A method for correcting the cervical-diaphyseal angle of the femur. Cervical-diaphyseal angle of the hip joint in children

Diagnostics of the hip joints
The date: Monday, February 26 @ 19:49:01 GMT
Topic: X-ray examination of the skeleton

Chapter 1. The hip joint. Terms and concepts.

1. Frontal inclination of the acetabulum- this is the antetorsion of the acetabulum i.e. deviation of the plane of entry into the acetabulum from the frontal plane. In children at the age of 10, the angle is 39º, in adults on average - 42 ° (for men - 40 °, for women - 45 °).

2. Neck-diaphyseal angle (inclination angle of the femoral neck)- the angle between the neck and the diaphysis. In adults, it is 125 ° - 135 °. In children: newborn. - 134°, 1 year - 148°, 3 years - 145°, 5 years - 142°, 9 years - 138°, in adolescence - 130°.

I. Yu. Zagumennova, E.S. Kuzminova
Regional specialized children's center, Stavropol

3. Antetorsion. At normal ratios, the plane that intersects the axis of the femoral head - femoral neck - diaphysis forms a ventrally open angle with the frontal plane that intersects the condyles of the knee. The reason for this lies in the rotation of the proximal part of the femur. If the turn occurs under the lesser trochanter, which means that the head, neck and body of the femur are equally affected, then they speak of antetorsion. If only the head and neck of the femur are involved in the rotation, then we are talking about anteversion. In the case of turning backwards, they speak of retroversion. At the age of 3 months. the value of antetorsion is 30°, then at the age of 3-4 years - 20°, in the pubertal period - about 18°, in adults the average value is 10-14°.
In the case of congenital dislocation of the hip, pathological antetorsion is of great importance in terms of the prognosis of what?. We speak of pathological antetorsion if the turn is 10° greater than the corresponding value at a given age. With congenital dislocation of the hip, more than in ⅔ of all cases, increased antetorsion is observed. The consequence of this is a discrepancy between the bones that form the joint, as a result of which the femoral head does not reach the bottom of the acetabulum and is placed outside the center of it. All this leads to defects in the development of the acetabulum, an increase in the tendency to dislocation, which is very significant from the point of view of the formation of subsequent arthrosis. In the event of an increase in antetorsion, the body exhibits an active defensive reaction: in order to avoid stress on the hip joint, the lower limbs are rotated inward. If at the end of treatment the antetorsion was more than 45°, then the risk of developing subluxation increases to 90%.

4. Varus deformity of the neck (plow vara) is a condition in which the cervical-diaphyseal angle is less than the average angle corresponding to age. It can be congenital and acquired.

5. Valgus deformity (plow valga) is a condition in which the cervical-diaphyseal angle is greater than the average angle corresponding to age. It can be congenital and acquired.

Chapter 2. Methods for measuring angles, indices and indicators of the hip joints.

Fig.1. Scheme for calculating the anteversion of the proximal end of the femur and the frontal inclination of the acetabulum according to the posterior (a) and axial (b) radiographs

1. cervical-diaphyseal angle- this is the angle formed at the intersection of the longitudinal axes of the neck and the diaphysis of the femur. In Fig. 1, a - this is the angle α

2. Acetabular index reflects the degree of deviation from the horizontal position of the bone part of the roof of the acetabulum visible on the radiograph and is characterized by the angle between the tangent to it and the line connecting both U-shaped cartilages. In Fig.1,a, this is the angle γ. Normal value: in children older than 5 years 12-16º. (Draw in Fig.1)

3. Sharpe angle is the angle DCB formed by the tangent to the entrance to the DC acetabulum DC (Fig. 1a) and the line AC connecting the lower poles of the tear figures.

4. Projection angle of anteversion- in Fig.1, b - this is the angle β.

5. Anteversion angle of the proximal end of the femur. It is found according to the table, where the desired value is located in the area of intersection of the values of the found angles α (cervical-diaphyseal angle) and β (projection angle of anteversion).

6. Angle of frontal inclination of the acetabulum. It is found according to the table, where the desired value is located in the area of intersection of the values of the found Sharpe angles and the angle D1C1A1, formed at the intersection of the tangent to the lower edge of the acetabulum A1C1 and the tangent to the entrance to the acetabulum D1C, and measured from the radiograph in the axial projection (Fig. 1b) .

Fig.2. Scheme for determining the indices of stability of the hip joint (explanation in the text).

7. Angle of vertical correspondence. The angle formed at the intersection of the tangent to the entrance to the acetabulum (DA) and the longitudinal axis of the femoral neck (BC), open downwards, is called the angle of vertical correspondence. X-ray anatomical landmarks for conducting a tangent are the lower pole of the "tear figure" and the outer edge of the roof of the acetabulum. The value of the vertical correspondence angle, which is normally 85-90° in children older than 6 years, reflects the degree of correspondence between the medial inclination of the femoral neck and the downward inclination of the plane of entry into the acetabulum.

8. Degree of bone coverage. On the radiograph made in the posterior projection, a line (HH1) is drawn from the outer edge of the roof of the acetabulum downwards, perpendicular to the line of the U-shaped cartilages (U-U1), and it is determined which part of the femoral head (¾,⅔,½, etc.) d.) is located medially from this line, that is, it is covered with the roof of the acetabulum. The normal values of this index for children over 5 years old are 1-3/4.

An option for determining the degree of coverage is the Wiberg angle formed by two straight lines drawn from the center of the head: one to the outer edge of the roof, the other perpendicular to the line of U-shaped cartilages. An angle of at least 25° is taken as the norm. Both of the latter indexes are a generalized sign of two different pathological conditions, since their magnitude changes both due to lateral displacements of the femoral head and the discrepancy between the length of the roof of the acetabulum and the diameter of the head. A differentiated indicator of the latter condition is the coefficient of bone coverage.

9. Bone coverage ratio. It is the ratio of the vertical diameter of the femoral head (LM) to the length of the roof of the acetabulum projected onto the line of U-shaped cartilages (EF - the length of the U-shaped cartilage line segment from the bottom of the acetabulum to the Ombredand line): LM ÷ EF. The normal values of this coefficient for children 3 months correspond to 2.5, 3 years more than 1.3, 4 years and older - more than 1.1, which means that the length of the roof of the acetabulum is sufficient to completely cover the femoral head.
The advantages of this indicator in comparison with the degree of coverage also lie in the fact that it can also be calculated with a complete dislocation of the femur to predict the state of stability of the hip joint after reduction.

10. Symptom of Ombredan. (for little ones). A perpendicular descending from the outermost edge of the acetabulum to a horizontal line connecting both Y-shaped cartilages, crossing this horizontal Y-line, divides the hip joint into four parts. Normally, the nucleus of ossification of the femoral head is placed in the lower inner quadrant, in case of subluxation - in the outer quadrant under the horizontal Y-line, in case of hip dislocation - in the outer quadrant above the horizontal Y-line (Fig. 2). Before the appearance of the nucleus of ossification of the femoral head, the medial protrusion of the femoral neck is taken as a landmark. Normally, it is placed in the lower inner quadrant, in case of subluxation and dislocation - in the lower outer quadrant, in case of high dislocation it is visible on the radiograph in the outer upper quadrant.

The description of the prolonged ossification of the junction of the ischium and pubic bones (synchondrosis ischiopubica) is associated with the name Horvath. The essence of this phenomenon is that during dislocation, the connection of the pubic and ischial bones through cartilage lasts longer than normal, and the synchronism itself is wider. After birth, the normal width of synchondrosis is approximately 10 mm. In case of dislocation in the hip joint, its width can reach 20 mm. In case of dislocation, ossification of synchondrosis occurs not at 4-5 years, as in the norm, but at 6-7 years. The direction and shape of the epiphyseal cartilage of the proximal part of the femur is considered important from the point of view of prognosis. A flaky, wide epiphysis with an indefinite border and a jagged edge allows us to conclude that growth is impaired. If the nucleus of ossification of the femoral head is located on the lateral edge of the epiphyseal cartilage, then there is a threat of the formation of coxa valga.

11. Horizontal Compliance Angle. It reflects the degree of anterior rotation of the proximal end of the femur and the acetabulum (Fig. 3).

Fig.3. Scheme of spatial relationships in the hip joint in the horizontal plane. The solid lines indicate the longitudinal axes of the femoral necks, the dotted lines indicate the tangents to the entrance to the acetabulum.

Unlike other stability indices, the horizontal compliance angle cannot be directly measured on any of the radiographs in technically feasible projections. Its value is calculated based on the data of separate determination of the frontal inclination of the acetabulum and the value of anteversion of the proximal end of the femur and is their difference. For example, it has been established that the angle of the frontal inclination of the acetabulum is 60°, and the angle of anteversion of the proximal end of the femur is 35°. The value of the horizontal correspondence angle 6 will be equal to 60° - 35° = 25°. If the value of the angle of anteversion exceeds the value of the angle of the frontal inclination, the value of the angle of horizontal correspondence is written with a minus sign. The lower limit of the norm is the angle +20°.

Fig.4. Scheme for determining the stability of the hip joint in the sagittal plane.

Determination of spatial relationships in the sagittal plane is carried out according to the radiograph made in the sacroacetabular projection (Fig. 6). The state of stability of the hip joint in this plane is assessed by three indicators: the centering of the head in the acetabulum, the angle of sagittal correspondence and the angle of the roof of the acetabulum.

12. Determining the centering of the femoral head. The longitudinal axis of the femoral neck is drawn (line OO1 in Fig. 4), continued in the cranial direction and tangent to the anterior and posterior edges of the roof of the acetabulum (line AB in Fig. 4). Normally, the longitudinal axis of the neck intersects the tangent in a section extending from the middle of the latter to the border of its anterior and middle thirds (points 1 and 2 in Fig. 4). Deviation of the longitudinal axis anteriorly from point 1 or posteriorly from point 2 is a sign of anterior or posterior decentration.

13. Sagittal correspondence angle- the angle formed at the intersection of the longitudinal axis of the femoral neck and the tangent to the anterior and posterior edges of the roof of the acetabulum (line AB in Fig. 3). Its normal value is 85-90°.

14. The inclination of the roof of the acetabulum. A horizontal line is drawn from its front edge (line CB in Fig. 3) and the value of the angle formed when it intersects with segment AB is measured. The limit of the norm of this angle is 12°.

15. The level of intersection of the longitudinal axis of the neck of the femur with the roof of the acetabulum(for children of the first months of life). With insufficient ossification of the femoral neck, the perpendicular restored from the middle of the tangent to the upper surface of the metaphysis can be taken as a basis.

Fig.5. The position of the longitudinal axis of the femoral neck is normal (a), with decentration (b), subluxation (c) and complete dislocation (d).

Due to the invisibility on the radiograph of the medial part of the neck, not ossified even at this age, the longitudinal axis of its bone part, and even more so perpendicular to the surface of the metaphysis, occupy a more lateral position in relation to the anatomical axis. Considering this circumstance, X-ray criterion for the correctness of the anatomical relationships in the hip joint in children under 6 months of age is the intersection of the axis of the neck with the contour of the roof of the acetabulum at the level of its medial quarter(Fig.5). A radiographic sign of decentration is the direction of the axis of the femoral neck (or perpendicular to the metaphysis) within the border of the medial and next quarter of the roof to the border of the third and last quarters, subluxation - to the lateral quarter of the roof of the acetabulum up to a tangent position to its lateral edge. The intersection of the axis of the neck with the lateral edge of the supraacetabular part of the ilium reflects the state of dislocation.

16. Adjustments for abduction and adduction. A change in the direction of the longitudinal axis of the femoral neck or pathological values of the angle of vertical correspondence are indicators of hip dysplasia only if the radiograph was taken with a strictly average position of the hips. If there are signs of an error in laying, it is necessary to correct for abduction or adduction of the limb (Fig. 6).

Fig.6. Correction scheme for hip laying errors.
α - hip adduction angle; OO1 - the position of the axis of the femoral neck in vicious laying; OO2 - the position of the axis after correction for hip adduction.

The value of the angle of adduction or abduction is measured, and the longitudinal axis of the neck deviates by the value of this angle when adducted - in the medial direction, when abducted - in the lateral direction.

17. Projection of the longitudinal axis of the femoral neck on the region of the acetabulum. With an anatomically confirmed correctness of the ratios in the joint, normally, the axis of the femoral neck, when it is extended in the cranial direction, passes through the U-shaped cartilage. (Fig. 2 axis BC).

18. Calculation of physiological deficit. The physiological instability of a child's joint is manifested by lower than in adults, indicators of the norm of stability indices. This difference is designated by the term "physiological deficit". The value of the physiological deficit is normally reduced to zero by the age of 5. In addition, it has been established that ½ of the deficit is covered by one year of age, ¾ by 3 years and the last ¼ by 3 to 5 years of age.

For example, the value of the angle of vertical correspondence in a child of 3 months of age is 70°. Its normal value in an adult is 85-90 °. Hence the magnitude of the physiological deficit 85° - 70° = 15°. At normal rates of development, ½ of this deficit should be covered by the age of one year, and the value of the angle of vertical correspondence should be 77 °, i.e. 70 ° (initial value) + 7 ° (½ physiological deficit) \u003d 77 °. The value of this indicator will turn out to be completely different by the age of one in a child with its initial value of 61 °. The magnitude of the deficit is 24°, ½ of it is 12°. 61º+ 12° = 73°, i.e. .5° less than the previous one.

19. Methodology for assessing the rate of coverage of pathological deficits and its interpretation we will show by the example of the angle of vertical correspondence.
The initial value of the vertical correspondence angle for all examples is 53°, from which the pathological deficit is 32°. Assessment is made at the age of one.
Option 1. The value of the angle of vertical correspondence reached 69° by the age of 1 year. The pathological deficit is covered at the same rate as the physiological one (69° - 53° = 16°; 16° is exactly ½ of the deficit). The prognosis is relatively favorable. Indeed, if the same rates of development are maintained, the value of the index will reach 77° by the age of 3, by 5 years. 83-85°.
Option 2. The value of the angle of vertical correspondence to the age of one year has reached 73°. The deficit is being covered at an accelerated pace (73° - - 53" = 20", i.e. more than ½ of the deficit). The task of normalizing joint stability can be considered solved (in this plane!).
Option 3. The value of the angle of vertical correspondence reached 65° by the age of 1 year. There is a delay in the rate of joint formation (65° - 53° = 12°, i.e. less than ½ of the pathological deficit). Residual instability of the hip joint. Indeed, by the age of 3, the value of this index will be equal to only 73° (not half of the remaining deficit will be covered, but, as by the age of one, only ⅜), and by the end of the formation processes, the value of the angle of vertical correspondence will not exceed

Chapter 3. Instability of the hip joint.

The state of instability may be the result of various pathological changes that determine the nature of its manifestations and severity, and, consequently, the radiological symptom complex.

The most pronounced manifestation of instability is violation of anatomical relationships. Depending on the degree of their severity, they are defined as dislocation, subluxation and decentration of the head within the acetabulum.

Analysis of the anatomical relationships in the hip joint is performed according to conventional radiographs taken in the posterior or in the axial, or in the sacroacetabular projections. According to the posterior radiograph, violations of the ratios in the frontal plane (displacement of the femur outwards and upwards) are determined, according to the other two - in the sagittal and horizontal (displacements anteriorly or posteriorly and pathological rotation of the femur around the vertical axis). Dislocations and severe subluxations are diagnosed without much difficulty. Identification of minor subluxations, and especially decentration, presents certain difficulties.

The criteria for the norm and pathology of the anatomical relationships in the hip joint in children do not require complex geometric constructions, provide a differential diagnosis of dislocations, subluxations and decentrations and allow you to make adjustments for errors in laying. The position of the longitudinal axis of the femoral neck, extended in the proximal direction, is used as a guide (see Chapter 2). It has also been established that each of the three forms of violation of anatomical relationships corresponds to a strictly defined area, the projection of the proximal end of this axis. With decentrations, the axis is projected onto the medial half of the roof of the acetabulum, with subluxations - on the lateral, with complete dislocation, the longitudinal axis of the neck passes lateral to the outer edge of the roof of the acetabulum.

The second most common cause of hip instability is discrepancy between the spatial relationships of the femoral and pelvic components. The magnitude of the flexures of the femoral neck does not correspond to the degree of downward inclination and anterior rotation of the entrance to the acetabulum, which reduces the area of support for the femoral head.

Features of the spatial position of the proximal end of the femur and the acetabulum are established on the basis of a comparison with the normative indicators of the values of the neck-diaphyseal angle, the angle of anteversion of the proximal end of the femur, the Sharpe angle and the frontal inclination of the acetabulum (see Chapter 2).

Deviation from the normal values of any of the listed angles, taken separately, although it indicates some violation of the structure of the hip joint, but still cannot serve as a basis for the conclusion of instability. Moderately pronounced deviations from the normal position of one of the components of the hip joint can be compensated by a positive change in the spatial position of the other. Thus, excessive anteversion of the proximal end of the femur can be compensated by a smaller anterior rotation of the acetabulum than in the average variant of the norm; a more vertical position of the entrance to the acetabulum - an increase in the medial inclination of the neck, etc.

A reasonable conclusion about the state of stability of the hip joint can only be made on the basis of determining the values of four so-called stability indices, which reflect the degree of correspondence between paired indicators of the features of the spatial position of the proximal end of the femur and the acetabulum:

angle of vertical correspondence,
degree of bone coverage,
bone coverage ratio,
angle of horizontal correspondence. (See Chapter 2 for a method for determining these angles and indicators.)

The basis for the conclusion about the instability of the hip joint is the detection of a pathological value of at least one of the listed indices.

When measuring stability indices, it is necessary to take into account the position of the pelvis and femur relative to the vertical and horizontal planes of the body. When the pelvis is skewed, the roof of the acetabulum on the side where the tilt occurred “rolls” onto the femoral head, the position of the roof with respect to the axis of the neck becomes more horizontal, as a result of which the magnitude of the angle of vertical correspondence and the degree of coverage turn out to be greater than their true values. The roof of the acetabulum on the elevated side of the pelvis seems to move away from the head of the femur and is located more vertically with respect to the axis of the neck, which leads to a decrease in the angle of vertical correspondence and the degree of coverage compared to the true ones. Similar situations arise when adducting or abducting a limb. The first of these positions is accompanied by a decrease in the angle of vertical correspondence and the degree of coverage of the head in comparison with the true ones, the second - by their increase. In the presence of these displacements, it is necessary to correct the measurements for the amount of pelvic tilt, adduction or abduction of the hip, measured directly on the radiograph.

Due to the complexity of obtaining radiographs of the hip joint in the lateral projection, the main object of the X-ray functional study is the state of its stability in the frontal plane.

With the greatest clarity, pathological mobility in this plane (if any) manifests itself during static loading and during limb adduction, since displacement of the femur in the frontal plane is possible only upward and outward. Accordingly, radiography of the hip joint to identify its instability is performed in three functional positions (standing, lying with standard laying and lying with the maximum extremity adducted). However, the use of all three of these provisions in most cases is not necessary. With a pronounced violation of the ratios, to determine the degree of displacement of the femur, it is sufficient to produce radiographs in the standard posterior projection and in the standing position. To identify instability of ligamentous-muscular origin, the optimal second position is passive limb adduction, as it imposes the greatest requirements on the viability of the stabilizing function of the muscular-ligamentous apparatus.

The X-ray sign of pathological mobility in the joint along the horizontal axis is the occurrence of subluxations and dislocations, determined by the above directions of the longitudinal axis of the femoral neck. In a normally stabilized hip joint, adduction is accompanied by slightly pronounced decentration, while static loading has no effect on the nature of the anatomical relationships. Displacement of the femur along the vertical axis is possible only with dislocation or severe subluxation. The severity of this type of pathological displacement of the femur in children can only be characterized approximately - on the basis of a change in the position of the upper pole of the head relative to the parts of the ilium. The expression of displacement in linear terms is impractical, since the displacement of the femur, for example, by 1.5 cm in a child of 3 and 12 years old, due to a significant difference in the size of the femur and pelvic bones, will reflect a different degree of pathological mobility.

An X-ray functional sign of instability of the hip joint due to a violation of the stabilizing functions of the ligamentous apparatus is the occurrence of a distinct violation of the anatomical relationship in the position of maximum passive adduction of the limb.

An indicator of the severity of instability of any kind is the degree of pathological displacement of the proximal end of the femur along the horizontal or vertical axes.

Chapter 4

The X-ray symptom complex of congenital hip dislocation has been developed and is being developed by many researchers. The literature describes a large number of radiological signs and indicators aimed both at identifying congenital hip dislocation and at identifying variants of the anatomical structure of the joint that are characteristic of this pathology. At the same time, the diagnostic schemes presented by various authors, calculations of the features of the spatial position and spatial ratios of the femoral and pelvic components of the joint, and indicators of impaired development of the joint largely duplicate each other, some of them are necessary to solve only highly specialized problems; there are also those that are derived without taking into account the age dynamics of the formation of the joint. In addition, the definition of all the details of the anatomical and functional state of the dysplastic joint is not always necessary.

The proposed method of X-ray examination is based on the general position that its nature and volume should be adequate to the tasks that the doctor has to solve at one or another of the main stages of managing a child with congenital hip dislocation. These stages are early detection of congenital dislocation of the hip (as a nosological unit), evaluation of the effectiveness of conservative treatment, determination of indications for surgical treatment and choice of methods for its implementation.

The most detailed X-ray characteristics of the anatomical and functional state of the hip joint require a solution to the question of the nature of the surgical intervention. The choice of one or another of its methods is determined by a number of factors: the severity of anatomical changes in the joint, the degree of impairment of the support and motor functions, the depth of the dysplastic process, etc. The method of X-ray examination and interpretation of the data obtained should provide the necessary and sufficient amount of information on all these questions.

According to modern data, the anatomical changes observed in congenital hip dislocation are divided into primary, i.e., which are manifestations of dysplasia of the components of the hip joint, and secondary - developing as a result of the functioning of the joint in pathological conditions.

Manifestations of hip dysplasia, in turn, can be divided into the following main types: pronounced violations of anatomical relationships, violations of the spatial orientation of the proximal end of the femur and acetabulum, violations of the growth processes and ossification of the bone components of the joint, dysplastic changes in soft tissue components.

Secondary changes include pathological restructuring of the femoral head structure, deformations of its cartilaginous model, pathological condition of the cartilaginous limbus, and changes in the volume of the articular capsule.

Severe violations of the anatomical relationships are established on the basis of the analysis of conventional radiographs. Identification of other manifestations of the dysplastic process and secondary anatomical changes requires the use of special methods of X-ray examination and special techniques for interpreting the data obtained. Typical for congenital dislocation of the hip, violations of the spatial orientation of the proximal end of the femur are more than normal, its rotation anteriorly (excessive anteversion) and an increase in the neck-diaphyseal angle. Violations of the spatial orientation of the acetabulum consist in a decrease in the angle of inclination downwards and a greater than normal, turning it anteriorly.

A change in the spatial position of the pelvic and femoral components of the joint causes a violation of the centering of the femoral head in relation to the acetabulum and creates a state of joint instability. The discrepancy between the values of the medial inclination of the femoral neck and the angle of inclination of the entrance to the acetabulum relative to the horizontal causes instability of the joint in the frontal plane, the angle of anteversion of the proximal end of the femur and the frontal inclination of the acetabulum - in the horizontal. The cause of instability of the hip joint in the sagittal plane may be either an anterior or posterior displacement of the femur, or an oblique position of the acetabular roof in this plane. (See chapter 2 for calculation methods).

The normal values of these values are different for different periods of joint formation. In principle, in children of the age that is considered the most favorable for surgical treatment (from 2 to 5 years), the spatial positions and spatial relationships of the bone components of the hip joint in the frontal and horizontal planes can be considered impaired if the cervical-diaphyseal angle is more than 130°, anteversion more than 40°, Sharpe angle more than 50°, frontal inclination of the acetabulum less than 55º, vertical correspondence angle less than 75° for 3 years of age and less than 80-85º in children older than 4 years, horizontal correspondence angle less than 20°.

The state of stability of the hip joint in this plane is assessed by three indicators: the centering of the head in the acetabulum, the angle of sagittal correspondence and the angle of the roof of the acetabulum (see Chapter 2 for the method of determining these angles). Determining the state of stability of the hip joint in the sagittal plane is important for clarifying the need to change the position or extent of the roof of the acetabulum in the anteroposterior direction during surgery and assessing the results of this displacement.

Violation of the enchondral development of the bone components of the joint in congenital hip dislocation can have the following variants of different severity:
1) inhibition of the process of ossification of cartilaginous models of the femoral head and acetabulum while maintaining their normal growth rates;
2) inhibition of the growth of cartilaginous models of the femoral head and acetabulum at normal rates of their ossification;
3) violation of the processes and growth, and ossification of the bone components of the hip joint.

When analyzing conventional radiographs, only a general idea of the state of the processes of enchondral development of the bone components of the joint can be obtained based on the fact of inhibition of ossification of the femoral head and an increase in the values of the acetabular index and bone coverage ratio (see the method for determining them in Chapter 2).

Unilateral inhibition of ossification of the femoral head is established on the basis of the later appearance of the ossification nucleus or its smaller size compared to a healthy joint. With bilateral dislocation, the rate of ossification can only be estimated approximately by comparison with the average time for the appearance of ossification nuclei (from 6 to 9 months). Approximate assessment is further aggravated by the fact that delayed ossification is not a condition pathognomonic only for congenital hip dislocation, and is observed in a number of systemic diseases (rickets, spondyloepiphyseal dysplasia, myelodysplasia). At the same time, it should be noted that if the disease with rickets can be established by characteristic pathological changes in the growth metaepiphyseal cartilages, then spondyloepiphyseal dysplasia in early childhood, especially with its mild severity, does not manifest itself in any other radiological signs, except for a delay in the appearance of ossification nuclei.

An increase in the acetabular index compared to the normal variants indicates a violation of the formation of the roof of the acetabulum, but does not allow us to decide whether it consists in its true obliqueness or only a violation of the ossification of a normally developing cartilaginous model.

The bone coverage coefficient reflects the degree of correspondence between the sizes of the ossified parts of the femoral head and the roof of the acetabulum and, thereby, the correspondence of the rates of their development. The expediency of introducing this indicator is due to the fact that one of the reasons for the development of subluxations and even dislocations in the hip joint in the postnatal period is the slower growth of the roof of the acetabulum compared to the growth of the head (for the calculation method, see Chapter 2). The value of this coefficient, firstly, shows whether or not a given length of the roof of the acetabulum provides a reliable support of the femoral head at a given stage of joint formation, and, secondly, indicates the synchronism or non-synchronism of the ossification rates. The length of the roof can be considered insufficient, and the synchronism of the ossification rate is disturbed when the value of the coefficient of bone coverage in children of three years of age is more than 1.3, 4 years and older - more than 1.1. The values of the bone coverage coefficient do not allow to resolve the issue of the degree of correspondence between the growth of the femoral head and the roof of the acetabulum and, like the values of the acetabular index, only indicate a violation of the processes of endochondral bone formation.

Secondary anatomical changes in congenital hip dislocation include deformity of the cartilaginous head of the femur, cartilaginous or soft tissue obliteration of the acetabular floor, and pathological changes in the joint capsule, which are visualized on contrast arthrograms.

Types of dysfunction of the hip joint typical for congenital dislocation of the hip are the state of instability and limitation of abduction.

Violation of the motor function of the joint with sufficient completeness is detected in a clinical study. Diagnosis of instability and its type (dislocation, subluxation, violations of the spatial relationships of the pelvic and femoral components of the joint) is provided by the methods of X-ray anatomical examination described above (see Chapter 2). Indications for the use of direct X-ray functional examination arise mainly when it is necessary to clarify the volume of pathological displacement of the femur and when deciding whether joint stability can be ensured by only correcting the spatial position of the proximal end of the femur.

The method of direct X-ray functional study of the pathological displacement of the femur, see Chapter 2. To solve the second question, radiography of the hip joint is performed when the hips are abducted at an angle equal to the excess value of the neck-diaphyseal angle with simultaneous maximum possible internal rotation. On the obtained radiograph, the nature of the centering of the femoral head, the magnitude of the angle of vertical correspondence and the degree of coverage of the head with the roof of the acetabulum are determined. Normalization of anatomical relationships is regarded in favor of the possibility of limiting ourselves to one corrective osteotomy of the femur; the persistence of the pathological values of these indicators indicates the need, in addition, for plastic surgery of the roof of the acetabulum.

According to all of the above, a detailed radiological characteristic of the anatomical and functional state of the hip joint with indications for surgical treatment of congenital hip dislocation includes the results of the analysis of the following indicators:
1) anatomical relationships in the joint in the frontal and sagittal planes;
2) the magnitude of the angle of vertical correspondence;
3) the magnitude of the anteversion of the proximal end of the femur and the frontal inclination of the acetabulum and the magnitude of the angle of horizontal correspondence calculated on their basis;
4) the angle of sagittal correspondence;
5) values of bone and cartilage acetabular indices;
6) the angle of inclination of the roof in the sagittal plane;
7) values of the coefficient of bone and cartilage coverage;
8) the position and severity of the cartilaginous limbus of the acetabulum;
9) the presence or absence of cartilaginous or soft tissue obliteration of the bottom of the acetabulum;
10) the shape and size of the ossified part of the femoral head and its cartilaginous model.

The cervical diaphyseal angle and the Sharpe angle are not included in the scheme, since the determination of their values is included in the method for calculating the true angle of anteversion and frontal inclination. The need to analyze such a large number of indicators is caused by the variety of variants of the violation of the anatomical structure and development of the joint, observed in congenital hip dislocation. So, hip dysplasia can be manifested mainly by violations of the spatial orientation and ratios of the proximal end of the femur and the acetabulum with significant violations of the enchondral formation; a pronounced violation of growth and development (mainly of the acetabulum) without significant violations of spatial relationships, as well as a combination of these pathological conditions. Violations of spatial relationships, in turn, can develop only in any one plane (frontal, sagittal or horizontal), in two planes in various combinations and in all three planes, and only one deviation from the normal position can be the cause of these disorders. either of the bony components of the hip joint, or both. In the same way, the types of violations of endochondral bone formation can vary. An effective surgical correction of a violation of the structure of a dysplastic one can be carried out only if all the features of its anatomical and functional state are taken into account.

The method of X-ray diagnostics of congenital dislocation of the hip in children during the first months of life is due to the following factors:
1) invisibility on conventional radiographs of the femoral head and most of the roof of the acetabulum,
2) the limited indications for the use of special methods of X-ray examination due to the need to minimize radiation exposure, as well as the fact that
3) when determining the intensity and duration of functional conservative treatment, only the severity of the violation of the ratios in the joint is taken into account.

The means of obtaining information is conventional radiography in the posterior projection with a strictly average position of the lower extremities. The interpretation of the data obtained in most cases is limited to the detection of violations of the anatomical relationships in the hip joint and their qualification in terms of severity. The simplest and at the same time fully responding to this task indicator is the level of intersection of the longitudinal axis of the femoral neck with the roof of the acetabulum (see Chapter 2).

Taking into account the complexity of interpreting the data of conventional radiography at this age and the comparative frequency of occurrence of various manifestations of hip dysplasia, the value of the vertical correspondence angle is determined first of all. Landmarks for its construction are the longitudinal axis of the neck (or perpendicular to the upper surface of the metaphysis), the lateral edge of the roof of the acetabulum and the lower pole of the “tear figure” are clearly visible on the radiograph. Indicators of the normal values of this angle in early childhood are much less than in adults and older children. This circumstance is associated, firstly, with the low ossification of the roof of the acetabulum both in the vertical and horizontal directions, as a result of which the tangent to the edges of the acetabulum, drawn along the bone landmarks, is located more vertically, as well as the presence of the so-called physiological instability - failure to achieve the normal orientation of the proximal end of the femur and acetabulum, which is still characteristic of the formed joint. The degree of physiological instability, as well as the rate of ossification of cartilage models, are subject to significant individual fluctuations, and therefore, when distinguishing between the norm and pathological changes, only the lower limits of the norm are used. For the angle of vertical correspondence in children under 6 months of age, the lower limit of the norm is 60 °. The value of the acetabular index can also be used as an additional indicator. However, it should be noted that, due to individual variants of the norm, an increase in the values of this index is a reliable evidence of dysplasia only with a sharp deviation from normal values or in combination with other changes.

A change in the direction of the longitudinal axis of the femoral neck or pathological values of the angle of vertical correspondence are indicators of hip dysplasia only if the radiograph was taken with a strictly average position of the hips. If there are signs of an error in laying, it is necessary to correct for abduction or adduction of the limb (see Chapter 2).

The detection of pathological values of the angle of vertical correspondence is a sufficient basis for the conclusion about the presence of hip dysplasia and the completion of the analysis of radiological data. If the value of the angle of vertical correspondence does not go beyond the lower limit of the age norm, then the presence or absence of signs of a violation of the processes of ossification of the roof of the acetabulum is determined based on the coefficient of bone coverage. The length of the projection of the bony part of the roof is determined by the method we have already described (see Chapter 2). The dimensions of the cartilaginous head can be determined on the basis of the following calculations. The need to calculate the coefficient of bone coverage, as already noted, occurs in children in the first months of life only in the absence of signs of violation of anatomical relationships. This means that the femoral head is not only within the acetabulum, but is also relatively well centered within it. Since the lag in the growth of the cartilaginous head, which is under normal load, is usually not observed, its dimensions correspond to the dimensions of the entrance to the acetabulum, minus the thickness of the articular cartilages of the latter. The longitudinal size of the head is equal to the length of the tangent to the entrance to the acetabulum, minus 4 mm (the total thickness of the articular cartilage of the cavity) (according to V.E. Kalenov). Exceeding the normal for this age values of the coefficient of bone coverage indicate dysplasia of the acetabulum.
It is determined by Ombredan's symptom (h).
Thus, X-ray diagnostics of hip dysplasia in children during the first months of life is provided by determining the nature of the centering of the head in the acetabulum and the values of the angle of vertical correspondence and the coefficient of bone coverage, as well as the Ombredan symptom.

The value of the angle of anteversion of the proximal end of the femur is not subject to determination at this age due to incomplete ossification of the neck and the difficulty of making an x-ray in the axial projection, while observing strictly correct laying. Therefore, the horizontal correspondence angle cannot be determined either.

The task of X-ray examination in terms of assessing the effectiveness of conservative treatment is to determine the degree of normalization of the anatomical relationships in the joint and determine the presence or absence of residual instability. The solution of the last question in children of the first year of life is associated with certain difficulties due to the variability in the rate of postnatal formation of the joint and the approximation, as a result, of the average statistical norms of angular and linear values characterizing the structural features of the joint. The method developed by us for determining the individual age norm is based on the following physiological pattern. It was previously noted that the physiological instability of the joint is manifested by lower than in adults, indicators of the norm of stability indices. This difference is designated by us by the term "physiological deficit". Proceeding from this, it becomes possible to calculate the value of any index due for a given child (see the calculation method in Chapter 2).

With hip dysplasia, the deficiency is no longer physiological, but pathological, which excludes the possibility of calculating an individual age norm. The most reliable idea of the state of joint stability in this case is given by the assessment of the rate of deficit coverage. According to studies, the coverage of pathological deficits under the influence of conservative treatment can occur in the same way as the physiological one, at a faster and slower pace. The second of these options can be considered as a sign of the success of the treatment. The interpretation of the effectiveness of the treatment in the first variant depends on the initial severity of the pathological deficiency. Less than ½ coverage of the pathological deficiency by one year of age is an undoubted indicator of residual instability.

See Chapter 2 for the methodology for assessing the rate of coverage of pathological deficits and its interpretation.

Bibliography:
1. Conservative treatment of children with congenital hip dislocation / N.Kh. Bakhteeva, V.A. Vinokurov, I.A. 34-37.
2. Varus deformity of the femoral neck in children / A.A. Belyaeva, O.A. Malakhov, O.V. Kozhevnikova, S.K. Taranova // Bulletin of traumatology and orthopedics. 33-36.
3. Our experience in the treatment of congenital hip dislocation in children of different ages /O.A. Malakhov, O.V. Kozhevnikov, I.V. - S.26-31.
4. Volkov M.V. Congenital dislocation of the hip / M.V. Volkov, G.M. Ter-Egizarov, G.P. Yukina. - M.: Medicine, 1972. - 159 p.: ill.
5. Korolyuk I.P. X-ray anatomical atlas of the skeleton (norm, variants, errors, interpretation). - M.: VIDAR - 1996, 192 p.
6. Reinberg S.A. X-ray diagnostics of diseases of bones and joints. - M.: Medicine, 1964.
7. Sadofyeva V.I. Normal X-ray anatomy of the osteoarticular system in children. - L .: Medicine, 1990. - 224 p.: ill.
8. Sadofeva V.I. X-ray functional diagnostics of diseases of the musculoskeletal system in children. - L.: Medicine, 1986. - 240 p.: ill.
9. Traumatology and orthopedics: In 3 volumes / Ed. Yu.G.Shaposhnakova.- M.: Medicine, 1997.
10. Filatov S.V. Early detection and treatment of the most common hip disorders in children and adolescents. - St. Petersburg, SPbMAPO, 1998. - 28 p.
11. Krasnov A. F. ORTHOPEDICS: A textbook for postgraduate doctors and senior students / A. F. Krasnov, G. P. Kotelnikov, K. A. Ivanova. - Samara: Samar. Press House, 1998. -480 p.

Pathology of the hip joints occupies an important place among congenital anomalies of the skeletal system. From 2 to 4% of children are born with underdevelopment of bone and cartilage elements, which is called dysplasia. And if changes in the hip joint are not detected in time, then as they grow older, there are problems with walking and other manifestations that interfere with normal life.

Diagnostic measures to identify structural abnormalities in the hip joint are presented by imaging studies. And given the high prevalence and availability, the first of them is performed x-rays. This method has already become firmly established in medical practice, including for diagnosing osteoarticular pathology in childhood.

General information

The hip joint is the largest joint in the human body. It is formed by the head of the femur and the acetabular (acetabular) cavity of the pelvic bone. A cartilaginous lip is attached along the edge of the latter, which increases the contact area of the articular surfaces. Thanks to the spherical shape, movements in all axes are available for the hip joint:

Flexion and extension.
Adduction and abduction.
External and internal rotation.

The joint is abundantly surrounded by ligaments and muscle tendons, which, along with its own capsule, strengthen and stabilize it, protecting it from excessive mobility. But this is possible only with the correct development of all structural components.

In young children, even in the norm, the hip joint is not sufficiently developed, i.e., its biomechanical immaturity is present. This is confirmed by the flattening and more vertical location of the acetabulum, excessive elasticity of the ligamentous apparatus. And with dysplasia, these phenomena develop into structural disorders that impede the normal physical development of the child.

After birth, it is necessary to identify structural anomalies in the hip joint in time, because the further development of the baby depends on this.

The essence of the technique

The study is based on the ability of body tissues to absorb x-rays to varying degrees. Hard tissues, which include bones, absorb them to a greater extent, while soft tissues, on the contrary, pass them better. The image is obtained by projection onto a special film, which is locally “illuminated” in proportion to the power of the radiation flux. There are also digital devices in which registration is performed on a photosensitive matrix, and the result is formed in electronic representation. But the image, if necessary, can be printed on paper.

Advantages and disadvantages

An x-ray examination of the hip joint can be done at any medical institution - from a district clinic to a large interregional center. The widespread use of the method is due to its clear advantages:

Availability.
Ease of implementation.
Good visualization of bone structures.
Low cost.

However, despite this, radiography also has some drawbacks that make it not the best study that exists at the moment. The disadvantages of the procedure include:

Radiation load on the body.
Inability to assess joint function (image static).
Lower information content compared to tomography.
Does not allow to determine the condition of soft tissues (without contrast).

In most cases, the advantages outweigh the disadvantages. Even the potential harm of X-rays is greatly exaggerated. Numerous studies have shown that an additional risk may appear only at doses exceeding 50 mSv per year. And when examining the hip joint, the radiation load on the body is in the range of 0.5–1 mSv. In modern digital devices, even lower radiation power is required, which is practically comparable to the norm of the radiation background.

Given the above, parents should not worry about possible radiation exposure when performing an x-ray of the hip joint in an infant. In acceptable doses, the study is practically harmless, but the belated diagnosis of dysplasia has much more serious consequences.

Despite certain disadvantages, X-ray examination in children is in many cases considered the method of choice.

Methodology

X-ray of the hip joint is indicated for suspected dysplasia in children after 3 months of age. Before the study, no special preparation is required - it is only important to remove all metal objects from the child's body or clothing. An important condition for obtaining an informative result: the baby should be in a position with straight legs. To achieve this, special fixing elements are used that exclude incorrect styling and extraneous movements. The procedure itself takes no more than 5-7 minutes. At this time, parents should be outside the x-ray room so as not to receive unnecessary radiation exposure.

results

The resulting images must be evaluated by a radiologist with the provision of an appropriate conclusion. Auxiliary lines allow to correctly interpret the image and make a diagnosis of hip dysplasia:

Median - through the center of the sacrum.
Hilgenreiner - through the lower edges of the ilium.
Shenton - through the edge of the obturator foramen, continuing on the inner surface of the femoral head (arcuate).
Perkina - through the outer upper edges of the cavity.

If the Hilgenreiner line is crossed by a tangent drawn along the roof of the glenoid cavity, then an acetabular angle or index is formed. It is very important in identifying dysplastic disorders and determining their degree. The value of this angle depends on the age of the child:

Newborn: 25-30 degrees.
4-6 months: 21-26 degrees.
7-9 months: 20-25 degrees.
1 year: 18-22 degrees.
2 years: 17-21 degrees.
3-4 years: 15-18 degrees.

Thus, by the age of 5, the acetabular angle should normally be less than 15 degrees, and in children at the age of 14 it reaches 10 degrees. In addition to the condition of the acetabulum, it is necessary to evaluate the proximal (upper) femur. In healthy children, the head is centered in relation to the acetabular surface. This means that the angle formed by the neck of the femur and the line drawn through the edges of the cavity is straight. And the shape of the proximal femur is closely related to it. Normally, the cervical-diaphyseal angle should be 126–135 degrees. This indicates the correct installation of the lower limb. Radiologists also evaluate other angles:

Vertical deflection (31–35 degrees).
Vertical fit (70-90 degrees).
Antetorsia (20-30 degrees).
Viberga (more than 20 degrees).

In addition to the presented indicators, the values of the vertical and external displacement of the articular head are taken into account. If there are no deviations in the relative position of the structures of the hip zone on the image, and there is only a slight bevel of the acetabulum and a delay in the formation of ossification nuclei, then they speak of initial dysplasia. The next stage of the pathology - subluxation - is accompanied by a partial displacement of the head, an increase in the acetabular, neck-diaphyseal angles. And the dislocation is indicated by the complete separation of the articular surfaces with the displacement of the axes of the limb.

The results of x-rays of the hip joints in children should be evaluated by an experienced specialist, which will exclude both under- and overdiagnosis of dysplasia.

Alternative Research Methods

The methods of choice in the diagnosis of hip dysplasia include ultrasound. Its advantage is that acoustic waves do not give radiation exposure and allow assessing the state of cartilage tissue, which at an early age has not yet had time to be completely replaced by bone. Ultrasound is used for suspected dysplasia in children under 3 months of age, as well as for everyone who has contraindications to performing an x-ray.

During the study, the image is displayed in such a way that a vertical cut through the center of the joint is obtained. The doctor determines the shape and position of the edge of the acetabulum, the condition of the cartilage and how well it covers the femoral head. Alpha and beta angles are assessed (the slope of the bone and cartilage of the acetabulum, respectively).

If we talk about computed tomography, then children do not perform it due to the high radiation exposure. But magnetic resonance imaging is possible because it is carried out without ionizing radiation. In this case, the accuracy of the result is much higher than with X-ray or ultrasound methods.

Thus, X-ray of the hip joint is a method that is widely used to diagnose various pathologies and, first of all, congenital dysplasia. It has sufficient accuracy and information content, but, unfortunately, it is not without its shortcomings. However, the latter are not so serious as to become an obstacle to diagnosis, because the timely detection of the disease is already half the success.

The hip joint and its pathologies

The hip joint is the junction of the pelvic bone, into the recess of which the femur enters with its head. The deepening of the joint is a hemispherical cavity, called the acetabulum.

The structure of the joint

The anatomy of the hip joint is quite complex, but it also provides quite wide opportunities for movement. The edge of the deepening of the pelvic bone is formed by fibrous cartilaginous tissue, which is why the cavity acquires maximum depth. The overall depth of the depression is more than a hemisphere due to this rim.

The interior of the socket is lined with hyaluronic cartilage where the socket is close to the cartilage that covers the femoral head. The rest of the surface inside the cavity is lined with loose connective tissue that covers the lower part in the region of the cavity opening and the central depression in the cavity. On the surface of the connective tissue there is a synovial membrane.

A rim of cartilage fibers along the edges of the cavity, called the articular lip, fits snugly against the head of the femoral bone and holds this bone. In this case, the lip continues with a transverse ligament. Under this ligament there is a space filled with loose connective tissue. Vessels and nerve endings pass through the thickness, which are directed to the head of the femur and pass into the head itself through the fibers of the ligament.

The articular capsule is attached to the pelvis behind the lip. The capsule is very durable. It can be mechanically affected only when a large force is applied. The femoral neck, for the most part, enters the joint capsule and is fixed in it.

The iliopsoas muscle is attached to the capsule in front. In this area, the thickness of the capsule is minimal, so 10-12% of people in this area may form a bag filled with synovial fluid.

Articular ligaments

The structure of the hip joint also includes a system of ligaments. The ligament of the femoral head is located inside the joint. The tissue that forms the ligament is covered with a synovial membrane. The fibers of the ligament contain the vessels of the circulatory system and go to the head of the femur. A depression (small fossa) in the central part inside the glenoid cavity is the area where the ligament begins. It ends in the fossa of the femoral head. The ligament is easily stretched even if the femoral head prolapses from the acetabulum. Therefore, the ligament, although it plays a certain role in the mechanics of the movement of the joint, its significance is small.

The strongest ligament in the entire human body belongs to the hip joint. This is the iliac-femoral ligament. Its thickness is 0.8-10 mm. The ligament starts from the anterior lower spine of the iliac wing and ends at the intertrochanteric line of the femur, fanning out towards it. Thanks to this ligament, the thigh does not bend inward.

Thanks to powerful muscles and strong ligaments on the anterior surface of the hip joint, the vertical position of the human body is ensured. Only these parts of the joint ensure the vertical position of the femoral bones of the trunk and pelvis balancing on the heads. Inhibition of extension is provided by a developed ilio-femoral ligament. The movement in the direction of extension can be performed by a maximum of 7-13 degrees.

The sciatic-femoral ligament is much less developed. It runs along the back of the joint. Its beginning is the area of the ischium involved in the formation of the acetabulum. The direction of the fibers of the ligament is outward and upward. The ligament intersects with the posterior surface of the femoral neck. Partially, the fibers that form the ligament are woven into the articular bag. The rest of the ligament ends at the posterior edge of the greater trochanter of the femur. Thanks to the ligament, the movement of the hip inward is inhibited.

From the pubic bone, the ligament runs outward and backward. The fibers are attached to the lesser trochanter of the femur and are partially woven into the joint capsule. If the hip joint is in an extended position, then it is this ligament that inhibits hip abduction.

Collagen ligamentous fibers, called the circular zone, pass through the thickness of the joint capsule. These fibers are attached to the middle of the femoral neck.

Physiology of the joint

The ability of a joint to move is determined by its type. The hip joint belongs to the group of walnut joints. This type of joint is multiaxial, so movement in it can have a variety of directions.

Around the frontal axis, a movement with a maximum scope can be made. The frontal axis passes through the head of the femur. The swing can be 122 degrees if the knee joint is bent. Further movement is inhibited by the anterior wall of the abdomen. Extension of the hip joint is possible no more than 7-13 degrees from the vertical line. Further movement in this direction is limited by stretching of the iliac-femoral ligament. If the hip makes a further backward movement, then this is provided by the curvature of the spine in the lumbar region.

Movement around the sagittal axis provides hip abduction and adduction. A 45 degree movement is made. Further, the greater trochanter rests against the wing of the ilium, which prevents movement in a larger volume. It is possible to abduct the hip 100 degrees in a bent position, since in this case the greater trochanter turns back. Around the vertical axis, the thigh can move 40-50 degrees. To make a circular movement with the foot, it is necessary to perform movement around three axes at the same time.

The hip joint provides movement to the pelvis, not just the hip. That is, the movements of the body relative to the hips are made in the hip joint. With various actions, such movements are made. For example, if a person is walking, then at certain moments one leg stands and serves as a support leg, and at this time the pelvis moves relative to the thigh of the supporting leg. The amplitude of these movements depends on the anatomical features of the structure of the skeleton. The following factors influence it:

femoral neck angle;
the size of the greater trochanter;
the size of the wings of the ilium.

These parts of the skeleton determine the angle between the vertical axis of motion, which passes through the head of the femur to the fulcrum in the foot, and the longitudinal axis of the femur. This angle is usually 5-7 degrees.

Moreover, if a person stands on one leg and balances on this fulcrum, the lever mechanism is activated, the upper arm of the lever - from the upper part of the greater trochanter to the iliac crest - becomes greater than the distance to the thigh from the ischium. The thrust towards a greater distance will be stronger, therefore, in the position on one leg, the pelvis will shift towards the supporting leg.

Due to the larger size of the upper arm of the lever in the female skeleton, a female swaying gait develops.

What does a hip x-ray show?

X-ray image of the hip joint allows you to visualize the contours of the edges and bottom of the acetabulum. But perhaps this is only at the age of 12-14 years. The compact plate of the acetabulum is thin on the side of the fossa, and thick on the side of the bottom.

The cervical-diaphyseal angle depends on the age of the patient. In newborns, the norm is 150 degrees, for children aged 5 years - 140 degrees, for adults - 120-130. The image clearly shows the contours of the neck of the femur, the trochanters - large and small, the structure of the spongy substance is visible. Quite often, on the radiograph of the hip joint of elderly patients, calcification of the articular lip is found.

Causes of pain in the hip joint

Pain in the hip joint can indicate not only directly the pathology that affected this part of the musculoskeletal system. Painful sensations here may indicate pathologies of the abdominal organs, reproductive system, spine (lumbar). Quite often, pain in the hip joint can be given to the knee.

The causes of joint pain are divided into the following groups:

trauma;
anatomical features and diseases of local origin (joint, its ligaments, surrounding muscles);
irradiation of pain in diseases of other organs and systems;
systemic diseases.

Traumatic damage to the hip joint can take the form of a dislocation, bruise, sprain. This group of causes of pain includes fractures of the pelvis, femoral neck in the area of the large and small trochanters of the thigh, fatigue fractures (or stress fractures) in the same areas.

It also requires the most complex treatment and long-term rehabilitation. Pain can be caused by a rupture of the articular lip, partial or complete ruptures of muscle fibers, sprains of muscles and ligaments, dislocation of the hip. Traumatic lesions also include APS syndrome and APC syndrome.

Diseases and pathological changes that cause pain in the hip joint include:

osteonecrosis of the femoral head;
coxarthrosis;
bursitis (trochanteric, iliac-comb, ischial);
femoral-acetabular impingement syndrome;
the formation of free intra-articular bodies;
snapping hip;
piriformis syndrome;
tenosynovitis and tendonitis;
proximal syndrome;
osteoporosis.

Pain can irradiate to the hip joints in diseases of other organs and systems:

neuralgia;
inguinal hernia;
spine diseases;
sports publicity.

Systemic diseases that cause pain in the hip joint include all types of arthritis, leukemia, infectious lesions of the hip joint, and Paget's disease.

Also, joint pain can be a sign of an oncological lesion of a primary or secondary nature. Osteomyelitis is one of the likely causes of pain. Often pain is caused by a complex of causes, since many of the pathologies of the hip joint can be related.

In childhood, there are some specific causes of hip pain:

juvenile rheumatoid arthritis;
epiphysiolysis;
Still's disease;
Legg-Calve-Perthes disease, etc.

The hip joint takes a lot of stress and is involved in almost every movement of the body, so its condition must be taken seriously. If pain occurs, it is recommended to immediately contact the clinic for diagnosis. Most often, an x-ray is prescribed for diagnostic purposes.

The human thigh is one of the large structures of the musculoskeletal system, which takes on part of the function of upright walking. It is made up of muscles and tendons that attach to the femur. Large blood vessels pass through the thigh, including the femoral artery, as well as nerves - femoral-genital, femoral and others. With the rest of the skeleton, the femur articulates in the acetabular pelvic cavity (above) and the patella (below). When the hip hurts, the most common cause of pain is either muscle or bone tissue.

Major diseases

In addition to soft tissue and bone injuries, pain often causes various processes in the bones. Sometimes pain radiates to the thigh with pathologies of the spine (osteochondrosis, spondylosis). To find out the cause of the pain, it is necessary to observe the nature of the painful sensations, their intensity, as well as the reaction to the load on the thigh, the change in the position of the limb. Pain in the thigh can be sharp, dull, aching, cutting - depending on the situation.

Soft tissue injury

Mechanical damage is the most common cause of pain in the hips. Blows and mechanical injuries refer to damage to the soft tissues of the thigh, accompanied by ruptures of blood vessels and nerve endings. In this case, the skin can remain intact, while an area of hemorrhage forms under them.

Hip soft tissue injury

Bruising occurs as a result of falls or blows. This diagnosis is characterized by the following features:

type of pain - dull, aching, aggravated by pressure on the damaged surface, the motor ability of the limb is preserved;
localization of pain - unilateral, at the site of injury;
additional symptoms are the formation of a hematoma (an irregularly shaped blue-violet area that appears as a result of rupture of small blood vessels under the skin).

A bruise is diagnosed during the examination, sometimes an x-ray is taken to rule out a fracture. With the integrity of the bone and the presence of a hematoma, the doctor makes a diagnosis of "contusion of the soft tissues of the thigh." In most cases, bruise treatment is not required, because. healing of damaged tissues occurs by itself without the need for outside help. But in some cases, the help of a surgeon or a traumatologist is required if the injury is severe and an extensive hematoma has formed in its place. In this case, a large volume of blood in the subcutaneous and intermuscular space can compress adjacent nerves, causing pain. The doctor opens the hematoma with a medical instrument and removes the blood.

Sprain of the hip ligaments

Sprain of the hip ligaments is a complete or partial rupture of small fibers of the ligamentous tissues, which occurs as a result of disproportionate physical exertion (when playing sports, lifting weights), falls, slips, a sudden change in body position or a strong load without prior preparation (warm-up). Most often, children and adolescents with an underdeveloped muscular structure, as well as the elderly against the background of osteoporosis, are susceptible to such injuries.

The main signs of stretching:

the type of pain is acute, aggravated when you try to make a movement with your foot;
localization of pain - in the hip joint, one-sided, eventually "spreads" along the thigh towards the lower leg, less often gives to the lower back;
additional symptoms - swelling at the site of injury, hyperemia of the skin over the injured area.

Sprained hip ligaments are diagnosed during examination and palpation. An orthopedist or traumatologist moves the patient's limb in different directions and asks the patient to perform simple exercises, and, based on the success of the implementation, makes a preliminary diagnosis. The final diagnosis is made using an x-ray, which usually shows joint deformity.

Treatment of the injury consists in the imposition of a fixing bandage that limits the mobility of the limb. Further therapy depends on the degree of damage to the ligaments. With a relative preservation of the integrity of the ligamentous tissues, conservative treatment is carried out (taking anti-inflammatory and analgesic drugs, ensuring rest). As the ligaments are restored, exercise therapy is prescribed, aimed at returning the functionality of the joint. With a complete rupture of the ligaments and / or avulsion fracture, a surgical operation is performed.

Bone injury

Fractures are another cause of hip pain. They also happen as a result of rough mechanical impact - shocks, falls, sharp compression, improper load distribution and other factors.

Often pain occurs due to a hip fracture, especially in people over 65 years of age. Aging is usually accompanied by osteoporosis - increased fragility of the bones, and even with mild loads, the integrity of the bone can be disturbed. The fracture usually occurs as a result of a fall.

Fracture symptoms include:

the nature of the pain is acute;
localization of pain - in the upper part of the thigh with irradiation in the groin;
additional symptoms - turning the foot outward relative to the knee, limited mobility of the leg, inability to walk and stand.

Damage is diagnosed using x-rays, as well as MRI of the joint. You can also determine a fracture of the femoral neck by tapping or pressing on the heel: the patient will experience unpleasant and even painful sensations.

Treatment of a hip fracture can be quite difficult, especially in the elderly. The application of gypsum has no effect, so the victim is prescribed surgery - osteosynthesis (fixation of joint fragments with metal screws), as well as endoprosthetics (complete or partial replacement of the joint).

Pertrochanteric hip fracture

This type of fracture is also most common in women over 65 years of age, and occurs as a result of a fall on the side (while walking on a slippery surface in winter, with sudden movements).

This diagnosis has the following features:

the nature of the pain is strong, very sharp;
localization - in the area of injury in the upper thigh;
additional symptoms are "stuck heel syndrome", in which the patient cannot raise his outstretched leg while lying on his back.

Accurate diagnosis is possible only on the basis of radiography. Treatment of a pertrochanteric fracture today is practiced in the form of a surgical intervention, in which the bone is pinned and fixed in the correct position. The operation allows you to quickly recover from an injury, and the procedure itself is minimally invasive (a small incision is made) and lasts about 20 minutes.

Soft tissue inflammation

Often, the thighs on the outside of the soft tissues hurt not due to mechanical damage, but due to the inflammatory process occurring in the soft tissues.

Myositis

One of the causes of pain in the soft tissues of the thigh is myositis, which occurs due to hypothermia, trauma, infectious or autoimmune processes, when the body begins to perceive tissue cells as foreign and attack them. The patient feels pain of moderate intensity against the background of weakening of the thigh muscles.

The disease is diagnosed on the basis of a survey, examination, and a blood test that detects eosinophilic leukocytosis. A soft tissue biopsy is also performed.

Treatment of myositis is complex:

providing rest (bed rest);
diet correction (strengthening the diet with vitamins and mineral complexes).

Depending on the cause of the disease, treatment is carried out with antibiotics (for infection), immunosuppressants and glucocorticosteroids (for an autoimmune cause), non-steroidal anti-inflammatory drugs, physiotherapy and massage (if the doctor allows).

Trochanteritis is an inflammation of the tendons that connect the lesser and greater trochanters to the femur. Most often, the pathological process occurs with injuries, due to hypothermia or overload. Pain - aching, pressing, aggravated by exertion (walking, climbing stairs), hypothermia. Localization of unpleasant sensations - in the outer side part ("breeches").

The disease is also diagnosed with the help of examination and questioning, blood tests, radiography or MRI of the thigh.

Treatment is conservative and involves the use of non-steroidal drugs. In more complex cases, injections of glucocorticosteroids into the tendon area are prescribed, which are done once every 2 weeks. Physical therapy is also prescribed, less often - laser therapy, massage with rubbing anti-inflammatory ointments.

Inflammatory damage to the bones

The bones and joints of the thigh are also subject to negative factors leading to pathological processes that cause pain.

Coxarthrosis

The main symptom of coxarthrosis is pain in the groin, radiating to the outer frontal and lateral part of the thigh, less often to the buttock and knee. It can hurt both joints, and one. It becomes difficult for the patient to move the limb, especially to take it to the side. A crunch is heard in the joint, and the leg may look somewhat shorter than the other.

Coxarthrosis is diagnosed using radiography (the image shows an increase in the cervical-diaphyseal angle, dysplasia, or changes in the proximal part of the femur).

Therapy of the disease:

conservative, at an early stage - with the help of anti-inflammatory drugs, chondroprotectors, intra-articular steroid injections, warming ointments,
operative - in case of severe destruction of the hip joint, arthroplasty (replacement) is performed.

Aseptic necrosis is very similar in symptoms to coxarthrosis, but is characterized by a high intensity of pain, which becomes unbearable with the development of the pathological process. The disease begins due to the cessation of blood supply to this part of the joint, the process itself proceeds quickly, and is accompanied by severe night pains. Characteristic for this disease is the age of patients: most often men from 20 to 45 years old suffer from it, while women are 5-6 times less likely.

Diagnosis of diseases of the hip joints is performed using modern research methods - X-ray and MRI. An experienced doctor can make a diagnosis based on the symptoms and examination of the limb, but in the end, everything is decided by an x-ray examination of the joint and bone.

Therapy consists in restoring the nutrition of the femoral head. Non-steroidal and steroid drugs, chondroprotectors and calcium preparations are also used, which accelerate the restoration of damaged bone tissues.

When should you contact a specialist?

Depending on the type and intensity of pain, as well as other signs, the patient can cope with the problem on their own, as well as seek help. Since the thigh is an important part of the body responsible for the ability to walk, pain in it should not be ignored. The location of large arteries and veins is another reason why it is necessary to monitor the condition very carefully.

Warning signs for which you need to see a doctor as soon as possible:

sharp and sharp pain, making movement of the leg impossible;
crunching and clicking in the joints and the bone itself when moving;
extensive hematoma, accompanied by edema;
uncharacteristic position of the leg relative to the axis of the body.

These symptoms indicate a serious injury or dysfunction of the hip, in which medical attention is indispensable.

First aid at home

In case of serious hip injuries, especially fractures, it is important to provide timely assistance to the victim even before the doctor arrives. The limb must be immobilized by putting a splint on it. It is important to keep the injured leg calm. For severe pain, ice or other cold objects can be applied, but a heating pad and other sources of heat should not be used. With severe unbearable pain, the victim can be given an analgesic, and then constantly monitor his condition, leaving him alone until the ambulance arrives.

Conclusion

Injuries to the bones and soft tissues of the thigh, as well as pathological processes in the bones, tendons and joints are the main factors in the occurrence of pain. Even if it does not prevent a person from going about their business, it is not necessary to let the situation take its course and self-medicate. This can lead to an aggravation of the inflammatory process, after which a longer and more complex treatment will be required. In case of fractures and bruises, professional help from a doctor is simply necessary, otherwise it is fraught with a lifelong limitation of limb function as a result of improper fusion or a chronic inflammatory process.

Acetabular angle or index is a radiological term for measuring deformity of the hip joint. The concept was first introduced by scientists Kleinberg and Liebermann in 1936. Normally, the value of the acetabular index of HBS in newborns is less than 28 degrees. The rate changes with age. By the end of the first year of life, it decreases to 22 degrees or less. Deviations from generally accepted standards indicate the presence of a pathology in a child: dysplasia, dislocation, subluxation. Timely detection of the disease will prevent its further development and preserve the health of the joint.

Angles of the hip joint and their norms in children

Measurement of the angles of the hip joint in children is carried out if congenital dysplasia is suspected. Timely medical care saves many from disability in adulthood, because dysplasia is a violation in the formation of the articulation. They suffer mainly from girls as a result of abnormal intrauterine development, frequent swaddling, lack of vitamins and minerals. The exact reason has not yet been established.

transverse scanning is carried out in order to determine the direction in which the femoral head is displaced in an unstable position (dislocation, subluxation). The X-ray sensor is placed in the region of the greater trochanter of the femur.

In the neutral position, the normal angle is 15-20 degrees. The round head of the femur is located in the acetabulum, the Y-shaped cartilage in the central part. In front is the pubic bone, and behind is the ischium.

To analyze the transverse section in the bent position of the hip (about 90 degrees), the sensor is installed in the projection of the acetabulum and the femoral head. Normally, the head should be completely immersed in the recess, and not move during dynamic tests. In the picture, the articulation looks like the Latin letter "U". With subluxation, the image will more likely resemble the letter "V", and with dislocation - "L".

Sagittal angle correspondence is formed at the intersection of the longitudinal neck of the femur and the tangent to the anterior and posterior edges of the roof of the acetabulum. The indicator is measured using a radiograph in the sacroacetabular projection. Additional factors that are taken into account when determining joint stability:

centering of the head in the acetabulum;
angle of inclination of the roof of the acetabulum.

If the radiograph was taken with the middle position of the hips, then any changes in the direction of the longitudinal axis of the femoral neck or pathological angle values are a sign of dysplasia.

To eliminate errors in styling, it is enough to make corrections for abduction and adduction of the hips.

Weisberg corner or central-border is formed by a vertical straight line and a line passing from the center of the femoral head to the lateral side of the acetabulum.

In the medical system vertically central corner called the VCA angle. It is formed by a straight line (V) and a line running from the center of the femoral head through the anterior edge of the femoral shadow beyond the anterior edge of the glenoid cavity. X-ray is carried out in the “false profile” position. The patient is in a standing position, and the cassette of the device is located behind the limb under study. The angle between the pelvis and the cassette should be 65 degrees, and the distance to the bone should be 110 cm. To obtain an image, a beam of rays is directed to the center of the femoral head. The side view can be rotated 25 degrees.

Second name Hilgenreiner angle- cartilage angle. It is measured using a radiograph. The plane lies between the limbus and the transverse plane of the small pelvis. The value allows you to determine the ossification of the hip bone. Delayed bone formation is another sign of congenital dysplasia.

The neck of the hip joint is one of the elements of the proximal articular end of the femur. In normal condition corner rotation of the femoral neck around its axis is 20-25 degrees.

With the diaphysis, the femoral neck forms cervical-diaphyseal angle(SHDU). Normally, in newborns, it is 140-150 degrees, and with age it decreases to 120-130 degrees. Pathological forms are considered to be an obtuse angle, which is formed as a result of a varus or valgus pelvis, and individual, constitutional features.

Sharpe angle(DCB) is the angle of the acetabulum in the vertical plane. It is formed by a horizontal line passing through the upper and lower edge of the acetabular fossa. To assess the indicator, a face radiograph is used. A photograph can be used to measure:

inclination of the depression in the vertical plane;
depth of the articular cavity;
the length of the entrance to the cavity;
joint cavity coefficient.

Angle of vertical correspondence called the part of the plane that is formed by crossing the tangent to the entrance to the acetabulum and the longitudinal axis of the femoral neck.

The reference point for the tangent (DA) is the lower pole of the "tear figure" and the outer edge of the roof of the acetabulum.

The normal value of the angle for children from 6 years old is 85-90 degrees.

Additional lines for diagnostics

In addition to angles, radiologists often operate in terms of lines. These data help determine the relationship between the femoral head and the acetabulum and identify pathology.

Lines used in the diagnosis of the hip joint:

Shenton line. It is carried out along the lower contour of the femur. It passes to the lower contour horizontally to the surface of the pubic bone. Forms a smooth arcuate line. With dysplasia, it has a broken shape.
Calve line. Crosses the outer contour of the ilium and goes to the upper contour of the femoral neck. With dysplasia, it also has a broken structure.
Ombredan-Perkins line. It follows vertically from the upper outer point of the acetabular notch and continues with the longitudinal axis of the femoral shaft. With the normal development of the musculoskeletal system, the proximal epiphysis is located medially from this line, with pathology - outwards.
Keller line. A horizontal line passing through both Y-shaped cartilages.

Lines are necessary for a schematic representation of the elements of the hip joint. A shift from the norm will allow you to easily determine the presence of a shift and its degree.

The dependence of the angles on the age of the child

After birth, children regularly undergo preventive examination by an orthopedist. An increase in the acetabular index with age increases the risk of pathology of the femoral head. However, at an early stage of the incorrect formation of the musculoskeletal system, the violation can be corrected without surgical intervention in a short time.

Table of norms for the angles of the hip joints in children by months:

3-4 months	25-30 degrees
5-24 months	20-25 degrees
2-3 years	18-23 degrees

If the angle is more than normal by 5 degrees, subluxation is diagnosed, by 10 - dislocation, more than 15 - high dislocation.

Definition and classification of the norm of angles in children

In children, the norms of the angles of the hip joint are classified depending on the diagnostic method that is used for measurement. Ultrasound is suitable for children up to 6 months, as it is completely harmless. An x-ray is prescribed to confirm the diagnosis and obtain more accurate information about the condition of the joint.

The advantage of ultrasound is the evaluation of indicators in real time. In particular, the ultrasonic method measures:

alpha angle. The measurement technique is very similar to the calculation of the acetabular index. Normally, the value is 60 degrees or more.
beta angle. Formed by the main line and lip of the triradial cartilage. The norm in children does not exceed 77 degrees.
The degree of coverage of the head by the roof of the acetabulum. In newborns and preschoolers, it reaches 50% and above.

X-ray allows you to assess the symmetry of the hip joint and determine the relationship between the proximal epiphysis and the pelvic bones at the stage of formation. The main indicators that are used for this are:

the Hilgenreiner line;
Perkin line;
acetabular angle;
Shenton line.

The Hilgenreiner and Perkin lines are perpendicular to each other. The first passes along the upper contour of the triradial cartilages in the horizontal plane. The second crosses the lateral contour of the roof of the acetabulum. The upper epiphysis should be located in the lower medial quadrant.

Children with a high risk factor for dysplasia are advised to visit an orthopedist every six months or according to an individual schedule prescribed by a doctor. During this period, you should engage in physiotherapy exercises, fully use the capabilities of the hip joints.

Use special carrying backpacks, slings, car seats. In them, the body of the child takes the correct position and is not deformed.
For newborns, special wide swaddling techniques are used. They can be mastered at courses for expectant mothers or at the consultation of a pediatrician, orthopedist.
Give your baby a massage or light exercise regularly. Knead all joints and bones by performing flexion, extension, rotation and abduction movements.
For reliable fixation of the baby's legs, pick up orthopedic devices with the doctor, for example, Pavlik's stirrups.

For prevention, swimming lessons, a visit to a gymnastic circle, breathing techniques, and children's yoga are also suitable.

However, the listed parameters may vary on the radiograph, and this must be taken into account in order not to make an erroneous diagnosis.

The main signs of Dysplasia on the radiograph should be considered the following:

The Norberg angle is less than 105 degrees.

B. The index of penetration of the femoral head into the cavity is less than 1

Widened and uneven joint space.

Joint incongruence.

D. The cervical-diaphyseal angle is greater than 145 degrees.

The parameters are taken from both joints and entered into the certificate of the condition of the hip joints.

The division of dysplasia into stages is carried out on the basis of a quantitative account of simultaneously identified radiological signs (Mitin V.N., 1983) (Table 2).

When assessing the staging of the process, only true signs of dysplasia are taken into account and radiographic signs of secondary arthrosis are not taken into account.

To bring this classification of DTS of dogs into conformity with the classification of the International Cynological Federation, a summary table should be used (Table 3).

Comparative characteristics of the parameters of a normal joint and those with DTS on an x-ray

Table 2

Options		Pathology
Norberg corner	105 degrees or more	Less than 105 deg.
Index of penetration of the femoral head into the cavity, units	Equal to one. The joint space is narrow, uniform.	Less than one. The joint space is enlarged and uneven. Incongruence in the joint
Tangential	Always negative or zero	Positive, with a rounded anterolateral edge of the acetabulum
diaphyseal angle	Equal to 145 deg.	More than 145 degrees.

Table 3

X-ray characteristics of different stages of hip dysplasia in dogs

Stages of the disease	X-ray changes
healthy joint	Missing
Stage of predisposition to dysplasia	The presence of one sign
predysplastic stage	The presence of two signs
Stage of initial destructive changes	The presence of three signs
Stage of pronounced destructive changes	The presence of four signs, subluxation in the joint is possible
Stage of severe destructive changes	The presence of four signs, the Norberg angle is less than 90 degrees, dislocation or subluxation in the joint

DIFFERENTIAL DIAGNOSIS

Pain and lameness by themselves do not allow a conclusion about hip dysplasia to be made with certainty, especially with the possible localization of lameness in one of them. In addition, lameness due to DTS not n it is constant, does not appear in all cases, and also depends on the stage of DTS and the changes caused by it. Indeed, in dogs there is a gradual transition from a normal, healthy state of the hip joint to the most severe form of DTS. With the clinical signs of dysplasia, which does not occur in a bright classical (with all its clinical signs) form, the signs of some other diseases are similar, among which destruction of the femoral head (aseptic necrosis), fracture of the femoral neck, dislocation and subluxation of the hip joint should be noted. Therefore, differential diagnosis of these diseases is necessary.

Destruction of the femoral head (aseptic necrosis), is associated with a violation of its blood supply, which eventually leads to the destruction of the hip joint. The disease is most typical for puppies of small breeds (Toy Poodle, Toy Terrier, Fox Terrier, Pikinese, Japanese Chin, etc.). SCH at the age of 4-10 months, as a rule, of a genetic nature, and almost never occurs in dogs of large breeds. Whereas DTS is a disease of large dog breeds. On the radiograph, with the destruction of the femoral head, the acetabulum and the angles do not change, but only resorption of the femoral head is noted.

Hip fracture a- this is a pathology of the hip joint that occurs suddenly and, as a rule, is associated with the influence of an external force. With this lameness, support on the injured limb is not possible. The diagnosis is specified radiographically.

Dislocation The hip joint arises from the influence of an external force and is accompanied by a complete impossibility of support, while the diseased limb is shortened compared to the healthy one. Diagnosis is not difficult

Subluxation hip joint may occur S. step enno in puppies of large breeds as a result of weakness of the ligamentous apparatus. - Most often occurs during a period of intensive growth - from 4-10 months. It differs from DTS in that, as a rule, one limb is affected (the opposite joint is not changed in shape). At the same time, the configuration of the femoral head and the angles of the acetabulum are preserved. Without timely treatment, this pathology can lead to arthrosis hip joint.

-- [ Page 3 ] --

Based on MSCT, there were no significant differences by gender and between the right and left hip joints in healthy children; the obtained values of the cervical-diaphyseal, acetabular angles, the angle of vertical deviation, vertical correspondence and the Wiberg angle are comparable with the X-ray data and have a smaller error. We have developed a technique for measuring the angle of antetorsion, sagittal correspondence and frontal inclination in the axial projection. The obtained data are not comparable with the X-ray data, which may be due to the need for complex mathematical transformations in the latter (Table 5). X-ray contrast structures of the hip joint are well visualized by MSCT, which made it possible to assess the state of the cartilage, capsule and muscles of the hip joint.

In our study, it was found that early visits (up to 3 months) to an orthopedist for hip dysplasia were in 41% of cases, in the first month of life - in single patients. However, in the second half of life, the diagnosis was initially made in 7% of cases.

Clinically, the most common signs were limited hip abduction and asymmetry of the subgluteal popliteal folds (more than 70%).

According to the ultrasound examination from the lateral access in children with preluxation in the B-mode, the oblique position of the roof of the acetabulum was recorded; deformed short cartilaginous protrusion. Lateralization of the femoral head at rest and during provocative tests; the angle was 55-60, the angle was 45-75. The echographic picture of the subluxation was characterized by the presence of a rounded bone protrusion. When conducting provocative tests, a slight lateralization of the femoral head was recorded; corner<45°, угол >75°.

In the case of hip dislocation, the femoral head was decentered. The deformed short cartilaginous protrusion did not cover the femoral head. In all patients with hip dysplasia, there was a delay in the formation of ossification nuclei.

When analyzing the results of the study from the anterior approach, it was found that the most sensitive is the echographic sign of the SCR/PPM ratio. In children of group 2, this indicator did not differ from the norm in any case. In children of the 3rd group, it changed only when the diagnosis was made after 6 months. In all examined children of the 4th group, the ratio of SCR/PPM increased. In addition, in children of the 4th group, with a late diagnosis, the joint capsule was thinned, stretched (p<0,05). По нашему мнению это может свидетельствовать о формировании торсионных изменений бедренной кости.

In all children of the 2nd, 3rd and most children of the 4th group, circumflex vessels of the femur were determined. The exception was 2 observations of the 4th group, in which the correct course of the circumflex vessels was not determined, they were represented by separate color signals. The diameter of the circumflex vessels in children of groups 2 and 3 did not differ significantly from the normative values. In children of 4 groups up to 3 months. vessel diameters did not significantly differ from the standard values (p<0,05), у детей старше 3 мес. диаметр сосудов уменьшался.

In the 2nd group of patients in 100% of cases, the cervical artery, vessels of the growth zone, round ligament and capsule of the hip joint were determined. In group 3, these vessels were determined only in 74% of children. Significant changes were determined in children of the 4th group. When the diagnosis is made within the first 6 months life blood flow in the femoral head was weakened, the cervical arteries were determined in 100% of cases. In patients of the 2nd half of the year, the vessels of the growth zone, the round ligament were not determined; blood flow in the cervical vessels was determined in 26.6% of cases. Apparently, changes in blood flow can be associated with changes in individual components of the hip joint, their spatial relationships. On the other hand, in some cases, there may be a vicious development of the vascular system.

In the pulse-wave Doppler mode in the circumflex vessels, we identified various variants of hemodynamic parameters.

In children of the 2nd group, the first three months of life did not differ significantly from the age norm. In children older than 3 months of the 2nd group, a statistically significant increase in the index of peripheral resistance and systolic velocity of arterial blood flow was determined; decrease in diastolic blood flow velocity and venous outflow velocity. Vessel diameters were not changed. Such changes could be associated with insufficient blood supply, but the possibility of its perception from the capillary bed and adequate venous outflow.
In part of the children of the 3rd group, there was a decrease in speed indicators in the circumflex arteries. The indicators of peripheral resistance in them did not change. Such changes were regarded by us as minimal and testified to the viability of metabolic processes. Another type of hemodynamic changes in this group of patients was characterized by the preservation of speed indicators, an increase in peripheral resistance in the circumflex arteries. The rate of venous outflow in them was significantly reduced. In the area of the round ligament, growth zone and cervical vessels, hemodynamic parameters decreased. Such changes were interpreted by us as a decrease in perfusion in the femoral head, which could lead to ischemic processes in it.
The most diverse types of hemodynamic disorders were detected in children of the 4th group.

In subgroup 1, in circumflex vessels, speed indicators and resistance index were reduced; which could indicate insufficient blood flow due to vasoconstriction.

In subgroup 2, systolic velocity and peripheral resistance index exceeded the age norm; venous outflow rates were reduced, which may have been due to a violation of the spatial ratio of the components of the hip joint, possible tension of the vessels. Probably, the volumetric blood flow exceeded the expected one, and a pronounced venous congestion was created in the femoral head.

In patients of the 3rd subgroup, the systolic velocity in the circumflex arteries and the resistance index were significantly reduced; diastolic and venous outflow rates increased. Such changes were regarded by us as a "gaping" capillary bed, which led to a rapid outflow of blood and ischemia of peripheral areas. In addition, a significant increase in the rate of venous outflow could indirectly indicate the inclusion of blood shunting processes and an even greater aggravation of the state of microcirculation.

In the area of the round ligament, growth zone and cervical vessels in children of the first six months of life, hemodynamic parameters decreased. After 6 months vessels of the growth zone, the round ligament were not determined. The revealed changes, in our opinion, spoke about the aggravation of the processes of ischemia of the femoral head.

When radiography in children of the 2nd group, there was an increase in the acetabular index to 32°-33°, bevelling of the bone protrusion of the acetabulum. In children of group 3, partial decentration of the femoral head, flattening of the acetabulum, an increase in the acetabular angle up to 32°-38°, an increase in d value up to 18 mm, a significant delay in the appearance of ossification nuclei, the Calvet and Shenton arches were detected. In children of the 4th group, the femoral head was completely decentered and was determined outside the acetabulum, the ossification nucleus was not determined. The nucleus of ossification of the ilium was underdeveloped, which caused a sharp obliqueness of the bone protrusion and the transition of the line of the acetabulum to the line of the wing of the ilium. The acetabular index was significantly higher than normal, more than 370-40°. The distance d increased by more than 25 mm, and the value h decreased to 3-5 mm. The arcs of Calvet and Shenton were broken.

Dynamic observation of children in groups 2-4 was carried out for 1 year. In children of the 2nd group after 3 months. from the beginning of treatment in the B-mode, ossification nuclei of varying severity appeared, but symmetrically on both sides; almost horizontal direction of the acetabulum; stability of the femoral head during provocative tests. In the study of hemodynamics, all indicators corresponded to the normative ones. In no case was a negative trend detected.

Table number 5

Morphometric angular indices in healthy children

Groups	1-3 years(n=28)		3-7 years(n=32)		7-15 years old(n=36)
corners	CT	R	CT	R	CT	R
frontal projection
cervical-diaphyseal angle	137.1±0.4	136.8±0.67	132.4±0.3	132.56±0.7	130.1±0.35	129.8±0.78
Angle of vertical deflection	49.0±1.2	48.85±1.8	46.9±3.5	47.1±3.47	45.1±1.3	46.6±3.8
Vertical fit angle	78.5±4.4	78.9±5.2	88.2±3	87.3±3.2	94±1.78	93.59±2.4
Acetabular angle	30±5.3	31.3±4.7	20.1±2.8	20.7±3.4	14.6±3.7	12.6±4.1
Wiberg angle	16.5±4.1	18±3.8	21.3±2.2	20±4.2	29.3±2.9	26±3.6
Axial projection
Antetorsion angle	18.0±2.6	26.9±8.7	16.4±5.2	24.6±7.2	14.8±3.7	23.5±5.9
Horizontal Compliance Angle	64.7±3.6	25±7.6	65.4±3.5	24.9±4.64	62.0±5.1	26.2±8.2
Frontal inclination angle	52.8±5.2	38±2.1	57.1±4.7	39.1±5.87	65.3±4.2	38.4±6.1
Sagittal projection
Sagittal correspondence angle	58.8±5.6	82±2.4	60.8±4.4	86±3.7	67.2±5.2	91±3.5
Head centering	Avg. third		Avg. third		Avg. third
The inclination of the roof of the acetabulum	31.0±1.3	14.6±2.8	30.6±2.5	14.3±1.9	29±2.8	12.5±2.0