A 6-month-old infant is being evaluated for developmental dysplasia of the hip (DDH). Which assessment finding would be most indicative of DDH in this infant?
1Positive Babinski reflex
2Asymmetrical gluteal and thigh skin folds✓ 정답
3Absence of the Moro reflex
4Increased muscle tone in lower extremities
해설
Asymmetrical gluteal and thigh skin folds are a classic sign of DDH in infants, indicating unequal leg lengths due to hip displacement. Other options (Babinski reflex, Moro reflex, increased muscle tone) are normal findings or unrelated to DDH.
Core Nursing ExplanationKey Concept Analysis
This question assesses the ability to identify a key physical sign of Developmental Dysplasia of the Hip (DDH) in an infant. DDH is a condition where the hip joint is improperly formed, ranging from a shallow acetabulum (hip socket) to complete dislocation of the femoral head. Early detection is critical for successful non-surgical treatment. The assessment focuses on identifying asymmetry caused by the unstable or dislocated hip.
Answer RationaleKey Point!Asymmetrical gluteal and thigh skin folds is a classic, observable sign of DDH. When one hip is dislocated, the affected leg may appear slightly shorter, causing the skin folds on the buttocks and inner thighs to appear uneven or asymmetric when the infant is placed prone (on their stomach). This is part of the standard Ortolani and Barlow maneuver assessment screening. Therefore, option 2 is the most indicative finding.
Distractor AnalysisWatch out for confusion! Let's analyze why the other options are not indicative of DDH:
Option 1 (Positive Babinski reflex): A positive Babinski reflex (toes fan upward when the sole is stroked) is a normal finding in infants up to about 12-24 months due to immature nervous system myelination. It is not related to hip joint integrity.
Option 3 (Absence of the Moro reflex): The Moro reflex (startle reflex) is present at birth and typically integrates by 4-6 months. Its absence in a newborn or young infant is concerning for neurological issues, not musculoskeletal problems like DDH.
Option 4 (Increased muscle tone in lower extremities): Increased or hypertonicity is more suggestive of neurological conditions like cerebral palsy. DDH is typically associated with decreased abduction (limited ability to spread the legs apart) due to tight adductor muscles, not a generalized increase in tone.
Related Concepts
Other key signs of DDH include: Limited hip abduction (the classic sign, especially when changing diapers), an audible or palpable "clunk" during the Ortolani maneuver (reducing a dislocated hip) or Barlow maneuver (dislocating an unstable hip), and leg length discrepancy (Galeazzi sign). Screening is vital during well-baby checks at birth, 2 weeks, 2 months, 4 months, and 6 months.
Concept Summary
Concept
Description
Clinical Relevance
Developmental Dysplasia of the Hip (DDH)
Spectrum of hip joint malformation (instability, subluxation, dislocation).
Early detection via newborn/infant screening is essential for non-surgical treatment (Pavlik harness).
Asymmetrical Skin Folds
Uneven folds on buttocks/thighs when infant is prone.
A soft sign of possible DDH, indicating leg length discrepancy.
Ortolani Maneuver
Hips flexed and abducted; a "clunk" is felt as dislocated hip reduces.
Test for a dislocated hip. Positive after 2-3 months is rare.
Barlow Maneuver
Adduct and gently push posteriorly; a "clunk" is felt as hip dislocates.
Test for a dislocatable (unstable) hip.
Limited Hip Abduction
Inability to abduct the affected hip beyond 45-60 degrees.
The most reliable sign in infants older than 3 months.
Side-by-Side Comparison!
Assessment Finding
Typical Age
Indicates
Not Indicative Of
Asymmetrical Gluteal Folds
Birth - 12 months
Possible DDH (leg length discrepancy)
Neurological status
Positive Babinski Reflex
Birth - 12-24 months
Normal immature nervous system
Pathology in infants (unless persistent past age 2)
Absent Moro Reflex
Newborn period
Possible neurological impairment (e.g., birth injury)
Musculoskeletal disorders like DDH
Limited Hip Abduction
> 3 months
Strong indicator of DDH
Normal hip development
Anatomy, Physiology & Pharmacology Points
Anatomy: The hip is a ball-and-socket joint. In DDH, the acetabulum (socket) is too shallow, and/or the femoral head (ball) is not stable within it.
Physiology: Hormonal relaxation of maternal ligaments (relaxin) and intrauterine positioning (breech) are risk factors. The hip is most developable in the first 6 months of life.
Treatment: No direct pharmacology. Mainstay is mechanical devices: Pavlik harness (for infants <6 months) holds hips in flexed and abducted position to promote proper socket development.
Memory Tips
ABCs of DDH Signs:Asymmetry (skin folds), Barlow/Button (click/clunk), Click/Clunk, Difference in leg length.
Timeline: Think "Hips for Dips" – check hips at every diaper change (well-visit). Limited abduction is the key sign after 3 months.
Reflex Confusion: Remember: Babinski is for Babies (normal). Moro is for More neurological concern if absent.
High-Frequency NCLEX Topics
DDH is a classic pediatric musculoskeletal topic. The NCLEX loves to test:
Identifying the most indicative assessment finding (asymmetry, limited abduction).
Knowing the purpose and use of the Pavlik harness (teaching parents about skin care, never adjusting straps, checking for redness).
Understanding that early intervention leads to the best outcomes, preventing lifelong disability (osteoarthritis, gait problems).
Watch Out for Question Variations!
From Sign to Intervention: "The nurse identifies asymmetrical gluteal folds in a 2-month-old. Which action should the nurse take first?" (Answer: Report the finding to the provider for further evaluation/Ortolani-Barlow testing).
Parent Education: "A 3-month-old is placed in a Pavlik harness for DDH. Which parent statement indicates understanding?" (Answer: "I will check my baby's skin under the straps several times a day.")
Complication Recognition: "An infant in a Pavlik harness develops skin breakdown on the knee. What is the nurse's priority?" (Answer: Remove the harness and notify the provider; do not reapply over broken skin).
Nursing Clinical Practice GuideClinical Scenario
You are a nurse in a pediatric clinic performing a 6-month well-baby check on infant "Leo." During the assessment, you place Leo prone to examine his back and note that the skin folds on his left buttock and inner thigh appear significantly higher and deeper than those on the right. His mother mentions she sometimes finds it harder to spread his left leg during diaper changes.
Nursing Intervention Strategy
Assessment: Perform a systematic hip assessment. With Leo supine, compare leg lengths (Galeazzi sign: flex hips and knees; uneven knee heights suggest discrepancy). Gently attempt hip abduction – note if one side is limited (<60 degrees). Perform the Ortolani and Barlow maneuvers (though these are less reliable after 2-3 months). Document findings precisely: "Asymmetric left gluteal and thigh folds noted. Left hip abduction limited to 45 degrees. No palpable clunk with Ortolani/Barlow."
Planning & Implementation: The priority is referral. Inform the pediatrician/provider immediately of your findings. The provider will likely order a hip ultrasound (gold standard for infants <6 months) to confirm DDH and assess severity. Your role includes preparing the parents for the next steps, explaining the purpose of the ultrasound in simple terms.
Patient/Family Education: If DDH is confirmed and a Pavlik harness is prescribed, provide thorough education:
Harness Application: Demonstrate how to put on/take off the harness. Emphasize it must be worn 23 hours a day, only removed for bathing.
Skin Care: Instruct parents to check skin under straps, at the knees, and in groin folds 2-3 times daily for redness or breakdown.
Diapering & Dressing: Show how to diaper and dress the infant with the harness on. Clothes should be worn under the harness to protect skin.
Follow-up: Stress the importance of weekly or bi-weekly follow-up appointments for harness adjustment and growth monitoring.
Evaluation: Evaluate parent understanding by having them demonstrate harness care. Monitor for treatment success via follow-up ultrasounds showing improved hip positioning.
Patient Safety and Precautions
Never force abduction during assessment. This can damage the hip.
Pavlik Harness Caution: The harness must be correctly fitted. Improper application can cause Femoral nerve palsy or Avascular necrosis (AVN) of the femoral head. Teach parents to report any loss of leg movement or swelling immediately.
Infection Prevention: Any skin breakdown under the harness must be addressed promptly to prevent infection. The harness should not be reapplied over broken skin.
Nursing Procedure & Medication FlowProcedure: Performing the Ortolani and Barlow Maneuvers
Place infant supine on a firm surface in a warm, quiet room.
Flex the infant's hips and knees to 90 degrees.
Ortolani (for reduction): Grasp thighs with thumbs on inner thighs, fingers on greater trochanters. Gently abduct (spread) the hips while lifting the femurs anteriorly. A palpable or audible "clunk" as the femoral head reduces into the acetabulum is a positive Ortolani sign (dislocated hip).
Barlow (for dislocation): From the same position, gently adduct (bring together) the hips while applying mild posterior pressure. A sensation of the femoral head slipping out of the socket (a "clunk") is a positive Barlow sign (dislocatable/unstable hip).
Perform one hip at a time for accuracy. Document findings for each hip separately.
Note: These tests are most reliable in the first few weeks of life. A "click" (high-pitched sound) is common and often benign; a "clunk" (low-pitched, palpable jerk) is significant.
A Word from Your Senior Nurse
"Spotting that little asymmetry during a routine check can change a child's entire life. DDH is a perfect example of why our detailed, hands-on assessments matter so much. In the clinic or hospital, you are the detective. Don't just go through the motions—really look, compare, and feel. When you teach parents about the Pavlik harness, remember they might be scared. Your calm, confident explanation and support turn them from anxious caregivers into empowered partners in their child's care. That's the heart of nursing."
Developmental Dysplasia of the Hip — A spectrum of disorders where the hip joint is improperly formed, ranging from instability and subluxation to complete dislocation.
Ortolani Maneuver — A physical exam maneuver used to detect a dislocated hip in infants. A palpable "clunk" is felt as the femoral head reduces into the acetabulum during hip abduction.
Barlow Maneuver — A physical exam maneuver used to detect a dislocatable (unstable) hip in infants. A "clunk" is felt as the femoral head is pushed posteriorly out of the acetabulum.
Pavlik Harness — A dynamic flexion-abduction orthosis used as the primary non-surgical treatment for DDH in infants under 6 months of age.
Limited Hip Abduction — The inability to abduct the hip beyond 45-60 degrees. It is the most reliable clinical sign of DDH in infants older than 2-3 months.