Congenital hip dislocation in children. Hip dysplasia - symptoms and signs of pathology. Treatment of dysplasia - massage, gymnastics, exercises. Causes of congenital dislocation of the hip

For many years there was an unfair opinion that congenital dislocation of the hip is the result of careless actions of obstetricians when a child is born. Perhaps, in some very rare cases, dislocations 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 femoral head of the fetus is loose in the cavity intended for it.

On radiographs, the articular cartilages are not visible, therefore, congenital dislocation of the hip can only be detected in a born baby. Therefore, it is strongly recommended that mothers in the first days, together with the doctor, carefully examine the newborn. If the baby has one leg at least a little shorter than the other, and the gluteal folds are asymmetrical, if he somehow lies unevenly and takes the legs to the sides unevenly, you have every reason for serious concern.

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 only in this way mothers should swaddle children at home until the age of three months. Doing this is not difficult at all.

If you use diapers, then on top of or under the diaper you need to lay a flannel diaper folded four times and fix 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 cavity. In no case, and even more so if the hip is dislocated, should the child be swaddled tightly. And do not believe anyone if they say that without tight swaddling, the child's legs will become crooked - this prejudice has long been refuted by practice.

What happens when the treatment of dysplasia is not started from the first days of a child's life? The baby's skeletal system develops, the femoral head gradually increases in size. At the same time, the non-working cavity is filled with connective tissue and becomes smaller, and it can be extremely difficult to set the enlarging head into it very soon. Very unfavorable secondary phenomena develop: the femoral head is displaced laterally or higher from the cavity. The “dangling” head during the movements of the baby, like a skating rink 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.

Parents are strongly advised to show the baby to an orthopedic surgeon as soon as possible after discharge from the hospital. To our great chagrin, some mothers and fathers wake up late and bring babies who are already starting to walk, and it becomes noticeable that they fall heavily on one leg.

Congenital dislocation of the hip in newborns is often combined with another serious disease - hypertonicity of the adductor muscles. The thigh is not retracted, not because its head is not in the cavity, but because of the overstrain of the natural muscles. To relieve spasm, a very long treatment is carried out, in which, in addition to an orthopedist, a neuropathologist also participates. Late treatment of dysplasia is very difficult and requires full understanding of 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 careful observance of all medical recommendations by the parents.

Even if it is possible to set the femoral head into the cavity, then at some stage a residual subluxation develops, because it was precisely because of the delay in treatment that the baby did not form the correct joint. A huge disaster for a child if mom and dad turn to chiropractors or some other “healers” for help, promising to cure congenital hip dislocation in one session. As a result of a simultaneous, sharp reduction of the dislocation, an equally sudden violation of blood circulation occurs and then a formidable complication develops - necrosis of the femoral head.

Therefore, parents should remember that it is impossible to cure this disease in a short time. With very early treatment with soft abduction pads, it is sometimes possible to reduce the dislocation in three to four months. In more complex cases, Pavlik's stirrups and other special devices are used for treatment. All remedies should be used only as prescribed by the orthopedist, and not on the advice of friends, relatives, friends.

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

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

Upon completion of treatment, a sparing regimen is prescribed, the observance of which depends entirely on the father and mother. First of all, it consists in a complete exemption from school physical education lessons. Running, jumping, somersaults - all this is not for your baby. Under the ban are: sports, dynamic dances, long hikes with weight lifting, and everything that creates an excessive load on the hip joints. Also needed are therapeutic exercises aimed at strengthening all the muscle groups that surround these joints. That is, for large and medium gluteal muscles and abdominal muscles, which are also involved in walking. It is useful to engage in swimming, cycling, but not to the point of fatigue.

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Congenital dislocation of the hip or, in other words, hip dysplasia, is the most common congenital anomaly in infants. Statistics say that, on average, in three to four cases per 1000 newborn babies, this pathology is detected, and the disease affects girls about six times more often than male babies.

Due to the abnormal development of the elements of the hip joint, a dislocation (complete separation of the articular surfaces of the bones) or subluxation (partial separation of the articular surfaces of the bones) appears, which can be corrected by conservative methods of treatment only in early infancy - usually up to six months. Therefore, it is important for young parents to know the main symptoms of pathology and the consequences of the development of its complications. If there is any suspicion of a baby’s disease, they should seek professional help from an orthopedic doctor in a timely manner.

The hip joint has the following elements: the articular (acetabular) cavity, the femoral head and the femoral neck. The acetabulum is cup-shaped, inside it is covered with cartilaginous tissue (roller) and filled with joint fluid. The femoral head has a similar external cartilaginous covering, and is additionally connected by ligaments to the articular cavity. The spherical shape of the head allows it to hold securely in the acetabulum, makes it possible to move the joint in different directions.

Congenital manifests itself in the following defects in the development of articular elements:

violation of the required dimensions of the articular cavity or deformation of the cartilage roller, as a result of which the cavity does not have the appropriate shape in order to hold the femoral head;
incorrect angle of inclination of the head in relation to the neck of the femur (“antetorsion angle”);
defect in the development of the ligaments of the joint (excessive elasticity).

The above pathologies in combination with weak muscle tissue favor the occurrence of congenital dislocation or subluxation of the hip in newborns. Pathology of the hip joint can develop on one side or simultaneously on both.

The reasons

The root causes of the abnormal development of the constituent elements of the hip joint have not been investigated or established. Congenital hip dislocation, according to clinicians, can be triggered by a number of external and internal factors, such as:

severe toxicosis (preeclampsia) of a pregnant woman;
the position of the child's body in the womb does not correspond to the norm, for example, there is a breech presentation;
large fruit;
the expectant mother is under the age of 18;
previously transferred infectious diseases of a pregnant woman;
retardation of the fetus in development;
unfavorable environmental conditions for bearing a baby (radiation, emissions of harmful substances into the air, water pollution, etc.);
bad habits;
gynecological diseases that limit the movement of the child in the process of intrauterine development (adhesions, fibroids);
premature birth;
injuries received by the child during childbirth;
genetic propensity to inherit pathology, when one of the parents was diagnosed with "congenital subluxation (dislocation) of the hip."

Dislocation of the femoral head without appropriate treatment provokes the development of dysplastic coxarthrosis. Such a change is accompanied by constant pain, reduces the mobility of the joint and ultimately leads to disability.

Degrees of dysplasia

Congenital dislocation of the hip has several degrees of severity of the course of the disease:

dysplasia - the surfaces remain congruent, however, there are obvious anatomical prerequisites for the development of dislocation;
pre-dislocation - normal fit between the articular elements is maintained, however, the joint capsule is stretched, there is displacement and excessive mobility of the femoral head inside the joint;
subluxation - the adhesion of the surfaces of the joint elements is disturbed, the ligament is significantly stretched, the femoral head is displaced;
dislocation - there is an absolute discrepancy between the femoral head and the articular cavity, the femoral head is outside the joint, the articular capsule is significantly tense and stretched.

To detect such changes in a child in the first months of his life, an ultrasonographic diagnostic method is used, and after four months from the date of birth of the baby, an x-ray examination is used.

Symptoms of the disease

Congenital dislocation of the hip has a number of non-specific symptoms, in the presence of which one can suspect a pathology in a child. At the age of up to a year and after a year, the symptoms manifest themselves differently due to growing up, the development of the child, and the aggravation of an undiagnosed pathology.

Congenital dislocation of the hip manifests itself in newborns from 0 to 12 months in the form of the following signs:

a symptom of Marx-Ortolani, which manifests itself in children under the age of three months in the form of a characteristic click (there is a free exit of the femoral head from the articular cavity) when the legs are bent at the knees and the hips are spread;
asymmetry of the gluteal-femoral skin folds;
Dupuytren's symptom, in which there is an unhindered movement of the femoral head up and down;
the baby has a shortening of the affected limb;
turning outward of the foot of a child with advanced pathology, usually occurs during sleep, but this symptom can also be in healthy children;
limited abduction of both legs or one leg when flexed (the angle of hip abduction is less than 80-90 degrees);
Barlow's symptom, in which, as a result of flexion of the leg in the thigh, a displacement of the femoral head is manifested.

Congenital dislocation of the hip in children older than 12 months is expressed in the form of the following symptoms:

the child begins to walk late - usually after a year;
in the presence of a unilateral dislocation, lameness on the sore leg appears, with a bilateral anomaly in the development of the hip joints, the child is characterized by a “duck gait”;
there is a curvature of the spine in the lower back;
standing on a sore leg, the child leans towards a healthy limb, and his pelvis leans towards the other (Duchen-Trendelenburg symptom);
the head of the femur is not palpable in the region of the hip joint.

In the presence of the above signs, an accurate diagnosis and further treatment for the child are established by an orthopedic doctor based on the results of examinations conducted using an x-ray (after 3 months of age), ultrasound or MRI of the hip joint.

Methods of treatment

Congenital dislocation of the hip should be treated immediately after diagnosis.

Treatment of congenital dislocation of the hip is carried out by conservative and surgical methods. If the disease is not detected at an early age, then in the future it is aggravated, complications arise that require surgical intervention. The most favorable period for the treatment of dysplasia by conservative methods is the age of the child up to 3 months, if the diagnosis is made later, then the treatment is considered late. However, even at the age of over 3 months, a number of conservative treatment methods give good results.

With congenital dislocation of the hip, conservative treatment is carried out in several ways or a combination of these methods.

Therapeutic massage is a mandatory procedure for dysplasia, it allows you to strengthen muscles, as well as stabilize and straighten the damaged joint.

Fixation of the legs with the help of plaster or orthopedic structures is performed for a long period of time, it allows you to fix the legs in a divorced position until the cartilage tissue grows on the acetabulum and all the constituent elements of the joint are stabilized. Designs are installed and regulated only by the attending physician. Examples of orthopedic structures are Pavlik's splint, Freik's splint, Vilensky's splint.

Physiotherapeutic procedures, such as electrophoresis, applications with ozocerite, UVI, are used in the complex treatment of dysplasia.

In the absence of effectiveness from the use of the above conservative methods of treatment, at the age of one to five years, a closed reduction of the dislocation is sometimes prescribed. After the procedure, a fixing gypsum structure is applied for up to six months, while the child's legs are fixed in a divorced position. After the removal of the structure, rehabilitation is carried out.

The operation is prescribed for congenital dislocation of the hip in cases where conservative methods have not yielded positive results. The appropriate age for the operation is 2-3 years. Surgical treatment is performed in several ways:

open arthroplastic reduction of congenital hip dislocation;
arthroplasty, or joint replacement;
reconstruction of the ilium and femur, the joint capsule is not opened;
a combination of the above treatment methods.

The method of surgical treatment is chosen by the doctor, taking into account the anatomical modifications of the joint.

Prevention

Prevention of congenital dislocation of the hip is carried out in several stages.

Prenatal (antenatal) and intranatal (birth) prevention involves the observance of the following rules by the expectant mother:

timely passage of periodic examinations by a gynecologist-obstetrician, the fulfillment of his prescriptions and appointments (passing an ultrasound of the fetus, passing tests, taking medications) to prevent the development and timely diagnosis of malformations in the fetus;
abstinence from smoking and drinking alcohol;
adherence to a healthy lifestyle (daily walks, doing gymnastics for pregnant women, sufficient sleep);
application of the principles of proper nutrition (fractional consumption of food; the diet should include a balanced diet rich in fiber and protein - dairy and meat products, fresh vegetables, herbs and fruits; it is necessary to exclude the use of fried, spicy, salty, canned, fatty foods);
timely access to a doctor in case of signs of preeclampsia (high blood pressure, swelling);
proper behavior during childbirth (following the doctor's instructions).

Postnatal prophylaxis involves the observance of the following rules by the mother in relation to a newborn child:

the exclusion of swaddling a baby with even legs, which can cause development, since this position of the baby's legs is unnatural;
wide free swaddling, preserving the physiological position of the baby's legs;
therapeutic and prophylactic massage, including exercises for breeding the legs of a newborn;
carrying a child with legs apart in "kangaroo" devices, starting from the age of 2 months, and excluding vertical load on children's legs until permission is obtained from a doctor to perform such actions;
in the presence of a genetic predisposition, a quarterly passage and observation by an orthopedic doctor is required.

Timely prevention, early diagnosis and treatment of the identified pathology contribute to a favorable outcome for the health of the child.

Congenital dislocation of the hip 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 the modern tasks 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 not clear. However, there are many theories that try to explain this very important issue to one degree or another, some of the theories of the occurrence of congenital hip dislocation are given below.

Theories of the occurrence of congenital dislocation of the hip

Traumatic theory of Hippocrates and A. Pare - trauma of the pregnant uterus.

Phelps' traumatic theory - trauma to the hip joints during childbirth.

The mechanical theory of Ludlof, Shants - chronic excessive pressure on the fundus of the uterus, oligohydramnios.

Pathological position of the fetus - Schneiderov (1934), breech presentation, extended position of the legs - Naura (1957).

The Pathological Theory of Pravitz (1837).

The theory of muscle imbalance - R.R. Vreden (1936).

The theory of the defect of the primary bookmark - Flight (VIII century).

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

Viral theory of Radulescu.

Teratogenic effect of endogenous, physical, chemical, biological and psychogenic factors.

Dysplasia of the nervous system - R. A. Shamburov (1961).

Hereditary theory - Ambroise Pare (1678), T. S. Zatsepin, Schwantz, Fishkin.

Congenital hip dislocation is an extreme degree of hip dysplasia. This underdevelopment captures 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 – predislocation, is characterized only by underdevelopment of the roof of the acetabulum (Fig. 101). Paraarticular tissues at the same time, due to minor changes, keep the femoral head in the correct position. Therefore, there is no displacement of the femur, the head is centered in the acetabulum.

2nd degree – subluxation. At the same time, in addition to the underdevelopment of the roof of the acetabulum, an outward displacement of the femoral head (lateroposition of the femur) is detected, but it does not go beyond the limbus.

3rd degree – congenital dislocation of the hip. 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 outwards and upwards (Fig. 102).

P athogenesis congenital dislocation of the hip is still little studied. Some researchers believe that a child is born not with a dislocation, but with a congenital inferiority of the hip joint, that is, with a predislocation. Then, under the influence of an increase in muscle tone, body weight, a displacement of the hip can occur, forming a subluxation or dislocation. Others believe that the cause of congenital dislocation of the hip is a defect in the anlage, i.e. the proximal part of the thigh is primarily laid outside the acetabulum. At the same time, due to the absence of a constant stimulus 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.

Hip dysplasia occurs in 16-21 cases per 1000 newborns, and III-I st. - in 5-7 cases per 1000. In Europe, this disease occurs 13 times more often than in America. And in the countries of Africa and Indochina - it is practically absent.

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

Clinic. The diagnosis of hip dysplasia should be made already in the maternity hospital. At the first examination of the child, one should take into account the aggravating factors of the anamnesis: heredity, breech presentation, abnormalities of the uterus, pathology of pregnancy. Then a clinical examination is carried out.

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

In a child older than one year, the diagnosis is more easily based on the following symptoms:

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

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 thigh consists almost entirely of cartilaginous, x-ray transparent tissue, the pelvic bones have not yet merged into one innominate bone. In children, it is too difficult to achieve symmetrical styling. To solve these complex diagnostic problems, many schemes and radiological signs have been proposed.

Putti established 3 main radiological signs of congenital hip dislocation:

excessive slope of the roof of the acetabulum;

displacement of the proximal end of the thigh outward-upward;

late appearance of the nucleus of ossification of the femoral head (normally, it appears at 3.5 months).

Hilgenreiner proposed a scheme for reading a child's radiograph to identify congenital pathology of the hip joint, shown in Fig. 110. For its construction it is necessary:

Draw the axial horizontal line of Koehler through the Y-shaped cartilages (located at the bottom of the acetabulum);

Lower the perpendicular from this line to the visible most protruding part of the thigh - height h(normally equal to 10 mm.);

from the bottom of the acetabulum, draw a tangent line to the most prominent part of the roof of the acetabulum. Thus, an acetabular angle (index) is formed -  . Normally, it is 26º-28.5º.

Determine the distance d- distance from the top of the acetabular angle to the perpendicular h on the Koehler line. Normally, it is 10-12 mm.

For various degrees of severity of hip dysplasia, the parameters of the Hilgenreiner scheme will be as follows:

AT the age of appearance on the radiograph of the contour of the nucleus of ossification of the femoral head (3.5 months) is used Ombredan scheme(Fig. 111). To do this, three lines are drawn on the radiograph: - the axial line of Koehler, as in the Hilgenreiner scheme and two perpendiculars to the right and left) from the most protruding point of the roof of the acetabulum to the Koehler line. In this case, each hip joint is divided into 4 quadrants. Normally, the ossification nucleus is located in the lower inner quadrant. Any displacement of the ossification nucleus to another quadrant indicates an existing displacement of the femur.

In older children and adults, attention is paid to the passage Shenton lines and the Calvet line. Shenton's line (Fig. 111a) normally passes from the upper semicircle of the obturator foramen and smoothly passes to the lower contour of the femoral neck, and in case of dislocation, the arcuate line is absent, because a ledge appears due to the higher location of the lower contour of the femoral neck. Line Calvet (Fig. 111b) - a regular arc, smoothly passing from the outer contour of the wing of the ilium to the proximal part of the thigh. With a dislocation, this arc is interrupted due to the high standing of the hip.

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

Conservative treatment of hip dysplasia is desirable to start in the hospital. The mother of the child is taught to conduct exercise therapy, the correct swaddling of the child, which should not be tight. The legs of the child in the blanket should lie freely and maximally retracted in the hip joints.

For prophylactic purposes, and children with suspected hip dysplasia, before the final diagnosis, you can assign wide swaddling. It consists in the fact that between the legs bent and retracted in the hip joints, after the diaper (diaper), a multilayer flannel diaper is laid (it is better to take two) in a width equal to the distance between the knee joints of the child.

P
After establishing the diagnosis of dysplasia of varying severity, the child is shown treatment in diverting splints (Fig. 101, 112). The essence of treatment in them lies in the fact that when abducted in the hip joint, the femoral head is centered in the acetabulum and is a constant irritant for rebuilding the underdeveloped roof of the cavity. The duration of the child's stay in the tavern is controlled radiographically: complete rebuilding of the roof of the acetabulum on the radiograph is an indication of the end of treatment. For these purposes, a variety of outlet tires have been proposed.

In children older than one year, a gradual reduction of the hip is applied using an adhesive plaster. traction(Fig. 113), proposed by Sommerville and improved Mau. At the same time, after applying adhesive plaster (bandage or adhesive) bandages to the lower leg and thigh with a system of weights through blocks, the legs are installed in the hip joints at a 90º flexion angle, and in the knee joints - full extension at an angle of 0º. Then gradually, within 3-4 weeks, they reach the level of full abduction in the hip joints up 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 rebuilding of the roof of the acetabulum, determined by the radiograph. The average duration of treatment is 5-6 months.

P In case of failure of treatment or late detection of pathology, surgical treatment is indicated. Most often it is done when the child reaches 3-4 years of age.

P a large number of surgical interventions have been proposed. But more often than others, on the basis of a large clinical material, preference is given to extra-articular operations in which the adaptive 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, preference is given to the Salter operation (Fig. 116), in adults Chiari osteotomy (Fig. 115) and other arthroplastic operations developed by A. M. Sokolovsky.

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

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

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

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

Through a shallow, flattened acetabular fossa, which is elongated and has an underdeveloped upper-posterior edge, which causes an excessive distortion of the arch (the depression resembles a triangle).

The head of the femur freely moves 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 upward displacement of the head, 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 absent altogether, hypoplastic muscles 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 knowledge of this pathology by obstetricians, gynecologists, pediatricians, midwives.

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

When examining an infant, attention is paid 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 asymmetric in congenital dislocation.

Early diagnosis is the key to successful treatment.

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

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

Gotta remember that these symptoms are also found in hip dysplasia.

Probable symptoms in congenital dislocation of the femur are a symptom of the reduction of the dislocation (click), or symptom of Ortolani-Marx, and shortening (relative) of the limb on the side of dislocation.

With bent legs in the hip and knee joints, it is clearly manifested that on the side of the dislocation, the knee is placed below the other.

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

The Ortolani-Marx symptom is a consequence of the head being repositioned into the acetabulum, and when adducted, it dislocates again with a characteristic click.

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

In addition, over time, the restriction of hip abduction increases.

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

In other cases, there is only a suspicion of dislocation, which is clarified with the help of X-ray or sonographic examination.

Children with congenital hip dislocation start walking late. With bilateral dislocations, the child sways in both directions - duck walk; with unilateral - diving lameness and relative shortening of the limb.

The tip of the greater trochanter is above the Roser-Nelaton line, the Briand triangle is violated, and the Schemacher line passes below the navel.

Positive Trendelenburg sign

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

If a child with a dislocated hip is put on his feet, and he bends his healthy leg at the hip and knee joints at an angle of 90 °, then he immediately leans 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, goes down, the gluteal folds are asymmetrical, on the side of the dislocation they are lower than the folds on the opposite side.

This is due not only to muscle hypotrophy, but most importantly, when the head is displaced proximally along the iliac wing, the attachment site and the beginning of the gluteal muscles approach each other, the latter lose their physiological tone and do not hold the pelvis in the correct position.

Gotta remember that Trendelenburg's symptom is always positive in congenital and acquired coxa vara.

With congenital dislocation of the femur, a positive Dupuytren's symptom, or a symptom of a piston: if the child is placed and pressed on the extended leg along the axis, then the leg moves up.

On the side of the dislocation there is always excessive rotational movement of the hip (Chassegnac symptom).

Radiography of the pelvis and hip joints

The procedure is performed in the position of the child lying on his back with extended lower limbs without rotation and distortion of the pelvis.

On the x-ray, 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 acetabular fossa.

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

After that, the distance from the center of the bottom of the acetabulum to the medial edge of the femoral head is checked, 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 Koehler line.

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

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

J. Calve described an X-ray symptom, the essence of which is as follows.

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

Displacement of the femur proximally leads to a rupture of the Calvet line. When dislocated, it is always interrupted.

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

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

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

I degree- head at the level of the acetabular fossa with its pronounced lateroposition;
II degree- the head is located above the Koehler line, but does not completely go beyond the edge of the arch - subluxation;
III degree- the head is located above the upper edge of the arch;
IV degree- the head is covered by the shadow of the iliac wing;
V degree- the head is located on the wing of the ilium.

In recent years, ultrasonographic examination of the hip joint, which is carried out after the 2nd week of life, has been widely used.

Differential Diagnosis

Congenital shortening of the hip

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 in congenital dislocation.

In addition, there is a negative symptom of Ortolani-Marx, there is no restriction of hip abduction, asymmetry of the folds, violations of the Briand's triangle and Schemacher's line.

Congenital coxa vara

The second congenital defect, from which it is necessary to differentiate congenital dislocation of the femur, is congenital coxa vara.

The latter is characterized by limited abduction of the hips, placement of the tip 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 established after X-ray examination.

Need to remember that newborns in the first days of life often have muscle hypertonicity with limited hip abduction, which may lead to the idea of congenital dysplasia or dislocation of the femur.

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

In addition, with the development of the baby, hypertonicity disappears and hip abduction becomes normal, while hypertonicity persists with dysplasia and dislocation.

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

X-ray examination allows a thorough differential diagnosis.

Treatment

In the treatment of congenital dislocation of the femur, the following stages are distinguished:

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 found dysplasia of the acetabular joint or congenital dislocation of the hip, a wide swaddling is prescribed, and after the healing of the umbilical wound, a stirrup shirt.

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.

Its floors should be wrapped in front, and the lower edge should not cover the navel (so as not to rub the skin).

On the shirt, two loops are made in the lower field and two in 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 lower leg 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 fixed them on the first pair, they are passed through the loops on the knitting needles of the shirt, and then through the loops on the floors.

With the help of ties, which are sewn on the ends of the second pair of strips, they regulate the degree of retraction and flexion of the hips. They do therapeutic exercises for the legs while swaddling the baby, aimed at eliminating the drive contractures of the hips.

After two months of age, appoint frejka pillow, orthopedic pants in such a way that the angle of hip abduction is constantly increasing.

After 3 months of life, a control radiography is done, they are convinced of the presence of pathology in the hip joint and impose Pavlik's stirrups, which are kept until the development of the arch of the acetabular fossa is completely normalized (up to 9-10 months of life).

In addition to Pavlik's stirrups, they use Vilensky spacers, the CITO tire, etc.

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

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

In case of subluxations and dislocations of the hip, the head must be adjusted and the legs kept fixed with the hips bent and abducted in the hip joints at an angle of 90 °, the lower leg 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, the time of initiation 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 the stirrups or tires, the children hold the legs in the position of abduction and flexion, which gradually disappears within 2-3 weeks and the legs take up a physiological position.

After immobilization is removed, massage, physiotherapy exercises are prescribed to restore muscle tone, and until the age of one, parents are not advised to allow children to walk.

Lorenz technique

The classic treatment for congenital dislocation after 1 year of life is the Lorentz technique, proposed in 1894.

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

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

Then, with moderate traction, it abducts the thigh and reaches full retraction, at which the head is set into the acetabulum.

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

With bilateral dislocations, a closed reduction according to the Lorentz method is first done on the side of the greater displacement of the head, and then the dislocation is reduced on the opposite side and a plaster coxite bandage is applied for a period of 6-9 months.

Necessarily after the imposition of a plaster bandage, X-ray control is carried out. During treatment, the child is given several x-ray controls.

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

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

Codeville method

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

Every day, the hips are bred by 1 cm; when full abduction of the hips is reached, self-adjustment of the head often occurs.

If the head is not reduced, the doctor places the thumbs of the hands on the greater trochanter, and puts the others on the wing of the ilium and pushes the head upward, which crosses the edge of the acetabular fossa and is reduced into the latter.

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

After removing the traction, the limbs are fixed with abducting splints, devices for the gradual transition of the limb to the physiological position.

Assign massage, therapeutic exercises, vitamins with trace elements. In 1-2 months after the removal of traction, the function of the joints is completely restored.

X-ray control of the state of the hip joint solves the issue of activating the static load, based on the degree of dystrophic 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, spa treatment.

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

According to prof. I WOULD. Kutsenko, the treatment of congenital hip dislocation by a functional method gives satisfactory stable consequences in 70-80% of cases.

The main reason for the unsatisfactory results 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

In case of ineffectiveness of conservative methods of treatment, the surgical method becomes the method of choice, which is used no earlier than 3-5 years of age, when it is possible to make contact with the child for postoperative rehabilitation.

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

radical;
corrective;
palliative.

to radical surgery include all methods and modifications of the 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), limb lengthening, transposition of the muscle attachment site, greater trochanter are eliminated.

Corrective surgery can be performed alone or in combination with radical joint surgery.

To the group of palliative operations Koenig's operation (the formation of a canopy over the head of the fornix), osteotomies of Shantz, Lorenz, Bayer.

Palliative surgery is sometimes used in combination with limb lengthening, ie. corrective operations (for unilateral dislocations).

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

Chiari pelvic osteotomies cause narrowing of the pelvic ring, so they are performed mainly in boys. Better outcomes with Salter pelvic osteotomy and Pembert acetabuloplasty.

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 osteogenesis disorders, namely, a small, saucer-shaped acetabular fossa.

On the other hand, too oblique vault, deformity of the head and antetorsion of the femoral neck, contraction of the muscles of the pelvic girdle are observed.

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

With a satisfactory ratio of the articular surfaces and the shape of the head, a vault is formed using reconstructions according to the methods of Korzh, Toms, Koenig and Pembert, osteotomies of the pelvis according to the methods of Salter, Hiari.

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 cervical-diaphyseal angle by removing the wedge from the proximal bone fragment.

Before ossification of the Y-like cartilage, deepening of the acetabular fossa is not indicated, since there is a significant violation of the formation of the acetabular fossa.

With high or acicular dislocations, it is impossible to bring the head to the acetabular fossa and set it, and if it is possible to set it, then it jams with loss of movement, the development of aseptic necrosis.

To prevent complications, Zahradnicek suggested doing a subtrochanteric resection of a segment of the femur.

With such a shortening, the head is reduced into the acetabular fossa without excessive effort and pressure, and complications such as ankylosis, aseptic necrosis do not occur.

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

Given the fact that in adolescents and adults with high or acicular dislocations after open reductions 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 there is an additional shortening of the limb. Therefore, G.A. Ilizarov proposed to apply a distraction apparatus after osteotomy and lengthen the limb.

This technique made it possible to obtain a statically supporting limb with the preservation of movements and the absence of shortening of the limb.

The treatment of congenital hip dislocations in adolescents and adults is not an easy problem, both in terms of the complexity of the surgical intervention itself and the restoration of the function of the hip joint.

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

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

Theories of the occurrence of congenital dislocation of the hip

- trauma of the pregnant uterus.

- trauma of 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).

- The theory of the defect of the primary bookmark - Flight (VIII 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 captures 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:

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

asymmetry of skin folds on the thigh (Fig. 103). Normally, in young children, three skin folds are most often determined on the inner surface of the thigh. Some orthopedists call them adductors. With congenital dislocation of the hip due to the existing relative shortening of the leg, there is an excess of soft tissues of the thigh in comparison with 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 the 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 leg. Especially manifested in a child during sleep.

leg shortening, associated with the displacement of the proximal part of the thigh 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 in the horizontal level will be located 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(sign of Pelteson) is due to this group of muscles on the affected side.

-restriction of hip abduction. This symptom is revealed as follows (Fig. 105): the legs of the children are given the same position as in determining its length. From this position produce abduction in the hip joints. Normally, when full abduction is reached, 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 muscles of the newborn.

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

absence of the femoral head in the femoral triangle on palpation is a very reliable sign of an extreme degree of hip dysplasia.

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

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

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

P In case of failure of treatment or late detection of pathology, surgical treatment is indicated. Most often it is done when the child reaches 3-4 years of age.