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Loosen strap D on the right
16%
577/3633
Tighten strap F on the right
1%
34/3633
Tighten strap E on the left
51/3633
Loosen strap C on the right
79%
2881/3633
Loosen strap A on the left and B on the right
36/3633
Select Answer to see Preferred Response
The clinical presentation is consistent with a femoral nerve palsy in an infant being treated with a Pavlik harness. Reducing hip flexion by loosening the strap depicted by C on the right would be the next step in treatment. Improper Pavlik harness wear can result in two complications: femoral nerve palsy and avascular necrosis of the the hip. Femoral nerve palsy occurs from excessive hip flexion and AVN from excessive hip abduction. Tibrewal et al. performed a systematic review on the Pavlik harness. Good results were found with ultrasound findings of head position below the labrum, initiation <7wks of age. Adduction contracture was associated with AVN. They found up to 83% success at long term followup. AVN rates were up to 30%, and correlated with more severe dislocation before initiation, and higher Tonnis grade. Murnaghan et al. retrospectively reviewed 1218 patients treated with a pavlik harness. Femoral nerve palsy was found in 2.5% of all patients treated with the Pavlik harness. Resolution of nerve palsy < 3 days predicted successful treatment, whereas lack of resolution within 10 days predicted failure. Treatment success of DDH was 94% in the control group and 47% in the palsy group. Figure A shows a child in the Pavlik harness. Illustration A shows the Yamamuro "distance a". Illustration B shows the Suzuki ultrasound classification of hip position. Illustration C shows the Tonnis grade of femoral head center/ossific nucleus position in relation to the acetabular rim (Grade 1, medial to Perkins line; Grade 2, the center lies lateral to Perkins line, but below the acetabular rim; Grade 3, at the level of the rim; Grade 4, above the rim). Illustration D shows the Graf classification. Incorrect Answers: Answers 1: Strap D adjusts abduction. Degree of abduction is not a risk factor for femoral nerve palsy. Answer 2: Strap F adjusts for foot fit and does not affect hip flexion. Answers 3: The left and right straps are independent. Adjusting the left straps will only affect the left leg. Answer 5: Strap A adjusts the chest strap height on the child. It does not affect leg position. Strap B adjusts chest fit.
2.4
(19)
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