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Hip, congenital dislocation

The hip, congenital dislocation (luxatio femoris congenitum) — occurs quite often, at 3 — 4 on 1000 newborns 5 — 7 times more often at girls, than at boys.
Cases of hereditary pathology are known. One authors (Bogdanov F. R., Timofeeva N. A., etc.) as the reason of this defect consider an arrest of development of a hip joint during an antenatal life of a fruit, others (Volkov M. V., Gorbunova R. L., etc.) proved that most of mothers who gave birth to children with a dysplasia of a hip joint had cardiovascular diseases (rheumatic heart disease) or gestoses of pregnant women and a nephropathy. At 50% inspected pelvic presentation was observed.
Disease the underdevelopment of elements of a hip joint, in particular is the cornerstone of an acetabular hollow, a hip neck head.
Newborns have an inborn dysplasia of a hip joint which can lead further to dislocation of a hip or as a result of normalization of anatomical structures to recovery. The acetabular hollow at children with an inborn dysplasia is usually less deep, than normal, and has the slanted upper edge ("roof"). On the party of defeat a head of a hip of the smaller size that promotes formation of dislocation of a hip. The inborn underdevelopment of his upper part — often is followed by a deviation of a neck of a kpereda more than it happens normal. Anteversiya at newborns reaches usually 30 ° (at adults — 10 — 15 °), and at congenital dislocation of a hip this corner increases to 60 — 90 °. If the treatment all is not carried out the described changes accrue: a hip head, lagging behind in growth and experiencing uneven strain, it is gradually deformed, the joint cartilage is exposed to degenerative changes. The acetabular hollow sharply lags behind in development, remains flattened, with filling of her cavity with cicatricial connecting fabric. The round linking of a head of a hip which is attached to a bottom of an acetabular hollow becomes thinner and stretches or sometimes is absent.
Early diagnosis of congenital dislocation of a hip is made at the first birthdays of the child. Leaders are the sliding symptom, or a symptom of "click" (Marx's symptom — Ortolani). At assignment and simultaneous bending of a hip at an angle 90 ° in hip joints at the child lying on spin restriction of passive assignment of legs is observed. At extension and reduction of legs to the average line the tolchkoobrazny vyvikhivaniye which is followed by the click felt by a hand of the doctor is felt again. It is sometimes heard at distance. This symptom of "click" remains only in the first 3 months of life of the child. An important diagnostic character of a dysplasia or dislocation of a hip is asymmetry of skin folds on a hip. On the party of defeat of folds it is more, they are higher, than on healthy. In the second half of the first year of life of the child on the party of dislocation it is possible to reveal shortening and outside rotation of a leg.
Radiological at three-months age the hip dysplasia is diagnosed. During a X-ray analysis the child lies on spin with the straightened and fixed legs in the provision of some of their rotation inside, strictly symmetrically. Basin has to adjoin densely to a table over the cartridge, of course, with soblyudeniye of all rules of protection of genital bodies of the child a lead plate. Radiological overdue emergence of a kernel of ossification of a head of a hip on the party of dislocation or lack of kernels of ossification of heads of hips is defined. The acetabular hollow does not give a contrast shadow. Significance is attached to a condition of the upper edge of an acetabular hollow and an arrangement of a cartilaginous head — it is higher also lateralny than normal situation. At dislocation the slanting arrangement of the upper edge of an acetabular hollow is observed. Before emergence of a kernel of ossification of a head of a hip Putti, Hilgenreyner's schemes help to decipher a X-ray pattern at the child at the age of 4 — 5 months.


Схемы ХильгенрейнераСхемы Хильгенрейнера 2
Fig. 1. Hilgenreyner's schemes.                                             

According to Putti's scheme the straight line is drawn by connection of upper parts of metaphyses of both hips, perpendicularly — two lines through the middle of joint hollows (a reference point at the last any), define distance from a bottom of an acetabular hollow to a point of intersection of both lines which normal identical on both sides, and at dislocation on the party of defeat the distance increases at the expense of the shift of a hip of a knaruzha. (fig. 1, B).
On Genreyner's (fig. 1, A) scheme draw a horizontal line through both At-shaped cartilages (Köhler's line), from the most highly located point of a diaphysis of a hip lower a perpendicular crossing with the horizontal line. Length — 1-1,5 cm is normal of it. The distance from a bottom of an acetabular hollow to a perpendicular is normal also of 1 — 1,5 cm. At dislocation you reduce distance of h, a d increases. From a bottom of an acetabular hollow carry out a tangent the formed corner (index) normal approaches the most peripheral department of a roof of an acetabular hollow to 20 °. Pr dysplasias it increases.
According to Reynberg's scheme draw three vertical lines: on the average line of a body, through verkhnelateralny edge (a roof ledge) of a healthy acetabular hollow and equally spaced from the average line on the party of dislocation. Normal the vertical line passes through a hip diaphysis, and at dislocation — medialny. A horizontal line is also drawn through At-shaped cartilages. Normal a head of a hip you find medialny vertical and below the horizontal line, at dislocation - lateralny and above these lines.
According to Ombredann's scheme the provision of a head in relation to the horizontal line and an arrangement of a diaphysis of a hip in relation to vertical is considered. At children of the second half of the year pay attention to Shenton's line. Normal it is the correct arc-shaped line connecting the lower contour of a horizontal branch of a pubic bone to a hip neck contour. At hip dislocation the arc-shaped line is absent as the ledge appears from behind higher arrangement of the lower contour of a neck of a hip. At newborns the head is not visible. The kernel of ossification of a head appears normal at the age of 4 — 6 months after the birth. On the party of dislocation the kernel of ossification is expressed less.
For early diagnosis of congenital dislocation of a hip the schemes allowing to define an underdevelopment of a hip joint are offered. The horizontal line A drawn through both At-shaped cartilages making a bottom of an acetabular hollow is normal crosses the middle or upper part of a bone kernel of a head of a hip. Otstoyaniye of a femur from the center of a joint decides on the help of the vertical line B which is carried out through a verkhnelateralny ledge of an acetabular hollow. Normal the head of a hip is located medialny the vertical line. If to draw a horizontal line C through the neck basis, then it crosses the lower part of "loop" or Köhler's "teardrop". Normal Shenton's line correct the arc-shaped, the hip necks connecting the lower contour of a horizontal branch of a pubic bone to a contour. The arc-shaped line at dislocation is absent, it becomes a broken line.
Important radiological sign is the atsetabulyarny index determining a tilt angle of "roof" of an acetabular hollow by two lines — horizontal, carried out through the At-shaped cartilage, and the line drawn on the outer edge of bone part of an acetabular hollow. Normal the tilt angle of "roof" does not exceed 25 °. When the child starts walking (years are more senior) diagnosis of congenital dislocation of a hip does not represent big difficulties. The late beginning of walking forces to think of congenital dislocation of a hip (most of children take the first steps in 14 — 15 months). Gait their unstable, lameness at unilateral dislocation, "duck gait" at bilateral. The child does not show complaints.
On the party of dislocation the extremity is in the provision of outside rotation (it is visible also during a dream). Relative shortening of an extremity on the party of dislocation in the absence of absolute shortening is characteristic. The top of a big spit is located above Roser's line — Nelatona. On the party of dislocation restriction of assignment of a hip, the rotational movements in bigger volume, than normal is noted. Positive symptom of Trendelenburga (fig. 2). Normal but support time for a healthy leg a buttock of other party rises; at congenital dislocation at a support it falls by a dislocated leg.
Симптом Треленбурга
Fig. 2. A symptom of Trelenburga (put on the right) at hip dislocation

The listed earlier radiological signs are expressed more clearly. At children 5 years radiological are aged more senior distinguish five degrees of dislocation: I \the head is lateralno, at the level of a hollow (predislocation); II \above the horizontal line of the At-shaped cartilage and in upper part of the displaced roof of a hollow (incomplete dislocation); III \over contours of an acetabular hollow; IV \it is covered with a shadow of a wing of an ileal bone; V \high standing of a head — at upper part of a wing of an ileal bone is characteristic.
Treatment has to begin at once after detection of dislocation. Functional ways of therapy are applied. At easy forms of a dysplasia physiotherapy exercises, broad swaddling by means of the diaper folded in several layers fixed in a crotch by other diaper in the form of a triangle are recommended. At a moderately severe dysplasia Freyk's pillow produced in the form of a butterfly is applied. Also Pavlik's stirrups, Vilensky's strut, the tire wall, etc. are used.

Shin Vilengsky it is improved by the author in CYTO and took more modified form in connection with use of a plastic strut and the same cuffs convenient in the hygienic relation, allows to change the angle of cultivation of legs. The child is in the tire throughout all time of day within 4 months. The X-ray analysis is made in 4 months: if forming of deeper acetabular hollow is defined, then the tire is removed.
The term of treatment of slight dysplasias on Vilensky's strut — 3 months. Volkov's tire produced from polyethylene is widely used. Mother has to be trained to make assignment exercises in hip joints during swaddling; it is desirable to combine them with massage, in particular gluteuses, at treatment of children years dislocation are aged more senior set an anesthesia by Lorentz's method with the subsequent fixing by a plaster bandage in the provision of assignment up to 90 °C long an immobilization about one year. Reposition of congenital dislocation of a hip of ms to be reached also by way of an extension per continuitatem. The way of vertical extension (Shede) is effective. Reposition it is made gradually for 2 — 3 weeks. Such way is effective aged till 3 flyings. Operational treatment is shown at children 2 years are more senior, at unreducible dislocations of a hip — at the age of 1 — 2, and also at a late relaxation and other complications after r: the dislocations set in the conservative ways.
Open reposition of congenital dislocation of a hip consists in release of an acetabular hollow from cicatricial fabric and its deepening. The head of a hip is set in an acetabular hollow. In the postoperative period rigidity of a joint develops often, vsyazi with what repeat courses of physiotherapeutic procedures, medical physical cultures, massage, balneological sanatorium treatment. About 30 accesses to a hip joint congenital dislocation of a hip are offered. In front apply perednelaterny, longitudinal more often (a section Smith-Petersen who is bending around a big spit cuts and from below — Ollye — Murphy — the Lexer, Bogdanova, etc. (fig. 3).

оступы к тазобедренному суставу
Fig. 3. Accesses to a hip joint.

Open reposition of dislocation with deepening of a hollow is most successfully developed by F. R. Bogdanov who offered opening of a joint capsule and its partial excision make release of a hollow from soft tissues and modeling of joints of a cartilage by means of maces. Open reposition in combination with restruktivnymi operations — opening of a joint and forming of a hollow by its deepening with an arthroplasty or formations of upper edge of a hollow, or operation which provides change of a cervical and diaphyseal corner of a femur for deeper entry of a head of a hip into a hollow. The capsuloplasty consists of opening of a joint in the place of an isthmus of the stretched capsule, its partial excision and bandaging by a ligature of an isthmus and impression of the head surrounded with a bag. This method is applied at children at the age of 5 — 8 at low dislocations. At children of advanced age Volkov's operation — deep forming of a hollow with an arthroplasty amniotic covers is carried out.

Остеотомия таза в области основания подвздошной кости
Fig. 4. A basin osteotomy in the field of the basis of an ileal bone according to Hiari (A) and Salter (B).
An ileal  bone operation belongs to group of extraarticular interventions: reconstruction of a roof of an acetabular hollow with the help auto-both allotransplants and operation of a full osteotomy of a basin in the field of the basis of an ileal bone (Hiari, Salter, Degas's operation, etc.; fig. 4). By Volkov's method make bringing down of highly standing femur head to the level of an acetabular hollow by means of a compression distraktsionnykh of devices of Ilizarov, Volkov — Oganesyan; a subtrochanterian osteotomy of a hip (cross, trapezoid) with its resection on   3-4 cm for correction of an antetorsiya (see) and valgusa of a neck; opening of a joint with full excision of a capsule; deepening of a hollow with acute maces of a design of the author and operation is finished amnioplastiky. Fragments of a hip fix a corkscrew of Sivash, set a head of a hip in a hollow. The extremity is fixed distraktsionno-compression devices in the provision of assignment. In a month the device is removed, impose manzhetochny extension for a shin and begin development of movements in a joint. The corkscrew of Sivash is deleted in 6 months, full load of a leg is possible in a year.

 
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