Congenital dislocation of hip, unilateral
ICD-10 Q65.0 is a billable code used to indicate a diagnosis of congenital dislocation of hip, unilateral.
Congenital dislocation of the hip (CDH) is a condition where the femoral head is not properly seated in the acetabulum of the pelvis. This condition can be unilateral, affecting one hip, and is often identified during routine physical examinations in newborns. The etiology of CDH is multifactorial, involving genetic predispositions, mechanical factors during pregnancy, and hormonal influences. Early diagnosis is crucial as untreated CDH can lead to significant complications, including hip osteoarthritis and gait abnormalities. Clinical evaluation typically includes physical examination maneuvers such as the Ortolani and Barlow tests. Imaging studies, particularly ultrasound, are often employed to confirm the diagnosis. Treatment options vary based on the age of diagnosis and severity of the dislocation, ranging from conservative management with harnesses to surgical interventions. The condition is often associated with other congenital malformations, necessitating a comprehensive evaluation of the infant's musculoskeletal and neurological systems.
Detailed physical examination findings, imaging results, and treatment plans must be documented. Growth and developmental milestones should also be noted.
A newborn presents with a positive Ortolani test; follow-up ultrasound confirms unilateral hip dislocation. Treatment with a Pavlik harness is initiated.
Consideration of family history of hip dysplasia and other congenital conditions is essential for accurate coding.
Family history of congenital conditions, genetic testing results, and any syndromic associations should be documented.
A child with unilateral hip dislocation is evaluated for potential syndromic associations, such as in cases of developmental dysplasia of the hip.
Genetic counseling may be warranted if there is a family history of congenital malformations.
Used in cases where non-surgical management fails.
Document the indication for the procedure and any imaging studies performed.
Orthopedic consultation may be necessary for surgical intervention.
Documenting associated congenital conditions is crucial for accurate coding, as it can affect treatment plans and reimbursement. It also provides a clearer clinical picture for ongoing management.
