Prevention and ultrasound screening: A universal nurse-led hip health model

Introduction

How can nurses worldwide help children walk into adulthood? Developmental dysplasia of the hip (DDH) is preventable and treatable, yet in many countries (e.g. Korea, Pakistan, and the UK), it continues to be diagnosed too late. When undetected, DDH can cause gait problems in childhood and hip osteoarthritis in adulthood, diminishing quality of life and increasing health costs (Muddaluru et al., 2023). Nurses are uniquely positioned to change this trajectory by combining primary prevention—educating parents on hip-health care—with secondary prevention through ultrasound screening. In doing so, they can safeguard hip development and promote lifelong mobility.

Why early detection matters

DDH ranges from mild instability to complete dislocation, with a prevalence of approximately 1% (Tao et al., 2023). Although risk factors such as breech birth, female sex, and family history cannot be changed, keeping infants’ legs in the natural ‘M-position’ supports healthy hip development (Ishida, 1977). Traditionally, screening has relied on physical examinations such as limited abduction tests, the Ortolani manoeuvre, and the Barlow manoeuvre. However, their sensitivity and specificity are 50.5% and 75.0% (Smart et al., 2024), leaving cases undetected, particularly acetabular dysplasia, which poses a major risk of osteoarthritis (Muddaluru et al., 2023). In hospital settings, ultrasound is widely used; this screening method is non-invasive and accurate, with a pooled sensitivity of 93% and specificity of 97% in Graf method studies (Chavoshi et al., 2021). Portable ultrasound now offers a practical alternative in community settings.

Finding answers in universal home visits

Japan’s tax-funded universal newborn home-visit program and child-rearing consultations, which reach nearly every family nationwide, provided an ideal platform to integrate prevention and screening. Public health nurses and midwives were trained through e-learning modules, hands-on seminars and objective structured clinical examinations to conduct portable ultrasounds alongside health education.

Pilot projects in Okinawa and Aichi demonstrated that public health nurses and midwives achieved a success rate of 85% in capturing standard ultrasound images. Additionally, using educational pamphlets from the Japanese Paediatric Orthopaedic Association, they provided parental guidance on maintaining the infant’s natural ‘M-position,’ and hip-safe holding (Yoshioka-Maeda et al., 2025).

This model illustrates how primary and secondary prevention can be delivered simultaneously during a single home visit and consultations, strengthening both family empowerment and community health systems. Building on this foundation, we conducted an implementation study in three communities to promote nurse-led hip health prevention and screening. Families valued seeing the ultrasound images, which reinforced their understanding and commitment to hip health care.

Lessons learned: Modernising assessment in nursing

Traditional physical assessments alone are not enough for the early detection of DDH. In pioneering municipalities, public health nurses lacked confidence in manual examinations. I shared evidence that 199 late-diagnosed cases were reported in Japan over 2 years after the age of 1 year, highlighting the urgent need for improvement (Hattori et al., 2017). In resource-limited areas, where families spend a full day reaching specialists, nurses resonated with the idea that strengthening assessment skills could improve screening accuracy and promote healthy hip development. Buy-in was supported through small pilot projects and ongoing accompaniment, including reviews of failed images and supplementary training with orthopaedic paediatric surgeons. This continuous exchange of knowledge among professionals and families not only strengthened screening practice but also built mutual trust, demonstrating how collaborative knowledge communication can drive innovation in public health nursing.

In the pilot projects, nurse-led ultrasound identified early-stage cases in approximately 10% of infants, enabling timely referral and treatment. While some professionals remain hesitant, fearing disruption of long-standing practices, evidence shows that supporting healthy hip development, enhancing children’s quality of life and reducing healthcare costs make nurse-led accurate assessment indispensable. Nursing leadership is essential to modernise practice and drive innovation in newborn and infant care.

Next steps: From local innovation to global action

Global collaboration is essential. Lessons from Japan’s universal home-visit system can be adapted to diverse contexts, ensuring that all infants—not only those in well-resourced cities—benefit from early detection. Primary prevention through parental education is globally feasible and can be implemented immediately by nurses everywhere; however, scaling up ultrasound requires further investment. By uniting nurses worldwide, we can reduce avoidable disability, promote equity and advance universal health coverage. 

Public awareness will also be key. Campaigns such as Hip Health Day, held annually on the first Sunday of June and initiated by the Hip Hope Network in 2021, demonstrate how community action can grow into global momentum. In collaboration with the International Hip Dysplasia Institute, we aim to expand these efforts. We call on the WHO and nursing leaders worldwide to join this movement and make hip health a child health priority.

Key take-home messages

1. Gaps remain: Inadequate prevention and low sensitivity and specificity of traditional examinations contribute to late diagnosis of DDH.

2. Education works: Parental guidance on hip-health care is simple, low-cost and globally scalable.

3. Nurse-led ultrasound modernises practice, reduces inequities and supports universal health coverage.

4. Collaborative knowledge communication builds trust, accelerates innovation and ensures equitable access.

5. A global call: Nursing is rooted in physical assessment. Nursing leadership can elevate the priority of DDH prevention, improving quality of life and lifelong mobility.

References

Bae, K., Cha, J. H., Kim, J. A., Ryu, S., Na, J. Y., Choi, Y. J. (2025). Incidence trends and perinatal risk factors of developmental dysplasia of the hip: A nationwide population-based study from South Korea. Acta Orthopaed, 96, 477–484. https://doi.org/10.2340/17453674.2025.43980

Chavoshi M, Soltani G, Shafiei Zargar S, Wyles CC, Kremers HM, & Rouzrokh P. Diagnostic performance of clinical examination versus ultrasonography in the detection of developmental dysplasia of hip: A systematic review and meta-analysis. Arch Bone Jt Surg. 10(5), 403-412. https://doi.org/10.22038/ABJS.2021.60504.2984

Ishida, K. (1977). Prevention of the development of the typical dislocation of the hip. Clin Orthop. Relat Res, 126, 167–169.

Bhatti, A., Soomro, M.H., Chinoy, M.A., Zaman, A.U.., Baloch, MA., Ali P., et al. (2025). Epidemiology of developmental dysplasia of hip in Pakistan: Insights from the Paediatric Orthopaedic Registry Pakistan (PORP). Pak J Med Sci, 41(3), 668-675. https://doi.org/10.12669/pjms.41.3.10922

Hattori, T., Inaba, Y., Ichinohe, S., Kitano, T., Kobayashi,, D, Saisu T., et al. (2017). The epidemiology of developmental dysplasia of the hip in Japan: Findings from a nationwide multi-center survey. J Orthop Sci, 22(1), 121-126. https://doi.org/10.1016/j.jos.2016.08.009

Hip Hope Network. (n.d.). Available from: https://www.hiphopenetwork.org/

Jamil, M., Peracha, A., Pirwani, M. A., Ahmed, Z. (2025). Epidemiology of developmental dysplasia of the hip in Pakistan: Insights from the Paediatric Orthopaedic Registry Pakistan (PORP). Pakistan Journal of Medical Sciences, 41(3), 668–675. https://doi.org/10.12669/pjms.41.3.10922

Muddaluru, V., Boughton, O., Donnelly, T., O’Byrne, J., Cashman, J., Green, C. (2023). Developmental dysplasia of the hip is common in patients undergoing total hip arthroplasty under 50 years of age. SICOT-J, 9 25. https://doi.org/10.1051/sicotj/2023020

Poacher, A. T., Hathaway, I., Crook, D. L., Froud, J. L. J., Scourfield, L., James, C., et al. (2023). The impact of the introduction of selective screening in the UK on the epidemiology, presentation, and treatment outcomes of developmental dysplasia of the hip. Bone Joint Open, 4(8), 635-642. https://boneandjoint.org.uk/Article/10.1302/2633-1462.48.BJO-2022-0158.R1

Smart, L., Cundy, W., Williams, N., Arnold, A., Childs, J., Pelentsov, L., et al. (2024). Screening accuracy for developmental dysplasia of the hip by child health nurses. Children, 11(8), 915. https://www.mdpi.com/2227-9067/11/8/915

Tao, Z., Wang, J., Li, Y., Zhou, Y., Yan, X., Yang, J., Liu, H., et al. (2023). Prevalence of developmental dysplasia of the hip (DDH) in infants: A systematic review and meta-analysis. BMJ Paediatr Open, 7(1), e002080. https://doi.org/10.1136/bmjpo-2023-002080

Yoshioka-Maeda, K., Matsumoto, H., Honda, C., Kinjo, T., Aoki, K., Hattori, T., et al. (2025). Integrating web-based and objective structured clinical examination training programs for nurses on ultrasound hip screening during neonatal and infant home visits: A case study. BMC Med Educ, 25, 1007. https://doi.org/10.1186/s12909-025-07519-7

To link to this article - DOI: https://doi.org/10.70253/OFJW1988 

Links to Additional Resources

https://chiikikango.m.u-tokyo.ac.jp/en/home-en/

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