Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of left hip dysplasia. History significant for [positive/negative] family history of DDH, [breech/vertex] presentation, and [oligohydramnios/normal amniotic fluid]. Caregiver reports [no/noted] asymmetry of skin folds or limited abduction of the left lower extremity. No prior hip ultrasound or radiographic imaging performed.
Clinical Examination Findings
General exam: Alert and active infant. Musculoskeletal: Left hip examination reveals [positive/negative] Ortolani and Barlow maneuvers. Asymmetric inguinal/gluteal skin folds noted on the left. Limited hip abduction noted on the left side compared to the right. Galeazzi sign [positive/negative] for limb length discrepancy. Lower extremity neurovascular status intact.
Treatment Protocol
Treatment plan: Initiate Pavlik harness therapy for stabilization of the left hip. Instructed caregiver on proper harness application, skin care, and hygiene. Schedule follow-up ultrasound in [number] weeks to assess hip reduction and acetabular development. Referral to pediatric orthopedics confirmed.