About the ossification nuclei of the hip joints in children.

Have you been diagnosed with hip dysplasia (Hip Dysplasia)? Then it turned out that there was no dysplasia? Or, on the contrary, did they not determine and prescribe treatment in time?

DTBS

is a congenital pathology that develops as a result of internal and external factors during pregnancy, leading to improper development of the glenoid cavity and the thigh area adjacent to the pelvis.

There are 4 degrees of severity of pathology:

1. Immaturity of the hip joint
   is a borderline condition, more often observed in premature infants. Characterized by a lag in the development of articular structures: Slow formation of ossification nuclei
2. Border angle indicators

Diagnostics

Clinically, hip dysplasia can be suspected based on:

1. Asymmetrical arrangement of femoral and gluteal skin folds
2. Limitations on abduction of legs bent at right angles at the hip joints and knee joints:
   For children in the first month of life, hip abduction is limited,
3. from 2 months to a year, limited hip abduction or, conversely, excessive hypermobility is characteristic.

3. Shortening of the lower extremities. 4. Excessive hip rotation. 5. Symptoms of “slipping” or “clicking” in the hip joint. 6. External rotation of the feet. 7. Palpation of the femoral head behind the posterior edge of the socket. 8. Oblique location of the genital fissure in girls.

Hip dysplasia: how to identify and can it be cured?

A disease such as hip dysplasia occurs in all countries. According to statistics, the prevalence of the disease among the population of our country is approximately 2–3%, and in regions with an unfavorable environmental situation up to 12%.

What are the signs of hip dysplasia in children and adults? Is it inherited? Is it possible to cure this pathology? Dmitry Borisovich Belanov, an orthopedic traumatologist at the Expert Clinic Tula, answered our questions.

— Dmitry Borisovich, what is hip dysplasia? Is this a common disease?

— This is a congenital disorder of joint development that can lead to dislocation or subluxation of the femoral head. There may be either insufficient development of the joint or its high mobility in combination with insufficiency of connective tissue.

In terms of prevalence, hip dysplasia is 4-6 cases per thousand newborns. In girls, the disease is detected 6–7 times more often than in boys. Also, as a rule, the most common lesion is unilateral, and according to statistics, the left hip joint is usually affected.

— What are the causes of hip dysplasia?

— Its development can be provoked by a number of factors. The main reason is hereditary predisposition. This disease is 10 times more common in patients whose parents had congenital disorders of the hip joint.

The risk of developing dysplasia increases with breech presentation of the fetus, as well as with toxicosis, taking certain medications during pregnancy, a large fetus, oligohydramnios and some other maternal diseases.

Experts also note that there is a clear dependence on the environmental situation in the region where the mother and child live. In disadvantaged areas, dysplasia is registered 5–6 times more often.

— Are there any types or forms of hip dysplasia? Is it classified at all?

— There are three main forms based on the severity of the disease. The first is pre-dislocation of the hip. In this position, the femoral head is centered in the socket, but there is excessive stretching of the joint capsule, which affects the mobility of the femoral head in this socket. That is, there is a dislocation and repositioning of the head back (the so-called positive symptom of slipping).

The next most severe type is hip subluxation. This is a position in which the head of the femur still remains inside the joint, but is already displaced to the side and upward, but does not protrude beyond the acetabulum of the pelvis.

The most severe type is hip dislocation. In this position, the femoral head moves significantly upward and completely loses contact with the acetabulum of the pelvis. In turn, hip dislocation is divided into five degrees: from a displacement of the femoral head by several millimeters in the first degree to a pronounced upward displacement of the hip in the fifth degree (a displacement of even 5–10 centimeters is possible).

— How does pathology manifest itself in children and adults?

— The first obvious manifestations of dysplasia occur when the child turns one year old. This is lameness on the affected side while walking or a “duck” gait if the process is bilateral.

Patients in whom the pathology was detected in adulthood complain of pain, severe limitation of movements in the affected joint, and shortening of the limb. All these symptoms are characteristic of the second, third degree of arthrosis of the hip joint, and in most cases, after examination, this diagnosis is fully confirmed, since it has special radiological signs. This type of arthrosis is called dysplastic.

You can learn more about arthrosis here: When a joint is “tired”. How to identify and treat arthrosis?

— Dmitry Borisovich, how to identify hip dysplasia?

— During the examination of the child in the first days after his birth, you can detect the so-called clicking symptom, or the sliding symptom. This is caused by dislocation and reduction of the hip at the joint. Hip dysplasia is also indicated by symptoms such as limited abduction of the hips, shortening of one leg if the process is unilateral, and rotation of the foot on the affected side outward from the neutral position. Parents are more familiar with such a symptom as asymmetry of the subgluteal folds. They can always watch it while swaddling. This, of course, is not a 100% indicator, and this sign can be caused by various factors, but its importance in diagnosing the disease should not be underestimated.

Ultrasound diagnostics is used to clarify the diagnosis. This is a painless, safe and affordable method. But it does not always give the right result. If the clinical picture does not coincide with the ultrasound readings, radiography is used. An x-ray gives a complete picture of the structure of the joint and the relative position of the femoral head and pelvic bones. But due to the rather high radiation exposure, this method (if possible) is used less frequently.

Today, for late diagnosis of hip dysplasia and monitoring the dynamics of the disease in adults, MRI is performed. This method allows you to study all the tissues of a given area, including ligaments, tendons, muscles, and cartilage. It is safe and becomes more accessible every year.

— Is MRI used to diagnose hip dysplasia in children?

- Yes, but from the age when the child can obey and is able to endure this procedure.

Want to learn more about joint MRI? Read our article: Crunchy? What will an MRI of joints tell you?

— How is hip dysplasia treated? Is it possible to get rid of this disease completely?

— Treatment of hip dysplasia should begin as early as possible. The main task is to center the femoral head in the joint and create the necessary conditions for the formation of a full-fledged acetabulum. With proper treatment, the anatomy and functioning of an undeveloped joint can be completely restored. Centering the hip in the joint is achieved using wide swaddling. In severe cases of dysplasia, special spacer splints are used to align the position of the femoral head. Later, therapeutic massage, physical therapy, and physiotherapy are performed. In case of untimely diagnosis or lack of the desired effect from treatment, long-term staged plaster casting is carried out. In addition, if treatment is ineffective, complex surgical treatment is used, which is selected individually for each patient.

— Can a woman give birth if she is diagnosed with hip dysplasia?

- Yes. But whether it will be a natural delivery or a cesarean section is determined by the obstetrician-gynecologist together with the orthopedist. There are no clear standards. Experts take into account the severity of dysplasia in childhood, the size of the pelvic bones, and the presentation of the fetus. After this, a decision is made that should be as safe as possible for both mother and child.

— What can be the consequences if hip dysplasia is not treated?

— In early childhood, the lack of necessary treatment can cause joint deformation and changes in the round shape of the articular surfaces. This can lead to pain, impaired joint mobility, and hip dislocation after the child begins to walk. In late childhood and adulthood, such disorders lead to rapidly progressing arthrosis, shortening of the affected limb and lameness. Very often, advanced forms of dysplasia result in the patient undergoing hip replacement and long-term rehabilitation after surgery.

Interviewed by Marina Volovik

You can make an appointment with a pediatric orthopedic traumatologist here. ATTENTION: the service is not available in all cities

The editors recommend:

Perthes disease: what is it? The child has scoliosis. What to do? How to correct flat feet in a child?

For reference:

Belanov Dmitry Borisovich

Graduated from Ryazan State Medical University in 2010. 2011 – internship in traumatology and orthopedics. Today he is an orthopedic traumatologist at the Expert Clinic in Tula. Reception is conducted at the address: st. Boldina, 74.

Predisposing factors

BEFORE PREGNANCY:

Gynecological and other diseases of the expectant mother

(uterine anomaly, fibroids, anemia, rheumatic disease);

Poor nutrition and unhealthy lifestyle of the expectant mother

Unfavorable environment

Heredity for dysplasia.

DURING PREGNANCY:

Pathological course of pregnancy

(oligohydramnios, threat of miscarriage, toxicosis, taking medications)

Acute viral and other infections (

ARVI, influenza, syphilis, etc.), especially from 10 to 15 weeks of pregnancy.

DURING CHILDREN:

First or difficult birth

Features of the fetus

(large size, transverse position, breech presentation, multiple pregnancy)

AFTER CHILDBIRTH:

Tight swaddling

Why is the process of development of ossification nuclei disrupted?

Anomalies in the formation of nuclei in the femoral head and acetabulum appear under the following circumstances: - The mechanism is disrupted in the womb, when there are errors in the formation of bone tissue cells. The reasons are endocrine diseases of the expectant mother, infections or intoxication during pregnancy. “Most often, premature babies are susceptible to such diagnoses, since they are weaker, and not all important processes were completed in time before birth. — Underdevelopment of the nuclei can be caused by a deficiency of calcium and vitamin D, which also leads to skeletal disorders (including the hip joint).

Delayed nuclear formation

Ossification nuclei should begin to appear by 3 months (0-5 mm) and by 10 months they are 9-11 mm.

If a child has only a violation of the rate of formation of ossification nuclei while maintaining angular parameters, then:

• up to 3-4 months dynamic observation;
• after 4 months - monitoring vitamin D, control ultrasound once a month, deciding on restorative treatment.

It is important to solve this problem by 6-7 months, when the baby begins to crawl. The nuclei should already be well formed by the beginning of walking (by 1 year), so that the part of the femur adjacent to the pelvis is able to withstand vertical load.

In cases of suspected THD, the child undergoes an ultrasound or x-ray. Currently, all children at the age of 1 month are recommended to undergo an ultrasound examination of the hip joint. The purpose of which is the early detection of improper formation of the hip joint.

Congenital hip dislocation

is the most unfavorable variant of hip dysplasia. Its occurrence is 3-4 cases per 1000 normal births. Most often detected in the maternity hospital or in the first weeks of the baby’s life

Ultrasound using the Graf method

1a and 1b. Normal hip joint. α >60, β < 55.

Type 2a and 2b (physiologically immature up to 4 months!) α=50-59, β>55. The bony protrusion is rounded, the head is centered, the cartilaginous part of the roof is wide, the bony part of the roof is sloping.

Type 2c Pre-dislocation α=43-49, β=70-77 The head of the femur is centered, but the cartilage does not cover it enough, the bony part of the roof is rounded. If the angles are outside the normal range, treatment is required.

Type 3. Subluxation. α <43, β >77. The head of the joint is located outside the glenoid cavity, the cartilaginous part of the roof is not defined. After 3 months of age, degenerative processes may begin, which will provoke coxarthrosis. Treatment is needed.

Type 4 Hip dislocation. α=43, β>77. The head is located outside the joint cavity, the symptom of “empty acetabular (articular) cavity” is noted. Treatment of such children must begin immediately.

In cases of abnormal angles according to ultrasound and/or suspicion during clinical examination, the child is sent for an X-ray examination. It is the most objective, and with a correctly performed image, it can confirm hip dysplasia, congenital dislocation and immaturity of the hip joint.

Developmental delay, or hypoplasia of ossification nuclei.

With normal formation of joints, ossification of the nuclei will be completed before 4-6 months (it is during this period that the baby begins to show interest in crawling). In some cases, the formation of nuclei is allowed up to 8 months, but this applies to premature babies. In the period from 6 months to 1.5 years, maximum development of bone nuclei should be observed, which gradually replace cartilaginous tissue. Starting from 1.5 years and until puberty, all individual nuclei must merge into strong plates. The lower and central parts of the acetabulum finally ossify during this period. The number of nuclei is less than normal in terms of timing, leads to a delay in articulation, and will become a risk of developing congenital dislocation in children. The delay in the timing of the formation and development of ossification nuclei is proportional to the delay in the beginning of crawling, standing, and walking. If you observe a late interest in these stages in your child, you should not label him as an individual. You will always have time to do this after correct diagnosis. Plus, if the nuclei are formed with disturbances, in the future this may become the basis for frequent injuries and diseases of the joints.

How to determine?

A diagnosis such as hip dysplasia is made on the basis of clinical manifestations and results of ultrasound and x-rays. These are extremely important and informative diagnostic methods, but they are secondary to the clinic.

An orthopedist should promptly suspect dysplasia while still in the maternity hospital and register the child. Such children are prescribed special treatment.

Correct formation of the joint can be determined by a number of tests:

1. Skin folds on the thighs and under the buttocks are visually visible. Normally they are symmetrical.
2. Hip abduction - the child’s legs are bent while pressing against the stomach and then gently spread to the sides. Normally this happens easily. With dysplasia, dilation is limited - this is pre-luxation, and the tone of the thigh muscles is increased.
3. At the same time, slipping is noted - when the legs are abducted from the affected side, a click is noted. This is the Ortolani-Marx symptom, and he speaks of poor fixation of the head. It is a subluxation, and the dislocation itself is determined when the child begins to walk. The baby may limp or have a duck's gait.
4. Shortening of one limb may occur. Even if one of these tests shows a positive result, an ultrasound scan is required.

If there is no ossification on both sides, this is not considered a serious pathology, since osteogenesis is still noted. But the unilateral process of delayed ossification nuclei requires immediate hospital treatment.

Carrying out a massage

It can be carried out even with tires, without removing them. For aplasia, stroking and rubbing are indicated.

Rules for performing massage:

• the child should lie on a changing table with a flat surface;
• cover the table with a diaper, because the child may wet himself;
• the baby’s mood should be cheerful and calm;
• the child should not be hungry;
• massage is performed once a day, a course of 10-15 procedures.

There should be only 3 courses, with breaks lasting 1.5 months.

The massage complex is selected individually by a specialist. After consultation with a doctor, the mother can massage the child independently and at home. Massage is not performed if the child has:

• heat;
• ARVI;
• hernias;
• congenital heart defects.

General understanding of kernels

Ossification nuclei are only a diagnostic sign indicating the development of the joint. There are no external signs, but the result is complete maturation of all elements of the joint.

This process has its own characteristics:

1. Ossification first occurs where the first load occurs.
2. Ossification nuclei in the head of the femur must appear before the child can begin to crawl and sit.
3. The nuclei in the acetabulum are first formed along its upper part (anatomically this is the roof of the joint). With its timely formation, the baby begins to stand freely on his feet, and then gradually learns to walk.
4. The first ossification nuclei of the hip joints should appear precisely in the femoral head and the upper part of the acetabulum. Otherwise, the hip joint is delayed in its development and the risk of congenital dislocation in the child increases. The diagnosis becomes synonymous with hip dysplasia.

If there are no ossification nuclei in the hip joint on ultrasound, then this is called aplasia.

Etiology of ossification

Ossification usually occurs in 50% of rachitic patients. This is due to a lack of nutrients, B vitamins and minerals (calcium, iron, iodine, phosphorus) in the tissues of muscles, ligaments and bones. The lack of formation of ossification nuclei in children is also associated with this.

The appearance of dysplasia may be associated with malpresentation of the fetus; in children who are bottle-fed, when immunity decreases. A lot depends on the health of the mother and father: for example, the presence of diabetes, thyroid disorders, hormonal imbalances. The child's metabolism is disrupted. The reason for the absence of bone nuclei can be a twin pregnancy, gynecological pathologies in the mother in the form of uterine hypertonicity, infections and viruses during pregnancy, the mother’s age over 40 years, severe toxicosis, heredity (every fifth case), premature birth, spinal diseases in the mother, large fetus.

Therapy for dysplasia

Therapy should only be prescribed by a doctor, and parents must strictly follow his recommendations. Parents need to be patient and strong, because the treatment process will be long.

The process of establishing normal development of nuclei in the hip joint area includes:

• treatment and prevention of rickets using ultraviolet irradiation and vitamin D intake;
• using a splint to realign the joint;
• electrophoresis with phosphorus and calcium, aminophylline on the lower back, procedures with bischofite;
• paraffin applications;
• massage and therapeutic exercises.

After therapy, an ultrasound is repeated to assess the effectiveness of treatment. During treatment, the baby should not be sat down or placed on its feet. The earlier therapy is started, the better the result will be. Exercise therapy and massage are used to strengthen and develop muscles.

It makes sense to use exercise therapy even if the child does not have dysplasia as such, but does have a genetic predisposition. Then the exercises are performed lying down, without putting stress on the joints.

In children

After birth, the newborn begins the processes of skeletal construction. And this is connected with the baby’s movements. Active leg movements develop thigh muscles. This causes blood flow to the deep parts of the bone. Dormant cells are put to work, destroyers of cartilage tissue and builders of bone beams appear. The replacement mechanism is accelerated by the fact that several bone nuclei appear.

The largest ossification nuclei are in the head of the femur, in its central sections. Simultaneously with the head of the femur, the acetabulum begins to form. It takes on its final form when the child stands on his feet. The norms of ossification nuclei, which, as already mentioned, are 3-6 mm, can be checked by ultrasound, but not earlier than in the 4th month of the baby’s life.

No cores

In some cases, aplasia or absence of ossification nuclei in the components of the hip joint is observed. In such cases, the body itself tries to exclude the joint from working. The violations are as follows: the legs are asymmetrical, any movements are sharply limited or impossible.

On ultrasound, the ossification nuclei of the femur are absent and the components of the joint remain at the cartilaginous level. They do not contain dense inclusions and are homogeneous. The joint is deformed. The acetabulum gradually flattens and is no longer able to withstand pressure.

The femoral head emerges from the socket and its roundness disappears. The outcome is arthrosis - the joint is destroyed. The cartilage tissue becomes scarred and a bone callus appears. Therefore, the only solution is joint replacement.

Carrying out gymnastics

You can learn to do gymnastics yourself. The conditions are the same as for massage. Exercises are done 3-4 times during the day. Children usually love this kind of gymnastics.

Any exercise should be done very carefully. Gymnastics in the absence of ossification of the hip joint includes the following actions:

1. Forming the frog pose while lying on your back. Ideally, when spreading your legs, your knees should reach the surface.
2. Imitate the crawling position by turning the baby onto his stomach.
3. Turn the baby over onto his back again, bending his straight legs. You need to touch the baby's head with them.
4. Straight, straightened legs spread to the sides.
5. Pull the straight legs towards the head and spread them to the sides.
6. Place the child's legs in the lotus position, placing the left leg on top.
7. Alternately bend your legs at the knees and at the pelvis.

Statistics

Dysplasia is common in all countries (2-3%), but in different ways, depending on racial and ethnic characteristics. For example, in the United States, the likelihood of its occurrence is significantly reduced in African American children.

In the Russian Federation, in environmentally unfavorable regions, the probability of having a child with this diagnosis reaches 12%. A direct connection between the occurrence of dysplasia and tight swaddling of the baby's straightened legs has been noted.

The population of tropical countries does not swaddle newborns, they carry them on their backs, and the incidence rate here is noticeably lower.

Proof is that in Japan, for example, the tradition of tight swaddling was changed by a national project in 1975. As a result, the probability of congenital hip dislocation decreased from 3.5 to 0.2%.

The pathology most often occurs in girls (80%), a third of cases are familial diseases.

Congenital dislocation of the hip is detected many times more often with breech presentation of the fetus and toxicosis. More often the left hip joint is affected (60%), less often the right one (20%) or both (20%).