Anatomy of bones in childhood

Содержание

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The Anatomical and physiological particularities of bone and muscular systems &

The Anatomical and physiological particularities of bone and muscular systems &

its clinical importance. The Teeth and teeth formula.
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The First kernel of the large bone ossification appears in a

The First kernel of the large bone ossification appears in

a 7-8 weeks aged embryo within its in uteri development. Consequently, at this time it is possible to consider that bones of the child skeleton arise.
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After birth the size of skeleton increases very intensively according the

After birth the size of skeleton increases very intensively according the

mass and length growth of baby body. In this period at list until to 3 years of age the child skeleton can not be estimated as stable, firm structure. So called the bone rebuilding processes are running very intensively. Alongside with bones growing lengthwise and width, big importance has a realignment of the direction of bone beems under gravitation stimulus influence changing in its direction within childhood.
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The fetus and newborn have a sponge like bone masses (A).

The fetus and newborn have a sponge like bone masses (A).

After age of 3-4 years children have the lamellar built big bones and their bone beems are orientated strictly against earth attraction (gravity, Б). For the first year of the life about 70% bone tissues are reutilized and rebuilt.
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The regeneration and healing processes in child bones occur in contrast

The regeneration and healing processes in child bones occur in

contrast with adult much sooner. Because of sponge like construction and special in contrast with adults chemical composition (pro rata more significant contents of water and organic material vs. mineral materials) the children bones are soft and flexible. That is way children are less predisposed to fractures by comparison with adults.
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Periosteal tissues (a bone cover) provide supplemental trofic function. By comparison

Periosteal tissues (a bone cover) provide supplemental trofic function. By comparison

with adult persons in children it makes the massive stretchy formation over the bones and can play an additional protective role to resist fractures. Even if the child brakes a bone there can be found only so called “subperiosteum fracture” (the fracture without bone parts offset). The other name of this fracture is toddler`s variant on type of "green branch".
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Toddler's fracture. Anterior-posterior radiograph of tibia. Spiral fracture is presented.

Toddler's fracture. Anterior-posterior radiograph of tibia. Spiral fracture is presented.

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3 parameters associated with bone tissue development and biochemicaly same teeth

3 parameters associated with bone tissue development and biochemicaly same

teeth matrix should participate in biological child age estimationon.

The Biological age can be evaluated on:
child growth (body length or height),
terms of bone ossification (ossification centers appearing),
terms of dentition (appearing of constant teeth).

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The Short Notion about kernels of the ossification. In wrist commonly

The Short Notion about kernels of the ossification.

In wrist commonly used

for bone age determination after birth the kernels (centers) of ossification come up in strictly determined sequences. The first kernel is forming in wrist in 6 months aged child. The one year old baby usually has two wrist ossification centers. And since the second year until the 9 each year adds 1 kernel more to the wrist. There are possible individual fluctuations, but, as a rule, spurt or decelerated of their appearance is important to indicate deceleration or speedup of the bone age in contrast with the passport age. This considerations are widely used for diagnostic work up in endocrinology.
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Wrist X-Ray in a 1 yr old infant 2 visible bones

Wrist X-Ray in a 1 yr old infant

2 visible bones

n=1+m,


где n – number visible wrist bones, m – age in yr till 9
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The bone, growth, teeth and passport age coincidence is indicative for

The bone, growth, teeth and passport age coincidence is indicative

for the normal biological development in a child. If the age of psychic development also corresponds to the biological and passport ages you should consider the child as a harmoniously developed one. In opposite event the conclusion about decelerated, accelerated or disproportional child development has to be done.
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The skeleton examination and the most important semiotics of bone diseases in children.

The skeleton examination and the most important semiotics of bone diseases

in children.
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Estimating the bone system the next clinical approaches are useful: Complaints

Estimating the bone system the next clinical approaches are useful:

Complaints
Additional questioning

(case history)
Objective methods:
visual inspection
palpation
bone percussion sometimes
Instrumental (mainly X-Ray) investigations.
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The most common complaint is the pain. Most often the extremities

The most common complaint is the pain. Most often the

extremities pain in children depends on posttraumatic origin.
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Complaints "Pains of the growing" are typical bed time accidental and

Complaints

"Pains of the growing" are typical bed time accidental and self

limited symptoms in a 4-5 years old children. Their origin is unclear. The pain in legs could be provoked by intensively periosteum stretching due to quick growth and nervous superstimulation. Often this "Pains" are provoked with previous high motor activity especially at evening. The Particularities of care. "Pains of the growing" should be overcame by careful inattention from side of the parents. If the child really require a help the heat procedures and massage are sufficient.
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Complaints The Flat foot Pains disturb some children commonly in shank

Complaints

The Flat foot Pains disturb some children commonly in shank and

appear more often at evening time after physical load. Do not forget that in children aged less 2 years the "physiological" flat foot exists. This phenomenon is better seen in a child standing on the table or having wet imprint from the feet. It disappears in tiptoe position. The guidelines of flat feet prevention and care are directed on the normal formed arc of foot shaping in a child. From the infancy the kid chooses must have an enough hard sole and low heel. If the foot is shaping flat the insole supported internal part of foot can be used.
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Complaints The most serious pain symptom which could be claimed by

Complaints

The most serious pain symptom which could be claimed by the

child is a night pain in bones. This pain often wakes up the child. Also it accompanies by sensations of blood pulsations and vascular noises. This symptom can be provoked by malignancy of bone (osteosarcoma) or leukemia (the bone tissues decay occurs due to leukemic cells infiltration). Also the bacterial osteomyelitis can be origin of this pain .
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The big diagnostic importance has combination of pain and fixed position

The big diagnostic importance has combination of pain and fixed position

of limb.

Septic arthritis and osteomyelitis of the hip.

Point of emergency puncture

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The big diagnostic importance has combination of pain and fixed position

The big diagnostic importance has combination of pain and fixed position

of limb.

Characteristic posture of a child with juvenile rheumatoid arthritis, showing the anxious appearance and guarding of joints.

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Visual inspection & palpation The Objective investigation of the skeleton is

Visual inspection & palpation

The Objective investigation of the skeleton is

recommended to conduct from the top to bottom (from the head vertex to the feet).
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The skull


The skull

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In newborns and early infants the skull has more developed brain

In newborns and early infants the skull has more developed brain

part in contrast with a face skeleton. The brain skull consists from paired or dabbled bones including frontal bones and unpaired occipital bone. The opened and formed by elastic membranes sutures separate one scull bone from another. This sutures are closing within the infancy period but lock up completely only in school age. This process is identified as a synostosis.
There are a fontanels in points of bones joining on. Anterior fontanel is situated between frontal and temporal bones. Its normal size at birth is 2-3 sm referring to a measurement perpendicular to the bone edges. Its synostosis occurs in age between 4 to 18 mo. Posterior fontanel is found between temporal and occipital bones. It is locked in 75% of full term newborns. In rest of the children the posterior fontanel closes by the end of the first month of life.
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During the difficult labor the skull bone edges are crawling one

During the difficult labor the skull bone edges are crawling one

another one. This is a molding. The molding can be palpated easy on a kid head and it reflects the physiological phenomena of head adjustment to delivery.
The broadly opened and soft skull sutures are indicative for hydrocephalus. In opposite event the premature scull sutures lock happens and skull is getting small. The small head size reflects microcephalus as a reduction in volume of the whole brain skull. The circumfiarence of the child head are smaller than 5-th percentille size. Often children with microcephalus suffer from mental deficit disorders and spasticity.
The pathological craniosynostosis is the disorder leading to skull growth partial limitation and various head deformations happen.
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The pathological craniosynostosis This newborn girl with venus suture craniosynostosis has

The pathological craniosynostosis

This newborn girl with venus suture craniosynostosis has

cloverleaf skull. In this cases the orbits can be very shallow causing protrusion of the eyes.
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Three-week-old infant with premature sagittal craniosynostosis. Lateral view demonstrates the elongated

Three-week-old infant with premature sagittal craniosynostosis.
Lateral view demonstrates the elongated

head shape with tapering in the occipital region. Except for the abnormal configuration of the head, the child is developmentally normal for age.
Vertex view reveals the characteristic long, narrow shape of the calvarium with premature closure of the sagittal suture.

The pathological craniosynostosis

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The kraniotabes is unusual softness of infantile skull. It can develop

The kraniotabes is unusual softness of infantile skull. It can develop

as a sign of vitamin-D-deficient rickets at age of 3 - 9 months. Do not forget that rickets causes systemic changes in different divisions of skeleton.

In this children with rickets dependent osteomalacia the skull asymmetries had appeared also as a result of long-lasting lying on crib in a room with lateral source of light.
For prevention of asymmetric deformations (and not only for this) it is necessary to take the child on hands more often and to change his position in bed.

Varying degrees of oblique-shaped plagiocephalic heads in two young infants.

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The Cephalhematoma is a wide-spreaded delivery trauma of bones forming skull

The Cephalhematoma is a wide-spreaded delivery trauma of bones forming skull

arc in newborns. The Cephalhematoma resultes as a traumatic damage of superostium. The Blood enters from ruptured diplopic vessels under superostium, separetes it from the skull bone and accumulates in the subsuperostium area. The resorbtion of hematome occurs spontaneously and in common situations does not require any treatment. It is a typical example of so called self limited disease.

Cephalohematoma of the right parietal bone. Note the absence of sutures crossing.

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The Neck.


The Neck.

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Congenital torticollis Left photo is an example of "position of discomfort"

Congenital torticollis Left photo is an example of "position of discomfort"

of a large baby who had been in an oblique presentation for some weeks before delivery, yielding the lopsided head with torticollis. Right, same baby at 5 months of age showing marked improvement from manipulation alone. The auricle, though improved, is still moderately deformed.
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The chest

The chest

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In small children the thorax has rounded form and starts to

In small children the thorax has rounded form and starts to

be flat in anterior-posterior axis in school age. In small children the breathing mostly is provided by diaphragm. The ribs for the first year of life are located horizontally as they were in position of the maximum inspiration in adults. When the child begins to walk the diaphragm is lowered gradually and ribs take a tilt position.
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The place of diaphragm fixing inside thorax in severe respiratory disease

The place of diaphragm fixing inside thorax in severe respiratory disease

being accompanied by forced breathing or in disease with osteomalacia of thorax can be seen on a chest skin in manner of Harrison groove.

Deformities in rickets, showing the curvature of the limbs, potbelly, and Harrison groove.

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Other thorax deformations are typical for rickets (for instance, asimmertic chest,

Other thorax deformations are typical for rickets (for instance, asimmertic

chest, pigeon thorax and others). It is specific for rickets that there are rosary which are defined at checkup, palpation or on X-ray films as solid limited excrescence on anterior surface of chest over the ribs
Rachitic rosary in a young infant
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Other thorax deformations The insulated thorax deformations most often are innate

Other thorax deformations

The insulated thorax deformations most often are

innate and same of them can be discovered in child`s relatives.
The big diagnostic importance in cases of advanced heart diseases with a cardiomegaly (big heart size) has a symptom of precordial bulge. The precordial bulge is formed on anterior thorax surface on area of the heart projection.
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The spine.


The spine.

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Spinal curves In newborns the spine is direct with a small

Spinal curves

In newborns the spine is direct with a small protuberance

backwards in the area of rump. There are not cervical, thorax or pelvic physiological spine deviations in anterior-posterior direction. They will be very useful for amortization of the spinal column when the child walks, jumps.
After the child lies in prone position and begins to raise slightly the head upwards the cervical lordosis (onwards spinal arc) is forming. When the child starts to sit down the lumbar lordosis and to stand up the chest kyphosis will appear. The cases of the exaggerated lordosis and kyphosis (backwards spinal arc especially in thorax) are defined as hyperlordosis and hyperkiphosis and are to be treated.
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The spine deviations aside are never being physiological and are nominated

The spine deviations aside are never being physiological and are

nominated as scoliotic.

One of the predisposing factors of scoliosis development is a phenomenon of functional human body asymmetry. By other words the left and right half of human body are seldom completely alike on size. Under monotonous load deforming spine the accustomed or functional scoliosis can appear.
That is way the parents and school teachers have to pay much attention on children bearing shaping. It means a pose correction at letter in school, advise do not carry briefcases etc. The bed in childhood has to have an enough hard better orthopedic mattress. All motor sports especially swimming as a rule promote the correct bearing shaping.
The pathological scoliosis appears as result of preceding diseases of bones and muscles.

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Structural changes in idiopathic scoliosis. As curvature increases, alterations in body

Structural changes in idiopathic scoliosis.
As curvature increases, alterations in body

configuration develop in both the primary and compensatory curve regions.
B) Asymmetry of shoulder height, waistline, and the elbow-to-flank distance are common findings.
C) Vertebral rotation and associated posterior displacement of the ribs on the convex side of the curve are responsible for the characteristic deformity of the chest wall in scoliosis patients.
In the school screening examination for scoliosis, the patient bends forward at the waist. Rib asymmetry of even a small degree is obvious.
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The limbs and tubular bones.

The limbs and tubular bones.

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In young children the tubular bones are filled with the actively-functioning

In young children the tubular bones are filled with the

actively-functioning red marrow. The long tubular bones include several parts. The diathesis and epiphysis parts are united with a soft cartilago`s layer. It is metaphysis or growing zone of tubular bone. The presence of such layer in radix in area of wrist joint in children of first three years of life can predispose them to bone trauma in type of metaphysic-take-off. Most often this type of bone fracture happens as a result of sudden child hand pulling up, for instance, if the child falls when the parent keeps him by his hand.

Intra-bone line for fluids infusion in young children

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Limb` deformations It is known that multiple symmetric deformations of upper

Limb` deformations

It is known that multiple symmetric deformations of upper and

lower limbs are characteristic of severe rickets. Especially so called knock-knee (valgus or X-shaped) deformity of knees or bowleg like deformity - varus angulation (О-shaped or genu varum) are related with rickets in children.
However it must be kept in mind that in children younger 2 yr the first impression is that their legs are slightly varus – formed, and children aged 2-7 yr – valgus - formed.
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Skeleton` deformations If the deformations of skeleton are conditioned by anatomical

Skeleton` deformations

If the deformations of skeleton are conditioned by anatomical elements

lost (for instance, absence of clavicles, radix or fibula), or there is an unusual construction of joints (arthrogriposis) or pathologicaly repeated bone fractures (osteogenesis imperfecta) such conditions pertain to innate hereditary diseases.
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Congenital absence of clavicles


Congenital absence of clavicles

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Often the palm abnormalities are symptoms of hereditary diseases. Brachydactylity (short

Often the palm abnormalities are symptoms of hereditary diseases.

Brachydactylity (short

fingers),
arachnodactylity (spider like),
syndactylity (finger`s joining),
adactylity (lost of fingers),
klinodactylity,
kamptodactylity etc.

А. Simple incomplete syndactyly III и IY.
В. Example of most common postaxial polydactyly. This form is complex in that it is associated with bone and tendon abnormality. Many of the postaxial defects are nothing more than skin tags.

А

В

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The symptoms of innate displastic/dislocative hip (DDH) in infants and children.

The symptoms of innate displastic/dislocative hip (DDH) in infants and

children.
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Acetabular hip dislocation as a complication of developmental dysplasia of the hip. DDH

Acetabular hip dislocation as a complication of developmental dysplasia of the

hip.

DDH

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DDH evaluation Limitation of hip abduction is indicative of soft tissue

DDH evaluation

Limitation of hip abduction is indicative of soft

tissue contractures and may indicate DDH. Conversely, hip abduction contractures may indicate dysplasia of the contralateral hip.
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DDH evaluation Barlow test is the most important maneuver in examination

DDH evaluation

Barlow test is the most important maneuver in examination of

the newborn hip. This is a provocative test that attempts to dislocate the unstable hip. The examiner stabilizes the infant's pelvis with one hand and then flexes and adducts the opposite hip and applies a posterior force. If the hip is dislocatable, this usually is readily felt. After release of the posterior pressure, the hip will usually relocate spontaneously.
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DDH evaluation The Ortolani test is a maneuver to reduce a

DDH evaluation

The Ortolani test is a maneuver to reduce a

recently dislocated hip. The result is most likely to be positive in infants 1-2 mo of age because adequate time must have passed for the true dislocation to have occurred.
In test, the infant's thigh is flexed and abducted and the femoral head is lifted anteriorly into the acetabulum. If reduction is possible, the relocation will be felt as a "clunk," not heard as a "click." After 2 mo of age, manual reduction of a dislocated hip is not usually possible because of the development of soft tissue contractures.
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DDH evaluation An asymmetric number of thigh skinfolds and apparent shortening

DDH evaluation
An asymmetric number of thigh skinfolds and apparent shortening

of an extremity when the supine infant's feet are placed together on the examining table with the hips and knees flexed (positive Galeazzi - Allias sign) is suggestive of DDH because these findings indicate proximal displacement of the femoral head.
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DDH evaluation In older or walking children, complaints of limping, waddling

DDH evaluation

In older or walking children, complaints of limping, waddling

(bilateral DDH), increased lumbar lordosis (swayback), toe-walking, and in-toeing may be associated with an unrecognized DDH.
In this children the Trendelenburg`s sign becomes positive. Looking on the trunk from the back the pelvic movements upwards and downwards are seen when the child stands up on well or affected limb alternately.
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The teeth and teeth formula in children. The semiotics of teeth diseases.

The teeth and teeth formula in children. The semiotics of teeth

diseases.
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The teeth are a skin appurtenance because they are derived from

The teeth are a skin appurtenance because they are derived

from the embrio ectoderma. But on their biochemistries and physiologies the teeth and especially dentin are very closed to bone tissue. That is way in pediatric practice traditionally the teeth condition is used as marker of the bone tissue welfare.
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The appearing of baby teeth (or primary deciduous teeth) is called

The appearing of baby teeth (or primary deciduous teeth) is

called as a dentition. The dentition or teething begins in children aged 6-7 mo. The process can de written by formula where the teeth are marked with five first letters of Latin alphabet. A one year old baby as a rule has all 8 primary incisors. This deciduous dentition (teeth formula) is:
BA|AB
BA|AB
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A 12 -15 mo old child as a rule has the

A 12 -15 mo old child as a rule has the

first or anterior premolar teeth( D):
D BA|AB D
D BA|AB D
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A 18 - 20 mo old child has the fangs (C)

A 18 - 20 mo old child has the fangs (C)

teethe:
DCBA|ABCD
DCBA|ABCD
A 22-24mo - second or posterior premolar teeth (E). So a 2 years old child as a rule has a full complement of baby teeth. They are 20:
EDCBA|ABCDE
EDCBA|ABCDE

Empirical formula for infantil teething is n = m – 4, where m – mo of age till 24, n – deciduous teeth quantity

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Unlike infantile teeth a succedaneous (secondary) teeth have a bone alveolus

Unlike infantile teeth a succedaneous (secondary) teeth have a bone alveolus

and developed roots. The order of succedaneous (secondary) teeth dentition (the formula is marking by Arabic numerals only) follows the primary baby teeth changing. The first molar (6) tooth appears at age of 5-7 years. This moment the teeth formula consists from primary and secondary teeth:
6EDCBA|ABCDE6
6EDCBA|ABCDE6
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The incisors are changing at age 7-9 years: 6EDC21|12CDE6 6EDC21|12CDE6 At

The incisors are changing at age 7-9 years:
6EDC21|12CDE6
6EDC21|12CDE6
At

age of 10-12 years in children the intensive secondary teething occurs. The succedaneous fangs (3) and premolars (4 and 5) change deciduous ones. The second molars (7) apeare. A little bit later the third molars (8) appear. This teeth are called “a teeth of wisdom". .
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What is the “difficult" teething? Pain, itching, hypersalivation. Head cold. Fever.

What is the “difficult" teething?

Pain, itching, hypersalivation.
Head cold.


Fever.
Diarrhea.
Always a physician has to pay attention to complicated dentition which a parents as a rule involve with term "difficult but harmless teething”.
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The caries and toothache in children. The caries is a destruction

The caries and toothache in children.

The caries is a destruction of

hard tissues of tooth. The initial caries can exist as a painless dental cavity up to the moment when it reaches the soft part of teeth - a pulp.
Thereby if the painful tooth is damaged by caries the toothache is always the pulpitis sign. The pulpitis is characteristic for extensive or wide-spread dental caries often accompanied with bacteremia and its septic complications.

Basic dental anatomy: 1 - enamel; 2 - dentin; 3 - gingival margin; 4 - pulp; 5 - cementum; 6 - periodontal ligament; 7 - alveolar bone;
8 - neurovascular bundle.

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In small children having deciduous teeth with small amount of dentin

In small children having deciduous teeth with small amount of dentin

the dental caries has some particularities.


Nursing bottle caries.

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The Particularities of dental traumas in children Intruded primary incisor that

The Particularities of dental traumas in children

Intruded primary

incisor that appears knocked out.

Radiograph documents intrusion of "missing tooth" presented in Figure left.

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Hutchinson`s teeth in congenital syphilis

Hutchinson`s teeth in congenital syphilis

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The features of muscles in children

The features of muscles in children

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Some features of muscles The hystomorfological studies of muscular tissues in

Some features of muscles

The hystomorfological studies of muscular tissues in young

children show the short and thick myocytes containing big amount of cell nuclei, abundance of interstitium and blood vessels.
The children skeleton muscles comparatively with such adults contain less myosin and actine contractive proteins and more water. As a result the children muscles are very stretchable and are not prone to ruptures.
The strength of muscular contractions is lesser then in adults.
It is considered that intensive blood flow in children muscles promote quick elimination of acidity forming during muscular load. This fact explains the high physiological muscular activity in children which can feel the true muscular joy moving. In any event it is prohibited to limit children in their motor activity.
Common muscular mass begins to increase only in teens - from 22 - 25% from body weight in pre-pubertal children up to 45% in male-teenagers aged 15 years. The muscular mass increasing occurs by account of each myocyte size increasing. The represented facts undoubtedly witness that so called "body building" and other athletics are for children younger 13 meaningless and even harmful.
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The skeleton muscles clinical investigation The complaints most often concern such

The skeleton muscles clinical investigation

The complaints most often concern such subjective

sensations of pain in limbs and motion restriction. This complaints commonly are related with consequences of traumas which happen in children very often.
The spontaneous pain is characteristic for myalgia. For children it is very typical the muscular pains related with fever. The mechanism of their origin is not clear yet.
The muscle groups clinical survey usually combines with their palpations. During this procedure it is necessary to reveal the muscular atrophies, hypertrophies, contracturas and tenderness.
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А. Myodistrophy. The paraspinal muscles are very thin, and winging of

А. Myodistrophy. The paraspinal muscles are very thin, and winging of

the scapulae is evident. The muscle mass of the extremities is also greatly reduced both proximally and distally.
В. Myastenia. Facial weakness and generalized muscle wasting are severe. The head is dolichocephalic. The mouth is usually open because the masseters are too weak to lift the mandible against gravity for more than a few seconds.

Diseases of muscles

А

В

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Right-sided diaphragmatic (obstetrics) paralysis secondary to phrenic nerve injury, with elevation

Right-sided diaphragmatic (obstetrics) paralysis secondary to phrenic nerve injury, with elevation

of the right hemidiaphragm and shift of the mediastinum to the left.
- Предыдущая
Строительные профессии
Следующая -
Психологическая структура личности и её социальная направленность

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