Annals of Orthopedics and Rheumatology

Inferior Hip Dislocation During Treatment of Developmental Dislocation of Hip. A Rare Complication from Hip Abduction Splint. A Case Report and Review of Literatures

Case Report | Open Access Volume 9 | Issue 1 |

  • 1. Department of Orthopedic, Al-Azhar University, Egypt
  • 3. Department of Orthopedic, El bakey General Hospital, Egypt
+ Show More - Show Less
Corresponding Authors
Abdel-aal MA, Orthopedic department, El bakey General Hospital, Egypt, Tel: 00201020995024

Background: DDH constitutes a group of conditions involving hip sublaxation and dislocation. It is mandatory for management of these cases to be followed by aftercare with Braces. Some complications may develop during follow-up in hip spica or hip brace.

Introduction: DDH encompasses a spectrum of diseases that includes dysplasia (a shallow or underdeveloped acetabulum), subluxation, and dislocation. These conditions are commonly seen with arthrogryposis, myelomeningocele, and Larsen’s syndrome. Cases of developmental dislocation of the hip (DDH) still occur after walking age because of Late or missed diagnosis and failed conservative treatment. Lack of follow-up leads to a lot of Complications.

Case Presentation: 4years old female child admitted to our hospital complaining of limbing and had neglected history of right DDH. She w managed by derotation femoral osteotomy and hip spica cast with smooth follow-up recovery. At 12 weeks an abduction hip brace was advised but follow-up last for few weeks. When returned back and during routine x-ray inferior dislocation was noticed. Patient planned for surgery and hip Spica cast. Follow-up passed smoothly for 12 months then the Spica cast replaced by Abduction hip brace. The reduction was confirmed by good x-ray.

Discussion: Bracing is an important step in follow-up treatment program of DDH. Loss of reduction as a complication may occur during follow-up regimen. Inferior hip dislocation in the hip abduction brace is a rare complication and rarely mentioned in the literatures. Avoidance of this complication can be achieved by having good orthotics in the hospital and applying the brace under supervision of the orthopedic surgeon. Immediate x-ray to check for good position of the head, and closed monitoring of the patient to detect any changes in the hip position.

Conclusion: Inferior hip subluxation in the hip brace rarely occurs as a complication during follow-up program of DDH treatment. Early recognition of this complication and reduction of the flexion angle led to a stable dislocation of the hip.


Developmental Hip Dislocation, Dysplasia, Hip Spica, Hip Brace


DDH: Developmental Dysplasia Of Hip, AVN: Avascular Necrosis


Ba K, Aa A, Abdel-aal MA (2022) Inferior Hip Dislocation During Treatment of Developmental Dislocation of Hip. A Rare Complication from Hip Abduction Splint. A Case Report and Review of Literatures. Ann Orthop Rheumatol 9(1): 1100.


Developmental hip dysplasia (DDH) encompasses a spectrum of conditions that include dysplasia (a flat or underdeveloped acetabulum), subluxation, or dislocation. There is also a teratologic hip that is dislocated in utero and irreducible on neonatal examination. It has a pseudo-acetabulum, and is associated with neuromuscular and genetic disorders. These disorders are common in arthrogryposis, myelomeningocele, and Larsen syndrome.

Cases of developmental hip dislocation (DDH) continue to occur even after walking age owing to late diagnosis or failure of conservative treatment [1]. Conservative or surgical treatment for DDH needs aftercare for braces. Lack of aftercare leads to a lot of complications related to Spica Casting – hip abduction braces Figure (1). These complications involve compression of femoral nerve due to hyperflexion, inferior dislocation, skin detachment and the most important one is avascular necrosis of femoral head. Care of the cast or the brace should bear attention to the fully reducible hip, child not attempting to stand, close regular follow-up (every 1-2 weeks) by imaging and adjustments of the brace when necessary by the surgeon [2, 3].

Pavlik Harness Failure may occur due to: Improper application and follow-up by the physician, inadequate initial reduction, failure to recognize persistent dislocation and poor parent compliance. The risk factors predispose to Pavilk harness failures include: bilateral hip dislocation, age greater than seven weeks prior to initiation of treatment with the harness and lack of Ortolani sign at initial examination.


Four years female child presented to the orthopedic department of El-Hussein University Hospital with painless limping, limb shortening and radiographs showed a neglected right DDH. The patient was scheduled for surgery (femoral shortening with derotation osteotomy) and hip spica. Recovery was smooth and follow-up care was good.

At 12 months the hip Spica was removed and the patient was advised to have an abduction hip brace. She went to a place outside the hospital and the technician applied the brace. The patient did not come back to the hospital to continue the followup program. After 6 weeks the child’s parents returned back to our hospital to make sure of the condition. Unfortunly plain x-ray showed strange inferior dislocation of hip Figure (2a & 2b) and CT confirmed the diagnosis Figure (3).


The patient was scheduled for operative intervention. Closed reduction was an attempt first but failed as there was a band of elasticity feeling preventing relocation of the hip. We decided to go to open intervention.


We used the same incision. The operative findings revealed the femoral head was buttonholed in the capsule that preventing reduction. The capsule was release and the head was relocated easily to the acetabulum. The position was checked by C-arm and hip Spica applied for 4 weeks. The abduction hip splint was applied by the orthopedic surgeon and an immediate X-ray was done and confirmed the good reduction Figure (4). The postoperative course was uneventful, with no early or late infection being observed.

The results were evaluated according to modified McKay criteria, Severin radiological criteria, and Bucholtz - Ogden system of AVN grading after a mean follow-up for 6 months.

In the last follow-up, the Clinical Evaluation patient reported no significant hip pain, and radiologically no signs of dislocation or AVN (Figure5).


Bracing is considered a gold standard in treating Developmental Dysplasia of the Hip (DDH) in infants less than 6 months of age with reducible hips. A variety of braces are available that work on similar principles of limiting hip adduction and extension. The brace eliminates dislocating forces from the hamstrings, the block to reduction of the psoas and improves the muscle line of pull to stabilize the hip joint [4]. The use of excessive force or exceeding the safe zone to maintain hip position can lead to complications, such as femoral nerve palsy and avascular necrosis (AVN) [5,6].

Inferior dislocation (obturator dislocation) from the abduction brace rarely mentioned in literature. Rombouts and, Kaelin [3] mention two cases of inferior dislocation but in a neonate due to the Pavlik harness. Also, they reviewed the literatures and mentioned Five cases of inferior (obturator) dislocation complicating the treatment of developmental dislocation of the hip that had been reported previously [7-10]. Only one of these cases was in a neonate [10].

Pediatric orthopedic surgeons have been aware of the problem but no one has studied it fully to declare why it happens and there were no studies to follow up and report on the final results for children with this complication.

Ramsey et al. [11] emphasized that adequate hip flexion must be obtainable so that the femoral head is directed towards the triradiate cartilage. Excessive hip flexion, however, directs the metaphysis of femur to come below the triradiate cartilage and may produce an inferior (obturator) dislocation.

This complication is classified as grade IIIb according to the Clavien-Dindo classification [12] (Intervention under general anesthesia). To avoid this complication we need to have good orthotics in the hospital, application of the brace should be under the supervision of the orthopedic surgeon, immediate x-ray to check for good position of the head, and closed monitoring of the patient to detect any changes in the hip

In our case and after open reduction; a hip spica cast was applied and followed for 4 weeks. After that an abduction brace was applied carefully by the surgeon and under C-arm image control to verify the proper location of the hip. The brace was gradually weaned over a period of several months [13].


Abduction brace can cause inferior hip dislocation during treatment of DDH. Gentle manipulation may be tried and if failed go for open reduction. Closed monitoring of the brace is mandatory. Early recognition of the complication and diminution of the angle of flexion gave a stable relocation of the hip joint.


1. Vivek Gulati, Kelechi Eseonu, Junaid Sayani, Nizar Ismail, Chika Uzoigwe, Choudhury MZ, et al. Developmental dysplasia of the hip in the newborn: A systematic review. World J. Orthop. 2013; 4: 32–41.

2. Viere RG, Birch JG, Herring JA, Roach JW, Johnston CE. Use of the Pavlik harness in congenital dislocation of the hip. An analysis of failures of treatment. J Bone Joint Surg Am. 1990; 72: 238-244.

3. Rombouts JJ, Kaelin A. Inferior (obturator) dislocation of the hip in neonates. A complication of treatment by Pavlik harness. J Bone Joint Surg Br. 1992; 74 : 708-10.

4. Rajiv Merchant , Abhinav Singh, Dala-Ali B, Sanghrajka AP, Deborah M Eastwood. Principles of Bracing in early management of Developmental Dysplasia of Hip. Indian J Orthop. 2021; 55: 1417–1427.

5. Tiruveedhula M, Reading IC, Clarke NMP. Failed Pavlik harness treatment for DDH as a risk factor for avascular necrosis. J Pediatr Orthop. 2015; 35: 140–143.

6. Pool RD, Foster BK, Paterson DC. Avascular necrosis in congenital hip dislocation. The significance of splintage. J Bone Joint Surg Br. 1986; 68: 427–430.

7. Lloyd-Roberts GC, Swann M. Pitfalls in the management of congenital dislocation of the hip. J Bone Joint Surg Br. 1966; 48: 666–681.

8. Mubarak S, Steven G, Raymond V, Bert McKinnon, David Sutherland D. Pitfalls in the Use of the Pavlik Harness for Treatment of Congenital Dysplasia, Subluxation, and Dislocation of the Hip. J Bone Joint Surg. 1981; 63: 1239-1248.

9. Mendez AA, Keret D, MacEwen GD. Obturator dislocation as a complication of closed reduction of the congenitally dislocated hip: a report of two cases. J Pediatr Orthop. 1990; 10: 265-9.

10. Langkamer VG, Clarke NM, Witherow PC. omplications of splintage in congenital dislocation of the hip. Archives of Disease in Childhood. 1991, 66: 1322-1325.

11. Ramsey PL, Lasser S, MacEwen GD. Congenital dislocation of the hip. Use of the Pavlik harness in the child during the first six months of life. J Bone Joint Surg Am. 1976; 58: 1000–1004.

12. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240: 205-213.

13. Emara K, Kersh MA, Hayyawi FA. Duration of immobilization after developmental dysplasia of the hip and open reduction surgery. Int Orthop. 2019; 43: 405-409.

Ba K, Aa A, Abdel-aal MA (2022) Inferior Hip Dislocation During Treatment of Developmental Dislocation of Hip. A Rare Complication from Hip Abduction Splint. A Case Report and Review of Literatures. Ann Orthop Rheumatol 9(1): 1100

Received : 27 Oct 2022
Accepted : 12 Dec 2022
Published : 15 Dec 2022
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
TEST Journal of Dentistry
ISSN : 1234-5678
Launched : 2014
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X