Screening for congenital dislocation of the hip.

Unlike many examinations carried out in child health surveillance programmes, screening for congenital dislocation of the hip cannot be said to be unresearched. A selective Medline search provided over 100 papers on the screening, diagnosis, and management of the condition. From the past six years they show that the early identification of the 15-20 children in 1000 at high risk of having instability and subluxation, dysplasia, or both, of the hip joint is of great benefit to the two to four (and perhaps more) of them who would go on to suffer the long term consequences if not treated. Workers dedicated to identifying congenital dislocation of the hip who have good back up services can identify 80-9o% of all the cases in the population in the first six weeks Qf life. Under these conditions the selectivity, sensitivity, and cost effectiveness of the test are acceptableanything less and the programmes fail.' 2 So, the important question is not whether to set up a screening programme but how to set up one that is effective. This important question has been partly answered by a revised version ofthe government handbook Screeningfor the Detection of Congenital Dislocation of the Hip.3 It is an excellent review of current thinking, and a doctor ignores it -at his peril. The handbook is concerned only with screening and offers no advice on management. It is directed specifically at those organising and running child health surveillance programmes and those carrying them outmidwives, paediatricians, obstetricians, health visitors, general practitioners, and clinical medical officers. More's the pity that all these groups did not receive a free copy: it went to most of the doctors but not to most of the nurses. Why not? The most important section is on who should do the screening. The district health authority should have a policy outlining who is responsible for examining for congenital dislocation of the hip at various stages and should appoint a designated officer to review the whole programme. Several health professionals may at some time have to examine a child's hips, and they should all be proficient-therefore training is crucially important. The handbook discusses future developments; and ultrasound may well be used much more in diagnosis. It looks good from the little research done so far, especially as it is non-invasive and its results are sensitive. Also clinically normal but dysplastic hips do probably exist, and ultrasound may be able todetect them.4 Further research must therefore be funded into using ultrasound both for initial screening and for secondary screening of those children already identified as being at high risk. These would include those with a clicking or dislocatable hip and those with some other risk factor such as a family history of the condition, other congenital postural deformities, or a history of breech presentation, caesarean delivery, oligohydramnios, or severe fetal growth retardation. For now, however, thescreening programme for congenital dislocation of the.hip must be that outlined in the handbook, and the next step has to be taken by those responsible for the child health surveillance programmes in the districts. If the suggestions are not already operational and they do not intend to make them so but have the funding they will need to think up a good excuse rapidly.