A 3-month-old female infant born to a 28-year-old primigravida is brought to the pediatric orthopedic clinic by her mother. The child was breech-presented at delivery. On examination, the left hip shows restricted abduction (30° instead of normal 60°), and a palpable clunk is felt when the hip is flexed and gently abducted. Ultrasound of the hip (Graf classification) shows a Type IIc hip. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis **Key Point:** This infant presents with classic signs of developmental dysplasia of the hip (DDH): breech delivery (major risk factor), restricted abduction, and a positive Barlow/Ortolani sign (the palpable clunk). Ultrasound confirms Graf Type IIc (immature but not dislocated). ## Graf Classification & Management Algorithm ```mermaid flowchart TD A[Ultrasound Hip Dysplasia]:::outcome --> B{Graf Type?}:::decision B -->|Type I| C[Normal]:::outcome B -->|Type IIa| D[Mild dysplasia]:::outcome B -->|Type IIc| E[Immature hip]:::outcome B -->|Type IId-IV| F[Dysplasia/Dislocation]:::outcome E --> G[Age < 6 months?]:::decision G -->|Yes| H[Pavlik Harness 12-16 weeks]:::action G -->|No| I[Consider abduction orthosis or surgery]:::action F --> J[Traction + Closed/Open Reduction]:::action H --> K[Ultrasound f/u at 4-6 weeks]:::action K --> L{Improved?}:::decision L -->|Yes| M[Continue harness, repeat US at 12 weeks]:::action L -->|No| N[Escalate to closed/open reduction]:::action ``` ## Pavlik Harness Protocol **High-Yield:** The Pavlik harness is the gold standard for DDH in infants < 6 months with Graf Type IIc–IId hips (immature or mildly dysplastic but not dislocated). | Parameter | Detail | | --- | --- | | **Age range** | < 6 months (optimal); efficacy drops after 6 months | | **Duration** | 12–16 weeks continuous wear | | **Success rate** | 85–95% for Type IIc–IId | | **Follow-up** | Ultrasound at 4–6 weeks to assess reduction; repeat at 12 weeks | | **Failure signs** | Persistent dysplasia or worsening on follow-up US → escalate to closed/open reduction | ## Why Pavlik Harness Works 1. **Mechanism:** Maintains hip flexion (100–110°) and abduction (45–50°), centering the femoral head in the acetabulum. 2. **Remodeling:** Allows acetabular development and femoral head coverage to normalize over weeks. 3. **Non-invasive:** Avoids surgery in the majority of early-detected cases. **Clinical Pearl:** The "clunk" (Ortolani sign) indicates the femoral head is dislocatable but currently reduced—this is a hallmark of DDH and indicates the hip is not yet fixed in dislocation, making it ideal for conservative management. **Key Point:** Type IIc hips (immature but not dislocated) have the best prognosis with Pavlik harness; success rates exceed 90% when started before 6 months of age.