A 2-month-old female infant born via breech delivery presents for routine screening. Ultrasonography (Graf classification) shows an alpha angle of 58° and beta angle of 72°. Regarding the management and natural history of DDH, all of the following are correct EXCEPT:

Explanation

## Management Algorithm for DDH by Age and Severity **Key Point:** Management of DDH is age-dependent and severity-dependent. Closed reduction under GA is NOT indicated for all cases — it is reserved for specific situations (failed conservative treatment, late presentation, or specific anatomical findings). ### Graf Classification and Management | Graf Type | Alpha Angle | Beta Angle | Management | | --- | --- | --- | --- | | Type I (Normal) | ≥ 60° | < 55° | No treatment; routine follow-up | | Type IIa (Immature) | 50–59° | 55–77° | Serial ultrasound; consider Pavlik harness if risk factors | | Type IIb (Immature) | 50–59° | > 77° | Pavlik harness or abduction splint | | Type III (Dysplastic) | 43–49° | > 77° | Pavlik harness or abduction splint | | Type IV (Dislocated) | < 43° | > 77° | Pavlik harness or closed reduction | **High-Yield:** The patient's ultrasound (alpha 58°, beta 72°) = **Graf Type IIa** → conservative management with serial imaging. ### Pavlik Harness: Indications and Efficacy **Clinical Pearl:** - First-line treatment for DDH diagnosed **before 6 months** of age - Success rate > 95% if initiated **before 3 months** - Success rate drops to 80–85% between 3–6 months - Rarely effective after 6 months (ossification and muscle contracture develop) **Mnemonic: PAVLIK** = **P**erfect for **A**nterior **V**alves, **L**ess after **I**nfancy, **K**eeps hips flexed-abducted ### When Closed Reduction is Indicated 1. Failed Pavlik harness (persistent dysplasia or dislocation after 3 months of treatment) 2. Late presentation (> 6 months) where Pavlik is ineffective 3. Irreducible dislocation or fixed contractures 4. Pre-operative preparation for open reduction if needed **Warning:** Closed reduction under GA is NOT a first-line treatment and is NOT indicated in all cases. Starting with Pavlik harness in early-diagnosed cases avoids the morbidity of anesthesia and surgery. ### Why Option 3 is Incorrect The statement "Closed reduction under general anesthesia is indicated for all cases of DDH regardless of age at presentation" is false. Closed reduction is a second-line or later intervention, reserved for cases that fail conservative management or present late. Early-diagnosed DDH (especially Type IIa) is managed conservatively with serial imaging and Pavlik harness if needed.