Archives ofDisease in Childhood 1991; 66: 1322-1325

Complications of splintage in congenital dislocationof the hip

V G Langkamer, N M P Clarke, P Witherow

AbstractThe use of abduction splintage in the treat-ment of congenital dislocation of the hip hasan important morbidity. Six children whodeveloped complications are presented in thispaper. Sustained splintage of an unreducedhip, overcorrection of the femoral head dis-placement, avascular necrosis of the femoralhead, full thickness pressure sores, and exces-sive tibial torsion may occur as a consequenceof treatment. Expert supervision of abductionsplintage, correct case selection, and regularreview are necessary to reduce the incidenceof such complications.

Department ofOrthopaedic Surgery,Bristol Children'sHospitalV G LangkamerP WitherowDepartment ofOrthopaedic Surgery,SouthamptonGeneral HospitalN M P ClarkeCorrespondence to:Mr V G Langkamer,Department of Orthopaedics,Directorate of Surgery,Bristol Royal Infirmary,Bristol BS2 8HW.

Accepted 2 July 1991

The treatment of congenital dislocation of thehip is associated with significant complications.Two factors that may influence their develop-ment are the method and supervision of thechosen splintage and the age of the patient at thecommencement of treatment. Before the intro-duction of splintage, the management of con-

genital dislocation of the hip consisted of eithertraction1 or forceful closed manipulation of thefemoral head.2 Closed reduction and prolongedfixed splintage in a cast was promoted on thebasis that redislocation would be prevented andin some cases even the presence of hyper-trophied soft tissue obstructing reduction wouldbe overcome with prolonged pressure.3 Sus-tained immobilisation was associated with re-

dislocation in splintage in 32% of cases andavascular necrosis of the femoral capital epi-physis in 50%.4 5

Splints such as the Denis Browne rigid barabduction device were originally introduced toreduce the total time spent in a cast and were

not recommended for use alone.6 Full abductionwas rigidly maintained for over nine months.Nursing and maintenance of these children was

greatly improved by the introduction of lighter,removable splints of which the Von Rosen was

one example. This device consisted of malleablealuminium strips covered in washable rubberand applied around the shoulders, trunk, andthighs.7The association between compressive vas-

cular injury of the femoral capital ossificepiphysis and forced abduction of the hip was

supported by cadaver angiographic studiesdemonstrating significant vascular compromisein the 'frog' position commonly used in rigidabduction splints.8 Experimental avascularnecrosis was reproduced by immobilising thehip joints of immature pigs in plasters in fullabduction after artificial adductor shortening.9This awareness led to a preference for a splint

which utilised hip flexion to site the femoralhead and gradual natural abduction to overcomeadductor contracture. The most populardynamic splint remains the Pavlik harness.The Pavlik harness was introduced in 1944

and consisted of an adjustable circumferentialabdominal band with crossed posterior strapsand leg stirrups. The straps were adjusted toprovide hip flexion and free abduction. Pavlikreported an 84% success rate with no avascularnecrosis.'0 Suitable modifications in the treat-ment protocols have produced success rates of90 to 99% with no avascular necrosis." 12However, important complications have alsobeen reported from the widespread use of thisharness. Avascular necrosis has been reportedto be as high as 28%. ' 14 Failure to achievereduction and redislocation'2-'5 as well asnerve and skin complications have beenreported." 12 115The decision to apply splintage early or

delayed is controversial and may influencethe development of complications, especiallyavascular necrosis. Early splintage was advo-cated in 1929 by Putti who recommendedcushioned abduction as soon as the diagnosiswas apparent. 16 Putti recognised a group whichunderwent 'spontaneous reduction' and did notrequire treatment. Early treatment was en-couraged in order to avoid the complications ofdelay, which included difficult reduction andan increase in the incidence of avascular necro-sis.11 12 17 18 Others have reported avascularnecrosis to be higher during treatment in thefirst six months of life when the develop-ing capital epiphysis is most vulnerable topressure. 17-19 Barlow's observation that 60% ofunstable hips would resolve spontaneouslyfurther behoves those who choose to splint allunstable hips at birth to ensure that 'normal'hips do not sustain a compressive vascularinjury with subsequent proximal femoralgrowth plate damage and deformity.20

Case historiesCASE 1 (OVERCORRECTION OF FEMORAL HEADDISPLACEMENT)A girl delivered normally was found to have anunstable right hip on examination. Splintagewas commenced on the fourth day in a Pavlikharness and she was reassessed clinically atintervals of three weeks. Clinical examination at6 weeks of age did not detect any abnormalitybut a radiograph suggested that the right hipwas positioned wide of the acetabulum. Anarthrogram confirmed overcorrection with thedevelopment of a large superior pool (fig 1). At

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Complications ofsplintage in congenital dislocation ofthe hip

Figure I Case I (overcorrection offemoral head displacement). Arthrogram ofthe right hipin a 6 week old girl. Note the inferior position ofthe overcorrectedfemoral capital epiphysisand superior pooling ofthe contrast medium.

Figure 2 Case 2 (epiphysitis). Pelvic radiograph ofa girl aged2years. There is a delay inossification ofthe left capitalfemoral ossific nucleus with somefragmentation; this appearanceis suggestive ofavascular necrosis.

Figure 3 Case 3 (persistent hip dislocation in the splint). Pelvic radiograph ofa boy at

9 months ofage. This radiograph was taken after 9 months ofsplintage. The left hip remainsdislocated.

7 months an open reduction was performed andthe acetabulum was observed to be shallow.Reduction could be achieved only after con-siderable soft tissue resection and recovery wasuneventful after six months of serial plasterspicas.

CASE 2 (EPIPHYSITIS)A girl was born prematurely and at birth adislocated left knee and hip were diagnosed.The knee dislocation was reduced in serialplasters and the hip was treated immediately ina Von Rosen splint. At 2 months of age thesplint was causing excessive pressure around thefront of the thighs and a Craig splint wasapplied for a further six months. The leftfemoral capital epiphysis was considerablydelayed in development and at 2 years theradiological signs of a epiphysitis were con-firmed (fig 2).

CASE 3 (PERSISTENT HIP DISLOCATION IN THESPLINT)A boy was found to have 'clicking' hips at birth.An Aberdeen type polythene abduction splintwas applied for nine months during which timehe was reassessed regularly. At 9 months of agethe left hip was found to be dislocated (fig 3). At11 months an open reduction was necessary, butthe dislocation persisted. Redislocation con-tinued to occur because of a shallow acetabulumand stability could not be achieved even after aPemberton pelvic osteotomy (fig 4). Persistentanterior acetabular deficiency required a furtheracetabuloplasty and a derotation femoralosteotomy.

CASE 4 (FULL THICKNESS PRESSURE SORE)A girl delivered normally was diagnosed ashaving clinical bilateral hip instability at birth.A Von Rosen splint was applied and the parentsinstructed that it should not be removed untilthe child was reassessed. Three weeks later ared pressure area was noted over the right iliaccrest posteriorly. Although the lesion wasdressed and the splint changed to an Aberdeentype polythene abduction splint the lesionulcerated (fig 5). At three years of age she isclinically normal but has a 2 cm by 1 cm fullthickness scar at the site of the ulcer.

CASE 5 (FAILURE OF FEMORAL HEAD RELOCATION)A girl was born by caesarean section anddiagnosed as having 'clicking' hips at birth. Shewas treated in double nappies until 6 weeks ofage and subsequently a Pavlik harness wasapplied. The mother was instructed to removethis for bathing. At 4 months the harness wasclearly too small and incorrectly applied withthe abdominal strap below her waist. A radio-graph demonstrated that the left hip had notbeen concentrically reduced. Successful reduc-tion was achieved with a larger, correctly fittedharness. Treatment was continued in this for afurther six months.

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Langkamer, Clarke, Witherow

Figure 4 Case 3 (persistent hip dislocation in the splint). Pelvic radiograph ofcase 3 after aPemberton pelvis osteotomy. The left hip remains dislocated. Note also delayed ossification ofthe nightfemoral capital epiphysts.

Figure 5 Case 4 (full thickness pressure sores). Girl at3 weeks ofage shortly after the removal ofa Von Rosensplint. Thefull thickness pressure sores seen here eventuallyhealed but large scars remain at 3 years ofage.

CASE 6 (EXTERNAL TIBIAL TORSION)A boy born in another country was noted tohave a dislocatable left hip at birth and was

treated in a Pavlik harness for six months. Atthat time the child's father was concerned thatan 'ankle strap' which had been added to thesplint was exceptionally tight and was turningthe left leg out excessively. Splintage was

continued for 11 months. At the age of 5 years,there was a 60 degree external rotation deformityof the tibia confirmed by computed tomography.The right leg is normal.

DiscussionThese cases illustrate that treatment of neonatalhip instability does have a significant complica-tion rate. The initial dilemma of those who treatthis condition is whether to splint all unstablehips or whether to delay splintage on the basisthat many hips will stabilise spontaneously.Advocates of immediate splintage have a specialresponsiblity to ensure that complications arereduced as it is possible that a treated hip wouldhave spontaneously stabilised without the needfor splintage.20 2' Delayed splintage risks thepossibility of clinical examination failing todetect displacement because the clinical signs ofinstability gradually resolve in the early weeks.This resolution is associated with an increasinglimitation of abduction and adductor tightness.This renders the femoral head vulnerable tocompressive vascular injury with forced hipabduction in a rigid abduction splint.9 22Careful assessment is required to ensure thatthe hip is splinted in the reduced position.Splintage of displaced hips or those that areeccentrically reduced will predispose to compli-cations that increase if operative reductionis necessary.23 The likelihood of avascularnecrosis is increased and this may predispose todeformity and osteoarthrosis in later years.24The dynamic type of splintage (for example,

Pavlik harness) reduces the risk of forcedabduction and compressive vascular injury.However, the harness must be applied correctlyand the posterior straps used to limit adductionacross the midline rather than abduct the hips.Similarly, the position of hip flexion is critical.The hip should be flexed to just above 90degrees. 12 Excessive flexion may result infemoral nerve palsy" 12 1 or inferior displace-ment of the hip.'" Medial knee ligament in-stability may occur as a consequence of valgusstrain applied by a medial strap slipping overthe knee.25 For these reasons expert supervisionof an infant in a harness is required on perhaps aweekly basis. Frequent strap adjustments arerequired and the position of the hip checked byclinical examination and radiography to preventpersistent posterior femoral head displacementor eccentric reduction. It may be useful for theclinician to mark the straps after adjustment toprevent interference and reduce the likelihoodof losing the reduction. If necessary, treatmentmay have to be abandoned in favour of alterna-tive procedures such as adductor tenotomy orplanned open reduction.2S29

Ultrasound has proved to be a useful adjunctto regular clinical examination of hips splintedparticularly in the Pavlik harness. Where ultra-sound is available the mandatory pelvic radio-graph of the infant in a Pavlik harness may notbe necessary.3 32 Additionally, ultrasound maybe able to detect the hips which do resolvespontaneously.33 A delayed examination of thehips at 2 weeks of age reduces the treatment rateand assists the assessment of hip location inthose cases that do require treatment.34

.CONCLUSIONSSix cases of complications resulting from the useof splintage are presented. Complications may

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Complications ofsplintage in congenital dislocation ofthe hip 1325

be prevented by observation of fundamentalprinciples. The decision to splint an infant mustnot be undertaken lightly. A proportion ofunstable hips do become normal by 2 weeks ofage and splinting a normal hip may causevascular injury. An infant placed in an abduc-tion splint requires regular supervision bytrained specialists to prevent any relapse ofinstability or complication resulting from thesplint itself. Excessive abduction against tighthip adductors must be avoided particularly ifrigid splintage is used. Diagnosis may beimproved by ultrasound examination and thesupervising specialist must also be aware that incertain cases splintage may have to be discon-tinued and alternative treatment such asadductor tenotomy or planned open reductionperformed.

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