Congenital dislocation of the hip. Congenital dislocation of the hip: causes, symptoms, treatment, consequences, recommendations of doctors Who can correct a congenital dislocation of the hip

Congenital dislocation of the hip is one of the manifestations of the abnormal development of the hip joint, which occurs in the early stages of intrauterine development of the fetus.

Development of congenital dislocation of the hip

Hollow of the hip joint

In cases of congenital exarticulations, when the head is outside the joint, the articular cavity does not develop at all. Its development is associated with functional irritation of the head. In 3-4-month-old embryos, the articular cavity has an oval shape - it is elongated upward and backward. The undeveloped cavity is supplemented with a cartilaginous edge, which forms a ring around it, filling the defect in the upper part and leveling the unevenness of the bone surface. The glenoid cavity together with the cup forms more than a hemisphere, thus more than 180% of the entire surface.

After childbirth, the oval shape of the glenoid cavity gradually turns into a round shape, the cartilage of the acetabular lip ossifies and complements the edges of the roof. Gradual ossification can be observed on x-rays, the edges of the articular cavity are supplemented with new appositions. The articular cavity in newborns covers 1/3 of the surface of the femoral head, the rest covers fibrocartilaginous rim that runs along the edge of the acetabulum and improves articulation with the femoral head. At the end of the first year of life, 42% of the surface of the head is already covered by the articular cavity, at the age of 3 - 54%, and at the age of 5 - 57% of the surface of the head.

The axis of the neck and head in newborns crosses the articular cavity. With age between the 1st and 6th year, the location of the neck and head changes so that at the age of 6 years their axis crosses the upper edge of the Y-shaped cartilage.

The change in the position and location of the articular cavity lies in the fact that in the embryonic period the articular cavity is located more ventrally and proximally, and as the pelvis develops, it moves distally and more posteriorly and occupies a frontal position. The articular cavity in newborn boys is turned evenly both anteriorly and outward, while in girls it is somewhat anterior and more outward. In women, the glenoid cavity is located more frontally than in men. This circumstance explains the more common congenital dislocation of the hip in girls.

The articular cavity completes its formation by the age of 10. After 10 years, the articular cavity, due to physiological conditions, no longer changes its shape. The Y-shaped cartilage grows together by 13-16 years. However, this does not mean that the shape of the articular cavity in the future can no longer change. With coxa vara congenita ( an extremely rare, insufficiently studied deformity, which is combined with a defect in the proximal part and shortening of the femur up to micromelia, sometimes with damage to the distal parts of the limb) the roof of the cavity is normal up to about 10 years, after 10 years, adapting to the head, it becomes steep. Also, with aseptic necrosis of the femoral head and with children's spinal paralysis, secondary deformations of the articular cavity occur. These observations indicate that the articular cavity, already developed, is very sensitive to any anatomical change in the femoral head. A properly shaped hip joint is the result of correct bone anatomical shape and proper function.

Antetorsion development

The head of the femur in embryos at the beginning of development is turned backwards - it stands in a retroversion position from 4 to 11°. Approximately in the middle of the embryonic period, the head and neck of the femur rotates anteriorly and by the end of pregnancy is an antetorsion of 20-40 °. In the first years of a child's life, this significant antetorsion levels off again in order to reach 8-11 ° in adults.

Development of the femur

In adults, the femoral head has a regular rounded shape. In the embryo, the back of the head in the area central recess flattened and elliptical in shape. Compared with the size of the whole body, the head is approximately 2 times larger than in adults. The neck is short and massive. A long, thin neck is formed only in the second half of the first decade, when it acquires its usual shape. The greater trochanter in embryos and newborns is massive, the lesser trochanter is directed backwards. The femoral head of the embryo shows a certain retroversion, the anterior side of the neck is longer than the posterior one. In more mature embryos and in newborns, this retroversion gradually levels off and completely disappears in the postpartum period.

The articular cavity during dislocation, as well as the articular cavity of the embryo, in the first half of the embryonic life has a pear-shaped shape, the upper, posterior face of which is not developed, the head is small. The socket in dislocation is thus the result of a belated development of the hip joint, pelvis, and the entire hip region.

Anthropoid dislocation occurrence

In a mammal, the lower limbs remain in a flexed position throughout life. They have almost no congenital dislocations of the hip. In humans, the femur after birth passes from flexion to extension; at birth, it lacks 30° to full extension, and 20° to full adduction. Said transition signifies a significant static change. The longitudinal muscles of the thigh prevent extension and, when extended, push the head out of the articular cavity.

Symptoms and Diagnosis

The development of dislocation in a child of the first year of life is such that at birth it is found only in completely exceptional cases. In the study of children 3 months old, mild processes of dysplasia and subluxations prevail, dislocations are rare; in the study of children 5-6 months of age, the percentage of luxations is already increasing and some of these dislocations are already very high. The older the child, the more luxation prevails over preluxation and subluxation.

Injuries during childbirth do not have any effect on the occurrence of congenital dysplasia. Bruises in a child in the first months after birth are also not the cause of congenital hip dislocation, since a bruise cannot cause delayed ossification of the entire pelvis.

Luxation is always intracapsular, the head stretches the joint capsule and remains permanently inside the capsule. In the further development of displacement, the extent to which the ligament of the femoral head is developed is also of decisive importance.

A. Anatomical changes in children during the first 6 months of life

The mildest degree of damage is delayed ossification of the nucleus of the head. At the same time, the outer edge of the articular cavity is normally developed, the head is located centrally in the articular cavity. This condition is not yet femoral dysplasia; delayed ossification of the head can also be caused by insufficient thyroid function.

The first group - predislocation

The core of the head ossifies late, the roof is steep, forming an angle of more than 30° with the horizontal, Shenton's line with extended lower limbs and with the patella facing anteriorly, remains intact.

Anterior dislocations heal spontaneously unless associated with adductor contracture. If the abduction of the hip joint is limited, they gradually move into the second group.

The second group - subluxation

The ossification of the core of the head is delayed, the roof is slightly steeper than in the first group. The head is shifted up against the outer edge of the articular cavity. Shenton's line is broken; during abduction, the head does not slip into the joint. This condition, before treatment, is associated with limited abduction, which is the most important sign of subluxation. If there is no complete abduction of the femur, the head presses on the outer edge of the articular cavity and prevents ossification of its outer edge. Only after elimination of the adductor contracture, further normal development of the joint is possible. Sometimes it is possible to achieve relaxation of the adductor contracture and systemic abductor movements carried out by the mother after childbirth and in the first months after childbirth, or by the abductor position - inserting a cloth or diaper between the legs. If this method fails to eliminate the abduction, then there is no hope that a spontaneous cure will occur. The head will either remain in a subluxation position, or gradually move into complete dislocation.

The third group - dislocation

With complete dislocation, ossification of the head is delayed, the roof is very steep. The head lies lateral and proximal to the articular cavity. Shenton's line is significantly impaired, abduction is limited, often less limited than with subluxation. With careful abduction, the head clearly slips over the outer edge of the articular cavity (Marx's symptom). In patients treated from the very beginning with abduction techniques or abductor position, there may be free abduction even with complete dislocation at an early age. A complete slipping dislocation may be developed already at birth, but usually it develops from the initial state of preluxation later. The third group includes, along with sliding luxation, high luxations that do not slip; the head in such cases is separated from the outer edge of the articular cavity.

B. Anatomical changes in children older than one year

Subluxatio coxae - subluxation

Subluxation is a transitional state to the development of complete dislocation, but it can also be a long-term condition. In school, youth and adulthood, there are patients who have a subluxation forever. The head in this case is only partially in the articular cavity, half and even 2/3 of the head is located outside the articular cavity. The inclination angle is increased and the defect is mistaken for coxa valga luxans. The presence of the head in the position of subluxation can sometimes be caused by high antetorsion, while the head is groped in front in the form of a tubercle that protrudes soft tissues.

Luxatio marginalis - marginal luxation

The head rests on the outer edge of the articular cavity and is palpated in front in the cavity between mm. rectus femoris and sartorius, on the one hand, and m. tensor fasciae latae, on the other. The articular bag is elongated, the head presses on the outer face of the articular cavity and prevents ossification of the cartilaginous limbus. The outer edge of the articular cavity does not develop at all, in the immediate vicinity of the original articular cavity, a new articular cavity arises, widely connected to the original articular cavity. Only the lower part of the articular cavity over time is filled with connective tissue, as well as adhesions between the capsule and the articular cavity. Reduction becomes impossible relatively late, after 10 years of a child's life. The head, resting on the bone surface of the pelvis, soon loses its cartilaginous cover, flattens relatively early on its medial side and has a conical or buffer shape.

Luxatio supracotyloidea - anterior dislocation

The head lies outside the joint above the outer edge of the articular cavity, which is better developed than with marginal dislocation. The head pulls the joint capsule behind it. The newly formed articular cavity is widely connected to the original articular cavity - the more the head moves upward, the more the capsule narrows at the site of the cartilaginous limbus and forms the so-called isthmus.

The articular cavity in young children is empty and well developed, in older children it is made up of connective tissue and partly fused with the articular capsule. After removal of the cartilaginous limbus, it can be seen that the original articular cavity has an oval, almost trihedral shape with a base located distally. This shape is obtained because the limbus cartilagineus in its outer upper quadrant does not ossify and remains cartilaginous.

The head of the femur in young children is deformed, flattened on the outside, and has a conical shape. The cartilage in the places of its contact with the ilium is damaged. Above the original articular cavity in older children, a new articular cavity is formed, at first very small, then it becomes deeper due to the formation of deforming changes. In this newly formed articular cavity, the head can be held for life. The mechanical stress of the head is always significant, and therefore, in adulthood, as a rule, severe deforming changes occur.

Luxatio intermedia - lateral, lateral, dislocation

With further movement upward backwards, the head lingers on the vertical edge, at the point of delimitation of the anterior and posterior surfaces of the ilium. In the presence of extension of the hip joint, the head is groped behind on the ilium. The head in this place is held for some time, and eventually moves further backwards and forms a posterior dislocation.

Luxatio ilica - rear luxation

The path of the posterior head on the outer surface of the ilium leaves a track running almost parallel to the face of the femur. The head is not in direct contact with the bone, but only with m. glutaeus minimus, whose fibers atrophy under pressure from the head. A new glenoid cavity does not appear on the ilium, even if the posterior dislocation remains for life. The head loses bone support.

Only muscles and an elongated articular capsule connect the femur to the pelvis, on which the thigh is suspended when walking and standing. The original articular cavity is made of connective tissue and fused with the articular capsule. Isthmus is narrow, impassable for the head, sometimes it is closed by connective tissue adhesions: the head is in most cases small, atrophic, adhering to the articular capsule.

B. Signs of congenital dislocation

It is necessary to distinguish between the following signs of congenital dislocation of the hip before the child begins to walk: asymmetry of the skin folds of the thigh and buttocks, the pelvis has the shape of a female pelvis. When viewed from the front, the lateral contour of the ilium is not flat, but convex. Under the iliac crest there is a larger or smaller bulge that gives the hip joint a convex shape. This bulge is caused by the high standing of the greater trochanter. In the prone position, the dislocated side is flat, less convex than the healthy side. The hip is in external rotation.

This important and very significant sign is found in dislocations in about 45% of cases. Shortening of one limb is observed only with unilateral dislocations, the high standing of the trochanter and a decrease in the distance between the anterior upper spine and the inner malleolus become noticeable. Measurement of length in newborns is very difficult. Shortening will be more noticeable if the child is placed on the back and the legs are bent at the knees and hip joints to the position of rectangular flexion, then the difference in the length of both femurs will be clearly noticeable. The shortening of the dislocated limb will be even more noticeable if the child is seated from a supine position.

On palpation, the greater trochanter is above the Roser-Nelaton line. The probing of the head is carried out as follows: if you put the thumbs of both hands on the anterior upper spine, and the index fingers on the large skewers of each side, you can feel a large difference in the height of the large skewers. The articular heads are rarely palpable on the ilium behind, more often they are palpable in front under the anterior superior spine. The articular cavity is empty. In children with a significant fat layer, the results of palpation are not satisfactory. When trying to place the hip in an abduction position, distinctly protruding tense adductors are palpated, on the sides of which there are depressions. When trying to bring the hip out of the abduction position, a distinct slipping (rustling of reduction) is sometimes felt. This symptom is examined in this way: the hand is placed on the outer side of the thigh so that the middle finger is in the region of the greater trochanter, and the thumb hugs the distal part of the thigh. With a certain degree of abduction, slippage occurs in the joint.

The most important sign of a dislocated hip is the restriction of abduction. This sign is absent in dysplasia and subluxation. With dislocations, abduction is either limited or completely impossible - the head rests against the outer edge of the articular cavity and the thigh is in adductor contracture. The remaining movements of the hip joint are performed in a larger volume than in a normal hip joint.

Adduction in young children is so free that the hip of the dislocated limb can be placed on the inguinal region of the other side. Rotation inward and outward is possible twice as much. In a healthy leg, rotation inward and outward up to 45° is possible, with dislocation - up to 90-100°. Thus, the total rotation for dislocations is 180-200°.

It is not always possible to find all the signs and it is rarely possible, especially with bilateral congenital hip dislocations, to make one or another diagnosis at an early age after an external examination. But every child who has asymmetry of skin folds, shortening of the limb, outward rotation of the femur, limited abduction and slippage of the head should be subjected to x-ray examination.

D. Signs in children who have started walking

Children with congenital hip dislocation begin to walk usually at 16-20 months.

In children who have begun to walk, congenital dislocation of the hip is manifested by lameness on the affected leg, the so-called "duck gait".

With a unilateral dislocation, the child limps on the affected leg, the position of the limb is unstable compared to the position of the pelvis. The femoral head moves proximal with each step. Lameness is also caused by Trendelenburg's symptom. When the child stands on a healthy leg, the gluteal muscles tighten and hold the pelvis in a horizontal position with their tension.

With congenital dislocation of the hip, muscles and especially mm. gluteus medius and minimus are shortened and weakened, m. gluteus maximus is weakened. When a child leans on a diseased limb, weakened muscles are not able to keep the pelvis in a horizontal position and the pelvis descends to the healthy side. Along with the pelvis, the spine could also descend. The patient, trying to equalize the resulting static defect, at the moment of lowering the leg to the floor, quickly deviates the torso to the side, towards the sore leg: these complex movements when walking give the impression of fluctuations in the hip joints and are called duck gait (Duchene's symptom). When examining Trendelenburg's symptom, the child stands on a sore leg, while lifting the other. The symptom is positive if the pelvis in this position descends to the healthy side, and the patient, wanting to maintain balance, tilts the body to the diseased side.

X-ray diagnostics

X-ray diagnosis in newborns and young children is possible. Although the nucleus of the head in healthy children appears between the 3-5th month of life, dislocation can be distinguished by the relative position of the bones even before the appearance of the ossified nucleus.

The outer edge of the articular cavity. The angle of the roof is found as follows: a horizontal line is drawn through both U-shaped cartilages and the angle that this horizontal line forms with the plane of the outer edge of the pelvis is found.

The head of the femur. When describing ossification, the size and shape of the head, special attention is paid to the development of the nucleus of the head and the difference in the development of the nuclei of both heads. Retarded development is manifested in the fact that even at the end of the first half of the child's life and later, the head either has not yet begun to form at all, or it is less than normal.

Distance of the proximal end of the femur from the pelvis. It shows the lateral distance of the head from the joint.

Shenton Line. This line is obtained by connecting the distal contour of the neck with the distal contour of the partis horizontalis ossis pubis. In normal hip joints, this line forms a regular arc. Each displacement of the head in the proximal direction breaks Shenton's line.

These four main indications give a complete picture of the condition of the pelvis and head and of the lateral and proximal displacement of the femur.

On an x-ray, dislocation from rickets should be distinguished in young children. Rickets is manifested by the fact that the inner face of the metaphysis of the neck in the medial direction is beak-like continued and the bone is generally calcified.

X-ray diagnosis is different according to the anatomical changes in the joint. With subluxations, the head is shifted laterally, initially stands in the articular cavity with only its inner part, part of the head remains uncovered, Shenton's line is broken. With marginal dislocation, the Shenton line is significantly disturbed, the outer face of the articular cavity is absent, the articular cavity is expanded in the proximal direction. The head is deformed, often flattened or mushroom-shaped. With iliac dislocations, the head lies laterally from the ilium, between both bones in young children there is a large gap. The outer edge of the glenoid cavity is steep, less developed than in a normal hip joint, but better developed than in marginal dislocation.

In older patients in adolescence, the head always rests on the ilium and is located in a newly formed cavity located proximal to the original cavity. The head has in this case a conical or mushroom shape. The bone, at the site of the formation of a new cavity, is sclerotically compacted and forms a powerful marginal ridge. With lateral dislocations, the head on the skiagrams touches the ilium. With posterior dislocations, the contour of the head is behind the ilium, the contours of both bones are superimposed. The outer edge of the articular cavity is steep, the head is small, deformed. In children over 10 years old, in adolescence and in adults, the head is too small, the articular cavity completely disappears.

With the consequences of purulent inflammation of the hip joint, the shadow of the head is not visible even in children aged several years. The stump of the neck stands against the outer edge of the articular cavity and above it, all movements of the hip joint are limited. History of severe purulent process in the first half of the first year of life. Fistula scars are present on the front, outer or back side of the thigh.

Tuberculous inflammation is manifested by pain in the joint, uniform limitation of joint movements and a typical x-ray diagnosis. Coxa vara congenita and femoral head necrosis have limited abduction and free flexion.

Conservative treatment

The head, dislocated partially or completely, must be set, and then try to keep it in the articular cavity for a long time. Both phases of treatment - both reposition and retention - are strictly necessary. In contrast to traumatic luxation, the joint in congenital hip dislocation is not developed; therefore, it is necessary to hold the head after reduction in the joint for as long as the roof and head grow to their normal anatomical shape.

1. Reposition with Pavlik's stirrups or Freik's pillow

If there are no anatomical obstructions, the stirrup reposition succeeds (usually). Repositioning is carried out in two stages. At the first stage, a gradual weakening of the adductor contracture occurs, at the second stage, the head in the abductor position itself is inserted into the articular cavity.

In the first and second stages, movement treatment is carried out. Elastic pressure and heaviness of the limb gradually increase abduction. This gradual and slow weakening of the abduction is accompanied by endless small movements: the head makes its way into the joint and finally, in a certain position, is inserted into the acetabulum. This gradual weakening is the essence of the treatment with a pillow and stirrups, this is the reduction of movement. In cases where the head cannot find its way to the articular cavity and when spontaneous reduction is not carried out, other sparing methods can be used to achieve reposition.

It is recommended to continue treatment with a pillow in internal rotation of the thigh or to apply a stepladder in internal rotation. Weakening of adduction occurs within 7-30 days. The development of the roof comes on slowly, gradually and continues in children treated at the age of one year for a relatively long time.

The time of treatment, despite the favorable development, is proportional to the degree of underdevelopment of the roofs; the larger the angle of the roof, the longer it lasts, until the full development of the roof.

When using a pillow and stirrups, abduction greater than 90° will never occur and the head will not be pushed forward. Therefore, there is no need for frequent x-ray checks. And with dislocations older than two years (almost three years of age), you can start treatment with a pillow at each luxation. During treatment, the contracture is weakened, and if the joint is free, then spontaneous reduction occurs in older children. In the future, supporting devices are prescribed to such children. Extension treatment is also appropriate. In most cases, such changes occur in the joint by this age that reposition, even after the weakening of the adductors, fails and the patient is indicated for surgery.

The most appropriate time to start treatment is the age of the 3rd month of a child's life. During this period, preluxations and slight subluxations predominate; sliding luxations also occur, but high luxations have not yet developed during this period. Therefore, most patients can be cured with simple remedies. In children of 5-6 months, there is already a greater percentage of luxations and there are cases when reposition fails.

2. Treatment with an abduction machine

At the age of 8 months, the development of the reduced joint is not yet complete. At this time, the roof is especially incompletely developed. It is impossible in such cases to continue treatment with either a pillow or stirrups, because the child begins to stand on his feet and will overcome the resistance of the pillow and stirrups. Therefore, when the child reaches 8-12 months, they switch to treatment with an abductor apparatus that fixes the hip joint in the position of 80° flexion and 70° abduction. This is a leather apparatus reinforced with metal splints, with a clip around the waist and around the hips. Comes almost to the knees. Tires can be extended.

The device does not completely fix the hip joint. From the fact that it only reaches the knees, the hip joints remain fairly free, and the abduction position is strictly maintained. The device is always bidirectional. In this apparatus, the head and roof develop to normal shape and the apparatus does not cause any damage. Most of the children using the device are walking. The apparatus is applied both day and night until the radiograph shows that the roof is sufficiently developed to keep the head in the joint. This usually depends on the degree of the disease, up to the period when the child reaches the age of 14-24 months. In the future, the child is given the opportunity to move during the day, and at night, in order to support the addition and further development of the roof, they still leave the apparatus. The device, applied only at night, does not constrain the child. X-ray control is carried out after 6 months and always in two projections - in the anteroposterior and in abduction and flexion at an angle of 90 °.

3. Treatment with Vilensky's abduction splint

The functional treatment of congenital hip dislocation in the first year of life with the Vilensky abduction splint deserves great attention. It is made in the form of a telescopic sliding graduated strut. At the ends of the strut, with the help of hinges, cuffs are fixed for fastening the splint in the lower third of the lower leg above the ankles of the child.

The essence of functional splint treatment consists in slow dosed stretching of the adductor muscles while maintaining movements in the joints of the lower extremities, excluding adduction of the hips. Functional treatment is complemented by therapeutic exercises, massage, warm baths. In the cases shown, traction by the tire is used with a gradually increasing load and abduction.

Under the influence of directed movements in the tire, the femoral head is gradually centered and, with a decrease in the tone of the adductor muscles, is introduced into the articular cavity.

Active movements improve blood and lymph circulation, strengthen the muscular apparatus, accelerate the ossification of the roof of the acetabulum and create favorable conditions for restoring the supporting function of the limbs.

After the onset of the centering of the head in the acetabulum, the child is allowed to walk in the splint. The Vilensky abduction splint is also used to improve the centering of the head after an open and bloodless reduction of a hip dislocation.

Surgical treatment

The simplest solution to the surgical treatment of congenital hip dislocation is the formation of a new articular cavity above the true articular cavity, joining them into one whole and repositioning the head into this new articular cavity.

Operation on Zahradnicek

During the operation according to Zahradnicek, a door-like incision starts from the anterior superior spine, goes obliquely outward, goes almost 2 fingers behind the proximal part of the femoral shaft. To this incision at its lateral end, a longitudinal incision is attached in the distal direction 5-8 cm in length. After the skin incision, the fascia is dissected. On the posterior side of the greater trochanter, another fascia is dissected transversely posteriorly, almost to the muscle. Then the periosteum is removed from the outer surface of the greater trochanter. The bone is not removed from the greater trochanter, since the apophyseal cartilage, which controls the growth of not only the greater trochanter, but also the entire trochanteric part of the femoral shaft, as well as the growth of the femoral neck, can be damaged by knocking down the greater trochanter. If this cartilage is damaged, the neck noticeably lengthens and occupies a valgus position. Therefore, only the periosteum with the upper layer of the bone is knocked off the greater trochanter and pulled in the proximal direction.

The femur is then dissected. On the posterior side of the femur and in the subtrochanteric region in the posterior direction, the muscles along with the periosteum are dissected with a sharp chisel. Then the limb is rotated to the outward rotation position and the periosteum is pushed forward with a raspator, almost under the edge of the greater trochanter. They move very close to the bone so as not to damage the coronary vessels of the trochanteric region. The raspator is inserted under the lesser trochanter to ensure that the iliopsoas tendon is not damaged during dissection. This muscle is always left on its attachment. The bone is dissected obliquely from the outer proximal side in the distal and medial direction, always starting under the greater trochanter and ending under the lesser trochanter. Parallel resection of the diaphysis of the femur is immediately attached to this dissection of the bone, cutting off, according to the x-ray, the desired section of the bone in order to have the graft necessary for the canopy. The final design of the medial and posterior wedge should be left for the last stage of the operation.

The joint capsule is dissected by a transverse incision approximately two fingers proximal to the attachment of the capsule to the femur. If the dissection of the capsule around is carried out incorrectly, the head loses its anterior support, after the operation relux occurs in the anterior direction. Therefore, in front, the soft parts should be carefully dissected from the capsule in such a way as to be sure that the iliopsoas muscle will remain intact, and only that part of the articular capsule that lies around the dislocated head should be dissected in the anterior direction. The acetabular part in front should not be opened. In the posterior direction, the istmus and the acetabular part of the capsule are dissected. When the bottom of the cavity is reached, the round ligament is cut off and the soft parts are turned away from the cartilage in the distal direction with a sharp spoon. Then, just above the lowest edge of the cavity, the articular capsule is cut across and its lowest part is extirpated together with the round ligament and with the ligamentum transversum acetabuli.

The limbus, which sometimes penetrates into the cavity and forms an interposition in the medial part of the joint, should be completely extirpated, its proximal part should be preserved if possible. After excision of the soft parts from the acetabular part, it is necessary to ligate the bleeding vessel.

The articular bag in young children is spherical; in older children, it mostly has the shape of a trihedral cone - it's just a deep groove between the anterior and posterior halves of the articular cavity. Sometimes the middle of the depression forms an irregular tubercle. These irregularities in the articular cavity should be eliminated with a cutter. However, one must work very carefully so that only the top layer of cartilage and bone is aligned and that the Y-shaped cartilage is damaged as little as possible. The head is processed in such a way as to cross the round ligament at the point of attachment. If possible, the shape of the head should be preserved, and not rounded off; in case of severe deformations, the head is treated with a sharp alignment of its edges. A canopy is formed in each case both in luxations and in subluxations. First, the small gluteal muscle is separated from the articular bag. In those places where the capsule has grown to the iliac wing, it is necessary to prepare it from the iliac wing almost to the outer edge of the articular cavity, then resect the outer edge of the articular capsule 2-3 fingers wide.

The capsule is a direct continuation of the articular cavity. The canopy is formed as a result of the omission of the entire arch of the articular cavity and the introduction of a graft taken from the resected femoral shaft. The bone graft is driven in and by probing the articular cavity, it is checked that the roof of the joint is satisfactory, uniformly formed and that no irregularities have been obtained on its surface from the introduction of the graft. In cases where there is not enough of your own bone material at hand, you need to use auto- or homoity. The postoperative course is ideal in cases where the newly formed roof is sufficient and has a horizontal direction.

Reposition of the head in the articular cavity is not difficult. If the head in the articular cavity does not hold well, it is treated as a glenoid cavity, removing all scars from it. Then the head is held so that it stands exactly in the center in the joint, while the assistant extends the limb at the knee so that in the position on the side the patella is facing straight forward. In this position, it is checked how much more trimming of the fragments is necessary to achieve the correct shortening, the correct inclination angle, and the correct alignment of the antetorsion. Both bone fragments are connected with a thin wire inserted into a drilled hole in the proximal femoral fragment. After connecting with a wire, the location of the fragments is checked again by removing the head from the joint. After a new reposition, the fragments are connected using two screws, one of them connects the fragments above the wire loop and enters the femoral neck, the other enters under the wire loop into the cortical layer of the bone in the area of the lesser trochanter.

Stitching of the joint capsule is carried out very carefully, the joint capsule is sutured in front, outside and behind, but especially diligently in front, so that anterior relux of the head cannot occur. Then once again control the roof and, if necessary, supplement it. Then the retracted small gluteal muscle is sewn to its original place. The periosteum of the greater trochanter is sewn very carefully in front and behind. After that, the wide fascia of the thigh, subcutaneous tissue and skin are sutured.

Before applying a plaster cast, the result of the operation must be checked by X-ray. A plaster bandage is applied to the operated leg in a moderate abduction position. The bandage should reach the fingertips, on a healthy leg - only up to the knee. The plaster bandage is left for 4 weeks, then it is carefully removed from the patient in bed and then an extensor bandage is applied. Exercises begin very carefully, the leg is in a suspended position.

3 weeks after the removal of the plaster cast, X-ray control is carried out. In cases where the exact central position of the head is achieved and when the neck has the correct inclination and torsion angle, there are no restrictions on the mobility of the joint. Conversely, in cases where antetorsion or retrotorsion remained, treatment is very difficult; despite all efforts, it is impossible to achieve free mobility. In these cases, it is necessary to operate again, put the head in the correct position. Patients are discharged home on crutches 2 months after removal of the plaster cast. The load of the operated limb is allowed only after six months.

Derotation osteotomy with canopy according to Zahradnicek

The incision is the same as in the Zahradnicek operation, oblique intersection of the femur, wedge resection with a wedge medially and posteriorly. Before suturing the bone, it is necessary to check that the head is exactly in the center of the joint. Both bone fragments are connected with a wire and two screws, then the joint is opened with a longitudinal incision almost to the outer edge of the articular cavity, while it can be seen that a free space has appeared between the head and the articular cavity. This space is filled by lowering the roof in the same way as in the Zahradnicek operation. The plaster bandage after the operation is left for 8 weeks, then movements without load are recommended, after 3 weeks they are allowed to walk on crutches, and full load joint is allowed only 6 months after the operation. The screws are removed six months after the operation.

Derotation osteotomy can be performed from the age of 3, not earlier, and up to approximately 14 years with an antetorsion of more than 45°. In older children, the head is so deformed that derotation brings the onset of deforming arthrosis closer.

In adults, derotational osteotomy is considered contraindicated, it always causes limitation of joint mobility.

The information provided in this article is for informational purposes only and cannot replace professional advice and qualified medical care. At the slightest suspicion that the child has this disease, be sure to consult a doctor!

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

- 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:

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 for the development of dysplasia.

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:

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.

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.

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

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

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

The hip joint consists of such elements as:

acetabulum;
femoral head;
femoral neck.

Congenital dislocation of the hip begins to develop even during the period of bearing a child. The baby's joint develops incorrectly, and the femoral head is not fixed in the acetabulum, but shifts upwards somewhat. Articular cartilage is not visible on x-ray. Therefore, it is possible to diagnose a dislocation only after the birth of a child. In the pathology of the joint, defects such as:

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

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

Main classification

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

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

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

dysplasia;
preluxation;
subluxation;
dislocation.

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

With subluxation, the adhesion of the surfaces of the elements of the joints is disturbed, the ligament is strongly stretched, and the head of the femur is somewhat displaced. Congenital hip dislocation (ICD-10 code - Q65) is characterized by the fact that there is a complete discrepancy between the femoral head and the articular cavity.

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

Causes

The reasons for the development of congenital dislocation of the hip in children have not yet been fully established. According to doctors, such a violation can be triggered by a number of external and internal factors, in particular, such as:

severe toxicosis during pregnancy;
breech presentation of the child;
retardation of the fetus in development;
too large fruit;
previous infections during pregnancy;
bad environmental factors;
gynecological diseases;
bad habits;
premature birth;
birth trauma;
hereditary factor.

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

Main symptoms

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

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

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

the child starts walking very late;
there is lameness on the affected leg;
curvature of the spine in the lower back;
the child tries to lean towards a healthy limb;
the femoral head is not palpable.

In the presence of all these signs, it is necessary to undergo a comprehensive diagnosis for the appointment of subsequent treatment.

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

The last diagnostic method is used only from 3 months. If up to this point the baby does not have ossification of the main areas, then the radiograph may show a false result.

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

During the study, the child is laid on its side, legs slightly bent at the hip joints. Based on the results of the study, it is possible to determine the nature of pathological changes.

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

Carrying out treatment

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

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

With congenital hip dislocation, conservative treatment is performed in several ways or in combination. Mandatory procedures include therapeutic massage. It helps to strengthen muscles, stabilize the damaged joint.

Fixation of the leg with the help of plaster or orthopedic structures helps to fix the legs in a divorced position until the full growth of cartilage tissue on the acetabulum and stabilization of the joint. They have been in use for a long time. Such a design is installed and regulated only by a doctor.

For the treatment of congenital dislocation of the hip in children, physiotherapy procedures are used, in particular, such as:

applications with ozocerite;
electrophoresis;

Physiotherapy techniques are used for complex treatment. In the absence of the effectiveness of ongoing therapy for 1-5 years, closed reduction of dislocations may be prescribed. After the procedure, a special plaster construction is applied for up to 6 months. In this case, the legs of the child are fixed in a divorced position. After the removal of the structure, a course of rehabilitation is required.

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

Conservative treatment

Congenital hip dislocation in newborns should be treated as soon as an accurate diagnosis is made. For babies up to 3 months, doctors recommend using the method of wide swaddling as a therapy. The child's legs should be in a divorced position. To securely fix the hips with swaddling, you need to fold the diaper in 4 layers so that it can hold the baby's hips in the correct position.

The kid must have complete freedom of movement, otherwise he will begin to act up, thereby expressing his displeasure. Strongly tight swaddling provokes circulatory disorders. In order for conservative treatment to be successful, certain rules must be observed, namely:

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

To eliminate congenital dislocation, various orthopedic devices are used. For babies and children up to 3 months, Pavlik's stirrups are used. They are 2 ankle bandages connected by straps.

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

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

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

radical;
corrective;
palliative.

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

Palliative operations imply the use of special structures. They can be combined with other therapies. The method of operation is selected separately for each child, depending on the anatomical features.

It should be noted that there may be complications. These include the process of suppuration in the area of suturing. The infection can affect nearby tissues. During the operation, the baby loses a lot of blood, and his body may also react poorly to the introduction of anesthesia.

Some children begin to develop osteomyelitis after a while, and this can also lead to pneumonia or purulent otitis media.

Rehabilitation

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

The baby needs to be put on its back, and then the straightened legs should be taken to the sides. It is necessary to make such 5-6 movements. Slightly pull the baby's leg towards you, holding his shoulders. Circular movements of the legs will help strengthen the muscles of the newborn. During gymnastics, the child should lie on his back. Alternately, you need to bend the legs of the child, trying to keep the knees touching the body.

Possible complications and prognosis

If you do not treat congenital dislocation in a timely manner, then you can face quite unpleasant consequences. They can manifest themselves in childhood and adulthood. Children with this disorder begin to walk much later.

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

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

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

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

Carrying out preventive measures

Prevention of congenital dislocation of the hip is performed in several stages. Prenatal and childbirth prevention implies the observance by the expectant mother of such rules as:

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

During pregnancy, it is imperative to undergo ultrasound diagnostics in order to timely determine the development of pathologies. It also requires compliance with certain rules regarding the child. It is necessary to exclude his swaddling with even legs, as this can lead to a problem, because this position of the child is unnatural. A massage is required, which includes exercises for breeding the baby's legs.

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

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

Congenital hip dislocation is a fairly common disorder, which for a number of reasons is difficult to diagnose in the early stages. However, the sooner it is determined, the sooner treatment is prescribed, the easier it will be to eliminate the pathology and reduce the risk of developing further changes. But violations in the skeletal system are always very serious.

It is known that among girls hip dislocation occurs up to ten times more often than among boys. Perhaps this is due to differences in the structure of the femoral joint. The joints in the pelvic region in women are, by definition, more mobile. Hip dislocation can be unilateral or bilateral. In the second case, both joints will be affected. Fortunately, bilateral lesion is several times less common. However, the treatment in both cases is no different.

For a long time, it was believed that congenital dislocation of the hip joint is a consequence of injuries during the birth period, and therefore, incorrect actions of the doctor. Rarely talked about various inflammatory processes. However, recent studies of pathology have shown that its cause lies in the violation of the intrauterine development of the child - dysplasia.

Various factors can provoke a deviation, for example, infectious diseases of the mother during the gestation period, abuse of drug treatment, unfavorable environmental conditions in the place where the expectant mother lives or in her place of work. All this negatively affects the process of fetal development, in particular, it can cause disturbances in the development of the musculoskeletal system.

Dysplasia is a primary developmental disorder that inevitably leads to others. Underdevelopment of the pelvic bones leads to partial or complete separation of the joint surfaces, and the head gradually leaves the articular cavity. In addition, dysplasia significantly affects the rate of ossification, reducing it.

There are three degrees of dysplasia:

Violations can affect only the glenoid cavity, while the neck and head of the femur are completely normal. In this case, it is too early to talk about a dislocation.
Dysplasia plus congenital subluxation of the hip, when the head is somewhat displaced relative to the articular cavity, but has not yet completely left it.
Congenital dislocation of the hip, when the articular surfaces are disconnected, and the femoral head is completely out of the articular cavity.

Possible Complications

If congenital dislocation is not cured in time, then there is a risk of facing very serious complications both in childhood and in adulthood. First of all, children with this pathology, as a rule, begin to walk much later. At the same time, their gait has changed. With a unilateral dislocation, the child limps on a sore leg, and with a bilateral dislocation, his gait begins to resemble a duck.

Due to the constant lameness and tilt of the body to one side, the child may develop scoliosis - rachiocampsis.

Naturally, untreated hip dislocation causes a gradual deformation of bone tissue, flattening of the bones of the joint, a decrease in the joint space, and further displacement of the joint head. In adults, such disorders are treated only by surgical intervention and complete replacement of the joint head with a metal counterpart.

Symptoms and diagnosis of pathology

It is very important to diagnose congenital dislocation of the hip joint in a child in time. However, the diagnosis process is complicated by the fact that the hip joint lies deeper than any other. It is densely covered with muscle and adipose tissue. This means that it cannot be felt by hand. You have to rely on not the most accurate signs of the disease.

There are several symptoms by which one can suspect the presence of hip dislocation already in the hospital, in the first days after birth. However, they are all very conditional, and, alas, not at all mandatory. Therefore, newborns are examined very carefully. The first time this is done in the maternity hospital, the second time - in the first days after the return of the mother and child to their home, then at preventive examinations every month, six months and a year.

As a rule, after the child begins to walk, the presence of a hip dislocation becomes apparent. But, alas, it's too late. Bone changes have already begun, and it is problematic to straighten the hip without consequences, this process is long and complicated.

The first thing an orthopedist does when examining a newborn is laying him on his back, bending his legs at the knee and hip joints, and gently, effortlessly, spreading him to the side. Normally, in a child, the legs in this position are bred 160-180 degrees. significant hip dislocation narrows this angle. . Especially if the lesion is bilateral.

However, it is important to remember that this situation can be caused not only by a dislocation of the hip, but also by a temporary muscle tone in the child's legs. During the examination, this is quite natural, because the child is tense.

Another symptom of congenital dislocation of the hip is called Marx's symptom, or click symptom . The actions of the doctor will be similar to the previous option. However, in this case, more attention is paid not to how exactly the legs are bred, but to sounds. A dry click will be heard from the side of the dislocation. It is usually quite quiet, but can sometimes be heard from a distance.

If you put the child on the tummy and stretch his legs, then in the event of a dislocation of the hip, it will be possible to observe some asymmetry of skin folds on the buttocks. On the affected side, the fold may be located lower and have a greater depth.

Another symptom is short legs . However, in the first days after childbirth, it is quite difficult to notice this, since the difference in the length of the legs will be insignificant. In order to determine this symptom, the child is again laid on the back, the legs are bent at the knees and at the hip joint and look at the knees. If they are at different levels, then we can assume a dislocation.

It often happens that congenital dislocation also affects neighboring joints. In this case, it can be determined by the so-called external rotation of the lower extremities: foot slightly outward .

Unfortunately, these symptoms may not appear. And they can talk about completely different diseases. Therefore, at the slightest suspicion of a congenital dislocation of the hip, the child is sent for ultrasound and x-rays. This is the only way to reliably diagnose and start treatment on time.

As already mentioned, at an older age, hip dislocation can also be determined by an altered gait. In addition, several other characteristic symptoms can be found in the child, named after the researchers who identified the relationship between the symptom and the disease. These include the symptom of insufficiency of the gluteal muscles (it is called the Duchenne-Trendelenburg symptom), the symptom of a non-disappearing pulse, and a number of others. But pain in children with hip dislocation is usually not observed.

How to help a child?

There are two possible methods of treatment of congenital dislocation of the hip joint - conservative and surgical. Fortunately, even in severe cases of bilateral dislocation, with timely diagnosis, as a rule, it is possible to manage with a conservative method.

That is why it is considered the leader and consists in individual selection special tire , which fixes the legs of the newborn in one position: bent at the knees and at the hip joints and divorced slightly to the side.

Thus, the head of the femoral joint is gradually reduced into place. It is important that this happens slowly, without haste and abruptness. Otherwise, you can damage the bone tissue, which will lead to even greater problems.

It is believed that in a year the dislocation is already thoroughly launched, but even in such a situation, they try to correct it with conservative methods. Only in very old cases resort to surgery.

What else can you advise parents who are faced with the problem of congenital dislocation of the hip joint in their young child? First of all, be careful. Now various gymnastics and massage for children have come into fashion, but it is important to understand that not all exercises and massage techniques are suitable for babies with congenital dislocation.

For massage in the case of such a pathology, a more thorough and intensive treatment of the lumbar and gluteal region is characteristic. Also, attention is paid to the hip joints. However, it is important not to make sudden, jerky movements.

Special mention should be made of swaddling children. For a long time tight swaddling was welcomed when the baby's legs were pulled together. It was believed that in this case the legs would be straighter. In fact, this position of the legs for newborns is unnatural. During the long months in the womb, babies get used to the bent-legged position. Tight swaddling is especially harmful for children with a dislocation of the hip joint, but it does not have a positive effect on healthy children either. Moreover, for development at such a young age, movements are of great importance. That's why ideal option will dress the child in romper suits. If you still prefer to swaddle, then do not try to twist the legs as tight as possible, leave the child the opportunity to bend and move them at will. Tight swaddling will only aggravate the situation with a dislocation of the hip joint, interfering with the process of repositioning the head into the articular cavity.

Gymnastics for children with congenital hip dislocation

Do not interfere with kids with such an ailment and gymnastics. Below are some simple and effective exercises. Remember that all of them must be performed without any additional effort.

Exercise 1. Put the baby on the tummy. Lightly rub the buttocks and outer thighs. Now gently move the bent leg of the child to the side and fix it in this position.

Exercise 2. The child lies on his stomach. Take him by the ankles and bring the feet together, while the knees at this time, on the contrary, should be divorced. Press the pelvis against the support.

Exercise 3 Lay the child on the ball with his tummy, so that he has to keep his legs on the weight.

Exercise 4 Lay the child on the back. Gently and slowly bend and unbend your legs at the hip joints, and also spread them apart. This must be done carefully, in no case do not rush, do not pull the child and do not press on the legs with force. Movement should be natural.

As you can see, this gymnastics is aimed at relaxing the muscles. It has a lot of static positions, fixations and slow, smooth movements. But fast and sharp are completely excluded. This is associated with the risk of further damage to the weakened joint.

Due to the deterioration of the environmental situation, the negligent attitude of many women to bearing a child, congenital dislocation of the hip is becoming more common. Doctors pay a lot of attention to the timely diagnosis of this problem in children. However, parents should fully rely not only on the opinion of doctors, but also on their own discretion.

Closely monitor your baby and at the slightest suspicion of a congenital dislocation of the hip, contact the pediatrician immediately. The doctor will examine the child and, if necessary, refer him to an orthopedist for examination. Only an attentive attitude to the child from the first days of life guarantees the timely identification of the problem and the cure of the baby before the development of serious complications.

Fortunately, congenital dislocation of the hip is a violation, although frequent, but quite easily corrected. Therefore, do not panic when you hear this diagnosis. Just follow the doctor's instructions clearly, and everything will be fine with your child very soon.

Consultation of a specialist on the signs of congenital dislocation of the hip in babies

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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 a plaster cast, proceed to next step treatment - 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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Development of congenital dislocation of the hip

Symptoms and Diagnosis

A. Anatomical changes in children during the first 6 months of life

The first group - predislocation

The second group - subluxation

The third group - dislocation

B. Anatomical changes in children older than one year

Subluxatio coxae - subluxation

Luxatio marginalis - marginal luxation

Luxatio supracotyloidea - anterior dislocation

Luxatio intermedia - lateral, lateral, dislocation

Luxatio ilica - rear luxation

B. Signs of congenital dislocation

D. Signs in children who have started walking

X-ray diagnostics

Conservative treatment

1. Reposition with Pavlik's stirrups or Freik's pillow

2. Treatment with an abduction machine

3. Treatment with Vilensky's abduction splint

Surgical treatment

Operation on Zahradnicek

Derotation osteotomy with canopy according to Zahradnicek

Theories of the occurrence of congenital dislocation of the hip

Main classification

Causes

Main symptoms

Carrying out treatment

Conservative treatment

Rehabilitation

Possible complications and prognosis

Carrying out preventive measures

Possible Complications

Symptoms and diagnosis of pathology

How to help a child?

Gymnastics for children with congenital hip dislocation

Consultation of a specialist on the signs of congenital dislocation of the hip in babies

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