Correction of pathological antetorsion and cervico-shaft angle of the femur in the treatment of residual hip dysplasia. Valgus deformity of the hip joints Cervical-diaphyseal angle in children, norm table

Date: 19.07.2019

Radiography allows specialists to see deviations from the state of the norm in the formation of hip joints in children, pathology of joint development. The main defect in the hip joints that can be detected by x-ray is joint dysplasia.

Without this examination, the diagnosis of dysplasia is difficult, since only the results of an external examination do not give complete confidence in the correctness of the diagnosis.

Dysplasia or congenital dislocation of the hip is a pathology in the development of the pelvic joints in the fetus. This happens due to the fact that all the components of the joint during the development of the fetus either slowed down their development, or stopped developing altogether.

With dysplasia of the hip joints, the joints themselves significantly change their shape, their structures also change in size. In this case, the glenoid cavity may become flatter, the ligaments become too elastic, therefore the articular capsule does not hold the head of the tibia in the acetabulum poorly. So, with any change in position femur its head "jumps out" of the cavity, this is how subluxation or dislocation occurs.

The correct location of the hip joints is determined by such a concept as the cervico-diaphyseal angle (or ShDU). ShDU is formed by the intersection of a straight line dividing the diaphysis in half, and a straight line connecting the conditional centers of the head and cervical femur bone.

On the x-ray, doctors measure the angles obtained. The norm is such a position of the joint relative to the acetabular notch, when an imaginary straight line passing through the head and cervical part of the femur bone divides the segment that connects the edges of the acetabular notch in half, and the angle obtained at the intersection of these lines is practically right.

Different types of hip dysplasia have different angles of inclination of the femur in relation to the acetabulum. When there are similar deviations from the norm in the baby, we can talk about the abnormal development of the upper tibia.

Definition of dislocation in a child

Exists different methods, with which you can determine the presence (or absence) of hip dislocation in a baby.

Norm, if children:

legs are of the same length and are located symmetrically relative to each other;

if folds skin, located under the buttocks of the baby, are symmetrical;
muscle tone in the legs within the permissible normal range;
the correct ratio of active and passive leg movements in infants.

If parents notice any deviations from the norm in their baby, then this is a reason to contact a pediatric surgeon. For more precise definition congenital dislocation of the hip, the doctor will definitely prescribe an x-ray hip joint... True, many parents believe that it is harmful for a child of the first year of life to do such a procedure.

However, the level of radiation that the baby receives during the X-ray examination is negligible, and will not harm the baby. But untimely treatment of dysplasia (especially in girls) can lead to irreversible consequences. The fact is that in children, bone tissues are just beginning to form, basically the whole bone skeleton of a baby consists of cartilaginous tissues, which are softer. Such tissues can take any shape, which is why it is so important to change the wrong position of the bones and joints of the pelvis and legs in time.

Dysplasia in children from the first days of life and during the first 12 months of life is usually not treated with surgical intervention, but not applied drug therapy... Usually, a wide swaddle, Pavlik stirrups and some similar devices are provided that keep the pelvic joints of young children in certain condition but do not interfere with children's movements.

If, during conservative treatment, the joints of children do not return to normal, surgical intervention is indicated.

Various changes in the functioning of the hip joint due to dysplasia usually lead to abnormalities in the development of the legs, both in children and in adults. The main deviation that occurs in the diseased joint is the discrepancy between the size of the head of the tibia and the notch, which is a deviation from the norm. Usually, with this disease, the acetabulum has big sizes than the head of the bone, so the contact of the joints will be less than normal, but the load on the trough increases. Of course, joints with such a difference in size have greater mobility, but at the same time they become less resistant to stress.

X-rays in babies

Before taking a picture infant, it must be correctly laid on the table so that all parts of its body are as symmetrical as possible relative to each other. The X-ray time should be as short as possible. Usually, special lead pads are applied to those parts of the body that do not need to be scanned to protect them from X-rays. Moreover, parents are present during such a survey in order to keep their baby in the required position.

Dysplasia on the roentgenogram has characteristic features:

characteristic bevels are visible at the apex of the acetabulum;
the head of the femur moves away from the central axis;
the glenoid cavity and the head of the bone are of different sizes;
the thigh is displaced forward relative to the vertical axis.

Radiography: indications and contraindications

X-ray of the hip joints is performed in cases where:

the patient has injuries (fractures or dislocations) of this joint;
if the doctor suspects some pathology in the bone tissue;
confirmation of the presence of changes in cartilage tissues.

X-rays are usually not taken:

if the patient has a sprain or muscle strain;
with diseases such as bursitis or tendinitis;
if metal parts are implanted in the bones of the hip joint;
X-rays are prohibited during pregnancy.

Usually radiography is performed (like fluorography) no more than 1 time per year. Only a highly qualified specialist can read X-rays. And it is not always possible to take pictures in the right place with the help of an X-ray machine - the view may be closed, or an incomprehensible darkening appears in the area on which the study is being carried out.

Experts say that X-rays performed on younger children school age, Is the only way to confirm the presence of dysplasia in patients of this age.

However, the listed parameters may vary on the radiograph, and this must be taken into account in order not to make an erroneous diagnosis.

The main signs of dysplasia on the radiograph should be considered the following:

Norberg's angle is less than 105 degrees.

B. Index of penetration of the femoral head into the cavity is less than 1

Widened and uneven joint space.

Joint incongruence.

D. Cervico-diaphyseal angle is more than 145 degrees.

The parameters are taken from both joints and entered in the certificate of the condition of the hip joints.

Dividing dysplasia at the stage is based on quantitative accounting of simultaneously identified radiological signs (Mitin VN, 1983) (Table 2).

When assessing the staging of the process, only the true signs of dysplasia are taken into account and the radiological signs of secondary arthrosis are not taken into account.

To bring this classification of TPA of dogs into conformity with the classification of the International Cynological Federation, use the summary table (Table 3).

Comparative characteristics of the parameters of the normal joint and in case of dts on the roentgenogram

Table 2

Options		Pathology
Norberg angle	105 degrees and more	Less than 105 degrees
Index of penetration of the femoral head into the cavity, units	Equal to one. The joint gap is narrow, uniform.	Less than one. The joint gap is widened and uneven. Incongruence in the joint
Tangential	Always negative or is zero	Positive, with a rounded antero-outer edge of the acetabulum
diaphyseal angle	Equal to 145 degrees.	More than 145 hail.

Table 3

X-ray characteristics of different stages of hip dysplasia in dogs

Stages of the disease	X-ray changes
Healthy joint	Absent
Dysplasia predisposition stage	The presence of one sign
Predysplasic stage	The presence of two signs
Stage of initial destructive changes	The presence of three signs
Stage of pronounced destructive changes	The presence of four signs, possible subluxation in the joint
Stage of severe destructive changes	The presence of four signs, the Norberg angle is less than 90 degrees, dislocation or subluxation in the joint

DIFFERENTIAL DIAGNOSTICS

Pain and lameness in themselves do not allow us to confidently draw a conclusion about dysplasia of the hip joints, especially with the possible localization of lameness in one of them. In addition, lameness due to TPA not n is constant, does not appear in all cases and also depends on the stage of TPA and the changes caused by it. Indeed, in dogs, there is a gradual transition from a normal, healthy state of the hip joint to the most severe form of TPA. WITH clinical signs dysplasia, which does not occur in a bright classical form (with all its inherent clinical signs), the signs of some other diseases are similar, among which should be noted the destruction of the femoral head (aseptic necrosis), hip fracture, dislocation and subluxation of the hip joint. Therefore, differential diagnosis from these diseases is necessary.

Destruction of the femoral head (aseptic necrosis), is associated with a violation of its blood supply, which eventually leads to the destruction of the hip joint. The disease is most typical for small breed puppies (Toy Poodle Toy Terrier, Fox Terrier, Pikinesse, Japanese Chin, etc. SCH at the age of 4-10 months, as a rule, of a genetic nature, and almost never occurs in large breed dogs. Whereas TPA is a disease of large dog breeds. On the roentgenogram with the destruction of the femoral head, the acetabulum and the angles are not changes, but only the resorption of the femoral head is noted.

Hip fracture a- This is a pathology of the hip joint that occurs suddenly and, as a rule, is associated with the influence of an external force. With this lameness, support on the injured limb is not possible. The diagnosis is clarified radiographically.

Dislocation of the hip joint arises from the influence of an external force and is accompanied by a complete impossibility of support, while the diseased limb is shortened in comparison with the healthy one. The diagnosis is straightforward ^

Subluxation hip joint S. gradual enno in large breed puppies as a result of weakness ligamentous apparatus... -Most often occurs during the period of intensive growth - from 4-10 months. It differs from TPA in that, as a rule, one limb is affected (the opposite joint is not changed in shape). At the same time, the configuration of the femoral head and the angles of the acetabulum are preserved. Without timely treatment, this pathology can lead to the occurrence arthrosis hip joint.

Diagnosis of congenital hip dislocation, the correctness of the development of the hip joint after treatment can be determined only with knowledge of the features of the formation of a healthy hip joint, radiological parameters proximal hip, glenoid cavity, joint in general and their relationship in terms of age.
In children over one year old, 5 degrees of congenital hip dislocation are radiologically distinguished (Fig.
29):

The magnitude and dynamics of the acetabular angle, which is determined by the data:
The development of the acetabulum is determined following degrees slope of the acetabulum. It is formed by the intersection of lines on the frontal radiograph connecting the Y-shaped cartilage, the center of both cavities, the Keller line and the lines connecting the center of the acetabulum to the outer ossification point of the acetabulum (Fig. 30).

The coefficient of the glenoid cavity is expressed by the ratio of the cavity depth to the length of its outlet K = h / a.
Angle of the frontal inclination of the depression is the angle of deflection of the depression anteriorly, formed by the sagittal plane and the plane of deflection of the acetabulum anteriorly

The proximal femur is determined by the following radiometric data:

The head ratio is determined by the ratio of its height to its diameter.

Head = 11 head / d head

The deviation of the femoral neck in the horizontal plane anteriorly or posteriorly (anteversion or retroversion) is determined by the angle formed by the intersection of the central axis of the neck and head with the transcondylar axis of the femur.

There are several methods for determining the value of the anteversion angle. According to A.M. Mironov (1979), on the frontal X-ray of the hip joint, the SDA is determined, and a perpendicular is lowered from the center of the head on the continuation of the axis of the diaphysis of the femur (Fig. 35).

Rice. 35. Determination of the value of the angle of anteversion according to A.M. Mironov
The perpendicular is measured in millimeters, the same perpendicular measurement is made on another facet X-ray of the child, but with internal rotation of the thigh. The value of the smaller perpendicular is divided by the value of the larger one to obtain four-digit numbers. In the table of Bradis cosines, the angle of antetorsion is determined from the obtained value.
Indicators of the centralization of the proximal femur in the cavity are:

Normally, it is 90 ° and determines the stability of the hip joint in the vertical plane.

Coefficient of coverage of the femoral head with a depression is determined on a frontal radiograph by the ratio of the depth of the cavity to the height of the head:

To cover = h vp. / Li head
For differential diagnosis causes of lateroposition of the femoral head M.M. Casco (1995) uses two indicators: the degree of bone coverage (BPC) and the ratio of bone coverage (BEC). The SPC shows how much of the femoral head is covered by the acetabulum (3/4, 2/3, 1/2, 1/3) - (Fig. 39).

FCR is the ratio of the vertical dimension of the femoral head and the projection of the length of the acetabular roof onto the line of Y-shaped cartilage (Fig. 40).

Normally, its value is 1.0-1.15, which indicates the same growth rates of the femoral head and the roof of the acetabulum.
Table 1
Age normal average radiometric values
(according to E.A. Abalmasova, 1983; I. I. Mirzoeva, 1976; E. S. Tikhonenkova, 1997)

X-ray indicators.	Eat face change rhenium.	Age (years)
X-ray indicators.	Eat face change rhenium.	1-2	3-4	5-6	7-8	9-10	12-13	14-15
Acetabular injection	Grad.	15,7-18,5	13,7-16	14,0-14,7	12,7-14,3	8-15	8-12	6-12
The angle of the vertical slope of the valley	Grad.	42-46	41-49	43-49	40-49	44-51	43-48	48-55
Depth of the hollow	mm	10,4-10,8	13,7-14,2	15,9-16,1	17,4-17,0	20,3	20,7	23,8
The length of the entrance to the depression	mm	39-50	42-53	49-57	55-61	55-64	64-70	67-75
Coefficient articular depressions	mm	0,24-0,25	0,24-0,29	0,29	0,29	0,32	0,32	0,31- 0,34
Injection frontal inclination	Grad.	35-40	35-40	30-50	30-50	30-50	30-50	30-50
Cervico-diaphyseal angle (projection)	Grad.	133-142	134-147	134-142	134-142	130- 139	132-139	129- 139
Diameter of the epiphysis of the head	MM	16,6-20	20-29	29,5-37,7	39-46	43-49	47-52	59-65
Height of the epiphysis of the femoral head	mm	10,6-15,8	13,2-15,8	15,5-19,8	20,0	19-25,5	19,5-22,5	23,2- 28,8
Femoral head ratio	Grad.	0,66-0,68	0,61-0,62	0,51	0,46-0,47	0,49- 0,50	0,44-0,46	0,43- 0,44
Injection anteversions	Grad.	15-45	10-40	8-38	5-31	5-31	9-30	9-30
Injection vertical compliance.	Grad.	73-84	80-89	76-87	79-91	83-94	84-92	85-93
Wiberg angle	Grad.	19-30	22-31	22-31,8	22-34	33-37	30-37	39-46
Femoral head coverage ratio		0,7-0,9	0,74-1,04	0,79-1,03	0,76-0,99	0,77- 1,05	0,85-1,05	0,88- U
Horizontal Matching Angle	Grad.	32-34	15-35	15-40	18-40	30-40	30-40	10-50

Analyzing the literature data and the numerical indicators provided in the table, certain patterns should be noted that determine the formation of a healthy hip joint. The acetabular index, which determines the shape of the acetabular roof, gradually decreases with age. The angle of vertical inclination of the plane of entry into the glenoid cavity determines the congruence of the articular surfaces and the stability of the joint; at the age of one year it is equal to 44 °, and by the age of 15 it reaches 50 °. The depth of the depression, the length of the entrance to the depression, and, accordingly, the coefficient
glenoid cavity, which is the main indicator of the development of the glenoid cavity, gradually increases with age. All authors unanimously note that the above indicators are slightly higher on the left than on the right.
The development of the proximal femur is characterized by the diameter and height of the epiphysis of the head, its coefficient, the magnitude of anteversion and the cervico-diaphyseal angle. The dimensions of the cervico-diaphyseal anteversion angle, which determine the centering of the head, vary over a wide range, but significantly decrease with age. The height of the epiphysis of the femoral head increases with age less intensively than its diameter, and, accordingly, the coefficient of the head decreases, especially intensively it decreases to 6-8 years, when ossification of cartilaginous structures occurs. The dynamics of the Viberg angle indices, the vertical and horizontal correspondence of the coefficient of coverage of the head with the cavity, which determine the correspondence of the articular surfaces in the hip joint, vary within wide limits, but their general tendency to increase ensures the stability of the joint at all age periods.
Thus, the hip joint is most unstable in children at the time of birth and in the first year of life, and the indicators on the left are somewhat worse, and especially in girls (ES Tikhonenkov, 1997).

The most complete answers to questions on the topic: "cervical-diaphyseal angle of the hip joint in children."

Diagnosis of congenital hip dislocation, the correctness of the development of the hip joint after treatment can be determined only with knowledge of the features of the formation of a healthy hip joint, radiological parameters of the proximal femur, glenoid cavity, the joint as a whole, and their relationship in the age aspect.

In children over one year old, 5 degrees of congenital hip dislocation are radiologically distinguished (Fig.

degree - the femoral head is lateral, but at the level of the acetabulum;
degree - the femoral head is above the horizontal line of the U-shaped cartilage and in the upper part of the sloped roof of the acetabulum;
degree - the entire head is located above the visor of the acetabulum;
degree - the entire head of the femur is covered with the shadow of the wing of the ilium;
degree - the femoral head is located at the top of the iliac wing.

The magnitude and dynamics of the acetabular angle, which is determined by the data:

The development of the acetabulum is determined by the following degrees of slope of the acetabulum. It is formed by the intersection of lines on the frontal radiograph connecting the Y-shaped cartilages, the center of both cavities, the Keller line, and the lines connecting the center of the acetabulum to the outer ossification point of the acetabulum (Fig. 30).

Rice. 30. Scheme for determining the acetobular angle.

The angle of vertical inclination of the acetabulum (Sharpe angle), which determines the angle of inclination of the acetabulum in the vertical plane on a face-to-face radiograph. Formed by a horizontal line passing through the upper and lower edges of the acetabulum.
The depth of the glenoid cavity is determined on the frontal radiograph: to the line connecting the upper and lower edge of the cavity from the center of the glenoid cavity, a perpendicular is restored, measured in millimeters (Fig. 31).

The length of the entrance to the cavity is determined on the frontal radiograph by the line connecting the upper and lower edges of the cavity, measured in millimeters (Fig. 31).

The coefficient of the glenoid cavity is expressed by the ratio of the cavity depth to the length of its outlet K = h / a.
Angle of the frontal inclination of the depression is the angle of deflection of the depression anteriorly, formed by the sagittal plane and the plane of deflection of the acetabulum anteriorly

The proximal femur is determined by the following radiometric data:

The cervico-diaphyseal angle (SCA) is formed from the intersection of lines drawn axially through the center of the femur diaphysis and the center of the head (Fig. 33). The projected cervico-diaphyseal angle is determined from the frontal radiograph, and the true angle is determined from the frontal radiograph with internal rotation of the thigh.

The epidiaphyseal angle is formed by the intersection of the axis of the diaphysis with the axis of the neck and femoral head. Normally, the SDA and the epidiaphyseal angle are equal, but with Sokha valga, the value of the epidiaphyseal angle increases.
The diameter of the epiphysis of the head (d head) is determined by the frontal radiograph by a line drawn at the base of the growth zone. Measured in millimeters.
The height of the epiphysis of the head (h head) is determined by the frontal radiograph, restoring the perpendicular from the middle of its diameter. Measured in millimeters (Fig. 34).

The head ratio is determined by the ratio of its height to its diameter.

Head = 11 head / d head

The deviation of the femoral neck in the horizontal plane anteriorly or posteriorly (anteversion or retroversion) is determined by the angle formed by the intersection of the central axis of the neck and head with the transcondylar axis of the femur.

Rice. 35. Determination of the value of the angle of anteversion according to A.M. Mironov

The perpendicular is measured in millimeters, the same perpendicular measurement is made on another facet X-ray of the child, but with internal rotation of the thigh. The value of the smaller perpendicular is divided by the value of the larger one to obtain four-digit numbers. In the table of Bradis cosines, the angle of antetorsion is determined from the obtained value.

Indicators of the centralization of the proximal femur in the cavity are:

The angle of vertical correspondence is determined on the frontal radiograph and is formed by the intersection of the line connecting the lower and upper points of the depression with the axis of the femoral neck (Fig. 36).

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Rice. 36. Determination of the centering of the proximal femur in the cavity

Normally, it is 90 ° and determines the stability of the hip joint in the vertical plane.

Horizontal correspondence angle - the angle formed by the axis of the femoral neck and the plane of entry into the acetabulum equal to 46-48 degrees
Decentration angle - determined on a faceted radiograph. Normally, the axis of the femoral neck passes through the center of the cavity. In case of subluxation, this axis is displaced by upper section cavity and between it and the center of the glenoid cavity, an angle of decentration of the head in the glenoid cavity is formed (Fig. 37). Normally, it does not exceed 10 °.

The Wiberg angle is determined on the frontal radiograph, formed from the intersection of two lines starting in the center of the head, one of which is perpendicular to the Hilgenreiner line passing through the center of the glenoid cavity, the other is connected to the outer bony edge of the cavity (Fig. 38).

Coefficient of coverage of the femoral head with a depression is determined on a frontal radiograph by the ratio of the depth of the cavity to the height of the head:

To cover = h vp. / Li head

For differential diagnosis of the cause of the lateroposition of the femoral head, M.M. Casco (1995) uses two indicators: the degree of bone coverage (BPC) and the ratio of bone coverage (BEC). The SPC shows how much of the femoral head is covered by the acetabulum (3/4, 2/3, 1/2, 1/3) - (Fig. 39).

Rice. 39. Determination of the degree of bone coverage according to Komosko

FCR is the ratio of the vertical dimension of the femoral head and the projection of the length of the acetabular roof onto the line of Y-shaped cartilage (Fig. 40).

Rice. 40. Determination of the coefficient of bone coverage according to Komosco

Normally, its value is 1.0-1.15, which indicates the same growth rates of the femoral head and the roof of the acetabulum.

Table 1

Age normal average radiometric values

(according to E.A. Abalmasova, 1983; I. I. Mirzoeva, 1976; E. S. Tikhonenkova, 1997)

X-ray indicators.	Eat face change rhenium.	Age (years)
X-ray indicators.	Eat face change rhenium.	1-2	3-4	5-6	7-8	9-10	12-13	14-15
Acetabular injection	Grad.	15,7-18,5	13,7-16	14,0-14,7	12,7-14,3	8-15	8-12	6-12
The angle of the vertical slope of the valley	Grad.	42-46	41-49	43-49	40-49	44-51	43-48	48-55
Depth of the hollow	mm	10,4-10,8	13,7-14,2	15,9-16,1	17,4-17,0	20,3	20,7	23,8
The length of the entrance to the depression	mm	39-50	42-53	49-57	55-61	55-64	64-70	67-75
Coefficient articular depressions	mm	0,24-0,25	0,24-0,29	0,29	0,29	0,32	0,32	0,31- 0,34
Injection frontal inclination	Grad.	35-40	35-40	30-50	30-50	30-50	30-50	30-50
Cervico-diaphyseal angle (projection)	Grad.	133-142	134-147	134-142	134-142	130- 139	132-139	129- 139
Diameter of the epiphysis of the head	MM	16,6-20	20-29	29,5-37,7	39-46	43-49	47-52	59-65
Height of the epiphysis of the femoral head	mm	10,6-15,8	13,2-15,8	15,5-19,8	20,0	19-25,5	19,5-22,5	23,2- 28,8
Femoral head ratio	Grad.	0,66-0,68	0,61-0,62	0,51	0,46-0,47	0,49- 0,50	0,44-0,46	0,43- 0,44
Injection anteversions	Grad.	15-45	10-40	8-38	5-31	5-31	9-30	9-30
Injection vertical compliance.	Grad.	73-84	80-89	76-87	79-91	83-94	84-92	85-93
Wiberg angle	Grad.	19-30	22-31	22-31,8	22-34	33-37	30-37	39-46
Femoral head coverage ratio		0,7-0,9	0,74-1,04	0,79-1,03	0,76-0,99	0,77- 1,05	0,85-1,05	0,88- U
Horizontal Matching Angle	Grad.	32-34	15-35	15-40	18-40	30-40	30-40	10-50

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glenoid cavity, which is the main indicator of the development of the glenoid cavity, gradually increases with age. All authors unanimously note that the above indicators are slightly higher on the left than on the right.

The development of the proximal femur is characterized by the diameter and height of the epiphysis of the head, its coefficient, the magnitude of anteversion and the cervico-diaphyseal angle. The indices of the sizes of the cervico-diaphyseal anteversion angle, which determine the centering of the head, vary over a wide range, but significantly decrease with age. The height of the epiphysis of the femoral head increases with age less intensively than its diameter, and, accordingly, the coefficient of the head decreases, especially intensively it decreases to 6-8 years, when ossification of cartilaginous structures occurs. The dynamics of the Viberg angle indices, the vertical and horizontal correspondence of the coefficient of coverage of the head with the cavity, which determine the correspondence of the articular surfaces in the hip joint, vary within wide limits, but their general tendency to increase ensures the stability of the joint at all age periods.

Thus, the hip joint is most unstable in children at the time of birth and in the first year of life, and the indicators on the left are somewhat worse, and especially in girls (ES Tikhonenkov, 1997).

Dysplasia of the hip joint or congenital dislocation of the hip (English: developmental dysplasia of the hip) - congenital joint inferiority, which is caused by its underdevelopment and can lead (or led) to subluxation or dislocation of the femoral head - "congenital dislocation of the hip" ( congenital dislocation of the hip).

Disruption of the biomechanics of the hip joint as a result of dysplasia can lead to severe violations functions of the lower extremities, to disability, both directly from the first steps of the child, and in adulthood.

It is important to timely identify the most early signs diseases, it is important to start treatment on time, it is important to show understanding, patience and consistency when following the doctor's recommendations.

The statistics of hip dysplasia in children requires clarification. Until the first half of the last century, only severe form dysplasia - congenital dislocation of the hip (3-4 cases per 1000 births). In those years, "mild forms" of dysplasia were not treated. From the 70s - 90s use the term "developmental dysplasia", meaning by this not only dislocation, but also pre-dislocation and subluxation of the hip joint. The incidence figures have increased tenfold.

It should be noted that the lack of clear standards and the fear of missing a severe orthopedic pathology is the reason for overdiagnosis (20-30% at the stage of preluxation). The dilemma of "immature hip and preluxation" is usually resolved in favor of dysplasia, which increases the incidence rate.

Dysplasia of the hip joints is common in almost all countries (2-3%), but there are significant racial and ethnic features of its distribution. For example, the incidence of congenital underdevelopment of the hip joints in newborns in Scandinavian countries reaches 4-5%, in Germany - 2-6%, in the United States it is higher among the white population than among African Americans, and is 1-2%, among American Indians - dislocation hip occurs in 25-50 per 1000, while congenital dislocation of the hip is almost never found in South American Indians, from the southern Chinese and blacks.

The relationship between morbidity and environmental problems has been noticed. The incidence in the Russian Federation is approximately 2-3%, and in ecologically unfavorable regions up to 12%.

A direct connection between the increased incidence and the tradition of tight swaddling of the straightened baby's legs was noted. In peoples living in the tropics, where newborns are not swaddled, their freedom of movement is not limited, they are worn on their backs (while the child's legs are in a state of flexion and abduction), the incidence is lower.

For example, in Japan, within the framework of a national project in 1975, the national tradition of tight swaddling of the straightened legs of babies was changed. Result: a decrease in congenital hip dislocation from 1.1-3.5 to 0.2%.

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Probably, there is a connection between morbidity and the socio-economic state of society. For example, in Ukraine (2002), congenital dysplasia, subluxation and dislocation of the hip occur from 50 to 200 cases per 1000 newborns, that is, significantly higher than in the same territory during the Soviet period.

More often this pathology occurs in girls (80% of cases detected), family cases of the disease account for about a third. Hip dysplasia is 10 times more common in those children whose parents had signs of congenital hip dislocation. Congenital dislocation of the hip is detected 10 times more often in those born with breech presentation fetus, more often during the first birth. Dysplasia is often detected when drug correction pregnancy, during pregnancy, complicated by toxicosis. The left hip joint is most often affected (60%), less often the right (20%) or both (20%).

Anatomy and biomechanics

The development of the hip joint begins in the womb, continues actively during the first 6-12 months after birth, then a change in the shape and biomechanics of the joint occurs throughout all age periods... The structure of the bone changes, its shape changes, the relative position of the bones that form the joint changes. An error in the development of the joint, which leads to its functional inferiority, is denoted by the term "hip dysplasia".

For proper development of the hip joint great importance has a full-fledged formation of the acetabulum and proximal femur, timely replacement of the cartilaginous structure bone tissue, and functional state muscles of the hip joint.

In fig. 1 shows a diagram of the hip joint, where the number 3 denotes the acetabulum, 2 - the head of the femur, 1 - the ilium, 5 - the pubic bone, 6 - large spit femur, 7 - femur diaphysis. In a newborn, part of the bone is represented by cartilage, which is gradually replaced by bone tissue as the child grows.

In fig. 2 in green shows the cartilaginous part of the hip joint in a newborn. Let's consider the formation of the hip joint during ontogenesis. In fig. 3 shows, for example, 4 x-rays of the hip joint: a newborn, a child at the age of 1 year, 5 years, and an adult.

V infancy we see that part of the bones that form the joint is represented by cartilage, it is not visible on x-ray... From 4-6 months of age, the nuclei of ossification (ossification) are visible. V childhood bone is actively growing in length and thickness due to cartilaginous growth zones. In an adult, hyaline cartilage is completely replaced by bone tissue, and bone growth stops.

The acetabulum is the location of the femoral head, as shown in Fig. 4, formed by three pelvic bones ( top part- iliac, anterior - pubic and lower posterior - sciatic). Between these bones is the so-called Y-shaped cartilage - an important X-ray sign.

The hip joint of a newborn even in normal conditions (see Fig. 5) is an immature biomechanical structure, its glenoid cavity is flattened, it is located more vertically, in comparison with the "adult joint", the joint ligaments are excessively elastic. The joint is held in the glenoid cavity due to the tension of the articular capsule, its own ligament (round ligament of the hip joint). The upward displacement of the femur is prevented by the cartilaginous plate of the acetabulum, which is called the "limbus" (acetabular labrum - lip, edge).

In violation of the development of the joint (with dysplasia), we see (see Fig. 6) a flatter and sloped glenoid cavity, excessively elastic ligaments and the articular capsule are not able to hold the head of the femur in the glenoid cavity, it shifts upward and laterally (to the outside) ... In this case, the limbus is inverted (displaced upward) and deformed laterally - it loses its ability to maintain the displacement of the femoral head. With certain movements, the femoral head can extend beyond the acetabulum. This condition of the joint is called "subluxation".

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In severe hip dysplasia, the head of the femur extends completely beyond the acetabulum, a condition called hip dislocation (see Fig. 7). The femoral head is located above the glenoid cavity, the limbus is screwed into the joint and is located below the femoral head, the glenoid cavity is filled with fat and connective tissue... This makes it much more difficult to reposition the dislocation.

If the dislocation of the femur is not eliminated, then, following the well-known biological law "function determines the shape," the growing bones of the pelvis and the femur change, adapting to the new load conditions (see Fig. 8). The femoral head loses its normal spherical, is flattened. The empty acetabulum decreases in size, and a new glenoid cavity is formed at the new location of the femoral head (in the iliac wing region). Again formed joint called "neoarthrosis". This is a defective joint, but it has served for decades for those patients who are different reasons congenital dislocation of the hip was not eliminated.

The development of the hip joint occurs in the process of close interaction between the femoral head and the acetabulum. The distribution of the load on the bone structures determines the acceleration or deceleration of bone formation, and ultimately determines the shape of the femoral head and acetabulum, as well as the geometry of the joint as a whole.

Dysplasia of the hip joint can manifest itself not only as a violation of the acetabulum (acetabular dysplasia), but also as an abnormal development of the proximal femur. The shape of the proximal femur is most often described by the cervico-shaft angle (SDA), which is formed by the midline of the diaphysis and a line drawn through the centers of the head and neck of the femur (see Fig. 9). These measurements are taken on a frontal radiograph.

Depending on the value of this angle, depending on how much it corresponds to the age norm, the normal shape of the proximal femur is distinguished, dysplasia with an increase in this angle - coxa valga, dysplasia with a decrease in this angle - coxa vara.

The relationship between the acetabulum and the head of the femur is very important. Many methods are used to assess the geometry of the hip joint, one of them is shown in Fig. 10. An important indicator is the centering of the femoral head and acetabulum. If you draw a line through the edges of the acetabulum (AB) and a line through the middle of the head and femoral neck (CF), then the CF line should pass through the middle (point O) of the AB line. Moreover, the angle formed by these lines should approach a straight line. This is a great biomechanical meaning: uniform load on the head and acetabulum and the normal development of these structures. The centering angle is closely related to the shape of the cervico-diaphyseal region.

The lower part of the figure shows some forms of hip dysplasia associated with a violation of the cervico-diaphyseal angle and the angle of inclination in the acetabulum. Figure A is the norm. The line of inclination of the acetabulum and the midline of the head and neck make up a right angle, the SDA and the angle of inclination of the acetabulum are not changed. Figure B - Varus of the proximal femur with misalignment. Figure B shows the shape of dysplasia with an increase in SDS at a normal acetabular angle. Figure D - dysplasia, in which both excessive SAD and excessive acetabular tilt are combined.

And finally, the so-called "rotational dysplasias" of the hip joint. These are the least known to a wide range of doctors. general practice dysplasia. We will not consider them in the format of this publication, but they should be mentioned.

Normally, in humans, the joints of the lower extremities are misaligned (see Fig. 11). What are we talking about? The axis of movement of each joint does not coincide with the axis of the above- and below-underlying joint. This is a great biomechanical sense. For example, if the leg is bent at the knee joint, then in the hip joint the flexion axis is located at an angle to it and there is no flexion. Otherwise, all joints would lower limbs would have formed like a house of cards. This is called "brace" of the leg. The axis of the hip joint (the axis of the joint in the horizontal plane) is at a certain angle to the axis of the knee. This is due to the fact that the femur is twisted in such a way that the head of the femur is turned forward (see Fig. 12).

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As shown in the figure, viewed from above, the axis knee joint, drawn through the femoral condyles (line B), forms a certain angle with the axis of the hip joint, a line drawn through the middle of the neck and head of the femur. This angle is called the "antetorsion angle". The yellow arrow shows the center of the acetabulum. The angle of antetorsion of the femur at birth is 15-570 (mean - 320), 20-500 (340) in 1-3-year-old children, 12-380 (250) in 4-6-year-old children and 25-370 ( 120) in adults. The phenomenon of a decrease in the angle of antetorsion with age is explained by the onset of walking and verticalization of the body. In most cases, thigh antetorsion is a constitutional norm. Excessive antetorsion is accompanied by a violation of the centering of the femoral head in relation to the acetabulum and is manifested by the peculiarity of the child's gait - gait with internal rotation of the leg, a kind of clubfoot gait (see Fig. 13).

The shape, relationship and size of the structures of the hip joint change significantly with dysplasia. In fig. 14 shows a computer model of the hip joints (the right joint is normal, the left one is hip subluxation against the background of dysplasia). We see a more vertically located, flattened acetabulum, a more forward-turned head of the femur, that is, an increased angle of antetorsion, a greater cervico-diaphyseal angle. Such a joint lags behind in development, which is clearly visible on an X-ray (Fig. 15) - a delay in ossification of the femoral head.

A characteristic feature of the dysplastic hip joint is its incongruence, that is, the mismatch of the shape of the femoral head with the shape of the acetabulum. The femoral head is usually smaller than normal, while the radius of the acetabulum, on the contrary, increases (see Fig. 16). This feature of biomechanics inevitably leads to early wear of the joint and to the development of the most frequent and most severe complication, which is called "dysplastic arthrosis of the hip joint" ("dysplastic coxarthrosis").

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What is hip dysplasia

Definition of the concept

Translated from Greek, the word "dysplasia" means "educational disorder". In medicine, this term means pathological conditions caused by impaired development of tissues, organs and systems.

This method is safe for health and provides enough information to confirm the diagnosis.

In the study, attention is paid to the state of the bony roof, cartilaginous protrusion (how much it covers the head of the femur), the centering of the head at rest and during provocation is studied, the angle of inclination of the acetabulum is calculated, indicating the degree of its maturation.

For the interpretation of the results, there are special tables, with the help of which the degree of deviation from the norm is calculated.

Ultrasound for hip dysplasia is a worthy alternative to X-ray examination up to six months of a baby's life.

X-ray diagnostics

X-ray examination is the most informative method diagnosis of hip dysplasia in children from the seventh month of life.

Most of the acetabulum and femoral head in infants is cartilaginous and cannot be visualized x-ray. Therefore, for X-ray diagnosis of hip dysplasia, a special marking is used to calculate the slope of the acetabulum and the displacement of the femoral head.

The delay in ossification of the femoral head is also of great importance for the diagnosis of hip dysplasia in infants (normally, the ossification nucleus appears in boys at four months, and in girls at six).

Treatment of hip dysplasia in children

Conservative treatment of hip dysplasia in infants

Modern conservative treatment dysplasia of the hip joint in infants is carried out according to the following basic principles:

giving the limb an ideal position for reduction (flexion and abduction);
the earliest possible start;
preservation of active movements;
long-term continuous therapy;
usage additional methods impacts (remedial gymnastics, massage, physiotherapy).

It has been noticed for a long time that when the child's legs are in the abducted state, self-dislocation and centering of the femoral head are observed. This feature is the basis for all currently existing methods of conservative treatment (wide swaddling, Frejk's pillow, Pavlik's stirrups, etc.).

Without adequate treatment, dysplasia of the hip joints in adolescents and adults leads to early disability, and the result of therapy directly depends on the timing of the start of treatment. That's why primary diagnosis spend in the hospital in the first days of a baby's life.

Today, scientists and clinicians have come to the conclusion that it is unacceptable to use rigid fixing orthopedic structures that restrict movement in the abducted and flexed joints in infants under six months of age. Maintaining mobility helps center the femoral head and increases the chances of healing.

Conservative treatment involves long-term therapy under the control of ultrasound and X-ray examination.

At the initial diagnosis of hip dysplasia in the hospital, based on the presence of risk factors and positive clinical symptoms immediately begin therapy, without waiting for confirmation of the ultrasound diagnosis.

The most widespread was standard circuit treatment: wide swaddling for up to three months, Frejk's pillow or Pavlik's stirrups until the end of the first half of the year, and later on - various diverting splints for after-treatment of residual defects.

The duration of treatment, and the choice of certain orthopedic devices, depends on the severity of dysplasia (pre-dislocation, subluxation, dislocation) and the time of initiation of treatment. Therapy during the first three to six months of life is carried out under the supervision of an ultrasound scan, and later - an X-ray examination.

Exercise therapy (physiotherapy exercises) with dysplasia of the hip joint, it is used from the first days of life. It not only helps to strengthen the muscles of the affected joint, but also provides a full physical and mental development child.

Physiotherapy procedures (paraffin baths, warm baths, mud therapy, underwater massage, etc.) are prescribed in consultation with the pediatrician.

Massage for dysplasia of the hip joints also begins from the first week of life, since it helps prevent secondary muscle dystrophy, improves blood supply to the affected limb, and thus contributes to the early elimination of the pathology.

It should be borne in mind that exercise therapy, massage and physiotherapy procedures have their own characteristics at each stage of treatment.

Surgical treatment of hip dysplasia in children

Operations for dysplasia of the hip joint are indicated in the case of a gross violation of the structure of the joint, when conservative treatment will be obviously ineffective.

Surgical methods are also used when the reduction of the dislocation without surgery is impossible (blocking the entrance to the acetabulum soft tissues, muscle contracture).

The reasons for the above conditions can be:

so-called true congenital dislocation of the hip (hip dysplasia caused by impaired early embryogenesis);
untimely treatment started;
mistakes during therapy.

Operations for dysplasia of the hip joint are of varying degrees of complexity and volume: from myotomy (incision) of the muscles that caused the contracture to joint plastic surgery. but general rule remains: best results ensures the timeliness of the intervention.

Preoperative preparation and postoperative period rehabilitation for hip dysplasia include exercise therapy, massage, physiotherapy procedures, appointment drugs improving the trophism of the joint.

Prevention of hip dysplasia

The prevention of dysplasia is, first of all, the prevention of pregnancy pathologies. The most difficult and least treatable lesions caused by disorders of the early embryonic development... Many cases of dysplasia are caused by the combined action of factors, among which not the last place is occupied by the irrational nutrition of the pregnant woman and the pathology of the second half of pregnancy ( increased tone uterus, etc.).

The next direction of prevention is to ensure timely diagnosis of the disease. The examination must be carried out in the maternity hospital in the first week of the child's life.

Since there are often cases when the disease is not diagnosed in time, parents should be aware of the risks associated with tight swaddling of an infant. Many practicing doctors, including the famous doctor Komarovsky, advise not to swaddle the baby, but from birth to dress him and cover him with a diaper. This care provides free movement, which contributes to the centering of the femoral head and the maturation of the joint.

Residual effects of hip dysplasia can suddenly appear in adults, and cause the development of dysplastic coxarthrosis.

The impetus for development this disease pregnancy can serve, hormonal changes organism or a sharp change in lifestyle (refusal to play sports).

As a preventive measure, patients from the risk group are prohibited from increasing loads on the joint (lifting weights, doing track and field athletics), it is recommended that a constant dispensary observation... Sports that strengthen and stabilize joints and muscles (swimming, skiing) are very useful.

Women at risk during pregnancy and in postpartum period must strictly follow all the recommendations of the orthopedist.

Before use, you must consult a specialist.