Pavlik Harness Guide

Fitting

The Pavlik Harness consists of a chest halter and leg stirrups. These are connected together with straps to hold the hips in an M position so the hips are flexed and abducted.

Below are a series of steps describing how to correctly apply the Pavlik Harness.

 

Step 1: Apply the chest halter

The easiest way to fit a Pavlik Harness is to apply the chest halter first. The transverse strap should be placed around the chest with adequate room for easy breathing. It should not be around the abdomen because most babies are abdominal breathers. It can be applied as a separate piece as shown here or with all the straps attached as in the alternative method. The shoulder straps should cross in the back to keep the straps from slipping off the shoulders.

Figure 1: Apply the chest halter at the level of the nipples or slightly lower. Note that the shoulder straps should cross in the backAlternative

Step 1: Apply the chest halter with all straps attached.The baby is laid on the chest halter and the shoulder straps are pulled over the head like a tee shirt. They may need to be loosened to do this.

Step 2: Apply the leg stirrups

The leg stirrups are fitted next. The proximal Velcro strap should be just below the popliteal fossa. If the stirrup is too short, the leg will rotate externally instead of being pulled into flexion.  Stirrups should include the entire leg from just below the knee The stirrups in this photo are too shortAlternative Step 2: Apply the leg stirrups with the other straps attached

Step 3: Adjust the flexion-abduction straps

The anterior buckle on the chest halter should be approximately in the anterior axillary line so that the hip is pulled into flexion instead of pulling the foot into external rotation.The posterior buckle should be approximately at the tip of the scapula to pull the hips into abduction. At times, these buckles may need to be adjusted to hold the hips in the best position. The knee should remain lateral to the anterior (flexion) strap as shown in the photo above. If the anterior buckle is too far lateral, there is a tendency for the knee to slip under the anterior strap and the hip will be in adduction.  In the prone position, the thighs should make approximately a 90° angle to the body.In the supine position, it should be possible to bring the knees to within 3-5cm of touching each other in the midline. Loosen the posterior abduction strap if the hips are  **need more

 

Treatment Suggestions

  1. Weekly or bi-weekly examination and ultrasound in the harness is a good way to determine if the hip is reduced. Stress testing during ultrasound is not necessary or beneficial.[1, 2]
  2. Discontinue the harness if the hip is not reduced in four weeks to avoid possible damage to the posterior acetabular wall.[3]
  3. The harness is rarely successful and is not generally recommended for children who are older than 8 months of age or those with neuromuscular conditions, arthrogryposis, teratalogic dislocations or other complex conditions.[1]
  4. Extremely small infants are difficult to fit and may be better candidates for other types of bracing or splinting
  5. Follow-up is recommended until the hip is stable and growing without any evidence of avascular necrosis or residual dysplasia. This is usually until the age of 18 months when treatment if the child is completely normal on clinical and radiographic evaluation.

 

Problems and recommendations during Pavlik Harness Treatment

  1. Unstable hip after four weeks: If the hip remains unstable, but reducible, then changing to fixed abduction orthosis has been successful in some cases.[4, 5] Another alternative is to consider re-routing the posterior leg strap (abduction strap) from the leg over the top of the anterior leg strap (flexion strap) and then attaching the abduction strap back to its buckle on the posterior chest halter.[6] This converts the Pavlik to function more like a fixed abduction brace and may eliminate the need to purchase a new orthosis. However, excessive tension in the straps should be avoided in order to reduce the risk of avascular necrosis.
  2. Excessive flexion can lead to femoral nerve palsy. If the child stops kicking the knee into extension, then the straps may be loosened or removed until function returns.[1]
  3. Excessive flexion may lead to inferior dislocation of either hip.[1] If this occurs, then the harness may be discontinued for a period of one to four weeks of observation. If the hip can then be reduced on gentle examination (Ortolani Positive) treatment can resume with a Pavlik Harness or other forms of brace management. Otherwise, closed reduction and cast treatment may be considered with or without preliminary traction.
  4. Failure to obtain reduction with the Pavlik Harness is reported in 15-40% of dislocated hips so do not blame yourself, the parents, or the harness if this is unsuccessful. However, it is important to recognize failures early and change to other forms of treatment such as reduction with abduction bracing or spica cast treatment with our without traction and arthrographic imaging.
  5. Success rates with mildly dysplastic hips are approximately 98%, but some patients may develop avascular necrosis of the femoral head. Avoidance of constant abduction is recommended along with adjustment of straps to accommodate growth.

Tips and Tricks

  1. Information for parents is found in the Parents’ section of this website. Please refer to that for instructions to parents. That information can be printed and given to parents so they know how to use the harness properly.
  2. Use an indelible marker to mark the flexion and abduction straps that connect the leg because these are the straps that hold the hips in the correct position. This will identify the preferred tension if the straps are moved during care of the infant. Also mark the shoulder straps so that the chest halter stays at the appropriate level on the torso.
  3. Tell the parents that the flexion and abduction straps are “your” straps and they should not be adjusted by the parents without instruction from you or a Nurse Practitioner

 

Useful References

  1. Mubarak, S., Garfin S, Vance R, McKinnon G, Sutherland D., Pitfalls in the use of the Pavlik harness for treatment of congenital dysplasia, subluxation, and dislocation of the hip. J. Bone Joint Surg., 1981. 63A: p. 1239-49.
  2. Taylor, G.R., Clarke NMP, Monitoring the treatment of developmental dysplasia of the hip withthe Pavlik harness: the role of ultrasound. J. Bone Joint Surg., 1997. 79B: p. 719-23.
  3. Jones, G.T., Schoenecker PL, Dias LS., Developmental hip dysplasia potentiated by inappropriate use of the Pavlik harness. J. Pediatr. Orthop., 1992. 12: p. 722-6.
  4. Hedequist, D., Kasser K, Emans J., Use of an abduction brace for developmental dysplasia of the hip after Pavlik Harness Use. J. Pediatr. Orthop., 2003. 23: p. 175-7.
  5. Swaroop, V.T., Mubarak SJ., Difficult-to-treat Ortolani-positive hip: improved success with new treatment protocol. J. Pediatr. Orthop., 2009. 29: p. 224-30.
  6. Maclean, J.G.B., Hawkins A, Campbell D, Taylor MA., A simple modification of the Pavlik Harness for unstable hips. J. Pediatr. Orthop., 2005. 25: p. 183-5.
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