Initial pre-referral workup

Clinical history

Risk factors:

• female sex
• breech delivery
• intrauterine packaging deformities e.g. plagiocephaly, foot deformities or torticollis
• family history of DDH

Physical examination

• hip examination to check for instability with Barlow’s or Ortolani’s test
• limitation of hip abduction
• deep uneven gluteal crease
• leg length discrepancy
• waddling gait after walking age

Investigations

Hip ultrasound if aged under six months (paediatric ultrasound service if possible).

Plain x-ray if aged over six months (paediatric radiology service if possible).

GP management

Screening ultrasound if risk factors present after the age of six weeks if no evidence of clinical instability.

Refer parents to Developmental dysplasia of the hip (fact sheet).

Indications for specialist referral

1.     Instability detected on screening at birth (newborn)

referral will only be accepted if coming from the birthing unit (i.e GP referral is inappropriate)

imaging is not required for the newborn

where a local service is available (Monash / Sunshine / Geelong) referral should be directed there

2.     Hip dysplasia confirmed on ultrasound  (age 6 weeks to 8 months)

referral must indicate the following:

— why the imaging was performed

            — who raised the concern about the possibility of DDH

            — what features led them to be concerned (i.e. the clinical features)

            — any known risk factors for DDH (positive family history / breech presentation)

— copies of all imaging reports:

            — as part of the triage process we may want to view the images : there must therefore be clear indication of the imaging provider, patient identifier and login details

            — should we be unable to view the images remotely, the referral will be rejected pending transfer of the images to our PACS (see below)

            — the ultrasound must confirm the presence of hip dysplasia rather than immaturity in which case a repeat ultrasound should be performed at 3 months of age

common reasons why referrals in this category are rejected

— referral made based on clinical concern about DDH but no imaging has been done to confirm diagnosis

— referral made where the ultrasound suggests possibility of immaturity rather than DDH and the reporting radiologist recommends repeat interval ultrasound

— referral made where the ultrasound report is misleading e.g. where femoral head ossification asymmetry or “rounding” is misinterpreted as DDH

— referral made where ultrasound shows no evidence of DDH but for some reason the doctor remains concerned about the possibility of DDH

— where a local service is available (Monash / Sunshine / Geelong)

3.     Hip dysplasia confirmed on x-ray

referral must indicate the following :

— why the imaging was performed

            — who raised the concern about the possibility of DDH

            — what features led them to be concerned (i.e. the clinical features)

            — any known risk factors for DDH (positive family history / breech presentation)

— copies of all imaging reports  :

            — as part of the triage process we may want to view the images : there must therefore be clear indication of the imaging provider, patient identifier and login details

            — should we be unable to view the images remotely, the referral will be rejected pending transfer of the images to our PACS (see below)

common reasons why referrals in this category are rejected

— referral made based on clinical concern about DDH but no imaging has been done to confirm diagnosis

— referral made where the x-ray report is misleading e.g. where femoral head ossification asymmetry is misinterpreted as DDH

— referral made where the x-ray shows no evidence of DDH but for some reason the doctor remains concerned about the possibility of DDH

— where a local service is available (Monash / Sunshine / Geelong) referral should be there

4.     Hp dysplasia treated elsewhere for which either second opinion or transfer of care is being requested

referrals from the currently managing orthopaedic team :

— must include a clear explanation of why a second opinion / transfer of care is being sought

— must include copies of any relevant medical records (including operation notes) plus transfer of imaging to our PACS

referrals from the GP :

— must include a clear explanation of why transfer of care is being requested : simply stating “family want second opinion” is not enough information

— must include details of the currently managing orthopaedic team / where the previous imaging has been done

Obtaining Quality Paediatric Hip Imaging

Paediatric Hip imaging is a specialised service and should only be performed in centres that see high volumes of paediatric hip problems, have appropriately trained paediatric radiologists and are able to transfer the images to the RCH PACS system for review

RCH is able to access the following systems directly

Imed

Lake Imaging

Capital

The Following organisations are able to transfer images to the RCH PACS system

Alfred Health

Austin Health

Ballarat Health

Barwon Health

Bendigo Health

Cabrini Hospital

Eastern Health

Goulburn Valley Health

Lake Imaging

Monash Health

Northern Health

Peninsular Health

Royal Melbourne Hospital

Royal Women’s

St Vincents Hospital

Tasmania Health

Western Health

I Med

Radiology Imaging Services

Future Medical Imaging Group

Capital Radiology

Epworth medical Imaging

Diagnostic Care

The referrer must contact the service and ask for the images to be transferred to the RCH PACS (Imaging Archive)