What is the treatment for a positive Garrick test indicating hip instability or dislocation in an infant?

Treatment for Positive Garrick Test (Hip Instability) in Infants

Note on Terminology

The "Garrick test" appears to be a non-standard term. Based on the clinical context of hip instability/dislocation detection in infants, this likely refers to either the Ortolani or Barlow maneuvers, which are the standard clinical examination techniques for detecting developmental dysplasia of the hip (DDH) 1, 2.

Immediate Management for Positive Hip Instability Test

For infants with a positive Barlow test (dislocatable hip) or Ortolani test (dislocated but reducible hip), initiate treatment with a Pavlik harness or similar abduction orthosis as soon as the diagnosis is confirmed. 3, 2

Initial Diagnostic Steps

• Confirm the finding through repeat physical examination by an experienced clinician, as the sensitivity of these tests depends heavily on examiner expertise 3, 1
• Obtain ultrasound imaging if the infant is under 4-6 months of age to confirm hip instability and assess acetabular morphology 3, 4
  • Ultrasound should ideally be performed at 4-6 weeks of age, not before 2 weeks due to high false-positive rates from physiologic laxity 4
  • Use combined static (Graf method) and dynamic (Harcke method) ultrasound techniques 3
• Obtain radiographs if the infant is older than 4-6 months when ossification makes x-rays more reliable 3, 4

Treatment Protocol

Brace treatment should be initiated promptly once hip instability is confirmed: 3, 2

• Pavlik harness is the first-line treatment for hip instability in infants, though limited evidence also supports the von Rosen splint 3
• Treatment is most effective when started early, ideally within the first few months of life 2, 5
• Early treatment with abduction orthosis is safe and strongly advised to prevent the need for later surgical intervention 2

Monitoring During Treatment

Serial physical examinations and periodic imaging assessments should be performed throughout treatment duration: 3

• Obtain follow-up ultrasound or radiograph within 1 week of initiating brace treatment to confirm hip reduction 3
• Continue monitoring with physical examination at each well-baby visit 1, 4
• Transition to radiographic monitoring after 4-6 months of age as ossification progresses 4

Referral Guidelines

All infants with confirmed hip instability should be managed by or in consultation with a pediatric orthopedic surgeon: 6

• Specialist involvement ensures appropriate brace selection, fitting, and monitoring 3, 6
• This reduces the risk of treatment complications, particularly avascular necrosis of the femoral head, which is the most serious complication and predictor of poor prognosis 1

Critical Pitfalls to Avoid

• Do not delay treatment while waiting for spontaneous resolution in cases of true instability (positive Ortolani or Barlow tests), as this differs from mild immaturity on ultrasound 3, 2
• Distinguish between true hip instability (positive Ortolani/Barlow with palpable "clunk") and benign clicking hips that have no laxity 3, 1
• Avoid ultrasound before 2 weeks of age as physiologic laxity causes high false-positive rates 4
• Do not rely solely on risk factors for screening, as most DDH occurs in infants without identifiable risk factors 2
• Recognize that limited hip abduction becomes a more reliable sign than Ortolani/Barlow tests after 3 months of age when the hip capsule tightens 1, 4

Expected Outcomes

• When treatment is initiated early with proper bracing, most unstable hips reduce successfully within the first week 3
• Untreated hip instability can lead to lifelong disability, early degenerative arthritis, and the need for complex surgical reconstruction 1, 5
• Despite normal newborn examinations, approximately 1 in 5000 infants may develop late-onset hip dislocation requiring treatment 2