Congenital dislocation of the hip. Treatment in infancy to walking age.

TREATMENT SUMMARY In the first 1 to 2 weeks of the newborn period, many dislocatable or subluxable (positive Barlow) hips will improve spontaneously. The hip can be managed in a flexed-abducted attitude with simple measures. If the hip is clearly dislocated (positive Ortolani), or instability continues, the hip should be continuously maintained in the reduced position by a secure restraint, such as the Pavlik harness. Although many hips will spontaneously improve, to ensure a good result, it is still wise to keep the hip in a reduced position while the capsule is returning to its normal shape. In the child under 6 months of age with a dislocated hip that reduces easily with the Ortolani maneuver, the reduction can be maintained reliably in a comfortable and physiologically safe position with the Pavlik harness. If the hip cannot be reduced with the Ortolani maneuver (negative Ortolani), the child is placed in the Pavlik harness for a short period (approximately 2 weeks) to see whether the irritability or guarding will resolve and allow the adductor muscles to loosen and the femoral head to spontaneously reduce (intermediate hip). Force should never be used to reduce the hip. If the hip fails to reduce with the Pavlik harness, or if the child is over 6 months of age, traction must be employed until the femoral head can be easily reduced or the femoral ossific nucleus is seen on the roentgenogram to be opposite the trira-diate cartilage. After traction and with general anesthesia, a gentle closed reduction is attempted. If the hip reduces easily and roentgenograms demonstrate the femoral head to be in a satisfactory position, one then determines the size of the safe zone. If it is large, the child is immobilized in a cast. If the safe zone is narrow, abductor tenotomy should be considered prior to cast application. Positioning of the child in the cast is critical. The flexed-abducted, or human, position should be maintained. Extreme abduction must be carefully avoided as this may be associated with avascular necrosis of the femoral head and a poor end result. If, after attempted closed reduction, the roentgenograms do not demonstrate a satisfactory position of the femoral head in the acetabulum, open reduction may be considered. In the older child with CDH, soft tissue contractures and bony adaptation to the abnormal position require a considerable surgical effort to reverse. Often, a combination of acetabular procedures, surgical reorientation of the femoral head and neck, and shortening of the femur will be necessary. It is more difficult to render a satisfactory end result. These procedures are beyond the scope of this article, but serve to underline the importance of early recognition, diagnosis, and treatment. The longer the femoral head is out of the acetabulum, the more difficult the reduction becomes, and the adaptive changes become more pronounced. These changes are reflected in the clinical and radiologic examinations, with the development of the classic picture associated with CDH. Initially, however, the only clue that a dislocation is present will be discovered by careful examination of the infant with the Ortolani test.