HIP JOINT [articulatio coxae (PNA, JNA, BNA)] — the multiaxis joint formed by an acetabular hollow of a haunch bone and a head of a femur.
By 6th week of embryonic development at a germ konturirutsya the head of a femur surrounded with bodies of ileal, pubic and sciatic bones. On the 7th week between the flattened acetabular hollow and a head of a femur the joint crack, a linking of a head and a cross linking of an acetabular hollow forms; on the 9th week a cavity of T. by page it is generally already created.
Vascular lacunas around a bookmark T. pages appear on the 5th week, on the 6th week the central artery of an extremity forms, from the 7th to the 10th week vessels form primary vascular network in the capsule.
Nervous trunks get into laying of an extremity throughout 4 — the 6th week. The first neuroplexes in the capsule form by the end of the 5th month, and on the 6th and 7th month diverse trailer receptors appear.
T. the page is a kind of a spherical joint (fig. 1). In it the movements of three types are carried out: flexion and extensive, reduction — assignment, rotary (rotation outside and internal).
The head of a femur has the form of an ellipsoid, is more rare than a spheroid or a sphere, is covered with a hyaline cartilage, thickness to-rogo on the upper pole which is the largest pressure down reaches 1,5 — 3,0 mm, and is closer to edges becomes thinner. The cervical and diaphyseal corner normal at adults makes 126 — 130 °.
An acetabular hollow — the conjunction of 3 bones — ileal, pubic and sciatic. Diameter of its 47 — 55 mm, radius of curvature is 23 — 28 mm, surface area is 33 — 49 mm2. In anteroinferior department the edge of an acetabular hollow is interrupted by cutting (incisura acetabuli).
At the person at a pryamostoyaniya the center of gravity is on the line passing in front from a lateral axis of T. page. Pressure of weight of a trunk and abdominal organs is directed through upper parts of acetabular hollows to heads of femurs. Pressure of the soil or a support during the walking, run or a jump is transmitted through the lower extremity on a head of a femur and an acetabular hollow.
Capsule T. the page stretches from edges of a cartilaginous lip (labium the expert-tabulare) an acetabular hollow to the intertrochanteric line, including all front side of a neck of a femur in a cavity of a joint. Behind the capsule goes to an acetabular pole, leaving the back side of a neck of a femur half open.
The copular device is presented by four sheaves strengthening the capsule of a joint and two intra joint. Extraarticular linking of T. page; iliofemoral (lig. iliofemorale) begins from an ileal bone and, fanlikely dispersing, is attached to the intertrochanteric line, provides vertical position of a body, together with muscles interferes with capsizing of a basin back and limits its lateral motions during the walking; pubic and femoral sheaf (lig. pubofe-morale) goes from a nizhnelateralny surface of an upper branch of a pubic bone and anteromedial edge of an acetabular hollow to the intertrochanteric line of a femur, being interwoven into the capsule T. page; sedalishchnobedrenny sheaf (lig. to an ischiofemora-1a) strengthens back department of the joint capsule, stretching from edge of an acetabular hollow on all extent of an ischium to the intertrochanteric line and a first line of a big spit of a hip; in the thickness of the joint capsule yarns form a circular zone (zona orbicularis) surrounding medial department of a neck of a femur.
Sites of the capsule between sciatic and femoral and pubic and femoral sheaves are least strong (at the level of cutting of an acetabular hollow) and at the level of the sinew of an iliolumbar muscle going to a trochantin, under the Crimea the iliopectineal synovial bag (bursa of an iliopecti-pe) in 10% of cases connected to a cavity of a joint is located. In T. pages are located: linking of a head of a femur (lig. capitis femoris), connecting a head of a femur to a pole of an acetabular hollow, and a cross linking of an acetabular hollow (lig. transversum acetabuli), connecting edges of cutting of an acetabular hollow.
The innervation is carried out femoral, locking, sciatic, top and bottom by buttock and sexual nerves, branches to-rykh together with joint branches of neuroplexes of a periosteum and vascular neuroplexes create shirokopetlisty neuroplex of a fibrous membrane p related connecting branches a texture in the thickness of a synovial membrane (fig. 2).
Blood supply is carried out by the medial and lateral arteries which are bending around a femur (aa. circumflexae femoris med. et lat.) and a locking artery (a. obturatoria) giving branches to a head and a neck of a femur, and also to an acetabular hollow (fig. 3). Non-constant branches go from first pro-butting (a. perforans), top and bottom buttock (a. a. gluteae sup. et int.) and an internal sexual (a. pudenda interna) artery to a neck of a femur and an acetabular hollow. On the outer edge of the last widely anastomosing arteries of a hip joint form closed ring.
The back branch of a locking artery (r. posterior a. obturatoriae) krovosnabzhat an acetabular hollow, a fatty pillow, a cross linking of an acetabular hollow and adjacent pieces of a cartilaginous lip, medial and nizhnemedialny departments of the joint capsule and a linking of a head of a hip, on a cut vessels get into an upper part of a head. In a fibrous membrane of the capsule T. pages vessels form the krupnopetlisty network anastomosing with more dense network of a synovial membrane.
Outflow of blood from T. the page is carried out generally through the medial and lateral veins surrounding a femur in a femoral vein and through branches of a locking vein in an internal ileal vein.
Limf, the vessels going on the course of circulatory collect a lymph from the located in a synovial membrane deep and two superficial networks limf, capillaries and go in front to outside ileal, behind — to internal ileal lymph nodes.
Radioanatomy. In formation of T. pages participate the bones having irregular shape to-rye give difficult projective rentgenol. picture; it can become complicated even more at deformations of a joint, changes of the situation investigated including and owing to negligent laying at a X-ray analysis.
At rentgenol. a research it is also necessary to consider the age features of the bones making a hip joint, connected with structural transformations to-rye are defined at X-ray inspection and are regarded as age norm (fig. 4).
At newborns the cartilaginous head of a femur has the correct spherical or oval shape. The kernel of ossification in it appears in the first half of the year and vigorously grows towards a linking of a head, increasing approximately by 10 times to 5 — to 6-year age. The neck of a femur grows up to 20 years; in the first years of life its lower and back parties especially increase. The She-echno-diafizarny corner averages at children of the first months 140 °.
The acetabular hollow at newborns is formed by bodies of ileal, sciatic and pubic bones and the Y-shaped cartilage connecting them. In the first years of life bone «roof» of a hollow strenuously grows, by 4 years the ledge on its outer edge forms. By 9 years there is a partial sinostozirovaniye of ileal and pubic bones and full — pubic and sciatic. By 14 — 15 years girls and by 15 — 17 years at boys in a zone of an acetabular hollow have a full sinostozirovaniye of all bones.
For definition according to the roentgenogram of ratios of bones in T. the page is offered several reference points connected with anatomic educations and geometrical constructions (fig. 5): the «figure of a tear» formed by an internal wall of an acetabular hollow and a wall of a cavity of a small pelvis in the field of cutting of an acetabular hollow, the «figure of a half moon» formed by a furrow between the back site of a semi-lunar surface and a body of an ischium; the vertical line (Ombredanna) drawn through the outer edge of the arch of an acetabular hollow; a corner and, formed by the horizontal line drawn through symmetric sites of a Y-shaped cartilage on both sides and the line passing through outside and internal points of the arch of an acetabular hollow; the arc-shaped line (Shenton) drawn on the upper edge of a locking opening and continued knaruzh on an inner edge of a neck of a femur.
Normal «the figure of a tear» has the identical form and the sizes on both sides and is located from a head of a femur equally spaced; «the figure of a half moon» is projected on a nizhnevnutrenny quadrant of a head of a femur symmetrically on both sides; the vertical line from the outer edge of the arch of an acetabular hollow passes outside from a head of a femur or through its outside site; the corner and is identical in both joints and does not exceed 22 — 26 °; Shenton's line shall smoothly, without excesses and ledges to pass from the upper edge of a locking opening to an inner edge of a neck of a femur. Shifts of a head of a femur in relation to the listed reference points testify to its incomplete dislocation or dislocation.
METHODS of INSPECTION
At survey of the patient with defeat of T. pages reveal disturbance of a bearing and change of a musculoskeletal system in general; define elongation ratio or shortenings of an extremity, its situation in relation to a pelvic girdle, the volume of active and passive movements in a joint. In a joint define existence of deformations (an anchylosis, a contracture), change of contours, volume and a shape of a joint, its skin temperature, and also patol. changes of skin (hyperemia, hems, ulcerations, fistulas).
Normal consider strictly horizontal position of a basin (in a standing position), an arrangement of hips, perpendicular to it, and a moderate lumbar lordosis (see). At a flexion contracture of T. to page and perpendicular installation of a hip the lumbar lordosis at the expense of an inclination of a basin of a kpereda sharply increases. It especially well comes to light at a research of the patient in a dorsal decubitus on a plane solid surface. For definition of a corner of a contracture the healthy leg is bent, eliminating thus a lordosis, at the same time the hip on the sick party passes into the provision of bending. This corner corresponds to a corner of a flexion contracture. In the presence of the bringing or taking away contracture of T. the village is possible to establish hips parallel to a longitudinal axis of a trunk only at a side inclination of a basin.
Deformation within a neck and a head of a femur judge on a row a wedge, signs, first of all based on the ratio of the absolute and relative length of an extremity. If absolute length (from a top of a big spit to a patella or an anklebone) on both sides is identical, and relative (from an anterosuperior awn of an ileal bone to a patella) on the party of defeat is shortened, assume the shift of a head of a femur up or varus deformation of a neck. About defeat of T. the page can be judged by existence of a symptom of Trendelenburga; the patient is asked to rise on a sore leg, having bent healthy; at the same time the basin bends in the healthy party. Visually change of situation (distortion) of a basin is perceived on decrease in an anterosuperior awn and buttock fold on the healthy party (fig. 6). For deduction of the case in balance the patient inclines it aside patholologically changed T. page. Such deviation of the case during the definition of a symptom of Trendelenburga is designated as Dyushenn's symptom. Often, especially at congenital dislocation of a hip, speak about Dyushenn's symptom — Trendelenburga.
For identification of deformation in the area T. villages use also several reference points. The following is most often applied. Roser's line — Nelatona connects a front upper awn of an ileal bone to the most outstanding point of a sciatic hillock. Normal at the bent hip at an angle 135 ° the big spit is located on this line. At dislocation of a hip and varus deformation of a neck the big spit is displaced above it.
Brayent's triangle is made by the following lines: through top of a big spit draw a vertical line (in position of the patient on spin — horizontal) and from a front upper awn lower on it a perpendicular; the third line is conducted from a front upper awn to top of a big spit. The isosceles rectangular triangle is formed. At the shift of a big spit the ravnobedrennost of a triangle of Brayent is broken. She-maker's line is drawn from top of a big spit to a front upper awn. Continuation of the line normal passes through a navel or is slightly higher, and at the shift of a big spit — below a navel.
Palpation of area T. the page aims at identification of painful points. Areas directly below an average third of a pupartovy sheaf, behind are the most available to a palpation of a joint and are slightly higher than a big spit. Morbidity in T. pages reveal also percussion on a heel of the extended leg or on a big spit, hands on both big twirled by simultaneous pressure, implementation of passive rotational movements in a joint.
At a research of volume of movements in T. pages proceed from the following normal indicators: extension (the movement back) — 10 — 15 °, bending (advance) — 120 — 130 °, assignment — 40 — 45 °, reduction — 25 — 30 °, rotation outside — 45 ° and inside — 40 °. The rotational movements investigate at position of the patient on spin and on a stomach.
Plays a large role in diagnosis rentgenol. research.
Before shooting of T. the page in a standard perednezadny projection should straighten, whenever possible, a lumbar lordosis for what legs of the patient bend in knee and hip joints, then level the provision of a basin so that front upper ileal awns were symmetrized in one horizontal plane. In such situation the basin is fixed, the healthy leg is unbent, the sore leg can be at the same time bent, and sometimes taken away or brought. If the rotational movements are kept, then for obtaining the correct image of a neck of a femur the extremity needs to be rotirovat inside on 15 — 20 ° from the initial position of foot in the sagittal plane (fig. 7). The central beam is directed to 3 — 4 cm of a knaruzha from the middle of an inguinal sheaf.
And also for definition of provision of a head of a femur at dislocations make shooting for obtaining the image of bodies of the ileal, sciatic and pubic bones forming an acetabular hollow in additional, semi-side (braid), projections for what the patient is stacked on a back and turn on 50 — 60 ° towards the studied joint. The central beam is directed to a joint perpendicular to a film. Correctness of laying is controlled, probing front and back upper ileal awns of the studied party, to-rye shall be located in one horizontal plane.
For obtaining the profile image of a head and a neck of a femur use laying across Lauenstein for what the hip is taken away and extremely rotirut knaruzh (fig. 8).
To pathology of T. pages carry malformations, damages, diseases, tumors.
Most often meet a dysplasia of T. page, inborn coxa vara and plow of valga, inborn dislocation and incomplete dislocation of a hip.
Dysplasia of T. the page consists in an underdevelopment of an acetabular hollow, reduction of its depth, discrepancy with sizes of a head of a femur. Wedge, signs are a little expressed; assignment of a hip and internal rotation are a little limited. The diagnosis is based by hl. obr. on data rentgenol. researches.
The underdevelopment of an acetabular hollow is characterized by its small depth, the arch mown up and flattened; it is usually accompanied to a greater or lesser extent by the expressed disturbances of development of a femur: a delay of emergence and lag in growth of kernels of ossification of a head, a valgus shape of a neck of a femur. At sharply expressed disturbance of formation of a femur the ossification center can consist of many not plums-shikhsya of fragments even at the age of 7 — 12 years. Dysplasia of T. page byvayetg as a rule, bilateral. Treatment of a dysplasia of T. page — see the table.
Inborn coxa vara — varus deformation of a neck of a hip, at a cut occurs reduction of a cervical and diaphyseal corner (fig. 9); meets more often at boys, can be unilateral and bilateral. At the patient lameness, «duck gait», broad standing of legs (P-position), a positive symptom of Trendelenburga — Dyushenna is noted, at hemilesion — shortening of an extremity, at bilateral — the expressed lumbar lordosis. Extent of shortening of an extremity depends on the size of a cervical and diaphyseal corner. Unlike congenital dislocation of a hip it is not possible to probe a head of a femur. Sometimes at a palpation mistakenly take highly located big spit for a head. At inborn coxa vara the leg is in the provision of nek-ry reduction and outside rotation, the ravnobedrennost of a triangle of Brayent is broken, the big spit appears above Roser's line — Nelatona, Shemaker's line is displaced. Assignment and internal rotation of a hip are limited. The epiphyseal line of a head of a hip from kosopoperechny (normal) accepts vertical position, it creates unfavorable biomechanical conditions in the field of an epiphyseal zone, its instability; functional overloads, an injury sometimes lead to sliding of an epiphysis of a head of a femur, the epiphysiolysis develops. Radiodiagnosis does not represent difficulties: vidnr considerable reduction of a cervical and diaphyseal corner; the research in two projections is obligatory.
At small children attempts to stop progressing of process by means of abduction tires, unloadings of a joint became, however the essential effect at the same time was not observed. The conservative methods of treatment applied in a crust, time at children — see the table. At children 12 years are more senior and at adults undertake operational treatment, a cut comes down to reconstruction of proximal department of a femur for the purpose of elimination of vicious provision of its head and a neck by various methods of an osteotomy (see) — intertrochanteric ugloobrazny, shartsirny, podvertel-ache wedge-shaped (see fig. 3, 5 to St. Osteotomy ).
The inborn plow of valga — deformation, at a cut cervical diafizar-ny a corner is more normal; meets considerably less than inborn coxa vara. Believe that the plow of valga promotes development disturbance of static factors, e.g., lack of normal loading of an extremity at the residual phenomena of poliomyelitis (see), malformations of a skeleton. Clinically, it is difficult to diagnose a plow of valga. About this deformation it is possible to judge by a low arrangement of a big spit, lengthening of an extremity, a positive symptom of Trendelenburga — Dyushchenna. The diagnosis is specified at a X-ray analysis — see the table.
If deformation does not cause functional frustration, special treatment is not required. In some cases, when valgus situation interferes with centration of a head of a femur in an acetabular hollow, the varization (reduction of a cervical and diaphyseal corner) by an intertrochanteric varizi-ruyushchy osteotomy is shown (see fig. 3, 4 to St. Osteotomy ).
Congenital dislocation of a hip belongs to one of rather frequent and serious orthopedic illness of children's age; it occurs at 0,2 — 0,5% of newborns (at girls 5 — 7 times more often). The existing theories of an etiology and pathogeny of congenital dislocation of a hip completely do not explain origins and development of this pathology. Assume that defect of primary bookmark T is the cornerstone of it. page.
Depending on degree of shift and relationship of a head of a femur with other elements T. pages distinguish his dislocation and an incomplete dislocation. At an incomplete dislocation the head of a femur does not go out of the region of an acetabular hollow; at dislocation it is located out of it. In process of the shift of a head of a femur up the capsule of a joint stretches; in several years below a head narrowing of the capsule is formed, it gets a form of hourglasses, its wall hypertrophies, sometimes reaching thickness in 1 cm. The acetabular hollow is flattened and filled with a hypertrophied round sheaf and a fatty pillow. The head of a femur is gradually deformed, especially at its incomplete dislocation.
For the purpose of diagnosis of congenital dislocation of a hip perform routine maintenance of the child by the orthopedist in the first 3 — 4 weeks of life, repeatedly — in 3, 6 and 12 months.
For diagnosis of congenital dislocation of a hip on the first year of life use the following main signs: asymmetry of skin folds on hips (on the party of dislocation of folds it is more and they are deeper, than on a healthy extremity), shortening of an extremity at unilateral dislocation, restriction of assignment of hips, a symptom of sliding of a head of a femur (Marx's symptom). Indirect sign of congenital dislocation or incomplete dislocation of a hip yavlyaetsts its outside rotation. Asymmetry of skin folds is not an absolute diagnostic character of congenital dislocation of a hip, it gains value in combination with other signs. Shortening of an extremity at unilateral dislocation at children of early age is defined in position of the child on spin: bend legs in hip and knee joints, having connected them together, c of foot at the same time put on the plane of a table nearby, on Krom the child lies. On the party of dislocation lower arrangement of a knee joint is noted. Restriction of assignment of hips is revealed at survey of the child in situation on a back and a stomach, having bent legs in knee and T. and parting with page them. Marx's symptom is revealed in situation on spin; at assignment of the leg bent in knee and T. page, the orthopedist feels the sliding of a head of a femur in an acetabular hollow which is followed by characteristic click (reposition), and at reduction its vyvikhivaniye. Identification of a symptom of a yagodichnobedrenny fold is important for early diagnosis of congenital dislocation: in position of the child on a stomach on the party of dislocation its higher arrangement is noted. At the same time the hypotrophy and nek-paradise slackness of gluteuses on the party of dislocation is observed. The known value also has definition of a symptom of pulse: on the party of dislocation the pulsation of a femoral artery below a pupartovy sheaf is weakened that is caused by absence under an artery of a dense basis (heads of a femur in an acetabular hollow). At children reveal also lameness, a symptom of Trendelenburga — Dyushenna, the expressed lordosis at bilateral dislocation, the wrong arrangement of a big spit (Roser's lines — Nelatona are higher), shift of the line of Shemaker, etc.
Klin, the diagnosis of congenital dislocation of a hip (at newborns it has often presumable character) shall be confirmed rentgenol. a research, at Krom extent of defeat is determined by disturbance of relationship of a head of a femur with the reference points described above (see fig. 10 to St. Dislocations ).
At the heart of treatment of congenital dislocation and an incomplete dislocation of a hip reposition and centration of a head of a femur in an acetabular hollow by conservative or operational methods lies. Till rather recent time Patxi's method — Lorentz was the main method of conservative treatment or as is more often than it call, Lorentz's way consisting in reposition of a head of a femur violent (under anesthetic) in an acetabular hollow with fixing of T. page plaster bandage. The method is traumatic, in some cases leads to an aseptic necrosis of an epiphysis of a head of a femur in this connection from it from -' seemed. Treatment is begun at early age, right after detection of dislocation or an incomplete dislocation of a femur at the newborn. First of all with the help to lay down. gymnastics stretchings of soft tissues, especially try to obtain adductors. Then use one of the devices holding a hip in the provision of assignment and outside rotation: a soft pillow of Freyki (fig. 10, a), Pavlik's stirrups, at children of advanced age — a bandage bed or the functional tire of Volkov (fig. 10, b), the abduction tire of Vilensky, etc. These devices, without limiting movements in T. pages, hold a head of a femur in an acetabular hollow; favorable conditions for formation of a joint hollow and proximal department of a hip are created.
If by means of functional tires reposition of dislocation does not work well, resort to a method of extension, a cut carry out by means of lipkoplastyrny drafts on an axis of a hip up (Shede's method) with gradual cultivation of legs. V. Ya. Vilensky carries out such extension for the abduction tire. Efficiency of extension is checked pylpatorno under the provision of a head of a femur, - whenever possible full assignment of hips, the identical length of an extremity. In some cases, when the head of a femur approached a hollow, reposition it is performed in the manual way. This manipulation, on condition of the reached stretching of fabrics, is not traumatic. An average term of extension of 1,5 — 2 months, however sometimes it reaches 3 months and more. Unreducible dislocations are subject to operational treatment. An operative measure is the most effective at the age of 1,5 — 2 years.
Operations at congenital dislocation divide into several groups: open reposition, reconstructive an ileal bone operations and top end of a femur without opening of a joint, a combination of open reposition in reconstructive operations and palliative operations. At early children's age at insufficiently developed joint hollow make open reposition of a head of a femur without deepening of a hollow, having only removed from it an adipose body. Open reposition with deepening of an acetabular hollow has a negative side: the joint cartilage of a head after reposition contacts to the processed bone that causes its bystry destruction. The ital. orthopedist A. Codivilla in 1900 offered, and P.Colonna in 1932 developed a technique of a kapsulyarny arthroplasty. The stretched capsule of a joint is allocated, thin Z'the account of a fibrous layer and without tension shroud in it in the form of a cap a head of a femur. After reposition of a head in a profound hollow the fibrous surface of the capsule grows to it, and the movements of a head happen in the capsule. At children to 8-year age this operation yields good results. M. V. Volkov suggested to use specially prepared caps consisting of 60 — 70 layers of an amniotic cover as laying (see. Arthroplasty ).
At the expressed antetorsiya of a head of a femur open reposition is combined with a corrective osteotomy. Distribution was gained by a cross intertrochanteric osteotomy with correction of an antetorsiya, and at indications — with a va-rization, an osteosynthesis a pin or other design. The patient 8 years are more senior make Kiari's operation — a horizontal osteotomy of a body of an ileal bone directly over a roof of an acetabular hollow. As a result of the shift of a distal fragment of a basin of a knutra over a head of a femur the proximal fragment of an ileal bone hangs. In the presence of an antetorsiya of a head operation is supplemented with an intertrochanteric osteotomy. For the purpose of creation of a strong canopy over a head of a femur at an incomplete dislocation some more operations are offered, from to-rykh the main Salter's operation is (an osteotomy of a body of an ileal bone with introduction to a split of the triangular autograft taken from a crest of an ileal bone, or allotransplant).
Among palliative operations it should be noted operation In — Lamy, to-ruyu apply as auxiliary intervention. Its principle comes down to bringing down of a part of a big spit together with the average and small gluteuses which are attached to it. The purpose of operation — to strengthen these muscles at the expense of their nek-ry tension. The dissected-away part of a big spit is fixed the screw or a wire to an outer surface of a femur in the field of the basis of a big spit or is slightly lower. The subtrochanterian osteotomy of a hip applied earlier at high ileal dislocation on Shantsa is almost not used now as it is ineffective and often leads to development of genu valgum (see. Knee joint). At teenagers and adults at unilateral congenital dislocation in some cases the artificial ankylosis is shown (see) — strengthening of a joint in the fixed situation. At the same time due to violent bringing down of a head of a femur and reposition it in a profound acetabular hollow it is possible to extend a leg. The most reliable the intraekstraartikulyarny artificial ankylosis with fixing of a head of a femur to a roof of an acetabular hollow three a bladed nail is considered. In addition to nailing, apply also bone plates and more difficult designs to fixing. As a result of operation the opo-rosposobnost of an extremity is recovered and joint pains are liquidated that allows the patient to perform even hard physical activity.
The forecast at patients with malformations of T. the page substantially is defined by timeliness of diagnosis and treatment; in most cases the good functional result is achieved by conservative methods. At congenital dislocation and an incomplete dislocation of a hip detection of defect in the first weeks and months of life allows to liquidate it without effects. In cases of later detection results of treatment of defect worsen; there is a need for use of an operative measure, a cut, however, does not provide a complete recovery of function of a hip joint.
Damages of T. pages include bruises, traumatic dislocations of a hip, traumatic dislocations of a hip in combinations with changes of a head, necks-zsh of a femur and an acetabular hollow, an epiphysiolysis, damages of a hip joint at a fighting injury.
Bruises of area T. pages can be followed by damage of soft tissues and elements of a joint, formation of hypodermic or intermuscular hematomas. Sometimes, especially against the background of arthrosis (see), elements of a joint — a joint cartilage, aculeiform outgrowths, the joint capsule are damaged. It can lead to long pains — coxalgias.
In detail a wedge, a picture, diagnosis and treatment — see the table. Forecast, as a rule, favorable.
Traumatic dislocations of a hip result from usually indirect injury. Depending on position of a hip at the time of an injury the shift of a head of a bone occurs differently. Distinguish posterior dislocations of a hip (the most frequent, the T making up to 80% of all dislocations. page). up and kzad — ileal dislocation (luxatio iliaca), down and kzad — sciatic dislocation (luxatio ischiadica); front dislocations: kpered and up — suprapubic dislocation (luxatio pubica), forward and down — locking dislocation (luxatio obturato-ria); at changes of a bottom of an acetabular hollow — the central dislocation (luxatio centralis). Clinically dislocations of a hip are shown by severe pain in a hip joint, the lack of active movements forced by the position of an extremity depending on a type of dislocation (see fig. 3 to St. Dislocations ).
The diagnosis is specified at a X-ray analysis: the acetabular hollow is empty, and the head of a femur is displaced up, to the level of a body of an ileal bone (fig. 11) or from top to bottom, to the level of the lower branch of a pubic bone (fig. 12). Radiodiagnosis of posterior dislocation is most difficult, for identification to-rogo investigate width of a joint crack throughout and the relation of a hip to the reference points described above. At a X-ray analysis in some cases reveal the accompanying fractures of a neck, a head of a femur and an acetabular hollow. The change of a head of a femur, is more often than its lower segment, occurs at the moment when it is displaced for edge of an acetabular hollow.
Changes of an acetabular hollow, according to L. G. Shkolnikov, V. P. Selivanov, V. M. Tsodyks (1966), make 7,7% of total number of changes of a basin and are usually combined with other changes basin (see). In particular, changes of walls of an acetabular hollow, as a rule, are followed by dislocation of a femur (fig. 13). The mechanism of changes of an acetabular hollow — a prelum of a basin in the frontal plane, blow to a big spit that quite often occurs during the falling from height. The change of the upper edge of an acetabular hollow radiological is diagnosed easily whereas otloma of the first or rear edge can mask a shadow of a femur and pelvic bones. Therefore at injuries of a joint it is not necessary to be limited to shooting in one standard projection, and to supplement it with the second — semi-side. The change of a bottom of an acetabular hollow often is followed by the central dislocation of a head of a femur. In this regard allocate two groups of changes of an acetabular hollow: without primary shift of a head and with shift it and the central dislocation (fig. 14). At the central dislocation-fracture the head of a femur which is displaced inside presses through an internal wall of an acetabular hollow and is displaced in a pelvic cavity. At the same time position of an extremity forced, the movements are impossible, retraction in the field of a big spit is noted. At a rectal research it is possible to define sometimes protrusion in the field of a bottom of an acetabular hollow. On the roentgenogram the shift of a head of a femur in a pelvic cavity, sometimes together with bone fragments of a bottom of an acetabular hollow is visible.
Treatment of traumatic dislocation of a hip includes the manual closed reposition, open reposition, sometimes in combination with other operations (an artificial ankylosis, endoprosthesis replacement, an osteosynthesis). The closed reposition of dislocation of a hip is made most often by Kokher's method under anesthetic, it is better with muscle relaxants. The patient is stacked on a back. The assistant holds hands a basin of the patient, and the surgeon bends the injured leg in T. the page at right angle also carries out draft along a hip, rotirut a hip inside, then outside, takes away and unbends. At this moment there is reposition (see). At difficult set ileal dislocations it is necessary to bring a head of a bone to cutting of an acetabular hollow and through it to set dislocation. Except described, also other ways of reposition of dislocation of a hip are offered (see Dislocations). At the same time success of operation more depends on good anesthesia and a relaxation of muscles, than on the choice of a way of reposition. After reposition of dislocation make an immobilization (see) with the help the cook-sitnoy of a plaster bandage, sticky and emplastic (at children) or skeletal traction of an extremity with a load of 3 — 4 kg. It is allowed to go on crutches in 3 — 4 weeks; it is possible to load an extremity in 5 — 6 months after an injury. Earlier loading is dangerous because of possible development of an aseptic necrosis of a head of a femur.
If dislocation was followed by a change of the rear edge of an acetabular hollow and reposition was unstable owing to a separation of a big bone fragment, fixing of fragment of a vnntama is shown. After that it is reasonable to carry out within 1 — 2 month skeletal traction on length of an extremity for prevention of an aseptic necrosis of a head of a femur.
Treatment of the central dislocation is performed skeletal traction for condyles of a femur. If the head is not removed, at the same time carry out skeletal traction for a big spit perpendicular to an axis of an extremity within 2 — 3 months. If in this case reposition of a head of a femur does not work well, resort to operational reposition of dislocation. Full load of an extremity is allowed in 6 months after an injury. At children's age at a change of an acetabular hollow injury of a Y-shaped cartilage is quite often observed that can lead to a growth disorder of a hollow and discrepancy to its sizes of a head of a femur.
Pathological dislocations in T. pages occur at destruction of a head of a femur inflammatory process (see the Coxitis). Quite often it arises at a coxitis at babies owing to the postponed umbilical sepsis. Carry to pathological also dislocation of a hip at the residual phenomena of poliomyelitis. Patol. the central dislocation is observed at destruction of a bottom of an acetabular hollow by a tumor. Treatment and forecast patol. dislocations depend on the nature of basic process.
The fracture of a neck of a femur often arises at advanced age. Such changes (subkapital-ny, intermediary). if they not driven, at conservative treatment do not grow together. The main operational method of treatment is the osteosynthesis (see), and at a subka-pitalny change — endoprosthesis replacement (see). At not accrete fracture or a nearthrosis of a neck of a femur apply the combined operation — an osteosynthesis a metal nail Smith-Petersen and an intertrochanteric osteotomy according to Mac-Marri. Sometimes to area of a nearthrosis bring a bone transplant from a big spit on a muscular leg (see the Hip).
The epiphysiolysis of a head of a femur is observed at teenagers, is more often during from 11 to 16 years. The epiphysis is displaced usually kzad and slightly down, in some cases occurs full Skhmeshcheny it down. The epiphysiolysis is observed, in particular, at inborn coxa vara. Clinically the epiphysiolysis is shown by lameness, restriction of movements in T. page, small shortening and outside rotation of an extremity, restriction of internal rotation. At rentgenol. a research, in addition to a direct picture, it is necessary to do also the side roentgenogram as quite often only on it the epiphysiolysis comes to light. Treatment of an epiphysiolysis is directed to the termination of a further epiphysiolysis or its reposition and fixing. If shift small, but exists a tendency to progressing, the closed osteosynthesis spokes or a nail is necessary. At the considerable shift of reposition reach skeletal traction with the subsequent osteosynthesis a nail. In cases of an old epiphysiolysis make an intertrochanteric osteotomy for elimination of coxa vara. In the presence of an epiphysiolysis on one party radiological control of a head of a femur of the opposite side is necessary.
The forecast at traumatic dislocation of a hip, especially in combination with changes of a head, a neck of a femur and an acetabular hollow, at most of patients concerning recovery of function T. page adverse in connection with development of complications: aseptic necrosis of a head of a femur, development of arthrosis, contracture.
At a traumatic epifizeoli-z arthrosis of T quite often develops. page; it is connected with difficulty of exact reposition of a head of a femur and disturbance of biomechanics of a joint.
Fighting damages, stage treatment
the Closed fighting injury of T. the page (dislocations, intra joint fractures) meets rather seldom and significantly does not differ from similar damages of peace time. Main type of a fighting injury of T. page — bullet and missile wounds. In the center of mass defeat also wounds secondary shells are probable.
Wounds of T. pages share on not getting, with damage only of soft tissues, and getting into a cavity of a joint, with injury of a bone tissue or without it. By experience of the Great Patriotic War, wound of T. pages made 6,6% of all wounds of large joints (excepting radiocarpal), and nearly a half of them — getting; injury of bones at the getting wounds was noted in 93,6% of cases. Fractures of bones are more extensive and difficult, than at the closed injury therefore their division into changes of a head of a femur, her necks, changes of a joint hollow, intertrochanteric and subtrochanterian is conditional. A hurting shell, injuring a bone, even out of a cavity of a joint, can cause formation of far-reaching cracks and large splinters, at the same time the change can actually be intra joint. Destruction of circumarticular soft tissues is sometimes very extensive, especially at wound a large splinter of metal, and bullet wounds quite often get through bones of a joint into a cavity of a small pelvis.
Fire injury of T. the page on weight of damages is on the first place among wounds of other large joints. Along with T. pages can be damaged ileal, femoral, buttock vessels, a sciatic nerve.
Klien, a picture at considerable destruction of bone elements of a joint and visible change of its form, situation and length of a hip is typical; the diagnosis in these cases does not cause difficulties. For specification of localization and a form of damage of T. the page is necessary rentgenol. research.
First aid (see) and the pre-medical help (see) include imposing of an aseptic bandage, administration of anesthetics, a transport immobilization of all extremity and trunk organic or make-shifts (see the Immobilization). During the rendering the first medical assistance (see) correct a bandage, korrigirut and will improve an immobilization with use of standard tires (see Splintage), enter antishock liquids, antibiotics. The qualified medical care (see) includes holding antishock actions, a final stop of bleeding, and also primary surgical treatment of a wound (see) in cases when its delay is inadmissible (the extensive, smashed or obviously contaminated wounds). The specialized medical care (see) provided in to lay down. GB institutions of the front, in traumatologic hospitals of hospital base of medical service GO, includes primary delayed or secondary surgical treatment of a wound and an operative measure on the joint. At the same time its resection since the arthrotomy does not provide sufficient drainage is most often shown. It is recommended to delete a head and a neck of a femur, comparing then opit it with an acetabular hollow, fixing an extremity a high plaster bandage in the provision of small assignment.
From complications are most frequent: suppurations of a wound (see Wounds, wounds), sometimes about zatekam, osteomyelitis (see), the mephitic gangrene (see), 20% of complications makes sepsis (see). Quite often repeated operations — opening of zatek and their drainage (including in a pelvic cavity) and, as a last resort, an exarticulation of a hip are required.
Forecast adverse. Fighting capacity at wounded is recovered by hl. obr. after extraarticular wounds and that not always. By experience of the Great Patriotic War, at the getting wounds duration of treatment in most cases made 200 days and more; nearly 9% of wounded lost an extremity and approximately it remained functionally defective with 50%.
See also table to the present article.
A periarthritis call the circumarticular defeats connected with infectious and allergic process, it is frequent against the background of dystrophic changes. Treatment comes down to holding thermal and physiotherapeutic procedures and purpose of antiinflammatory medicamentous therapy. Forecast favorable.
A bursitis in the area T. the page sometimes accepts a heavy current. Usually synovial bags of a big spit and an iliopectineal bag are surprised. At a purulent inflammation of the last process can extend to T. page. The bursitis in the field of a big spit often has a tubercular etiology (see the Trochanteritisis; Tuberculosis is extra-pulmonary, a tuberculosis of bones and joints.). Treatment is antiinflammatory, antibacterial; outcome favorable.
Arthritis I.e. Yayuzhet to be various etiology — tubercular, acute purulent, rheumatic, gonorrheal, etc. (see the Coxitis, and also the table to the present article).
Dystrophic diseases of T. pages are very widespread. Injuries of T are their cornerstone. page, coxites, inborn deformations, exchange and trophic disturbances (see Arthroses). At inefficiency of their conservative treatment the operative measures aiming to change biomechanics of a joint are shown (an osteotomy, cutting off and change of regional muscles, etc. To creation of an anchylosis (see the Artificial ankylosis), and in some cases endoprosthesis replacement (see).
Osteochondromatosis of T. the page (see the Chondromatosis of joints) meets seldom. Clinically it is shown by periodic blocking of a joint (infringement of free osteo-hondromatoznykh bodies) which is followed by sharp sudden pain. Treatment operational — an arthrotomy and removal of free bodies. In cases of rough damages of a joint cartilage apply the same operational methods, as at arthrosis. Timely and radical removal of hondromatozny bodies leads to recovery.
The aseptic necrosis of a head of a femur arises as a complication after violent reposition of congenital dislocation of a hip or after a fracture of a neck of a femur, especially subkapitalno-go, and also can be the obscure etiology. At children this disease has a number of kliniko-morphological features and it is known under the name of a disease of Legga — Kalva — Pertesa (see Pertes a disease). It is shown by lameness, pains in T. page, irradiiruyushchtsh in a knee joint, a contracture. Treatment comes down to unloading of an extremity (circulation on crutches), to holding physiotherapeutic procedures; at inefficiency of these measures operational treatment is shown. At adults make an osteotomy, an artificial ankylosis or endoprosthesis replacement that substantially recovers function T. page.
To diseases of T. pages carry also acquired coxa vara forms arising owing to rickets, osteomyelitis of a neck of a femur, an injury of the proximal end of a femur.
Tumors of T. pages can proceed from the capsule of a joint (see the Synovioma). from cartilaginous and bone fabrics. In a neck of a femur benign tumors — an osteoma (see), an osteoid osteoma (see), an osteoblastoclastoma (see), a chondroma (see), a hondroblastoma (see), and also malignant tumors — a chondrosarcoma (see), an osteosarcoma are observed (see).
Treatment of benign tumors provides usually their ekskokhleation (scraping) or a resection of the affected bone within healthy fabrics. It is reasonable to fill postoperative defect bone auto-or allotransplants. At malignant tumors the expanded resection of the proximal end of a femur with the subsequent substitution of the resected site bone allotransplant or an endoprosthesis is shown. In far come cases carry out an exarticulation of a hip or mezhpodvzdosh-but-belly amputation. According to indications apply beam and chemotherapy.
The forecast at benign tumors favorable, however in the subsequent development of the deforming arthrosis of T is possible. page. At malignant tumors the forecast is defined gistol. form of a tumor and timeliness of treatment.
Clinicodiagnostic characteristic and methods of treatment of the main malformations, damages, diseases and tumors of T. page — see the table.
Operative measures on T. pages make at destructive processes in the joint and near it, at tumors, dystrophic diseases, the inborn and acquired deformations, etc. They are characterized by rather high degree of injury therefore as an effective remedy of anesthesia the anesthesia is in most cases preferable (see); use also spinal, peridural and local anesthesia (see).
Quick accesses to T. pages are numerous. Variety of pathology, complexity of anatomy of area T. the village demands the differentiated approach to the choice of access. Front accesses are shown for operations on a head and a neck of a femur; accesses across Eger — to Tekstor, Gyuter, Lyukke — to Sheda, Garibdzhanyan belong to the most used (see the Coxitis). Outside accesses include operational approaches according to Whyte, Shpren-gelyu, Gagen-Thorn, Shassenyak (see the Coxitis). With their help the exposure of distal departments of a neck of a femur and back lower parts of an ileal bone (the back atsetabulyarny centers) is reached. Access across Ollye — to the Lexer — Murphy — Vre-denu consisting in the arc-shaped (curvature from top to bottom) a section of skin under a big spit, cutting off of the last and an otvorachivaniye of a musculocutaneous rag up is more traumatic. At the same time the wide review of all joint is reached.
The most widespread back accesses are accesses on Kokhera and Langenbeka, at to-rykh a big gluteus stratify along fibers, and open a joint behind. These accesses are most shown for drainage arthrotomies (see) at a purulent coxitis.
Operations on T. pages can be divided with the known convention on diagnostic, corrective, radical, palliative. Treat a puncture for the purpose of extraction of intra joint liquid or a biopsy of tissues of joint diagnostic. The puncture is made in front, outside and behind.
Arthrotomy of T. villages use for an exposure of a joint as quick access or with to lay down. the purpose (e.g., for drainage of a joint).
Resection of T. to page it is shown at destructive processes and tumors. This operation consists at a distance patholologically the changed fabrics within a healthy bone and pursues the aim along with sanitation of a joint its ankilozirovaniye.
The osteotomy of trochanterian area of a hip is made most often for elimination of vicious position of an extremity at a contracture of T. page, arthrosis, aseptic necrosis of a head of a femur. At the last two indications usually carry out an osteotomy according to Mac-Marri; do a slit from a top of a big spit 12 — 15 cm long down, subperiostalno separate muscles from trochanterian area; a chisel make a kosopoperechny osteotomy and, taking away a hip, displace a proximal fragment medially under a neck and a head of a femur. Operation is finished with imposing of a plaster bandage. Change of load of a head of a femur, and also stimulation of reparative processes in its head and a neck are result of this operation.
In some cases the osteotomy (see) has palliative character, napr, an osteotomy on Shantsa — a subspit a fa-ny osteotomy with an emphasis of a proximal fragment in an ischium.
Artificial ankyloses of T. pages are various. The intra joint artificial ankylosis on the equipment is close to a resection. In some cases it is supplemented with implementation of bone transplants between a head of a femur and an acetabular hollow or fixing of a head in a hollow metal fixers (pins, screws, the compressing devices). At an artificial ankylosis on Vredena the role of the fixer carries out the long bone transplant which is carried out through a neck, a head and an acetabular hollow. The extra articulate artificial ankylosis provides immobilization of a joint without its opening, napr, by means of a bone autograft between a big spit and an ileal bone. The artificial ankylosis (see) has an ultimate goal an anchylosis of a joint, however does not provide direct intervention on patol. the center therefore in most cases belongs to the category of palliative operations. In a crust, time the artificial ankylosis is applied more and more seldom.
Arthroplasty (see) — various interventions providing mobilization of T. page, recovery of its mobility; it can be carried out using auto-and allotransplants.
Endoprosthesis replacement (see) it is applied widely. Various models of the metal, metalpolymeric and ceramic endoprostheses allowing to recover mobility in T are used. page at its destructions or after extensive resections concerning tumors.
At malformations of T. page, in addition to corrective osteotomies of a femur, the reconstructive operations on an acetabular hollow directed to its deepening gained distribution (Salter's operations, Kiari, etc.); at congenital dislocation of a hip at children up to 8 years with success apply a kapsulyarny arthroplasty (Kodivilla's operation — Columns and its modifications). Operation of the Column is offered for recovery of mobility of T. page at destruction of a head of a femur: instead of a head in an acetabular hollow implement the dissected-away big spit. Operation is ineffective also in a crust, time is applied seldom.
Maintaining patients after operations on a hip joint includes the general actions (see. Postoperative period ), and also an immobilization of a joint for various terms depending on character patol. process and operation. Drainage of a joint for the purpose of the prevention of formation of a hematoma is obligatory. At a long immobilization much attention is paid to prevention of developments of stagnation in easy, vascular disorders, decubituses.
Table. CLINICODIAGNOSTIC CHARACTERISTIC AND METHODS of TREATMENT of the MAIN MALFORMATIONS, DAMAGES, DISEASES AND TUMOURS of the HIP JOINT
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I. A. Movshovich; P. L. Zharkov (rents.), S. A. Rusanov (soldier.), JI. K. Semenova (An.); authors of the tab. V. V. Gusev, M. A. Korendyasev, E. R. Mathis, V. P. Pavlov, V. F. Pozharisky.