Pediatrics

Screening and Diagnosing Hip Issues

At a Glance

Developmental dysplasia of the hip can be missed on a newborn exam, especially in babies with risk factors such as breech birth. Doctors use physical exams, ultrasound around 4–8 weeks, and pelvic X-rays after about 6 months to monitor hip development.

Diagnosing Developmental Dysplasia of the Hip (DDH) is a process that begins at birth and continues through your baby’s first year. Because the hip joint is made mostly of soft cartilage in newborns, it can be difficult to see or feel every issue during a single checkup ^[1]. To ensure no cases are missed, doctors use a “selective screening” strategy based on guidelines from organizations like the American Academy of Pediatrics (AAP) and the American Academy of Orthopaedic Surgeons (AAOS): they perform physical exams on every baby and reserve specialized imaging for those with specific major risk factors or abnormal physical findings ^[2]^[3].

The Screening Timeline

While screening protocols can vary depending on your location, a standard approach includes ^[4]:

At Routine Visits: Your clinician will physically check your baby’s hips for stability and range of motion at routine well-baby checks using age-appropriate techniques.
Selective Ultrasound (often 4-8 Weeks): If your baby was breech, has a strong family history of DDH, or had a clearly abnormal hip exam, an ultrasound is typically scheduled for when the baby is between 4 and 8 weeks old (commonly around 6 weeks) ^[2]^[5]. Note that an isolated benign “click” or being female, while a risk factor, is usually not enough on its own to mandate an ultrasound without other indications.
Follow-Up (6 Months): In some high-risk cases, a doctor may recommend a follow-up X-ray around 6 months of age, even if the earlier ultrasound was normal ^[2].

Immediate Referral vs. Routine Screening

It is crucial to understand the difference between routine screening and a diagnostic evaluation.

If your doctor feels a distinct “clunk” (a positive Ortolani sign) or finds that the hip is dislocated, this requires prompt referral to a pediatric orthopedist and imaging according to the specialist’s plan. You should not delay evaluation in this scenario ^[6].

However, if your baby’s physical exam is normal but they have risk factors (like being breech), the routine screening ultrasound is usually scheduled for around 6 weeks.
Why wait? Waiting in these clinically stable cases is intentional. Many newborns are born with slightly loose hips that naturally tighten up within the first month ^[7]. Performing a routine screening ultrasound too early (within the first 4 weeks) often identifies early physiologic immaturity—showing a minor issue that would have fixed itself—which can lead to unnecessary parental anxiety and overtreatment ^[8]^[9].

Ultrasound: The Preferred Imaging for Infants

For babies under 4 to 6 months old, ultrasound is the preferred diagnostic test ^[1]. It uses sound waves to safely create a picture of the hip joint without radiation ^[10].

Doctors often use the Graf method to grade the hip ^[11]. They look at two main things:

Morphology (Shape): Using a measurement called the alpha angle, the radiologist determines how deep and well-shaped the hip socket is ^[12].
Stability: During a dynamic ultrasound, the clinician may gently move the baby’s hip to see if the ball stays centered in the socket under mild pressure ^[13].

Transitioning to X-rays

As your baby grows, ultrasound becomes less effective. This is due to a process called ossification, where the soft cartilage in the “ball” of the hip begins to turn into hard bone ^[14].

4 to 6 Months: This is the typical transition period. Once the femoral head (the ball) begins to harden, it blocks the ultrasound waves, making it difficult to see the socket clearly ^[15].
After 6 Months: A pelvic X-ray becomes the primary tool for diagnosing DDH ^[16]. X-rays provide a clear view of the bony structures and allow doctors to measure the angles of the hip socket.

The most important takeaway is that a “normal” physical exam at birth does not completely rule out DDH, especially for high-risk babies (such as those born breech) ^[17]. Following through with your clinician’s recommended imaging plan is the best way to ensure your baby’s hips are developing properly.

Common questions in this guide

How is developmental dysplasia of the hip screened in a baby?

Clinicians check a baby’s hip stability and movement during routine visits. Babies with risk factors such as breech birth, a family history of DDH, or an abnormal examination may also receive a targeted ultrasound, usually around 4 to 8 weeks of age.

When should a breech baby have a hip ultrasound?

A breech baby with a normal physical examination is commonly scheduled for a hip ultrasound at about 4 to 8 weeks, often near 6 weeks. The exact timing can vary by local practice and your clinician’s assessment, and a normal newborn examination does not always eliminate the need for follow-up imaging.

Why might doctors wait to perform a routine hip ultrasound?

Many newborns have mildly loose hips that become stable during the first month. Imaging too early can show temporary immaturity that would resolve on its own, which may lead to unnecessary anxiety or treatment; a distinct clunk or suspected dislocation is different and needs prompt specialist evaluation.

What do the Graf type and alpha angle mean on a baby’s hip ultrasound?

The Graf method evaluates the shape and development of the hip socket and whether the hip stays centered during gentle movement. The alpha angle is a measurement that helps describe how deep and well-shaped the socket is, so your clinician should interpret it together with the complete ultrasound findings.

When does a baby switch from hip ultrasound to an X-ray?

Ultrasound is generally preferred for babies younger than about 4 to 6 months because much of the hip is still cartilage. As the hip bones develop, a pelvic X-ray usually becomes the main imaging test after about 6 months, although the transition depends on the child and clinical situation.

Can a baby develop or have DDH even if the newborn hip exam was normal?

Yes. A normal examination at birth does not completely rule out DDH, particularly in a baby with risk factors such as breech presentation or a family history. Keeping scheduled examinations and recommended imaging appointments helps detect hip problems that are not apparent at first.

Get notified when new evidence is published on developmental dysplasia of the hip.

We monitor PubMed for new peer-reviewed studies on this topic and email a short summary when something meaningful changes.

References (17)

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This page explains how clinicians screen and diagnose developmental dysplasia of the hip in babies for informational purposes only and does not constitute medical advice. Your baby’s clinician or pediatric orthopedist should interpret examination and imaging results and advise you about next steps.

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