Congenital hip dislocation. Congenital dislocation of the hip joint in children and adults: treatment and prevention Congenital dislocation of the hip surgical treatment up to a year

(ICD-10 code - Q65) - the most common anomaly in infants. According to statistics, this pathology mainly occurs in girls. Due to abnormal development of the hip joint, dislocation or subluxation occurs. It is possible to correct pathologies using a conservative method only in early infancy.

That is why it is very important for parents to know what the signs of this disorder are and the consequences of its complications. If there is any suspicion of a disease in a child, you should promptly seek help from an orthopedic doctor.

The hip joint consists of elements such as:

acetabulum;
femoral head;
femoral neck.

Congenital hip dislocation begins to develop during pregnancy. The baby’s joint develops incorrectly, and the femoral head is not fixed in the acetabulum, but is slightly displaced upward. Articular cartilage is not visible on an x-ray. Therefore, a dislocation can be diagnosed only after the birth of the child. With joint pathology, defects such as:

the acetabulum has an even shape, but should be in the form of a cup;
along the edge of the cavity the cartilaginous ridge is underdeveloped;
incorrect length of joint ligaments;
The angle of the femur is sharper.

All these disorders, in combination with weak muscle tissue, lead to congenital dislocation or subluxation of the hip in a newborn child. Pathology of the hip joint can develop only on one side or simultaneously on both.

Main classification

Congenital hip dislocation (ICD-10 code - Q65) refers to congenital pathologies that develop in the prenatal period. There are several different types of such violations, in particular, such as:

slight subluxation of the joint;
primary or residual subluxation of the femoral head;
anterior, lateral, high bone displacement.

In addition, doctors distinguish between several degrees of severity of the disease, namely:

dysplasia;
preluxation;
subluxation;
dislocation.

The ICD code for congenital hip dislocation or dysplasia is Q65.8. This is the initial stage of the disorder. In this case, the surfaces remain almost unchanged, however, there are certain anatomical prerequisites for the subsequent development of dislocation. Pre-luxation is characterized by the fact that the normal fit between the joints is maintained. However, the joint capsule is tense, there is displacement and excessive mobility of the femoral head.

With subluxation, the fit of the surfaces of the joint elements is disrupted, the ligament is strongly stretched, and the head of the femur is slightly displaced. Congenital dislocation of the hip (ICD-10 code - Q65) is characterized by the fact that there is a complete discrepancy between the head of the femur and the glenoid cavity.

To identify such changes, it is imperative to undergo a full diagnosis to determine the presence of pathology and subsequent treatment.

Causes

The causes of congenital hip dislocation in children have not yet been fully established. According to doctors, such a disorder can be provoked by a number of external and internal factors, in particular, such as:

severe toxicosis during pregnancy;
breech presentation of the child;
fetal developmental delay;
the fruit is too large;
previous infections during pregnancy;
poor environmental factors;
gynecological diseases;
bad habits;
premature birth;
birth injuries;
hereditary factor.

Congenital dislocation of the hips without appropriate treatment provokes the development of coxarthrosis. Such a change is accompanied by constant pain, reduces joint mobility and, as a result, leads to disability.

Main symptoms

The symptoms of congenital hip dislocation are quite specific, and if these signs are present, you can suspect this pathology in your child. In a baby under one year old and at an older age, the signs manifest themselves completely differently due to the maturation, development of the child, as well as the worsening of the pathology. Congenital hip dislocation in newborns manifests itself in the form of symptoms such as:

the presence of a characteristic click when bending the legs at the knees when spreading the hips;
asymmetry of the gluteal-femoral folds;
unimpeded movement of the femoral head;
shortening of the affected limb;
limitation of abduction of one leg or both when bending;
turning the foot outward;
displacement of the femoral head.

Congenital dislocation of the hips in children older than 12 months can be expressed in the form of such signs as:

the child begins to walk very late;
there is lameness on the affected leg;
curvature of the spine in the lower back;
the child tries to lean towards the healthy limb;
the head of the femur cannot be palpated.

If all these signs are present, you need to undergo a comprehensive diagnosis to prescribe subsequent treatment.

Diagnosis of congenital hip dislocation is based on an examination by an orthopedist, as well as instrumental examination. To confirm the presence of the disease, a consultation with a pediatric orthopedist is required. The doctor may additionally prescribe an ultrasound of the joints, and x-rays are also required.

The last diagnostic method is used only from 3 months. If until this moment the baby does not ossify the main areas, then the x-ray may show a false result.

The examination is carried out in a calm environment, 30 minutes after feeding. For a successful examination, maximum muscle relaxation is necessary. Ultrasound diagnostics is used at the age of 1-2 months. In this case, the location of the femur is assessed.

During the examination, the child is placed on his side, with his legs slightly bent at the hip joints. Based on the results of the study, the nature of the pathological changes can be determined.

In particularly difficult cases, computed tomography is used, which allows one to assess the condition of the cartilage tissue and detect changes in the joint capsule. Magnetic resonance imaging involves layer-by-layer scanning, which allows you to very clearly visualize cartilage structures and assess the nature of their changes.

Carrying out treatment

Treatment of congenital hip dislocation should begin immediately after diagnosis. Therapy is carried out using conservative and surgical methods. If the disease was not detected in early childhood, then later it only gets worse, and various complications develop that require urgent surgical intervention.

Congenital hip dislocation (ICD-10 - Q65) is a complex pathology, therefore, the most favorable period for treatment with conservative methods is considered to be the age of a child up to 3 months. However, it is worth noting that even at an older age, such methods can give quite good results.

For congenital dislocation of the hip, conservative treatment is performed in several ways or a combination of them. Mandatory procedures include therapeutic massage. It helps strengthen muscles and stabilize damaged joints.

Fixing the leg with plaster or orthopedic structures helps to fix the legs in an abducted position until the cartilage tissue on the acetabulum fully grows and the joint is stabilized. They are used for a long time. This design can only be installed and adjusted by a doctor.

Physiotherapeutic procedures are used to treat congenital hip dislocation in children, in particular, such as:

applications with ozokerite;
electrophoresis;

Physiotherapeutic techniques are used for complex treatment. If the therapy is not effective within 1-5 years, closed reduction of dislocations may be prescribed. After the procedure, a special plaster construction is applied for up to 6 months. In this case, the child’s legs are secured in an extended position. After removal of the structure, a rehabilitation course is required.

Surgery for congenital hip dislocation is prescribed in cases where conservative methods have not brought a positive result. Surgery is performed at the age of 2-3 years. The method of performing the operation is selected by the doctor, taking into account the anatomical features of the joint.

Conservative treatment

Congenital hip dislocation in newborns should be treated immediately after an accurate diagnosis has been made. For infants up to 3 months of age, doctors recommend using the wide swaddling method as therapy. The child's legs should be spread apart. To securely secure the hips with a swaddle, you need to fold the swaddle in 4 layers so that it can hold the baby's hips in the correct position.

The baby must have complete freedom of movement, otherwise he will begin to act up, thereby expressing his dissatisfaction. Very tight swaddling provokes poor circulation. For conservative treatment to be successful, certain rules must be followed, namely:

the baby's feet should be outside the mattress;
starting from 6 months, you need to teach your child to sit with his legs apart;
you need to hold it correctly in your arms so that the child’s legs cover the adult’s torso.

To eliminate congenital dislocation, various orthopedic devices are used. For infants and children up to 3 months, Pavlik stirrups are used. They consist of 2 ankle braces connected by straps.

To treat a child older than 3 months, doctors prescribe Vilensky splints. A child at the age of 6 months is put on a Volkov splint for correction. Such an orthopedic device consists of 2 plastic plates. They are attached to the hips with a cord.

Massage is an integral part of conservative therapy, but it should only be performed by a qualified specialist. The duration of treatment is generally 2 months, subject to daily procedures. Physical therapy is also required. The procedures must be repeated every day 3-4 times.

If conservative methods do not bring the required result, the doctor may prescribe surgery. Surgical methods that are used to treat congenital dislocations are divided into 3 groups, namely:

radical;
corrective;
palliative.

Radical methods include all methods of open elimination of congenital dislocation. Corrective operations mean that during surgical intervention, deviations from the norm are eliminated and the limb is lengthened. They are carried out separately or in combination with radical ones.

Palliative operations involve the use of special structures. They can be combined with other therapy methods. The surgical method is selected separately for each child, depending on the anatomical features.

It is worth noting that complications may arise. These include the process of suppuration in the area of sutures. The infection can affect nearby tissues. During the operation, the baby loses a lot of blood, and his body may react poorly to the administration of anesthesia.

Some children begin to develop osteomyelitis over time, and this can also lead to pneumonia or purulent otitis media.

Rehabilitation

The rehabilitation process is very important. Therapeutic gymnastics is used not only to normalize and restore motor skills. It allows you to return the correct shape of the affected joint. With the help of special exercises, muscles are strengthened and the abnormal position of joints is corrected.

The baby should be placed on his back, and then the straightened legs should be moved to the sides. You need to make these 5-6 movements. Pull the baby's leg towards you slightly, holding his shoulders. Circular movements of the legs will help strengthen the muscles of the newborn. While performing gymnastics, the child should lie on his back. One by one, you need to bend the child’s legs, trying to ensure that the knees touch the body.

Possible complications and prognosis

If congenital dislocation is not treated in a timely manner, you may encounter quite unpleasant consequences. They can manifest themselves in childhood and adulthood. Children with this disorder begin to walk much later.

Unilateral hip dislocation often manifests as lameness in the affected limb. Since there is a constant tilt of the body on only one side, the child develops scoliosis. This is a rather serious disease that is characterized by curvature of the spine.

As a result of the pathology, thinning and deformation of the joint is observed due to constant friction. People over 25 years of age may develop coxarthrosis. Due to malnutrition of bone tissue with prolonged pressure on the joint, dystrophic changes occur in the area of the head of the femur.

If a dislocation is not treated in a timely manner, it gradually leads to deformation of bone tissue and subsequent displacement of the position of the femoral head. Such consequences can only be treated surgically. During the operation, the surgeon replaces the head of the joint with a special metal prosthesis.

If it was possible to carry out complex treatment and eliminate the pathology in childhood, then the prognosis for full recovery is often favorable. However, many people live with a similar problem and do not even suspect that they have problems with their health. The disease very often occurs latently and does not manifest itself even with significant physical exertion.

Carrying out preventive measures

Prevention of congenital hip dislocation is carried out in several stages. Prenatal and birth prevention implies compliance by the expectant mother with such rules as:

timely examinations by a gynecologist, as well as compliance with absolutely all his instructions;
abstinence from smoking and drinking alcohol;
maintaining a healthy lifestyle;
proper nutrition;
timely consultation with a doctor in the presence of edema or high blood pressure;
correct behavior during childbirth.

During pregnancy, it is imperative to undergo ultrasound diagnostics in order to promptly determine the development of pathologies. It is also required to comply with certain rules regarding the child. It is necessary to exclude his swaddling with straight legs, as this can lead to problems, because this position of the child is unnatural. A massage is required, which includes exercises to spread the baby’s legs.

Starting from the age of two months, it is recommended to carry the child in special devices with legs apart. If there is a genetic predisposition, an ultrasound scan and observation by an orthopedic surgeon are required. Only strict compliance with all rules and requirements will prevent the development of the disease and problems in the future.

Congenital dislocation of the hip (ICD-10 - Q65) is considered a very complex disorder of the normal development of the hip joint, which must be treated immediately after identifying the problem in order to prevent the development of complications.

For many years, there was an unfair opinion that congenital hip dislocation is the result of careless actions of obstetricians when a child is born. Perhaps, in some very rare cases, dislocations also occur in maternity hospitals, but congenital dislocation is a completely different and much more serious disease. This disease is formed in utero. Due to improper development of the joint, the fetal femoral head becomes loose in the socket intended for it.

The articular cartilage is not visible on radiographs, so congenital hip dislocation can be detected only in a born baby. Therefore, it is strongly recommended that mothers, together with the doctor, carefully examine the newborn in the first days. If the baby has one leg even slightly shorter than the other, and the buttock folds are asymmetrical, if he lies unevenly and unequally moves his legs to the sides, you have every reason to be seriously concerned.

One of the first methods of prevention and treatment of congenital hip dislocation, the easiest and at the same time effective, is wide swaddling. Doctors insist that this is how babies are swaddled in maternity hospitals, including those who do not have any defects. And this is the only way mothers should swaddle their children at home until they are three months old. It's not at all difficult to do this.

If you use diapers, then on top of the diaper or under it you need to place a flannel diaper, folded in four, and secure it with a simple diaper folded in a triangle. With this method, the baby is in the “frog” position, and the femoral head takes its place in the socket. Under no circumstances, and especially if the hip is dislocated, should you swaddle your baby tightly. And don’t believe anyone if they say that without tight swaddling, the baby’s legs will become crooked - this prejudice has long been refuted by practice.

What happens when treatment for dysplasia is not started from the first days of a child’s life? The baby's skeletal system is developing, the femoral head gradually increases in size. At the same time, the idle cavity fills with connective tissue and becomes smaller, and it may very soon become extremely difficult to set the enlarging head into it. Very unfavorable secondary phenomena develop: the femoral head moves sideways or higher from the socket. When the baby moves, the “dangling” head, like a roller on asphalt, rolls along the cavity and crushes it to such an extent that this area stops growing - in the future it will have to be increased surgically.

It is strongly recommended that parents show their baby to an orthopedic surgeon as soon as possible after discharge from the hospital. Much to our chagrin, some mothers and fathers come to their senses too late and bring in babies who are already starting to walk, and it becomes noticeable that they fall heavily on one leg.

Congenital hip dislocation in newborns is often combined with another serious disease - hypertonicity of the adductor muscles. The hip does not abduct not because its head is not in the socket, but because the natural muscles are overstrained. To relieve the spasm, a very long-term treatment is carried out, in which, in addition to the orthopedist, a neurologist is also involved. Late treatment of dysplasia is very difficult and requires complete mutual understanding between the doctor and parents. It lasts for many months or even years, and the result depends on the professionalism of the one who treats the child, and on the parents’ careful compliance with all medical recommendations.

Even if it is possible to straighten the femoral head into the socket, at some stage a residual subluxation develops, because it is precisely because of the delay in treatment that the baby has not formed the correct joint. It is a huge disaster for a child if mom and dad seek help from chiropractors or any other “healers” who promise to cure congenital hip dislocation in one session. As a result of a simultaneous, sharp reduction of the dislocation, an equally sudden disturbance of blood circulation occurs and then a terrible complication develops - necrosis of the femoral head.

Therefore, parents must remember that it is impossible to cure this disease in a short time. When treatment is started very early with the help of soft diverting pads, it is sometimes possible to reduce the dislocation within three to four months. In more complex cases, Pavlik stirrups and other special devices are used for treatment. All medications should be used only as prescribed by an orthopedist, and not on the advice of friends, relatives, or acquaintances.

If treatment begins at three months of age, then no devices are prescribed, but a functional plaster cast is applied. Reduction of the dislocation under its influence occurs within one to six months. If it is impossible to reduce the dislocation using a plaster cast, they move on to the next stage of treatment - they do this under anesthesia and achieve good results. But unlike chiropractors, doctors spend a very long time preparing the child for this procedure.

In very severe cases, when all these methods are not enough, they resort to surgical intervention. Sometimes a dislocated hip becomes so rotated around its axis that a detorsion osteotomy has to be performed. This is a corrective operation and there is no need to be afraid of it. If the roof of the cavity is undeveloped, plastic surgery is performed, which is called roof plastic surgery.

Upon completion of treatment, a gentle regimen is prescribed, compliance with which depends entirely on dad and mom. First of all, it consists of complete exemption from school physical education lessons. Running, jumping, somersaults - all this is not for your baby. The following are prohibited: sports, dynamic dancing, long hikes with heavy lifting, and anything that creates excessive stress on the hip joints. Therapeutic exercises aimed at strengthening all muscle groups that surround these joints are also necessary. That is, for the gluteus maximus and medius and abdominal muscles, which are also involved in walking. It is useful to engage in swimming and cycling, but not to the point of fatigue.

Congenital hip dislocation is one of the most severe and common diseases of the musculoskeletal system in children. The problem of early detection and treatment of this disease is still very important among modern problems of pediatric orthopedics. Early treatment of congenital hip dislocation is the basis for the prevention of disability in this disease, since complete recovery can only be achieved by treating children from the first weeks of life.

The causes of this pathology are still unclear. However, there are many theories that try to explain this very important issue to one degree or another; we present some of the theories of the occurrence of congenital hip dislocation below.

Theories of congenital hip dislocation

– trauma to the pregnant uterus.

– injury to the hip joints during childbirth.

– chronic excessive pressure on the fundus of the uterus, oligohydramnios.

Pathological position of the fetus, breech presentation, extended position of the legs - Naura (1957).

- Theory of the defect of the primary anlage - Flight (8th century).

The theory of delayed development of the hip joints - T. S. Zatsepin, M. O. Friedland, Lorenz.

Congenital hip dislocation is an extreme degree of hip dysplasia. This underdevelopment affects all elements of the hip joint, both bone formations and surrounding soft tissues.

There are three degrees of severity of underdevelopment of the hip joint:

1st degree – pre-luxation, is characterized only by underdevelopment of the roof of the acetabulum (Fig. 101). In this case, the paraarticular tissues, thanks to minor changes, keep the femoral head in the correct position. Consequently, there is no displacement of the femur, the head is centered in the acetabulum.

2nd degree – subluxation. In addition to the underdevelopment of the roof of the acetabulum, an outward displacement of the femoral head (lateral position of the femur) is detected, but it does not extend beyond the limbus.

3rd degree – congenital hip dislocation. This is an extreme degree of hip dysplasia, which is characterized by the fact that the femoral head completely loses contact with the underdeveloped acetabulum. In this case, the thigh is displaced outward and upward (Fig. 102).

P atogenesis congenital hip dislocation is still poorly understood. Some researchers believe that a child is born not with a dislocation, but with a congenital inferiority of the hip joint, i.e., with a pre-dislocation. Then, under the influence of increased muscle tone and body weight, the hip may shift, forming a subluxation or dislocation. Others believe that the cause of congenital hip dislocation is a defect of the anlage, i.e. the proximal part of the femur is primarily formed outside the acetabulum. At the same time, due to the absence of a constant irritant in the cavity - the main stimulus for the normal formation of the pelvic component of the joint, the necessary conditions are created for the development of dysplasia.

Girls get sick 3-6 times more often than boys. Often the process is two-way. The left joint is affected more often than the right. In children from their first pregnancy, congenital dislocation occurs twice as often.

Clinic. The diagnosis of hip dysplasia should be made already in the maternity hospital. When first examining a child, aggravating factors in the medical history should be taken into account: heredity, breech presentation, uterine anomalies, pregnancy pathology. Then a clinical examination is carried out.

U In a newborn, the following symptoms can be identified, which are characteristic only of congenital hip dislocation:

asymmetry of skin folds on the thigh (Fig. 103). Normally, in young children, three skin folds are most often identified on the inner surface of the thigh. Some orthopedists call them adductor. With congenital dislocation of the hip, due to the existing relative shortening of the leg, there is an excess of soft tissue of the hip compared to the norm and therefore the number of folds can be increased, in addition, they can be deeper or their location is not symmetrical to the folds of a healthy leg. At the same time, parents often complain about existing diaper rash in such folds with which it is very difficult for them to “fight”. It should be noted that it is not possible to make a diagnosis based on the presence of this symptom, especially since almost 40% of healthy children can have such asymmetry of the folds on the thigh.

external rotation of the pedicle. It especially manifests itself in a child during sleep.

shortening of the leg, is associated with a displacement of the proximal part of the femur outward and upward. Therefore, it is called relative or dislocation. It should be determined by giving the position of flexion in the hip joints to an angle of 90, and in the knee joints - to an acute angle and look at the level of standing of the knee joints (Fig. 104). The knee joint of the diseased leg will be located horizontally below the healthy one. When determining this symptom, it is necessary to securely fix the child’s pelvis to the changing table. Otherwise, shortening of any leg, even a healthy one, can be detected.

flattening of the gluteal region(Pelteson's sign) is caused by this muscle group on the affected side.

-limitation of hip abduction. This symptom is revealed as follows (Fig. 105): the children’s legs are given the same position as when determining its length. From this position abduction is performed in the hip joints. Normally, when full abduction is achieved, the doctor’s hands touch the changing table, which corresponds to 80 - 85. With congenital dislocation, hip abduction will be significantly less. It should be remembered that in the first 3 months this symptom can be positive in absolutely healthy children. This is most often associated with the presence of physiological hypertonicity of the newborn’s muscles.

head slippage(click or Ortolani-Marx symptom). Identified during determination of the level of abduction in the hip joints. A click is a reliable sign of reduction for any dislocation. Congenital dislocation is no exception. The symptom is not detected in all patients and lasts only 5-7 days from the date of birth.

absence of the femoral head in the femoral triangle upon palpation, it is a very reliable sign of extreme dysplasia of the hip joint.

X-ray diagnostics. To confirm the diagnosis, an X-ray examination of the hip joints is indicated at the age of 3 months.

D To clarify the diagnosis in doubtful cases, an X-ray examination of the hip joints can be performed at any age.

Reading radiographs under the age of 3 months presents certain difficulties, because the proximal part of the femur consists almost entirely of cartilaginous, x-ray transparent tissue; the pelvic bones have not yet merged into one innominate bone. It is too difficult to achieve symmetrical styling in children. A variety of patterns and radiological features have been proposed to address these challenging diagnostic challenges.

L treatment congenital pathology , and equally, congenital dislocation of the hip is more successful the earlier it is started.

It is advisable to begin conservative treatment of hip dysplasia in the maternity hospital. The mother of the child is taught how to perform exercise therapy and how to properly swaddle the child, which should not be tight. The child's legs in the blanket should lie freely and be maximally abducted at the hip joints.

For preventive purposes, children with suspected hip dysplasia can be prescribed wide swaddling until a final diagnosis is made. It consists in laying a multi-layer flannel diaper (it is better to take two) between the legs bent and abducted at the hip joints after the diaper (diaper) with a width equal to the distance between the child’s knee joints.

P
After a diagnosis of dysplasia of varying severity has been established, the child is indicated for treatment in diverting splints (Fig. 101, 112). The essence of their treatment is that when abducted in the hip joint, the femoral head is centered in the acetabulum and is a constant irritant for the reconstruction of the underdeveloped roof of the acetabulum. The duration of the child's stay in the splint is monitored radiologically: complete deconstruction of the roof of the acetabulum on the radiograph is an indication of the end of treatment. For these purposes, many outlet busbars have been proposed.

In children older than one year, gradual reduction of the hip is used using adhesive tape. traction(Fig. 113), proposed by Sommerville and improved Mau. In this case, after applying sticky-plaster (bandage or adhesive) bandages to the legs and thighs with a system of weights through blocks, the legs are installed in the hip joints at a flexion angle of 90º, and in the knee joints - full extension at an angle of 0º. Then gradually, over 3-4 weeks, they reach a level of full abduction in the hip joints to an angle close to 90º. In this position, the position of the legs is fixed with a plaster cast (Fig. 114) for the period of complete deconstruction of the roof of the acetabulum, determined by radiographs. The average treatment period is 5-6 months.

P If treatment is unsuccessful or pathology is detected late, surgical treatment is indicated. Most often it is performed when the child reaches 3-4 years of age.

P A large number of surgical interventions have been proposed. But more often than others, based on a large clinical material, preference is given to extra-articular operations in which the adaptation mechanisms that have developed in the joint as a result of its underdevelopment are preserved, but create favorable conditions for the further life of both the joint and the patient. In childhood and adolescence, Salter's operation is preferred (Fig. 116), in adults, Khiari osteotomy

This is a dislocation of the femoral head from the acetabulum, caused by congenital inferiority of the joint. Undiagnosed in infancy, hip dislocation is manifested by lameness of the child during the first attempts to walk independently. Conservative treatment of congenital hip dislocation in children in the first 3-4 months of life is most effective. If it is ineffective or the pathology is diagnosed late, surgical interventions are performed. Lack of timely treatment for congenital hip dislocation leads to the gradual development of coxarthrosis and disability of the patient.

General information

Hip dysplasia and congenital hip dislocation are different degrees of the same pathology, resulting from disruption of the normal development of the hip joints. Congenital hip dislocation is one of the most common developmental defects. According to international researchers, this congenital pathology affects 1 in 7,000 newborns. The disease affects girls approximately 6 times more often than boys. Unilateral lesions occur 1.5-2 times more often than bilateral ones.

Hip dysplasia is a serious disease. Modern traumatology and orthopedics have accumulated quite a lot of experience in diagnosing and treating this pathology. The data obtained indicate that in the absence of timely treatment, the disease can lead to early disability. The sooner treatment begins, the better the result will be, therefore, at the slightest suspicion of congenital hip dislocation, it is necessary to show the child to an orthopedic doctor as soon as possible.

Classification

There are three degrees of dysplasia:

Hip dysplasia. The articular cavity, head and neck of the femur are changed. The normal ratio of articular surfaces is maintained.
Congenital subluxation of the hip. The articular cavity, head and neck of the femur are changed. The relationship between the articular surfaces is disturbed. The femoral head is displaced and is located near the outer edge of the hip joint.
Congenital hip dislocation. The articular cavity, head and neck of the femur are changed. The articular surfaces are separated. The head of the femur is located above the glenoid cavity and away from it.

Symptoms

The hip joints are located quite deep, covered with soft tissue and powerful muscles. Direct examination of joints is difficult, so pathology is detected mainly on the basis of indirect signs.

Clicking sign (Marx-Ortolani sign)

It is detected only in children under 2-3 months of age. The baby is placed on his back, his legs are bent, and then carefully brought together and spread apart. With an unstable hip joint, the hip dislocates and realigns, accompanied by a characteristic click.

Lead limitation

It is detected in children under one year of age. The child is placed on his back, his legs are bent, and then spread apart without effort. In a healthy child, the hip abduction angle is 80–90°. Limited abduction may indicate hip dysplasia.

It should be borne in mind that in some cases, abduction limitation is due to a natural increase in muscle tone in a healthy child. In this regard, unilateral limitation of hip abduction, which cannot be associated with changes in muscle tone, is of greater diagnostic importance.

Limb shortening

The child is placed on his back, his legs are bent and pressed to his stomach. With unilateral hip dysplasia, asymmetry in the location of the knee joints is revealed, caused by shortening of the femur on the affected side.

Asymmetry of skin folds

The child is placed first on his back and then on his stomach to examine the inguinal, gluteal and popliteal skin folds. Normally, all folds are symmetrical. Asymmetry is evidence of a congenital pathology.

External rotation of the limb

The child's foot on the affected side is turned outward. The symptom is more noticeable when the child is sleeping. It must be taken into account that external rotation of the limb can also be detected in healthy children.

Other symptoms

In children over the age of 1 year, gait disturbances (“duck gait”, lameness), insufficiency of the gluteal muscles (Duchenne-Trendelenburg sign) and a higher location of the greater trochanter are detected.

The diagnosis of this congenital pathology is made on the basis of radiography, ultrasound and MRI of the hip joint.

Complications

If the pathology is not treated at an early age, the outcome of dysplasia will be early dysplastic coxarthrosis (at the age of 25-30 years), accompanied by pain, limited joint mobility and gradually leading to disability of the patient. With untreated subluxation of the hip, lameness and pain in the joint appear already at the age of 3-5 years; with congenital dislocation of the hip, pain and lameness occur immediately after the start of walking.

Treatment of congenital hip dislocation

Conservative therapy

With timely initiation of treatment, conservative therapy is used. A special individually selected splint is used to keep the child’s legs abducted and bent at the hip and knee joints. Timely alignment of the femoral head with the acetabulum creates normal conditions for the proper development of the joint. The earlier treatment begins, the better results can be achieved.

It is best if treatment begins in the first days of the baby’s life. The start of treatment for hip dysplasia is considered timely if the child is not yet 3 months old. In all other cases, treatment is considered to be delayed. However, in certain situations, conservative therapy is quite effective when treating children over 1 year of age.

Surgical treatment

The best results in the surgical treatment of this pathology are achieved if the child was operated on before the age of 5 years. Subsequently, the older the child, the less effect can be expected from the operation.

Surgeries for congenital hip dislocation can be intra-articular or extra-articular. Children under adolescence undergo intra-articular interventions. During the operation, the acetabulum is deepened. Adolescents and adults are shown extra-articular operations, the essence of which is to create a roof of the acetabulum. Hip replacement is performed in severe and late diagnosed cases of congenital hip dislocation with severe dysfunction of the joint.

The cause of congenital hip dislocations is both endogenous and exogenous factors.

They cause deficiencies in the formation of joint elements or a delay in their development during the prenatal period, hormonal disorders, toxicosis, vitamin B2 deficiency, metabolic disorders, and heredity.

With congenital hip dislocation, joint dysplasia always occurs, namely:

acetabular fossa hypoplasia;
small size of the femoral head;
late appearance of ossification nuclei;
excessive anterior rotation of the proximal end of the femur (antetorsion);
dysplastic changes in the neuromuscular apparatus of the hip joint.

Through a small, flattened acetabulum, which is elongated in length and has an underdeveloped upper-posterior edge, which causes excessive skew of the arch (the depression resembles a triangle).

The head of the femur moves freely outward and upward - the flattening of the acetabulum increases due to the thickening of the cartilaginous layer of the bottom and the development of a “fat pad” at the bottom.

With the development of the gluteal muscles, the bent position of the fetal legs contributes to the displacement of the head upward and in this position the physiological pressure of the muscles falls on the medial surface of the head, which leads to its deformation.

The joint capsule is constantly overstretched, sometimes has an hourglass shape, the round ligament is hypoplastic or completely absent, hypoplastic muscles are on the side of the dislocation.

So, with congenital dislocation of the hip, there is a lack of all elements of the hip joint, which must be remembered when treating patients.

Symptoms

It is necessary to identify congenital hip dislocation in the maternity hospital, which indicates the need for obstetricians-gynecologists, pediatricians, and midwives to know this pathology.

In doubtful cases, it is important that newborns are examined by orthopedists.

When examining a baby, pay attention to the presence of additional folds on the medial surface of the thighs below the inguinal ligaments, their asymmetry, depth, and on the posterior surface of the pelvis - to the position of the gluteal folds, which are asymmetrical with congenital dislocation.

Early diagnosis is the key to successful treatment.

After the examination, the doctor bends the legs to a right angle at the hip and knee joints and smoothly, without jerking, performs hip extensions, which is significantly limited in case of congenital dislocation of the femur.

In contrast to physiological muscle rigidity, in newborns with congenital dislocation, the limitation of abduction is permanent and does not disappear with the development of the child.

We must remember that these symptoms are also found in hip dysplasia.

Possible symptoms for congenital dislocation of the femur are a symptom of reduction of the dislocation (clicking), or Ortolani-Marx sign, and shortening (relative) of the limb on the side of the dislocation.

When the legs are bent at the hip and knee joints, it is clearly evident that on the side of the dislocation the knee is placed lower than the other.

With high dislocations, there is significant external rotation of the limb, lateroposition of the patella up to 90°.

The Ortolani-Marx sign is a consequence of the reduction of the head into the acetabulum, and upon adduction it dislocates again with a characteristic click.

The symptom of dislocation and reduction (clicking) is long-lasting only in premature infants, and in normally developed infants it quickly disappears (within a few days), which is due to the development of tone of the gluteal and adductor muscles.

In addition, limitation of hip abduction increases over time.

The diagnosis of congenital hip dislocation can be reliably established only in the presence of absolute symptoms (reduction and dislocation, shortening of the limb).

In other cases, there is only a suspicion of dislocation, which is clarified using x-ray or sonographic examination.

Children with congenital dislocation of the hips begin to walk late. With bilateral dislocations, the child swings in both directions - duck walk; with unilateral ones - diving lameness and relative shortening of the limb.

The apex of the greater trochanter is above the Roser-Nelaton line, Briand's triangle is broken, and Schemacher's line passes below the navel.

Positive Trendelenburg sign

Normally, when a child stands on a healthy leg, bending the second limb at the hip and knee joints to an angle of 90°, no deviations of the body occur, the gluteal folds are located at the same level.

If a child with a dislocated hip is placed on his feet, and he bends the healthy leg at the hip and knee joints at an angle of 90°, he immediately bends towards the dislocation so that the head can rest against the wing of the ilium.

At this time, the healthy half of the pelvis warps, falls down, the gluteal folds turn out to be asymmetrical, on the side of the dislocation they are lower than the folds on the opposite side.

This is due not only to muscle wasting, but most importantly to the fact that when the head moves proximally along the wing of the ilium, the attachment point and the beginning of the gluteal muscles come closer, the latter lose their physiological tone and do not hold the pelvis in the correct position.

We must remember that the Trendelenburg symptom is always positive in congenital and acquired coxa vara.

With congenital dislocation of the femur, a positive Dupuytren's sign, or piston sign: if the child is placed and pressed on the straightened leg along the axis, the leg moves upward.

On the side of the dislocation there is always excessive rotational movements of the hip (Chassaignac's sign).

X-ray of the pelvis and hip joints

The procedure is carried out with the child lying on his back with straightened lower limbs without rotation or distortion of the pelvis.

On the radiograph, a horizontal line is drawn through the V-shaped cartilages.

An oblique line is drawn to it through the protruding upper edge of the arch parallel to the acetabulum.

An angle is formed, which always exceeds 30-40° during dislocations (normally it should be no more than 30°).

After this, check the distance from the center of the bottom of the acetabulum to the medial edge of the femoral head, which should be no more than 1.5 cm.

Dislocations are characterized by the placement of the tip of the proximal end of the femur (epiphysis) above the Köhler line.

With intra-articular displacements, and especially with congenital and acquired dislocations of the femur, Shenton's line is always violated.

If you draw a line along the contour of the medial edge of the femoral neck, then it normally smoothly transitions to the superomedial contour of the obturator foramen. With dislocations, Shelton's line is interrupted and passes above the superomedial contour.

J. Calvet described a radiological symptom, the essence of which is as follows.

If you draw a line along the outer contour of the recess of the ilium and continue it to the neck of the femur, then it smoothly passes along the outer contour of the neck.

Proximal displacement of the femur results in a disruption of Calvet's line. In case of dislocations, it is always interrupted.

Early radiological symptoms of congenital dislocation of the femur were described in 1927 by Bolognese orthopedist P. Putti, which entered the literature as Putti triad.

It is characterized by increased skewness of the arch of the acetabulum, displacement of the proximal end of the femur outward and upward relative to the acetabulum, and late appearance or hypoplasia of the ossification nucleus of the femoral head.

Based on X-ray data, 5 degrees of dislocation are distinguished:

I degree- the head is at the level of the acetabulum with its pronounced later position;
II degree- the head is located above the Köhler line, but does not completely extend beyond the edge of the arch - subluxation;
III degree- the head is placed above the upper edge of the arch;
IV degree- the head is covered by the shadow of the ilium wing;
V degree- the head is located on the wing of the ilium.

In recent years, Ultrasonographic examination of the hip joint, which is performed after the 2nd week of life, has become widely used.

Differential diagnosis

Congenital shortening of the femur

Congenital dislocation of the femur must be differentiated from congenital shortening of the femur.

The latter is characterized by anatomical shortening of the hip, and not relative, as with congenital dislocation.

In addition, there is a negative Ortolani-Marx sign, there is no limitation of hip abduction, fold asymmetry, violations of Briand's triangle and Schemacher's line.

Congenital coxa vara

The second congenital defect from which congenital dislocation of the femur must be differentiated is congenital coxa vara.

The latter is characterized by limited abduction of the hips and placement of the apex of the greater trochanter above the Roser-Nelaton line.

With unilateral coxa vara, there is a relative shortening of the limb, but there are no symptoms of Ortolani-Marx, Dupuytren, or asymmetry of the folds.

In older children with bilateral plow vara, as with congenital dislocation, a typical duck gait also occurs. The diagnosis is made after an X-ray examination.

Must be remembered that in the first days of life newborns often have muscle hypertonicity with limited abduction of the hips, which may suggest congenital dysplasia or dislocation of the femur.

A careful examination indicates the absence of relative and probable symptoms of dislocation, which gives grounds to prevent a diagnostic error.

In addition, as the baby develops, hypertonicity disappears and hip abduction becomes normal, but with dysplasia and dislocation, hypertonicity remains.

Deformation of the proximal end of the femur occurs due to Perthes disease and epiphysiolysis of the femoral head, which have a typical history and course of the disease. Such patients do not have diving lameness, Dupuytren's and Chassaignac's symptoms.

X-ray examination allows for a thorough differential diagnosis.

Treatment

The following stages are distinguished in the treatment of congenital dislocation of the femur:

Infants in the first 3 months of life.
Children from 3 months to 1 year.
Children from 1 to 3 years old.
Surgical treatment of children from 3 to 5 years.
Surgical treatment of adolescents and adults.

Having discovered dysplasia of the acetabular joint or congenital dislocation of the hip, wide swaddling is prescribed, and after the umbilical wound has healed, a stirrup shirt is prescribed.

Consists of two parts: shirt and stirrups.

It is sewn from soft, light white fabric (for example, madapolama) in the form of a kimono with short sleeves.

Her hems should be wrapped in front, and the bottom edge should not cover the navel (so as not to chafe the skin).

On the shirt, two loops are made on the bottom field and two at the back in the middle of the back, which are placed obliquely from the center down and out.

The stirrups consist of two pairs of strips. One pair of strips, 15 cm long and 3 cm wide, is placed on the shin below the knee joint, and the second, 35 cm long and 4 cm wide, is attached tightly along the back surface of the first pair of strips.

This pair of strips is needed to abduct the hips. Having secured them to the first pair, they are passed through the loops on the knitting needles of the shirt, and then through the loops on the floors.

Using the ties, which are sewn on the ends of the second pair of strips, the degree of abduction and flexion of the hips is adjusted. They do therapeutic exercises for the legs while swaddling the baby, aimed at eliminating drive contractures of the hips.

After two months of age it is prescribed Frejka pillow, orthopedic pants so that the angle of hip abduction constantly increases.

After 3 months of life, a control x-ray is taken to make sure there is pathology in the hip joint and apply Pavlik stirrups, which are kept until the development of the acetabular arch is completely normalized (up to 9-10 months of life).

In addition to Pavlik stirrups, Vilensky spacers, CITO splints, etc. are used.

For subluxations and dislocations of the hips up to three months of age, a stirrup shirt, a Freik pillow are also prescribed, and after a control x-ray - Pavlik stirrups, a CITO splint or a splint from the Kharkov Institute of Pathology of the Spine and Joints, which are made of duralumin and galvanized iron.

These tires are wrapped in cotton wool and covered with gauze, and then with children's oilcloth. The splints are fixed with soft flannel bandages (1 m long and 5 cm wide).

In case of subluxation and dislocation of the hip, the head must be straightened and the legs must be kept fixed with the hips bent and abducted in the hip joints at an angle of 90°, the shins in the knee joints bent at an angle of 90°.

The duration of treatment depends on the degree of dysplasia of the acetabular fossa, its arch, and the time of treatment. The average duration of treatment for subluxations and dislocations of the hip is at least 6-9 months, for subluxations - 5-6 months.

After removing stirrups or splints, children hold their legs in a position of abduction and flexion, which gradually passes over 2-3 weeks and the legs take a physiological position.

After immobilization is removed, massage and physical therapy are prescribed to restore muscle tone, and parents are not advised to allow children to walk until they are one year of age.

Lorenz technique

The classic method of treating congenital dislocation after 1 year of life is the Lorenz technique, proposed in 1894.

Reduction is carried out under anesthesia. The child lies on his back. An assistant fixes the pelvis to the table. The doctor bends the leg at the hip and knee joints to a right angle.

Places the fist of the other hand under the greater trochanter, creating a fulcrum between two levers: a short lever - the neck and a long lever - the thigh.

Then, with moderate traction, the hip abducts and reaches full abduction, at which the head is reduced into the acetabulum.

A coxite plaster cast is applied in the Lorenz-1 position: the hip is bent at an angle of 90° with full abduction and the knee joint is bent at an angle of 90°.

For bilateral dislocations, closed reduction using the Lorenz technique is done first on the side of the greater displacement of the head, and then the dislocation is reduced on the opposite side and a plaster bandage is applied for a period of 6-9 months.

After applying a plaster cast, an X-ray inspection is required. During treatment, the child undergoes several x-ray controls.

After removing the plaster immobilization, the child is kept in bed for 3-4 weeks, gradually eliminating abduction of the hips, fixed positions in the knee joints, and restoring range of motion.

But when using the Lorenz technique, a frequent complication is traumatization of the ossification nucleus of the head with the development of severe epiphysitis.

Codeville method

Therefore, the method of choice was the Codeville method - constant adhesive traction of the legs in a vertical plane with gradual retraction on a special metal arch, which is attached to the bed.

Every day the hips are separated by 1 cm; When full abduction of the hips is achieved, self-reduction of the head often occurs.

If the head cannot be reduced, the doctor places the thumbs of the hands on the greater trochanter, and places the others on the wing of the ilium and pushes the head from the bottom up, which crosses the edge of the acetabulum and is reduced into the latter.

This technique is more gentle, but it also causes epiphysitis, although much less frequently.

After the traction is removed, the limbs are fixed with abductor splints and devices for the gradual transition of the limb to a physiological position.

Prescribe massage, therapeutic exercises, vitamins and microelements. 1-2 months after removing the traction, the function of the joints is completely restored.

X-ray monitoring of the condition of the hip joint resolves the issue of activating the static load, based on the degree of degenerative manifestations in the joint.

The main treatment for dystrophic manifestations is limb unloading, balneotherapy, calcium electrophoresis, Nerobol, calcium and phosphorus preparations, vitamins (videin-3), ATP, sanatorium treatment.

A complication of the dystrophic process is the development of coxa plana followed by progressive deforming osteoarthritis.

According to Prof. Ya.B. Kutsenko, treatment of congenital hip dislocation with a functional method gives satisfactory lasting results in 70-80% of cases.

The main reason for unsatisfactory consequences is aseptic necrosis(8-9.5%), irreducibility of dislocation as a result of constriction of the joint capsule and recurrence of dislocation. Surgical treatment is necessary in 13% of patients.

Surgical treatment

If conservative treatment methods are ineffective, surgical treatment becomes the method of choice, which is used no earlier than 3-5 years of age, when it is possible to come into contact with the child for postoperative rehabilitation.

Surgical methods used to treat congenital hip dislocations are divided into three groups:

radical;
corrective;
palliative.

To radical surgical interventions include all methods and modifications of open elimination of congenital hip dislocation, as well as arthrodesis in adult patients.

Corrective operations- these are operations in which deviations from the norm of the proximal end of the femur (coxa vara, valga, antetorsia), lengthening of the limb, transposition of the site of muscle attachment, and the greater trochanter are eliminated.

Corrective surgeries can be performed separately or in combination with radical joint surgeries.

To the group of palliative operations This includes Koenig's operation (formation of a canopy over the head of the vault), Schantz, Lorenz, and Bayer osteotomies.

Palliative surgeries are sometimes used in combination with limb lengthening, i.e. corrective operations (for unilateral dislocations).

In the 50s of the XX century. Methods for treating congenital hip dislocations have been developed using pelvic osteotomy(K. Hiari, 1955; P. Pembert, 1958; R. Salter, 1960).

Pelvic osteotomies according to Chiari cause a narrowing of the pelvic ring, so they are performed mainly in boys. The best consequences for pelvic osteotomy according to Salter and acetabuloplasty according to Pembert.

Conservative treatment of adolescents and adults is not effective, that is, closed reduction of hip dislocation on one side is impossible due to the following secondary disorders of osteogenesis, namely, a small, saucer-shaped acetabular fossa.

On the other hand, an excessively oblique arch, deformation of the head and antetorsion of the femoral neck, and contraction of the pelvic girdle muscles are observed.

Therefore, the surgical method is the method of choice. Complex reconstructive operations are used, aimed at restoring anatomical and biomechanical relationships in the joint while maintaining its function.

If the relationship between the articular surfaces and the shape of the head is satisfactory, the vault is formed using reconstructions using the methods of Korzh, Toms, Koenig and Pembert, and pelvic osteotomies using the methods of Salter and Khiari.

If there is excessive antetorsion, then an additional detorsion subtrochanteric osteotomy of the femur is performed, which makes it possible not only to eliminate radical antetorsion, but also to restore the neck-shaft angle by removing a wedge from the proximal bone fragment.

Before ossification of the Y-like cartilage, deepening the acetabulum is not indicated, since a significant disruption of the formation of the acetabulum occurs.

With high iliac dislocations, it is impossible to bring the head to the acetabulum and straighten it, and if it is possible to straighten it, it becomes jammed with loss of movement and the development of aseptic necrosis.

To prevent complications, Zahradnichek suggested performing a subtrochanteric resection of a segment of the femur.

With this shortening, the head is reduced into the acetabulum without excessive force and pressure, and complications such as ankylosis and avascular necrosis do not occur.

In adult patients, open elimination of congenital dislocation of the femur occurs during the formation of the acetabulum.

Considering the fact that in adolescents and adults with high iliac dislocations, after open reduction of the dislocation of the femur, it is often not possible to obtain good functional results, palliative operations are performed - Shants osteotomy.

Its disadvantage is that after osteotomy additional shortening of the limb occurs. Therefore G.A. Ilizarov suggested applying a distraction device after the osteotomy and lengthening the limb.

This technique made it possible to obtain a statically supporting limb while maintaining movements and without shortening the limb.

Treatment of congenital hip dislocations in adolescents and adults is not a simple problem, both in terms of the complexity of the surgical intervention itself and the restoration of hip joint function.

Therefore, the main task is early detection of dislocation and initiation of treatment from the first weeks of birth.

For unreduced dislocations, early surgical treatment at the age of 3-5 years makes it possible to obtain significantly better immediate and long-term consequences.