Developmental Dysplasia of the Hip-Child

Variant: 1 Child, younger than 4 weeks of age. Equivocal physical examination or risk factors for DDH. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US hips	Usually Not Appropriate	O
Radiography pelvis	Usually Not Appropriate	☢☢

Variant: 2 Child, between 4 weeks to 4 months of age. Equivocal physical examination or risk factors for DDH. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US hips	Usually Appropriate	O
Radiography pelvis	Usually Not Appropriate	☢☢

Variant: 3 Child, younger than 4 months of age. Physical findings of DDH. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US hips	Usually Appropriate	O
Radiography pelvis	Usually Not Appropriate	☢☢

Variant: 4 Child, between 4 to 6 months of age. Concern for DDH. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Radiography pelvis	Usually Appropriate	☢☢
US hips	May Be Appropriate	O

Variant: 5 Child, older than 6 months of age. Concern for DDH. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Radiography pelvis	Usually Appropriate	☢☢
US hips	Usually Not Appropriate	O

Variant: 6 Child, younger than 6 months of age. Known diagnosis of DDH, nonoperative surveillance imaging in harness.

Procedure	Appropriateness Category	Peds Relative Radiation Level
US hips	Usually Appropriate	O
Radiography pelvis	Usually Not Appropriate	☢☢
MRI pelvis without and with IV contrast	Usually Not Appropriate	O
MRI pelvis without IV contrast	Usually Not Appropriate	O
CT pelvis with IV contrast	Usually Not Appropriate	☢☢☢☢
CT pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
CT pelvis without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Panel Members

Jie C. Nguyen, MD, MS^a; Scott R. Dorfman, MD^b; Cynthia K. Rigsby, MD^c; Ramesh S. Iyer, MD^d; Adina L. Alazraki, MD^e; Sudha A. Anupindi, MD^f; Dianna M. E. Bardo, MD^g; Brandon P. Brown, MD^h; Sherwin S. Chan, MD, PhDⁱ; Tushar Chandra, MD^j; Matthew D. Garber, MD^k; Michael M. Moore, MD^l; Nirav K. Pandya, MD^m; Narendra S. Shet, MDⁿ; Alan Siegel, MD, MS^o; Boaz Karmazyn, MD^p.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Discussion of Procedures by Variant

Variant 1: Child, younger than 4 weeks of age. Equivocal physical examination or risk factors for DDH. Initial imaging.

Variant 1: Child, younger than 4 weeks of age. Equivocal physical examination or risk factors for DDH. Initial imaging.
A. US Hips

Variant 1: Child, younger than 4 weeks of age. Equivocal physical examination or risk factors for DDH. Initial imaging.
B. Radiography Pelvis

Variant 2: Child, between 4 weeks to 4 months of age. Equivocal physical examination or risk factors for DDH. Initial imaging.

Variant 2: Child, between 4 weeks to 4 months of age. Equivocal physical examination or risk factors for DDH. Initial imaging.
A. US Hips

Variant 2: Child, between 4 weeks to 4 months of age. Equivocal physical examination or risk factors for DDH. Initial imaging.
B. Radiography Pelvis

Variant 3: Child, younger than 4 months of age. Physical findings of DDH. Initial imaging.

Variant 3: Child, younger than 4 months of age. Physical findings of DDH. Initial imaging.
A. US Hips

Variant 3: Child, younger than 4 months of age. Physical findings of DDH. Initial imaging.
B. Radiography Pelvis

Variant 4: Child, between 4 to 6 months of age. Concern for DDH. Initial imaging.

Variant 4: Child, between 4 to 6 months of age. Concern for DDH. Initial imaging.
A. US Hips

Variant 4: Child, between 4 to 6 months of age. Concern for DDH. Initial imaging.
B. Radiography Pelvis

Variant 5: Child, older than 6 months of age. Concern for DDH. Initial imaging.

Variant 5: Child, older than 6 months of age. Concern for DDH. Initial imaging.
A. US Hips

Variant 5: Child, older than 6 months of age. Concern for DDH. Initial imaging.
B. Radiography Pelvis

Variant 6: Child, younger than 6 months of age. Known diagnosis of DDH, nonoperative surveillance imaging in harness.

Variant 6: Child, younger than 6 months of age. Known diagnosis of DDH, nonoperative surveillance imaging in harness.
A. US Hips

Variant 6: Child, younger than 6 months of age. Known diagnosis of DDH, nonoperative surveillance imaging in harness.
B. Radiography Pelvis

Variant 6: Child, younger than 6 months of age. Known diagnosis of DDH, nonoperative surveillance imaging in harness.
C. CT Pelvis

Variant 6: Child, younger than 6 months of age. Known diagnosis of DDH, nonoperative surveillance imaging in harness.
D. MRI Pelvis

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.