A 6-month-old male infant is referred by a health worker for suspected developmental dysplasia of the hip. On examination, the Ortolani test is positive on the right side. Ultrasound (Graf classification) shows a Type III hip. The parents are counselled about the diagnosis. What is the most appropriate next step in management?

Explanation

## Clinical Context A 6-month-old with a positive Ortolani test (hip can be reduced with abduction and external rotation) and Graf Type III (dysplastic but reducible) hip indicates DDH requiring conservative management. ## Pavlik Harness: First-Line Treatment **Key Point:** The Pavlik harness is the gold standard first-line treatment for DDH in infants aged 2–8 months with a reducible hip (Ortolani positive, Graf Type II–III). Success rates are >95% when applied early. **High-Yield:** Pavlik harness mechanism: - Maintains hip in flexion (100–110°) and abduction (45–60°) - Allows dynamic reduction and promotes femoral head remodeling - Applied for 6–8 weeks continuously (removed only for bathing) - Ultrasound follow-up at 6 weeks to assess reduction and guide discontinuation **Mnemonic: PAVLIK** — **P**ositive Ortolani, **A**ge 2–8 months, **V**alid for reducible hips, **L**ow morbidity, **I**nfant-friendly, **K**eep 6–8 weeks ## Treatment Decision Tree ```mermaid flowchart TD A[DDH confirmed<br/>Graf Type III]:::outcome --> B{Age & Hip<br/>reducibility?}:::decision B -->|2-8 months<br/>Reducible| C[Pavlik harness<br/>6-8 weeks]:::action B -->|>8 months OR<br/>Irreducible| D[Closed/open reduction<br/>+ spica cast]:::action C --> E[Ultrasound at<br/>6 weeks]:::action E --> F{Reduction<br/>achieved?}:::decision F -->|Yes| G[Discontinue harness<br/>Clinical follow-up]:::action F -->|No| H[Extend harness or<br/>escalate to reduction]:::action D --> I[Spica cast<br/>12 weeks]:::action I --> J[Progressive mobilization<br/>Long-term follow-up]:::action ``` **Clinical Pearl:** The Ortolani test is positive (hip reduces) in Type II–III hips, indicating the hip is dislocated but reducible — perfect for Pavlik harness. Type IV (irreducible) or presentation >8 months may require closed reduction under anesthesia. **Tip:** Ultrasound at 6 weeks is critical to confirm reduction before discontinuing the harness. Premature discontinuation risks re-dislocation.