation is rarely used and is not included in this review. The five stages used include: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarising and reporting the results (Arksey and O’Malley, 2005). Whilst Arksey and O’Malley’s (2005) framework will be the predominant methodology, the findings of the review including study selection, charting of the data and reporting of results will use considerations from the recently published PRISMA-ScR framework (Tricco et al., 2018). There was no protocol registered for this scoping review.

Inclusion criteria

Clinicians identified in the scoping review were any health professional who identifies as a: nurse, child health nurse, midwife, maternal and child health nurse, health visitor or any other term that identifies a 'nurse' who conducts physical screening assessments on infants/children. Explored concepts included an assessment, screening or examination for DDH in children and infants. The context of the scoping review was any setting where nurses performed the assessments. Only publications in English were considered for inclusion. Primary research was only included if it was identified that the research had an explicit ethics statement. Qualitative, quantitative and mixed-methods primary research, policy documents, expert opinion, case studies and commentaries were all considered in order to capture all assessment techniques used by nurses when screening for DDH. No restrictions were places on time range for included publications.

Search strategy and study selection

To ensure a rigorous and replicable search of the databases, a university academic librarian was consulted to advise on the search strategy including; identifying key search terms and phrases and the chosen databases appropriate to the research question. Using the predefined types of participants, concept and context of the study, the key terms were developed with the application of medical subject headings (MeSH) (U.S. National Library of Medicine, 2019).

To identify potentially relevant sources the following databases were searched: Medline, EMBASE, Scopus, Informit, Joanna Briggs Institute, The Cochrane Library and Web of Science. The databases searched were selected to identify relevant sources including policy documents and primary research from nursing, paediatric and child health perspectives with the aim of searching multiple peer-reviewed sources. Arksey and O’Malley (2005) recommend the routine checking of all bibliographies of studies found through electronic database searching to ensure all relevant evidence is included in the ‘scoping’. This step was followed during study selection stage to ensure again rigour and replication of the scoping review. The final point in identifying relevant sources suggested by Arksey and O’Malley (2005) is to search existing networks, relevant organisations and conferences. A Google Scholar search was conducted at this stage to identify relevant policy documents. The search of the databases was conducted by the first author (LS) in March 2019. The identified articles were then imported into Covidence® to be screened and reviewed by two additional authors (LP and JC) for inclusion in the final review. Any difference of opinion between the authors was resolved by the fourth author (AE). The PRISMA flow diagram showing the flow of material through the different stages of the review is shown in Figure 1.

Figure 1.

PRISMA flow diagram for article selection.

Data charting and collation

The fourth stage of Arksey and O’Malley’s (2005) framework is the charting of the selected articles. Summaries were developed of the included articles related to author, year, location, purpose of study, participants/assessors, DDH assessments used, timing of assessments, study outcomes and comments. A second summary table was developed for practice guidelines. This table included information related to facility, date and state; participants or discipline; DDH assessments used and author comments. Details of the summary for the included articles can be found in Table 1; details of the summary for included practice guidelines can be found in Table 2.

Table 1.

Summary of included articles.

Author/Year/Country	Purpose of study		Participants/Discipline	Number of infants assessed	Assessment type	Timing of assessment	Study outcomes	Comments
Bloomfield et al. (2003) UK	Identify differences in quality of newborn examinations between SHOs and MWs		SHO MW	39	Barlow Relaxed (hip examination) Flat surface (hip examination) Manoeuvred simultaneously Abduction 60–90 (Ortolani-left) Abduction 60–90 (right) Pelvis stabilised Nappy off (hip examination) History of hip problems	Newborn examination	MW provided a higher quality newborn assessment than SHOs. The midwives included in this study had received specific training in order to carry out the examinations. SHO carrying out the assessment require further formalised training, similar to the MW training	23% of assessments were excluded from the study due to assessors not completing the Barlow assessment. Screening for hip abnormalities was poor for both SHO and MW, there were inconsistencies in how this assessment was performed, for example, checking hips individually or simultaneously
Carr and Foster (2014) UK	Feature article, describing importance of examination of the hips by MW during screening processes		MW	N/A	History of risk factors Asymmetrical skin creases Allis or Galeazzi sign Ortolani Barlow	No timing indicated	The article outlines the assessment process and possible abnormalities that may be detected in the aforementioned assessments	The article highlights the importance of assessing the hips individually while stabilising the pelvis. Simultaneous assessment is not recommended
Causen (2010) UK	Opinion piece on the RN’s role in diagnosis and treatment of DDH.		RN	N/A	Barlow Ortolani Leg length Galeazzi sign Asymmetrical skin creases	Newborn examination (within 72 h of delivery)	Early detection and treatment improve outcomes for infants diagnosed with DDH. Screening needs to be performed by properly trained and skilled practitioners. Treatment for DDH needs to be a partnership between the MDT and family	Article highlights RN practice relating to DDH. Very thorough explanation regarding involvement in treatment. However, the role of the RN in the detection and diagnosis was limited
Cooke and Kiely (2011) UK	Effectiveness of screening for DDH by the HV at 8 months of age	HV		525	Leg length Limitation of abduction 'Persisting features of intrauterine moulding' Clicky hips Asymmetrical thigh creases	Newborn examination 6–8 weeks 8 months	Screening for DDH by HV at 8 months has a high false positive rate. The false positive rate was 6%, meaning 30 children were referred unnecessarily to their GP.	The overall results show that no patients were identified as having DDH by either the primary (HV) assessment or when referred for a secondary (GP) assessment. One patient was later identified as being missed by both primary and secondary assessments
Haugh et al. (1997) UK	Can nurses detect infant hip abnormalities?	RN		887	Barlow Ortolani Leg length ROM Observation of skin creases	Newborn examination Continual surveillance until walking	Experienced nurses can screen for infant hip abnormalities	No cases of DDH diagnosed after 6 months of age required treatment. The overall aim was to determine viability and accuracy hip abnormality diagnosis by an expert nurse. To do this the specialty clinic ran for the trial period. The diagnostic accuracy of the nurses was greater than 90%. Other unintentional benefits of the study included detection of gait abnormalities which could then be treated
Trainor et al. (1994) UK	To assess the effect of extra training for HV’s when screening for DDH.	HV		N/A	Barlow Ortolani Vibration Arthrometry	No timing indicated	The study demonstrated the importance of skills in hip testing and indicated a need for additional allocated training during basic training and regular updates after qualification	There is no description of the analysis undertaken to determine the study outcomes mentioned
Way (1991) N/A	Opinion piece of the role of the midwife in DDH screening	DR MW		N/A	Barlow Ortolani	Newborn examination	The review identified that only MW should assess infant hips and a specific programme should be designed for the education of student MW.	Poorly conducted literature review, no format or measurable outcomes. Important outcomes regarding education program to support students when beginning their practice in DDH screening
Wright et al. (2018) Australia	Describe DDH screening practices in a rural area	CHN GP Paeds Physio		49	Ortolani Barlow Leg length Galeazzi sign Uneven creases ROM Gait	Newborn examination 1–4 weeks 6–8 weeks 3 months 4 months 6 months 9 months 12 months 18 months 4 years	A clinician survey was distributed to eligible clinicians. 78% identified that the regularly screen for DDH. 43% use guidelines to screen for DDH. 51% have had training in DDH screening beyond their primary training. 76% would like further training	A well conducted study. The survey was administered to a variety of clinicians who screen for DDH in their practice. Only 9 CHN’s responded to the survey. Of the 9 responses 100% of CHN’s screen using Ortolani, leg length and uneven creases in infants <3 months of age.The survey was not tested for reliability or validity

Note: SHO: senior house officer; MW: midwife; RN: registered nurse; DDH: developmental dysplasia of the hip; MDT: multi-disciplinary team; HV: home visitor; GP: general practitioner; DR: doctor; CHN: child health nurse; Paeds: paediatrician; Physio: physiotherapist; ROM: range of movement.

Table 2.

Summary of included practice guidelines.

Facility/Date/State	Participants/Discipline	Assessment type	Timing of Assessment	Comments
Committee on Quality Improvement American Academy of Pediatrics (2000) USA	Clinicians	Signs of asymmetry Galeazzi sign Limb length discrepancy Restricted motion Ortolani Barlow Limited abduction	Newborn examination (within 48 hours of delivery) 1 month 2 months 4 months 6 months 9 months 12 months	International guidelines, extensive rationale, explanation of assessment and screening and surveillance recommendations
Health Vic 2018 Victoria, Australia	Clinicians	Barlow Leg length discrepancy Asymmetrical skin folds Buttock flattening Ortolani Widened perineum on affected side	Newborn examination At regular intervals in the first 12 months	Guideline states that all infants should have the Ortolani and Barlow tests performed by a trained clinician at birth. It identifies regular re-screening during the first year of life as a priority, however, does not state who is responsible for this
Hunter New England Area Health Service 2011 New South Wales, Australia	Clinicians GP CHN	Ortolani Barlow Restricted abduction Leg length discrepancy Asymmetrical thigh and gluteal skin folds	Newborn examination 6–8 weeks 6 months	The guideline states it is not 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 within the clinical area. Includes flow chart for CHN assessment
King Edward Memorial Hospital 2018 Western Australia, Australia	Paeds MO MW	Barlow Ortolani	Newborn examination Discharge from hospital	Newborn hip examination guidelines only
Queensland Health 2014 Queensland, Australia	Clinicians	Ortolani Barlow Leg length Leg symmetry	Newborn examination (within 48 hours of delivery) 5–7 days 6 weeks	This guideline is for the newborn assessment, however, identifies DDH screening as part of this assessment
Royal Prince Alfred Hospital 2004 New South Wales, Australia	Clinicians	Barlow Ortolani Asymmetric thigh or gluteal folds Shortened Leg Prominent greater trochanter Limited abduction Abnormalities of walking or gait	Newborn examination	Guidelines discusses importance of hip assessment in neonatal period and periodically during the first year of life. Description of Barlow and Ortolani manoeuvrers
SA Health 2017 South Australia, Australia	Clinicians HP	Barlow Ortolani Reduced abduction Leg length discrepancy Asymmetrical leg and buttocks creases	Newborn examination 1–4 weeks 6–8 weeks 6–9 months	The guideline recommends screening at the well child checks by an experienced practitioner

Note: GP: general practitioner; CHN: child health nurse; Paeds MO: paediatric medical officer; MW: midwife; HP: health practitioner.

Results

The fifth stage of the scoping review framework outlined by Arksey and O’Malley (2005) is to summarise and report the findings. A total of 15 (N = 15; 100%) sources of evidence met the inclusion criteria (Table 1 and 2). The sources included original research articles (n = 6; 40%), expert opinion pieces (n = 2; 13.3%) and practice guidelines (n = 7; 46.7%). There were 18 physical assessments to detect DDH identified, detail of these assessments is provided in Figure 2. All (N = 15; 100%) included sources identified assessments in three key areas; Barlow manoeuvre, Ortolani manoeuvre and assessment of legs (Bloomfield et al., 2003; Carr and Foster, 2014; Causon, 2010; Committee on Quality Improvement, 2000; Cooke and Kiely, 2011; Government of South Australia, 2017; Government of Western Australia, 2016; Haugh et al., 1997; New South Wales Health, 2004; New South Wales Health, 2011; Trainor et al., 1994; Queensland Government, 2014; Victoria State Government, 2018; Way 1991; Wright et al., 2018). A majority (n = 14; 93.3%) of the sources, identified the Barlow manoeuvre as a key assessment (Bloomfield et al., 2003; Carr and Foster, 2014; Causon, 2010; Committee on Quality Improvement, 2000; Government of South Australia, 2017; Government of Western Australia, 2016; Haugh et al., 1997; New South Wales Health, 2011, 2004; Trainor et al., 1994; Queensland Government, 2014; Victoria State Government, 2018; Way, 1991; Wright et al., 2018). Although 13 (n = 13; 86.7%) of the included sources, identified the Ortolani manoeuvre as an additional screening assessment (Carr and Foster, 2014; Causon, 2010; Committee on Quality Improvement, 2000; Government of South Australia, 2017; Government of Western Australia North Metropolitan Health Service, 2016; Gross and Hitch, 1979; Haugh et al., 1997; New South Wales Health, 2011; New South Wales Health, 2004; Queensland Government, 2014; Trainor et al., 1994; Victoria State Government, 2018; Way, 1991; Wright et al., 2018). Finally, assessment of legs was identified in 11 (n = 11; 73.3%) included sources (Carr and Foster, 2014; Causon, 2010; Committee on Quality Improvement, 2000; Cooke and Kiely, 2011; Government of South Australia, 2017; Haugh et al., 1997; New South Wales Health, 2011; New South Wales Health, 2004; Queensland Government, 2014; Victoria State Government, 2018; Wright et al., 2018), assessments of legs included asymmetric skin folds, leg length discrepancy, Galeazzi sign, range of movement, limitation of abduction, leg symmetry and short femur sign.

Figure 2.

Summary of assessments identified through scoping review.

Discussion

The aim of this literature review was to identify and understand the physical assessments that nurses use when assessing for DDH, specifically as they relate to practice in Australia. This review identified three key assessments used in practice; Barlow manoeuvre, Ortolani manoeuvre and assessment of legs. Use of these physical assessments to screen for DDH is recommended in children from birth until four years of age and is commonly done by nurses at home visits and in clinical environments.

Barlow manoeuvre

The Barlow manoeuvre was first described by Dr Thomas Barlow, in Salford, England 1962 (Barlow, 1962). The manoeuvre involves adducting the infant’s hip and exertion of forward pressure applied behind the greater trochanter, each hip should be examined individually (Barlow, 1962). If the hip is dislocatable this gentle force will cause the head of the femur to slip out of the acetabulum (Barlow, 1962; Williams, 2018). The Barlow test is considered positive if the infant’s hip can be manually dislocated as described (Barlow, 1962; Williams, 2018). Due to the complexity of this assessment nearly all the included sources discussed the need for extensive experience and additional training to adequately complete the manoeuvre (Bloomfield et al., 2003; Carr and Foster, 2014; Causon, 2010; Committee on Quality Improvement, 2000; Government of South Australia, 2017; Trainor et al., 1994; Wright et al., 2018). Bloomfield et al. (2003) found both nurses and doctors inadequately performed the Barlow manoeuvre when rated by a specialist observer. An additional study supported this finding, showing that specific training and extensive experience was essential to detect hip abnormalities using the Barlow manoeuvre (Trainor et al., 1994). The complexity of this assessment means that one third to one half of positive findings will be missed when not conducted by a trained expert (Cooke and Kiely, 2011). No sources included information on the sensitivity or specificity of the Barlow manoeuvre when performed by nurses. Additionally, beyond the initial newborn examination it was not clear as to the timing of the Barlow manoeuvre when performed by nurses.

Ortolani manoeuvre

The Ortolani manoeuvre was first described by Dr Marino Ortolani in 1936 (Ortolani, 1937). The manoeuvre involves flexing and adducting the hip, then abducting the hip while applying gentle traction and pressure on the greater trochanter (Barlow, 1962; Williams, 2018). If the hip is dislocated the head of the femur will relocate into the acetabulum with a ‘clunk’ (Barlow, 1962; Williams, 2018). The Ortolani test is considered positive if the dislocated hip is able to be manually reduced as described (Barlow, 1962; Williams, 2018). The included sources which explained the Ortolani manoeuvre, identified either a ‘click’ or a ‘clunk’ when an assessment was positive (Carr and Foster, 2014; Causon, 2010; Committee on Quality Improvement, 2000; Government of South Australia, 2017; Government of Western Australia North Metropolitan Health Service, 2016; Haugh et al., 1997; New South Wales Health, 2011; New South Wales Health, 2004; Queensland Government, 2014; Trainor et al., 1994; Victoria State Government, 2018; Way, 1991; Wright et al., 2018). Additional studies have found that a ‘click’, however, is not a positive finding or an indicator of hip abnormality (Bolander, 2016; Committee on Quality Improvement, 2000). This inconsistency means that there is no agreement in the literature as to how the Ortolani manoeuvre should be performed. As with the Barlow manoeuvre there is no information as to the timing beyond the newborn period, sensitivity and specificity of the Ortolani manoeuvre in nurses screening practices.

Assessments of legs

Assessments of the legs included visual inspection for asymmetrical skin folds, testing for Galeazzi’s sign and assessment of leg length. To assess for asymmetrical skin folds, symmetry of the folds was observed bilaterally in the thigh buttocks and leg (Carr and Foster, 2014; Committee on Quality Improvement, 2000). Although the included sources stated that asymmetry of skin folds was a positive finding for DDH, a 2019 study has determined that this is not an accurate assessment for DDH (Kang et al., 2019). Four (n = 4; 26.7%) sources identified a positive Galeazzi sign as an indicator of DDH (Carr and Foster, 2014; Causon, 2010; Committee on Quality Improvement, 2000; Wright et al., 2018). Galeazzi sign is assessed when the infant is placed in the supine position with their knees and hips flexed, uneven knee height is considered positive for DDH (Committee on Quality Improvement, 2000; Williams, 2018). Similarly, to asymmetrical skin folds, 10 (n = 10; 66.7%) studies identified that a discrepancy in leg length was a positive indicator of DDH. This assessment was not described in any of the sources, and as with the Barlow and Ortolani manoeuvre no information was provided regarding the accuracy of this assessment. Overall, assessment of legs was the most common physical assessment performed by nurses in conjunction with the Barlow and Ortolani manoeuvre (Carr and Foster, 2014; Causon, 2010; Committee on Quality Improvement, 2000; Cooke and Kiely, 2011; Government of South Australia, 2017; New South Wales Health, 2011; New South Wales Health, 2004; Queensland Government, 2014; Victoria State Government, 2018; Wright et al., 2018).

Timing of assessment

In addition to the assessments performed, an area of interest was the timing of these physical assessments. Similarly to the assessments used, there is limited agreement in the literature as to when these assessments should occur and the appropriateness of these assessments in the ongoing screening process. Thirteen (n = 13; 86.7%) of the included sources identified specific times that the physical assessments should be used to screen for DDH (Bloomfield et al., 2003; Causon, 2010; Committee on Quality Improvement, 2000; Cooke and Kiely, 2011; Government of South Australia, 2017; Government of Western Australia North Metropolitan Health Service, 2016; Haugh et al., 1997; New South Wales Health, 2011; New South Wales Health, 2004; Queensland Government, 2014; Victoria State Government, 2018; Way, 1991; Wright et al., 2018). All of these 13 (n = 13; 86.7%) sources identified the newborn examination as the appropriate time to assess for DDH using physical assessment (Bloomfield et al., 2003; Causon, 2010; Committee on Quality Improvement, 2000; Cooke and Kiely, 2011; Government of South Australia, 2017; Government of Western Australia North Metropolitan Health Service, 2016; Haugh et al., 1997; New South Wales Health, 2011; New South Wales Health, 2004; Queensland Government, 2014; Victoria State Government, 2018; Way, 1991; Wright et al., 2018). There were though discrepancies in the timing of the newborn examination, with two (n = 2; 13.3%) sources stating the newborn examination should occur with 48 h post birth (Committee on Quality Improvement, 2000; Queensland Government, 2014) and another (n = 1; 6.7%) stating within 72 h post birth (Causon, 2010). Although the newborn examination is cited in the literature as a critical point for DDH assessment, the ongoing surveillance throughout early childhood is equally important (Committee on Quality Improvement, 2000). Despite the recognised international importance of screening into early childhood (Committee on Quality Improvement, 2000), only 8 (n = 8; 53.3%) of the included sources made recommendations that included forms of ongoing surveillance from birth until the age of four (Committee on Quality Improvement, 2000; Cooke and Kiely, 2011; Government of South Australia, 2017; Haugh et al., 1997; New South Wales Health, 2011; Victoria State Government, 2018; Wright et al., 2018). The included studies did not provide information on when particular assessments should be conducted with respect to the age of the infant and the accuracy of the physical assessment (Bloomfield et al., 2003; Causon, 2010; Committee on Quality Improvement, 2000; Cooke and Kiely, 2011; Government of South Australia, 2017; Government of Western Australia North Metropolitan Health Service, 2016; Haugh et al., 1997; New South Wales Health, 2011; New South Wales Health, 2004; Queensland Government, 2014; Victoria State Government, 2018; Way, 1991; Wright et al., 2018). The two predominant physical assessments identified in this review, the Barlow and Ortolani manoeuvres are reliant on the infant being relaxed and lying supine without its nappy, with a trained expert performing the assessments (Sewell et al., 2009). The Barlow attempts to dislocate an articulated femoral head; while the Ortolani aims to relocate a dislocated femoral head (Committee on Quality Improvement, 2000; Sewell et al., 2009). In a newborn muscle tone and soft tissues are lax; therefore, a dislocated hip may be easily manipulated using physical assessment (Sewell et al., 2009). As an infant develops muscle tone and changes in soft tissue occur, these physical assessments become less useful (Sewell et al., 2009; Paton, 2017). Therefore, to conduct an accurate physical assessment the Barlow and Ortolani manoeuvres may only be reliable in early infancy, in the first 2–3 months of life (Sewell et al., 2009).

Implications for practice

The primary aim of this scoping review was to identify the physical assessments used by nurses in the screening process for DDH. The review identified three key methods of assessment; Barlow manoeuvre, Ortolani manoeuvre and assessment of legs. All included sources emphasised the need for clinical expertise and additional training in physical assessment when performing these tests. Although both the Barlow and Ortolani manoeuvres will detect an unstable hip, they will not detect a dislocated irreducible hip or a stable hip with abnormal anatomy (Sewell et al., 2009). An assessment of leg length and hip abduction will assist clinicians in detecting a dislocated irreducible hip (Sewell et al., 2009). It has further been suggested that only an ultrasound will identify a stable hip with abnormal anatomy (Sewell et al., 2009). The complexities in understanding the pathology of DDH, performing the physical assessments, identifying the timing of the assessments and interpreting the screening results may mean that DDH is being under or over-identified, and subsequently under or over-treated.

Although this review specifically looked at the role of nurses, it is relevant for any health professional that is responsible for the initial and ongoing screening and surveillance of DDH.

Strengths and limitations

This literature review was undertaken in a systematic and rigorous way with advice from an Academic Librarian with respect to the search strategy. A limitation of this review is that only sources published in English were included. Therefore, relevant published sources in other languages may have been missed. Included practice guidelines were predominantly from Australian health facilities, reflective of the research teams’ location of practice. Additionally, while three key methods of assessment were identified, there was no information concerning the effectiveness of these physical assessments when performed by nurses.

This scoping review was constrained by the small number of sources that identified nurses as a clinician who screens for DDH. This limitation may have overlooked additional information regarding DDH assessment conducted by other clinicians.

Conclusion

This scoping review identified that there are 18 assessments that nurses use in practice to assess for DDH and many of these should only be performed by a trained expert. Despite recommendations for these assessments there is no reported evidence of diagnostic accuracy related to either the physical assessments used or the timing of these physical assessments.

It is recommended that future research examines nursing practice related to the assessment of DDH, including, nursing knowledge, attitude and practice relating to DDH, timing of assessment, and specificity and sensitivity of the physical assessments used. Further research in this area would potentially benefit all nurses and other health professionals who screen infants for DDH and increase associated detection and treatment rates for infants with DDH.

Supplemental Material

Supplemental Material for Nurses assessment of development hip dysplasia: A scoping review

Supplemental Material for Nurses assessment of development hip dysplasia: A scoping review by Larissa Smart, Lemuel Pelentsov, Jessie Childs, Nicole Williams and Adrian Esterman in Journal of Child Health Care

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Orcid iD

Larissa Smart

Supplemental material

Supplemental material for this article is available online.

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