A 1-month-old girl is brought to the office for a routine newborn examination. She was born at 39 weeks gestation to a 26-year-old primigravida by cesarean section for breech presentation. The pregnancy and delivery were otherwise uncomplicated, and prenatal ultrasound revealed normal fetal anatomy. The infant is formula fed every 3-4 hours and sleeps 5-6 hours overnight. The patient lives at home with her parents and grandparents. She received the hepatitis B vaccine at age 5 days. Physical examination shows an alert infant who is moving all extremities equally. There are 4 skin creases along the patient's inner left thigh and 1 on the right thigh. When supine with the knees flexed, the left knee appears to be inferior to the right knee. Skin examination shows a nonblanching, blue-grey macule with indefinite borders over the sacrum. The rest of the examination is normal. Which of the following is the most appropriate next step in management of this patient?

Question

A 1-month-old girl is brought to the office for a routine newborn examination.  She was born at 39 weeks gestation to a 26-year-old primigravida by cesarean section for breech presentation.  The pregnancy and delivery were otherwise uncomplicated, and prenatal ultrasound revealed normal fetal anatomy.  The infant is formula fed every 3-4 hours and sleeps 5-6 hours overnight.  The patient lives at home with her parents and grandparents.  She received the hepatitis B vaccine at age 5 days.  Physical examination shows an alert infant who is moving all extremities equally.  There are 4 skin creases along the patient's inner left thigh and 1 on the right thigh.  When supine with the knees flexed, the left knee appears to be inferior to the right knee.  Skin examination shows a nonblanching, blue-grey macule with indefinite borders over the sacrum.  The rest of the examination is normal.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d60c_746f_bc81_d18a4e7af942_MD0003_00 This patient's presentation is concerning for developmental dysplasia of the hip (DDH), an abnormal development of the femoral head and acetabulum. Risk factors include breech presentation, female sex, white ethnicity, and family history of DDH. Because many patients have no risk factors, all infants should have serial hip examinations from birth until age 1. The Barlow and Ortolani maneuvers assess joint stability, and a palpable "clunk" should prompt referral to an orthopedic surgeon. These maneuvers may be negative or equivocal, and additional signs, such as leg-length discrepancy (eg, Galeazzi test) or asymmetric inguinal skin folds, can also be indicators of DDH. Barlow and Ortolani maneuvers Galeazzi test asymmetric inguinal skin folds Infants with abnormal examination should undergo bilateral hip ultrasonography. After age 4 months, when the femoral head and acetabulum are ossified, x-rays are preferred to evaluate acetabular development and positioning (Choice F). Confirmed DDH is treated with a Pavlik harness, a splint that holds the hip in flexion and abduction while preventing extension and adduction. Pavlik harness (Choices A and E) The blue-grey macule on this patient's sacrum is consistent with congenital dermal melanocytosis (Mongolian spot), a benign skin lesion. A lumbosacral ultrasound is indicated for neonates with a sacral dimple or tuft of hair, a potential indication of a neural tube defect (eg, spina bifida occulta). Abnormal ultrasound is usually followed by MRI to assess the extent of the defect. This patient has no other abnormalities and does not warrant additional imaging. (Choices B and C) Reassurance is inappropriate in the setting of asymmetric skin folds, a clinical finding suggestive of DDH. Repeat examination at a subsequent visit could be appropriate for hip laxity without a palpable "clunk" or asymmetry. Early diagnosis of DDH is critical, as treatment initiation before age 6 months portends a favorable prognosis. Educational objective: Suspected developmental dysplasia of the hip (eg, asymmetric gluteal/thigh/inguinal creases, apparent leg-length discrepancy) in early infancy should be evaluated with hip ultrasound. References: Clinical practice guideline: early detection of developmental dysplasia of the hip. Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. American Academy of Pediatrics. (http://www.ncbi.nlm.nih.gov/pubmed/10742345) Musculoskeletal screening: developmental dysplasia of the hip. (http://www.ncbi.nlm.nih.gov/pubmed/24168117)

A 1-Month-Old Girl Is Brought to the Office for a Routine