Special Communication
A Practical Guide to the Use of a Pavlik Harness for the Treatment of Dislocated Hip in
Infants
Hugh G. Watts, MD
From the Department of Orthopedic Surgery, King Faisal Specialist Hospital and Research Centre, and Department of Orthopedics, College of Medicine,
King Saud University, Riyadh.
Address reprint requests and correspondence to Dr. Watts: Department of Orthopedic Surgery, King Faisal Specialist Hospital and Research Centre, P.O.
Box 3354, Riyadh 11211, Saudi Arabia.
Accepted for publication 23 November 1988.
The Pavlik harness is a useful device for treating infants up to 10 months of age with congenital dislocation of the
hip(s). The hip is left dislocated when the harness is applied, and the dislocation reduces spontaneously over the next
month of harness wearing. In our hands, the technique has been successful in over 90% of children. It is a highly
cost-effective system which can be readily used in Saudi Arabia.
HG Watts, A Practical Guide to the Use of a Pavlik Harness for the Treatment of Dislocated Hip in Infants. 1989;
9(4): 393-396
The treatment of a child with a dislocated hip is clearly easiest when the diagnosis has been made at birth.
However, for orthopedic surgeons working in Saudi Arabia, this is an uncommon event. More likely, the orthopedist
is faced with a child who is a few months to 3 or 4 years old. While children over the age of 1 year will require
conventional traction, followed by closed reduction for younger children and open reduction for older children, the
Pavlik harness is an ideal tool to use in the treatment of the dislocated hip in infants from birth to 8 months of age
and perhaps up to 1 year of age.
Many orthopedic surgeons are still not aware that the Pavlik harness can be used for treating the child whose
hip is dislocated and have reserved the use of the Pavlik harness only for children with acetabular dysplasia or for
the later phases of treatment once the hip is well located. However, it is an established observation 1-5 that an infant
whose hip is dislocated can be placed in a Pavlik harness, and without manipulation of the hip, the joint will reduce
spontaneously in the harness. The mechanism of this reduction is not understood, which reinforces the disbelief of
orthopedic surgeons who have not experienced this phenomenon. The purpose of this paper is to emphasize this
important use of the Pavlik harness, to point out that it is a practical and cost-effective technique that has been
acceptable to Saudi Arabian families, and to review the details of this technique of management without which the
treatment may fail.
Technique
In the past, the infant with the dislocated hip was treated by a prior period of traction. Once the distal movement
of the proximal femur had taken place, the hip was reduced under anesthesia and maintained in abduction in a
plaster spica. Hip stability was maintained by hip abduction. With the Pavlik harness, the emphasis is on flexion of
the hip rather than abduction.
When a dislocated hip is flexed, the point of rotation is at the lesser trochanter (not the femoral head), and the
head of the femur moves distally. In the Pavlik harness, the child is then left to kick in the brace, and somewhere
between 2 and 4 weeks, the hip usually spontaneously relocates. Once the hip relocates, the brace is maintained for
another 2 to 3 months to allow the tissues to accommodate to the new relationship of the femoral head inside the
acetabulum.
A Practical Guide to the Use of a Pavlik Harness for the Treatment of Dislocated Hip in Infants
Application of Pavlik Harness
A harness size should be selected so that the "waist" strap fits not around the waist but the chest. If the strap is
too low, the strap may interfere with feeding and also makes diaper changing more difficult. The foot straps should
be sufficiently tight that the top of the knees are approximately at the level of the umbilicus giving flexion of 100 to
120 degrees. Effort should be made to achieve flexion, and the posterior straps (which control abduction) do not
need to be tight. In fact, posterior straps fixed too tightly may be harmful.
When satisfactory adjustments have been made, it is strongly recommended that the loose ends of the straps be
covered with adhesive tape so that parents will not be tempted to remove the harness. The only straps which the
parent should be allowed to open are the two Velcro closures on the lateral aspect of the chest strap and the booties.
The harness stays on 24 hours a day.
Socks should be worn over the feet inside the brace. Parents need to be instructed in how the posterior strap of
the foot piece ("bootie") can be opened to change the socks, but the parents must be urged to keep the hip and knee
in flexion while this is being performed.
The child's diapers can readily be changed without removal of the harness. The undershirt, which should be
worn under the brace, can also be changed without removing the harness by loosening the side straps of the chest
strap. The child is bathed by using a wet washcloth around the straps.
Subsequent Management
Parents should be encouraged to have the child lie face down. In Saudi Arabia, where children are largely left to
lie flat on their backs, parents are rather alarmed to have a child lie on its face, and such children who have never
lain face down may be irritable when initially placed prone until they get used to this position. While prone lying is
probably helpful, it is not mandatory.
Once again, it should be pointed out to the parents that this brace is worn full time for several months.
When the patient's initial visit is over, it is strongly advised that the child be brought back in approximately a
week for general review with the parents. This visit has been found to be an extremely important one, since parents
frequently do not remember all of the instructions in the confusion in the first visit and will be subject to many
"helpful suggestions" by well-meaning relatives once they get home.
Following this second visit, the child is seen again in 3 to 4 weeks at which time an anteroposterior
roentgenogram of the hips is taken. Usually the hips are relocated at this point. One potential problem is that of
overlooking a persisting dislocation. Because of the flexed position of the thigh, the head of the femur shifts
inferiorly. If it is still dislocated posterior to the acetabulum, the orthopedic surgeon may not recognize it. One can
suspect such a situation if the head of the femur appears to be too close to the acetabulum. The problem can be
confirmed by taking "acetabular view" x-rays in the harness which allows the hips to be viewed at right angles to the
anteroposterior views (Figures 1 and 2).
If the hips are relocated, the harness is maintained for 2 more months. It is preferable to see the child at the end
of 1 month with repeat x-ray films. At that visit, the circumferential straps around the legs may need to be loosened
(because of the growth of the legs), and the leg straps may need to be lengthened (again because of growth). Care
must be taken to maintain the flexion.
When the hips have been in place for 2 months, the harness is used as a nighttime device. At this point, the child
will have spent several months in flexion and will have bilateral hip flexion contractures. This is of no concern.
Some orthopedic surgeons have been alarmed at the flexion contracture and advised parents to do hip extension
exercises. This may lead to redislocation of the hips. Children are allowed to do their normal kicking, and these
flexion contractures have always resolved spontaneously.
Annals of Saudi Medicine, Vol 9 No. 4; 1989
A Practical Guide to the Use of a Pavlik Harness for the Treatment of Dislocated Hip in Infants
Figure 1. Anteroposterior view of 6-month-old girl in a Pavlik harness.
Note that the left femur appears to be too close to the acetabulum.
Figure 2. Acetabular views of the same child seen in Figure 1.
Top, right hip; bottom, left hip. Note thatthe left hip is posteriorly dislocated.
If, at the end of the first month, the hip is not relocated, it is important to review the situation and to see if there
was something wrong in the wearing of the harness. Primarily the question is "Were the hips flexed enough?" If this
has not been the case, it is worthwhile continuing the treatment with adequate flexion. If, however, adequate flexion
has been present and the hip is still not relocated, the child should be admitted for more conventional traction and
closed reduction. If that should be the case, very little has been lost except 1 month of time during which time the
child is at home.
Avascular necrosis has been reported with an incidence of 0.9% to 7.2% with an average of 2.38% in a large
multicenter study.6 The higher incidence of avascular necrosis results from tightening the posterior straps to force
hip abduction rather than seeking the goal of hip flexion. When the posterior straps are not done tightly, avascular
Annals of Saudi Medicine, Vol 9 No. 4; 1989
A Practical Guide to the Use of a Pavlik Harness for the Treatment of Dislocated Hip in Infants
necrosis has been minimal.
Experience elsewhere has shown that this treatment is effective in approximately 90% of patients. Between July
1984 and March 1987, at the King Faisal Specialist Hospital and Research Centre, 11 Saudi infants (10 girls and 1
boy) ages 1 to 10 months (four over the age of 6 months) were treated by this system. Ten patients relocated their
hips spontaneously. There has been no avascular necrosis. The 11th child, a girl, subsequently was admitted to the
Hospital for traction, then could not be stably reduced, and ultimately required an open reduction.
Treating children older than 6 months has not usually been recommended in the United States; however, in a
large European study, children up to age 11 months had no problems. 6 Children over 1 year of age will not
ordinarily tolerate the restriction of a Pavlik harness. There is one report of a child developing valgus of the knees
(successfully treated with a brace) after she was treated with a Pavlik harness at 6 months of age 7; however, this
child was treated for an excessive time (8 months).
The cost of a Pavlik harness currently is approximately SR100. (They can also be made locally from webbing
straps and buckles.) This is clearly a great deal cheaper than any kind of in-hospital management.
References
1. Ramsey PL, Lasser S, MacEwen GD. Congenital dislocation of the hip: use of the Pavlik harness in the child during the first
six months of life. J Bone Joint Surg Am 1976;58-A(7):1000-4.
2. Green WT Jr. Congenital dislocation of the hip treated by the Pavlik harness (abstract). J Bone Joint Surg Am 1976;58A(2):285.
3. Munger DH. The Pavlik sling in congenital dislocation of the hip (abstract). J Bone Joint Surg Am 1976;58-A(5):736.
4. Iwasaki K. Treatment of congenital dislocation of the hip by the Pavlik harness: mechanism of reduction and usage. J Bone
Joint Surg Am 1983;65-A:760-7.
5. Mubarak S, Garfin S, Vance R, et al. Pitfalls in the use of the Pavlik harness for treatment of congenital dysplasia, subluxation,
and dislocation of the hip. J Bone Joint Surg Am 1981;63-A:1239-48.
6. Grill F, Bensahel H, Canadell J, et al. The Pavlik harness in the treatment of congenital dislocating hip: report of a multicenter
study of the European Paediatric Orthopaedic Society. J Pediatr Orthop 1988;8(1):1-8.
7. Schwentker EP, Zaleski RJ, Skinner SR. Medial knee instability complicating the Pavlik-harness treatment of congenital hip
subluxation: case report. J Bone Joint Surg Am 1983;65-A:678-80.
Annals of Saudi Medicine, Vol 9 No. 4; 1989