Juvenile epiphysis of the femoral head: causes, symptoms, diagnosis, treatment

ICD-10 code

M93.0 Slipping of the upper epiphysis of the femur (non-traumatic).

Juvenile epiphysis of the head of the femur is on the third place in a number of diseases of the hip joint. At the heart of this endocrine-orthopedic disease is the violation of the correlation between sex hormones and growth hormones - two groups of hormones that play a major role in the vital activity of cartilaginous epiphyseal plates. Against the background of insufficiency of sex hormones, a relative predominance of the action of growth hormone, which reduces the mechanical strength of the proximal growth zone of the femur, creates conditions for the displacement of the proximal epiphysis of the femur downwards and backwards. Hormonal imbalance is confirmed by clinical data. In patients with epiphysis of the head of the femur, signs of delay in sexual development, metabolic disorders (obesity, latent diabetes mellitus) are often observed - 50.5-71% of patients. The disease is characterized by a long asymptomatic course. Gradually formed symptomatic complexes: pain in the knee joint, movements in the hip joint in a vicious position (withdrawal and external rotation of the thigh, symptom of Hofmeister with bilateral lesions - crosses of the shins) and lameness.

X-ray signs:

• violation of the structure of the proximal growth zone and subepiphyseal region of the femoral neck;
• a positive symptom of the segment - the Klein line does not cut off the segment of the head when the epiphysis is displaced downwards;
• decrease in the height of the epiphysis without disturbing its structure;
• double inner contour of the neck of the thigh;
• reduction of epiphysodiophyseal and epiphyseal angles against the background of regional osteoporosis.

Classification of juvenile epiphysis of the head of the femur

Flow:

• chronic (I-III stages);
• acute (stage IV).

Degree of violation of joint function:

• light (1-II stage);
• medium and heavy (III-V stage).

Degree of displacement of the epiphysis posteriorly:

• light - up to 30 °;
• average - up to 50 °;
• heavy - more than 50 °. 

• I stage - a prediction. Absence of signs of bias of the epiphysis, marked structural changes in the proximal growth zone and the femoral neck.
• Stage II - displacement of the epiphysis posterior to 30 ° and down to 15 ° against the background of structural changes in the cervix and the "open" proximal growth zone of the thigh.
• Stage III - displacement of the epiphysis posteriorly more than 30 ° and downward more than 15 ° against the background of structural changes in the cervix and the "open" growth zone of the thigh.
• IV stage - acute displacement of the epiphysis posteriorly and downwards with inadequate trauma and an "open" growth zone of the thigh.
• Stage V - residual deformation of the proximal femur with varying degrees of epiphysis displacement and synostosis of the proximal growth zone.

Treatment of juvenile epiphysis of the head of the femur

Surgery

Based on the experience of patient treatment, tactics of surgical treatment are developed. When the disease is always affected, both hip joints, so you need to perform the operation from two sides.

The initial stage (I-II). When the epiphysis is displaced posteriorly to 30 ° and down to 15 °, a two-sided epiphiseose is produced simultaneously with the Noules knife and an auto- or allograft after tunneling the cervix to stop the epiphysis and prevent one-sided limb shortening. Transarticular conducting of the spokes and graft is inadmissible in view of the danger of development of chondrolis of the hip joint.

III stage. When the epiphysis is displaced more than 35 ° back and 15 ° down, against the background of the "open" growth zone, the goal of the operation is to restore the epiphysis center in the acetabulum. Apply two- and three-plane osteotomy of the femur in order to center the femoral head in the cavity and distal the anteroposterior zone of the femoral neck from the edge of the acetabulum to eliminate its action as anterior "brake" even against the background of the "open" proximal growth zone.

IV stage. With acute displacement of the epiphysis, the operation is aimed at the closed repositioning of the biased epiphysis and the achievement of the synostosis of the proximal growth zone.

When entering a patient's hospital at this stage of the disease, you need:

• puncture of the hip joint for evacuation of the hematoma and joint decompression, paraarticular administration of 0.25-0.5% solution of procaine (novocain);
• Carrying out Kirschner's needle for skeletal traction through the supracondylar area in the plane of the initial external rotation of the thigh above the distal stalk of the thigh.

During the first week, thrust along the axis is gradually increased by a load of 5 to 8 kg (depending on the weight of the patient). By the end of the second week, the limb was withdrawn to 45/135 °. When the reposition is achieved, the epiphiseodesis with spokes and graft.

Transarticular conducting of the spokes and graft is inadmissible.

Immobilization of the limb in the middle position is carried out with a degrotation boot with a stabilizer for 6-8 weeks.

V stage. When the epiphysis is displaced posteriorly to 35 ° and downwards to 15 ° and to the synostosis of the proximal growth zone, the operation is aimed at restoring the Center of the epiphysis and eliminating the vicious position of the limb. If the duration of the disease does not exceed 12-18 months and is accompanied by good mobility In the joint, it is usually possible to restore approaching the normal ratio in the hip with the use of detrusive-rotational Valgis osteotomy.

In some neglected cases of the prescription of the disease for more than 2-2,5 years, it is necessary to confine itself to the detrusive-osteotomy osteotomy to eliminate the vicious position and some lengthening of the limb.

After all the operations, the immobilization is carried out with a gypsum decontamination "boot" for 4-6 weeks.

Since the first days after the operation passive, and since the third week - active movements in the hip and knee joints on the background of drug therapy: pentoxifylline (trental), xanthinal nicotinate, dipyridamole (curantil), orotic acid (potassium orotate) at age dosages.

Physiotherapy treatment: calcium, sulfur, ascorbic acid electrophoresis according to the tripolar technique, nicotinic acid, humisol, pulmonary pulse amplitude or darsonvalization of the operated limb and lower back 3-4 weeks after the operation.

In the absence of X-ray contraindications (narrowing of the joint gap, delayed consolidation, spotted osteoporosis), the dosed load after epiphiseosis in the I-II stage is carried out 8-10 weeks after osteotomy - after 4-6 months. Full load after epiphiseosis is resolved after 3 months, after osteotomy - after 6-8 months and after epiphiseosis for acute dislocation of the epiphysis - after 10-12 months.

The best results of surgical treatment were obtained in the early stages of the disease (stages I-II).

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