Congenital hip dislocation in children. Congenital Hip Dislocation: Causes, Symptoms and Treatment Treatment of Congenital Hip Dislocation in the First Year

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Hip dysplasia (DTS, or congenital hip dislocation) is a pathology of the development of the musculoskeletal system in newborns, which is manifested by a violation of the structure of all elements of the hip joint.

This defect provokes a dislocation of the femoral head during fetal development or immediately after birth.

Hip dysplasia in children under one year old is a common pathology, which is diagnosed in 4% of cases. It is important to identify the disease in time and carry out competent treatment.

Otherwise, only surgery will help. In addition, if the problem is ignored, dangerous complications arise that threaten disability.

Congenital dislocation of the hip joint in children and newborns

To understand what pathology is, it is necessary to delve into the anatomy of the hip joint. It consists of the acetabulum of the pelvic bone, which is adjacent to the head of the femur. The acetabulum is a cup-shaped depression in the ilium.

From the inside, the acetabular recess is lined with hyaline cartilage and fatty tissue. The cartilaginous rim also covers the head of the femur. A ligament at the top of the femoral head connects it to the acetabulum and is responsible for nutrition. The joint capsule, muscles and extra-articular ligaments strengthen the joint from above.

All of the above structures guarantee a secure fixation of the femoral head in the acetabulum. And thanks to the spherical structure, the joint can move in different directions.

With improper development of the joint, all these structures are defective, as a result, the head is not securely attached to the acetabular recess and dislocation occurs.

In most cases, dysplasia is manifested by the following anatomical defects:

• Wrong size or shape (flattening) of the glenoid cavity;
• Underdevelopment of cartilaginous tissue along the edge of the acetabular recess;
• Pathological angle between the head and neck of the femur;
• Joint ligaments are weak or too long.

All of the above anatomical defects with poorly developed muscles in a newborn provoke hip dislocation.

Causes of congenital dislocation of the hip

Orthopedists have not yet determined the exact causes of joint dysplasia. However, there are several versions:

• The influence of relaxin. This hormone is produced in the female body before childbirth. Thanks to him, the ligaments soften so that the fetus leaves the pelvis. Relaxin enters the child's bloodstream, affects his hip joint, the ligaments of which are stretched. Women are more susceptible to the effects of this hormone, for this reason girls suffer from dysplasia more often than boys;
• breech presentation. If the fetus is in this position for a long time, then its hip joint is subjected to strong pressure. Blood circulation in the pelvis worsens, the development of the structural components of the joint is disrupted. In addition, the joint can be damaged during childbirth;
• Insufficient amount of amniotic fluid. If in the early stages the volume of amniotic fluid is less than 1 liter, then the movement of the child becomes difficult and the likelihood of malformations of the musculoskeletal system increases;
• Toxicosis. The hormonal, digestive and nervous systems are rebuilt, pregnancy is complicated, as a result, the development of the fetus is disturbed;
• Fetal weight from 4 kg and above. In this case, the hip joint may be damaged during the passage of the child through the narrow birth canal;
• Early pregnancy. In a woman who gives birth for the first time before the age of 18, the concentration of relaxin is the highest;
• late pregnancy. Women over 35 are more likely to suffer from chronic diseases, pelvic circulation disorders, and toxicosis;
• Infections. If a pregnant woman has had an infectious disease, then the risk of fetal developmental disorders increases;
• Thyroid pathologies. Diseases of the thyroid gland disrupt the development of joints in a child;
• genetic predisposition. If close relatives were diagnosed with hip dysplasia, then the likelihood of developing a pathology in a child increases;
• External influence. If a pregnant woman is exposed to radioactive radiation, takes medications or drinks alcohol, then the development of the joints in the fetus is disturbed.

If at least one of these factors is present, then the newborn should be examined by an orthopedist.

Symptoms and degrees of congenital dislocation of the hip

Hip dysplasia can be identified by the following signs and symptoms:

• Different leg lengths. To determine this parameter, the child's legs are bent at the knees, and the heels are pressed against the buttocks. If the knees are at different levels, then the length of the legs is different;
• Asymmetric skin folds on the lower body. In a healthy child, skin folds are symmetrical and have the same depth. Otherwise, the baby should be examined by an orthopedist;
• slip symptom. This is the most objective diagnostic method up to 3 weeks after the birth of a child. During the breeding of the legs in the hip joint, a click is heard, which resembles the reduction of a bone. If the leg is released, it will return to its original position, and with a repeated sharp movement, the head will again slip out of the articular cavity with a characteristic click;
• Difficulty in moving the hip joint. This symptom is present in sick children after 3 weeks of life. At the moment the leg is abducted to the side at an angle of 80–90 °, movement becomes difficult, while normally the limb can almost be put on the surface.

A little later, dysplasia can manifest itself as a gait disorder, a more noticeable difference in the length of the legs. If the child has a bilateral dislocation, then a "duck" gait develops.

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Doctors distinguish 4 degrees of hip dysplasia:

1. Dysplasia. There is no dislocation yet, but anatomical prerequisites for pathology exist. The congruence of the articular surfaces is broken, that is, when one object is superimposed on another, they do not coincide. Dysplasia can be detected using ultrasound;
2. Hip dislocation. There is a stretching of the capsule of the hip joint, a slight displacement of the femoral head, which easily returns to its original position.
3. Subluxation. This degree is characterized by a partial displacement of the femoral head relative to the acetabulum upward and to the side. The ligament, which is located at the top point of the head, is stretched;
4. Dislocation. There is a complete displacement of the femoral head in relation to the articular cavity. It extends beyond the acetabular recess up and out. The joint capsule and head of the femur are tense and stretched.

If symptoms of hip dysplasia occur, it is necessary to contact an orthopedist who will prescribe the necessary studies, determine the degree of pathology and prescribe competent treatment.

Diagnosis of hip dysplasia

If congenital hip dislocation is suspected, it is necessary to conduct a whole range of diagnostics: examination by a pediatric orthopedist, X-ray or ultrasound examination.

With timely detection, the pathology can be completely cured, but for this, therapy must be started no later than 6 months. To do this, the doctor must examine the newborn in the hospital, after that - at 1 month, and then - at 3, 6 and 12 months. If you suspect dysplasia, the doctor will prescribe an ultrasound or x-ray.

An x-ray of the hip joint is performed for children from 3 months. This is due to the fact that some parts of the femur and pelvic bone have not yet ossified in patients up to 3 months.

In their place is cartilaginous tissue, which is not displayed by x-rays. Therefore, the results of the study in a child younger than 3 months will be unreliable.

It is possible to detect hip dysplasia and dislocation in an infant from birth to 3 months using ultrasound. It is a safe and highly informative diagnostic method.

Conservative treatment of congenital hip dislocation

Congenital dislocation of the hip is treated conservatively or surgically. The decision on the choice of treatment method is made by the doctor after the examination.

If hip dysplasia is detected immediately after birth, then wide swaddling is used. This technique is more prophylactic than therapeutic, and therefore it is used for grade 1 dysplasia.

Wide swaddling for hip dysplasia:

1. Lay the child on his back;
2. Place 2 diapers between the legs so that the baby cannot connect them;
3. Fix the diaper roll on the belt with the 3rd diaper.

After swaddling, the legs are separated, and the head of the thigh is in place.

For the treatment of serious hip pathologies, the following orthopedic structures are used:

In addition, massage is used to treat dysplasia, but only as directed by a doctor. For this, the child is placed on a flat surface, stroked, rubbed and slightly kneaded the muscles of the lower back. Then in the same way you need to massage the buttocks and thighs.

Therapeutic massage for hip dysplasia in children can only be performed by a professional.

Parents are allowed to have a general relaxing massage. One course consists of 10 sessions.

Exercise therapy for congenital hip dislocation restores the normal configuration of the hip joint, strengthens muscles, ensures normal physical activity of the baby, improves blood circulation and prevents complications (necrosis of the femoral head).

Therapeutic exercises for hip dysplasia for children under 3 years old:

• The child is placed on his back and the hips are bent in a divorced state;
• The baby independently changes position from lying to sitting;
• The child must crawl;
• The patient must independently change the position from sitting to standing;
• Walk;
• Build throwing skills.

In addition, a whole range of exercises for the legs, the press, as well as breathing exercises are performed. The specialist will develop a set of exercises for each patient individually.

Surgical intervention

Surgical treatment of hip dysplasia is performed in the following cases:

• Hip dislocation was diagnosed in a 2-year-old patient;
• There are anatomical pathologies due to which the closed reduction of the dislocation cannot be performed;
• Pinched cartilage in the cavity of the hip joint;
• Intense displacement of the femoral head, which cannot be reduced by the closed method.

The method of treatment is chosen by the doctor for each patient individually.

In the presence of the above indications, the doctor performs surgical treatment of hip dislocation:

• Open reduction of dislocation. To do this, the surgeon dissects the tissues, the joint capsule and sets the head into place. If necessary, the acetabular recess is enlarged with a cutter. After the operation, a cast is applied to the leg, which is worn for 2-3 weeks;
• The second method of reducing the dislocation is an osteotomy. To do this, the doctor cuts the skin and gives the end of the femur closest to the pelvis the necessary configuration;
• Operations on the pelvic bones. There are several methods of such treatment, but their main goal is to create a stop over the head of the femur so that it does not move;
• Palliative operations are used when it is impossible to correct the configuration of the hip joint. They are used to improve the general condition of the patient and restore his performance.

Rehabilitation

After surgery, it is necessary to strengthen the muscles and restore the range of motion in the damaged limb.

Rehabilitation is divided into 3 periods:

1. During immobilization, the affected leg is bent at an angle of 30° and fixed with a bandage, which can be removed after 2 weeks;
2. The bandage is removed, the Vilensky splint is put on with a load of 1 kg. The recovery period begins 5 weeks after surgery. During this period, you need to perform therapeutic exercises, alternate passive movements with active ones. This is necessary to strengthen the femoral, dorsal and abdominal muscles;
3. In the final period, which lasts 1.5 years, the child is taught to walk correctly. For this purpose, a special path is used, on which small feet are depicted. The duration of the exercises is from 10 to 30 minutes.

If a pathology is detected in a child of 1-2 years old, then surgical treatment is performed, which does not always end successfully. That is why it is necessary to control the condition of the baby from birth.

Complications and consequences of congenital dislocation of the hip in adults

In the absence of competent treatment of hip dysplasia in infants, the likelihood of dangerous complications at an older age increases:

• Due to the constant friction and pressure of the femoral head on the joint bag, it becomes thinner, deformed and atrophied;
• The femoral head flattens, the acetabular recess decreases. In the place where the femoral head rests against the bone, a false joint is formed. This defect is called neoarthrosis;
• If you do not treat hip dysplasia in a child, then at the age of 25, coxarthrosis develops. Most often, this complication occurs due to hormonal imbalance, an inactive lifestyle, or being overweight. Coxarthrosis is manifested by pain in the hip joint, limitation of movement, as a result, the thigh bends, turns outward and remains in this position. In this case, only endoprosthetics (replacement of the hip joint with a prosthesis) will help.

Thus, hip dysplasia in newborns and children is a dangerous pathology that requires treatment at an early age. Otherwise, the likelihood of complications that are much harder to cure increases. Therefore, it is important to monitor the condition of your child and, if suspicious symptoms occur, consult a doctor.

The cause of congenital hip dislocations are 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 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 back 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 infants 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 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 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 arch of the acetabulum, 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:

1. Infants in the first 3 months of life.
2. Children from 3 months to 1 year.
3. Children from 1 to 3 years old.
4. Surgical treatment of children from 3 to 5 years.
5. 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 the age of three months, a stirrup shirt, a Freik pillow are also prescribed, and after a 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 femur, 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 Codeville method became the method of choice - 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 from bottom to top, 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, and 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 satisfactory ratios 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 neck-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 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 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.

CONGENITAL HIP DISTROCATION honey.
Frequency - over 3% of all orthopedic diseases. Girls are registered more often. 10 times more often observed in children born in the breech presentation. Unilateral hip dislocation is noted 7 times more often than bilateral.
Etiology - underdevelopment of the hip joint (dysplasia). Classification. There are 3 degrees of underdevelopment of the hip joint
1 - predislocation (obliqueness of the acetabulum, late appearance of ossification nuclei in the femoral head, pronounced antetorsion, the head is centered in the joint)
2 - subluxation (the femoral head is displaced outward and upward, but does not go beyond the limbus, remaining in the joint; the center of the head does not correspond to the center of the acetabulum)
3 - dislocation with displacement of the femoral head upwards (the femoral head is displaced even more outwards and upwards, the limbus, due to elasticity, wraps itself in the cavity of the cavity, the femoral head is outside the articular cavity outside the limbus).

Clinical picture

ICD

Disease Handbook. 2012 .

See what "CONGENITAL HIP DISTRUCTION" is in other dictionaries:

Congenital dislocation of the hip- Congenital dislocation of the hip. ICD 10 Q65. ICD 9 ... Wikipedia

Dislocation- right ankle joint ... Wikipedia

Honey. Dislocation is a complete and persistent displacement of the articular surfaces of bones with loss of contact in the articulation area. Dislocated consider the distal part of the limb (exceptions: dislocation of the acromial end of the clavicle, dislocation of the vertebrae). Frequency: 1.5 3%… … Disease Handbook

Dislocation- displacement of the articular ends of the bones, in which their correct contact is lost. According to the degree of displacement, V. can be complete (complete divergence of the articular ends) and incomplete subluxation (the articular surfaces remain in partial ... ...

Dislocation- I Dislocation is a permanent displacement of the articular ends of the bones, which causes dysfunction of the joint. There are congenital dislocations caused by a violation of the process of joint formation (congenital dislocation of the hip is more common than others), and acquired ... ... Medical Encyclopedia- honey. Flaccid skin Atrophic, pasty skin, easily retracted and forming flabby folds. The condition is combined with SCARF syndrome (312830), congenital hemolytic anemia with emphysema (235360), Kaufman syndromes (244450) and Ehlers Dunlb ... ... Disease Handbook

hip joint- articulation between the acetabulum of the pelvis and the head of the femur (See Hip). According to the shape of the articular surfaces, it is a kind of spherical joint. Movements in it are possible around three mutually perpendicular axes: bending and ... ... Great Soviet Encyclopedia

Main symptoms:

• Asymmetry of the buttocks
• Hypertonicity of the back muscles
• Extra crease on the buttock
• Limited movement of the affected leg
• C-shaped body position
• Clenching one hand into a fist
• Slouch
• Shortening of one leg
• duck walk
• X-shaped installation of the foot
• walking on toes
• Lameness
• Crunch when bending the leg

Congenital dislocation of the hip is one of the most common developmental anomalies. Underdevelopment or dysplasia of the hip joint is both unilateral and bilateral. The reasons for the development of pathology are not fully understood, but clinicians know a wide range of predisposing factors that can act as a provocateur of the disease, ranging from a genetic predisposition to an inadequate pregnancy.

Pathology has a rather specific clinical picture, which is based on the shortening of the limbs or the sore leg, the presence of an additional fold on the buttock, the inability to spread the legs with the legs bent at the knees, the appearance of a characteristic click, the baby's habit of standing and walking on his toes. In adults, with an ailment not diagnosed in childhood, lameness is noted.

With the establishment of the correct diagnosis, there are often no problems - the basis of the diagnosis is a physical examination, and confirmation of the presence of this disease in a baby can be achieved after studying the data of instrumental examinations.

The treatment of hip dislocation in the vast majority of cases is surgical, however, in some situations, conservative methods of therapy are sufficient to eliminate the disease.

In the International Classification of Diseases of the tenth revision of hip dysplasia, an individual code has been allocated. Thus, the ICD-10 code will be Q 65.0.

Etiology

Despite the existence of a wide range of predisposing factors, the causes of congenital hip dislocation in children remain unknown. Nevertheless, specialists from the field of orthopedics and pediatrics distinguish as provocateurs:

• incorrect position of the fetus in the womb, namely its breech presentation;
• heavy ;
• bearing a large fetus;
• young age category of the mother - less than 18 years;
• a wide range of infectious diseases suffered by the expectant mother;
• delayed intrauterine development of the baby;
• unfavorable ecological situation;
• specific working conditions;
• the effect on the pregnant woman's body of exhaust gases or ionizing radiation;
• addiction to bad habits - passive smoking should also be included here;
• the presence of a female representative of gynecological pathologies, for example, or the development of an adhesive process. Such ailments adversely affect the intrauterine movement of the child;
• excessively short umbilical cord;
• the birth of a baby before the predetermined date;
• entanglement of the fetus with the umbilical cord;
• trauma to the newborn during labor or after childbirth.

In addition, the cause of hip dislocation in infants can be a genetic predisposition. Moreover, congenital hip dislocation is inherited in an autosomal dominant manner. This means that in order for a child to be born with a similar diagnosis, a similar pathology must be diagnosed in at least one of the parents.

Classification

To date, several stages of the severity of the course of congenital hip dislocation are known, which is why the disease is divided into:

• dysplasia- the articular cavity, head and neck of the femur are changed. In addition, there is a normal preservation of the ratio between the articular surfaces;
• predislocation- there is free mobility of the femoral head, which moves freely inside the joint;
• subluxation- the main difference from the previous form is that there is a violation of the ratio of the articular surfaces;
• congenital dislocation of the hip- in such situations, the surfaces of the joint are separated, and the head of the bone lies outside the joint.

Due to the presence of such changes, it is possible to make a correct diagnosis in newborns in the second week after the baby is born.

Depending on the location of the pathology is:

• unilateral- this variant of the course of the disease is detected twice as often as bilateral;
• bilateral- is less common, while both the left and right legs are involved in the pathology.

Symptoms

With congenital dislocation of the hip, the presence of quite pronounced clinical signs is observed, which parents pay attention to. However, sometimes the pathology is not diagnosed in infancy, which causes irreparable consequences in adults.

Thus, the symptoms of congenital dislocation are presented:

• high tone of the back muscles;
• visual shortening of the affected limb;
• the presence of an extra fold on the buttock;
• asymmetry of the buttocks;
• C-shaped position of the torso of newborns;
• squeezing one hand into a fist, often from the side of the sore leg;
• the appearance of a characteristic crunch in the process of bending the leg;
• X-shaped installation of the foot;
• the baby's habit of standing and walking, relying only on his fingers;
• a pronounced curvature of the spine in the lumbar region - while there is a "duck" gait;
• stoop;
• restriction of movement of the affected limb.

In those situations where the pathology was not cured in childhood, in adults, signs of congenital hip dislocation will be lameness, rollover from side to side while walking, and shortening of the affected leg.

Diagnostics

Due to the fact that the disease has characteristic clinical manifestations, the clinician may suspect the presence of congenital hip dislocation in newborns at the stage of primary diagnosis, which consists of such manipulations:

• studying the medical history of close relatives of a small patient - such a need is due to the fact that the pathology has autosomal dominant inheritance;
• collection and analysis of life history - this includes information about the course of pregnancy and labor;
• a thorough physical examination of the patient;
• a detailed survey of the patient's parents - to establish the first time of onset of symptoms, which may indicate the severity of the course of the disease.

With congenital dislocation, the following instrumental procedures are shown:

• radiography of the lower extremities;
• Ultrasound and MRI of the affected joint - indicated for infants from 3 months of age, and, if necessary, for adults;
• ultrasonography - will show the presence of such a deviation in babies who are 2 weeks old.

Laboratory diagnostic methods are of no value in confirming dysplasia or underdevelopment of the hip joint.

Treatment

Often, in order to eliminate the disease, surgical intervention is necessary, but sometimes conservative methods of therapy are sufficient.

An inoperable method of therapy can only be carried out with early diagnosis, namely in those situations when the patient is 4 months old. At the same time, it is possible to treat the disease with the help of:

• the use of an individual splint, which makes it possible to keep the baby's legs abducted and bent at the same time in the hip and knee joint;
• performing exercises of therapeutic gymnastics or exercise therapy;
• implementation of physiotherapy.

As for the surgical treatment of congenital hip dislocation, it is best if it is carried out before the child is 5 years old. Clinicians argue that the older the patient, the less effective the operation will be, therefore, it is extremely difficult to get rid of the pathology in adults.

There are two most effective methods of operable therapy:

• intra-articular operations - shown only to children. In such situations, the intervention is aimed at deepening the acetabulum;
• extra-articular operations - performed on adolescents and adult patients, while creating the roof of the acetabulum.

With the ineffectiveness of the above methods of treatment, the only method of therapy is hip arthroplasty.

In any case, after surgery, patients need physiotherapy and exercise therapy.

Possible Complications

The lack of treatment of such a disease in infancy increases the likelihood of the child acquiring consequences.

The most common complication is dysplastic - this is a serious disease that leads to disability of the patient, accompanied by:

• intense pain syndrome;
• wrong gait;
• dysfunction of the joint.

Treatment of such an ailment is only surgical, and patients often require nursing care.

Prevention and prognosis

So that newborns and adults do not have problems with the formation of congenital hip dislocation, you must follow these rules:

• in cases with a genetic predisposition, every 3 months from the moment the baby is born, undergo an ultrasound scan of the hip joints on both legs;
• be examined by a pediatric orthopedist every 3 months after birth;
• complete exclusion of vertical load on the baby's legs without the approval of the clinician;
• control the adequate course of pregnancy and timely visit an obstetrician-gynecologist;
• implementation of exercise therapy from the first days of a baby's life.

A favorable prognosis of such a disease is possible only with early diagnosis and timely treatment. The presence of an untreated disease in adults and the development of consequences threatens with disability.

Normally, any joint, including the hip joint, is a complex mechanism of bones, cartilage, ligaments, and muscles.
The hip joint has:

1. A recess (depression) in the pelvic bone where the head of the femur is inserted, similar to puzzles.
2. The bones inside the joint are covered with cartilage.
3. The entire structure is held together by ligaments, and a capsule covers the top. The ligaments and capsule must be elastic enough to allow the joint to move, and at the same time not too fragile so that the structure does not fall apart.
4. The muscles surrounding the joint keep the limb in the correct position.

Dysplasia is a developmental disorder of the hip joint.

Symptoms of hip dysplasia:

• Flattening of the cavity of the pelvic bone.
• Underdevelopment of the femoral head.
• Rotation of the femur in the wrong direction.
• Excessive elasticity of the capsule and ligaments of the joint.
• Change in the muscles surrounding the joint.

All components of underdevelopment in each child have their own degree of severity, but they to some extent affect the location of the bones in the joint. The head of the femur is not in place, "flies" out of the cavity. If she flew out completely - this will be a dislocation of the hip, if partially - a subluxation. And if there is only dysplasia without displacement of the bones, this condition is called pre-luxation.

Causes of hip dysplasia and congenital dislocation of the hip

The process of normal development of the hip joint is associated with various adverse factors that affected the woman in the early stages of pregnancy:

• Viruses and protozoa.
• Ionizing radiation.
• Hormonal disorders in women.
• Deficiency of vitamins (mainly vitamin D) and calcium in a pregnant woman.
• Toxic effects: medication, work in the chemical industry, drug use, etc.

Symptoms of congenital dislocation of the hip

Slip (or click) symptom. A specific symptom that the doctor in the maternity hospital or the pediatrician who came for the first patronage must notice.

Limitation of the breeding of the legs in the hip joints. The same is revealed by the doctor during the examination.

Asymmetry of skin folds. If the child is laid directly on the back or tummy, the skin folds (colloquially constriction) on both legs normally coincide. In an infant with congenital dislocation, the skin folds are asymmetrical.

Different length of the legs due to the shortening of one of them. If the child is laid directly on the back or tummy, the heels should normally be at the same level. In an infant with congenital dislocation one leg will be shorter than the other.

If the detection of the first two symptoms lies entirely on the conscience of the doctors, then you may well notice the asymmetry of the folds or the shortening of the limb yourself.

Important point! A dislocated hip is very easy to miss because complaints will only appear when the child is standing up and trying to walk. And he won't be able to do it. Meanwhile, congenital dislocation is perfectly corrected and does not leave any consequences if treatment is started early, at three, maximum, six months. And although congenital dislocation Doesn't happen very often so be careful.

For the purpose of early diagnosis of congenital dislocation of the hip, it is necessary:

1. Examination of a newborn in the hospital.
2. Examination of the child by an orthopedist at 1 month.
3. Repeated examinations by an orthopedist at 3, 6, 12 months.

If congenital dislocation is suspected:

1. Ultrasound examination (ultrasound, now doing 3d ultrasound) of the joint. This is an indicative method.
2. X-ray of the pelvic bones. Changes in the picture give a 100% diagnosis of dysplasia and dislocation and determine the degree of their severity.

Treatment of congenital dislocation of the hip

The key to success is early treatment. The basic principle is to fix the joint in the desired position (legs apart at the hip joints) for a long time until it is fully restored.

With pre-dislocation (there is only dysplasia without displacement of the femur in the joint), wide swaddling is sufficient.

To reduce the subluxation, special spacers are used for 3-5 months.
Dislocation of the hip. Long-term use of spacers (4-6 months), plastering, massage, gymnastics and physiotherapy are necessary.

If a congenital dislocation missed and the diagnosis was made at 1-2 years old, only spacers with plastering will no longer help, an operation will be required here. Surgery is a very traumatic event and congenital dislocation of the hip, unfortunately, does not completely eliminate changes in the joint, the consequences will remain for life.

Prevention

• Prevention of pathology of pregnancy.
• Visit the orthopedist in time!