Hip Dysplasia in Babies: Screening, Diagnosis, and the Pavlik Harness

The hip examination at the newborn check is one of the more skilled bits of the routine postnatal review. It looks like a quick wiggle of the legs, but it's a specific manoeuvre — the Barlow and Ortolani tests — designed to pick up unstable or dislocated hips that look entirely normal from the outside. Nothing is foolproof, which is why it's repeated at the 6–8 week check and why parents are gently asked to keep an eye out for asymmetry as the baby grows. When DDH is found early, the treatment is remarkably effective and avoids surgery in the great majority of cases. For a comprehensive overview, see our complete guide to child health. Healthbooq covers newborn health and screening.

What's Going On in the Hip

The hip is a ball-and-socket joint: the rounded top of the thigh bone (the femoral head) sits inside a cup in the pelvis (the acetabulum). In a normal hip, ball and socket fit closely together and the joint is stable. In DDH, the socket is too shallow, the ball sits part-way out (subluxation), or the ball is fully out (dislocation).

DDH isn't a single condition — it's a spectrum:

• Stable but shallow socket (acetabular dysplasia). May correct itself with normal growth and movement; sometimes needs treatment if it doesn't.
• Unstable hip (Barlow-positive). Located in the socket but can be pushed out of it on examination.
• Dislocated but reducible hip (Ortolani-positive). Out of the socket but can be returned by gentle manoeuvre.
• Fixed dislocation. Out of the socket and stays out.

A useful thing to know: hips can change. Some unstable hips at birth normalise over the first few weeks as the ligamentous laxity from maternal hormones wears off. Others that look normal at birth become dysplastic as the baby grows. Late-presenting DDH (picked up at six, twelve, or eighteen months) can occur even when newborn screening was done well.

Who's at Higher Risk

About 1 to 2 per 1,000 babies require treatment for DDH; hip instability detectable at birth is somewhat commoner and a fair proportion settles on its own. The well-established risk factors are:

• Female sex. Around 80% of treated DDH is in girls. The reason is biological — female babies are more affected by the relaxin and oestrogen circulating in late pregnancy, which loosens ligaments.
• Breech position in the third trimester. Counted whether or not the baby was breech at delivery — what matters is the position the hips were held in for the last weeks of pregnancy. A baby born by ECV from breech, or by elective caesarean for persistent breech, is still at higher risk.
• First-degree family history. Parent or sibling with DDH multiplies risk.
• Oligohydramnios (low amniotic fluid) and multiple pregnancy — both reduce foetal movement, which matters for hip development.
• Other postural conditions: torticollis, foot deformities (talipes), and metatarsus adductus all sit alongside DDH at higher rates.

Babies with any of these risk factors, regardless of how the newborn examination looks, should be offered a hip ultrasound at around 6 weeks.

The Newborn Examination

Every UK newborn is checked twice for hip stability: at the Newborn and Infant Physical Examination (NIPE) within 72 hours, and again at 6–8 weeks with the GP. Both checks use the same two specific manoeuvres:

Barlow. Attempts to provoke dislocation in a located-but-unstable hip. The baby is laid on their back, the hip flexed to 90°, and gentle posterior pressure applied while adducting (bringing the leg towards midline). A palpable "clunk" — the femoral head slipping out of the socket — is positive.

Ortolani. Attempts to relocate a dislocated hip. Hip flexed to 90°, gently abducted (the leg moved outwards) with anterior pressure on the greater trochanter. A clunk as the femoral head reduces back into the socket is positive.

A few clinically important distinctions:

• A "clunk" is the abnormal finding, not a "click." Soft, high-pitched clicks during the manoeuvre are very common (sometimes called "ligamentous clicks" or just normal noise from a flexible hip) and usually mean nothing. A genuine clunk feels like the hip moving out or in.
• A "limited abduction" — the hip won't open out as far as the other side, or as far as expected — is itself an important sign. After about six weeks of age, hip abduction limitation often replaces a positive Barlow/Ortolani as the leading clinical sign, because the soft tissues tighten around an out-of-place hip.

When Imaging Is Used

A hip ultrasound at around six weeks is offered to:

• Any baby with risk factors (breech, family history, oligohydramnios, multiples, postural foot/neck conditions), regardless of clinical examination
• Any baby with an abnormal newborn examination

Ultrasound is the imaging of choice up to six months of age because the femoral head and acetabulum are still cartilaginous (not yet ossified) and visible to ultrasound. The Graf classification gives a quantitative assessment of how deep and well-formed the socket is. Beyond about six months, ossification limits ultrasound and plain X-ray is used instead.

A hip ultrasound is painless, quick, and uses no radiation.

Late Presentation: What to Watch For

DDH that wasn't picked up at NIPE or the 6–8 week check sometimes declares itself later, particularly as the baby starts to bear weight. Signs to be aware of:

• Limited hip abduction. The thigh on the affected side can't be opened out as far as the other when changing nappies. Often the most reliable late sign.
• Asymmetrical thigh or gluteal skin folds — uneven creases. On their own, asymmetric folds are common and not always significant; combined with other signs, they matter more.
• Leg-length discrepancy. The affected leg appears shorter when the knees are bent up with the heels together (Galeazzi sign).
• Limp or waddling gait once walking begins. A unilateral DDH produces a Trendelenburg-type gait (the pelvis drops to the opposite side on each step on the affected leg). Bilateral DDH produces a waddling gait.
• Toe-walking on one side, or refusal to bear weight on one leg.
• Late walking in combination with any of the above.

Any of these warrants GP review and orthopaedic referral. The earlier late-presenting DDH is treated, the better the result; once a child is over 18–24 months, the treatment options become more invasive.

The Pavlik Harness

The Pavlik harness is the first-line treatment for DDH found in the first six months of life. It's a soft fabric splint that holds the hips in flexion (knees up) and abduction (legs out) — the "frog leg" position. This is the position in which a shallow acetabulum is most likely to deepen around the femoral head, and an unstable or recently reduced hip is most likely to stay located.

What treatment looks like in practice:

• Worn 24 hours a day initially, removed only briefly for nappy changes and (sometimes) bathing in the early phase.
• Several weeks of full-time wear, then often part-time as the ultrasound shows improvement.
• Total treatment duration: typically 6 to 12 weeks, depending on starting severity and progress.
• Repeat ultrasound at intervals to confirm the hip is improving.
• Skin checks — parents are taught to look for pressure marks, particularly behind the knees and in the groin.
• Dressing the baby over the harness with a vest underneath; nappy changes happen with the harness in place.

Success rates with the Pavlik harness are very good when treatment starts early:

• Subluxable / dislocatable hips: 85–90% success
• Frankly dislocated hips: 60–70% success
• Younger infants do better than older ones — every week of delay matters.

When the harness doesn't work — or when DDH is diagnosed beyond six months — treatment moves to:

• Closed reduction under general anaesthetic + hip spica cast. The hip is gently put back into place under sedation and held in a plaster cast for several weeks.
• Open reduction (surgery) for fixed dislocations or those that fail closed reduction.
• Pelvic and femoral osteotomies — bony procedures — for older children or particularly severe cases.

Can DDH Be Prevented or Made Worse?

Some hip-positioning practices in the early months matter:

• Avoid tight swaddling that holds the legs straight. The "legs straight, arms in" wrap commonly used decades ago is associated with higher DDH rates. Modern advice (including from the International Hip Dysplasia Institute) is to swaddle with the legs free to flex up — the natural frog-leg position. Hip-healthy sleep sacks and looser swaddle methods that allow leg movement are fine.
• Carrying babies in the frog-leg position is hip-healthy. Slings, carriers, and traditional carrying methods that hold the baby's legs spread with knees up — the "M" or "spread-squat" position — support hip development. Carriers that dangle the legs straight down with no thigh support are not ideal for very young babies; reputable ergonomic carriers do this part well.
• Forward-facing carriers with no thigh support before 6 months — generally avoid. Once the hips are confirmed normal and the baby has good head control, brief forward-facing in a supportive carrier is fine.

When to Get Advice

Worth seeing your GP for:

• Any clunk, click, or asymmetry you've noticed during nappy changes
• A baby who can't open one hip out as far as the other
• A leg that looks shorter than the other when you bring the heels together with knees bent
• Any limp once walking, or refusal to bear weight on a leg
• A baby with risk factors who hasn't had the 6-week ultrasound

The picture worth holding: most DDH found early can be sorted with a soft harness and time. The job of the screening pathway is to find it early. The job of parents is to know the late signs in case the screening missed it, and to ask for review the moment something looks asymmetrical.

Developmental dysplasia of the hip (DDH) is a spectrum, from a shallow socket that may resolve on its own to a fully dislocated hip that needs treatment. Around 1 to 2 per 1,000 babies require treatment, with hip instability detectable at birth somewhat commoner. Four-fifths of cases are girls; breech position at any point in the third trimester, a first-degree family history, oligohydramnios, and multiples are the other risk factors. Every UK baby is screened with the Barlow and Ortolani manoeuvres at the NIPE check within 72 hours and again at 6–8 weeks. Babies with risk factors are also offered a hip ultrasound at around 6 weeks, regardless of exam findings. Caught early, the Pavlik harness — a simple soft splint that holds the hips in a frog-leg position — has success rates of 85–90% for reducible hips and avoids surgery. Late-presenting DDH is harder to treat. Any limp, leg-length difference, or limited hip abduction in an older baby or toddler warrants prompt orthopaedic referral.