Hip dysplasia in children and newborns

Gynecology recognizes cervical dysplasia as non-invasive changes in the cervix in the transition zone of the single-layer columnar epithelium of the cervical canal into the multilayered squamous epithelium of the vaginal part of the cervix, often occurring after infection with HPV and HSV type 2. Moreover, cervical intraepithelial neoplasia (CIN), as cervical dysplasia is also called, implies processes of structural and cellular atypia (impaired cell differentiation) with a violation of the layering of the epithelium without involving the basement membrane.

These atypical changes refer to precancerous processes, in which the index of malignancy (oncological transformation) can reach 50%. In the early stages of their development, dysplastic changes are reversible, so gynecologists consider their timely detection and elimination to be a reliable way to prevent the risk of cervical cancer.

ICD-10 code N87 Cervical dysplasia.

General information

Connective tissue dysplasia in the body often manifests itself as pathology of the musculoskeletal system, including pathology of large (hip and knee) joints in the form of knee dysplasia and hip dysplasia.
Congenital hip dislocation (synonymous with congenital hip dysplasia) is a severe malformation of the musculoskeletal system and occupies one of the leading places among all congenital joint diseases. According to the literature, various degrees of underdevelopment of the hip joint (dysplasia) occur in 0.5-5% of newborns. Instability of the hip joint, subluxation/dislocation of the hip of dysplastic origin in children tends to rapidly progress and is the leading cause of the development of dysplastic deforming coxarthrosis already in adolescence. In the absence of adequate treatment, progressive trophic/functional disorders in the pelvic joint (JJ) lead to secondary severe disorders of the joint structures, which causes dysfunction of the support of the limb and its movement, disturbances in the physiological position of the pelvis, curvature of the spine and the subsequent development of deforming coxarthrosis and osteochondrosis , which are the leading cause of disability in adults.

ICD-10 code for hip dysplasia: Q65.0; Q65.1; Q65.2; Q65.3; Q65.4; Q65.5; Q65.6; Q65.9. Hip dysplasia in children is characterized by underdevelopment of almost all elements of the hip joint (bones, muscles, joint capsule, ligaments, vessels, nerves) and altered spatial relationships of the acetabulum and femoral head. In general, according to the literature, various degrees of underdevelopment of the hip joint (dysplasia) occur in 0.5-5% of newborns. At the same time, dysplastic changes in the hip joints are detected on both sides in 25% of cases. Left-sided lesions are more common (1:1.5) than right-sided lesions. TS pathologies are statistically significantly more common in girls (1:3). Moreover, girls experience more severe degrees of joint development delay, i.e. this pathology can be considered gender-related.

Features of the anatomy of the hip joint with dysplasia

The hip joint performs not only the physiological function of multi-axis movement. Its peculiarity (in combination with the function of the spine) is the formation of correct human posture, which is due to its anatomical structure (Fig. below) - a combination of the spherical head of the femur and the acetabulum, which form an extremely stable joint with the help of the ligamentous-muscular apparatus.

At the same time, in a newborn child, even normally, the structure of the hip joint is characterized by immaturity (not fully formed structure), excessive elasticity of the joint ligaments, which manifests itself:

shallow flattened acetabulum;
discrepancy between the size of the femoral head relative to the size of the acetabulum;
insufficient density of the joint capsule;
poor development of pelvic muscle tissue (gluteus muscle).

Essentially, the femoral head in infants is held in the acetabulum only by the round ligament, joint capsule and acetabular labrum. In addition, the predominant part of the joint elements at birth is cartilaginous, and the process of ossification and bone growth actively continues from 1 to 3 years. , the ossification of the femoral neck mainly increases , preserving the cartilaginous structure only in its upper part. During the same period, the highest growth rates of the acetabulum are observed. Normally, the growth of the femoral head and acetabulum occurs synchronously.

With hip dysplasia in newborns, the articular cavity and the head/neck of the femur are changed, but the ratio of the articular surfaces is still normal. It is the severity of anatomical defects of the joint, which are a consequence of tissue segmental inferiority, that determines the degree of dysplasia. Congenital hip dysplasia manifests itself in three forms, which gradually transform into one another (pictures below):

Unstable hip (pre-dislocation) - characterized by joint instability due to connective tissue dysplasia. Its anatomical manifestation is the periodic displacement of the femoral head inside the articular cavity. Those. the head of the femur does not move beyond the acetabulum. At the same time, dislocation and reduction are carried out easily.
Femoral subluxation - the articular surface of the femoral head is partially displaced outward and upward relative to the acetabulum, but does not extend beyond the limbus. At the same time, the contact between these elements of the joint is preserved. The round ligament and capsule are stretched, and the limbus moves upward, losing its support function, which allows the femoral head to move upward and partially to the sides.
Hip dislocation - the head of the femur moves even higher and extends beyond the acetabulum. In this case, the contact of the femoral head with the glenoid cavity is completely lost. The limbus is displaced downwards, the ligaments and joint capsule are stretched. Dislocation is the most common form of damage to the hip joint (about 70%).

In the absence of treatment/or its ineffectiveness, the acetabulum gradually fills with connective fatty tissue, which complicates or makes the procedure of reducing the joint difficult or impossible.

Early detection of hip joint instability and timely initiation of treatment are of great importance, since as the child grows, the disease progresses, which significantly disrupts the biomechanics of the lower extremities and requires corrective surgical interventions aimed at stabilizing the joint, which significantly reduces the quality of life.

Development mechanism

The cervix performs a barrier function, protecting the uterine cavity from the penetration of pathogenic microflora into it, as well as the reproductive cavity, stretching during labor, ensuring the passage of the child. The vast majority of women with cervical neoplasia are of reproductive age, and the trend toward incidence at younger ages is increasing. This means that if there is no treatment for atypia of epithelial tissue, then the woman’s reproductive function suffers, in some cases it can end in infertility.

Cervical dysplasia (cervical intraepithelial neoplasia) is characterized by atypical changes in the epithelium of the part of the cervix located in the vaginal part. The organ has a layered structure: basal and parabasal layers, intermediate and superficial. Round shaped epithelial cells with a small nucleus are formed in the basal layer. When moving to the surface layer, the cells become flatter and the nucleus becomes smaller. With atypical changes, cells and nuclei become enlarged, binucleate or multinucleate may appear. Penetrating to ever greater depths, atypia leads to the disappearance of differentiation of boundaries between layers.

What is cervical dysplasia

Pathogenesis

Hip dysplasia is caused by a deficiency of connective tissue caused by mutations of various genes in different combinations and exposure to adverse environmental factors. Characteristic anatomical manifestations of hip dysplasia are underdevelopment of the joint: hypoplasia and flattening of the acetabulum in a newborn, slow development of the femoral head, bursal-ligamentous and neuromuscular apparatus of the joint, which causes its increased mobility.

Classification

There are several types of hip dysplasia:

Femoral dysplasia . The mechanism of development of TB dysplasia is a violation of the neck-diaphyseal angle, which determines the centralization of the femoral head in the acetabulum (the angle of articulation of the femoral neck with its body). Both a decrease in the angle of the hip joint - coxa vara, and an increase in it - coxa valga can be observed (Fig. below).
Acetabular dysplasia . The pathology is caused by a violation of the development of the acetabulum, which is reduced in size, flatter, with an underdeveloped cartilaginous rim.
Rotational dysplasia . The movement of all joints of the lower limb is caused by a mismatch of axes (excessive antetorsion angle of the femur), that is, a violation of the location of the femoral head relative to the acetabulum.

According to clinical and radiological criteria preluxation (unstable hip), subluxation (primary, residual and hip dislocation (anterolateral/lateral), supraacetabular and iliac high dislocation .

Kinds

Cervical neoplasia is classified depending on the depth of epithelial damage. At the first stage (CIN 1 or weak, mild), the smallest area of damage is noted and the greatest chances for complete recovery.

In the second stage (CIN 2 or moderate), approximately half the thickness of the epithelium is affected, but the process is still reversible.

With grade 3 cervical dysplasia (CIN 3 or severe, severe), the pathological process extends to 2/3 of the epithelial layer. Characterized by the appearance of pathological mitosis (cell division), which is dangerous due to the occurrence of mutations.

Types of dysplasia

Causes

In the etiology of hip dysplasia in children, the leading role is played by the delayed development of the joint during intrauterine development (embryonic anlage), which develops under the influence of unfavorable endo/exofactors, as well as external influences on the joint after the birth of the child. Factors contributing to the development of hip dysplasia include:

Unfavorable heredity (transmitted in an autosomal dominant manner from parents to child).
Complications and unfavorable course of pregnancy (breech presentation of the fetus, large fetus, oligohydramnios, toxicosis of the first half of pregnancy, childbirth in women under 18 and over 35 years of age).
Increased production of relaxin hormone , which is secreted in a woman’s body by the tissues of the uterus and placenta to prepare directly for childbirth (affects the ligaments, increasing their elasticity).
Thyroid diseases.
Infectious diseases from 10 to 15 weeks of pregnancy ( ARVI , rubella , influenza ).
External influences - uncontrolled use of medications during pregnancy and alcohol, x-rays, radiation, unfavorable environmental conditions.
Poor nutrition during pregnancy, contributing to the development of disorders of water-salt and protein metabolism, deficiency of vitamins and minerals in the body.
Tight swaddling of the baby with straightened legs.

Pregnancy with severe dysplasia

For the formation and development of the fetus, grade 3 cervical dysplasia does not pose any particular danger. But hormonal surges during the gestational period can aggravate the pathological process, promote infection of organs, and this can already negatively affect the course of pregnancy. In addition, when passing through the birth canal during childbirth, the baby can become infected with HPV, other viruses or bacteria. In this regard, every pregnant woman with dysplasia is specially registered and carefully monitored. In this case, it is recommended to remove the neoplasia after childbirth.

Many women come to the gynecologist when they are already pregnant. Therefore, it is strongly recommended to plan your pregnancy and undergo standard diagnostics, so that if cervical neoplasia is detected, you can take professional measures and approach conception in a healthy state.

Symptoms of hip dysplasia

Signs of hip dysplasia in infants

As a rule, the symptoms in a newborn with hip dysplasia in the absence of displacement of the femoral head are extremely scarce. The main symptom in this period can be considered the presence of excessive rotation in one/both joints, as well as an increase in passive mobility in the hip joint. In infants, the early and main clinical symptoms of an unstable hip are:

Limitation of the angle of passive extension of the legs in the hip joints of a newborn, bent at a right angle. Normally, the hips should be abducted to a horizontal plane (80-90); in the presence of pathology, there is a limitation in hip abduction (bilateral or on the affected side).
Asymmetry of the buttock folds and skin folds on the thigh.
Relative shortening of the leg and outward rotation of the limb.
Marks-Ortolani/Barlow clicking or slipping sign.

Later symptoms of hip dislocation appear with the onset of independent walking and are manifested by a pronounced limitation of hip abduction, shortening of the hip (Galeazzi sign).

Sign of Galeazzi

Characteristic symptoms in children over one year of age include gait disturbance: the child clearly limps on one leg (symptoms of hip dislocation, on the one hand) or has a characteristic “duck” gait (pathology of both hip joints).

Symptoms in adults are manifested by pain in the hip joint, rapid fatigue when walking, a higher located greater trochanter and impaired locomotor functions (a specific pathobiomechanical symptom complex manifested by insufficiency of the gluteus medius muscle - Trendelenburg symptom ).

A decrease in the function of the gluteal muscle contributes to a violation of the stability of the pelvis - the occurrence of its lateral tilt, which is compensatory manifested by the Duchenne symptom (greater tilt of the body), due to increased function of the oblique abdominal muscles.

Functional shortening of the lower limb caused by upward displacement of the femoral head, changes in the gluteal muscles and lack of support for the femoral head contribute to the appearance of disturbances in the biomechanics of gait, namely: swaying of the pelvis and body when walking, disturbance of the rhythm of walking, and the appearance of lameness.

Symptoms

Cervical dysplasia of the 3rd degree, despite the fact that it is considered non-invasive cancer, just like with the other two stages, does not give a specific clinical picture, which makes diagnosis difficult. Typically, complaints arise from bacterial infection of the uterine appendages and genital tract. Basically, the patient is bothered by pain in the lower abdomen of varying intensity, depending on the stage of inflammation, irradiation into the anus and lower back (not necessarily), vaginal discharge of a stretchy consistency and an unpleasant odor. During sex, bowel movements and urination, discomfort, burning in the labia area, and severe itching are typical.

There may be problems with the menstrual cycle, discharge outside the cycle, increased pain during menstruation. During intimacy, there may be bleeding with an unpleasant odor. With acute urogenital inflammation, body temperature rises and intoxication phenomena appear.

Symptoms of dysplasia

Treatment of hip dysplasia

Treatment of hip dysplasia in children includes conservative and surgical methods. It should be understood that treatment of congenital dysplasia in newborns should begin as early as possible, since the later it is started, the longer the treatment process takes and the lower its effectiveness.

As a rule, in children under one year of age, dislocation of the hip joint is relatively easy to reduce using various functional techniques. Once a child reaches 5-6 years of age, it is no longer possible to correct a dislocated hip. Early therapeutic measures are aimed at gradual correction of disrupted relationships in the joint, provided that the age-related range of motion in the joints is maintained. The main goal of treatment is to achieve stable, complete reduction of the femoral head into the acetabulum while minimizing the risk of iatrogenic damage to the articular components.

Conservative treatment

Treatment of hip dysplasia in a child begins as early as possible with conservative treatment methods, including various orthopedic structures (stirrups, devices, splints, special pillows and panties) of a soft elastic design to hold the child’s legs in abduction and flexion.

For this purpose, the devices given below are used.

Pavlik stirrups

Frejk bandage (Frejk abduction panties, Frejk splint)

They work according to the well-known principle of wide swaddling. Made of dense material, they allow you to ensure that the child’s legs are constantly spread by more than 90°. Indicated for use for dysplasia in infants in the absence of dislocation, that is, in the presence of hip subluxation (Fig. below).

Vilensky tire

Designed to be worn constantly and cannot be removed even when changing the child's clothes. It is important to carefully adjust the length of the spacer. A modification of the Vilensky splint is the CITO splint.

Tübinger splint (orthosis)

It is a design combining Pavlik stirrups and Vilensky splints (Fig. below).

Only the most common orthopedic structures used to treat dysplasia are listed. There are other options, which you can familiarize yourself with by going to a specialized forum. Each design option has its own advantages and disadvantages in different clinics, and different doctors prefer one or another design.

However, parents should not choose an orthopedic design and carry out treatment on their own, but rather rely on the recommendations and prescriptions given by an orthopedic doctor. The duration of wearing orthopedic structures is quite long and is determined by the doctor individually. We should not forget that it is prohibited to put a child on his feet without the permission of an orthopedist.

Parents need to be patient. Despite the child’s whims, under no circumstances should you be cowardly and do not remove the structure, considering that a short break in wearing them does not pose a threat, since such behavior can lead to the child’s disability in the future.

As a rule, when wearing such functional splints, gradual closed reduction occurs; if necessary, wearing the splints is supplemented by myotomy (crossing the tendon) of the adductor muscles. For treatment, in addition to orthopedic splints, special children's massage, physical therapy (physical therapy) and physiotherapy are widely used. Drug treatment is not required during this period.

In some cases, even early functional treatment of congenital hip dislocation does not lead to reduction of the femoral head into the socket and its stable retention. In such cases (if there are indications - a mature dislocation of the hip in a child from one to 5 years of age without pronounced underdevelopment of the acetabulum or displacement of the femoral head), closed reduction of the hip is performed. It is performed under anesthesia.

The doctor performs a reduction, i.e., returning the femoral head to the correct position, guided by ultrasound/radiography data, after which a plaster cast is applied to the pelvis/lower limbs for 6 months, fixing the child’s legs in an extended position. After its removal, massage, physiotherapy and therapeutic exercises are prescribed. In case of combined dysplasia of several joints of the lower extremities (hip and knee joints), along with the treatment of hip dislocation, treatment of dysplasia of the knee joints in children is carried out.

Hip dysplasia in adults

Treatment of hip dysplasia in adults is significantly difficult, which is due to the gradual (by the age of 25-30) development of hip arthrosis, and later - deforming coxarthrosis and osteochondrosis , accompanied by severe pain, disturbance of gait, posture, and a significant decrease in the range of movements in the hip joint. Treatment of the disease in adults includes medication.

To relieve pain, symptomatic therapy is used - NSAIDs ( Diclofenac , Ibuprofen , Ketoprofen , etc.). To normalize the synthesis/catabolism of glycosaminoglycans Chondroitin sulfate , Glucosamine sulfate ( Structum , Chondroxide , DONA , Rumalon , etc.) or combined chondroprotectors ( Teraflex , Artra , Artroflex ) are prescribed in courses of 2–4 months.

To improve collagen formation, it is recommended to take Solcoseryl , Vitreous , L-lysine , L-proline in combination with a complex of vitamins D2/D3 and group B, C, E, nicotinic acid , as well as micro/macroelements ( Magnerot , Magne B6 , Zinc Aspartate , Zincite , Copper sulfate , Selenium ).

Physiotherapeutic treatment, exercise therapy, and massage are provided. If necessary, orthopedic correction using special devices to reduce the load on the hip joint. In severe cases - surgical treatment, and in case of joint dysfunction - endoprosthetics.

Medicines

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Procedures and operations

Massage for hip dysplasia.

It is carried out as prescribed by an orthopedic doctor and is carried out without removing orthopedic structures. The massage is aimed at reducing/relieving increased muscle tone in the legs and improving blood circulation in the joint by actively influencing the muscles in the buttocks, back and legs. Massage for children with hip dysplasia is necessary for any degree of dysplasia.

Parents need to undergo training with a specialist and be sure to massage the child’s buttocks, joints and feet before performing physical therapy exercises. For massage, you can use only natural oil that does not contain fragrances or fragrances. The child is placed on a flat and hard surface on his back, having previously laid a blanket/diaper. It is important to follow the sequence of techniques (stroking, rubbing, kneading).

First, warm up (light massaging strokes on the surfaces of the thighs, joints, gradually moving, without pressing, to circular movements for 5 minutes). Next, applying a little effort, the sore joints are rubbed by alternating direct movements with careful circular strokes. Then the child turns over on his tummy and the lumbar area and buttocks are massaged (Fig. below). Course 10-15 sessions.

Physiotherapeutic procedures for hip dysplasia

Applications with ozokerite , electrophoresis with calcium, iodine and phosphorus, UV therapy, and salt baths are widely used.

Physiotherapy

Gymnastics is a mandatory component of treatment. In this case, a set of exercises is selected for each stage of exercise therapy (leg extension, stabilization of joints in a physiological position and rehabilitation). The most commonly used exercises are spreading the hips to the sides, rotating the hips along the axis, “bicycle”, games “ladki”, “butterfly”, imitation of crawling, exercises (swimming) in the water.

Surgery

Indications are severe displacement of the femoral head, which cannot be reduced using a closed method; child's age after 5-6 years; pinching of articular cartilage in the joint cavity, pronounced anatomical defects (underdevelopment of joint structures). Various types of surgical interventions are used:

Open reduction of dislocation through cut tissues of the thigh.
Operations on the femur (osteotomy) - dissection of the proximal end of the femur to give it the required configuration.
Reconstructive operations on the pelvic bones to create a support above the femoral head, which prevents it from moving upward.
In late diagnosed cases of hip joint dislocation with severe impairment of its function, hip replacement is performed.

The most important component of restoring joint function is rehabilitation after surgery.

Prevention

Prevention of hip dysplasia consists in the high alertness of doctors regarding newborns in mothers with a high risk of developing hip dysplasia and parents regarding the risk of developing this pathology of the hip joints. The basis of prevention is a thorough repeated examination of newborn children and monitoring them during the first year of life, and if a pathology is detected, its treatment as early as possible. It is necessary to carry out educational work so that parents know how to identify hip dysplasia in children (characteristic symptoms).

The famous pediatrician Komarovsky believes that in the presence of initial degree joint dysplasia (unstable/immature hip), proper care for the child is necessary and, above all, wide swaddling (Fig. below). Wide swaddling for hip dysplasia in infants is mandatory for all babies at risk with signs of an immature joint.

Dr. Komarovsky, as an alternative, recommends (see the forum) to use disposable diapers 1-2 sizes larger than necessary (with a wide layer of sorbent between the child’s legs). In addition, all children diagnosed with “immaturity of the hip joint” should be classified as a risk group and be registered with a pediatric orthopedist with periodic ultrasonography of the hip joints. If the dynamics are negative, the doctor prescribes the wearing of specialized orthopedic structures.

In the future, children at risk are recommended to undergo a control X-ray examination of the hip joint 1-2 times a year. Also, for such children, physical activity is limited and attendance at special orthopedic groups is recommended.

How to diagnose grade 3 dysplasia

A number of techniques are used to diagnose stage 3 cervical dysplasia:

PAP test.
PCR.
Colposcopy.
Biopsy.

The PAP test is one of the mandatory tests that a woman must undergo. A smear obtained from the cervix is examined for cytology. The number, size, shape, and location of atypical cells obtained during a smear are examined under a microscope. Based on the results of the smear, the presence of pathogens and the fact of atypical cell changes can be determined. When infected with HPV, cells have shriveled nuclei and rims.

Colposcopy allows you to visualize the changed areas and determine their boundaries. During extended colposcopy, visual signs of cervical dysplasia 3 can be identified. Additionally, a test with acetic acid and Lugol is performed. A weak solution of 3% acetic acid stains damaged tissues white, but Lugol does not stain damaged areas.

PCR analysis is carried out to detect the presence of HPV in the body, determine its subtype and the load on the body. The load can be significant or insignificant. If the test shows negative results, but altered cells are found in the smear, the woman needs further monitoring.

Biopsy is the most accurate research method that allows you to study the affected tissue and determine the presence of oncological changes. The procedure is performed in an inpatient or outpatient setting, as it involves the use of anesthesia. A biopsy can be performed using one of the following methods:

Using a scalpel. This method of taking material allows you to obtain a sample of not only damaged, but also healthy tissue for analysis.
Loop biopsy. The material is taken using a tungsten loop that is connected to a current source. This technique is considered one of the gentlest, as it does not involve direct contact with tissues.
Puncture. The most widely used technique. This is due to the fact that the material is not damaged during sampling, and the small diameter of the instrument creates a small wound.

Radio wave and laser biopsy involve sampling materials under the control of a colposcope. Precisely adjusting the device to a certain depth and area helps prevent damage to healthy tissue. These biopsy sampling techniques are most often used for dysplasia, as they allow not only to obtain samples, but also to have a therapeutic effect.

Consequences and complications

Delayed diagnosis and lack/ineffective treatment can lead to a number of complications:

Impaired functions of the hip joint.
Shortening of the injured limb.
Deformations of the glenoid cavity.
Development of pelvic asymmetry and curvature of the spinal column.
Formation of flexion-adduction contracture.
Avascular post-reposition necrosis of the femoral head .
Multiplanar deformations.
Development of hip arthrosis / dysplastic coxarthrosis .

List of sources

Lukash Yu.V., Shamik V.B. Early diagnosis of hip dysplasia in newborns // Modern problems of science and education. – 2012. – No. 6.
Sertakova A.V., Morozova O.L., Norkin I.A., Anisimov D.I. Modern ideas about the mechanisms of development of hip dysplasia in children (review). Saratov scientific and medical journal. 2011. T. 7. No. 3. P. 704–710.
Congenital dislocation of the hip in infants. Clinic, diagnosis, conservative treatment and rehabilitation / Baindurashvili A.G., Voloshin S.Yu., Krasnov A.I. – 2016
Evseev, V.I. Biomechanical substantiation of the mechanogenesis of subluxation and dislocation in hip dysplasia / V. I. Evseev, V. D. Sharpar, I. A. Komolkin // Current issues in pediatric traumatology and orthopedics. St. Petersburg, 2004. - pp. 234-237.
Goncherenko V. A., Stronina S. N., Klestova E. O. Congenital hip dislocation: frequency, structure, analysis of diagnostic and treatment methods // Young scientist. - 2021. - No. 3. — P. 257-259.