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OR12.1 | Congenital Lesions — Assignment
CLINICAL SCENARIO
This assignment asks you to construct a structured clinical management plan for a child presenting with one of the four major congenital orthopaedic conditions covered in this module (DDH, CTEV, congenital muscular torticollis, or scoliosis/spina bifida). You will demonstrate your ability to integrate clinical assessment findings, select appropriate investigations, formulate a staged treatment plan, and counsel a parent — skills central to final-year clinical practice.
Instructions
- Read the following case: A 6-week-old girl is brought to the paediatric orthopaedic clinic by her mother. This was a first-born child after a breech presentation. The baby holds the left lower limb in adduction. On examination, skin-fold asymmetry is noted on the left thigh; the left knee is visibly lower when both hips and knees are flexed to 90°; Ortolani test is positive on the left (palpable clunk on abduction-reduction). No other abnormalities are noted. 2. Write a structured management plan covering the sections below. 3. Use scientific terminology appropriate for final-year MBBS. 4. Keep your response to 600–900 words total. 5. Cite at least one relevant clinical investigation finding (e.g., USG classification) to support your management decisions. 6. Submit before the deadline; your plan will be peer-reviewed by one classmate.
Length: 600–900 words
What to Submit
1. Clinical Diagnosis and Justification
Guidance: State the most likely diagnosis and the clinical findings that support it. Specifically explain what the Ortolani test detects (clunk, not click) and what the Galeazzi sign (lower knee) means. Differentiate from a positive Barlow test.
2. Investigations
Guidance: Identify the investigation of choice at 6 weeks of age and explain why plain X-ray is not appropriate at this stage. Describe what a Graf Type III ultrasound finding would mean and how it guides treatment.
3. Initial Management
Guidance: Describe the Pavlik harness — the position it maintains (flexion ~100°, abduction), mechanism of action (dynamic reduction stimulates acetabular remodelling), and duration of treatment (until stable + normal USG, typically 6–12 weeks). State what should be checked at the first harness review (skin, nerve check, harness fit).
4. Escalation if Harness Fails
Guidance: Briefly outline the management pathway if the Pavlik harness fails or is started late (> 6 months): closed reduction under GA with arthrogram, spica casting, open reduction if needed. Mention the most serious complication (AVN) and how it is prevented (avoid extreme abduction > 60°).
5. Parent Counselling
Guidance: Summarise in plain language how you would counsel the parent about: prognosis (excellent if treated early), compliance with harness (22–24 h/day), signs of complications (skin irritation, asymmetric leg movement suggesting femoral nerve palsy), and the importance of follow-up ultrasound.
Grading Rubric — Congenital Lesions Assignment Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Accuracy of diagnosis and interpretation of clinical signs | 10 pts | Correctly identifies DDH with a precise, evidence-based explanation of the Ortolani clunk, Galeazzi sign, and the distinction from Barlow's test; no factual errors. |
| Appropriate investigation selection and interpretation | 10 pts | Correctly selects ultrasound (Graf method) as the investigation of choice at 6 weeks; explains why X-ray is unreliable; accurately describes Graf Type III significance. |
| Completeness and accuracy of Pavlik harness management plan | 10 pts | Describes harness position (flexion ~100°, abduction), mechanism (dynamic reduction + acetabular stimulation), wear time (22–24 h/day), duration, and follow-up checks (skin, femoral nerve, USG review) completely and accurately. |
| Recognition of complications and escalation pathway | 10 pts | Clearly identifies AVN as the most serious complication and correctly states that extreme abduction (>60°) is its cause; outlines the escalation pathway (closed reduction → spica → open reduction) accurately. |
| Quality of parent counselling and communication | 10 pts | Counselling is patient-centred, accurate, and covers prognosis, harness compliance, warning signs (skin breakdown, nerve palsy), and follow-up in language accessible to a parent; empathetic tone. |
PEER REVIEW
Read your classmate's management plan carefully. Using the rubric criteria, assess each section and provide: (1) one specific strength per criterion, (2) one specific suggestion for improvement per criterion, and (3) an overall comment on clinical reasoning quality. Your feedback should be constructive and referenced to the clinical evidence where possible. Do not simply award maximum marks without justification.