Physiological immaturity of the hip joints. Narrow pelvis during pregnancy: degrees, course of labor

After birth, hip dysplasia is common in newborns. Diagnosis of such diseases is quite difficult. Parents will be able to suspect the first signs in children under one year old. This disease is dangerous due to the development of adverse complications that can significantly worsen the baby’s quality of life.

What it is?

This pathology musculoskeletal system arises from the influence of numerous causes that lead to disruption of intrauterine organ formation. These factors contribute to underdevelopment of the hip joints, as well as all the articular elements that form the hip joints.

With severe pathology, the articulation between the head is disrupted femur and the acetabulum, which form the joint. Such violations lead to the appearance of unfavorable symptoms of the disease and even complications.

Congenital underdevelopment of the hip joints is quite common. Almost every third of a hundred children born is diagnosed with this disease. It is important to note that susceptibility to this disease is higher in girls, and boys get sick somewhat less frequently.

IN European countries dysplasia of large joints more common occurrence than in African countries.

Pathology is usually found on the left side; right-sided processes are recorded much less frequently, as are cases of bilateral processes.

Causes

There are several dozen provoking factors that can lead to the development of physiological immaturity of large joints. Most of the impacts that lead to immaturity and disruption of the structure of large joints occur in the first 2 months of pregnancy from the moment the baby is conceived. It is at this time that the intrauterine structure of all elements of the child’s musculoskeletal system takes place.

The most common causes of the disease include:

• Genetics. Typically, in families where cases of this disease have occurred, the likelihood of having a baby with pathologies of large joints increases by 40%. At the same time, girls have a higher risk of getting sick.
• Exposure to toxic chemical substances during pregnancy. This situation is most dangerous in the first trimester, when intrauterine development of the musculoskeletal system occurs.
• Unfavorable environmental situation. Harmful factors external environment have negative action on the development of the unborn child. An insufficient amount of incoming oxygen and a high concentration of carbon dioxide can cause intrauterine hypoxia of the fetus and lead to disruption of the structure of the joints.
• The expectant mother is over 35 years old.
• The baby weighs more than 4 kilograms at birth.
• The birth of a baby ahead of schedule.
• Breech presentation.

• Carrying a large fetus with an initially small uterus. In this case, the baby physically does not have enough space to active movements. This forced passivity during fetal development can lead to limited mobility or congenital dislocations after birth.
• Infection with various infections expectant mother. During pregnancy, any viruses or bacteria easily pass through the placenta. Such infection in the early stages of a baby’s development can lead to birth defects in the structure of large joints and ligaments.
• Poor quality nutrition, lack of vital vitamins, which are necessary for the full development of cartilage and ossification - the formation of bone tissue.
• Excessive and very tight swaddling. Excessive pressing of the child's legs to the body can lead to the development of various types of dysplasia.

Kinds

Doctors classify various forms of the disease according to several main characteristics. For dysplasia, such criteria are combined into two large groups: according to the anatomical level of the lesion and according to the severity of the disease.

According to the anatomical level of the lesion:

• Acetabular. There is a violation in the structure of the main large elements that make up the hip joint. Basically, with this option, damage to the limbus and marginal surface occurs. At the same time, the architecture and structure of the joint changes greatly. These injuries lead to disruption of movements that should be performed by the hip joint normally.
• Epiphyseal. A pronounced impairment of mobility in the joint is characteristic. In this case, the norm of the angles that are measured to assess the work of large joints is noticeably distorted.
• Rotary. With this variant of the disease, a violation may occur anatomical structure in the joints. This is manifested by the deviation of the main structures that form the hip joint from the median plane. Most often, this form is manifested by gait disturbance.

By severity:

• Mild degree. Doctors also call this form preluxation. Severe disorders that arise with this option and lead to disability, as a rule, do not occur.
• Medium heavy. It may also be called a subluxation. With this option, the head of the femur usually extends beyond the articulation during active movements. This form of the disease leads to the development of adverse symptoms and even long-term negative consequences diseases that require more active treatment.
• Heavy current. Such a congenital dislocation can lead to adduction contracture. With this form, a pronounced violation and deformation of the hip joint occurs.

Symptoms

Identification of the first symptoms of anatomical defects of large joints is carried out already in the first months after the birth of the baby. The disease can already be suspected in an infant. When the first signs of illness appear, the baby should be shown to an orthopedic doctor. The doctor will take care of everything additional examinations which will help clarify the diagnosis.

The most characteristic manifestations and signs of the disease include:

• Asymmetry in the location of skin folds. They are usually quite well identified in newborns and infants. Estimate this symptom every mother can. All skin folds should be approximately at the same level. Pronounced asymmetry should alert parents and suggest that the child has signs of dysplasia.
• The appearance of a characteristic sound resembling a click, during adduction of the hip joints. This symptom can also be detected with any movements in the joint in which abduction or adduction occurs. This sound occurs due to active movements of the femoral head along the articular surfaces.
• Shortening of the lower limbs. It can occur on one side or on both. With a bilateral process, the baby often experiences growth retardation. If the pathology occurs only on one side, then the child may develop lameness and gait disturbance. However, this symptom is detected somewhat less frequently when the baby tries to stand on his feet.
• Pain in large joints. This sign intensifies when the child tries to stand on his feet. Increased pain occurs when performing various movements at a faster pace or with a wide amplitude.
• Secondary signs of the disease: slight muscle atrophy in the lower extremities, as a compensatory reaction. When trying to determine the pulse in the femoral arteries, a slightly reduced impulse may be observed.

Consequences

Dysplasia is dangerous due to the development of unfavorable complications, which can occur with a long course of the disease, as well as with insufficiently effective and well-chosen treatment of the disease in the initial stages.

With a long course of the disease, persistent gait disturbances may develop. In this case, surgical treatment is required. After such therapy, the baby may limp slightly. However, later this unfavorable symptom completely disappears.

Also, if signs of the disease have been observed for a long time, muscle atrophy may occur in the damaged area. lower limb. On the contrary, the muscles on a healthy leg may be excessively hypertrophied.

Severe shortening also quite often leads to gait disturbances and severe lameness. IN severe cases This situation can even lead to the development of scoliosis and various posture disorders. This occurs due to a shift in the supporting function of damaged joints.

Large joint dysplasia can lead to various adverse consequences in adulthood. Quite often, such people have cases of osteochondrosis, flat feet or dysplastic coxarthrosis.

Diagnostics

As a rule, this pathology begins quite mildly. Only a specialist can identify the first symptoms; it is quite difficult for parents to do this on their own at home.

The first step in establishing a diagnosis is a consultation with an orthopedic doctor. Already in the first year of a child’s life, the doctor determines the presence of predisposing factors, as well as primary symptoms of the disease. Usually, the first orthopedic signs of the disease can be recognized during the first six months of a child’s life. To accurately verify the diagnosis, various types of additional examinations are prescribed.

The safest and most informative method that can be used in infants is ultrasound. Interpretation of ultrasound allows you to establish various signs characteristic of the disease. This method also helps to establish the transient form of the disease and describe the specific changes that occur in the joint characteristic of this variant. Using ultrasound, you can accurately determine the timing of nuclear ossification hip joints.

Ultrasound diagnostics is also a highly informative method that clearly describes all anatomical defects observed in various types of dysplasia. This study is absolutely safe and is performed from the very first months after the birth of the baby. There is no significant radiation exposure to the joints during this examination.

X-ray diagnostics is used only in the most difficult cases diseases. X-rays should not be performed on children under one year of age. The study makes it possible to fairly accurately describe various anatomical defects that arose after birth. Such diagnostics are also used in complex clinical cases, in which the exclusion of concomitant diseases is required.

All surgical methods examination of large joints in newborns is not used. During arthroscopy, doctors use instrumental instruments to examine all the elements that make up the hip joint. During such studies the risk secondary infection increases several times.

Typically, magnetic resonance and computed tomography of large joints are performed before planning various surgical interventions. In difficult cases, orthopedic doctors can prescribe examination data to exclude various diseases which may present with similar symptoms.

Treatment

Diseases of the musculoskeletal system need to be treated for a long time and with strict observance recommendations. Only such therapy makes it possible to eliminate as much as possible all the unfavorable symptoms that arise with this pathology. A complex of orthopedic therapy is prescribed by an orthopedic doctor after examining and examining the baby.

Among the most effective and commonly used treatment methods are the following:

• Using wide swaddling. This option allows you to maintain the most comfortable position for the hip joints - they are in a slightly apart state. This type of swaddling can be used even for babies from the first days after birth. Becker's pants are one of the wide swaddling options.
• The use of various technical means. The most commonly used are various tires and spacers. They can be of different rigidity and fixation. The selection of such technical means is carried out only on the recommendation of an orthopedic doctor.
• Physical exercises and exercise therapy should be performed regularly. Typically, such exercises are recommended to be done daily. The complexes should be performed under the guidance of the medical staff of the clinic, and subsequently independently.
• Massage. It is prescribed from the first days after the birth of the baby. Courses are conducted several times a year. With this massage, the specialist works well on the baby’s legs and back. This method of treatment is well accepted by the child and, when carried out correctly, does not cause any pain.
• Gymnastics. A special set of exercises must be performed daily. Abduction and adduction of the legs in a certain sequence allows you to improve movement in the hip joints and reduce the manifestations of stiffness in the joints.
• Physiotherapeutic methods of treatment. The baby can undergo ozokerite and electrophoresis. Various types of thermal treatment and inductotherapy are also actively used for children. Physiotherapeutic procedures for the treatment of dysplasia can be performed in a clinic or specialized children's hospitals.

• Spa treatment. Helps effectively cope with adverse symptoms that arise from dysplasia. Staying in a sanatorium can significantly affect the course of the disease and even improve the baby’s well-being. For children with hip dysplasia, it is recommended to undergo Spa treatment annually.
• Adequate nutrition with the obligatory inclusion of all necessary vitamins and microelements. Children with disorders of the musculoskeletal system must eat a sufficient amount of fermented milk products. The calcium they contain has a beneficial effect on the structure of bone tissue and improves the growth and physical development of the child.
• Surgical treatment in newborns is usually not performed. Such therapy is possible only in older children. Usually, before reaching 3-5 years of age, doctors try to carry out everything necessary methods treatments that do not require surgery.
• The use of painkillers, non-steroidal anti-inflammatory drugs to eliminate severe pain. Such drugs are prescribed mainly for severe variants of the disease. An orthopedic doctor or pediatrician prescribes painkillers after examining the child and identifying contraindications to such medications.
• Plaster application. It is used quite rarely. In this case, the affected leg is fixed quite tightly plaster cast. After some time, the cast is usually removed. The use of this method is quite limited and has a number of contraindications.

In order to reduce the risk of possible development of dysplasia, use the following tips:

1. Try to choose a looser or wider swaddle if the child has several risk factors for the development of dysplasia of large joints. This method of swaddling can reduce the risk of developing disorders in the hip joints.
2. Monitoring a healthy pregnancy. Try to limit the impact of various toxic substances on the body of the expectant mother. Severe stress and different infections can cause different intrauterine malformations. The expectant mother must ensure that she protects her body from contact with any sick or feverish acquaintances.
3. Using special car seats. In this case, the child's legs are in an anatomically correct position throughout the entire trip in the car.
4. Try to hold your baby correctly. Do not press the baby's legs tightly to the body. An anatomically more advantageous position is considered to be a more abducted position of the hip joints. Also remember this rule while breastfeeding.
5. Preventive complex gymnastic exercises . Such gymnastics can be performed from the first months after the birth of the child. The combination of exercises and massage significantly improves the prognosis of the disease.
6. Choose the right diapers. A smaller size can cause a forced adducted state of the child’s legs. Avoid overfilling the diaper and change them often enough.
7. Get regular check-ups with an orthopedic surgeon. Every baby must attend such consultations before the age of six months. The doctor will be able to identify the first signs of the disease and prescribe the appropriate treatment package.

With high-quality treatment, most negative manifestations of dysplasia can be eliminated almost completely. Medical supervision of a child diagnosed with dysplasia should be carried out over a long period of time. Such babies undergo regular examinations by a neurologist and orthopedist. Controlling the course of the disease helps prevent the development of dangerous and unfavorable complications.

To learn about what hip dysplasia is, how it is treated and at what age it is best to start treatment, watch the following video.

Molostov Valery Dmitrievich

Candidate of Medical Sciences

As strange as it may seem to pediatricians, a newborn child has direct indications for treatment with manual therapy. Of course, applying manual therapy to a newly born baby requires great care and tenderness. A good chiropractor should feel the norm physical impact to an infant. A too weak and overly delicate influence on the baby will not cure the disease and will be useless. Too harsh an impact will only harm the child’s health and make him disabled for life. Therefore, when manually influencing an infant, all actions should be slow and careful. For 9 months, the baby is inside the mother and, as a rule, in a head down position. After 6 months of pregnancy, the child is fully formed anatomically. The remaining 3 months before birth, the child is in a head-down position, and any shocks, jumps or falls of the mother from a small height are perceived by the child as blows to the head and neck area. Therefore, it can be argued that in the prenatal state, a child often receives bruises to the cervical spine, which can lead to the development of osteochondrosis even in a newborn.

1. The compressive effect of childbirth on the child’s spine. During 9 months of pregnancy, a woman’s number of muscle fibers in the uterus and vagina increases almost 3 times. The fetus is “covered” by the muscular layer of the uterus of 3 - 4 centimeters, then there is a layer amniotic fluid 2 - 3 centimeters thick. The fetus remains in a state of “free floating in the aquatic environment” until the rapid release of water before birth. The enormous thickness of the muscular layer of the uterus is necessary to create powerful pressure on the fetus during childbirth. During contractions, the thick muscular wall of the uterus compresses the newborn's spine in the direction from the pelvis to the head. Childbirth creates a direct traumatic effect on the child's spine. The force of compression of the fetus during childbirth is quite strong, up to 5 kilograms for every centimeter of the surface of the child’s body, both in the transverse and longitudinal direction. During childbirth, the fetus often experiences extreme compression of the delicate cartilaginous intervertebral discs. The consequences of excessive compression of the spine in the longitudinal direction are osteochondrosis, which may not resolve for up to 2 years. If you trace the difficult path that a child overcomes during childbirth, you can only wonder how the newborn’s spine can withstand such loads along the axis of the spine. See Figure 116.

Figure 116. The direction of pressure of the powerful muscles of the uterus on the child’s spine is from the buttocks to the head.

The powerful muscle fibers of the uterus squeeze the fetus with such force that it (in the literal sense of the word) squeezed out through the narrow female reproductive tract. Under the influence of the pressure of the uterus on the spine, the crown of the child’s skull moves apart and opens the muscular sphincter, which is the cervix. Next, the fetal head experiences monstrous pressure from the thick vaginal muscles. The child’s head is compressed quite strongly around the circumference, especially in primiparous women and in the elderly (over 35 years of age), in whom the elasticity of muscle tissue is reduced. If it weren’t for the natural fatty lubrication of the newborn’s head and torso, moving it “through the tunnel of the female genital organs” would be impossible due to strong friction and resistance. Due to compression of the child's skull by the mother's birth canal, a cephalohematoma often occurs on the newborn's head - hemorrhage under the periosteum of the skull bone. The cervical region is subject to the strongest pressure along the axis, since it is the most “unprotected” place, the “weakest link” in the entire spine. The main clinical manifestation of severe compression of the intervertebral discs along the axis of the spine immediately after birth is intense crying from pain. Newly born babies always cry. And the child is crying because his spine hurts. This is not a “normal reflex reaction” of a newly born child, it is not the norm, but a pathology. In most children, clinical and pathological-anatomical manifestations of osteochondrosis (pain) that occur immediately after birth completely disappear after 2 months. But in 36% of children various manifestations osteochondrosis continues to bother them for up to 1 - 2 years. From peripheral anatomy nervous system It is well known that 90% of the somatic nerves and 80% of the autonomic nervous system emerge from the spinal cord. With osteochondrosis, compression occurs on the nerves emerging from the spinal cord, which innervate the lungs, heart, gallbladder and liver, stomach, intestines, bladder. An infant has the following symptoms of osteochondrosis:

1) Sudden sharp pain. In infants, quite often and suddenly a pain attack occurs in the spine and the child (previously sleeping quietly or playing lying on his back) cries “out loud” for several hours, turns blue from exertion, jerks his legs and arms, screams non-stop, intensely, loudly . In half of the cases, the source of sudden pain in an infant is osteochondrosis, and in the other half of the cases, the sudden formation of more gases in the intestines from pathological microflora entering there with food. The source of sharp pain in 70% of cases is the cervical spine, and in 20% of cases - the lumbar spine, in 10% of cases - overstretched ligaments of the sacroiliac joint. When the child begins to cry in pain, mothers immediately take him in their arms and begin to rock him intensively, pressing him tightly to the body. The baby's head swings in all directions, hanging backward from the mother's hand and stretching the cervical vertebrae under the influence of its weight. Under the influence of compression by the mother’s hands, the thoracic and lumbar spine of the child bends. In fact, mothers perform manual therapy on their child: they bend and stretch the neck, bend the spine. So mothers quite unconsciously perform spinal traction, “reposition” of the vertebrae, “self-healing” occurs, the pain stops and the child falls asleep peacefully.

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Figure 117 - 1, 2. Manual therapy techniques for influencing the cervical spine of a newborn.

2) Manual therapy with pathology of the cervical spine in a child. Manual therapy is carried out using a number of simple techniques. First there is a massage neck muscles, stretching, isometric muscle relaxation. After this, with the child lying on his stomach (the child’s head is turned to the side to the right or left), the doctor places one hand on the head and the other on both shoulder blades or the shoulder opposite to the view. The hand that is on the head begins to rotate (roll) the head towards the back of the head, increasing the rotation of the head to a certain limit. Crunching and clicking often occurs in the child's neck joints, after which recovery occurs - pain in the neck ceases to bother the child.See Figure 117.

3) Radicular pathology of the gastrointestinal tract. During the movement of the head along the birth canal, the child's spine bends strongly in the thoracolumbar region. The angle of the child's spine, with strong pressure from the uterus on his body, especially on the buttocks and head, bends back at an angle of up to 90 degrees. This part of the spinal cord innervates the liver, gall bladder, and intestines. Important symptoms Osteochondrosis in a newborn child is accompanied by pathological symptoms from the gastrointestinal tract. Compression of the nerves extending from the spine and innervating the stomach causes frequent regurgitation of food. In addition, a process of excessive gas formation occurs in a child with lumbar osteochondrosis due to deterioration of innervation and slower intestinal motility. Feces remain in the intestines “longer than expected”, and therefore fermentation occurs and more gases occur. An important indicator of pathological innervation of the gallbladder due to osteochondrosis thoracic spine, manifested by its convulsive spasm, are diarrhea with dark green stool. It is typical that immediately after the first session of gentle manual therapy, the child’s stool acquires a normal yellow color.

4) Manual therapy for the treatment of osteochondrosis of the thoracic and lumbar regions a newborn can be treated with the following simple techniques. See Figure 118 - 1, 2. First, the back muscles are massaged to relax them.

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Figure 118 - 1, 2. Two methods of manual therapy of the thoracic region in a newborn.

The doctor bends the child lying on his stomach in the lumbar and thoracic region. Often there is crunching and clicking in the intervertebral joints child, after which recovery occurs.

3. Symptoms of traumatization of the child’s body from transverse, ring-shaped compression by the mother’s birth organs. During passage through the birth canal (along the cervix and vagina), the baby experiences additional circumferential and transverse pressure.

1) The “pioneer” during childbirth is parietal part heads. From the action of muscles compressing around the circumference, hemorrhage occurs under the periosteum of the bones of the head, which is located on the very top of the head. These are the so-called cephalohematomas. Cephalohematoma is a hemorrhage between the periosteum and the outer surface of the cranial bones. The most common location is the parietal bone, less commonly the occipital bone. The symptoms of the pathology are as follows. After birth, a fluctuating tumor is detected on the child’s head, delimited by the edges of one or another skull bone. Usually the process is one-sided (right parietal bone or left). During the 1st week after birth, the tumor tends to increase. Complete resorption of the hematoma occurs after 6-8 weeks. No treatment required. Puncture of uncomplicated cephalohematoma is not recommended. If infection occurs, an incision is made and antibiotics are used.

2) If the pressure in the mother’s birth canal around the circumference was excessive, then the newborn experiences displacements of the skull bones relative to each other andintracranial hemorrhages. Pathogenesis of intracranial hemorrhages. Hemorrhage occurs at birth under the influence of a number of factors - lack of vitamin K, increased fragility of brain vessels, easy displacement of the skull bones, intrauterine asphyxia. There are hemorrhages: 1) epidural, 2) subdural, 3) subarachnoid, 4) hemorrhages in the brain, 5) intraventricular. Clinical manifestations depend on the size and location of the hemorrhage. With minor hemorrhages, lethargy and drowsiness are noted at birth; Sucking and swallowing are impaired. With subarachnoid hemorrhages, the leading symptom is frequent attacks of asphyxia. The child is characterized by lethargy. The child lies with his eyes open, is inactive and indifferent, has no appetite, and cries quietly. Convulsive twitching of the muscles of the face or limbs, as well as tonic convulsions, are noted.

3) Direct evidence of very strong compression of the child’s body in the mother’s birth canal is fracture of one or two collarbones in a baby . This is a fairly common pathology for newborns. There is usually a small hematoma at the fracture site. On palpation, crepitus is detected. Displacement of two bone fragments, as a rule, is absent, since this is prevented by the dense and strong periosteum, which covers all the tubular bones of the newborn. Active hand movements are not impaired. Often a fracture is detected only at the stage of callus formation. Treatment. When a fracture is recognized, a fixing bandage is applied.

4) Congenital dislocation of the hip. Cause of occurrence. The most dangerous pathology for a newborn is another pathology that occurs due to transverse compression of the child’s pelvis in the mother’s birth canal - congenital hip dislocation. However, this name for the pathology is fundamentally incorrect. This is not a genetically congenital pathology, not congenital. This is an acquired pathology for a child in the narrow birth canal, in the mother’s vagina. The normal pelvis of a newborn has an oval shape. The normal pelvis of a newborn in the lateral, transverse dimension (from one edge of the pterygoid bone to the other) is 2 times longer than the anterior-posterior dimension, that is, from the sacrum to the suprapubic surface of the abdomen. The direction of the acetabulum relative to each other in a normal child’s pelvis is almost on the same line, that is, they are equal to almost 180 degrees. See Figure 119 - 1, 2. If you measure the size of the pelvis in a child with congenital dislocation of the hip, the transverse size of the pelvis will be almost equal to the longitudinal size. In a child with a “congenital” dislocation of the hip, the shape of the pelvis approaches a regular circle, in which the acetabulum is not located on the side, but is directed anteriorly. See Figure 119 - 3. Passing through the mother's birth canal, which looks like a regular circle, the baby's pelvis was deformed due to severe stretching of the ligaments of the sacroiliac joint. For a child, this is a rather serious injury, which can sometimes be accompanied by severe pain, but in most cases it is asymptomatic. Instead of an oval shape, the pelvis takes on the appearance of a circle. The direction of the acetabulum relative to each other in the pathologically narrowed pelvis of a child is almost at an angle of 90º, that is, this angle has become 2 times smaller than that of a normal pelvic bone. This entails partial insertion of the femoral head into the acetabulum, which orthopedists regard as hip subluxation.

Figure 119 - 1. Oval configuration of normal pelvic bones (top view).

Figure 119 - 2. Oval configuration of normal pelvic bones (top view).

Figure 119 - 3. Round configuration of the pelvic bones (viewed from above) in an infant with a “congenital” hip dislocation.

The first clinical symptom of hip subluxation acquired during childbirth is limited abduction of the hips raised upward in a child lying on his back. Pediatric orthopedists, when examining children in clinics, attach great importance to limiting the volume of hip abduction. Of course, the forward-directed acetabulum with its edges does not make it possible to spread the child’s legs to the fullest extent. Therefore, this symptom is natural for this pathology. The strong muscles of the buttock pull the hip back, and almost pull the femoral head out of the acetabulum, as they are stretched from the pathological movement of the hip forward. Further incorrect positioning of the femoral head in the acetabulum leads to overstretching of the ligaments in the front of the hip joint. Together with the ligaments they stretch and tear small vessels and nerves, dysplasia of the femoral head occurs (softening of the bone of the head, its irregular shape occurs). By the age of 10, dysplasia leads to ankylosis (immobilization) of the bones in the child’s hip joint. The child becomes disabled for life.

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Figure 120 - 1, 2. Two methods of manual therapy for the treatment of sprain of the ligamentous apparatus of the sacroiliac joint in a newborn.

4. Treatment of congenital hip dislocation with manual therapy. As is known, treatment of congenital dislocation of the hip in clinics is long-term - for up to 3 - 5 months, the child’s parents keep the baby in special orthopedic devices that fix the child’s legs in a position spread in different directions. It is difficult to dress a child with such a device for a walk on the street, especially in winter. It is difficult to care for a child. The device reduces motor activity and inhibits the baby’s physical development. However, with the help of manual therapy, a child can be cured of congenital hip dislocation in almost one second. To do this, a chiropractor or orthopedist must force the child’s pterygoid bones into the correct state, bringing them closer to the sacrum. There are many excellent treatments for congenital hip dislocation. Let's pay attention to two of them.See Figure 120 - 1, 2.

First method. First, the back muscles are massaged to relax them. As found from the previous discussions, the cause of congenital hip dislocation is the pathological approach of the pterygoid bones to each other. Treatment involves the opposite actions of those who are guilty of the disease. To do this, it is necessary to bring the pterygoid bones to the sacrum, that is, to cure the sprain of the posterior ligaments inside the sacro-pterygoid joint. This is done as follows. The child lies on his stomach. One hand of the doctor rests on the child’s sacrum, and the other pulls the pterygoid bone upward by its ridge. Often there is a crunching and clicking sound in the child’s sacro-pterygoid joint, after which recovery occurs.

Second method. The doctor presses the sacrum of the child lying on his stomach from above with both hands. The semi-ring of the pelvis of a lying child (on the anterior iliac crest) rests on the horizontal surface of the couch. When you press from above on the child’s sacrum, the two pelvic bones (sacrum and pterygoid) are brought closer together. Often there is a crunching and clicking sound in the child’s sacro-pterygoid joint, after which recovery occurs.

The use of manual therapy for several of the most common diseases that have arisen is described. However, there are much more orthopedic and therapeutic postpartum pathologies. Many complications arise during forceps delivery. When the fetus is breech, childbirth, as a rule, occurs with complications in the newborn in the form of increased pain in the spine (especially from osteochondrosis in cervical spine), dislocations of limbs, chest deformations and much more occur. Currently, there are no pediatric chiropractors in children's clinics in Russia and Belarus, and this is very bad. I would like to hope that in the next decade the attitude towards pediatric orthopedics and manual therapy will radically change.

A narrow pelvis is considered one of the most complex and difficult sections of obstetrics, since this pathology can lead to the development dangerous complications during childbirth, especially if it is carried out incorrectly. According to statistics, anatomical narrowing of the pelvic bones occurs in 1-7.7% of cases, while during childbirth such a pelvis becomes clinically narrow in 30%. If we take the total number of all births, then this pathology accounts for about 1.7% of cases.

The concept of “narrow pelvis”

During the period when the fetus is expelled from the uterus or during the pushing period, the child must overcome the bone ring that is formed by the pelvic bones. This ring consists of 4 bones: the coccyx, the sacrum and two pelvic bones, which are formed by the ischium, pubis and ilium. These bones are connected to each other using ligaments and cartilage. The female pelvis, unlike the male one, is larger and wider, but has less depth. A pelvis with normal parameters plays an important role in the normal, physiological course of childbirth without complications. If there are deviations in the symmetry and configuration of the pelvis, its size decreases, then the bony pelvis serves as a kind of obstacle to the passage of the fetal head.

In practical terms, two types of narrow pelvis are classified:

a clinically narrow pelvis occurs in the event of a discrepancy between the anatomical dimensions of the woman’s pelvis and the dimensions of the child’s head during childbirth (however, even in the presence of an anatomical narrowing of the pelvis during childbirth, a functionally narrow pelvis may not always occur, for example, when the fetus is small in size, or vice versa, when functional pelvic indicators are normal, but the large size of the baby leads to the development of a clinically narrow pelvis);

An anatomically narrow pelvis is characterized by a narrowing of several or one size by 2 or more centimeters.

Causes

The causes of a narrow pelvis are different - in the event of a disproportion between the parameters of the mother’s pelvic bones and the baby’s head or in the presence of an anatomical narrowing.

Etiology of anatomically narrowed pelvis

The following factors can provoke the occurrence of an anatomically narrowed pelvis:

heavy physical labor and malnutrition in childhood;

frequent colds, as well as increased physical activity in adolescence;

neuroendocrine pathologies;

late onset of menstruation, impaired fertility, disruptions in menstrual function.

Anatomical narrowing of the pelvis occurs due to the following reasons:

dislocations of the hip joints;

excess androgens, hyper- and hypoestrogenism;

impaired mineral metabolism;

practicing professional sports (swimming, gymnastics, licking);

psycho-emotional stress and stressful situations, which provoke the occurrence of “compensatory hyperfunction of the body”, as a result of which a transversely narrowed pelvis is formed;

acceleration (rapid growth of the body in length against the background of a slow increase in transverse pelvic parameters);

damaging factors that affected the fetus in the antenatal period;

tumors and exostoses of the pelvis;

polio;

heredity and constitutional features;

cerebral palsy;

curvature of the spine (coccyx fractures, scoliosis, kyphosis, lordosis);

pelvic bone fractures;

bone tumors, bone tuberculosis, osteomalacia;

• delayed sexual development;

  infantilism, both sexual and general.

Etiology of a functionally narrow pelvis

Disproportion between the mother's pelvis and the baby's head during childbirth is caused by:

preposition with the pelvic end;

atresia (narrowing) of the vagina;

neoplasms of the ovaries and uterus;

pathological insertion of the head (frontal insertions, asynclitism);

malposition;

difficulty in the process of configuration of the bones of the baby’s skull (in case of true postmaturity);

large weight and size of the fetus;

anatomical narrowing of the pelvis.

Childbirth, which is complicated by a clinically narrow pelvis, ends with a cesarean section in 9-50% of cases.

Narrow pelvis: varieties

There are many classifications of anatomically narrowed pelvis. Quite often in the obstetric literature a classification is presented that is based on morphological and radiological characteristics:

Gynecoid type

It makes up about 55% of the total number of pelvises and is a normal type of female pelvis. The physique of the expectant mother is female, thin waist and neck, hips are wide, height and weight are within the average range.

Android pelvis

It is a male-type pelvis and occurs in 20% of cases. The woman has a masculine physique, namely an undefined waist, a thick neck against the backdrop of narrow hips and broad shoulders.

Anthropoid pelvis

It is characteristic of primates and accounts for about 22% of cases. This form is distinguished by an increase in the direct size of the entrance, which significantly exceeds the transverse size. Women with this pelvic configuration are tall, lean, their shoulders are quite wide, while their hips and waist are narrow, their legs are thin and elongated.

Platypeloid pelvis

Its shape resembles a flat pelvis and occurs in 3% of women. A woman with such a pelvis is tall, markedly thin, has reduced skin elasticity and underdeveloped muscles.

Narrowed pelvis: forms

Classification of a narrow pelvis according to Krassovsky:

Common forms:

transversely narrowed pelvis (Robertovsky);

generally uniformly narrowed pelvis (ORST) is the most common type, which is observed in 40-50% of the total number of pelvises;

flat pelvis, occurs in 37% of cases, is divided into:

• pelvis with reduced wide part pelvic cavity;

  flat-rachitic;

  simple flat (Deventrovsky).

Rare forms:

pelvic deformation by fractures, exostoses, bone tumors;

obliquely contracted and obliquely displaced;

other forms:

• assimilation;

  osteomalatic;

  spondylolisthetic form;

  kyphotic form;

  funnel-shaped;

  generally narrowed flat.

Degrees of narrowing

The classification proposed by Palmov is based on the degree of narrowing of the pelvis:

along the length of the true conjugate (normally 11 cm) refers to the flat pelvis and ORST:

• first degree – less than 11 cm, not shorter than 9 cm;

  second degree - true conjugate indicators from 9 to 7.5 cm;

  third degree – the length of the true conjugate is from 7.5 to 6.5 cm;

  fourth degree – absolutely narrow pelvis, shorter than 6.5 cm.

according to the parameter of the transverse diameter of the pelvic inlet (the norm is 12.5-13 cm), it refers to a transversely narrowed pelvis:

• first degree - the transverse diameter of the entrance to the pelvis is within 12.4-11.5 cm;

  second degree - transverse diameter of the entrance - 11.4-10.5 cm;

  third degree - the transverse diameter of the entrance to the small pelvis is shorter than 10.5 cm.

in terms of the diameter of the wide part of the pelvic cavity (norm 12.5 cm):

• first degree – diameter is 12.4-11.5 cm;

  second degree – diameter less than 11.5 cm.

Dimensions of anatomically narrowed pelvis of various shapes

Narrow pelvis: size table in centimeters

	Pelvic shape
	Simple flat	flat-rachitic		transversely narrowed	normal
external					25/26-28/29-30/31
External conjugate
Diagonal conjugate
True conjugate
Michaelis rhombus
Vertical diagonal
Horizontal diagonal
Entrance plane
Lateral conjugate
Transverse
Differential criterion	Reducing direct dimensions in all planes	Reducing the direct size of the pelvic inlet plane	Uniform decrease in parameters (all) by 1.5 cm	Shortening transverse dimensions	None

Diagnostics

A narrowed pelvis is diagnosed and assessed in a antenatal clinic, on the day a pregnant woman is registered. To determine a narrow pelvis during pregnancy, the doctor must study the anamnesis, perform an objective examination, including a vaginal examination, measurement of the pelvis, palpation of the uterus and pelvic bones, examination of the body, and anthropometry. If necessary, additional research methods may be prescribed: ultrasound scanning and X-ray pelviometry.

Anamnesis

It is important to pay attention and study the living conditions and illnesses of a pregnant woman in childhood ( chronic pathology and injuries, intense stress in sports, heavy physical work and poor nutrition, hormonal imbalance, bone tuberculosis and osteomyelitis, polio and rickets). Obstetric history data are also important:

whether there was stillbirth or death of the newborn in the neonatal period;

for what reason was surgical delivery performed, whether there were traumatic brain injuries in the fetus during childbirth;

how the previous births proceeded.

Objective research

Anthropometry

Low height (less than 145 cm) in most cases indicates the presence of a narrowed pelvis. However, it is possible to have a transversely narrowed pelvis in tall women.

Assessment: silhouette, build, gait

It has been proven that in the presence of a strongly protruding abdomen forward, the center of the upper body shifts posteriorly to maintain balance, while the lower back moves forward, increasing lumbar lordosis, as well as the angle of inclination of the pelvis.

Abdominal shape assessment

It is known that primiparous women have an elastic abdominal anterior wall, as a result of which the abdomen acquires a pointed shape. Multiparous women have a saggy abdomen, since the head at the end of the gestation period is not inserted into the entrance of the pelvis (narrowed), while the uterine fundus is high, and the uterus itself has a deviation anteriorly and upwardly from the hypochondrium.

Palpation of the Michaelis diamond and inspection.

Identification of signs of virilization and sexual infantilism.

The Michaelis rhombus is formed by the following anatomical formations:

on the sides - the upper posterior projections (or spines) of the ilium;

below – the apex of the sacrum;

above – the lower border of the fifth lumbar vertebra.

Pelvic palpation

During palpation of the iliac bones, their location, contours and slope are determined. During palpation of the trochanters (greater trochanters of the femurs), it is possible to determine the presence of an obliquely displaced pelvis if the trochanters are located on different levels and deformed.

Vaginal examination

Allows you to determine the capacity of the pelvis, evaluate the shape and examine the sacrum, the presence of bony protrusions, and the depth of the sacral cavity. It is also possible to determine the deformation of the lateral walls of the pelvis, determine the diagonal conjugate and the height of the symphysis.

Pelvis measurement

Basic measurements:

the uterus is measured to determine the approximate weight of the fetus;

the height of the pubic symphysis is set;

the pubic angle is determined (the norm is 90 degrees);

measuring the pubosacral size (measure the segment from the junction of the second and third sacral vertebrae to the middle of the symphysis). Normal is 21.8 cm;

Solovyov index – measurement of the wrist circumference at the level of the forearm condyles. Using this index, the thickness of the bones is determined: a small index is responsible for thin bones, and a large index for thick bones, respectively. The norm is 14.5 - 15 centimeters;

Michaelis rhombus measurement (horizontal diagonal 10 cm, vertical diagonal 11 cm). The presence of asymmetry of the rhombus indicates curvature spinal column or pelvis;

external conjugate - measuring the distance from the upper edge of the womb to the upper corner of the Michaelis rhombus. Normal is 20 centimeters;

Distantia trohanterica - the segment between the two trochanters of the femur, normally 31-32 centimeters;

Distantia cristarum - the segment between the most distant points of the iliac crests. Normally – 28-29 centimeters;

Distantia spinarum - the segment between the upper anterior projections of the ilium. Normal is 25-26 centimeters.

Additional measurements:

if pelvic asymmetry is suspected, the lateral Kerner conjugate and oblique dimensions are determined;

measure the pelvic outlet;

measure the angle of inclination of the pelvis.

Special research methods

X-ray pelviometry

Allowed to execute x-ray examination only during childbirth or after 37 weeks of pregnancy. With its help, the nature of the structure is determined pelvic walls, the size and shape of the pubic arch, the severity of the sacral curvature, features of the ischial bones, this method also allows you to determine all the diameters of the pelvis, the size of the fetal head and its position relative to the pelvic planes, the presence of fractures and tumors.

Ultrasound

Allows you to determine the size of the head and its location, the true conjugate, and evaluate the features of insertion of the fetal head into the entrance. Using a transvaginal sensor, you can set all the necessary pelvic diameters.

Method for calculating true conjugates

For this purpose, the following methods are used:

on ultrasound examination of the pelvis;

according to X-ray pelviometry;

according to the Michaelis diamond: the upper size of the diamond corresponds to the conjugate (true) indicator;

1.5-2 centimeters are subtracted from the diagonal conjugate index (if the Solovyov index is 14-16 cm or less, 1.5 cm is subtracted, if the Solovyov index exceeds 16 cm, then 2 cm is subtracted);

subtract 9 from the size of the external conjugate (the norm is at least 11 cm).

Features of pregnancy

In the first half of the gestation period, complications in the presence of a narrowed pelvis are not observed. However, the nature of the course of pregnancy in the second half is aggravated by the influence of the underlying pathology, which led to the formation of a narrow pelvis, while complications (intrauterine infection, gestosis) and extragenital pathologies have a certain influence. Pregnant women with a narrow pelvis are characterized by:

high position of the head against the background of the inability to insert it into the pelvis. This is due to the high position of the diaphragm and uterine fundus, causing increased heart rate, fatigue and shortness of breath;

Quite often, pregnancy can be complicated by premature discharge of amniotic fluid due to lack of contact with the pelvic inlet due to the high position of the head;

significant fetal mobility can cause extensor or breech presentation and abnormal fetal position;

the risk of premature birth increases;

the formation of a saggy abdomen in multiparous women and a pointed abdomen in primiparous women can provoke asynclitic insertion of the head during labor.

Pregnancy management

All pregnant women with a narrow pelvis are placed on a special register with an obstetrician. A few weeks before the onset of labor, a woman should be hospitalized as planned. antenatal department. Here the gestational age is clarified, and the estimated weight of the fetus is calculated, the pelvis is measured, the presentation of the fetus and its condition are clarified, and based on the data obtained, the most suitable delivery option is selected (a labor management plan is formed).

The method of delivery is selected based on medical history, the degree and form of anatomical narrowing of the pelvis, the approximate weight of the child, as well as other complications of pregnancy. Natural childbirth can be carried out in the case of prematurity, first degree contraction with a mature cervix and normal fetal size, in the absence of an aggravating medical history.

Planned surgical delivery (caesarean section) is performed if there are the following indications:

3-4 degree of narrowing of the pelvis (very rare);

a combination of any obstetric pathology requiring a cesarean section and a narrow pelvis;

birth of a fetus with birth trauma, complications in previous births, history of stillbirth, older women in labor;

a combination of the first or second degree of contraction with the presence of a large fetus, post-term pregnancy, abnormal position of the child, breech presentation.

Pregnancy and pain in the pelvic bones

Pain in the pelvic bones begins to appear after 20 weeks and can be caused by various reasons:

Calcium deficiency

Aching constant pain, which are not associated with changes in body position or movement. It is recommended to take vitamin D in combination with calcium supplements.

Separation of the pelvic bones and sprain of the uterine ligaments

The larger the size of the uterus, the greater the tension experienced by the uterine ligaments that hold it, this manifests itself in discomfort and pain while walking, as well as when the child moves. The provocateurs of the process are relaxin and prolactin, under the influence of which the pelvic cartilage and ligaments swell and soften in order to facilitate the passage of the fetus through the bone ring. To relieve such pain, it is recommended to wear a bandage.

Divergence of the symphysis pubis

Excessive swelling of the symphysis, which is quite rare pathology, accompanied by bursting pain in the pubic area, it also becomes impossible to raise the leg while in horizontal position. This pathology is called symphysitis, it is accompanied by divergence of the symphysis pubis. Effective treatment by surgical intervention after delivery.

Course of labor

Today, the tactics of labor management in the presence of a narrow pelvis imply a significant increase in the indications for performing abdominal delivery, both planned and emergency, in the presence of complications during childbirth. Natural childbirth is a very difficult task, since the outcome can be either favorable or unfavorable for both the child and the woman. In the presence of the third and fourth degree of narrowing, the birth of a full-term live baby is impossible - only elective surgery. If there is a narrowing of the pelvis to the first or second degree, the successful outcome of natural childbirth depends on the parameters of the fetal head, its ability to shape, the nature of the insertion and the intensity of labor itself.

Complications during childbirth in the presence of a narrow pelvis

First period

During the opening of the uterine pharynx, the following complication of childbirth may occur:

oxygen starvation of the fetus;

loss of small parts or loops of the baby’s umbilical cord;

early rupture of amniotic fluid;

weakness of labor forces (in 10-38% of cases).

Second period

During the expulsion of the fetus through the birth canal, the following complications may occur:

damage to the nerve plexuses of the pelvis;

damage to the symphysis pubis;

necrosis (death) of tissues of the birth canal with subsequent formation of fistulas;

birth injury;

threat of uterine rupture;

intrauterine hypoxia;

development of secondary weakness of generic forces.

Third period

In the last stage of labor, as well as in the early postpartum period, bleeding may occur, which occurs due to a long anhydrous interval and the course of labor.

Management of childbirth

Today, the most correct tactics for managing labor in the presence of such a pathology is active expectant tactics. At the same time, the tactics for conducting the birth process should be purely individual and based not only on the degree of narrowing of the pelvis and the results of an objective study of the expectant mother, but also on the prognosis for the child and the woman. The birth plan should have the following points:

fruit-destroying surgery for intrauterine fetal death;

performing a cesarean section when the fetus is alive and there are indications for surgery;

preventive measures in the afterbirth and early postpartum periods;

identifying signs of clinical inconsistency;

prevention of infectious complications;

prevention of intrauterine starvation of a child;

prevention of the development of weakness of generic forces;

bed rest during labor, which can prevent early release of water (the woman should be on the side to which the baby’s back is adjacent).

During childbirth, monitoring of discharge from the genital tract (bloody, leakage of water, mucous membranes), urination, and the condition of the vulva (presence of swelling) is carried out. If there is urinary retention, bladder catheterization is performed, but it should be remembered that such a sign may indicate a disproportion between the baby’s head and the pelvic dimensions of the woman in labor.

The most common complication during childbirth in the presence of a narrowed pelvis is premature rupture of amniotic fluid. If there is an “immature” cervix, surgical delivery is required. With a “mature” cervix, labor-inducing manipulations are indicated (provided that the child’s weight does not exceed 3.6 kg and the first degree of narrowing is present).

During the period of contractions, in order to prevent their weakness, it is necessary to create an energy background; the woman in labor receives medicated sleep and rest in a timely manner. When assessing the effectiveness of labor, the obstetrician must monitor not only the dynamics of cervical dilatation, but also the nature of the movement of the head along the birth canal.

Induction of labor should be performed carefully, and its duration cannot exceed 3 hours (if there is no effect, a caesarean section). In addition, in the first stage of labor, antispasmodics must be administered (with an interval of 4 hours), Nikolaev’s triad is performed to prevent hypoxia, and antibiotics are prescribed as the anhydrous period increases.

The period of expulsion may be complicated by secondary weakness, the development of fetal hypoxia, and if the fetal head remains in the birth canal for a long time, fistulas may form. Therefore, timely emptying of the bladder and episiotomy are required.

Disproportions between the mother's pelvis and the baby's head

The occurrence of a clinically narrow pelvis is promoted by:

abnormal forms of a narrow pelvis;

a large head of the child in the presence of normal pelvic sizes;

incorrect presentation of the fetus or unsuccessful insertion of the head;

large fetus and slight narrowing of the pelvis.

During childbirth, it is mandatory to perform functional assessment pelvis, which consists of:

in identifying signs of Zangheimester and Vasten (after the discharge of amniotic fluid);

in the diagnosis of a generic tumor of the soft tissues of the head, the rate of its growth and appearance;

assessing the configuration of the child’s head;

in determining the characteristics of the insertion and subsequent assessment of the biomechanism of labor based on insertion data.

Signs of a clinically narrow pelvis:

premature and early rupture of water;

significant head configuration;

protracted course of 1st period;

the emergence of a clinical threat of uterine rupture;

positive signs according to Zangheimester, Vasten;

symptoms of constriction of the bladder and soft tissues (blood in the urine, urinary retention, swelling of the vulva and cervix);

the occurrence of attempts when the fetal head is pressed to the entrance to the pelvis;

the head does not move forward when contractions are strong enough, water breaks and the uterine os is fully opened;

the biomechanism of labor is disrupted and does not correspond to this type of pelvic narrowing.

Vasten's sign is determined by palpation (the relationship between the inlet of the pelvis and the baby's head is determined). A negative sign of Vasten is a condition in which the head is inserted into the pelvis, located below the pubic symphysis (the obstetrician’s palm drops below the pubis). Level symptom – the doctor’s palm is located at the level of the womb (the symphysis and the head are in the same plane). A positive sign is that the obstetrician’s palm is located higher from the symphysis (the head is located above the plane of the pubis).

If present negative sign– childbirth ends on its own (since the sizes of the pelvis and head correspond). If the symptom is level, with an adequate configuration of the head and effective labor, labor is also independent. If the sign is positive, spontaneous childbirth is excluded.

Kalganova proposed using three degrees of discrepancy between the head and pelvic dimensions:

First degree, or relative non-conformity.

There is correct head insertion and adequate configuration. The contractions are of sufficient strength and duration, however, the advancement of the head and the opening of the uterus are slowed down, in addition, the discharge of water is untimely. Urination is difficult, but Vasten's sign is negative. Another option is to complete the birth on your own.

Second degree, or significant discrepancy.

The insertion of the head and the biomechanism of labor are not normal; the head has a sharp configuration and remains in the same plane for a long time. Urinary retention and abnormalities in labor forces (weakness or incoordination) appear. Westen's sign - level.

Third degree, or absolute inconsistency.

Attempts occur prematurely against the background of a complete lack of advancement of the head, even despite complete opening and good contractions. The birth tumor grows rapidly, signs of compression of the bladder appear, and there is a threat of uterine rupture. Westen's sign is positive.

The presence of second and third degrees of discrepancy is an indication for immediate surgical delivery.

Case Study

A woman with her first birth (20 years old) was admitted to the maternity hospital complaining of contractions for two hours. There was no outpouring of water. General state the woman in labor is satisfactory, pelvic dimensions: 24.5-26-29-20, abdominal circumference - 103 centimeters, height of the uterine fundus - 39 centimeters. The position of the fetus is longitudinal, the head is pressed to the entrance to the pelvis. Auscultation: no pain, heartbeat is clear. Contractions are of good duration and strength. The approximate weight of the fetus is 4 kg.

During a vaginal examination, it was determined: the cervical dilatation is 4 cm, has stretchable thin edges, and is smoothed. The amniotic sac is functioning normally, the fluid is intact. The head is pressed, the cape is not accessible. Diagnosis: pregnancy 38 weeks, first stage of first full-term labor. Transversely narrowed pelvis of the first degree, the fetus is large.

After six hours of active contractions, a second vaginal examination was performed: cervical dilatation to six centimeters, amniotic sac absent. The head is pressed with a sagittal suture in a straight line, placing the small fontanel anteriorly.

Diagnosis: pregnancy 38 weeks, first stage of first full-term labor. Transversely narrowed pelvis of the first degree, the fetus is large, straight high standing sagittal suture.

It was decided to end the birth through surgery (large fetus, narrowing of the pelvis, incorrect insertion). The caesarean section was performed without complications, and a baby weighing 4.3 kilograms was delivered.

Deviations in the development of the musculoskeletal system in newborns in the early stages are easily determined using ultrasound. The examination is error-free and is carried out in the first months of the child’s life. It reveals such a common deviation as dysplasia, when the joints develop incorrectly. An orthopedic specialist is referred to conduct an ultrasound examination of the hip joints in infants. This study is a screening study, i.e. mandatory for use as part of a comprehensive ultrasound scan of a newborn at 1 month.

With this diagnosis, children are noted to have underdeveloped hip joints that are in a dislocated state. In this position, the heads of the femurs are displaced relative to articular surface pelvis

During growth, the hip joints may be subject to disturbances such as changes in the structure and position of the glenoid cavity, lack of formation of the ossification heads of the femur, and increased flexibility of the ligaments.

Stages of hip dysplasia

• preluxation - the joint is not held within the boundaries of the glenoid cavity;
• subluxation - the head of the femur is not completely displaced;
• dislocation - complete displacement of the joint; lameness is possible at this stage if treatment has not been carried out.

Ultrasound of the hip joint can detect all stages of dysplasia. To eliminate the problem, a number of individual therapeutic exercises, which are selected for a certain type of deviation. If treatment was not prescribed on time, then various complications arise during the growth of the body, such as the appearance of arthrosis and impaired movement. Otherwise, therapy will help get rid of the danger of serious consequences.

Diagnosis of dysplasia

Symptoms and indications for ultrasound

The following causes of dysplasia are identified:

1. joint pathologies in the family;
2. breech presentation in children;
3. a woman living in an area of ​​poor ecology during pregnancy;
4. toxicosis and oligohydramnios;
5. infectious diseases and poor nutrition of the expectant mother.

A specific factor that causes disturbances in the development of joints in children has not yet been identified. However, it is possible to identify a number of symptoms indicating a disease of the musculoskeletal system.

Indications for the study are:

• difference in the depth and symmetry of the skin folds on the buttocks;
• restriction in movement when spreading the hips;
• clicking and crunching of joints;
• different lengths of a newborn's legs;
• increased tone of the lower extremities;
• the presence of disembryogenesis (asymmetrical arrangement of the ears, rib cage has a keel shape, shortened neck, etc.);
• birth of twins, triplets, etc.;
• the baby was born premature;
• neurological abnormalities.

Hip joint diagnostic procedure

First of all, for a successful ultrasound, the child must be as motionless as possible and must be fed. Excessive activity in children will interfere with obtaining accurate examination results. Feeding should preferably be done 30 minutes before the procedure. You need to have two diapers with you. You will need to cover the couch with one diaper, and the second one will wipe the gel from the newborn’s pelvis.

To begin the procedure, the baby is placed on its side, bending the legs at the hip joints. The doctor applies the gel to the required areas and begins to examine both joints in turn, moving the ultrasound sensor. Decentration of the joint head is detected by bringing the thigh toward the abdomen and rotating the limb.

Procedure ultrasound examination hip joints are not performed more often than twice a month. It is also pointless to do an ultrasound on children aged two to eight months, since the head of the femur ossifies. Due to this, the lower edge of the ilium is not visible well enough, which is caused by the casting of a shadow of the ossification nucleus.

Interpretation of ultrasound results

If the hip joint is formed correctly, then the structure of the femoral diaphysis and the dome of the acetabulum will be hyperechoic. In this case, the cartilaginous plate and femoral head will be hypoechoic.

Based on the data obtained, the doctor needs to assess the angle of the head of the femur relative to the acetabulum (the part of the pelvic bone where the head of the femur fits), the condition of the bone and surrounding tissues. The findings are saved and analyzed. The specialist draws lines that form angles alpha and beta. If a line drawn through bottom part the small muscle of the buttock and the external zone of the ilium, looks like a horizontal straight line, and at the place of transition to the cartilage of the acetabulum it bends, then this is the exact norm.

Angles are classified according to the Graph table. Angle A (alpha) indicates the level of the bony eminence of the acetabulum, and angle B (beta) indicates the development of the cartilaginous space of the acetabulum. For newborn babies 2-3 months old there is next norm angles:

• angle Α – more than 60 degrees;
• angle Β is less than 55 degrees.

A normally formed hip joint is called type I. The beta angle for type Ia is< 55 градусов, как и говорилось выше, однако также зрелым считается сустав с типом Ib - в этом случае угол бета незначительно больше 55 градусов. Если угол бета больше, чем 77 градусов, то он является признаком подвывиха и вывиха. Если угол альфа показывает от 43 до 49 градусов, то это является показателем подвывиха. Вывих: угол менее 43 градусов. Подробная таблица с нормами углов представлена ниже:

Joint type	Formation of the bony part of the acetabulum. Alpha angle	bony prominence	Cartilaginous part of the roof. Cartilaginous angle beta
Type I Mature TBS Any age	Full Alpha = 60º or more	Rectangular "smoothed"	Covers the head of the femur Ia – beta less than 55º Ib – beta > 55º
Type IIa Physiologically immature	Insufficient formation Alpha = 50º - 59º	Rounded	Covers the head of the femur
Type IIb Delayed ossification > 12 weeks	Insufficient formation Alpha = 50º - 59º	Rounded to Flat	Covers the head of the femur
Type IIc Prognostically unfavorable Any age	High degree of immaturity Alpha = 43º - 49º	Rounded to Flat	Also covers the femoral head Beta less than 77º
Type D Beginning decentration Any age	High degree of immaturity Alpha = 43º - 49º	Flat	Pushed aside Beta over 77º
Type IIIa Decentered joint	Absolute immaturity Alpha less than 43º	Flat	Proximal displacement without structural changes
Type IIIb Decentered joint	Absolute immaturity Alpha less than 43º	Flat	Proximal displacement, structural changes
Type IV Decentered joint	Absolute immaturity Alpha less than 43º	Flat	Mediocaudal pushback
Exception: Type II with delayed ossification	Insufficient formation	Rectangular (as an indicator of delayed ossification)	Covers the head of the femur

Thus, there are four types of joints and, accordingly, 3 degrees of dysplasia:

1. Norm:

• A – the joint is formed without disturbances;
• B – the cartilaginous plate is wide and short in shape.

2. Delay in joint formation:

• A – slow formation (up to three months);
• B – slow formation (age more than 3 months);
• C – pre-dislocation.

3. Subluxation - alignment of the roof of the acetabulum:

• A – there are changes in the structure of the cartilaginous protrusion of the cavity;
• B – there are transformations in the structure.

4. Dislocation:

• the joint is not formed correctly;
• the head of the femur is not covered by a cartilaginous protrusion.

According to the age of the baby, the data will change. Four month old babies need to do X-ray. Only a doctor can decipher the results obtained. He determines the degree of complication of the disease in the newborn and prescribes a course of treatment. The main thing is to do it on time ultrasound examination baby and identify the disease. The sooner the diagnosis is made and therapy is started, the easier it is to eliminate disturbances in the development and formation of the hip joints.

In 1701, the Dutch obstetrician Deventer described the generally narrowed and flat pelvis and noted the peculiarities of the course of labor depending on the shape and degree of narrowing. Subsequently, the features of childbirth during pelvic contraction were studied by Levret, Smellie, Roederer, Litzmann, N. M. Maksimovich-Ambodik, Michaelis, A. Ya. Krassovsky, N. N. Fenomenov and other obstetricians. In recent years, E. A. Chernukha has paid special attention to this problem.
An anatomically narrow pelvis is one in which all dimensions are shortened or at least one of them is shortened by 2 cm. An anatomically narrow pelvis is not always an obstacle to childbirth.

The outcome of childbirth depends not only on its size, but also on the nature of labor, the size of the fetus and the ability of the fetal head to change. If labor is good, the fetus is not large, the head is well configured, then with a small degree of narrowing of the pelvis, childbirth usually ends well for the mother and fetus.
In addition to the anatomically narrow pelvis, the concept of clinically narrow pelvis is distinguished.
A narrow pelvis can be quite functional, while a normal-sized pelvis can be narrow for a large fetus.

Diagnostics anatomically narrow pelvis is based on its measurement with a pelvimeter, magnetic resonance imaging or ultrasonic pelviometry; the question of whether a given pelvis is functionally narrow is decided during childbirth by assessing the nature of labor, the advancement of the head, etc. With narrow pelvises, the shape of the abdomen pays attention: a pointed abdomen in young women, a saggy abdomen in those who have given birth.

Etiology. The causes of a narrow pelvis include unfavorable living conditions, severe long-term illnesses in childhood and during puberty. Disturbances in the development of the skeletal system and the process of formation of the pelvis can occur due to poor nutrition of the pregnant woman, lack of calcium, and vitamins.
Tuberculosis of bones and joints leads to disruption of the shape of the pelvis and its narrowing, especially damage to the hip and knee joints and spine in childhood, fractures, dislocations, including congenital, complications of fractures, rickets, hormonal disorders, excessive physical exercise, incorrectly selected clothes and shoes.

Classification of narrow pelvises. According to one of modern classifications, used abroad, cans are distinguished:
gynecoid pelvis (normal female pelvis);
android pelvis (male type);
anthropoid pelvis (characteristic of primates), observed in humans, the main feature is an increase in the direct size of the entrance to the pelvis and its predominance over the transverse one;
platipeloid pelvis (flat).
In practice, classifications are usually used that take into account the shape of the narrowing and the degree of narrowing.
The degree of narrowing is assessed by the value of the true conjugate.
There are common and rare forms of pelvic narrowing.

A. Common forms:
generally uniformly narrowed pelvis;
transversely narrowed pelvis;
flat pelvis:
a) simple flat pelvis;
b) flat-rachitic pelvis;
c) common flat pelvis.

B. Rare forms:
oblique and oblique pelvis;
assimilation pelvis;
funnel-shaped pelvis;
kyphotic pelvis;
spondylolytic pelvis;
osteomalatic pelvis;
pelvis narrowed by exostoses and bone tumors.

Common forms of narrow pelvis. Generally uniformly narrowed pelvis. All dimensions (straight, transverse and oblique) are reduced by the same amount, most often by 2 cm.
A generally uniformly narrowed pelvis of the pure type is observed in women of small stature and regular physique; the pelvis has the correct shape of a normal, well-developed pelvis, but all its dimensions are reduced. The Michaelis rhombus is elongated.

The following types of generally uniformly narrowed pelvis are observed:
the infantile pelvis occurs in women with morphological and functional signs of infantilism: underdeveloped secondary sexual characteristics, menstrual dysfunction, etc. Along with shortening of all sizes, the pelvis retains some of the characteristics inherent childhood: the sacrum is narrow and slightly curved, the promontory is high, the pubic angle is acute;
A male-type pelvis occurs in tall women with signs of intersexuality (massive bones, male-type hair growth, etc.). The structure of the pelvis is close to that of a man: a high funnel-shaped cavity, a sharp pubic angle;
dwarf pelvis. Extreme degree narrowing of the generally uniformly narrowed pelvis. It is extremely rare in women of small stature (120-145 cm), but of proportional build.

Features of the biomechanism of childbirth in the case of a generally uniformly narrowed pelvis. The biomechanism resembles the usual biomechanism of childbirth, however, labor proceeds more slowly, the fetal head is installed with a sagittal suture in the oblique or transverse dimension of the entrance plane, while excessive flexion occurs and the head passes through the suboccipital or suboccipital dimension, which is 0.5 cm less than the small oblique. Sacral rotation, asynclitism and head configuration are expressed to a very significant extent. There is a pronounced dolichocephalic form and a large birth tumor. Extension of the head is difficult due to the narrow pubic angle, and internal rotation of the shoulders is also difficult.

Transversely narrowed pelvis. It is characterized by a decrease in the transverse dimensions of the pelvis by 0.5-1 cm or more with a normal (or increased) size of the true conjugate. The shape of the pelvic inlet is round or longitudinally oval instead of the transverse oval, inherent in the normal female pelvis. With transverse narrowing of the pelvis, flattening of the sacrum is often observed.
There are different types of transverse pelvis: a transversely narrowed pelvis with a normal straight size and a transversely narrowed pelvis with a long straight size. With these pelvises, the features of the biomechanism of childbirth are clearly expressed, but childbirth can also occur through the natural birth canal.
In the case of a transversely narrowed pelvis with a shortened straight dimension or a shortened straight dimension of the third plane, a cesarean section is usually required in a full-term pregnancy.

Features of the biomechanism of childbirth with a transversely narrowed pelvis. The head is inserted in a straight size, excessive bending is observed, and the head may stand for a long time in a straight size. If the head descends, then the sagittal suture passes downward in a straight dimension and erupts in a suboccipital dimension. Extension at the exit is difficult, and perineal rupture is likely. According to a number of authors, a transversely narrowed pelvis accounts for 20-30% of all cases of a narrow pelvis; its development is facilitated by an excess of androgens and a lack of estrogen.

Flat pelvis. It has shortened straight dimensions with the usual values ​​of transverse and oblique dimensions. With a simple flat pelvis, all direct dimensions are narrowed, and the rest are normal. This pelvis is characterized by a long high position of the head with a sagittal suture in the transverse dimension of the pelvis. The head unbends and goes down, passing into the pelvis with its transverse size. Possible pathological posterior or anterior asynclitism, prolonged low standing of the sagittal suture in the transverse dimension of the pelvis, in some cases the head cannot turn.

Flat-rachitic pelvis has a number of deformations: the wings of the iliac bones are deployed, the distance between the anterosuperior spines of the iliac bones is increased, distantia spinarum is close in size to distantia cristarum. With significant rachitic deformation of the pelvis, distantia spinarum is equal to distantia cristarum or even exceeds its value; Normally, distantia spinarum is 3 cm smaller than distantia cristarum. The sacrum is shortened, flattened and rotated around a horizontal axis so that its base approaches the symphysis, and the apex together with the coccyx is directed posteriorly, the promontory of the sacrum sharply protrudes anteriorly. Sometimes the coccyx, together with the lower sacral vertebra, is bent anteriorly (hook-shaped). Due to the anterior rotation of the base of the sacrum by the promontory, the entrance to the pelvis has a kidney-shaped shape, the direct size of the entrance is reduced, the transverse and oblique dimensions are normal.

The more the promontory protrudes anteriorly, the more shortened the true conjugate is. Sometimes an additional (false) promontory appears on the anterior surface of the flat sacrum, formed as a result of ossification of the cartilage between the sacral vertebrae. The accessory promontory may present difficulties for the advancement of the presenting part of the fetus. The dimensions of the pelvic outlet are increased. The direct size of the outlet is increased due to the posterior deviation of the apex of the sacrum. The transverse size of the pelvic outlet is increased, since the ischial tuberosities are located at a greater distance from one another than in a normal pelvis; The pubic angle in the flat-rachitic pelvis is obtuse. The dimensions of the cavity of the flat-rachitic pelvis are normal or slightly enlarged.

Women who have had rickets may have other changes in their skeletal system: flat back of the head, S-shaped clavicles, curvature of the legs, spine, sternum, etc.

Features of the biomechanism of childbirth: long high standing of the head, significant extension, pronounced asynclitism. Clinical inconsistency may occur. If the head goes down, then due to the wide size of the exit there can be a very fast “storm” during labor. To increase the direct size of the entrance, the Walcher position is recommended (with the body in a horizontal position, the legs are lowered down from the edge of the delivery bed).

Generally narrowed flat pelvis. All sizes are reduced in it, but the straight sizes are shortened the most. Usually the degree of narrowing is 2 or more, and delivery through the birth canal is possible only with a severely premature fetus. This type of pelvis is much less common than a generally uniformly narrowed, transversely narrowed and flat pelvis.
Obliquely displaced, or obliquely narrowed (asymmetrical),
The pelvis occurs after rickets suffered in childhood, a dislocation of the hip joint, or an improperly healed fracture of the femur or shin bones. The cause of a constricted pelvis may be scoliosis, in which the weight of the body on the limbs is distributed unevenly, as a result of which the acetabulum on the healthy side is depressed and the pelvis is deformed.
Obliquely displaced (coxalgic, scoliotic)
the pelvis does not always impede the progress of labor, since the narrowing is usually slight. The narrowing of one side is compensated by the fact that the other is relatively spacious.
Assimilation (“long”) pelvis. It is characterized by an increase in the height of the sacrum due to its fusion with the V lumbar vertebra.

Funnel-shaped pelvis. Rarely encountered; its occurrence is associated with impaired development of the pelvis due to endocrine disorders. A funnel pelvis is characterized by a narrowing of the pelvic outlet. The degree of narrowing increases from top to bottom, as a result of which the pelvic cavity takes on the appearance of a funnel, tapering towards the outlet. The sacrum is elongated, the pubic arch is narrow, the transverse size of the exit can be narrowed significantly.

The kyphotic pelvis is a funnel-shaped pelvis. Spinal kyphosis most often occurs as a result of tuberculous spondylitis suffered in childhood. When a hump occurs in the lower spine, the center of gravity of the body shifts anteriorly; top part In this case, the sacrum shifts posteriorly, the true conjugate increases, the transverse size can remain normal, the entrance to the pelvis takes on a longitudinal oval shape. The transverse size of the pelvic outlet decreases due to the convergence of the ischial tuberosities; the pubic angle is sharp, the pelvic cavity narrows funnel-shaped towards the exit. Childbirth with kyphosis often proceeds normally if the hump is located in upper section spine. The lower the hump is located and the more pronounced the pelvic deformation, the worse the prognosis for childbirth.

Spondylolytic pelvis. This rare form of the pelvis is formed as a result of the body of the fifth lumbar vertebra slipping from the base of the sacrum. With mild slippage, the V lumbar vertebra protrudes only slightly above the edge of the sacrum. With complete sliding, the lower surface of the lumbar vertebral body covers the anterior surface of the first sacral vertebra and prevents the lowering of the presenting part.

Osteomalatige pelvis is rare. Osteomalacia is characterized by softening of bones caused by decalcification of bone tissue. The osteomalatic pelvis is sharply deformed; with severe deformation, a collapsed pelvis is formed.
In the case of diagnosing a narrow pelvis, it is necessary to analyze risk factors for other types of pathology, for example, miscarriage. A pregnant woman and a woman in labor are led by a doctor who, together with the woman, chooses the delivery tactics.
With a narrow pelvis, early hospitalization is indicated at 38 weeks.

In the presence of the 1st degree of narrowing, childbirth is possible through the natural birth canal, provided that the fetus is not large and labor is good, as well as the absence of other pathology.
With the 2nd degree of contraction, childbirth is possible only with a full-term fetus.
In the case of the 3rd and 4th degree of narrowing, a cesarean section is performed as planned. (With the 4th degree of narrowing of the pelvis, problems arise even with performing an abortion and fetal destruction surgery.)

With narrow pelvises, anomalies of position or insertion often occur.
Complications of childbirth in the case of narrow pelvises are: weakness of labor, premature rupture of water, fetal hypoxia, birth trauma of the mother (ruptures of the cervix, perineum, vulva, even ruptures of the uterus and pelvis), birth trauma of the fetus, postpartum hemorrhage, fistulas, uterine subinvolution, postpartum infectious diseases. Due to the lack of a contact belt, the umbilical cord may fall out.
Due to the likelihood of complications, the percentage of medications and surgical interventions is high.

A clinically narrow pelvis can occur even with normal pelvic sizes due to the presence of a large fetus, anomalies in the insertion of the head, postmaturity, etc.
Risk factors for the formation of clinical inconsistency can be identified in advance. However, the final diagnosis is made already with full disclosure.

R.I. Kalganova proposed a classification of a clinically narrow pelvis depending on the degree of discrepancy between the mother’s pelvis and the fetal head:
1st degree of discrepancy (relative discrepancy):
- the features of insertion of the head and the biomechanism of labor correspond to the shape of the pelvis and the degree of narrowing;
- good head configuration;
2nd degree of non-compliance (major non-compliance):
- the features of insertion of the head and the biomechanism of labor correspond to the shape and degree of narrowing;
- pronounced head configuration;
- long standing of the head in one plane of the pelvis;
- symptoms of bladder pressure (difficulty urinating);
- Vasten’s sign is level;
3rd degree of non-compliance (absolute non-compliance):
- violation of the biomechanism of childbirth, characteristic of a given form of the pelvis, the degree of narrowing;
- pronounced configuration of the head or its absence during postmaturity;
- positive Vasten sign;
- pronounced pressure on the bladder (blood);
- premature appearance of pushing;
- absence of forward movements of the head with good labor and full dilatation;
- symptoms of impending uterine rupture.

Vasten's sign is checked as follows: one palm is placed on the pubis and the other on the head. If the hand on the pubis is higher, the sign is negative, if lower, it is positive and indicates a clinical discrepancy. It is necessary to check it when urine is released.

In case of severe discrepancy, a caesarean section is indicated. As first aid needs to be removed labor and prepare the woman for surgery. The midwife is required to diagnose the shape of the pelvis and the degree of narrowing, know the rules of pregnancy and childbirth with a narrow pelvis, know the features of the biomechanism of childbirth, be able to provide obstetric care, and prevent bleeding, birth injuries, and other postpartum complications.