Torsion and lower limb version. Norms and anomalies

Congenital hip dislocation and dysplasia

Which doctors should I contact?

The clinical picture of the disease can be blurred, so it is imperative to visit a pediatric orthopedist in the first year of a child’s life.

Treatment of congenital hip dislocation

Treatment is selected individually for each small patient and depends on age, weight, clinical and radiological picture. Treatment is usually complex and long-term - from several months to a year.

The main task of conservative therapy is the correct comparison and fixation of the femoral head in the acetabulum in order to ensure the correct formation of the joint in the future. Standard treatment methods include:

• Wide swaddling
  - two diapers are placed between the baby’s legs, giving the position of flexion and abduction in the hip joints, and the third one fixes the legs, which allows maintaining the position of abduction and flexion at an angle of 60-80°.
• Frayka pillow (splint)
  is a special orthopedic device that is placed and secured between the child’s legs, which allows you to fix the hips in an abducted position at the required angle (90⁰ or more). Wearing a Freik splint is indicated for children under 1 year of age with pre-dislocation or subluxation of the hip to ensure the correct formation of the hip joint in case of confirmed dysplasia. In case of complete dislocation of the hip joint, the product is contraindicated.
• Pavlik's soft stirrups
  are the most gentle orthopedic product for the hip joint and the most comfortable for children and parents; they are considered the gold standard of pediatric orthopedics. It is used to reduce and fix congenital dislocation of the hip joint in a functionally advantageous position until the joint has fully matured.
• Functional rigid plaster casts
  are applied for high hip dislocation in young children, untreated subluxation in children 1-1.5 years old with the presence of adductor contracture of the hip muscles.
• Abduction splints
  can be used to completely stabilize the joint. For children over the age of 1 year, it is recommended to wear John and Korn abductor orthoses - special devices that do not allow the child to bring his legs together, but at the same time leave the possibility of independent walking. Such orthoses are worn in case of pre-dislocation or subluxation of the hip, as well as in the postoperative period for correct rehabilitation.

In parallel, physiotherapeutic treatment and, if necessary, massage are carried out.
It is worth noting that when treating hip dysplasia, a small patient does not begin to walk for a long time. At this point, it is important that parents do not force this process. The optimal age for starting conservative treatment is the first days of a child’s life. If the pathology was discovered after the child reached 1-2 years of age or with an obvious dislocation of the hip, then the effectiveness of the bandage is significantly reduced, so doctors recommend surgical intervention.

Surgical intervention is prescribed for children older than 12-24 months in case of failure or futility (in the opinion of the attending physician) of conservative therapy, as well as in the presence of complete hip dislocation. In the postoperative period, the child is advised to wear abduction orthoses, sometimes for a long period - up to 12 months.

You need to understand that congenital hip dislocation is not a simple traumatic dislocation, but a consequence of the inferiority of the hip joint itself.

In some cases, closed reduction of the dislocation helps solve the problem. This method is most effective if the child is under 24 months of age, but it does not replace subsequent wearing of abduction orthoses or even surgical intervention, since without eliminating hip dysplasia, the problem will be detected again and again. In the future, the effectiveness of closed reduction decreases, and after 5 years its use is contraindicated.

Complications

It must be remembered that untreated and untreated dysplasia, dislocations and subluxations of the hip can lead to lameness and disability. In advanced cases, we are often talking only about eliminating the pain syndrome and restoring the ability to lean on the leg.

If dysplasia is not eliminated in a timely manner, the child may develop osteochondrosis, scoliosis, poor posture, coxarthrosis, flat feet, shortening of one leg, neoarthrosis, aseptic necrosis of the femoral head and disability.

The occurrence of recurrent hip dislocations and subluxations is most often associated with early cessation of skeletal traction and premature loading on the injured limb. This entails adverse consequences that sharply disrupt the static-dynamic function of the limb, and often requires long-term, difficult and persistent rehabilitation treatment. Hip replacement can successfully solve problems, but such an operation is only possible in adult patients with an already formed skeleton.

Prevention of congenital hip dislocation

Orthopedic examination of newborns is mandatory. You cannot swaddle the baby tightly, forcefully straighten the legs, or put the baby on his feet prematurely.

The femoral head consists of cartilage tissue. The ossification core is located inside the femoral head and, gradually increasing, it seems to reinforce it from the inside and gives the structure stability under axial load. In the absence of an ossification nucleus, any axial load on the hip leads to its deformation, as a result of which subluxation and then hip dislocation can develop. Accordingly, if the ossification nucleus does not develop or develops with a delay, any axial loads are strictly prohibited: standing, much less walking, is prohibited.

The formation of ossification nuclei is influenced primarily by activity. It is recommended to do gymnastics with your baby every day immediately after birth. This should be a normal, static load, when the child lies and the mother spreads his arms and legs. We categorically do not recommend “dynamic gymnastics” - a set of exercises in which the child is twisted, twirled, rocked, rotated by the arms and legs, etc. From 2.5 months, the child can and even needs to go to the pool.

With timely treatment, it is possible to completely eliminate congenital hip dislocation or even prevent its development if dysplasia was discovered in infancy. After the first 3-4 months of a child’s life, the prognosis for the success of conservative treatment worsens, and the necessary course of therapy takes much longer.

Sources:

1. A.G. Baindurashvili, S.Yu. Voloshin, A.I. Krasnov Congenital dislocation of the hip in infants. Clinic, diagnosis, conservative treatment and rehabilitation. St. Petersburg, SpetsLit, 2016, 103 P.
2. Treatment of high congenital hip dislocation in young children. Clinical recommendations. All-Russian public organization Association of Traumatologists and Orthopedists of Russia, Moscow, 2014.
3. Kamosko M.M., Poznovich M.S. Conservative treatment of hip dysplasia. Orthopedics, traumatology and reconstructive surgery of children. Volume II. Issue 4. 2014. pp. 51-60.

IMPORTANT!

The information in this section cannot be used for self-diagnosis and self-treatment. In case of pain or other exacerbation of the disease, diagnostic tests should be prescribed only by the attending physician. To make a diagnosis and properly prescribe treatment, you should contact your doctor.

Publications in the media

Frequency - over 3% of all orthopedic diseases. It is registered more often in girls. It is 10 times more common in children born in a breech position. Unilateral hip dislocation is noted 7 times more often than bilateral hip dislocation.

Etiology : underdevelopment of the hip joint (dysplasia).

Classification. There are 3 degrees of underdevelopment of the hip joint: • 1 - preluxation (obliquity of the acetabulum, late appearance of ossification nuclei in the head of the femur, pronounced antetorsion, the head is centered in the joint) • 2 - subluxation (the femoral head is displaced outward and upward, but does not extend beyond the limbus , remaining in the joint; the center of the head does not correspond to the center of the acetabulum) • 3 - dislocation with upward displacement of the femoral head (the femoral head is displaced even more outward and upward, the limbus, due to elasticity, is wrapped in the cavity of the socket, the head of the femur is outside the articular cavity outside the limbus) .

Clinical picture

• In young children •• Asymmetry of the gluteal folds - the gluteal-femoral and popliteal folds with dislocation and subluxation are located higher than on a healthy leg •• Shortening of the lower limb •• External rotation of the lower limb, especially during sleep •• Marx-Ortolani symptom (symptom of sliding, or click) - a characteristic click of the femoral head sliding into the acetabulum when bending the legs at the knee and hip joints, followed by uniform abduction of the hips •• Dupuytren's symptom - free movement of the head both up and down •• Limitation of hip abduction. In children in the first months of life, abduction should be at least 70–90° •• Barlow's test - displacement of the femoral head when the leg is flexed at the hip joint (at an angle of 90°).

• In children over 1 year of age •• The child begins to walk later than healthy peers (by 14 months) •• With unilateral dislocation - unsteady gait, lameness; with bilateral dislocation - waddling gait (duck-like) •• Increased lumbar lordosis •• Trendelenburg's symptom - tilt of the pelvis to the affected side, drooping of the gluteal fold, tilt of the child to the healthy side when standing on the affected leg; when standing on a healthy leg, the pelvis rises •• Chassaignac's sign - an increase in the amplitude of hip abduction in the hip joint •• The head of the femur in the femoral triangle medially from the vascular bundle is not palpable •• The greater trochanter is located above the Roser-Nelaton line.

X-ray is indicated to confirm the diagnosis. Interpretation of radiographs of newborns is difficult because Until 3–6 months of life, the head of the femur and the acetabulum consist of cartilage and are not visible on the image. The medial and lateral protrusions of the femoral neck and the relationship between the upper end of the femur and the acetabulum are taken into account. For radiological diagnosis, several schemes are used • An increase in the Hilgenreiner angle formed by a horizontal line connecting both Y-shaped cartilages and a line running along the edge of the acetabulum • Putti's triad: increased bevel of the acetabulum, upward displacement of the proximal end of the femur relative to the acetabulum and late appearance ossification nuclei • Putti's diagram - a perpendicular descended from the most medial point of the femoral neck to a horizontal line connecting both Y-shaped cartilages, normally bisects the roof of the acetabulum. In case of congenital dislocation, a displacement of the intersection point to the lateral side is noted • Violation of Shenton's line, which normally runs along the superior internal border of the obturator foramen and passes into the line of the femoral neck. Violation of the correct location of the line indicates a dislocation in the hip joint. Before the appearance of the ossification nucleus of the femoral head, the medial protuberance of the femoral neck is taken as a landmark.

Treatment should be early (after 2 weeks of life)

• From the moment of birth, wide swaddling is used: between the baby’s legs, bent at the knee and hip joints and when the limb is abducted by 60–80°, 2 diapers are placed, folded in the form of a pad up to 20 cm wide, and in this position the baby’s legs are fixed with a third diaper.

• Conservative treatment: Freik pillow, Pavlik stirrups, therapeutic splints. At the same time, physiotherapy (ozokerite, mud), massage, exercise therapy (abduction of the legs, bent at the knee and hip joints, to the plane of the table; rotational movements of the hip with some axial pressure on the knee joints with the legs bent and spread apart; exercises are done 6–7 times /day [each time the child is swaddled], 15–20 exercises in one session).

• When indicating surgical treatment, the degree of anatomical changes in the hip joint should be taken into account. The optimal age for surgical treatment of congenital hip dislocation is considered to be 2–3 years.

• Types of operations •• Open reduction surgery with arthroplasty •• Reconstructive surgeries on the ilium and proximal femur without opening the joint capsule •• Combination of open reduction and reconstructive surgeries •• Alloarthroplasty •• Palliative surgeries.

ICD-10 • Q65 Congenital deformities of the hip

Torsion and lower limb version. Norms and anomalies

Torsion of the bone structure of the lower extremities affects not only gait, but also foot function. Of clinical interest are mainly femoral torsion and ankle torsion. The clinical picture of hip torsion is complicated by positional (soft tissue) relationships in the hip joint. This article describes the normal torsion of the hip bones and the position of the hip in relation to the pelvic bone. Abnormal torsional deformities of the femur and tibia are also considered. The effects of these types of torsion on foot function and gait will be described at the end of the article.

Normal femoral torsion

In healthy adults, the femoral head and neck are positioned at an angle of up to 12 degrees relative to the femoral condyles, as shown in the figure below.

Positional relationships in the hip joint (version angles)

In healthy adults, the femoral head and neck are positioned at an angle of approximately 12 degrees relative to the frontal plane of the body. In other words, the angle of the femoral head and neck is measured in relation to the posterior surface of the pelvis. Notice that the legs are pointing straight ahead. The intergluteal fold is drawn for orientation purposes only, and without anatomical accuracy. This drawing shows a normal femur that is properly “positioned” in the acetabulum. Note that the angle between the head and neck of the femur and the femoral condyles coincides with the angle between the head, neck and the frontal plane of the body.

Anteversion is an increase in the angle that the head and neck of the femur form in relation to the frontal plane of the body. Anteversion is a normal femur that is malpositioned in the acetabulum. The result of this positional position is external rotation of the lower extremity.

Retroversion is a decrease in the angle that the head and neck of the femur form in relation to the frontal plane of the body. Retroversion is a normal femur that is malpositioned in the acetabulum. The result of this positional position is internal rotation of the lower limb.

In the three previous illustrations, the angular relationship between the femoral head, neck, and femoral condyles (torsion) is normal. These three illustrations show the position of the normal femur in relation to the frontal plane of the pelvis. In the following description of hip torsion disorders, it is important to understand that the angle that the head and neck of the femur form with the frontal plane of the body is 12 degrees. In other words, the position of the head and neck in relation to the pelvis is normal, but the torsion of the bone is abnormal.

Antetorsion is the increase in the angle that the head and neck of the femur make in relation to the femoral condyles, as shown in the figure below. In the figure, this angle is shown as 30 degrees. Note that the angle that the femoral head and neck makes with respect to the frontal plane of the body is normal, and therefore antetorsion causes internal rotation of the hip.

Retrotorsion is a decrease in the angle that the head and neck of the femur form in relation to the femoral condyles. In the picture the angle is about 8 degrees. Note that the angle that the femoral head and neck makes with respect to the frontal plane of the body is normal, and therefore retrotorsion causes external rotation of the hip.

For clarity, we will illustrate the values ​​of normal torsion, retrotorsion, and antetorsion.

Remember: when talking about torsion angles, the angle that the femoral head and neck makes with respect to the femoral condyles is measured. Speaking of version, the angle that the head and neck of the femur forms in relation to the frontal plane of the body is measured.

In order not to confuse terminology and concepts, I propose the following “crutch” diagram. If antetorsion causes internal rotation of the limbs, then retrotorsion leads to external rotation of the limb. If antetorsion causes internal rotation, then anteversion (anterior displacement of the head and neck) causes the opposite, i.e., external rotation of the limb.

In healthy adults, the torsion angle is equal to the version angle. "Torsion" = "Version" = 12 degrees.

At birth, hip torsion and the position of the hip in relation to the frontal plane of the body are markedly different from those in adults. Examination of the newborn should demonstrate an externally rotated limb at an angle of approximately 30 degrees. Antetorsion = 30 degrees Anteversion = 60 degrees

The limb is rotated outward, since the angle of anteversion is 30 degrees greater than the angle of antetorsion. From birth to adulthood, anteversion decreases from 60 degrees to 12 degrees, a difference of 48 degrees. Thus, the effect of this reduction is to change the position of the limb by 48 degrees, resulting in a decrease in external rotation of the limbs. At the same time, antetorsion decreases from 30 degrees to 12 degrees - a difference of 18 degrees. The effect of this reduction in antetorsion is to reduce internal rotation of the limbs. These changes usually occur in the first six years of life, but may continue into adolescence.

Statistically, 95% of abnormal femoral torsion decreases by adolescence. From 6 years of age to adolescence, the presence of a gait with inwardly rotated toes due to internal torsion may indicate an abnormality that may not resolve into adulthood or a delay in limb development. While the clinician may have to wait until adolescence to be sure of spontaneous correction, clues may be found in the families of the child's parents. The presence of a similar gait in an adult child suggests a true torsion deformity (which will not disappear with time), while the absence of this gait in an adult child indicates delayed limb development and likely spontaneous resolution.

At birth, tibial (ankle) torsion is 0, but it soon develops with the onset of walking and weight bearing. Normal ankle torsion values ​​for adults range from 18 to 23 degrees. Decreasing this value results in foot adduction, while increasing this value results in foot abduction when walking.

Clinical picture

The following description of the clinical picture is divided into two parts. The first describes the most common foot reactions, i.e. top-down compensations, while the latter will describe the unusual but intriguing bottom-up compensations that are associated with internal femoral torsion.

With retrotorsion or anteversion, the limb will be externally rotated and the neutral rotational alignment of the hip joint will be displaced externally. The knees and feet will rotate outward and an increase in gait angle may be noted clinically. In external torsion/installation at the hip joint, a retrograde pronator force is applied to the foot and can be easily demonstrated. If you stand up, abduct your feet significantly, and lean forward then (voila!) your feet will pronate, illustrating retrograde pronator force. With antetorsion or retroversion, the limb will be internally rotated and the neutral rotational position in the hip joint will be displaced medially. The knees and feet will be turned outwardly inwards.

In this situation, the patient has three options: (a) ignore the internally rotated limb and adducted feet (b) use active muscle contractions to externally rotate the leg or (c) contract the peroneus brevis muscle to abduct the foot. In an uncomplicated situation, in the case of internal installation of the limb, a retrograde supination force acts on the foot. (Stand up, bring your feet and lean forward and (voila!) your feet supinate). The problem when walking with adducted feet is mainly cosmetic, not functional, the feet cope well with the load.

A gait with the toes turned inwards is generally unacceptable for adults and children. Parents or the child begin to understand that the gait is specific and try to change the position of the feet while walking. The limb can be rotated outward by contracting the thigh muscles, but this takes too much muscle effort. It is much easier and more effective to abduct the feet while walking by contracting the peroneus brevis muscle. The peroneus brevis muscle, which is involved in the support phase of the step, begins to be used in the swing phase of the leg for abduction of the foot.

Unfortunately, it turns out that the foot is abducted and pronated during the swing phase, abducted and pronated throughout the entire support phase, starting with support on the heel and ending with pushing off with the toes. This is an open kinetic chain of foot pronation. A foot that never supinates is a pathological foot, with symptoms and subluxation of the joints. Shoe wear is quite specific: excessive wear on the medial heel and medial forefoot. Shoes quickly become unusable.

Thus, with the internal positioning of the limbs, one can see two extremes: a child/adult with adduction of the feet during walking and a retrograde supination force on the foot, or a relatively normal gait angle with subluxation of the feet due to the open kinetic chain of contraction of the peroneus brevis muscle.

When using arch supports to treat flat feet, cosmetic problems may arise due to the internal placement of the limbs. Controlling foot pronation using conventional arch supports leads to adduction of the feet. Both adults and children should be informed of this consequence.

Compensation upwards is very difficult. As mentioned previously, downward compensation due to internal hip torsion (antetorsion) causes 2 extremes of foot function: an adducted gait (with relatively good foot function) or very flat feet (open pronation kinetic chain) with a relatively normal gait angle. Upward compensations, as a rule, occur with unilateral internal torsion or asymmetrical bilateral internal torsion, i.e. when one limb is rotated more than the other.

The figure below illustrates unilateral internal femoral torsion on the right limb. The first illustration shows the pelvis, its plane of motion (straight forward), normal left limb, and internal rotation of the right limb. The right foot may be adducted or may be in secondary subluxation due to the open kinetic chain of pronation.

In the second picture (same scenario - internal torsion of only the right limb), the patient learned to move the opposite hip forward (upward compensation). Despite the deviation of the pelvis, the line of movement of the body remains straight. Note that the right leg is parallel to the plane of movement - reducing the need to compensate through the right foot. The most interesting thing happens in the left limb. The left leg is now in internal rotation relative to the plane of motion, but is normally positioned relative to the pelvis. Please note that the leg on the side opposite to the deformity is rotated medially (foot adducted) relative to the plane of movement.

Clinically, the left foot may be adducted and relatively stable. At the other extreme, the left foot may be subluxated due to the open kinetic chain of pronation (an attempt to improve the angle of gait). In this last example, one may note flat feet on the side opposite to the main deformity of the limb.

Anterior displacement of the hip joint (upward compensation) will also occur with bilateral but asymmetrical internal torsion, or, in other words, when one limb is twisted more inward than the other. In these cases, the anterior displacement of the hip joint is always on the side opposite to the main deformity. The anterior extension of the hip joint can be easily seen by the gait. During heel contact, the pelvis on this side moves forward further than on the opposite side.