Splints in DDH

Details of types of splints used fin the treatment of children with DDH

1. SPLINTS IN
DDH
Suppervised By:
Dr.Laween Omar


Ageed Ameer
2
nd
year student

2. What is a Splint? Harness?

•A splint is defined as “a rigid or flexible device
that maintains in position a displaced or
movable part; also used to keep in place and
protect an injured part” or as “a rigid or
flexible material used to protect, immobilize,
or restrict motion in a part.

3. What is a Splint? Harness?

4. History Of Splits
•Evidence suggests that splint usage dates back to
1500 B.C.
•Leaves, reeds, bamboo, and bark padded with
linen… [and] copper."
•In 1517, after the evolution of the armor trade,
injuries were being treated by metal braces
secured by screws.
•In1592, the first written piece on splints by
surgeon Hieronymus Fabricius, shows various
drawings of armor-like splints for the entire body.

5. History Of Splits
•In the mid-1700, doctors and mechanics worked
with each other to create splints for certain
injuries(PoP)
•In the 1800s it was beginning to be recognized
that rehabilitation after an injury was important.
Orthopedics began to become a separate field
from general surgery. A famous British Surgeon,
Hugh Owen Thomas, created specialty splints
that were cheap and best for injuries that were
being rehabilitated.

6. Uses
•Splints are most commonly used to immobilize
broken bones or dislocated joints.
• When a broken bone has been properly set.
•Immobilize unset fractures .
• Other injuries ;
•soft tissue sprains, tendon injuries.

7. Indications of Splinting In DDH
•1.A hip that is dislocated and that can be
reduced by the examiner (Ortolani sign) at
the time the diagnosis is made.
•2. Hips that are located but that can be
subluxated by the examiner (Barlow sign).

8. Indications of Splinting In DDH
•Some of these hips will spontaneously stabilize,
and some clinicians prefer to wait a few weeks
and reexamine the child before initiating
treatment.
• When observation is chosen, steps should be
taken to ensure follow-up because some of these
hips will subsequently dislocate if they are left
alone.
•3. Less certain are the indications for the
treatment of hips that are normal on clinical
examination but abnormal on ultrasonography.

9. Rules IN Splinting : DDH
•1. Hips must be properly reduced before
splinting or in a position that reduction
occures spontaneously .
•2. Extreme positions must be avoided.
•3. Hips should be able to move .(wide
abduction and forced internal rotation lead to
AVN).

10. Pavlic Harness
By Dr.Arnold Pavlic(1902-1962)a Czcheh Orthopedist

11. Pavlic Harness/Neonates
•The Pavlik harness is applied by first placing
the chest strap just below the nipple line
• The child’s feet are placed in the stirrups, the
hips are placed in 120 degrees of flexion, and
the straps are secured.
• The posterior straps are fastened loosely to
allow for the abduction of the hips to occur by
gravity alone.

12. Harness/Neonates Pavlic
•Weekly visit for bathing or change to a larger
size(3-4weeks).
•Hyperflexion leads to FNP and less than 90
deg. is inadequate for reduction.
•Compliant parents needed.
•On the 3rd wk U/S : if unstable hip switch to
abduction orthosis(93% s.rate and no AVN).
•On the 6th wk week: examination and U/S .

13. Harness/Neonates Pavlic
•If both are toward stability start weaning.(gradual
weaning is preferable by some authors).
•At 3-4 months of age :radiograph.
•At 1 year of age a standing radiograph.
•If normal the follow up in once-twice /year till
skeletal maturity (significant incidiense of
asymmetric closure of the femoral head epiphysis
leading to valgus and inadequate coverage of the
head ).

14. Harness/Neonates Pavlic
•If the hip remains dislocated after 3 to 4
weeks of harness wear, the use of the harness
should be discontinued,and the hip should be
examined while the child is under anesthesia.
An arthrogram may show the cause of the
instability, and the hip should be managed
with either closed or open reduction.

15. Harness/Neonates Pavlic
•If the hip is reduced at 3 weeks but dislocates
during examination, the harness should be
worn for 3 to 6 more weeks until the hip
stabilizes.
• An abduction orthosis may be used for hips
that have not stabilized after 3 or more weeks
of treatment in the harness.

16. Months6 -1Harness Pavlic
•To be effective, the harness must hold the hips
in more than 90 degrees of flexion, with the
position of the upper femoral metaphysis
pointed toward the triradiate cartilage.
•Higher dislocation have a higher faliure rate.
•Weekly examination.
•Follow up by U/S.

17. Months6 -1Harness Pavlic
•If reduction is not obtained by3-4 wks /other
treatment plan.
•If reduction is obtained continue for 6 wks
after stability has achieved .
•When harness treatment is completed, some
clinicians elect to place the child in an
abduction splint for several more months.

18. Months6 -1Harness Pavlic
•It is recommended for older children to have it
for a longer time to encourage acetabular
development.
•Precise guidelines of stoppage ???
•As the harness is discontinued, another AP
radiograph is obtained to assess hip reduction
and acetabular development.

19. A notch above the
acetabulum often
appears after the hip is
reduced, and this finding
is usually followed by
improved acetabular
development
Acetabular development
may be enhanced by
abduction splinting.

20. Months6 -1Harness Pavlic
•Overall, the reported rate of AVN when the
Pavlik harness is used ranges from 0% to15%.
• Factors that are associated with the failure of
Pavlik harness treatment include
•1.Patient age of more than 7 weeks .
•2.Bilateral hip dislocation.
•3.Absent Ortolani sign.

21. Backs-DrawHarness Pavlic
•1. AVN (INPROPER APP VS dynamic process of dis).
•2.Failure to reduce the hip.
•3.Femoral nerve palsy.
•4.The so-called Pavlik harness disease was reported by
Jones and associates, who found that prolonged positioning
of the dislocated hip in flexion and abduction potentiated
dysplasia and resulted in a hip that was likely to require an
open reduction.
• They noted a flattening of the posterolateral acetabulum in
these hips and recommended discontinuing the harness if
reduction had not occurred after 3 or 4 weeks.
•5. Long-term follow-up is recommended for treated hips.

22. A, Anteroposterior (AP) radiograph obtained at
presentationwhen patient was 5 months old shows a
dislocated left hip.
B, AP radiograph of patient in the harness with
inadequate flexion.

23. C, AP radiograph obtained 2 weeks later shows adequate
flexion of the hip, although the hip is still dislocated.
D, AP radiograph obtained
1 month later shows that the hip has been reduced.

24. E, AP radiograph obtained when patient was 5
years old shows good acetabular
development.

25. Ilfeld Splint(CRAIG SPLINT)
•Since October 1951 a splint
•(FREDERIC W. ILFELD, M.D an American
orthopedic surgeon) .with two thigh cuffs
connected to an adjustable bar has been used
in about 250 cases of congenital hip disease
with good results.

26. Splint Ilfeld

27. Splint Ilfeld
•With this splint the thighs are gradually and
without force directed into abduction and
external rotation, the "frog position."
•The surgeon adjusts the splint into further
abduction at weekly intervals until the desired
position is obtained.
• The splint is removed several times a day by
the mother for rotation-abduction exercise.

28. Splint Ilfeld
•This exercise as well as the kicking and natural
movement of the hips in the splint tend to
improve local circulation, increase abduction,
and apply gentle pressure of the femoral head
against the acetabulum.

29. Splint Ilfeld
•In the frog position the thigh muscles exert a
force along the femoral shaft "pulling" the
head into the acetabulum. In this way the
dislocation of the femoral head is reduced.
•In dysplasia of the hip with delay in the
development of the femoral head and
acetabulum, the pressure of the femoral head
in the abducted position is thought to
stimulate bony growth.

30. Splint Ilfeld
•In dysplasia the splint is usually worn only at
night.
• In dislocation the splint is worn continuously
for several months being removed daily for
bathing and exercise.
• The splint is then worn only at night until hip
development is complete.

31. Splint Ilfeld
• In older children it may be used after closed
or open reduction, even without preliminary
plaster fixation.
•In some cases the splint may replace the cast
after 4-6 weeks thus eliminating many months
of plaster immobilization.

32. AdvantagesSplint Ilfeld
•1. Reduce a dislocation of the hip without
anesthesia, hospitalization, or plaster cast
•2. Dynamic, permitting crawling, walking, and
running.
•3. Adjustable for growth, cool and comfortable,
light and handy.
•4. Prevents stiffness of the hips and knees,
stimulates acetabular and femoral growth.
•5. Convenient.
•6. Allows mobility of the child.

33. Frejka pillow & Tripple diappers
•Proff.Dr. Bedrich Frejka (1890-1972) a Czech
Orthopedic Sx,
• has a poor outcome :
•1. Forcefully abduct the hips.
•2. High rate of AVN (pressure over epiphyseal vsl)
• The use of triple diapers should also be
abandoned because they do not effectively
position the hips, and their use may falsely
suggest to parents that something positive is
being accomplished.

34. Pillow Frejka

35. Avascular necrosis after the use of the Frejka pillow.
Anteroposterior radiograph obtained when patient was 16 years
old shows a shortened femoral neck with trochanteric
overgrowth.
The valgus tilt of the femoral head indicates a lateral physeal
injury from avascular necrosis

36. Von Rosen Splint
•Designed by Professor Sophus Von Rosen of
Sweden in 1956.
•With reported 95% success rate and less than
1% risk of AVN.
•Hips are held in 90 deg. flexion and 60-70 deg.
abduction

37. Von Rosen Splint

38. Follow UpVon Rosen Splint
•1.The child should be seen once weekly for:

•A. check for position and a possible change to
a larger size(7).
•B. to have a bath.
•C. check for skin problems.
•D. general advices for the parents.

39. Follow UpVon Rosen Splint
•2. U/S every 4-6 weeks

•3. Treatment continues for 6-12 weeks.
Depending on the degree of displacement and
the U/S finding in 6 wks.

40. Advices for Parents Von Rosen Splint
•1.Never remove the splint at home.
•2.The child should lie on his back not on his
tummy.
•3.Bathing: use unperfumed soap and carefully
wipe the skin and dry with a towel .then use an
unperfumed powder for skin.
•4.Diappers changing frequently.
•5.Contact the clinic for any concern.
•6.To lay your child on their side, support them
with a rolled-up towel or blanket.

41. Tubingen Splint

42. Tubingen Splint
•(By a German Professor Dr.Bernau for more
than 25 yrs )in a trial to match the treated hip
in a best position of being treated and safely
development
•“seated squat position”
•The same as the child assumes in whomb
before birth.
•A flexion of an excess of 90 deg. of hips and
spreads them slightly.

43. Tubingen Splint
•Advantages:
•1.Freely movements of the child.
•2.Natural body posture.
•3.Easy handling.
•4.Fast conditioning, suitable for everyday use.
•5.Safe.

44. Tubingen Splint
•Indications:
•Dysplasia up to 12 months w/o instability.
•Graf Type IIa,IIb and IIc .

45. Any Question?

46. Thank You