A 9-month-old girl is brought by her mother who noticed asymmetric skin folds on the thighs and difficulty abducting the left hip during diaper changes. She was a firstborn, delivered in breech presentation. Examination reveals limited abduction of the left hip to 30 degrees. The pelvis radiograph is shown (Image 1). Which of the following is the most appropriate next step in management?

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B. Closed reduction under general anaesthesia followed by hip spica casting. ***B. Closed reduction under general anaesthesia followed by hip spica casting***
  - For children aged **6 to 18 months** with **Developmental Dysplasia of the Hip (DDH)**, the standard of care is **closed reduction** under general anesthesia to ensure proper seating of the femoral head.
  - The **hip spica cast** is then applied for several months to maintain stable reduction and allow the **acetabulum** and femoral head to develop correctly.

*A. Pavlik harness application with ultrasound follow-up at 6 weeks*
  - The **Pavlik harness** is primarily indicated for infants **under 6 months** of age; it is generally ineffective once the child starts crawling or has established stiffness.
  - In this 9-month-old, the **adductor contracture** and increased muscle strength make a dynamic splint like the Pavlik harness likely to fail.

*C. Open reduction with pelvic osteotomy as primary intervention*
  - **Open reduction** is typically reserved for cases where **closed reduction fails** due to anatomical obstacles or for children presenting after **18-24 months** of age.
  - **Pelvic osteotomies** such as Salter or Dega are secondary procedures performed when there is significant **acetabular dysplasia** that does not improve after reduction.

*D. Observation and repeat radiograph at 12 months of age*
  - **Observation** is inappropriate as DDH is a progressive condition that leads to irreversible **joint remodeling**, limb length discrepancy, and early **osteoarthritis**.
  - Clinical signs like **asymmetric skin folds** and limited **abduction**, combined with radiographic evidence of dislocation, necessitate immediate intervention. [Practice more Orthopaedics questions on OnCourse]

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