Approach to DDH – Newborn – 6 months
The hip can be one of three things:
1. Ortolani positive – dislocated, but reducible
2. Barlow positive – located, but dislocatable
Any of the above gets:
– a Pavlik harness, ultrasound to be sure that it is in, and reassessment in a week.
– hips should be flexed 90-110, and the knees should be able to be brough to within 4-5 cm of one another (ie – don’t crank them too far into abduction). Basically, do a Barlow once the Pavlik is on to see at what point of adduction the hips dislocate – then tighten up the posterior straps to prevent adduction to this point, but no more.
– at one week, check motion, check femoral nerve, check stability, get an ultrasound
* if stable in a week – continue Pavlik for 6 weeks
* if not stable but reduced – continue Pavlik until they are stable, then 6 weeks after that
* if not reduced within 2-3 weeks in the Pavlik – give up. Closed reduction and spica.
* if not able to reduce and keep reduced within the first 2 months, even with a Pavlik or closed reduction – may have a teratologic dislocation, and the acetabulum has never really formed. Back off – aim for range of motion and plan for open reduction and acetabular osteotomy at 6-12 months.
Note: this algorithm works best in the NEWBORN. After 2 months, and up to 6 months, you can still try the Pavlik even in the dislocated hip. But these need to be watched very carefully. Ultrasound to confirm that the hips are reduced. If you are starting late and are not totally reduced with the Pavlik within a couple weeks, back off. The kid needs a closed reduction and a spica cast (GO TO discussion on closed reduction and spica cast)
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