Bristol Hip Surveillance Guidelines for Children with Cerebral Palsy
1. All children with a diagnosis of Cerebral Palsy should have a Hip X-Ray (requested by Community
Paediatrician) by the age of 24 months (or before if indicated clinically).
2. X-Ray request to be flagged up as ‘CP Hip Surveillance’ to indicate the standardised position required
and for the Radiologists to report on Reimer’s Migration Index (RMI) / Migration Percentage (MP).
3. When to refer to the Orthopaedic Surgeon:

Clinical concern (see clinical signs of possible hip displacement listed on page 2)

If the Migration Percentage is greater than 30 %

If there is more than 7% change in the Migration Percentage from the last X-Ray or per year.
4. All children with a diagnosis of Cerebral Palsy should have a documented GMFCS (Gross Motor
Function Classification Score), regular medical and motor review including joint ranges, and to
have Hip Surveillance X-Rays as per pathway below. [All correspondence should be copied to ‘locality
Community Paediatrician’, ‘locality Community Physiotherapist’ and if involved Orthopaedic Surgeon]
Hip Surveillance Pathway:
GMFCS I
GMFCS II
GMFCS III / IV / V
or WGH IV
Hemiplegia
X-Ray at 24 months
(or before if indicated)
X-Ray at 24 months
(or before if indicated)
X-Ray at 24 months
(or before if indicated)
Annual Motor Review
Annual Motor Review
Annual Motor Review
No concerns
Hip X-Ray:
every 2 years
Hip X-Ray:
yearly
No concerns
No concerns
Discharge from
radiological Hip
Surveillance*
Discharge from
radiological Hip
Surveillance at
10 years old*
Discharge from
radiological Hip
Surveillance when MP
is stable or skeletal
maturity achieved*
Ongoing Annual
Motor Review
Ongoing Annual
Motor Review
Ongoing Annual
Motor Review
* But X-ray if clinical signs of hip displacement (listed pg 2)
Motor Disorders including Cerebral Palsy Working Group Bristol CCHP April 2014
Clinical Signs of Possible Hip Displacement Include:
Objective:
 Presence of clinically important leg length difference
 Deterioration in range of movement of the hip (eg. less than 40 degrees unilateral hip abduction in
flexion) or significant discrepancy between hip range of movement on either side
 Onset of windsweeping of legs
 Presence of spinal deformity or pelvic obliquity.
Subjective:





Deterioration of function – altered gait, decreased ability of tolerance of sitting or standing or those
previously mobile, but become increasingly wheelchair bound (often at age transition to 2ndy school)
Increased difficulty with perineal care or hygiene
Onset or increase in pain referable to the hip
Pain of unknown origin that requires investigation.
Action: Hip X-ray and consider referral to Orthopaedic Surgeon.
How to calculate the Migration Percentage / Reimer’s Migration Index:
H = Hilgenreiner’s line (a horizontal line joining the triradiate cartilages)
P = Perkins line (perpendicular to Hilgenreiner’s line
drawn at the lateral margin of the bony acetabulum)
AI = Acetabular index (the slope of the acetabulum ie
angle is measured between Hilgenreiner’s line ‘H’ and
the bony roof of the acetabulum)
Migration Percentage (MP) is the proportion of ossified femoral head lateral to Perkin’s line ‘P’ = A / B x 100
Winters, Gage and Hicks Hemiplegia Type:
WGH IV hemiplegia gait pattern usually present by age 4-5 years old.
Note: WGH IV has potential for late onset hip displacement regardless of GMFCS level.
References:
Gait Patterns on spastic hemiplegic children and young adults. Winters TF Jr, Gage JR, Hicks RJ. Bone Joint Surgery Am. 1987 March 69
(3) 437-41
Consensus Statement on Hip surveillance for children with cerebral Palsy. Australian Standards of Care 2008
Spasticity in children and young people with non-progressive brain disorders. July 2012 National Institute for Health and clinical
Excellence
Motor Disorders including Cerebral Palsy Working Group Bristol CCHP April 2014