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PubMed This is a summary of 17 peer-reviewed journal articles Updated
Pediatrics

Risk Factors and Physical Signs of DDH

At a Glance

Developmental dysplasia of the hip is often painless, so doctors rely on risk factors and age-appropriate examinations to find it. Breech presentation, family history, female sex, and low amniotic fluid raise risk, while limited hip movement or unequal leg length may signal a problem.

Detecting Developmental Dysplasia of the Hip (DDH) can be challenging for parents because the condition is typically painless and “clinically silent” during the first year of life [1][2]. Unlike a broken bone or an infection, a baby with DDH will usually not cry, fuss, or show discomfort when their hip is out of place [3]. Because there are no obvious signs of pain, doctors rely on specific risk factors and age-appropriate physical exams to identify babies who need extra attention.

Major Risk Factors

While any baby can have DDH, certain factors during pregnancy and birth increase the likelihood. Doctors use these to decide if a baby needs a screening ultrasound even if their physical exam looks normal [4].

  • Breech Presentation: This is one of the strongest risk factors. Babies who are positioned feet or bottom first—especially if they remain breech after 30 weeks of pregnancy—have a higher risk [5][6].
  • Family History: Having a first-degree relative (a parent or sibling) who had DDH increases a baby’s risk significantly [7][8].
  • Female Sex: Girls are roughly 2.5 to 5 times more likely than boys to have DDH [7][8].
  • Oligohydramnios: This is a condition where there is low amniotic fluid during pregnancy. Without enough fluid to move around, the baby’s hips can be compressed, which may interfere with normal joint development [7][9].

How Doctors Check Newborns

In the first few weeks of life, your pediatrician will perform specific maneuvers to feel for hip instability. These are highly skilled movements and should only be performed by a healthcare professional—parents should not attempt them at home.

  1. The Ortolani Test: The doctor gently moves the baby’s hips outward. If the hip is dislocated, they may feel a distinctive “clunk” as the ball slides back into the socket [10].
  2. The Barlow Test: This is a gentle “stress test.” The doctor moves the hips toward the center to see if the joint is loose or if the ball can be easily nudged out of the socket [10].

It is important to know that these tests are not perfect. A baby can have DDH even if these maneuvers feel normal at birth, which is why repeat exams and ultrasounds for at-risk babies are so important [11][12]. Note that an audible “click” is common and generally benign; a “clunk” indicates true instability.

Signs in Older Babies (3-12 Months)

As a baby grows, the newborn instability tests become less useful, and the signs of DDH change. After about 3 months, doctors use age-appropriate examinations to look for different clues [4]:

  • Limited Hip Abduction: This is a key sign in older infants. It means the hip cannot open as wide as it should [13]. You might notice this during diaper changes if one leg feels stiff and doesn’t move outward as far as the other.
  • Galeazzi Sign (Leg-Length Discrepancy): When the baby lies on their back with knees bent and feet flat on the table, one knee may appear lower than the other [4][14]. This suggests the hip ball is sitting outside or above the socket.
  • The “Waddling” Limp: If DDH is not caught until a child begins to walk, they may have a noticeable limp or a gait where the pelvis drops on one side while walking [4][15].

The Truth About Skin Folds

Many parents become worried when they notice that the skin folds on their baby’s thighs or buttocks are not symmetrical. While doctors do note these folds, asymmetric skin folds alone are not a reliable way to diagnose DDH [16].

In fact, many perfectly healthy babies have uneven thigh folds, and most babies referred for imaging based only on skin folds turn out to have normal hips [17][16]. Skin folds are only concerning if they are seen alongside other signs, such as limited hip movement or a difference in leg length [14]. If you notice uneven folds, mention it to your doctor, but it is rarely a cause for panic on its own.

Common questions in this guide

What increases a baby's risk of developmental dysplasia of the hip?
Important risk factors include breech presentation, a parent or sibling with DDH, female sex, and low amniotic fluid during pregnancy. Any baby can develop DDH, so risk factors are considered alongside physical examinations.
Can a baby have DDH without seeming to be in pain?
Yes. DDH is often painless and may have no obvious symptoms during the first year, which is why clinicians use risk-factor assessment, repeat examinations, and imaging when appropriate.
What is the difference between a hip click and a hip clunk?
An audible click is common and usually harmless, while a palpable clunk during a clinician's examination can indicate that the hip is unstable or moving in and out of the socket. Parents should not try to reproduce either sound or sensation at home.
What do the Ortolani and Barlow tests check?
These are newborn hip maneuvers performed by trained healthcare professionals. The Ortolani maneuver checks whether a dislocated hip can move back into the socket, while the Barlow maneuver checks whether a loose hip can be gently moved out.
What signs of DDH may appear in an older baby?
After about 3 months, limited movement of one hip outward and a difference in knee height or leg length may be clues. If DDH remains undiagnosed when a child starts walking, a limp, waddling gait, or pelvic drop may occur.
Are uneven thigh or buttock folds a reliable sign of DDH?
No. Uneven skin folds are common in healthy babies and are not reliable by themselves; they are more concerning when paired with limited hip movement or a leg-length difference. Mention them to the child's clinician, who can decide whether further evaluation is needed.
Should my baby have a hip ultrasound after a normal physical exam?
A normal newborn examination does not completely rule out DDH. Babies with risk factors such as breech presentation or a first-degree family history may need repeat examinations and an ultrasound, so ask your pediatrician about the appropriate timing.

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References

References (17)
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    Evaluation and Referral for Developmental Dysplasia of the Hip in Infants.

    Shaw BA, Segal LS,

    Pediatrics 2016; (138(6)).

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  2. 2

    Ultrasound of the neonatal hip as a screening tool for DDH: how to screen and differences in screening programs between European countries.

    Kilsdonk I, Witbreuk M, Van Der Woude HJ

    Journal of ultrasonography 2021; (21(85)):e147-e153 doi:10.15557/JoU.2021.0024.

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    Developmental dysplasia of the hip.

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    British journal of hospital medicine (London, England : 2005) 2020; (81(7)):1-8 doi:10.12968/hmed.2020.0223.

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    Surveillance for Developmental Dysplasia of the Hip in India: Consensus Guidelines From the Pediatric Orthopaedic Society of India, Indian Academy of Pediatrics, National Neonatology Forum of India, Indian Radiological and Imaging Association, Indian Federation of Ultrasound in Medicine and Biology, Federation of Obstetric and Gynaecological Societies of India, and Indian Orthopaedic Association.

    Aroojis A, Anne RP, Li J, et al.

    Indian pediatrics 2022; (59(8)):626-635.

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  5. 5

    Association between timing and duration of breech presentation during pregnancy and developmental dysplasia of the hip: A case-control study.

    Konijnendijk A, Vrugteveen E, Voorthuis B, Boere-Boonekamp M

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    A mini-review of risk factors for developmental dysplasia of the hip: insights from multiple comparative cohort studies.

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    Risk Factors for Developmental Dysplasia of the Hip Before 3 Months of Age: A Meta-Analysis.

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    Revisiting selected risk factors and their association with ultrasonographic hip types in developmental dysplasia of the hip: a multivariate regression analysis.

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    BMC pediatrics 2026; (26(1)).

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    The Ortolani test has a high positive predictive value in clinical hip screening for developmental dysplasia of the hip.

    Maikku M, Rantala T, Valkama M

    Acta paediatrica (Oslo, Norway : 1992) 2023; (112(7)):1586-1591 doi:10.1111/apa.16757.

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  11. 11

    Sensitivity of clinical screening for detecting developmental dysplasia of the hip: a retrospective study.

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  12. 12

    Early detection of developmental dysplasia of hip by ultrasound.

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    The positive predictive value of asymmetrical skin creases in the diagnosis of pathological developmental dysplasia of the hip.

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    Clinical significance of asymmetric skin folds in the medial thigh for the infantile screening of developmental dysplasia of the hip.

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    Asymmetrical thigh creases or isolated thigh crease may be a false positive sign with low predictive value in the diagnosis of developmental dysplasia of the hip in infants: a prospective cohort study of 117 patients.

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This page about DDH risk factors and physical signs is for informational purposes only and does not constitute medical advice or diagnose your baby. Do not perform hip tests at home; ask your pediatrician about examination and screening.

Guide contents developmental dysplasia of the hip
Research & Literature
01 Understanding Your Baby's Hip Development 03 Screening and Diagnosing Hip Issues