Pseudoparalysis in the Pavlik Harness: Beware of septic arthritis

Abstract

Purpose Pseudoparalysis of the leg occurring during use of the Pavlik Harness (PH) is a seldom-reported condition. Three cases of pseudoparalysis are reported here to illustrate the need for careful assessment of this condition. Methods A series of patients using the PH and presenting with pseudoparalysis was compiled following a retrospective review of case notes. Results In 3 cases, infants treated for developmental dysplasia of the hip using the PH were found to have developed a pseudoparalysis of the affected limb. All presented with similar signs, with the infant being systemically irritable and reluctant to move the limb. In 2 of the cases, this was related to the harness-its removal resulted in recovery of the affected limb. The third case was proven to be septic arthritis, unrelated to the harness, and treatment by means of arthrotomy, intravenous antibiotics and use of the PH for hip stabilisation was used successfully. In the first two cases, the pseudoparalysis was noticed at routine review clinic, and clinical assessment, ultrasound scan and blood tests were performed. The case of septic arthritis was similarly assessed, following referral by paediatric physicians. Conclusion Pseudoparalysis in the PH is a rare event and requires careful investigation.

Overview of Paediatric Bone and Joint Infections

“…50% have a reduced range of motion in the joint and 50% have reduced weight-bearing through that joint. In young infants pseudoparalysis is an important sign [15] as is irritability, but symptoms are often non-specific and the diagnosis can be challenging as a result. There may or not be erythema at the site of infection.…”

“…The European Society for Paediatric Infectious Diseases recommends a full blood count, CRP and ESR for any patient with suspected bone and joint infection [15] . Procalcitonin is not recommended as it has a low sensitivity and positive predictive value [19] .…”

“…All patients with suspected BJI should have an X-ray of the affected bone or joint as a baseline investigation and to rule out other possible mimics such as fracture [15] . Further imaging depends on whether osteomyelitis or septic arthritis are suspected.…”

“…Most children with BJI should be treated initially with IV antibiotics. ESPID advise that IV antibiotics should be continued until there is clinical improvement, absence of fever and a decrease in CRP by 30-50% of the initial value [15] . The total duration of antibiotic should be at least 2-3 weeks for SA and 3-4 weeks for OM.…”

“…significant pathogenic organisms in bone and joint infections in childhood. Methicillin-sensitive Staph aureus is most common, but the incidence of MRSA & PVL-positive species are rising[9] Streptococcus speciesKingella kingaeEstimated prevalence 15-40%[1,11,15] Most common pathogen in children aged <4 years of age[10,12] May require 16S rRNA gene PCR to identify Salmonella species High association with osteomyelitis in patients with sickle cell disease…”