The formation of the skeleton in humans begins with its individual parts in the womb and lasts up to almost 25 years. During this time, the body grows, and the bones gradually increase in length and width.
A feature of the formation of the skeleton is the unevenness and phasing of its growth and the distal direction from top to bottom. Faster than others, those parts of the musculoskeletal system that receive the maximum axial load mature. This refers to the tubular bones with their articular ends, where the muscles are attached. Here are the nuclei of ossification, which also appear as the body develops. If this happens in a timely manner by age, then the development process occurs normally.
One of the most important segments is the bones of TBS (hip joint). With a delay in the development or ossification of nuclei, a congenital dislocation of the hip may occur.
Understanding Kernels
The nuclei of ossification are only a diagnostic sign indicating the development of the joint. There are no external signs, but the result is the complete maturation of all elements of the joint.
This process has its own characteristics:
- Ossification first occurs where the first load occurs.
- The ossification nuclei in the femoral head should appear so that the child can begin to crawl and sit.
- Nuclei in the acetabulum are first formed along its upper part (anatomically this is the roof of the joint). With its timely formation, the baby begins to stand free, and then gradually learns to walk.
- The first nuclei of ossification of the hip joints should appear precisely in the femoral head and upper part of the acetabulum. Otherwise, TBS is delayed in its development and the risk of a congenital dislocation in a child increases. The diagnosis becomes synonymous with TBS dysplasia.
If in TBS on ultrasound there are no ossification nuclei, then this is called aplasia.
Statistics
Dysplasia is common in all countries (2-3%), but in different ways, which depends on racial and ethnic characteristics. For example, in the United States, the likelihood of its occurrence is significantly reduced in African American children.
In the Russian Federation, in ecologically unfavorable regions, the probability of having a child with such a diagnosis reaches 12%. A direct relationship between the occurrence of dysplasia and tight swaddling of the straightened legs of the baby is noted.
In the population of tropical countries, newborns are not swaddled, they are worn on their backs, and the incidence rate here is noticeably lower.
The proof is that in Japan, for example, the tradition of tight swaddling was changed by a national project in 1975. As a result, the likelihood of congenital dislocation of the hip decreased from 3.5 to 0.2%.
Pathology is most often found in girls (80%), a third of cases are family diseases.
Congenital dislocation of the thigh is detected at times more often with pelvic presentation of the fetus, toxicosis. The left TBS (60%) is more often affected, less often the right (20%) or both (20%).
TBS bone nuclei
Bone tissue is formed in the fetus in the womb, at 3-5 months of pregnancy. Then the formation of TBS begins. At birth, the size of the nuclei is 3-6 mm - this is the norm.
In premature infants, the nuclei of ossification of the hip joints are smaller in size. But normal children can also have small cores. If there are no nuclei, this is considered a pathology. If the nuclei did not appear during the first year of life, the functioning of the TBS will not be correct.
Pathology of the nucleus
If the dislocation in the pelvic area is not detected in the newborn and the joint works fine, then with the slow development of the nuclei this is not considered a pathology. If violations of the skeletal system and dislocation are detected, while the bone nuclei are absent, then this is a pathology dangerous to health.
Normal process
There are 3 stages of normal development:
- From the bookmark of TBS elements in the fetus to the first 3-4 months of life. The norm of the nuclei of ossification of the hip joints in the first months of a child’s life is 3-6 mm in diameter.
- The second stage takes place from the age of 6 months to 1.5 years. Bone nuclei develop at maximum speed, and the cartilage tissue begins to gradually be replaced by bone.
- The third stage lasts until adolescence. Here, individual nuclei already merge into strong plates. The lower and central sections of the acetabulum are ossified.
The correct development of the nuclei of the ossification of the hip joints goes in parallel with the development of the child, first he learns to crawl and sit, and soon he can stand and walk.
In the fetus
Ultrasound during this period can show only gross anomalies in the development of TBS in the form of a complete absence of ossification nuclei or other deformations. Dysplasia on it is not determined.
In children
After the birth of a newborn, the processes of building a skeleton are launched. And this is due to the movements of the baby. Active leg movements develop the thigh muscles. This causes blood flow to the deep parts of the bone. Sleeping cells start to work, cartilage destroyers and builders of bone beams appear. The replacement mechanism is accelerated by the fact that several bone nuclei appear.
The largest ossification nuclei are in the femoral head, in its central parts. Simultaneously with the femoral head, the acetabulum begins to form. It takes its final form when the child gets on its feet. The norms of ossification nuclei, which, as already mentioned, are 3-6 mm, can be checked by ultrasound, but not earlier than at the 4th month of the baby’s life.
How to determine?
Such a diagnosis as TBS dysplasia is made on the basis of clinical manifestations and the results of ultrasound, X-ray. These are extremely important and informative diagnostic methods, but they are secondary to the clinic.
An orthopedist should still suspect dysplasia in the hospital and put the child on record. Such children are prescribed special treatment.
The correct formation of the joint can be determined by a number of tests:
- Visually visible skin folds on the hips and under the buttocks. Normally they are symmetrical.
- Hip abduction - the child’s legs are bent with pressure to the stomach and then gently spread apart. Normally, this happens easily. With dysplasia, breeding is limited - this is a pre-dislocation, the tone of the thigh muscles is increased.
- At the same time, slippage is noted - when the legs are abducted from the affected side, a click is noted. This is a symptom of Ortolani-Marx, and he says about poor fixation of the head. It is a subluxation, and the dislocation itself is determined already when the child begins to walk. The baby may limp or have a duck walk.
- Shortening of one limb may occur. Even if one of these tests shows a positive result, an ultrasound scan is required.
If there is no ossification on both sides, this is not considered a serious pathology, since osteogenesis is still noted. But the one-sided process of delaying ossification nuclei requires immediate inpatient treatment.
Lack of cores
In some cases, aplasia or the absence of ossification nuclei in the components of TBS is observed. In such cases, the body itself tries to exclude the joint from work. Violations in this case are as follows: the legs are asymmetrical, any movements are sharply limited or impossible.
On ultrasound, the nuclei of the ossification of the femur are absent and the components of the joint remain at the level of cartilage. They do not contain dense inclusions and are homogeneous. The joint is deformed. The acetabulum is gradually flattened and it is already incapable of transferring pressure.
The femoral head emerges from the cavity and its roundness disappears. The result is arthrosis - the joint is destroyed. Cartilage is scarring, bone marrow occurs. Therefore, the only way out is prosthetics of the joint.
The etiology of ossification
Ossification usually occurs in 50% of rickets. This is due to a lack of nutrients, B vitamins and minerals (calcium, iron, iodine, phosphorus) in the tissues of muscles, ligaments and bones. The absence of the formation of ossification nuclei in children is also associated with this.
The appearance of dysplasia may be associated with improper presentation of the fetus; in children who are breast-fed when immunity is reduced. A lot depends on the health of the mother and father: for example, the presence of diabetes, thyroid disorders, hormonal disruptions. In this case, the child is disturbed in metabolism. The reason for the lack of bone nuclei can be a double pregnancy, maternal gynecological pathologies in the form of uterine hypertonicity, infections and viruses during pregnancy, mother's age over 40, severe toxicosis, heredity (every fifth case), premature birth, maternal spinal diseases, large fetus.
TBS development
The formation of the core of the ossification of the femoral heads is noted in 5-6 months, and by 5-6 years the process accelerates tenfold. At the age of 15-17, cartilage is completely replaced by bone tissue. The femoral neck continues to grow up to 20 years, and only then the cartilage is replaced by bone.
Dysplasia therapy
Therapy should be prescribed only by a doctor, and parents are required to strictly comply with his recommendations. Parents need patience and strength, because the treatment process will be long.
The process of establishing the normal development of nuclei in the field of TBS includes:
- treatment and prevention of rickets with the help of UV and vitamin D;
- use of a tire to set the joint;
- electrophoresis with phosphorus and calcium, aminophylline on the lower back, procedures with bischofite;
- paraffin baths;
- massage and therapeutic exercises.
After therapy, an ultrasound scan is repeated to evaluate the effectiveness of the treatment. During treatment, the baby should not be seated and placed on its feet. The sooner therapy is started, the better the result. To strengthen and develop muscles, exercise therapy and massage are used.
Exercise therapy makes sense even if the child does not have dysplasia per se, but there is a genetic predisposition. Then the exercises are carried out lying down, without putting pressure on the joints.
Massage
It can be carried out even in the presence of tires, without removing them. With aplasia, stroking and rubbing are indicated.
Massage rules:
- the child should lie on a changing table with a flat surface;
- to lay a table with a diaper, because the child can describe;
- the mood of the baby should be cheerful and calm;
- the child should not be hungry;
- massage is performed once a day, a course of 10-15 procedures.
There should be only 3 courses, with breaks lasting 1.5 months.
The massage complex is selected individually by a specialist. After consulting a doctor, mom can massage the baby on her own and at home. Massage is not performed if the child:
- heat;
- ARVI;
- hernias;
- congenital heart defects.
Gymnastics
You can learn to do gymnastics yourself. The conditions are the same as for massage. Exercises are done 3-4 times a day. Children usually like this kind of gymnastics.
Any exercise should be done very carefully. Gymnastics in the absence of ossification of TBS includes the following actions:
- The formation of a frog pose in a supine position. Ideally, when kneading the legs, the knees should reach the surface.
- Simulate a crawl pose by turning the baby on his stomach.
- Turn the baby back again, bend straight legs. They need to touch the baby’s head.
- Raise straight, straightened legs to the sides.
- Pull straight legs to the head and spread to the sides.
- The legs of the child are folded into the lotus position, putting the left leg on top.
- Alternately bend the legs in the knees and in the pelvis.
Paraffin Wraps
They warm tissues and remove toxins. Only special processed paraffin is used for the procedure. The duration of the first procedure does not exceed 1/4 hour, then the application time can be gradually increased to 30 minutes. Also useful are baths with sea salt.
Orthopedic Tires
- Koszha splint - helps fix the femoral head in the center, fixes the hips in a diluted state, but does not limit the movements of the pelvic joints.
- Pavlik Stirrups - a tissue thoracic bandage, strengthens the ligaments of TBS. The legs are not straightened, but other movements are possible. Effective up to a year.
- Freyk's tire - used for mild dysplasia under the age of 6 months. When dislocation is not used. The tire holds the hips at an angle of 90 degrees.
- In the treatment of other types of pathology, Koshl, Vilensky, Mirzoeva, Orlett tires, the Wrath apparatus, gypsum are used.
- After a year, plastering is often used to fix the legs. If the child is 1.5 years old, and dysplasia is not cured, surgery is usually prescribed (according to Salter). The essence of the pelvic osteotomy according to Salter is that they change the spatial position of the acetabulum without changing its size.
Forecast
The prognosis for an early visit to a doctor is good. In case of insufficient prophylaxis, dysplastic coxarthrosis is formed , the treatment of which requires joint replacement.
Preventive measures for mother
A woman should eat fully during pregnancy and during lactation. At 7 months, the baby’s diet should already include additional foods.
In addition to nutrition, regular walks in the fresh air, massage, exercise and hardening are of great importance. In autumn and winter, for the prevention of vitamin D hypovitaminosis, the child should receive it in drops. Wide swaddling of the baby also applies to preventive measures so that the child can freely move its legs.