Hip dysplasia in children under 1 year of age

Hip dysplasia in newborns (infants)

Hip dysplasia is a congenital defect of the joint that can lead to joint damage. Dysplasia in newborns is the direct cause of congenital hip dislocation. This pathology, in turn, can lead to changes in gait, chronic pain syndrome and significantly limit mobility in the future.

The newborn itself (a newborn is a child in the first 28 days of life) is not bothered by dysplasia; Parents and doctors identify the disease based on external symptoms, and not on the basis of the baby’s crying or restlessness. If the pathology is not treated on time, it leads to deformation of the musculoskeletal system, disruption of the formation of the musculoskeletal system and disability. The disease can affect one leg (usually) or both. Boys suffer from hip dysplasia 7 times less often than girls.

What it is?

Today, hip dysplasia is considered the most common pathology of the musculoskeletal system in newborns and infants. “Dysplasia” translated means “improper growth,” in this case of one or both hip joints.

The development of the disease is associated with disruption of the formation of the main joint structures in the prenatal period:

• ligamentous apparatus;
• bone structures and cartilage;
• muscles;
• change in the innervation of the joint.

Most often, hip dysplasia in newborns and the treatment of this pathology is associated with a change in the location of the femoral head in relation to the bony pelvic ring. Therefore, in medicine this disease is called congenital hip dislocation.

Treatment must begin from the moment the pathology is diagnosed, the earlier the better, and before the baby begins to walk - from this moment irreversible complications appear. They are associated with an increasing load on the joint and the exit of the bone head completely from the acetabulum with an upward or sideways displacement.

The child develops changes when walking: a “duck” gait, significant shortening of the limb, compensatory curvature of the spine. These disorders can only be corrected through surgery. With pronounced changes in the joint, the baby may remain disabled for life.

Why hip dysplasia occurs: causes and mechanisms of development

A whole range of reasons lead to the occurrence of hip dysplasia. Under certain circumstances, the likelihood of its occurrence increases several times. Predisposing factors:

1. Hereditary predisposition - in children whose parents suffered from dysplasia, it occurs 12 times more often.
2. Breech presentation of the fetus increases the likelihood of developing hip dysplasia by 10 times.
3. Toxicosis of pregnant women.
4. Oligohydramnios during pregnancy.
5. Multiple pregnancy.
6. High baby weight at birth.
7. Drug correction of pregnancy (administration of various medications to maintain pregnancy).

There are several theories about the occurrence of hip dysplasia. Within the framework of the hormonal theory, it is assumed that one of the key factors in the development of pathology is an imbalance between estrogen and progesterone. In an experiment on rats (https://link.springer.com/article/10.1007/BF00266341) it was shown that increased estrogen levels prevent the development of dysplasia, while increased progesterone concentrations promote its formation.

Within the framework of the mechanical theory, great importance is attached to the mechanical factors acting on the fetus during the period of its intensive growth. Thus, the large size of the fetus and its breech presentation are accompanied by a more intense effect of deforming forces on the hip joint. Which ultimately leads to its instability, dislocation or subluxation.

This is interesting! In peoples whose traditions include tight swaddling of children, hip dysplasia is more common (https://www.sciencedirect.com/science/article/abs/pii/S0031395514001461?via%3Dihub).

The mechanism of development of hip dysplasia is directly related to its anatomical and physiological characteristics in children. In children, the acetabulum is flatter, it is located almost vertically (in adults - obliquely), the ligamentous apparatus is more elastic. The head of the femur is held in the acetabulum by the round ligament, labrum and ligamentous apparatus.

Depending on which element of the hip joint is predominantly affected, the following forms of dysplasia are distinguished:

1. Acetabular - associated with impaired development of the acetabulum itself.
2. Rotational dysplasia is caused by a violation of bone geometry in the horizontal plane.
3. Dysplasia associated with underdevelopment of the upper femur.

Disturbances in the development of one of the above-mentioned elements of the hip joint lead to the fact that the head of the femur cannot remain in the acetabulum - it moves outward and upward. When the articular surface of the head partially extends beyond the socket, subluxation of the head develops. As the process progresses, the articular surfaces of the socket and head lose contact, and the articular lip is tucked inside the joint - this is how true hip dislocation develops.

Statistics

Hip dysplasia is common in all countries (2 - 3%), but there are racial and ethnic characteristics of its distribution. For example, the incidence of congenital underdevelopment of the hip joints in newborn children in Scandinavian countries reaches 4%, in Germany - 2%, in the USA it is higher among the white population than African Americans, and is 1 - 2%, among American Indians, hip dislocation occurs in 25- 50 per 1000, while congenital hip dislocation almost never occurs among South American Indians, southern Chinese and Africans.

A connection between morbidity and environmental problems has been noted. The incidence in the Russian Federation is approximately 2 - 3%, and in environmentally unfavorable regions up to 12%. Statistics on dysplasia are contradictory. Thus, in Ukraine (2004), congenital dysplasia, subluxation and dislocation of the hip occur in 50 to 200 cases per 1000 (5 - 20%) newborns, that is, significantly (5-10 times) higher than in the same territory during the Soviet period.

A direct connection has been noted between the increased incidence and the tradition of tightly swaddling the baby's straightened legs. Among peoples living in the tropics, newborns are not swaddled, their freedom of movement is not limited, they are carried on their backs (while the child’s legs are in a state of flexion and abduction), the incidence is lower. For example, in Japan, as part of a national project in 1975, the national tradition of tightly swaddling the straightened legs of infants was changed. The training program was aimed at grandmothers to prevent traditional swaddling of babies. As a result, there was a decrease in congenital hip dislocation from 1.1-3.5 to 0.2%.

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

Until the first half of the last century, only the severe form of dysplasia, congenital hip dislocation (3-4 cases per 1000 births) was taken into account. In those years, “mild forms” of dysplasia were not detected or treated. From the 70s - 90s. The term “hip dysplasia” is used, meaning not only dislocation, but also preluxation and subluxation of the hip joint. The incidence numbers have increased tenfold.

It should be noted that the lack of clear standards and the fear of missing severe orthopedic pathology is the reason for overdiagnosis (20-30% at the pre-dislocation stage). The dilemma of “immature hip joint and preluxation” is usually resolved in favor of dysplasia, which increases morbidity figures.

Indications and contraindications

To determine normal values ​​or deviations from it, ultrasound of the hip joint in newborns is indicated for all children under 6 months. It is often carried out within a few days after the birth of the child, especially if during pregnancy the woman’s body was affected by external or internal unfavorable factors. Here are the main indications for ultrasound of a newborn:

• a premature baby, the likelihood of developing dysplasia is quite high. The risk group also includes children from multiple pregnancies;
• gluteal or pelvic position of the fetus before childbirth, causing congenital dislocation of the joint;
• difficult pregnancy, especially complicated by severe toxicosis or deficiency of vitamins and microelements;
• a woman taking drugs belonging to various clinical and pharmacological groups during pregnancy - antibiotics, diuretics, cytostatics, immunomodulators, antivirals;
• Acute viral, bacterial or mycotic infections suffered by a woman during pregnancy. Intestinal or respiratory pathologies are especially dangerous in the 2nd and 3rd trimesters, when the fetal hip joint begins to form and foci of ossification nuclei of the articular heads form.

Any of these factors can cause the development of dysplasia. An ultrasound is performed either directly in the maternity hospital, or a few days after the mother and baby are discharged.

After birth, the child is examined by a pediatrician 1-2 times a month to monitor his development. He may prescribe an ultrasound examination if one of the signs of impaired articulation formation is detected: asymmetrical arrangement of skin folds in the groin or buttocks, shortening of the leg, specific clicking during abduction of the child’s hip.

Causes of dysplasia

Underdevelopment and improper formation of the hip joint occur when the intrauterine development of a child is disrupted due to disturbances in the formation, development and differentiation of the baby’s musculoskeletal system (from 4-5 weeks of intrauterine development until the formation of full walking).

Reasons that negatively affect the fetus and disrupt organogenesis:

• gene mutations, as a result of which orthopedic deviations develop with disturbances of the primary anlage and the formation of defects in the hip joints of the embryo;
• exposure to negative physical and chemical agents directly on the fetus (ionizing radiation, pesticides, use of medications);
• a large fetus or breech presentation, causing displacement in the joints due to a violation of the anatomical norms of the location of the child in the uterus;
• disturbance of water-salt metabolism in the fetus due to kidney pathology and intrauterine infections.

Factors that negatively affect the development of the fetus and cause the formation of dysplasia on the mother’s side are:

• severe somatic diseases during pregnancy - cardiac dysfunction and vascular pathology, severe kidney and liver diseases, heart defects;
• vitamin deficiency, anemia;
• violation of metabolic processes;
• severe infectious and viral diseases suffered during pregnancy;
• unhealthy lifestyle, unhealthy diet and bad habits (smoking, drug addiction, drinking alcohol);
• early or late toxicosis.

In the risk group for the development of this pathology, contributing to the early diagnosis of dysplasia in infants. At the same time, even in the maternity hospital, the neonatologist and pediatrician at the site observe the baby more actively.

This group primarily includes premature babies, large children, with a breech presentation of the fetus, a pathological pregnancy and with a family history. It should be noted that this pathology occurs more often in girls than in boys.

Also, in addition to true dysplasia, infants (impaired development of the joint) may exhibit immaturity of the joint (slow development), which is considered a borderline state for the development of dislocation of the hip joint.

Treatment prognosis

Timely and high-quality treatment of pathological changes implies positive prognoses.

The absence or insufficiency of treatment, deviation from the course determined by the attending physician, or refusal of therapeutic procedures can lead to serious consequences, including the development of severe deforming arthrosis.

There are cases when patients with dysplasia live without knowing they have the disease. In a situation where pathology is detected by chance during an X-ray examination, it is important to ensure constant monitoring by an orthopedist (at least once a year).

In order to preserve the quality of life, it is recommended to conduct timely preventive examinations of all newborns, as well as to implement complete and timely treatment of the identified disease.

Symptoms of dysplasia

When examining a baby, pay attention to the following signs (see photo):

• position and size of the lower extremities;
• position of skin folds in the thigh area (symmetrical or asymmetrical);
• muscle tone;
• volume of active and passive movements.

Hip dysplasia in infants manifests itself with characteristic symptoms.

1. Limitation of hip abduction. Childhood hip dysplasia is manifested by limited abduction to 80 degrees or less. The symptom is most typical for unilateral lesions.
2. Slipping symptom (synonym: clicking symptom). The child is placed on his back, bending his legs at both the knee and hip joints at an angle of 90 degrees (the examiner’s thumbs are placed on the inner surface of the thighs, the remaining fingers are on the outer surface). When the hips are abducted, pressure is applied to the greater trochanter, resulting in the reduction of the femoral head. The process is accompanied by a characteristic click.
3. External rotation of the lower extremity is a sign characterized by outward rotation of the hip on the affected side. It can also occur in healthy children.
4. Relative shortening of the limb. The symptom is rare in newborns and is observed with high dislocations.
5. The asymmetrical position of the femoral and gluteal folds is revealed during an external examination.

Secondary (auxiliary) signs of hip dysplasia in a newborn:

• atrophy of soft tissues (muscles) on the affected side;
• pulsation of the femoral artery is reduced on the side of the dysplastic joint.

Asymptomatic cases of congenital hip dislocation are rare.

Diagnostics

The diagnosis usually occurs in the maternity hospital, in accordance with the signs of hip dysplasia in children, but can also be made at a later date. The issue of diagnosis can be dealt with by a pediatrician or highly specialized specialists, including a pediatric orthopedist.

If it is necessary to clarify the features, additional research methods are used. Let's look at them in more detail.

X-ray diagnostics

Children have certain structural features of the spine, which implies the absence of ossification of some components of the hip joint. In place of the femur and pelvic bone there is cartilaginous tissue, which is quite difficult to x-ray.

In order to assess the correct configuration of anatomical structures, special schemes are used, which include performing radiography in a direct projection with drawing auxiliary lines that have a name and are outlined in a certain place:

• midline – a vertical straight line passing through the middle of the sacrum;
• Hilgenreiner's line is a horizontal straight line passing through the upper outer edge of the acetabulum;
• Perkin's line is a vertical straight line passing through the upper outer edge of the acetabulum;
• Shenton's line is straight, continuing the edge of the obturator foramen of the pelvic joint.

The level of formation of the hip joint is determined by the acetabular angle, the normal indicators of which are considered to be:

• at birth – 25-29°;
• per year - for boys up to 18.5°, for girls up to 20°;
• at 5 years of age – 15°, regardless of gender.

Ultrasound diagnostics

Ultrasound diagnostics involves the use of ultrasonography and is actively used in the diagnosis of children under 1 year of age.

The key advantage of this technique is obtaining optimally accurate results, without causing harm to the child’s body. There are no contraindications to this type of procedure.

Indications for ultrasonography are considered to be:

• the presence of factors that include the patient at risk;
• determination of characteristic features.

During the diagnostic process, the doctor takes a picture, the results of which are in many ways similar to the results of an x-ray examination in the anteroposterior projection.

When forming a conclusion for a diagnostic procedure of the presented type, the following indicators are assessed:

• alpha angle – gives an assessment of the degree of formation and allows you to determine the inclination of the acetabulum (its bony part);
• beta angle - helps to assess the degree of formation and the angle of inclination of the acetabulum (its cartilaginous part).

Ultrasound is the preferred research method for suspected dysplasia in young children, due to the safety and informativeness of the results.

Severity of traffic accidents

1. I degree – pre-dislocation. A developmental deviation in which the muscles and ligaments are not changed, the head is located inside the beveled cavity of the joint.
2. II degree – subluxation. Only part of the femoral head is located inside the articulation cavity, as it moves upward. The ligaments are stretched and lose tension.
3. III degree – dislocation. The head of the femur comes completely out of the socket and is located higher. The ligaments are tense and stretched, and the cartilaginous rim fits inside the joint.

Diagnostics

In a baby, signs of hip dysplasia in the form of a dislocation can be diagnosed in the maternity hospital. The neonatologist should carefully examine the child for the presence of such abnormalities in certain pregnancy complications.

The risk group includes children who belong to the category of large children, children with deformed feet and those with heredity burdened by this characteristic. In addition, attention is paid to toxicosis of pregnancy in the mother and the gender of the child. Newborn girls are subject to mandatory examination.

Examination methods:

1. Ultrasound diagnostics is an effective method for identifying abnormalities in the structure of joints in children in the first three months of life. Ultrasound can be performed multiple times and is acceptable when examining newborns. The specialist pays attention to the condition of the cartilage, bones, joints, and calculates the angle of the hip joint.
2. Arthroscopy and arthrography are performed in severe, advanced cases of dysplasia. These invasive techniques require general anesthesia to obtain detailed information about the joint.
3. CT and MRI provide a complete picture of pathological changes in the joints in various projections. The need for such an examination appears when planning surgical intervention.
4. The X-ray image is not inferior in reliability to ultrasound diagnostics, but has a number of significant limitations. The hip joint in children under seven months of age is poorly visible due to the low level of ossification of these tissues. Radiation is not recommended for children in their first year of life. In addition, placing an active baby under the device while maintaining symmetry is problematic.
5. External examination and palpation are carried out to identify characteristic symptoms of the disease. In infants, hip dysplasia has signs of both dislocation and subluxation, which are difficult to identify clinically. Any symptoms of abnormalities require a more detailed instrumental examination.

How to put on and wear splints correctly?

Based on the type of orthopedic mechanisms, features are distinguished in their use so that the baby is comfortable. First, you need to choose the right spacer size: focus on the age of the children and the degree of dysplasia. All straps must be carefully secured, the splint should be laced tightly enough, but not to squeeze the child’s blood vessels.

The Vilensky splint must be worn continuously for about six months.

Also pay attention to the frequency of wearing the retainers. For example, a Vilensky splint is prescribed for 4-6 months. It cannot be removed during the entire course, except for the time required for swimming. It is also important to clearly regulate the degree of abduction of the baby’s hips. This can be done using a special wheel. It may move during children's activities, so do not forget to secure it with electrical tape.

Trust your child's doctor to put on the spacer for the first time.

To make fitting easier, place your baby on his back and spread his hips in different directions. Thread the legs through the straps one at a time and secure well. Do not rely only on your knowledge; record the sequence of putting it on at an appointment with an orthopedist. The main thing is to choose from the entire list of tires the one that matches the age and health status of the little patient.

Consequences

If there is no treatment, then at an early age this can threaten the child with serious troubles. Children develop a limp when walking; it can be either barely noticeable or pronounced. Also, the baby will not be able to move his leg to the side, or will do it with great difficulty. The child will be bothered by constant pain in the knees and pelvis with possible bone distortion. Depending on the severity of the symptoms of dysplasia, children experience muscle atrophy of varying severity.

Gradually, as the child grows, the consequences of untreated dysplasia will worsen and be expressed in the development of the so-called “duck gait,” when the baby rolls from one leg to the other, protruding the pelvis back. The motor activity of such a child will be limited, which will entail underdevelopment not only of other joints, but will also affect the functioning of all organs and overall physical development. In the future, the leg muscles can completely atrophy, and the person will begin to be haunted by constant, incessant pain. In adult patients, hyperlordosis of the spine in the lumbar region is observed. All organs located in the pelvic area are also affected.

All this can be avoided if you start treatment on time and follow preventive measures.

Treatment of hip dysplasia in newborns

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

• giving the limb an ideal position for reduction (flexion and abduction);
• start as early as possible;
• maintaining active movements;
• long-term continuous therapy;
• the use of additional methods of influence (therapeutic gymnastics, massage, physiotherapy).

It was noticed quite a long time ago that when the child’s legs are positioned in an abducted state, self-reduction of the dislocation and centering of the femoral head are observed. This feature forms the basis for all currently existing methods of conservative treatment (wide swaddling, Freik's pillow, Pavlik stirrups, etc.).

1. Without adequate treatment, hip dysplasia in adolescents and adults leads to early disability, and the result of therapy directly depends on the timing of the start of treatment. Therefore, primary diagnosis is carried out in the maternity hospital in the first days of the baby’s life.
2. Today, scientists and clinicians have come to the conclusion that it is inadmissible to use rigid fixing orthopedic structures that limit movement in 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 ultrasound and X-ray control.

Treatment methods

Therapy is aimed at the correct further formation of the hip joint in newborns. Only an integrated approach is used using all conservative methods of treating dysplasia. They complement each other, enhance and prolong the therapeutic effect.

Plastering

If dysplasia of high severity is detected, treatment is carried out by simultaneous reduction of the dislocation with further immobilization of the limb by casting. Orthopedists perform such manipulation only when the child reaches 2 years of age. Treatment can also be supplemented with skeletal traction.

Orthopedic devices

Orthopedic correction is the most effective method of treating underdevelopment of the hip joint of any severity. Long-term, often constant use of devices contributes to the correct formation of the hip joint, a gradual increase in range of motion, and restoration of all its functions.

Pavlik stirrups

Pavlik stirrups are the first soft orthopedic structure that began to be used in the treatment of pathology. It is still in demand today, as it does not unduly restrict freedom of movement in the hip joints. Pavlik stirrups consist of a chest bandage attached to the body with straps, small soft pads on the knees and straps connecting all parts of the product into one. Depending on the severity of the pathology, the device is worn for a period of 2 to 12 hours a day.

Freyka's pillow

Freika's pillow is a soft orthopedic product that fixes and holds children's legs bent at the knees in an extended position. Its design includes a thick knee roller, straps and fasteners for securely attaching the device to the child’s body. Freyka's pillow can be used in the treatment of dysplasia from 1 month. It is usually worn during the day and removed before bed. But with congenital dislocation, round-the-clock wearing is often indicated.

Vilensky tire

The Vilensky splint is an orthopedic device in the form of a leg spacer, equipped with fixing straps and lacing. The design also includes a regulator, with which the doctor adjusts the angle of hip abduction. The Vilensky splint is more often used in the treatment of severe underdevelopment of the hip joint. The device is designed to be worn around the clock for 3-6 months.

Tübinger tire

The Tübinger splint is an abductor orthopedic mechanism for the treatment of dysplasia in infants from birth to 1 year. The main components of the device are soft shoulder pads, hip pads, an adjustable spacer, white and red fasteners, and threads with beads. The Tübinger splint is used for continuous wear with short breaks for hygiene procedures.

Tire Volkova

The Volkov splint is an orthopedic product made of polyethylene, consisting of a bed for the back, an upper part that fits on the stomach and side elements that fix the legs and hips. The wearing regimen is determined individually depending on the severity of the pathology and the age of the child. The Volkov splint has recently been almost never used due to the lack of a regulating mechanism in the design and severe limitation of movements.

https://youtu.be/neMJT10nV6Y

Gymnastic and massage techniques

Therapeutic gymnastics is used from the first days of therapy. Regular exercises help strengthen the muscles, ligamentous-tendon apparatus, and maintain the femoral head in the acetabulum. When choosing exercises, the doctor takes into account the child’s age, his general health, as well as the current stage of therapy - leg extension, hip joint stabilization or rehabilitation. A referral to a professional massage therapist specializing in the treatment of dysplasia to treat the gluteal muscles is required.

Physiotherapy

Throughout the treatment of dysplasia in newborns, physiotherapeutic procedures are carried out - magnetic therapy, laser therapy, hyperbaric oxygenation, amplipulse therapy, ultrasound therapy. Under the influence of physical activity, the blood supply to tissues with nutrients necessary for the proper formation of bone and cartilaginous structures of the hip joint improves.

Surgery

If conservative therapy is ineffective and there is severe deformation of the hip joint elements, surgical treatment is indicated. More often, open reduction of the dislocation is performed - dissection of the articular capsule followed by installation of the femoral head in the acetabulum. Surgical methods for treating dysplasia also include osteotomy, which is performed to give the proximal end of the femur the correct configuration.

Wide swaddling of baby

Wide swaddling can rather be attributed not to therapeutic, but to preventive measures for hip dysplasia.

Indications for wide swaddling:

• the child is at risk for hip dysplasia;
• During an ultrasound scan, immaturity of the hip joint was revealed in a newborn child;
• there is hip dysplasia, while other treatment methods are impossible for one reason or another.

Wide swaddling technique:

• the child is placed on his back;
• two diapers are placed between the legs, which will limit the bringing of the legs together;
• These two diapers are fixed on the child’s belt with the third one.

Loose swaddling allows you to keep the baby's legs apart at approximately 60 - 80°.

Diagnosis of dysplasia in children

You can suspect hip dysplasia in a newborn child while still in the maternity hospital. If a pathology is suspected, doctors definitely recommend contacting a pediatric orthopedist within 3 weeks after discharge. Children with a questionable diagnosis and the presence of a large number of risk factors are examined by a specialist every 3 months.

Diagnosis of hip dysplasia in children includes:

1. Clinical examination of a child by an orthopedist. During the examination, the doctor evaluates the symmetry of the legs and determines the presence or absence of the Marx-Ortolani symptom.
2. X-ray of the hip joints. It is performed only on children older than 3 months, since this diagnostic method is not effective at a younger age.
3. Ultrasonography of the hip joint is the “gold standard” for diagnosing dysplasia.

The final diagnosis is made only if clinical signs are present in combination with instrumentally identified pathological changes in the joints.

Massage and exercise therapy

Exercises and massage are performed before feeding: these procedures stimulate blood circulation and improve nutrition of the structures of the hip joint. As a result, the growth processes of cartilage and bone tissue are stimulated, nerve conduction is enhanced - and the joint is formed correctly.

Massage movements are performed smoothly and gently. Apply stroking, rubbing and kneading the muscles of the thighs, buttocks, and lower back. The newborn is laid out on both his back and stomach. The duration of the massage is about 5 minutes. After the procedure, you can leave him to lie on his stomach for some time so that his legs hang down to the sides. This hardens and further strengthens the body.

A set of exercises is selected by a physical therapy doctor or pediatrician according to the degree of development of the disease. Most often this is: abduction of bent legs to the sides (contraindicated in slip syndrome), flexion and extension in the hip and knee joints. The movements are performed very smoothly. At first, they are recommended to be done in water, while swimming. The duration of the gymnastics is also about 5 minutes.

To work with a newborn at home, parents need to attend massage and exercise therapy courses at the clinic.

Prognosis and complications

With timely treatment, the prognosis is favorable. If for some reason therapy was carried out late, then there is a possibility of developing coxarthrosis in adults - arthrosis of the hip joint. Unreduced hip dislocations are also dangerous. Over time, a “false” joint forms in combination with shortening of the leg and pathological changes in the muscles.

Wearing various orthopedic devices

Freik's pillow, Pavlik's stirrups and others. All this also helps to keep the baby's legs spread and bent. It is this method of treating hip dysplasia in infants that seems blasphemous to many parents, since they have to constantly see their baby “shackled” in orthopedic spacers.

It is worth remembering that this measure is necessary, but temporary, and should be treated with patience and understanding. The child's initial discomfort goes away within about a week, then he gets used to it and no longer feels any discomfort from wearing the splint. The duration of use of such devices is determined by the doctor based on periodic examinations and ultrasound diagnostics.

Benefits of Sonography

When conducting an ultrasound examination, high-frequency acoustic waves are reflected from surfaces encountered in their path. All tissues in the human body have their own special structure. They differ in density, contain a certain amount of liquid, and therefore differ significantly in the speed of reflection. These values ​​are read by special sensors and then visualized on the monitor in the form of images. An experienced diagnostician, when interpreting an ultrasound of the hip joints in infants, identifies ligaments, tendons, bone, and cartilaginous tissues, and then assesses their condition. Ultrasound has many advantages over other methods of studying the hip joint in young children:

• there is no aggressive and extremely undesirable radiation when examining newborns;
• one of the parents is present during the diagnostic procedure, hold and calm the baby;
• there is no need for the child to be in a stationary position, so the doctor can assess the state of the joint in dynamics.

3% of newborns are diagnosed with congenital dysplasia of varying degrees. This is the name for defective one- or two-sided development of the hip joints, which is characterized by a decrease in the functional activity of the joint. The disease is highly treatable, especially if diagnosed early. The resulting images make it possible to determine the shape and degree of dysplasia, and differentiate it from other congenital pathologies. What can be diagnosed using ultrasound:

• improper development of the acetabulum;
• underdevelopment of the cartilaginous rims surrounded by the acetabulum;
• broken ligament structure;
• degrees of dysplasia - preluxations, subluxations, complete dislocations.

If any form of dysplasia is detected, doctors immediately begin therapy. To assess its effectiveness, frequent ultrasound examinations of the hip joints in infants are required. This is another advantage of the diagnostic technique. Unlike radiography, sonography can be used to constantly monitor the baby’s condition and the rate of tissue regeneration. The diagnostic procedure has only one contraindication - the child’s hypersensitivity to the ingredients of the gel used to conduct acoustic signals.

X-ray examination is also less informative due to the structural features of the hip joint in newborns. There is still little bone tissue in it, but a lot of cartilaginous tissue. And in the images obtained during radiography, only the pathological state of the bone structures is clearly visible.

Physiotherapy

Many physiotherapeutic procedures are used that eliminate the inflammatory reaction, improve joint trophism and reduce joint pain. The most commonly used procedures are:

Features of caring for newborns with dysplasia

With the right approach to treatment and care, dysplasia in newborns can be overcome. If your baby has disorders in the development of the hip joints, then he needs daily care and constant observance of special rules when carrying, feeding, and putting to bed.

1. Hip dysplasia in newborns eliminates vertical loads on the legs.
2. If the child is in a lying position, then his feet should hang slightly, this way better relieves tension from the thigh muscles.
3. Transportation by car in a special child seat that does not interfere with the wide spread of the legs.
4. The correct position when carrying in your arms: hold the baby in front of you by the back, while his legs should tightly grasp you from behind.
5. Make sure that when feeding and sitting down, the hips are separated as much as possible.

The hip joint is an important supporting element of the human skeleton. He is constantly exposed to heavy loads when carrying heavy loads, running, and long walks. It is necessary to monitor the correct full development of this joint from infancy, otherwise in adult life the disease will still make itself felt, but it will be much more difficult to cure than dysplasia in newborns.

Carrying out a diagnostic procedure

During an ultrasound, the child is placed on his side so that the examined joint is on top and bent at an angle of 20°. A gel is applied to the hip joint to facilitate the sliding of the sensor and improve the conductivity of acoustic waves. During manipulations, all articular and periarticular structures are displayed on the screen. The doctor takes pictures in the positions necessary to assess the condition of the tissues. Usually there are five of them: in the initial position, when bending and extending the leg, when abducting and bringing it to the body.

To prevent the procedure from being interrupted, pediatricians who prescribe a referral for sonography recommend not feeding the baby immediately before the examination. The child must be well-fed so as not to be capricious, but the process of regurgitation can interfere with diagnosis.

Reduction of congenital hip dislocation

Indications for reduction of congenital hip dislocation:

1. The child is over 1 year old. Before this, the dislocation is relatively easily reduced using functional techniques (splints and orthoses, see above). But there is no single unambiguous algorithm. Sometimes a dislocation after 3 months of age cannot be corrected by any means other than surgery.
2. The child's age is no more than 5 years. At an older age, it is usually necessary to resort to surgery.
3. The presence of a mature hip dislocation, which is determined by radiography and/or ultrasound.

Contraindications to closed reduction of congenital hip dislocation:

1. Severe underdevelopment of the acetabulum;
2. Severe displacement of the head of the femur, inversion of the articular capsule into the joint cavity.

Closed reduction for congenital hip dislocation is performed under anesthesia. The doctor, guided by X-ray and ultrasound data, performs a reduction - returning the femoral head to the correct position. Then, for 6 months, a coxite (on the pelvis and lower limbs) plaster cast is applied, which fixes the child’s legs in an extended position. After removing the bandage, massage, therapeutic exercises, and physiotherapy are performed.

However, some children develop a relapse after closed reduction of congenital hip dislocation. The older the child, the more likely it is that surgery will eventually be necessary.

How to diagnose

The primary diagnosis is made on the basis of an external examination of the newborn and a series of functional tests to assess muscle strength, sensitivity, and range of motion. But even if characteristic signs of hip dysplasia are detected, additional diagnostic measures are required.

Instrumental

The diagnosis is clarified using radiography and (or) ultrasound examination of the hip joint. Ultrasound is informative in detecting joint underdevelopment in children from the first days of life. X-rays are carried out only after they reach 2-3 months, since the resulting images do not visualize non-ossified cartilaginous structures.

Differential

Symptoms of hip dysplasia may mask other diseases of the musculoskeletal system. X-ray and ultrasound examinations are also carried out as a differential diagnosis to exclude pathological and paralytic hip dislocation, metaphyseal fracture, arthrogryposis, rickets, and epiphyseal osteodysplasia.

Prevention of pathology

If you do not want dysplasia to appear in your baby, you must take certain precautions:

1. Taking vitamins, proper nutrition, light physical activity during pregnancy.
2. Constantly following your doctor's recommendations during pregnancy. In this case, an important element of the examination is ultrasound, which can show health problems at an early stage of fetal development.
3. Postpartum examination by an orthopedist, as well as an ultrasound of the hip joint.
4. It is necessary to eliminate the causes that can lead to the appearance of pathology and provoke dislocation.
5. The use of therapeutic exercises and regular physical activity, which will help place and fix the bone in place.
6. Carrying a baby in a sling, as well as using wide swaddling.
7. If the diagnosis of “dysplasia” is nevertheless made, then the baby cannot be put on his feet until the doctor allows it.

Modern methods of diagnosing and treating hip dysplasia are still far from perfect. In outpatient settings (clinics), cases of underdiagnosis (the diagnosis is not made in time for existing pathology) and overdiagnosis (the diagnosis is made in healthy children) are still common.

Many orthopedic structures and surgical treatment options have been proposed. But none of them can be called completely perfect. There is always a certain risk of relapses and complications. Different clinics practice different approaches to the diagnosis and treatment of pathology. Currently, research continues to be actively conducted.

spacers for children with dysplasia

Why would an orthopedist treat a problem that doesn’t exist? Because he must support a huge industry, which includes manufacturers and sellers of supposedly “correct” shoes and insoles, massage therapists.

I warn you right away that my opinion is unprofessional, incompetent, emotional and, apparently, unpopular in Russia. I’m just Masha, who knows how to google, analyze information and observe what kind of shoes foreign children wear. And I want to tell you that, in addition to the domestic school of orthopedics, there are some other points of view and they are very common throughout the civilized world.

You can swear, you can disagree, you can consider me a fool, you can breathe a sigh of relief, you can thank me, I’m still not responsible for my words)

***

Every orthopedist in Varina’s life said: “flat-valgus placement of the feet. The right shoes, massage, exercise therapy.” Particularly sophisticated ones recommended paraffin, electrical stimulation, standing on peas, cutting off the soles of sandals on an incline.

Of course, I bought supposedly correct orthopedic shoes with high, hard heels, arch support, heels and other crap. We had a massage once every six months. I haven't seen any improvement.

As usually happens, the truth was born from doubt

Varina's last correct sandals ran out when we were getting ready to go abroad. I didn’t have time to order ortho shoes in Russia and left on our long trip with the hope of buying shoes there. “There’s probably a larger selection of good shoes abroad,” I thought.

I came to a shopping mall in Hong Kong and there were no proper shoes in either the first mall, or the second, or the third. I only found the Dr Kong store, but even these shoes did not fully meet the precepts of domestic orthopedics.

Meanwhile, 70% of Hong Kong children were wearing Crocs, another 20% were wearing New Balance, and the rest were wearing unidentified Chinese shoes.

In Bali, I also did not see a single child wearing preventative or orthopedic shoes. Not from locals, not from foreign tourists.

There is such a cool joke that is actually not a joke at all: children from Russia abroad can be recognized by their shoes. Indeed, if a child walks towards you in socks and high sandals with a backdrop, arch support and other conditions, then this is a Russian-speaking kid. In Hong Kong, Indonesia, Singapore and Thailand, all foreign children wear random shoes.

Again, if you order clothes from European or American online stores, you have probably noticed that their entire range of shoes completely contradicts the logic of domestic orthopedics.

And here I finally come to an explanation of my position. There are two schools of orthopedics, roughly speaking, ours and not ours. True, if you read the Medservice forum, you can conclude that some orthopedists are finally emerging from the darkness and are leaning toward Western orthopedic thought. Which is what I'm trying to convey in this post.

Overdiagnosis

Why would an orthopedist treat a problem that doesn’t exist? Because he must support a huge industry, which includes manufacturers and sellers of supposedly “correct” shoes and insoles, massage therapists. Because if flat feet or valgus does not go away with age, no one will be able to say that they did nothing. Because mothers are often not satisfied with the recommendation “don’t do anything - everything will go away on its own.”

Most children have no problems with their feet (and below I will tell you that neither flat feet, nor valgus, nor club feet are something that needs to be corrected), and the tradition of taking a child to an orthopedist before the age of 3 can be abolished.

Okay, not all children are equally healthy. But if the child really has something, then the doctor does not write down “correct shoes, massage” on the card, but undertakes a real therapeutic attack, gives directions for x-rays, examinations, a prescription for making shoes, etc. If your child was not sent along this route, then you can relax: everything is normal with him.

When an orthopedist tells some abstract mother (actually, me) that the child has hallux valgus, her world collapses, she comes home and begins to monitor the Internet for this terrible diagnosis.

There are a lot of articles on the Internet, written in beautiful and incomprehensible semi-medical language, which explain in detail why children from birth need to wear orthopedic (even not prophylactic) shoes. (For example). But for some reason all these articles are posted on the websites of stores of orthopedic shoes, insoles and other gadgets. Even I, a person without a medical education, am perplexed by the following words:

In the absence of rational shoes - with a rigid sole and a bend line at the level of the metatarsophalangeal joint, fixation of the talocalcaneal joint due to the rigid rear part with lateral tibia and alignment of the longitudinal-transverse arch of the foot with the help of an instep support - flat feet are formed, and subsequently - planovalgus deformity stop.

It turns out that flat feet happen when a parent does not buy orthopedic shoes for their child.

Orthopedic, preventive, correct shoes

Let me start with the fact that orthopedic shoes are not orthopedic shoes at all :) For some reason, many parents believe (not without the marketing efforts of sellers of children's shoes) that a) any shoes that look orthopedic are orthopedic, b) orthopedic shoes are useful.

Although, by the way, ortho shoes are therapeutic shoes, the insoles for which are made according to an individual impression or scan of the foot and the purpose of wearing them is to treat various deviations from the normal development of the foot.

Everything that is mass-produced and sold in stores is ordinary shoes that want to look like orthopedic ones. For some reason they call it preventative. These shoes are supposedly a guarantee that the child who wears them will not develop flat feet or valgus.

And these shoes seem to work, because by adulthood, children really become ok with their feet. Although this happens not thanks to the shoes, but in spite of them. Despite the rigid, inflexible sole, which prevents the leg from bending. Contrary to the anatomically incorrectly positioned arch support. Contrary to the boot that constrains the leg. Because a normal active child will in any case overcome parental care for his legs.

The situation with ortho shoes is as if wheelchairs or crutches became fashionable and all healthy people began to buy themselves something similar to a wheelchair or crutches.

In our country, people like to buy orthopedic shoes for children just in case, just in case. Ortho shoes for the first step, ortho shoes for walking, ortho shoes for the home. It’s good if these pseudo-orthopedic shoes are just a marketing scam.

Our first orthopedist named Gabisonia (St. Petersburg, clinic No. 112) looked at Varya at the age of 1. He really looked, without getting up from his chair, without touching the child with a finger. Varya did not walk on her own then, only by hand.

With his golden eye, he diagnosed flat-valgus feet (and I do not dispute this fact) and prescribed sandals with high tops, arch supports, and heels. Wear at home all day. (The same orthopedist found dysplasia in my friend’s daughter, prescribed a cast and some kind of spacers. At the Research Institute of Orthopedics and Traumatology, the doctors pointed a finger at this matter and sent my friends home).

Orthopedist Gabisonia showed me an example of “correct” shoes (it seems to me that in hell they give out something like this):

Our whole family goes barefoot at home. And the news that Varya has to walk around in uncomfortable sandals all day upset me. I also didn’t understand why a child who had just gotten to his feet and was still tentatively taking his first steps needed to be shackled in shoes. I still don't understand this logic.

The experiment with wearing “orthopedic” shoes at home lasted a couple of days. Varya was uncomfortable, I decided not to torture the child. Shoes were worn only where they were supposed to be worn - on the street.

The most common orthopedic “diagnoses”

Flat feet

Well, everything is clear here. 100% of children have physiological flat feet. The feet of a child under 3 years of age seem flat, because... the recess of the arch is filled with a soft fat pad. This form of flatfoot does not require treatment, since the arch of the foot, with proper development, normalizes on its own by the age of 5-6 years of a child’s life.

Some people believe that shoes with arch supports are a good prevention for flat feet. This is a lie and a provocation from shoe sellers, more on that below.

Plano-valgus placement of feet

I will dwell in more detail on the flat-valgus position of the foot, because Varya’s chart says exactly that. I deliberately do not call this a diagnosis, because it is not a diagnosis at all, but simply a statement of fact. It’s the same as if an ophthalmologist wrote “the child has brown eyes.”

If an orthopedist writes in the chart of a child who is 1 (2, 3, 4 years old) “flat valgus feet,” then he is Captain Obvious. Because up to 5 years old, flat-valgus feet are a normal variant and do not require treatment or adjustment. For a child who leads an active lifestyle, everything will correct itself. If at the age of 5 it has not yet improved, then you need to do something, attack orthopedists, tear out your hair, gouge out your eyes.

Valgus (and varus) occurs when some muscles are not sufficiently developed. In Varin's case, this is the inner part of the calves. Will shoes fix this situation? Has any person you know pumped up any muscle simply because they wore some special clothes or shoes? Only active activities and physical exercise, only hardcore!

What to do?

Buy shoes that don't hurt. (More on this below).

Allow the child to run, jump, crawl on climbing frames, and climb stairs.

Jump - on mats, on a trampoline, on a bed.

Climb the wall bars, stand on the crossbar.

Ride a bike.

From a certain age, you can send your child to choreography or dancing. Or go swimming. Or everywhere.

Please don't waste your money on "orthopedic" or "prevention" shoes. Use the money you save to buy a wall bars, mat or trampoline.

Buy special massage mats with uneven surfaces and place them at home in your child’s favorite hangout spots.

Allow your child to walk barefoot on grass, sand, stones - over any uneven surfaces.

Collect stones and pebbles from the street and take baths by walking on these stones (you can add sea salt to the water).

Contrast shower for feet.

Massage for very small children.

Meanwhile, paraffin and electrical stimulation have not proven their effectiveness.

What shoes should I buy?

Just comfortable, beautiful shoes made from natural materials with a flat insole and flexible sole, without instep support.

What specific brands can I recommend? Based on this opinion, I’ll name Little blue lamb, Jack&Lily, Pediped, See Kai Run. On my own behalf I’ll add Birkenstock and Ecco. Now I bought Varya Little blue lamb sandals and they are very cool:

Without arch support

Everyday children's shoes should not have an instep support. For some reason, everyone thinks that an instep support is a thing that will “press” the foot in the right place and there will be no flat feet. Bullshield! An instep support is a thing that cushions during physical activity.

If a child is prescribed shoes or insoles with arch support, then these must be custom-made insoles/shoes based on a cast or photograph. Because the arch support must be positioned correctly. In short, for a specific child - a specific instep support. But! Most children do not need an arch support at all.

Almost all domestic children's shoes already have an instep support. In most cases, however, this is only its appearance and a dummy. In fact, it breaks down after a week, does not absorb shock, and is a marketing bait for lovers of “ortho” shoes.

An instep support is needed when the foot cannot cope with shock absorption on its own. Then the instep support helps relieve the load on the leg. So, arch support is necessary in sports shoes for children and adults. At the same time, in children's everyday shoes, a really effective arch support can cause harm because:

1. the area of ​​the foot where the shock-absorbing arch should be formed is not trained and developed properly (since the arch support is in the shoe),
2. when buying shoes for growth, the instep ends up in the wrong place and, instead of cushioning, interferes with the development of the longitudinal arches of the foot.

No rigid sole, the sole should bend.

Shoes should be made from natural materials (crocs are an exception wow).

Wide toe cap to prevent your toes from being squeezed.

The heel should be stable, securely fixing the heel.

Ideally, shoes should look as if they are not there and the child is walking barefoot.

So, brief conclusions of this huge post

• There are two diametrically opposed directions in orthopedics. Whom to believe is your choice.
• There is no need to “treat” with shoes and wear arch supports; this can stop the process of arch formation and flat feet will remain for life.
• Any correction must be individual. Fixing it incorrectly or unprofessionally can lead to even bigger problems. Here is a review from a mother who treated her child with shoes and instep supports.
• Arch supports in the form of soft “pillows” in ordinary shoes are not effective, because... they are too soft (hence they cannot support anything).
• Most “foot problems” noticed by parents are part of the natural development of a child’s foot, which ends by age 6.
• The “improvements” noticed by parents are not the result of wearing the “right shoes”, but only the natural development of the child’s foot.
• The need for mandatory instep supports in children's shoes (unless they are individually recommended by an orthopedic doctor) is nothing more than a myth, unconfirmed by official medicine, and is used by shoe manufacturers to increase shoe sales.

PS. Varyulya is 2 years old, and the valgus has become significantly less. I attribute this to the beginning of an active period of running and jumping, walking on uneven surfaces and refusing to wear the “right” shoes.

Masha Buzanova

Source