Study highlights ineffective hospital hip tests for newborns
The study, reported by the BBC, says that the tests conducted routinely in hospitals on all babies have had little impact on cases of late diagnosis of hip dysplasia. The rate of late diagnosis has actually increased in the 30 years since the test was introduced.
While this is a very worrying statistic, sadly it is not surprising. I represent many children in medical negligence claims for late diagnosis of hip dysplasia. Those examining newborn babies use the 'Barlow' and 'Ortolani' tests to check whether the hips are stable. These tests are known to be indicative only highlighting the need for further investigation which is often not carried through.
The Barlow test involves bringing the thighs together (adducting) and then gentle pressure being applied to the hip to see whether it can be pushed out of socket and is therefore ''loose''. The Ortolani test involves moving the hips outwards (abducting) and manipulating the hip joint to see if the hip can be relocated. A positive test results in a 'clunk' sound as the head of the femur (ball) is momentarily out of the acetabulum (socket).
The head of the femur in a newborn is no bigger than half an adult's thumb. The margins in these tests are very fine and rarely conclusive. The examiner must understand the difference between the 'click' sound (normal) and a 'clunk'' sound, which indicates hip dysplasia. It is therefore not surprising that the condition can be missed even in the most competent and experienced hands.
If an abnormality is picked up, treatment is fairly straightforward - a newborn will wear a corrective splint for two to three months after which most babies will have no further problems. Unfortunately, delay in diagnosis of more than a year is much more difficult to correct and generally results in long-term complications requiring far more invasive surgery, premature arthritis and the need for hip replacement surgeries in later life.
Sometimes multiple corrective surgeries are necessary during childhood, including a pelvic osteotomy or a femoral osteotomy or both. Further surgery is often needed to take out metalwork. Children often develop a fear of hospital settings and can become isolated at school because they can't join in team games and sports – or when they do, are unable to keep up and are picked on for being 'different'. I have seen too many examples of bullying and teasing at an age when children are self-conscious and incredibly susceptible to peer pressure.
The tragedy is that this pain and unhappiness is easily avoidable. Other countries routinely scan all newborns using ultrasound rather than relying on a much cheaper general examination.
The argument made by Professor Anne Mackie, director of public screening at Public Health England, against universal scanning is that children would be incorrectly diagnosed with hip dysplasia and that wearing a splint during early months can affect the mother/baby bond and can cause avascular necrosis where the hip 'dies'."
I would question whether Germany and Austria, which routinely ultrasound all newborns, have a serious problem with avascular necrosis due to increased diagnosis. What I do know is that late diagnosis of hip dysplasia has significant implications in later life.
Early diagnosis and treatment means the child grows up to have a healthy hip and can join in with all activities at school. It means all career options are open to the child, rather than ruling out careers in the police and armed forces and any hope of playing high-level sport. It means no increased risk of premature arthritis and no hip replacement surgeries later in life.
Neonatal examination is not the only opportunity to pick up hip dysplasia. Every child should undergo a physical examination with a health visitor and there is a routine GP examination at six to eight weeks which includes examination of the hips. Often parents will be concerned about asymmetrical creases, commando crawling (dragging one leg behind the other), not pulling to stand, taking longer than normal to walk or walking with an unusual gait.
But I have cases where a GP has ignored parental concerns – sometimes on as many as five or six separate occasions, before finally making a referral.
True, universal scanning of newborns would be an investment. But, in the long run, it would save the NHS money and give those who are born with hip dysplasia a much better quality of life. Sadly, it does not appear to be an investment the NHS will make.