Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Visit:
Newborn screening for DDH (positive or abnormal)
Infant/child with suspected DDH (e.g., abnormal hip exam, family history)
Follow-up visit for DDH treatment
II. History of Present Illness:
Age of child
Presenting concerns (positive newborn screen, abnormal hip exam findings)
Family history of DDH
Current treatment interventions (if any) – spreader bar, Pavlik harness, etc.
III. Past Medical History:
Prenatal history (breech presentation)
Birth history (prematurity)
Medical history (relevant conditions)
IV. Physical Exam:
General physical exam (looking for dysmorphic features)
Hip exam:
Ortolani maneuver (clicking sound) and Barlow maneuver (apprehension) to assess hip stability
Range of motion of hips
Leg length discrepancy (possible with dislocation)
V. Imaging Studies (consider as appropriate):
Ultrasound: First-line imaging for diagnosing DDH in infants (less than 6 months old).
X-ray: May be used in older infants and children to assess bone development and severity of DDH.
VI. Assessment:
Diagnosis of DDH based on clinical presentation (positive Ortolani/Barlow maneuvers, limited hip abduction) and imaging studies.
Classification of DDH severity (dislocation, subluxation, at-risk)
Consideration of underlying causes (genetic, intrauterine positioning)
VII. Plan:
Treatment for DDH depends on the age of the child and severity of the condition. Options include:
Early intervention (infants): Wide swaddling, Pavlik harness, or other abduction orthosis to maintain proper hip position.
Closed reduction and casting (older infants): Manipulation of the hip joint to achieve proper positioning followed by casting.
Surgery (severe cases): Surgical intervention may be necessary in some cases.
Serial monitoring: Regular follow-up visits with hip exams and imaging studies to assess progress and ensure proper hip development.
VIII. Prognosis:
Discuss the prognosis based on the severity of DDH at diagnosis, age of the child, and adherence to treatment.
Early diagnosis and treatment can achieve successful outcomes with normal hip development in most cases.
IX. Notes:
Address the family’s concerns and provide emotional support.
Explain the diagnosis and treatment plan in clear and understandable language.
Offer resources and referrals for support groups or educational materials.
X. Resources:
Consider providing patient education materials on DDH from reputable sources (e.g., American Academy of Orthopaedic Surgeons (AAOS), Hip Dysplasia Association).