Nottingham Neonatal Service Clinical Guidelines

Transcription

1 This screening programme is in the Nottinghamshire Programme for Child Health Promotion from birth to nineteen years. This is in line with the Department of Health Healthy Child Programme (2009) and the NHS Newborn and Infant Physical Examination Programme (NIPE updated in 2010) 1. Aim Nottingham operates a selective ultrasound screening programme for Developmental Dysplasia of the Hip (DDH), based on universal clinical examination of all newborns and ultrasound assessment of those with clinical concerns or risk factors. The aim of this screening is to: Identify children with DDH as early as possible to allow timely treatment. To prevent late diagnosis as we know this is leads to a greater magnitude of treatment, more complications and poorer outcomes. Summary of Hip Screening Programme Newborn clinical examination (within 72h of birth) Clinical examination as described below Urgent referral for clinical instability, leg length discrepancy or limited abduction in flexion Routine referral for risk factors or click Midwife / health visitor check (14-28 days) Clinical examination as described below Urgent referral for clinical instability, leg length discrepancy or limited abduction in flexion Routine referral for risk factors or click GP hip check (6-10 weeks) Clinical examination as described below Urgent referral for clinical instability, leg length discrepancy or limited abduction in flexion Routine referral for risk factors or click Page 1 of 15

2 The NIPE programme does not mandate a formal screening programme for DDH past 10 weeks of age, however the NHS screening committee report of 2004 stated that it is good clinical practice to examine the hips at each clinical encounter. Past 3 months of age limited abduction in flexion and leg length discrepancy are more easily identified. We therefore encourage our colleagues to perform this examination at every opportunity. Referral Criteria Urgent Referrals Please immediately to NUHNT.CentralAppointments@nhs.net or call Ext to refer children with: Signs of clinical instability Ortolani or Barlow positive Leg length discrepancy Limited abduction in flexion Routine Referrals Repeatable click on examination Risk factors for DDH o Breech presentation past 36/40 gestation or at delivery o Foot deformity o Family history in a first degree relative of DDH requiring treatment o Multiple births where one child is breech presentation Page 2 of 15

3 Referral Methods Under 5 months of age Urgent Immediate to or call Ext Routine Referral to hip instability clinic through central appointments QMC Over 5 months of age GP to arrange urgent pelvic x- ray and urgent referral to paediatric orthopaedics if positive GP to arrange a pelvic x-ray and urgent referral to paediatric orthopaedics if positive Timing of Ultrasound Urgent referrals should be scanned as soon as possible to allow early treatment for DDH: o For newborn baby referrals this should be within 14 days of birth o For 6-10 week checks it should be within 2 weeks of referral Routine referrals should be scanned after the age of 5 weeks to prevent excessive parental concern over immature hips: o For newborn baby referrals this should be at 5 to 8 weeks of age o For 6-10 week checks it should be between 6 and 16 weeks of age If you are unable to book an appropriate appointment within these timings please contact central appointments for us to arrange an appointment. Page 3 of 15

4 Hip Screening Training Everyone performing NIPE hip assessments must receive appropriate training to enable them to examine the child properly. Paediatric trainees training will be arranged as part of induction Midwives training arranged on the midwifery course Community training for new practitioners arranged by the training and development team Refresher training should be undertaken every 3 years. Refresher courses can be arranged by contacting the lead clinician for the local DDH screening programme (currently Miss Kathryn Price kathryn.price@nuh.nhs.uk). Hip Screening Inclusion Criteria Nottingham operates a selective ultrasound screening programme based on universal clinical examination and ultrasound assessment of children with clinical concerns or risk factors. Reasons for assessment following clinical examination include: Ortolani or Barlow positive (see description below) Leg length discrepancy Limited abduction of the hip in flexion Reproducible click on examination Asymmetrical skin creases Inability to perform the hip assessment due to other conditions such as Spina Bifida or Osteogenesis Imperfecta. Page 4 of 15

5 Regardless of clinical examination findings, children with risk factors for DDH should be referred for ultrasound assessment. These include: Family history a first degree relative requiring treatment for DDH. You should ask is there anyone in the close family that had a problem with the hip in and around birth that needed treatment with a splint, harness or operation? Breech presentation o at delivery o past 36 weeks gestation including children undergoing external cephalic version (ECV) o in multiple births, if any child is breech then all children should be referred for assessment Other risk factors o Foot deformity CTEV, metatarsus adductus, calcaneovalgus o High female birth weight Page 5 of 15

6 Hip Screening Procedure 1. Take a careful history for risk factors and elicit any parental concerns 2. Ensure that you are in a warm room with the baby relaxed on a firm surface for the examination 3. Examine for any additional risk factors such as: Foot deformity Plagiocephaly / scoliosis / torticollis / hypermobility Syndromic appearance of child 4. Hip examination see Table 1 and description below for details 5. Record information in the health record describing examination performed and result. Hips is not sufficient. 6. Advise parents that most ultrasounds are normal, however treatment for DDH is time-dependent. They should definitely keep their appointment for an ultrasound even if they are told later that the hips are fine. For those with suspected instability advise the use of double nappies and never swaddle the legs. 7. Further reading: Jones DA Hip Screening in the Newborn, A Practical Guide. Pub. Butterworth and Heinemann (1998). ISBN Page 6 of 15

7 Clinical Examination for DDH The examination for DDH is tailored to the age of the patient. Instability signs (Ortolani and Barlow) may be present in the newborn, but have usually resolved by the age of 6 weeks. Leg length discrepancy and limited abduction in flexion are the most reliable signs of a hip dislocation. These should be visible in any age but certainly become more apparent as the child grows. For the older child, assessment of gait is helpful in the diagnosis. See Table 1 for clarification of the appropriate examination. Table 1: Appropriate assessment for DDH based on age. < 3 months 3 months walking age Walking age Instability signs Crease asymmetry Leg length discrepancy Limited abduction in flexion Gait Instability Signs (Barlow and Ortolani) Barlow s test is looking for instability in the hip joint, where the examiner subluxes the femoral head from the acetabulum. The test is performed on each hip separately. For the right hip, the examiner stabilises the pelvis with the left hand holding the sacrum and pubic Page 7 of 15

8 symphysis to isolate any movement to the hip. The right leg is taken by the examiner with the hip and knee flexed as shown below. The hip is flexed beyond 90 0 and the hip is adducted beyond the midline. The examiner gently puts pressure on the knee in the line of the femur pushing the hip down and out the back of the acetabulum. In the normal situation there should be a firm end point as the hip is located in the socket, if it is subluxable the hip will glide back in to the soft tissues. The hands are then reversed to examine the contralateral hip. Left: Picture showing positioning of hands for instability assessments. Right: Picture showing Ortolani test. Ortolani s test attempts to reduce an already dislocated hip. With one hand stabilising the pelvis, the other hand holds the leg with the hip and knee flexed as shown above. With the hip flexed beyond 90 0, the leg is gently abducted with slight pressure under the greater trochanter. If the hip is dislocated and reducible, the examiner will hear a loud clunk Page 8 of 15

9 as the hip falls back in to the acetabulum. They will feel the hip reducing and also be able to see a change in the contour of the soft tissues on the medial aspect of the thigh. It is important to realise that if the hip is irreducible then this test will be negative, however, there should be a leg length discrepancy and limited abduction in flexion. Leg Length Discrepancy If the hip is posteriorly dislocated then there will be a leg length discrepancy. First examine the child with the legs in extension. Make sure that the pelvis is square to the couch and hold the ankles together. If the hip is dislocated the knee should appear to be more proximal than the knee on the other side and there will probably be more creases in the medial thigh on this leg as shown below on the left. Page 9 of 15

10 Left: Leg length assessment with legs in extension. Asymmetrical creases on right thigh with right knee appearing to be slightly higher than left. Right: Galeazzi test with knees flexed shows clear leg length discrrepancy with right knee being much lower than that on the left. The Galeazzi test is performed by flexing the knees. With the pelvis square to the table, the ankles are held together with the knees flexed. As the examiner looks from the end of the table, the knee will be lower if the hip is dislocated as shown above. Limited Abduction in Flexion If the hip is dislocated then abduction will be restricted. With the ankles held together, flex the hips and the knees to From this position, let both legs fall out in to a frog position assessing the degree of abduction. In a newborn, the child should be able to abduct the hips to approximately If there is not good, wide abduction on both legs then there is an abnormality as shown below. Limited abduction in flexion of right leg in a newborn. Page 10 of 15

11 Gait In the older child with a unilateral dislocation, there will be an obvious leg length discrepancy and a vaulting gait. When the legs are examined the Trendelenburg test will be positive for the affected hip (shown below). For bilateral dislocations, there will not necessarily be a leg length discrepancy. The child will have a Trendelenburg gait, waddling to both sides. On examination of both hips, the Trendelenburg test will be positive. There will be increased lumbar lordosis, fixed flexion and limited abduction of both hips leading to diagnosis. Parental Advice Parents should always be told why their child is being referred for an ultrasound of the hips. They should be reassured that the vast majority of scans are normal, however, for those with DDH early treatment makes a huge difference to the outcome. Advise them to keep the appointment for the ultrasound scan even if they are told that the hips are normal at a later examination. For those with suspected Page 11 of 15

12 instability please advise them to start double nappy treatment immediately and advise all parents not to swaddle the legs. NIPE Key Performance Indicator Targets Target Referral type Timing of scan ST2a Urgent >95% scanned within 2 weeks of birth ST2b Urgent >95% seen by specialist within 3 weeks of birth ST2c Routine >95% scanned within 6 weeks of birth ST2d Routine >95% seen by specialist within 8 weeks of birth References 1. Newborn and Infant Physical Examination. Standards and competencies. March Chan et al, Perinatal risk factors for developmental dysplasia of the hip 3. Yiv et al, Developmental dysplasia of the hip in South Australia in 1991: Prevalence and risk factors 4. JE Andersson and A Oden, Acta Paediatrica 90: 895± NHS Newborn & Infant Physical Examination Programme Update 26 October Page 12 of 15

13 Developmental Dysplasia Of The Hip (Parent Advice Sheet) Explanation: In a small number of babies, the hip joint is shallow at birth and, if left untreated, this can lead to problems for the baby. Treatment is necessary to ensure that the hip joint can form properly. Hints for Parents 1. Are your baby s hips normal? If your baby has any of the following signs, please get your babies hips checked by your Health Visitor, General Practitioner or Community Paediatrician: If your baby s legs do not separate easily when you change the nappy If one leg looks shorter than the other If one leg turns out more than the other If your child walks with a limp If your child is not walking by 18 months of age 2. Your baby s hips should be regularly checked. 3. Have your baby s hips been checked: After birth by the Paediatrician or General Practitioner? At the day check by the Health Visitor? At the 4-8 week check by the General Practitioner? At 3-4 months by the Health Visitor/Practice Nurse or GP 6 months and older Ask your Health Visitor or General Practitioner to check your babies hips at any age if you have noticed any of the above signs or have any concerns about your babies hips or legs 4. If a check has been missed please ask for it to be done! Page 13 of 15

14 Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author) Directorate & Speciality Screening For Developmental Dysplasia Of The Hip (Incomplete or aberrant development of the hip socket) Miss Kathryn Price (Consultant Paediatric Orthopaedic Surgeon) Paediatric Orthopaedics, MSKN Date of submission April 2015 Date on which guideline must be reviewed (this should be one to three years) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Abstract April 2017 All newborn infants This guideline describes the assessment of newborn infants for Developmental Dysplasia of the Hip (DDH) and the criteria for referral for ultrasound assessment. Version 6 (Vs , Vs , Vs , Vs , Vs ) Key Words Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a 2b 3a meta analysis of randomised controlled trials at least one randomised controlled trial at least one well-designed controlled study without randomisation Developmental Dysplasia of the Hip (DDH), hip dislocation, screening, ultrasound NICE guidance re. newborn examination (Postnatal care NICE clinical guideline ) NHS Newborn Infant Physical Examination (NIPE) Programme ( updated Oct 2010 NHS National Screening Committee report on Screening for Developmental Dysplasia of the Hip 2004 Department of Health Healthy Child Programme ( uploads/systems/uploads/attachment_data /file/167998/health_child_programme.pdf) 3b at least one other type of well-designed Page 14 of 15

15 quasi-experimental study 4 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Target audience Mr James Hunter (Consultant Paediatric Orthopaedic Surgeon) and Dr Stephen Wardle (Nottingham Neonatal Service) Staff of the Nottingham Neonatal service This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. Page 15 of 15