International Journal of Orthopaedic and Trauma Nursing (2010) 14, 4047

International Journal of Orthopaedic and Trauma Nursing

www.elsevier.com/locate/ijotn

The nurses role in educating, counselling and preparing parents to care for a child with Developmental Dysplasia of the Hip (DDH)
Eileen Causon RGN (Staff Nurse)
*

Orthopaedic Clinic, Lincoln County Hospital, Greetwell Road, Lincoln LN2 5QY, United Kingdom

KEYWORDS
Developmental; Dysplasia; Hip

Summary

Infants can be affected by a number of musculo-skeletal conditions at birth. One of the most common is Developmental Dysplasia of the Hip (DDH). DDH is thought to occur in utero, during birth, and also during infancy and childhood. DDH is a condition that involves a hip joint that is unstable, subluxated, or completely dislocated. This can include a range of conditions from mild malformation of the acetabulum to a dislocation that cannot be reduced. It can be caused by a combination of factors that include hereditary factors, hormonal, and positioning in the uterus due to breech position and multiple births and oligohydramnios. Nurses caring for infants with DDH should have knowledge of the pathophysiology of this condition, and be able to relate it to the treatment interventions and care that is given. The importance of detection cannot be over emphasised, as the risk of developing osteonecrosis and osteoarthritis of the hip into adult life is increased if DDH is left untreated. Along with chronic pain and poor mobility the lifelong implications can be disastrous. There is also a risk of the development of avascular necrosis (AVN) not only in the affected hip, but also the contralateral hip, resulting directly from the treatment given to correct the deformity [Read, H.S., Evans G.A., 2002. Avascular necrosis as a complication in the management of developmental dysplasia of the hip. Current Orthopaedics 16(3), 205212]. The treatment for DDH can consist of surgical and non-surgical methods depending on severity. These can include various methods of abduction of the hip using splints and casts, ultrasoundmonitoring, and surgery such as pelvic and femoral osteotomies to enable correction of the problem. The nurses role in educating, counselling and preparing parents to care for a child with DDH is very important. The psychological impact on parents from discovering their child is not as physically perfect as they were expecting has to be considered. In the authors own workplace, an orthopaedic clinic, nurses meet children and their parents diagnosed and treated for DDH during pre operative

* Tel.: +44 01522 826852. E-mail address: eileen.causon@ntlworld.com 1361-3111/$ - see front matter c 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.joon.2009.07.048

The nurses role in educating, counselling and preparing parents to care for a child

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assessment, in the plaster room and in consultation with the doctor. As a profession it is essential that nurses have the knowledge and understanding of the condition to full this role [Hart, E.S., Albright, M.B., Rebello, G.N., Grottkau, B.E., 2006. Developmental dysplasia of the hip. Nursing implications and anticipatory guidance for parents. Orthopaedic Nursing 25(2), 100109]. c 2009 Elsevier Ltd. All rights reserved.

Editors comments Development Dysplasia of the Hip is one of the most common musculo-skeletal problems of childhood. Advances in treatment and understanding over the last 50 years have enabled most children with the condition to become adults with few problems as a result of the condition. The management of the condition in the early years, however, requires considerable effort and inconvenience on the part of both the children and their families. An understanding of what to expect and how this impacts on the lives of everyone involved is central to ensuring the experience is without distress and anxiety and that children have the opportunity to develop normally. JS

Epidemiology
Literature gives varying gures as to the numbers affected, being anywhere between 1 and 2 per thousand live births (American Academy of Pediatrics, 2000) to as many as the 7.3 per thousand identied in an Australian study (Sharpe et al., 2005). Benson and Wainright (2004) report that up to 20 per thousand infants born in Europe may have a demonstrable hip instability at birth. DDH has a tendency to run in families and is more common in western countries. Ethnic groups where postnatal swaddling and use of cradleboards cause the hips to be held in adduction have high rates of DDH (Dezateux and Rosendahl, 2007). The incidence is lower in African populations post natally and this is thought to be due to the position of the babies when being carried on the mothers back, with hips abducted (Solomon et al., 2005). DDH is most common in girls (Dezateux and Rosendahl, 2007). The ratio is quoted as being anything from 4:1(Benson and Wainright, 2004) to 8:1 (Dandy and Edwards 2003). The increased susceptibility of infants to the maternal hormone relaxin in later pregnancy is thought to be responsible for an increase in the risk of laxity of the joints and subsequent DDH (Solomon et al., 2005). Hart et al. (2006) report that girls are more susceptible to relaxin than boys. A child whose older sibling is affected will be 10 times more at risk of developing the condition, and if a parent and rst child are diagnosed with DDH subsequent children will have a 1:3 chance of being affected (Campion and Benson, 2007). DDH is associated with other disabilities such as cerebral palsy and diplegia (Haugh et al., 1997). The left hip is affected more often than the right, and both hips are affected in 1 in 5 cases of DDH (Solomon et al., 2005). An increased

risk of DDH is also associated with other conditions such as metatarsus adductus, congenital muscular torticollis, congenital dislocation of the knee (AAP, 2000) and plagiocephaly (Benson and Wainright, 2004). These risk factors can be associated with intrauterine crowding and other mechanical factors in late pregnancy (Hart et al., 2006).

Pathophysiology
Developmental hip dysplasia (DDH) is a term used to describe an entire spectrum of disease ranging from minor acetabular dysplasia to irreducible dislocation (Buxton et al., 2004, p 452). Hip dysplasia is an irregularity in the shape, size and position of the femoral head, acetabularor both, and acetabular dysplasia refers to the immature, shallow acetabulum (Storer and Skaggs, 2006). The normal hip joint develops during the embryonic period from a block of primitive mesenchymal cells. From this, limb buds begin to form at about 4 weeks and grow to develop into the upper and lower extremities. Muscles, tendons, bony structures and cartilage develop from the mesoderm layer (Connolly and Weinstein, 2007). The joint cleft forms to separate the femoral head from the acetabulum at about 78 weeks gestation and the initial structures of the hip joint (Hart et al., 2006, p101) are completely developed by 1112 weeks gestation. It is at this early stage of development that dislocation could occur (Hart et al., 2006). At 16 weeks the ossication of the femur has completed, but only to the level of the lesser trochanter (Lee and Eberson, 2006) as ossication of the femoral head does not take place until between four and six months after birth (Storer and Skaggs, 2006). The hip is also at risk

42 of dislocation at 18 weeks gestation, in the nal 4 weeks of pregnancy, and during the postnatal period (American Academy of Paediatrics, 2000). The hip structure can develop normally in the foetus but positioning in the uterus in the later stages of pregnancy can cause hip instability. Benson and Wainright (2004) report the incidence of DDH may be as high as 15% in breech births. Lowry et al. (2005) report a lower incidence of DDH in full term breech births where the infants were delivered by caesarian section. Oligohydramnios and twin pregnancies restrict foetal movement making breech presentation more likely thus increasing the risk of DDH. Inherited joint laxity and hormonal changes in pregnancy can cause instability of the hip joint. This can result in spontaneous dislocation that may then relocate and become stable within a few days, resulting in normal development subsequently (American Academy of pediatrics, 2000). Failure to diagnose and treat hip dislocation will result in changes to the bony structure, muscles and tendons including stretching of the hip capsule, muscle contracture and attening of the femoral head (McCullough and Pellino, 1994). If DDH remains untreated these changes will become increasingly more difcult to correct. Children with cerebral palsy can be prone to exion deformities and adductor spasm that can cause internal rotation and make it difcult to extend or externally rotate the affected hip joint. This can result in progressive subluxation of the hip (Dandy and Edwards, 2003).

E. Causon 2004). Any infants identied with increased risk factors for DDH will need to be referred for ultrasound examination (National Screening Committee 2004). These procedures are subject to discussion in several papers including French and Dietz (1999) and Paton et al. (2005), regarding the tests being unreliable when carried out by inexperienced medical personnel. Buxton et al. (2004) point out that there is no legal requirement in the UK for the examiner, regardless of professional qualication, to receive any special training before carrying out these procedures. A false negative result may be due to an inexperienced examiner or tense infant (Grissom and Harcke, 2000). Sharpe et als. (2005) study to identify differences in risk factors between cases of early and late diagnosed DDH, concluded that babies born in rural areas were 4 times more likely to be at risk of late diagnosis. One explanation was that professionals in more heavily populated areas had more opportunity to examine babies and therefore would become more experienced. Although only a small number of cases of late diagnosis were identied it could demonstrate the importance of training in examination techniques. As this is a study on the South Australian population the facts in it cannot be attributed generally but it does contain some useful points. Nurses in the authors own workplace are not involved in this aspect of care. Some larger hospitals in the UK do have nurse led DDH clinics where paediatric and orthopaedic nurse specialists are involved in examination of infants, and so adequate training and supervision would have the same relevance to ensure an appropriate level of expertise is maintained (Lee, 2005). This could also apply to nurse practitioners in other countries who are responsible for examining infants where this training could be useful. Other clinical examination indicators of DDH are leg length discrepancy, positive Galleazzi sign and asymmetric skin folds. The Galleazzi sign is positive when the knees show an inequality in height, and can be elicited by laying the child in the supine position and holding the knees and hips in a exed position with feet on the examination table close to the buttocks (Storer and Skaggs, 2006). Ultrasound of the hip is used to detect abnormalities before six months of age, as the femoral head is cartilaginous until around this time, and not easily denable on plain X-rays. It can be used in conjunction with the Ortolani and Barlow manoeuvres for neonates so that the movement of the hip is visualized during the procedure (Grissom and Harcke, 2000). It is not standard practice for ultrasound to be used routinely to screen

Diagnosis and treatment

At birth, infants in the United Kingdom have been routinely screened for hip instability since the 1960s (Grissom and Harcke, 2000) using Ortolani and Barlows tests. During the Ortolani test the hip is exed gently to 90 and moved from adduction to abduction, but if the hip is dislocated full abduction is not possible (Benson and Wainright, 2004). A positive test induces a clunk that would indicate a reduction of a dislocated hip. In Barlows test an attempt is made to move the femoral head out of the acetabulum and back again when the hip is exed and in an adducted position (Paton, 2005). The hip is said to be unstable if this can be achieved (Solomon et al., 2005). The National Screening Committee Report (2004) recommends that all infants should be screened using these methods within 72 h of delivery. If an abnormality is detected an ultrasound examination should be performed to investigate further (Buxton et al.,

The nurses role in educating, counselling and preparing parents to care for a child for DDH in the UK and North America. Elbourne et al. (2002) mention the higher costs of ultrasound monitoring in their study comparing outcomes where it was used with clinical examination compared to clinical assessment alone. Some European countries advocate universal ultrasound screening (Woolacott et al., 2005) and this has led to an increase in the number of babies undergoing abduction splinting but reduced the incidence of surgery (Dezateux et al., 2003). Dandy and Edwards (2003) report that if instability is diagnosed early enough babies can be cared for in double nappies, to enable the hips to be held in an abducted and exed position while being worn. If this fails to achieve the desired result further treatment will be necessary. Judd and Wright (2005) point out this method is only of use on a temporary basis for suspected hip dislocation, after assessment and diagnosis by a paediatrician. The American Academy of pediatrics (2000) report that this method, although common, lacks research as to its effectiveness and may be responsible for delaying more appropriate treatment. The Pavlik harness is used to hold the hips in abduction and exed to about 100 (Solomon et al., 2005) and is used for up to 26 weeks. It is made up from shoulder and leg straps and is made from a soft material. The head of femur is located concentrically in the acetabulum thus stimulating its growth (Judd and Wright, 2005). The UK Hip Trial (Elbourne et al., 2002) showed that the Pavlik harness was the most frequently used splint in initial treatment. Ultrasound is then used to monitor progress along with regular checks of the harness. A six-year prospective study by Taylor and Clarke (1997) assessed the value of ultrasound when monitoring treatment of babies in the Pavlik harness. The rate of successful reduction was 95.7% but it could not say that monitoring contributed to this rate. A Canadian study (Patel, 2001) concluded that the true rate of success using the harness is unknown as there is a rate of spontaneous correction that could account for some of the successful reductions and that ultrasound itself could increase the rate of splinting due to false positive diagnosis of DDH. However, the UK multicentre randomised controlled hip trial covering 33 centres (Elbourne et al., 2002), concluded that babies in the ultrasonagraphy group were less likely to have their hips splinted than the group that underwent clinical screening only. Wilkinson et al. (2002) describe their comparative study of the Pavlik harness, Craig splint and von Rosen splint when used on 134 hips in 96 children. They concluded that treatment in the von Rosen splint resulted in improved ultrasound appearance and less radiological abnormalities

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than those treated in the Pavlik harness or no splinting at all. This was a small retrospective study where the von Rosen splints were applied at an earlier age and follow up was for a short time. The research authors recommend that a larger study would be needed to compare the efcacy of treatment with the different methods. Taylor and Clarkes (1997) study emphasised the importance of appropriate supervision by skilled professionals when monitoring compliance, preventing complications and making any adjustment necessary. Paediatric physiotherapists did this during clinic appointments in this study. This happens in the authors own work area and parents are encouraged to express any concerns and ask questions at the same time. A leaet is also provided giving an explanation of DDH, the aim of the treatment and the timescale involved. There are many leaets available on the Internet published by hospitals and charities giving broadly similar information. Parental compliance with the Pavlik Harness could be an issue so it is important that the information given emphasises the importance of following the guidelines precisely. Malkawi (1998) recommended that close monitoring and active engagement of the mother in group therapy to explain details of treatment, along with ultrasound monitoring, could contribute to a shorter period of treatment in the harness. Hart et al. (2006) point out that all parents remove the harness at some time and then nd it difcult to reapply. They advocate a strong support system of monitoring and parental education to help parents come to terms with the diagnosis and treatment. Complications of abduction splinting are mentioned in several papers. Patel (2001) reported that AVN of the femoral head had been observed in 14% of all infants who underwent treatment with double or triple nappies, or abduction splinting, commonly the Pavlik harness. The incidence was reported as being higher in younger infants where the epiphysis is more prone to vascular damage. Wilkinson et al. (2002) quote an incidence of AVN in 2% of infants treated with the von Rosen splint and 5.413% in studies involving the Pavlik Harness. However, they point out that the splints were tted at different ages and this could explain the different rates as well as the difference in the splints used. Weinstein et al. (2003) report the higher prevalence of AVN in cases where the Pavlik harness was used to treat complete hip dislocation as opposed to acetabular dysplasia or subluxation. Surgery is considered when splinting methods are unsuccessful. This can involve closed or open reduction of the hip. An arthrogram is performed

44 by the injection of dye so that the hip joint becomes visible under an image intensier. Function of the joint can be assessed using this method and soft tissue abnormalities identied (Hart et al., 2006). An adductor tenotomy is sometimes performed at this stage to enable greater mobility of the joint (Judd and Wright, 2005). A closed reduction is performed under anaesthetic. This allows the surgeon to manipulate the femoral head into the acetabulum. This is performed with the aid of an image intensier, enabling the surgeon to see the structure of the hip joint without having to resort to a surgical incision and opening of the joint capsule itself. A spica cast is then applied with the hip maintained in the appropriate degree of abduction. Open reduction of the hip would be performed if this fails. If the hip remains irreducible after closed reduction, a pelvic or femoral osteotomy, or both may be required. The femur is shortened as part of the procedure so that pressure on the femoral head is reduced (Campion and Benson, 2007). A pelvic osteotomy will be performed if instability remains, in order to provide adequate coverage of the head of femur, by repositioning of the innominate bone (Dandy and Edwards, 2003). The type of surgery depends on the severity of the dislocation and the childs age. Preoperatively, gallows skin traction is applied and is aimed at gently stretching soft tissues around the hip joint to reduce the risk of avascular necrosis (Judd and Wright, 2005) and increase the possibility of successful closed reduction of the hip joint (Hart et al., 2006). Neurovascular observations must be performed frequently by nursing staff while traction continues, to prevent circulatory complications arising (Judd and Wright, 2005). As discussed, postoperatively a spica cast can be used to maintain the correction of DDH after the child has undergone examination under anaesthesia to reduce the hip when reduction in an abduction splint fails (Read and Evans, 2002), or after surgery for pelvic osteotomy or varus derotational osteotomy. The cast will then be applied with the hip in the correct position to gain the appropriate abduction required. The role of the nurse in postoperative care includes pain management, assessment of neurovascular status, hygiene and nutrition needs. Mobility and cast care should be achieved in partnership with the childs carers. This partnership should begin prior to admission by encouraging carers to participate in ward visits to enable them to meet with the ward nurses, who will provide nursing care during the inpatient phase of treatment (Sparks et al., 2004).

E. Causon Care of the child in a spica cast is probably the one area where the orthopaedic nurse becomes most involved with the child and parents in outpatient care. In the authors own work area hip spicas are applied in theatre by nurses from the plaster room under the supervision of the consultant. Parents can nd coming to terms with the diagnosis of DDH and subsequent treatment distressing and may have feelings of guilt that their child is affected by this condition. Doctors explain the diagnosis and go through the treatment required, then explain the prospects of correction and possible further options if early treatment fails. This can be a lot of information to absorb and nurses can help by providing the right information from appropriate sources. While information regarding discharge of a child is always important, more specic information is vital if families with young children or babies in spica casts can hope to live as normal a life as possible. Smith (2004) conducted a literature review of the care of babies and young children in spica casts and identied some common themes. In the articles reviewed, written and verbal information needs and practical, emotional and social support needs were included. It was concluded from this study that nurses should be aware of any support networks that exist to help families cope with the stresses of discharge, and use this in the co-ordination of discharge plans designed for that families specic needs. A study conducted by Newman and Fawcett (1995) analysed responses to questionnaires by 35 mothers to identify stressors relating to caring for a child in a spica cast. The results demonstrated the degree to which the mothers with children in spica casts relied on family members for support with household, social and community activities, and the major adjustments required in all aspects of daily life to enable them to provide care for their child. A telephone support network was suggested here as a way to help mothers who nd themselves conned to home. Complications that may arise as a result of a child being in a spica cast need to be addressed with carers prior to admission, and again before discharge. This can involve a lot of teaching and giving of information in a very short period of time. Recognising signs of pain and discomfort, neurovascular observations, keeping the cast clean and dry particularly during nappy change, preventing skin breakdown, positioning of the child in a cast or harness, and safe transportation by car are a few of the many issues that carers will face during this time (Hart et al., 2006). Mothers who are breastfeeding will need lots of support to adapt in order to be able to continue with this, or in accepting

The nurses role in educating, counselling and preparing parents to care for a child that it may not be achievable (Newman, 2005). Communication with health visitors prior to discharge to discuss the breastfeeding issue may lessen stress for the mother if she feels the support has already been established. The risk of back injury to the carer through incorrect moving and handling of the child can be avoided through teaching of correct techniques (Judd and Wright, 2005). Smith (2004) suggests development of a discharge package by the multidisciplinary team may increase satisfaction with information and support provided for carers. This is something that is being developed in the authors own workplace. Guidelines from the Department of Health (2003b) give useful guidance on presenting information at an appropriate level and excluding unnecessary jargon. Families from the ethnic minorities and those with learning disabilities or sensory decits must also be considered (Clarke, 2006). The RCN (Royal College of Nursing, 2007) Benchmarks for Childrens Orthopaedic Care gives evidence based benchmarks as guidance for nurses to set standards to achieve competencies in both pre and post operative care, cast care, and on how to improve practice. This certainly could be useful when looking at planning care and providing information connected with children with DDH. The National Service Framework for Children (Department of Health, 2003) describes children and young people receiving integrated care coordinated to meet their own individual needs and those of the family. It requires that support and information should be provided that enables them to cope with their condition and the treatment required. With young children and babies the family will be the active partners in the care given. Information can be obtained from many different sources such as leaets, books, videotape and the Internet. Articles such as those by Sparks et al. (2004, 2005) provide useful guidelines for a nurse to use as a checklist regarding the information needed to enable carers to care for the child in a spica cast. It also helps when considering the development needs, particularly of older children who would normally be ready to crawl, walk or for toilet training. Charities such as STEPS and Hip-Baby.org have websites that provide easier to understand information on all aspects of DDH. Sparks et al. (2004) rightly discuss the need for healthcare professionals to recognise carers strengths, limitations and personal needs when providing information and education. This is essential if compliance with care and a successful outcome is to be achieved. There is no nurse led DDH clinic in the authors workplace, and children are seen by a paediatric

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orthopaedic surgeon in a busy orthopaedic/fracture clinic area. Parents and carers are however given time to ask questions and given explanations regarding all aspects of care by the appropriate multidisciplinary team members. This is important if trust is to be built up, and continuity of care, which can be over a long period of time is to be achieved (Lee, 2005).

Conclusion
Early detection and treatment improves the prognosis for babies diagnosed with DDH (Hart et al., 2006). It is essential therefore for hip examinations to be performed by professionals who are properly trained and skilled in the process. Training programmes conducted by experts should therefore be a priority. This would reinforce the importance of proper screening so that appropriate referral is made as early as possible. Training for specialist practitioners involved in nurse led DDH clinics would be included here. An in depth knowledge of the pathophysiology of DDH is important and will help in this process. Effective teaching strategies for parents and carers should be a priority to ensure their condence when giving care to affected infants and young children. The needs of the child and their carers should be addressed on an individualised basis, and where possible the one size ts all approach should be avoided when devising care packages and discharge plans. Treatment for DDH is effectively a partnership between the multidisciplinary team and the childs carers. Excellent communication between members of the team should support systems put in place (Sparks et al., 2004). The difculties faced by parents and carers at home will be challenging (Hart et al., 2006) and so information regarding support networks in the community and any available counselling could be invaluable, along with information gained from recognised websites. The development of parent and carer information and educational leaets with the multidisciplinary team should continue within the authors own clinic area. Liaising with other hospitals to see how they provide support for families could be of benet. Devising a simple questionnaire for parents to answer to assess the type information they feel they need would be an appropriate beginning. The results could then be presented to managers, nurses, doctors and other members of the multidisciplinary team so that a plan of action for implementing change could be devised. Ward based nurses at the authors own workplace

46 already provide good support for parents and should be included in any plans to develop further education and information. Support networks that already exist outside of the hospital setting should be combined with this to ensure a comprehensive well thought out package. The RCN Benchmarks for Childrens Orthopaedic Care (Royal College of Nursing, 2007) and the National Service Framework (2003) are documents that can be used to help ensure ofcial guidelines are accounted for when planning any care.

E. Causon
anticipatory guidance for parents. Orthopaedic Nursing 25 (2), 100109. Haugh, P., Trainor, B., Kernohan, G., 1997. Nurses detecting hip abnormalities. Journal of Orthopaedic Nursing 1 (1), 1116. Hip-baby.org. Hip Dysplasia: What Is It? (Internet) <http:// www.hip-baby.org/index.html> (accessed 20.05.08). Judd, J., Wright, L., 2005. Joint and limb problems in children and adolescents. In: Kneale, J., Davis, P.S. (Eds.), Orthopaedic and Trauma Nursing, second ed. Churchill Livingstone, London, pp. 244264. Lee, A., 2005. A satisfaction survey of a nurse led paediatric clinic for hip dysplasia in infants. Journal of Orthopaedic Nursing 9 (2), 7780. Lee, M.C., Eberson, C.P., 2006. Growth and development of the childs hip. Orthopaedic Clinics of North America 37(2), 119 132. Lowry, C.A., Donoghue, V.B., OHerlihy, C.O., Murphy, J.F., 2005. Elective Caesarian section is associated with a reduction in developmental dysplasia of the hip in term breech infants. Journal of Joint and Bone Surgery (Br) 87-B (7), 984 985. Malkawi, H., 1998. Sonographic monitoring of developmental disturbances of the hip by the Pavlik harness. Journal of Paediatric Orthopaedics 7 (2), 144149. McCullough, L.M., Pellino, T.A., 1994. Congenital and developmental disorders. In: Mahe, A.B., Salmond, S.W., Pellino, T.A. (Eds.), Orthopaedic Nursing. W.B. Saunders Co., Philadelphia, pp. 620699. National Screening Committee, 2004. Child Health Sub-Group Report: Dysplasia of the Hip. Department of Health, London (TSO). Newman, D.M.L., 2005. Functional status, personal health, and self-esteem of caregivers of children in a body cast: a pilot study. Orthopaedic Nursing 24 (6), 416423. Newman, D.M.L., Fawcett, J., 1995. Caring for a young child in a body cast: impact on the care giver. Orthopaedic Nursing 14 (1), 4146. Patel, H.The Canadian Task Force on Preventative Health, 2001. Preventative health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns. Canadian Medical Association Journal 164 (12), 16691677. Paton, R.W., 2005. Screening for hip abnormality in the neonate. Early Human Development 81 (10), 803806. Paton, R.W., Hinduja, K., Thomas, C.D., 2005. The signicance of at-risk factors in ultrasound surveillance of developmental dysplasia of the hip. The Journal of Bone and Joint Surgery 87-B (9), 12641266. Read, H.S., Evans, G.A., 2002. Avascular necrosis as a complication in the management of developmental dysplasia of the hip. Current Orthopaedics 16 (3), 205212. Royal College of Nursing, 2007. Benchmarks for Childrens Orthopaedic Nursing Care. RCN Guidance. Royal College of Nursing, London. Sharpe, P., Mulpuri, K., Chan, A., Cundy, P.J., 2005. Differences in risk factors between early and late diagnosed developmental dysplasia of the hip. Archives of Disease in Childhood Fetal and Neonatal Edition 91, 158162 (<http:// www.fn.bmj.com> (accessed 25.03.08)). Smith, J., 2004. A literature review of the care of babies and young children in hip spicas. Journal of Orthopaedic Nursing 8 (2), 8390. Solomon, L., Warwick, D.J., Nayagam, S., 2005. Apleys Concise System of Orthopaedics and Fractures, third ed. Hodder Arnold, London. Sparks, L., Rush Ortman, M., Aubuchon, B.S., 2004. Care of the child in a body cast. Journal of Orthopaedic Nursing 8 (4), 231235.

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