Graf · Pediatria

Graf ultrasound classification of developmental dysplasia of the hip

vigente

Per-hip infant ultrasound classification combining a valid standard plane, bony-roof morphology and alpha angle, cartilaginous-roof morphology and beta angle, chronological age, and stress behavior where indicated.

Índice de referência, não é suporte à decisão clínica. O RadCommons apresenta conteúdo de referência reescrito a partir de critérios publicados e com link para a fonte primária. Confira sempre a publicação primária vigente. Não é um dispositivo médico nem substitui o julgamento clínico. O radiologista responsável pelo laudo permanece o autor e o responsável.

Escala de categorias

I Ia Ib IIa IIa+IIa-IIb IIc IIc-stable IIc-unstable D III IIIa IIIb IV

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Procedência e vigência

Órgão emissor: Graf
Versão: complete subtype model
Ano: 1984
Família: léxico
Tipo de lógica: flat
Modalidade: US
Fonte primária: Fundamentals of sonographic diagnosis of infant hip dysplasia · doi:10.1097/01241398-198411000-00015
Última verificação: 2026-07-24
Última checagem: 2026-08-12

Lógica de decisão

Forma estruturada (flat). Uma futura calculadora a lê; as categorias abaixo são a superfície legível.

Classify each hip only from a valid standard plane and return the most specific supported code. Parent codes preserve compatibility and make missing subtype inputs explicit instead of turning uncertainty into a false Ia/Ib, IIa+/IIa-, IIc stability, or IIIa/IIIb assignment.

Mostrar a lógica estruturada (JSON)

{
  "categories": [
    {
      "outcome_code": "I",
      "state": "mature_parent_type",
      "alpha_deg": ">=60",
      "subtype_when_beta_available": [
        "Ia",
        "Ib"
      ]
    },
    {
      "outcome_code": "Ia",
      "state": "mature",
      "alpha_deg": ">=60",
      "beta_deg": "<=55",
      "bony_roof": "good",
      "bony_rim": "angular",
      "cartilage_roof": "covers_femoral_head"
    },
    {
      "outcome_code": "Ib",
      "state": "mature",
      "alpha_deg": ">=60",
      "beta_deg": ">55",
      "bony_roof": "good",
      "bony_rim": "blunt_or_slightly_rounded",
      "cartilage_roof": "covers_femoral_head"
    },
    {
      "outcome_code": "IIa",
      "state": "physiologically_immature_parent_type",
      "alpha_deg": "50-59",
      "chronological_age_weeks": "0-12",
      "subtype_status": "not_assigned_before_week_6_or_age_curve_unavailable"
    },
    {
      "outcome_code": "IIa+",
      "state": "physiologically_immature_with_age_appropriate_maturation",
      "alpha_deg": "50-59",
      "chronological_age_weeks": "6-12",
      "maturation_curve_position": "at_or_above_minimum_linear_curve_to_alpha_60_by_week_12"
    },
    {
      "outcome_code": "IIa-",
      "state": "physiologically_immature_with_maturational_deficit",
      "alpha_deg": "50-59",
      "chronological_age_weeks": "6-12",
      "maturation_curve_position": "below_minimum_linear_curve_to_alpha_60_by_week_12"
    },
    {
      "outcome_code": "IIb",
      "state": "delayed_ossification_or_dysplastic_for_age",
      "alpha_deg": "50-59",
      "chronological_age_weeks": ">12",
      "bony_roof": "deficient",
      "bony_rim": "rounded",
      "cartilage_roof": "covers_femoral_head"
    },
    {
      "outcome_code": "IIc",
      "state": "critical_centered_parent_type",
      "alpha_deg": "43-49",
      "resting_beta_deg": "<=77",
      "stress_status": "not_available_or_not_valid"
    },
    {
      "outcome_code": "IIc-stable",
      "state": "critical_centered_stable",
      "alpha_deg": "43-49",
      "resting_beta_deg": "<=77",
      "stress_behavior": "remains_centered_and_does_not_convert_to_type_D"
    },
    {
      "outcome_code": "IIc-unstable",
      "state": "critical_centered_at_rest_but_pathologically_unstable",
      "alpha_deg": "43-49",
      "resting_beta_deg": "<=77",
      "stress_behavior": "converts_to_type_D_with_beta_above_77"
    },
    {
      "outcome_code": "D",
      "state": "decentering_at_rest",
      "alpha_deg": "43-49",
      "resting_beta_deg": ">77",
      "cartilage_roof": "displaced"
    },
    {
      "outcome_code": "III",
      "state": "decentered_parent_type",
      "alpha_deg": "<43",
      "cartilage_roof": "pressed_cranially",
      "subtype_when_cartilage_echogenicity_available": [
        "IIIa",
        "IIIb"
      ]
    },
    {
      "outcome_code": "IIIa",
      "state": "decentered_without_structural_cartilage_alteration",
      "alpha_deg": "<43",
      "cartilage_roof": "pressed_cranially_and_hypoechoic_or_without_internal_echoes"
    },
    {
      "outcome_code": "IIIb",
      "state": "decentered_with_structural_cartilage_alteration",
      "alpha_deg": "<43",
      "cartilage_roof": "pressed_cranially_and_echogenic"
    },
    {
      "outcome_code": "IV",
      "state": "severely_decentered",
      "alpha_deg": "<43",
      "cartilage_roof": "pressed_caudally",
      "proximal_perichondrium": "horizontal_or_dips_caudally"
    }
  ],
  "applicability": {
    "use_for": "Morphologic classification of each infant hip on a technically valid Graf ultrasound examination.",
    "classification_unit": "one_hip_at_one_examination",
    "required_inputs": [
      "side",
      "chronological_age_in_weeks",
      "standard_plane_images",
      "bony_roof_morphology",
      "bony_rim_morphology",
      "cartilage_roof_position",
      "alpha_angle_deg",
      "beta_angle_deg"
    ],
    "conditional_inputs": [
      "stress_examination_for_type_IIc_stability",
      "cartilage_roof_echogenicity_for_type_III_subtyping",
      "gestational_age_for_management_context_in_preterm_infants"
    ],
    "outside_scope": [
      "radiographic_DDH_classification_after_ossification",
      "clinical_instability_without_valid_ultrasound",
      "treatment_selection_without_age_stability_and_orthopaedic_assessment"
    ]
  },
  "image_quality_gate": {
    "required_identification": [
      "lower_limb_of_ilium",
      "mid_acetabular_standard_plane",
      "labrum",
      "chondro_osseous_junction",
      "straight_iliac_contour"
    ],
    "minimum_documentation": "Two standard-plane images of each hip, with side, patient age, examination date, alpha and beta measurement lines, and morphology visible.",
    "failure_rule": "If the standard plane or required landmarks are not demonstrated, do not measure or assign a definitive Graf type; request repeat technically adequate imaging.",
    "anti_tilt_rule": "Probe tilt can make a normal hip appear abnormal. Reject an image with a missing lower limb, non-straight iliac reference, or other standard-plane failure rather than classifying the artifact."
  },
  "measurement_model": {
    "alpha_angle": "Angle between the iliac baseline and the bony-roof line; it establishes the main type.",
    "beta_angle": "Angle between the iliac baseline and the cartilage-roof line through the labrum; it refines Type I and separates centered IIc from decentering D.",
    "morphology_rule": "Angles never replace the qualitative description of the bony roof, bony rim, cartilage roof and femoral-head centering.",
    "borderline_rule": "Preserve the measured angles and acquisition quality. Do not round a borderline or low-confidence measurement solely to force a category."
  },
  "age_dependent_type_IIa": {
    "before_week_6": "Use parent code IIa; Graf advises against IIa+/IIa- differentiation before week 6 because measurement imprecision can exceed the maturational difference.",
    "weeks_6_to_12": "Compare alpha with the Graf sonometer or its minimum linear maturation curve from alpha 50 at birth to alpha 60 at week 12.",
    "curve_formula_for_unrounded_age": "minimum_alpha_deg = 50 + (10 * chronological_age_weeks / 12)",
    "example_at_week_6": {
      "IIa_plus": "alpha_55_or_more",
      "IIa_minus": "alpha_below_55_but_at_least_50"
    },
    "after_week_12": "An alpha angle of 50-59 is IIb, not IIa.",
    "preterm_rule": "Assign the morphologic type using chronological age; interpret management timing in the context of gestational age and specialist assessment."
  },
  "stability_model": {
    "resting_position_controls_base_type": true,
    "IIc_stress_rule": "A resting IIc hip that becomes D under pressure is IIc-unstable; if it remains centered it is IIc-stable.",
    "physiological_elasticity_rule": "Labral or capsular movement in a hip with adequate bony coverage is elasticity and must not be mislabeled pathological instability.",
    "decentered_rule": "D, III and IV are already decentered at rest and are intrinsically unstable; do not rename III as IV solely because stress increases displacement.",
    "terminology_guard": "Use D rather than IId. In the Graf model every Type II hip is centered; D is the distinct decentering category."
  },
  "classification_sequence": [
    "validate_standard_plane_and_side",
    "describe_bony_roof_bony_rim_cartilage_roof_and_centering",
    "measure_alpha_and_beta_without_forced_rounding",
    "assign_main_type_from_alpha_and_morphology",
    "apply_chronological_age_to_the_50_to_59_degree_range",
    "apply_beta_to_Type_I_and_to_IIc_versus_D",
    "if_resting_IIc_apply_valid_stress_assessment_for_stable_or_unstable_subtype",
    "if_Type_III_apply_cartilage_echogenicity_for_IIIa_or_IIIb"
  ],
  "management_context": {
    "stable_morphologic_abnormality": "The AAOS guideline supports observation without a brace as an option for a clinically stable hip with morphologic ultrasound abnormalities, based on limited evidence; this is not a type-only mandate.",
    "positive_instability_examination": "The AAOS guideline supports either immediate or delayed brace treatment as options, based on limited evidence, with serial examination and age-appropriate imaging during treatment.",
    "safety_rule": "The Graf code informs urgency and follow-up but does not independently select a brace, reduction method, operation, or surveillance interval."
  },
  "output_contract": [
    "right_or_left_hip",
    "chronological_age_and_prematurity_context",
    "technical_adequacy_and_standard_plane",
    "alpha_and_beta_angles_in_degrees",
    "bony_roof_bony_rim_and_cartilage_roof_morphology",
    "femoral_head_centering_at_rest",
    "stress_result_when_used",
    "most_specific_supported_Graf_code",
    "explicit_parent_code_when_subtype_input_is_missing",
    "orthopaedic_follow_up_flag_without_autonomous_treatment"
  ],
  "missing_input_behavior": [
    "If age is unknown in an alpha 50-59 hip, do not choose IIa or IIb; report the measured Type II range and request age.",
    "If beta is unavailable in a mature hip, return parent I rather than inventing Ia or Ib.",
    "If stress imaging is absent for a resting IIc hip, return parent IIc and do not infer stable or unstable from the static image.",
    "If cartilage-roof echogenicity is not documented in Type III, return parent III rather than guessing IIIa or IIIb.",
    "If image quality is invalid, return no definitive type even when an angle was supplied."
  ],
  "interpretation_limits": [
    "Graf is a morphology and maturation classification, not a patient-specific prognosis or a substitute for the clinical instability examination.",
    "Do not translate the sequence of labels into a numeric risk percentage or prescribe treatment without age, stability, examination findings and pediatric orthopaedic context.",
    "Do not apply the infant ultrasound thresholds to radiographs, CT, MRI, or an older child outside the validated sonographic setting."
  ],
  "source_locator": "Graf, J Pediatr Orthop 1984;4:735-740, PMID 6392336, DOI 10.1097/01241398-198411000-00015; Graf, Hip Sonography, 2006, Table 6.1 and Chapters 7-9 for standard plane, sonometer, IIa maturation, IIc stress stability and III subtypes; AAOS DDH guideline 2014, Summary recommendations on stable morphologic abnormalities, clinical instability and monitoring."
}

Categorias num relance

Cat.	Significado	Conduta	Risco	Fonte
I	Type I, mature (subtype unresolved) Mature parent type on a technically valid standard-plane examination: alpha angle at least 60 degrees, good bony roof, and cartilaginous roof covering the femoral head. Use parent I when beta is unavailable or unreliable, rather than guessing Ia or Ib.	A mature Type I label does not generate a brace or procedure recommendation. Continue the age- and risk-appropriate clinical surveillance program; if the examination or beta measurement is technically inadequate, repeat the ultrasound rather than forcing a subtype.	Type I is morphologically mature and is not a numeric zero-risk guarantee. The code does not replace the clinical hip examination or eliminate follow-up that is indicated by instability, risk factors, or the local screening pathway.	okfonte Graf 1984, PMID 6392336 (normal according to age as the first basic category); Graf 2006, Table 6.1 (Type I alpha >=60 and mature morphology); AAOS 2014 guideline, Summary recommendations on surveillance after a normal infant hip examination.
Ia	Type Ia, mature with long cartilaginous-roof coverage Mature hip with alpha angle at least 60 degrees and beta angle at or below 55 degrees, good bony roof, angular bony rim, and cartilaginous roof extending well over the femoral head.	No type-directed treatment follows from Ia. Preserve side and measurements, and use routine clinical surveillance or risk-factor imaging only when otherwise indicated.	Ia is a mature morphology, not a calibrated probability of future dysplasia. A technically invalid plane or discordant clinical instability must override reassurance from a copied angle value.	okfonte Graf 2006, Table 6.1 and Chapter 8 beta-value discussion (Type Ia, alpha >=60, beta threshold 55, long cartilage-roof coverage); Graf 1984, PMID 6392336.
Ib	Type Ib, mature with shorter cartilaginous-roof coverage Mature hip with alpha angle at least 60 degrees and beta angle above 55 degrees, good bony roof, a blunt or slightly rounded bony rim, and shorter cartilaginous-roof coverage than Ia. Ib remains a mature Type I hip.	Do not treat Ib as dysplasia solely because beta exceeds 55 degrees. Record the mature type and use the clinical examination and screening context for any follow-up decision.	The Ia/Ib distinction describes cartilage-roof geometry and is not an ordinal risk or treatment scale. Ib does not by itself predict instability or adverse outcome.	okfonte Graf 2006, Table 6.1 and Chapter 8 (Type Ib alpha >=60, beta >55, shorter cartilage-roof coverage); Graf 1984, PMID 6392336.
IIa	Type IIa, physiologically immature (subtype unresolved) Centered, physiologically immature parent type in the first 12 weeks: alpha 50-59 degrees, deficient but potentially age-appropriate bony roof, rounded rim, and cartilage roof covering the femoral head. Use parent IIa before week 6 or when the age-specific maturation curve cannot be applied.	Document chronological age and arrange age-appropriate clinical and sonographic follow-up. A static IIa label alone does not justify automatic bracing; clinical stability, maturation trajectory and pediatric orthopaedic assessment determine the plan.	Many immature hips mature, but parent IIa does not state whether maturation is on schedule. Without age trajectory and stability, it cannot provide a patient-specific persistence or dislocation probability.	okfonte Graf 2006, Table 6.1 and Section 8.1.1 (Type IIa alpha 50-59, age 0-12 weeks, no +/- differentiation before week 6); AAOS 2014 guideline, stable hip with morphologic ultrasound abnormalities.
IIa+	Type IIa+, age-appropriate maturation Centered physiologically immature hip from week 6 through week 12 with alpha 50-59 degrees at or above the age-specific minimum Graf maturation curve toward alpha 60 by week 12. At week 6, alpha 55 degrees or more is the published example.	Track maturation to a mature Type I endpoint with the clinically appropriate interval. Observation is an option for a clinically stable morphologic abnormality under the AAOS guideline; the code does not set a universal scan interval or brace decision.	IIa+ means the measured bony maturation is age appropriate within the Graf model, not that normalization or long-term outcome is guaranteed. Instability and technical error remain separate concerns.	okfonte Graf 2006, Section 8.1.1 and maturation curve (IIa+ at or above the minimum linear maturation path; week-6 example alpha >=55); AAOS 2014 guideline, stable morphologic abnormality and surveillance recommendations.
IIa-	Type IIa-, maturational deficit Centered physiologically immature hip after week 6 and through week 12 with alpha 50-59 degrees below the age-specific minimum Graf maturation curve. At week 6, alpha below 55 but at least 50 degrees is the published example.	Flag a maturational deficit for prompt pediatric orthopaedic review and documented follow-up. Do not prescribe a brace from the code alone; combine age, stability, serial change, clinical examination and specialist judgment.	IIa- identifies lagging maturation and greater concern than IIa+, but it is not a calibrated dislocation, residual-dysplasia or treatment-failure probability.	okfonte Graf 2006, Section 8.1.1 (IIa- below the minimum linear maturation curve; do not distinguish before week 6); AAOS 2014 guideline, clinical stability and treatment-of-instability recommendations.
IIb	Type IIb, delayed ossification after 12 weeks Centered hip after 12 weeks with alpha 50-59 degrees, deficient bony roof, rounded rim, and cartilage roof still covering the femoral head. The same angle range that can be physiologically immature earlier is dysplastic or delayed for this age.	Flag IIb for pediatric orthopaedic assessment and an explicit management plan. The type identifies age-inappropriate ossification but does not independently select observation, bracing or another intervention.	IIb represents persistent age-inappropriate acetabular development, but Graf type alone does not quantify residual dysplasia, progression, treatment response or long-term outcome.	okfonte Graf 2006, Table 6.1 and Section 8.1.1 (Type IIb alpha 50-59 after 12 weeks, dysplastic); AAOS 2014 guideline limitations and individualized-care disclaimer.
IIc	Type IIc, critical centered hip (stability unresolved) Critical but centered parent type at rest: alpha 43-49 degrees, severely deficient bony roof, rounded-to-flat rim, cartilage roof still covering the femoral head, and resting beta at or below the 77-degree separation boundary. Use parent IIc when a valid stress result is unavailable.	Flag the severely deficient centered hip for prompt specialist assessment and document that stability is unresolved. Do not infer stable or unstable or choose treatment from the static image alone.	IIc is close to decentering in the Graf morphology, but without stress assessment it does not determine whether pathological instability is present or supply a numeric dislocation risk.	okfonte Graf 2006, Table 6.1, Sections 8.1-8.2 and Chapter 9 (IIc alpha 43-49, beta <77, centered; stress distinguishes stable from unstable); Graf 1984, PMID 6392336.
IIc-stable	Type IIc stable A resting Type IIc hip that remains centered during a valid stress examination and does not convert to Type D. Resting morphology remains alpha 43-49 degrees and beta at or below the 77-degree separation boundary.	Prompt pediatric orthopaedic evaluation remains appropriate because the bony roof is severely deficient. Clinical stability may support observation in selected infants under limited AAOS evidence, but the complete age, examination and follow-up context governs care.	Stable refers to the observed stress behavior, not a benign or zero-risk state. The severe acetabular deficiency remains and the classification does not quantify persistence or later dysplasia.	okfonte Graf 2006, Section 9.2.2 (IIc stable when stress does not alter the type); AAOS 2014 guideline, stable hip with morphologic ultrasound abnormalities.
IIc-unstable	Type IIc unstable A hip that is Type IIc at rest but becomes Type D during a valid stress examination, with pathological decentering and beta rising above 77 degrees under pressure.	Communicate pathological instability promptly for pediatric orthopaedic management. AAOS supports immediate or delayed brace treatment as options for a positive instability examination based on limited evidence, but device, timing and monitoring are clinician decisions.	IIc-unstable documents demonstrable pathological instability and risk of decentering; it is not a calibrated probability of failed bracing, surgery or residual dysplasia.	okfonte Graf 2006, Figure 9.2 and Section 9.2.2 (resting IIc converts to D under stress); AAOS 2014 guideline, treatment of clinical instability and serial monitoring during brace treatment.
D	Type D, decentering at rest Decentering hip at rest with alpha 43-49 degrees and beta above 77 degrees, severely deficient bony roof, rounded-to-flat rim, and displaced cartilage roof. Use D, not IId.	Treat the resting decentering finding as a prompt pediatric orthopaedic referral and report centering, reducibility or stress behavior when safely assessed. The code does not select the reduction or retention method.	D is already decentered at rest and therefore more urgent than a centered IIc morphology, but it supplies no patient-specific treatment-success or complication percentage.	okfonte Graf 2006, Figure 8.3, Table 6.1 and Chapter 9 (D alpha 43-49, beta >77, decentering; explicit rejection of the IId label); AAOS 2014 guideline.
III	Type III, decentered (subtype unresolved) Decentered parent Type III hip with alpha below 43 degrees, poor bony roof, flattened rim, and cartilage roof pressed cranially. Use parent III when cartilage-roof echogenicity is not adequately documented.	Communicate a decentered hip promptly and obtain pediatric orthopaedic management. Do not infer IIIa or IIIb or prescribe a reduction strategy when the cartilage subtype or clinical context is missing.	Type III denotes advanced decentering, not a numeric prognosis. Parent III does not state whether structural cartilage alteration is present and cannot quantify reduction success, osteonecrosis or later dysplasia.	okfonte Graf 2006, Table 6.1 (Type III alpha <43, poor roof, cranially displaced cartilage) and Chapter 9 resting-position rule; Graf 1984, PMID 6392336.
IIIa	Type IIIa, no structural cartilage alteration Decentered Type III hip with alpha below 43 degrees and cartilage roof pressed cranially without structural alteration, appearing hypoechoic or without internal echoes relative to the altered IIIb pattern.	Report the decentered hip and preserved cartilage echotexture as separate facts and obtain prompt pediatric orthopaedic management. IIIa does not by itself choose a device, reduction method or operation.	Absence of the IIIb echogenic structural alteration does not make a Type III hip stable or low risk. The subtype is morphologic and not a calibrated outcome prediction.	okfonte Graf 2006, Table 6.1 (IIIa alpha <43, cranially pressed cartilage without structural alteration); complete subtype table reproduced in PMC3965765.
IIIb	Type IIIb, structural cartilage alteration Decentered Type III hip with alpha below 43 degrees and cartilage roof pressed cranially with structural alteration, manifested by abnormal echogenicity.	Report the structural cartilage alteration and decentering explicitly and obtain prompt pediatric orthopaedic management. The code is not an autonomous treatment instruction.	IIIb records altered cartilage morphology in an already decentered hip, but the classification does not provide an individual probability of reduction failure, osteonecrosis, surgery or residual dysplasia.	okfonte Graf 2006, Table 6.1 (IIIb alpha <43, cranially pressed echogenic cartilage with structural alteration); complete subtype table reproduced in PMC3965765.
IV	Type IV, severe decentering with caudally displaced cartilage roof Severely decentered Type IV hip with poor bony roof, flattened rim, alpha below 43 degrees, and cartilage roof pressed caudally; the proximal perichondrium is horizontal or dips caudally.	Communicate the severe decentering urgently for pediatric orthopaedic management and describe reducibility only when appropriately assessed. Type IV does not independently prescribe closed reduction, casting or surgery.	Type IV is the most severely displaced morphology in the Graf map, but the label is not a calibrated probability of treatment failure, osteonecrosis, surgery or long-term impairment.	okfonte Graf 2006, Table 6.1 (Type IV alpha <43, poor roof and caudally pressed cartilage roof); Graf 1984, PMID 6392336; AAOS 2014 guideline individualized-care disclaimer.

Histórico de versões

Data	Evento	Detalhe	Situação
2026-07-25	revised	Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. evidência	aguardando revisão
1984-11-01	published	Graf described four basic sonographic categories for infant hip dysplasia and established ultrasound as a screening and classification method.	confirmado

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