Ministry of health of Ukraine

Malformations of the musculoskeletal system

1. Background.

The frequency of congenital malformations of the musculoskeletal system occur frequently. In the first place birth defects thigh, the second - congenital clubfoot, the third - torticollis. Early diagnosis and timely treatment initiated these defects lead to improved treatment effects, reducing the percentage of disability and promotes full recovery of the child.

2. Specific objectives of employment:

1. Analyze etiologic and pathogenetic factors of the most common malformations of the musculoskeletal system in children: congenital malformations of the hip, clubfoot, torticollis, scoliosis.
2. Analyze the typical clinical picture of the most common malformations of the musculoskeletal system in children: congenital malformations of the hip, clubfoot, torticollis, scoliosis.
3. Demonstrate a clinical examination of the child with the most common malformations of the musculoskeletal system.
4. Make a plan to survey and analyze the data of laboratory and instrumental investigations at a typical course most common malformations of the musculoskeletal system in children.
5. To demonstrate the principles of diagnosis, treatment, rehabilitation and prevention of the most common malformations of the musculoskeletal system in children: congenital malformations of the hip, clubfoot, torticollis, scoliosis.
6. To analyze the clinical and medical history and the results of additional methods of examination for staging clinical diagnosis according to the classification and prove it.
7. Conduct differential diagnostics of the most common malformations of the musculoskeletal system in children: congenital malformations of the hip, clubfoot, torticollis, scoliosis.
8. To analyze the results of treatment of congenital malformations and make rehabilitation for children with congenital disorders of the musculoskeletal system.

4.2. Theoretical questions to studies.

1. Identify the major clinical manifestations of disorders forming hip in children: dysplasia, subluxation hip dislocation.
2. Identify the major clinical manifestations of congenital clubfoot, torticollis in children.
3. Identify the major clinical manifestations of disorders of posture and scoliosis in children.
4. Define auxiliary methods for children with developmental disabilities, musculoskeletal (ultrasound, x-ray, CT, MRI), laboratory and biochemical analyzes.
5. Classification of defects in children. Classification malformation of the hip joints, congenital clubfoot, torticollis.
6. Classification of disorders of posture, scoliosis in children.
7. Identify the major clinical manifestations of malformations in children. Methods of prenatal diagnosis.
8. Algorithm of doctor congenital malformation. Principles of treatment in newborns.
9. Treatment of children with developmental disabilities, musculoskeletal, indications for surgical treatment.
10. Principles of surgical treatment of children with congenital dislocation of the hip, clubfoot, torticollis.
11. Principles of conservative treatment of disorders of posture and scoliosis. Surgical treatment of children with progressive forms of scoliosis.
12. Rehabilitation of children with disabilities of the musculoskeletal system.

4.3. Practical tasks performed in class.

1. Absorb the history of life and disease in a child with a defect of the musculoskeletal system: a violation of the formation of the hip joints, clubfoot, torticollis, incorrect posture, scoliosis.
2. Conduct review of the patient, palpation, auscultation, biomechanical research in child in violation of formation of the hip joints, clubfoot, torticollis, incorrect posture, scoliosis.
3. Describe the objective status and determine the clinical and radiological signs of a child in violation of formation of the hip joints, clubfoot, torticollis, incorrect posture, scoliosis.
4. Settle and make a plan of examination and treatment of a child in violation of formation of the hip joints, clubfoot, torticollis, incorrect posture, scoliosis.
5. Definition symtomu "click" and symptom asymmetry leather folds of the buttocks and thighs in newborns.
6. Measurement of absolute and relative length of limbs.
7. Wide swaddling newborns dressing preventive pants and strementsiv Pavlik.
8. Overview of a child in violation of posture and scoliosis.
9. To demonstrate the technique for bandaging feet Fincom-Etinhenom and Cast corrective dressings.
10. Identify the general principles of treatment of a child in violation of formation of the hip joints, clubfoot, torticollis, incorrect posture, scoliosis.
11. Identify indications and contraindications for conservative and operative treatment, especially of children in the postoperative period.
12. Assign rehabilitation for children with abnormal formation of the hip joints, clubfoot, torticollis, incorrect posture, scoliosis.

Contents subject.

Congenital dislocation of the hip.
Diagnosis of congenital hip joint formation is important because only timely treatment started in the neonatal period, in most cases, provides the most complete further updates joints. Clinical diagnosis may not provide complete detection of pathology, as found from 10 to 30% of asymptomatic cases (H.Casser, 1992, R. Craf, 1993). At the same time, the early detection of violations of the formation of the hip joints is very difficult and requires confirmation to instrumental studies.
The concept of breach formation dysplasia includes all or part of the hip joint components: delayed ossification roof Acetabular or kernel skosteninnya head, a violation of its innervation and blood supply, "weakening" bags-binding unit of the hip joint.
Observed various options and combinations of individual displays of varying degree of dysplasia, which complicates diagnosis of this pathology.
There are degrees of dysplasia:
I. No displacement of the femur, in violation of formation, but with the preservation of relationships in the hip joint-peredvyvyh.
II. Subluxation - a partial violation of relationships in the hip joint, but the head is shifted beyond limbusa, kept contact between the head and the acetabulum.
III. Dislocation of hip - in which there is no head contact and depression often observed interposition, complete displacement of the femur.
Diagnosis of disease of the hip joints in newborns and infants can not imagine the difficulties must first thorough history: the presence of the family of patients with congenital dislocation of the hip joint disease, determine pregnancy in the mother (early, late toxicosis, oligohydramnios, inflammatory disease before pregnancy and during it, the number of abortions, obstructed labor, fetal position, obstetric rotation, and so on.).
Symptoms of congenital dislocation of the hip.
For younger children characteristic clinical symptoms:
Major, the most likely:
• Symptom reduction and vyvyhuvannya, "a symptom of instability", "click" or "slippage" - a symptom of Marx - Ortolani;
• limited hip abduction - muscle hypertonicity thighs;
• shortening of the leg (on the side of dislocation with unilateral disease).
Secondary or auxiliary:
• asymmetry of skin folds on the buttocks and thighs;
• rozbovtanist hip (cherezmirna mobility);
• external rotation of the lower limbs;
• symptom Bogdanov symptom Lyandresa.
Symptom "reposition and vyvyhuvannya" first described V.O.Marks (1934), calling it a symptom of slipping. This symptom should be checked in the delivery room, and then at 3-5 day and before discharge from the hospital as follows: newborn laid back. Thumbs exploring covers knee child and II-IV fingers places in the area major swivels. Along with the challenge made by the axis of the femoral traction in the distal direction, and middle fingers slightly pressed into large swivels toward the acetabulum, while bringing performed light traction on the hip axis directed backwards. During these actions by extraction femoral head enters the articular cavity, while bringing - out of it. Reduction and vyvyhuvannya head of the femur is accompanied by a distinctive sound - "click" researchers on fingers feel it "click". All movements must be performed slowly, without effort. This symptom may disappear over 7-20 days after birth.

According to studies, this symptom is found in 24-31 children per 1000 births (Ya.B.Kutsenyuk, 1992). Later, in the months of age, the symptom has been reported in only 34% of infants.

Second, a likely symptom is limited hip abduction (Figure 2). This symptom is present in 70-75% of children with various forms of violations of the formation of the hip joints. Immediately after birth the newborn was observed several low muscle tone and only 3-5 days you can determine the degree of hip abduction. In muscle tone is influenced by many factors that must be considered in the differential diagnosis (traumatic brain injury, spinal injury, perinatal hypoxic-CNS, asphyxia, arthrogryposis and others.).

With increasing frequency of child symptom reduction and vyvyhuvannya significantly reduced, while limited hip abduction occurs frequently.

Installing the pathology of the hip joints in newborns in the hospital can not guarantee the timely start of treatment. Most mothers do not turn to the surgeon, podiatrist at the place of residence after discharge and during the first months. With the growth of the baby have not seen him in pathology and clinic visits, so doctors at hospital discharge must emphasize that diagnosis, symptoms set when viewed child orthopedic surgeon which treatment is intended, when you need to visit a specialist, and district pediatrician should monitor this.
Other symptoms found in children as the first year of life, and elders. Diagnosis of unilateral disease is much easier to identify the most difficult bilateral lesions and a small degree of dysplasia.
With age, all the symptoms become more pronounced. When di ¬ Tina begins to walk, for unilateral dislocation of the femur she limps when duplex - there shaky "duck" gait. Above a large swivel located above the Rozera-Nelatona that connects sciatic hump of the upper front ostyu ilium. Observe positive symptom Duchenne - Trendelenburg (Figure 3) - a symptom of lowered buttocks (get on up on the side of congenital dislocation STEG ¬ on, and bend the other leg at the knee and hip joints observed omission buttocks curved limbs).

Examination of the child with hip joint pathology. Indications for instrumental examination in neonates and infants:

1. Clinical symptoms
• Symptom reduction and vyvyhuvannya ("click");
• limited hip abduction;
• Asymmetry of gluteal and thigh folds;
• different length limbs.
2. Heredity: a mother, father or other relatives is a pathology of the hip, the other congenital abnormality.
3. Features of pregnancy: multiple pregnancy, sciatic peredloha, early, late toxicosis, and other complications.
4. Features genera: pelvic peredloha, oligohydramnios, obstructed labor, obstetric help.
5. Children with rickets and diseases of the central nervous system (spinal trauma, hydrocephalic syndrome and others.).
Ultrasonography (USG).
Relatively new method that extends diagnostic capability assessment of the hip joint in newborns and infants up to 8-9 months is USD.
The basis of the diagnostic use of ultrasound is the phenomenon of reflection of ultrasonic energy at the interface or tissues with different acoustic resistance. Biological effects of ultrasound depends on its frequency, intensity, and exposure mode. The diagnostic use of ultrasound to very low intensity, with short exposure and high frequency (0.8 to 20 MHz), well below the parameters used for therapeutic purposes, so it does not cause any changes in the organs and tissues nor wrong person investigated, nor staff working on ultrasound equipment.
Title of study with ultrasound in several different countries differ. In the U.S. and England, this method is called sonography or ultrazvukohrafiyeyu. In Germany - zonohrafiyeyu or ultrasound tomography, France - ehotomohrafiyeyu, ultrasonography. We stuck two names: Ultrasound (USG) and sonography.
For ultrasound using three groups of methods:
• assessment of cartilage and bone parts acetabulum;
• Assessment perekrytttya roof acetabulum;
• Assessment of hip and femoral head overlapping roof acetabulum in different positions and load the limb.
The most common method, which belongs to the first group and most closely reflects the morphological characteristics of the hip joint.
Ultrasound scan performed linear transducer with a frequency of 3,5-7,5 MHz. For studies in infants and children during the first three months of life used 7.5 MHz transducer, from three to six months - 5 MHz, in children older than six months - 3.5 MHz. Display is fixed on the thermal, x-ray film (multiformat camera). Before examining the child lay on its side, fold the thigh in the hip joint to 300, and the knee. The ultrasonic beam successively passes through the skin, subcutaneous fat, fascia, muscle, cartilage peryhondriy ilium, joint capsule, the head of the femur, acetabulum. For a clearer display replacement sensor installed in the frontal projection of large swivel.
In cases of insufficient visualization of the joint, the sensor should be rotated in the dorsal or ventral side. To perform a similar study second joint child turn over to the other side and manipulitsiya repeated. Sometimes, for a clearer identification of decentration head of the femur, it is necessary to perform functional tests using axle limb or of bringing the thigh to the abdomen and simultaneous internal rotation. To evaluate the resulting image is important to know the topography of the various structures of the joint in the frontal projection.
Hyperechoic characterization with bony components of the joint. This - bone part acetabulum, external bony protrusion, the outer parts of the cartilaginous roof ilium, femur. Hypoechoic structure arthroplasty: the femoral head, limbus, U-shaped cartilage. In the development of the joint can determine the formation of nuclei of ossification heads femur as echogenic structures round or oval in different age periods.
After conducting research and the resulting image on the screen and the thermal to qualitatively and quantitatively assess the degree of joint. ., , For this purpose, angular figures: angles For their determination to hold a major lines:
• baseline - conducted through the outer office ilium;
• acebular line (line bone roof) is made from the bottom of the bone of the acetabulum to its upper edge;
• inklinatsiyna line - made through a medial limbusa and external bony protrusion acetabulum (jetty bone, cartilage roof line);
• convexital line proetsyruyetsya on external parts of the bone of the acetabulum roof.
Angles characterize the degree of development of the acetabulum, the and  serves estimation bias limbusa in cases of decentration of theangle femoral head.
Development of joint evaluated not only quantitatively but also qualitatively, including the assessment:
• bone roof - good enough, sharply enough, bad;
• Bone bay window - angular, rounded, round, uploschenyy, flat;
• cartilage roof - rectangular, obtuse, scalene triangle, covering the femoral head completely insufficient or will not cover.
For practical application GY Vovchenko (1995), proposed a working classification of variants of the hip joint.
Option 1. Normally zformovanyy mature joint. Children from the first option does not require treatment in the presence of CNS pathologies and to rickets dynamic monitoring - control review in 2-3 months.

Option 2. Detained in the formation of the hip joint with delayed ossification of the outer edge of the acetabulum (bone jetty), part of the roof cartilage acetabulum covers the femoral head. Angle , = 50-55  angle . = 56-69 

When performing a functional test (axle load) angle  increases less than 10 , hip remains stable.
Children with these developments require joint control check in 2-3 months, in the presence of risk factors and diseases of the central nervous system - often.

Option 3. Delayed development of the hip joint with an imaginary uploschennyam acetabular roof, roof insufficient ossification, bone rounded bay window, roof acetabulum almost completely covers the head of the femur.

When functional samples observed steady decentration of the femoral head displacement limbusa dozovni. Angle   49  ,  70 . 44-65    When performing a functional test angle  increases more than 10 .
Children with this option the formation of the hip joint require supervision and treatment podiatrist.
Ultrasonography performed to evaluate the effectiveness of treatment and changes in the joint after 4 - 6 weeks, the presence of clinical indicators - often.

Option 4. Severe developmental delay joint, which corresponds with X-rays of the hip subluxation. Head when performing ultrasound decentralized, is in the lateropozytsiyi, bone roof dramatically insufficient bone oriel considerably flattened. Some patients may increase celebrated эhohennoyi roof. Angles   43  ,  77 ,  at loading angle increases to 15  and more.

Children should be treated by a podiatrist. Ultrasound is done to determine the effectiveness of fixation, confirmation of normal relations in the hip joint, assessing the results of treatment with a doctor's prescription, which determines the frequency of the ultrasound.

Option 5. Development hip meets radiological picture of congenital hip dislocation.

Joint sharply behind in their development, all elements with severe dysplasia and hypoplasia. Bone roof insufficient uploschena, bone oriel flat limbus displaced, when loading limbus shifted down and sits between the acetabulum and femoral head. In this embodiment of the angles are not measured.
This joint development requires long-term treatment with a podiatrist who to appoint conservative treatment stages ultrasound to assess reposition hip joint development of the stages of treatment.
The frequency in each case is determined individually. All these changes may have dvobichnnyy character.

X-ray method study.

The traditional method of instrumental research remains X-ray method in children is not earlier than 3 months due to radiation exposure harmfulness children during the first months of life, and lack the elements of ossification of the hip joint.
In children under one year of X-ray examination should be performed in the position of a child lying on his back. Be sure to follow the correct conclusion: pelvis conclude symmetrically, feet placed parallel to each other, the distance between the knee joint from 3 to 6 cm, depending on the age of the child, the lower limbs rotuyutsya inside 15-20 0. Pay attention to the fact that the pelvis should be adjacent to the tape (table) so that the lumbar area between the back and the table could push hands. X-ray study carried out in rear projection with mandatory protection genital plate, which is at the correct position will not prevent further reading radiographs.
Interpretation of radiographs to ossification of the femoral head, especially in the presence of dysplasia is quite difficult, because in this case it must be examined by orthopedist.
For ease of reading radiographs proposed scheme. A certain point of the pelvis and proximal femur on radiographs, which fix on Densitometers, hold a pencil series of vertical, horizontal and smooth curves.
The most complete picture of the state of the hip joint in infants and children during the first months of life gives Hilhenreynera scheme. Basic guidelines for this scheme are:
- entitled acebular index.* Angle A line of "A" through both in-like cartilage (line Keller). From the bottom of Acetabular held the line, tangent to the most peripheral of Acetabular roof. .Between them and the determined angle The degree of inclination of the "roof" the sustainability femoral head. If the "roof" is aimed low, close to the ground, it is a normal relationship. Newborn index does not exceed 35-40 0, the year he pryblyzhuyetsya 25-30 0
* The second ingredient for X-ray decryption dysplasia is the distance, which is determined by the most highly placed of the diaphysis to the intersection perpepndykulyara from this point of the horizontal line. On average, a child up to 3 months on the radiograph, this distance is 8-10 mm, increasing the distance indicates the degree of displacement of the proximal end of the femur upwards.
medially contour of the femur and acetabulum.* Symptom Erlahera displayed as the distance between It allows us to determine the degree lateropozytsiyi proximal end of the femur. less than 5 mm.Sure
* Line-Ombredana Perkins falls as vertically from the bone edge "roof" of the basin and peresichuye normal proximal femur by shifting the line determined by the degree of dislocation.

Plain radiographs of the pelvis with both hip joints hold the line Keller, then a vertical line that divides the pelvis into two symmetrical halves. Because of the extreme outer point head healthy hip conduct tangent vertical line. On the other hand the same distance from the average vertical hold third vertical line. All lines are parallel to each other and to the line perpendkulyarni Keller. Skewness "roof", thigh high position and his imaginary laterolizatsiya thus distinctly.

In older children for diagnosis of hip pathology commonly used scheme Ombredana

Conservative treatment of congenital dysplasia of the hip

Treatments chosen depending on the child's age and the nature of the morphological changes in the hip joint. However, a common condition in the application of any method of treatment should be the principles of gradual reduction of dislocation, restore relationships between depression and the head of the femur, maximal preservation of blood vessels, nerves, V-shaped cartilage and twisted inside cartilaginous acetabular lip (limbusa). The role should be assigned to preserve joint function after reposition the dislocated femoral head. Only such a treatment strategy can ensure the normal development of the hip joint.
General acceptance and dissemination of the method of early functional treatment based on the use of children under 1 year of various devices for hip abduction (tires, pads, stirrups, etc..), Which do not limit the mobility of the joints.
Treatment of hip dysplasia should begin as soon as possible to functionally under unfavorable factors it did not cause the development of severe and irreversible changes in the hip joint. Early treatment of hip dysplasia is the prevention of congenital dislocation of the hip.
It is now considerable experience on early detection and treatment of hip dysplasia. The results of treatment are directly dependent on the starting time of treatment - the sooner it is started, the better its performance. If dysplasia or congenital dislocation of the hip revealed during his stay in hospital, the treatment must begin immediately.
During his stay in the hospital the mother of a sick child needs to be taught proper technique and wide changing the exercises necessary for functional recovery of the hip joints.

Children under the age of 1 month. make swaddling and gymnastics aimed at eliminating contracture thighs.

In the treatment of congenital dysplasia of the hip in children aged 1-2 months used functional devices that divert hips: strementsi, pillow Freyka. Starting from 1 month baby wearing strementsi Pavlik on the testimony, but in the absence of stretching the joint capsule.

Originally diverting device worn so that they kept his feet in position flexion and abduction as widely as they can take without effort. Required removal legs reach for the first 3-6 days dosed by pulling straps. Due to the elasticity of muscles and ligaments hip abduction angle gradually increases. This femoral head cysts close to the acetabulum and joined it. Typically, the period samovpravlennya lasts 10.6 days and more. Therefore, in this period is not permitted to bathe the baby and shoot device. When hip flexion angle 75-800 and lead them at an angle 70-750 achieved centering the femoral head in the acetabulum. The successful samovpravlennya showed the following clinical signs: symptoms disappear dislocation and limitations hip abduction, probing the head of the femur in skarpovskoho triangle disappearance rate on peripheral vessels in pinning the femoral artery to the head of the femur, presence of severe posterior gluteal-femoral folds. Strementsi need to carry to full normalization of the hip joints.

Strementsi Pavlik used as an independent method of treatment of children under 6 months of congenital hip dislocation in children aged 9-10 months with hip subluxation or dysplasia. When X-ray control, making for children aged 3 months, you can specify the degree of hypoplasia of the hip joint and tentatively identify the necessary treatment time.
If you suspect the presence of hip dysplasia recommend starting treatment at the hospital, continuing in the clinic in the community. After discharge of the child from the hospital prescribed preventive wearing pants, and children older than one month put strementsi Pavlik, providing adequate drainage and bending hips. When treating dysplasia can also be used tire Vylenskoho, CITO and other devices.
Children with congenital hip dislocation after imposing strementsiv (tires) should be inspected weekly for a month specialist. This allows you to verify the reliability and stability of the hip reposition the hip joint, if necessary, performed ultrasound to determine efektovnosti fixing thighs.
As mentioned above, the duration of treatment depends on the degree of dysplasia and the age of the child when treatment started functional method. The average duration of treatment of hip dislocation is 5-8 months subluxations - 5-6 and peredvyvyhiv - 2-4 months.
After treatment, special attention should be given to gradual bringing and leg extension. To avoid drastic reduction feet during sleep in position on the side recommended after treatment for 1 month baby wear strementsi overnight. Day child between the legs should lay diaper, folded in the form roller. After removing strementsiv for 2 weeks, and sometimes more, children themselves hold feet in position allocation. The longer it lasts, the better the conditions are for the development of the hip joints. After treatment the child through the process of strementsiv hip does not reach full normalization, so you should pay attention to the parents to follow the orthopedic treatment. After 2-3 months after treatment, the child is sitting alone, but only in the position of the shoulders hips ("extras" in a chair, in the saddle, or laid between the legs of the platen). Keep position hip abduction recommended and when worn on the hands of a child. Children with low muscle tone and rickets needed massage and therapeutic exercises.
Children are treated for underdevelopment hip, up to 1 year can not walk.
In 99% of children with hip dysplasia who were treated before the age of 3 months, anatomy and function of the limb completely recovered. Up to 10% of children with disorders of the hip joints, which were treated at the age of 4-6 months, 3-10 years radiograph revealed signs of dysplasia.
In the outpatient treatment of children congenital hip dislocation over the age of 6 months, there has been good results, prompting the need to treat these patients in the hospital through continuous extraction.
Value of the role of hereditary factors in the etiology of congenital hip dislocation plays an important role in the early diagnosis of this pathology. Children in families where there were congenital hip dislocation, deforming arthrosis of the hip joints and relaxation bursal-zvyazuvalnoho machine are at risk.
When relaxation bursal-zvyazuvalnoho apparatus, muscular hypotonia in children with neurological disorders, absent a symptom of congenital hip dysplasia as limiting hip abduction. Therefore, in such cases, even with normal hip abduction and no other signs of a developmental disorder of the hip joints, must be sonography or x-ray.
When treating children with congenital hip dislocation aged 1 to 3 years of choice is kleolove traction in the vertical plane with a gradual increase in hip abduction or horizontal. Angle bending hip is 70-90 °. Its value is less, the greater femoral neck cysts rejected doperedu. This femoral head positioned behind posterior lower edge of the acetabulum, which increases the probability of spontaneous reduction.
When traction in the vertical plane, unlike traction in the horizontal plane dislocation reduction is due to the posterior lower edge, so not injured skosteninnya nucleus, located in the upper and anterior acetabulum. In the process of extracting active leg movement remains conducive to spontaneous reposition the head of the femur. When hip flexion converging point of beginning and attachment iliac-lumbar muscles that you remove the horizontal plane often prevents reduction of dislocation.
In the process of extraction is widely used physical therapies aimed at stimulating the body's (total irradiation quartz), improving trophic hip joints and reduce muscle tension (electrophoresis of novocaine, ronidazy kokarboksilaza, sollux). The child engaged in active and passive exercises, parents must teach massage techniques and therapeutic exercises.
Upon reaching full hip abduction, as evidenced clinically and radiologically, extraction removed, fixed limb plaster cast for Lorentz for 4-6 weeks and then superimposed apparatus Hnivkovskoho. If the reduction of dislocation functional method was slow and there is no instability fix the limb in a position of full hip abduction machine can Hnivkovskoho immediately after reduction.
After 5-6 months depending on the severity of defects on a limb shypu Vilna impose a maximum dilution of struts. Then gradually over 2 - 3 months, reduce the width of the struts, reach full erection of the lower extremities. After the X-ray control to decide whether to lift tires and permission to go.
Children who have had hip dysplasia, after 1 year of prescribed physiotherapy, massage, gymnastics. Very useful baths: warm at 37-38 ° C - salt, pine, valerian for excited children 2 - 3 times per week for 12.5 minutes, swimming. If the process behind skosteninnya femoral head, in addition to thermal treatments prescribed electrophoresis kokarboksilaza, B vitamins, calcium and phosphorus, total ultraviolet irradiation.
In congenital hip dislocation, which does not reduce a conservative methods, in children aged 1 - 2 years, at late relyuksatsiyah or when other complications of surgical treatment is shown. All surgery is divided into three main groups: intraarticular and extra-articular combined.
Intra transactions - is opening the joint cavity. Follow them, usually at nevpravymyh dislocations when reduction in head cavity preventing anatomical obstacles: hypertrophied round ligament, cartilage kozyrok depression that zavernuvsya (limbus), as amended hourglass joint capsule, excessive antetorsiya, underdeveloped acetabulum.
Functional treatment of patients who were operated for congenital hip dislocation, is divided into four periods: pre-operative (one period) and postoperative (three periods).
In the preoperative period, given the physiological features of the orhahizmu must teach the child to perform the necessary surgery in her future therapeutic exercise, relaxation of muscles and teach the use of special devices, crutches.
On the first postoperative period length of stay of patients in plaster bandage depends on the nature of the surgery. At this time it is necessary to begin functional treatment: to improve the functioning of the body of the child using bracing exercises for improving the overall body tone. Pick exercises that strengthen the muscles of the upper limbs, back and abdomen, as well as other lower extremity. Not recommended exercises with isometric (static) muscle tension the operated limb.
The second period begins postoperative treatment after removal of plaster bandages. The main task of this period should be considered restoration movement in the operated joint, preventing contractures, increase muscle strength and further strengthen the overall body of the child. Operated limb in bed providing provisions slight abduction and internal rotation.
The main importance for the restoration of function of the hip joint in this period has therapeutic exercise. Gymnastics should begin with passive exercises with gradually increasing amplitude of movement and change provisions in the hip joint. After 2-3 weeks of performing active exercises lightweight nature. Particular attention is paid to active exercises for hip abduction to strengthen the gluteal muscles. This whole period is the preparation of the child for learning walk.
The objective of the latter third postoperative period is the increase in the achieved range of motion, muscle strengthening operated joint training right away. Walking fugacious first 5-10 minutes, gradually increasing the duration to 30 minutes and alternated with periods of rest.
In addition to walking, using active exercises in a standing position. The patient does squats, drainage sore feet and bending it, and underneath the movements leg first holding hands on the headboard. A special role in this period of allocating swimming, physio-and balneotherapy others.
For the full range of post-operative treatment of children should be in the hospital or in the rehabilitation department at least one year. All children treated for congenital dislocation of the hip require clinical supervision and rehabilitation therapy during the entire period of its growth and development.

Congenital clubfoot

Congenital clubfoot (pes equino-varus, exavatus-congenitus) - Drive-resistant flexion contracture of the foot, which is driven ¬ county congenital hypoplasia and internal shortening ¬ sibilities and the back of the thigh muscles and ligaments. Among deformations of the musculoskeletal system is one of the first places. Bilateral clubfoot is more common than unilateral and mostly boys.
Causes of congenital clubfoot described differently in the literature and are reduced to the endogenous (bookmarks fetal malformation) and exogenous (malformation of the fetus).
Endogenous factors include genetic predisposition, underripe germ cells, age of parents (over 35 years).
The reasons that lead to fetal malformations, may be the mechanical effects on the fetus, the thermal factor (fever pregnant women), bacteriological (action toxicity ¬ bers), chemical (oxygen deficiency), chemotherapy, including sulfonamides, endocrine changes in the mother , ¬ toksoplaz Health, mental health and others.
TS Zatsepin congenital clubfoot divides into two cus ¬ nocturnal forms: typical (75%) and atypical (25%). Among the typical forms of MO Friedland distinguishes three levels of difficulty: easy, medium and hard. In mild foot deformities corrected passively, with average - partially correct ¬ Xia passively, but very difficult, with severe degrees - passively correct the deformity is not possible. Typically, mild to moderate degrees of clubfoot include its soft tissue form, to heavy - the presence of changes in the skeletal system.
By atypical forms include clubfoot from arthrogryposis, amniotic membranes, defects shin bones and others.
The main clinical features of congenital clubfoot (Fig. 14): ekvinus (pidoshvenyy plies foot), foot supination (return pidoshvenoyi surface medially with drooping outer edge of the foot), adduction (bringing the forefoot), increase target country ¬ transverse foot arch (hollow foot) . The degree of these characteristics can vary considerably, the foot can reach a position where the inner surface of the heel tor ¬ repents inner shin bone.

In addition to these symptoms, clubfoot can be defined as the rotation of the lower leg inward and limitation of movement in nadp'yatko ¬ hydrogen ankle joint. The severity of foot deformities could magnify ¬ lyuvatysya with the growth of the child, especially the time when the child begins to walk. On the dorsum of the foot can be "natoptysh" leg muscle atrophy, gait uncertain child develops rekurvatsiya knee.

Treatment of congenital clubfoot should begin immediately after birth, when the skeleton is more malleable, much easier to prevent bone deformities and improper development of muscles and ligaments. Methods of treating clubfoot is divided into conservative and operative.
In the first months of life orthopedic surgeon should at ¬ teach the mother to perform daily gentle corrective redresa ¬ tion with subsequent fixation achieved correction of foot flavonoids ¬ nelevym bandage for Fincom-Ettinhenom (Fig. 15). Soft bandage must be applied as indicated in the figure. How to use a soft bandage strips flannel length of 2 m and a width of 5-6 cm Wrapping repeated up to 10 times a day. If soaking bandages urine it is recommended to immediately remove, repeat redresuvalni techniques and apply a new bandage. Particular attention should be paid to the color of the toes, when the finished bandaging ¬ - they must be normal color. If they are cyanotic or pale, you should immediately remove the bandage and apply it more freely after restoration of normal co ¬ loru leather fingers.

If mild clubfoot, then when you reach the required correction (approximately 2-3 weeks) bandaging at ¬ pynyayut; overnight recommended impose on the foot and lower leg plaster or plastic splint that keeps the foot in position hiperkorektsiyi.

At medium and severe forms of the disease by bandaging Fincom-Ettinhenom be seen as a preparatory stage, which ne ¬ Reduit MILESTONES conservative treatment of congenital clubfoot using landmark casts to be imposed, ranging from 2 to 3 weeks of age. Plaster bandage should be with a cotton lining. After 7-10 days the bandage removed and after re redresatsiyi foot impose new. After 10-15 casts should strive to bring the foot into position hiperkorektsiyi on Varus and ekvinusu. Even if regular removal of plaster cast is determined steady result, the patient should be placed in a plaster bandage in position hiperkorektsiyi foot another 2-3 months, changing it every 2-3 weeks. If the baby is trying to walk, casts should not limit it to that. After this purpose ¬ nd time and achieving sustainable correction of foot deformities child should prepare orthopedic shoes, and at night - Tutors. If this be neglected, there will be a relapse strain. However prescribe massage, baths, corrective exercises, but ¬ sanatorium-resort treatment.
When running congenital clubfoot or failed conservative treatment in 1-3-year-olds spend surgical tech ¬ treatment on tendon-ligament or bone apa ¬ army. At this age, choose the method of intervention pa ¬ hydrogen tendons ligaments transaction with TS Zatsepin.
The operation was performed under general anesthesia, the thigh tourniquet impose. Eliminating high-REDD foot performing subcutaneous dissection pidoshvovoho aponeurosis. Posterior tendon great femoris and long finger flexor stages, shidtsepodibno cut into 2-3 cm in their extension of the vertical cut is made through the middle of the medial malleolus, then cut ¬ tion binding machine medial ankle joint, Deltoid communication circle pits, cross all ties to gape joint space. Foot deduce from varus position. Zadnomedialnym access oholyayut Achilles tendon after the V-shaped section cut through the ram ¬ no-calcaneal joint, eliminating ekvinus foot. Sometimes it is necessary to extend the V-like tendons of long flexor and toe.
Dissected tendons stitched in corrective foot position. Links are not stitched. Foot fix the average polo ¬ ing circular plaster cast to the upper third of STEG ¬ on. In 10-12 days after surgery in ¬ sticky plaster removed and impose new circular bandage on all leg and foot for 4-5 months. Change bandages make every 2 weeks. Later appointed baths, massage, gym, thermal procedures, orthopedic shoes at night - braces.
Some changes in surgical treatment kly ¬ shonohosti proposed VA Sturm and P. Frost, aimed at creating the right relationships between the bones of the foot. In severe forms of clubfoot pronounced adduction and supination of the foot wedge resection conduct by you ¬ rizuvannya wedge in the middle section of the foot to the base wedge on the outer curved edges and tip in the area of ​​ram ¬ no-navicular joints ¬ tion. Typically, this opera ¬ tion shows teens who increase skeletal foot CoP can reap ¬ complete. After opera ¬ tion limb fix plaster bandage ¬ tion to the upper third of the femur. For prevention of foot edema ¬ tion the first 3-4 days after surgery end trickle ¬ is ¬ tion in an increased position. After 2 weeks of plaster cast to impose the upper third of the tibia, 1 month later the patient can walk ¬ you on crutches, and after 2 months bandage made removable. Desig ¬ chayut foot baths, massage, gymnastics, orthopedic shoes you carried major ¬ lacing and pronator.
In wedge resection of the foot in severe degrees kly ¬ shonohosti common sickle resection foot for Kuslykom that can be recommended for children older than 8 years before endings ¬ tion growth skileta.
In older children with severe clubfoot charac ¬ Terne twisting shin bones. Orthopedic devices warehouse ¬ tion designs that offer to remove the torsion legs, not always yield positive results. More rational to correct axis tibia osteotomy find application both shin bones in the middle third, which further contributes to significantly improve ¬ tion statics patients.
In recent years, for correcting the position of the foot in severe degrees of clubfoot recommend the use of different in ¬ outfits, such as compression-distraction apparatus Ilizarov, by which some patients can prevent serious surgical intervention.
All children who has been a clubfoot, regardless of stu ¬ fine its severity, requiring lengthy rehabilitation therapy and dynamic supervision before the child grows.

Congenital muscular torticollis

Torticollis - a neck strain, characterized by unequal ¬ lnym head position - its slope away and return in the opposite direction.
According to ST Zacepin, it is 12.4% among other congenital disorders of the musculoskeletal system. Pathology is the second-third place after congenital hip dislocation and congenital clubfoot, occurs predominantly in girls and is more often right-sided (MO Frydlyand, ST Zatsepin).

Given in literature theory of deformation can not begin ¬ zhut explain the origin of this anomaly. Clinical and experimental studies have categorically reject, but not completely under ¬ assumptions been confirmed by the authors of the possibility of muscular torticollis due to improper placement of the embryo in the uterus and damage hrudnynno-clavicular-mastoid muscle during childbirth. Not confirmed theory you ¬ muscular torticollis penetration through the inflammatory process, and as a consequence of ischemia hrudnynno-clavicular-mastoid muscle. The most convincing is the assumption ¬ ST Zacepin (1960), MV Volkov and VD Dedov (1980), congenital muscular torticollis which is a consequence of congenital malformations hrudnynno-clavicular-mastoid muscle.

Congenital muscular torticollis clinic depends on the age di ¬ slime. In the first 7-10 days of life during a careful examination excrete ¬ born child guardian swelling dense, not soldered to the underlying tissues and tension hrudnynno-clavicular-mastoid muscle, which further reduces to at ¬ noticeable tilt of the head and return it ¬ ing in the opposite direction.
In the first year of life changes hrudnynno-clavicular-mastoid muscle progresses, it decreases in volume, becomes less elastic, lagging in growth from the same muscle on the opposite side of the neck ¬ tion and is similar to the tendinous strand. Increase ¬ etsya head tilt toward the affected muscle and return to face the healthy side, the amount of head movements is reduced, there is asym ¬ metry of the skull and face. Later deformation progresses, which usually leads to distortion and other cervical spine. Observe a high standing shoulder and scapula on the affected side, changing the shape of the clavicle and nipple ¬ this process, the direction of the canal. Half of the head on the affected side becomes tighter and wider eyes and eyebrows devel ¬ disposed lower than in healthy, there is incorrect ¬ ing the development of the upper and lower jaws, paranasal cavities of the nose, nasal septum, palate. Expressed denotes ¬ ing restrictions sight.
Very rarely observed shortening both hrudnynno-clavicular-mastoid muscle. This baby's head tilted back so that the neck close to the back and face the inverse upward or forward. Typically, such patients head movements sharply limited, mainly in the sagittal plane, shy ¬ ing spine shortened.
X-ray study of children enough informa ¬ erative.
Differentiate congenital muscular torticollis necessary with Klippel-feil syndrome, which is characterized by significant synostozuvannyam cervical vertebrae or verhnohrudnynnyh. Cus ¬ nightly is shortening the neck, restriction of movements of the head, low arrangement limits of hair growth. Diagnosis is confirmed ¬ dzhuyut during radiological examination.
Muscle torticollis should also be differentiated from krylopodib ¬ Noah neck, the presence of additional wedge vertebrae are clinically characterized by asymmetry of the face and skull, then it ¬ limitation of active motion in the cervical spine.
Acquired torticollis may result from deferred inflammation in the neck: myositis, lymphadenitis, cellulitis, ¬ nd typhus fever, malaria, scarlet fever, chronic inflammation in the throat, Hryzelya disease, the pathological process in the body of the cervical vertebrae - osteomyelitis, tuberculosis, actinomycosis, novoutvo ¬ Rainier, and traumatic brain injury (spastic hemiparesis) or encephalitis.
Medical history, clinical features, additional methods usually allow navigate in establishing the diagnosis.
Treatment of muscular torticollis should begin with a two week old baby. It aims to stretch shortened hrudnynno-clavicular-mastoid muscle. For this child vkla ¬ give back, grab his head with both hands and tilted to the healthy side and turn the face toward the affected muscle. Co ¬ ryhuvalni gymnastics spend 3-4 times a day for 5-20 minutes. Simultaneously prescribe massage healthy hrudnynno-clavicular-mastoid muscle and kneading affected; course of physiotherapy (UHF), and children aged 1 month can be performed electrophoresis potassium iodide, ronidazy, lidasa, paraffin baths.
To keep the child's head in a trimmed position recommended pulp and cotton collar trenches, supine child's head record between the ridges of sand. Bed and child must be established so that the wall was returned healthy part of the neck. The child has to turn his head toward the affected muscle and thus gradually give him the correct position. Con ¬ servatyvne treatment, especially in the case of large nedorozvy ¬ tion hrudnynno-clavicular-mastoid muscle, spend up to three years of age and only with no effect and progression of facial and skull asymmetry conduct surgery.

The operation was performed under general anesthesia. One of the methods of surgical interventions are crossing and partial rezek ¬ tion areas hrudnynno-clavicular-mastoid muscle 3 cm at the bottom by Mikulic-Zatsepin. At the operational ¬ nd table the patient lies on his back, under the shoulder blades is co ¬ ryhuvalnyy roller thickness 7-10 cm for throwing head back and increase tensions shortened hrudnynno-clavicular-soskopodibpoho muscle. Cut a length of 5 cm make 2 cm above the upper edge of the clavicle and parallel to it. Vydi ¬ lyayutsya and gradually rezektuyut within 2-3 cm scar-modified hrudnynnu and clavicular leg muscle. At both ends of each than ¬ ing muscle impose catgut ligatures. Then anesthesiologist returns the child's head in the opposite direction. If the tension is the external surface and deep layers equ ¬ tion of the neck, to prevent the recurrence of ST Zatsepin offers their ne ¬ rerizaty. Tightly wound layers ushyvayut impose aseptych ¬ well bandage. In order to keep the head in position correction or hiperkorektsiyi in the postoperative period outstretched spend ¬ ing loop Glisson on inclined plane, under the scapula patient enclose roller. Child's head tilted to the healthy side and return to the postoperative scar. In 10-12 days after removal of sutures, depending on the severity of muscular torticollis and the operation to preserve diastase between kiptsyamy re ¬ zektovanoho muscle stretching shortened soft tissues loop Glisson filmed impose detachable collar trenches or torakokranialnyy plaster cast. After 1 month after surgery, the child was in a plaster cast, remove it, put the collar trenches and prescribe therapeutic exercises, massage muscles neck physiotherapy. In order to prevent recurrence of deformity detachable collar trenches recommend wearing at least 5-6 months after surgery.

In operations Mikulich-Zatsepin about muscular torticollis, which gained wide acceptance and application in medicine, there are other types of surgeries - that cutting ¬ spaces legs hrudnynno-clavicular-mastoid ¬ m'ya for, cutting, partial excision m 'muscles, replacing ¬ defects that alosuhozhylkovym graft; drabynchaste tendon lengthening and cutting hrudnynno-clavicular-mastoid muscle from the mastoid process. These methods are either less reliable or more traumatic because no widely used ¬ suvannya.
Prediction of congenital muscular torticollis if early initiation of treatment is usually favorable.
In older children, when there were changes in the face and neck, surgical treatment reduces the cosmetic defects. After treatment, the child must be under medical supervision throughout the period of growth.
Congenital diseases of the spine.
Spinal deformity.
Terms kyphosis, scoliosis, lordosis were offered Galen in the second century BC. Scoliosis - a curvature of the spine in the frontal plane, kyphosis-axis deviation in the sagittal plane backwards, lordosis - doperedu deviation.
Spine child develops and changes during growth. Newborn spine is shaped sloping, curved backward arc. When the baby begins to lift and keep the head, formed physiological cervical lordosis, then, at the age of 5-6 months, when the baby starts to sit, developing kyphosis of the thoracic spine. In 8-9 months, when the child begins to stand and walk, there is a lumbar lordosis. All these physiological curves of the spine are formed mostly during the first year of life, then refined and individually changed across the period of growth of the child. Finally, in the 20-21 year determined by the type of posture.
Posture - is the usual posture acquired during the growth of the child. Normal development and growth of the child form correct posture. Violations occur under the influence of negative factors.
To determine the posture should examine the child in the bright, warm room. Light should fall front. Determined posture while standing in front, back, side. Particular attention is paid to the position of head, shoulder, spine, pelvis and lower extremities, the symmetry of the chest, shoulder blades, upper, front propeller, waist triangles that are formed between the straight lines and hand bends the waist, buttocks and the gluteal folds, the lower extremities. Be sure to study gait, its impact on the change of posture, the volume of active and passive movements of the joints of the upper and lower extremities, different parts of the spine.
Pathological posture associated with lower limb length difference, corrected compensation shortening in a standing position, and placing special stelky or kosyachka, manufacture orthopedic shoes considering shortening.
For Shteffelem define 5 types of posture:

The flap posture more often in children asthenic type. Chest flap, anteroposterior dimension of its much reduced, stomach involve, or vice versa, vyp'yachenyy. Signs physiological bends minor shoulder bulge. Muscular system developed bad. The amount of movement of the spine normal. This posture is a prerequisite of scoliosis.

Lordychna posture more often in children of preschool age. The main manifestation of it is the increased lumbar lordosis, leading to slope doperedu shoulders, buttocks - backwards, in this connection, a bend in the thoracic spine reduced. Lordychna posture in children develops as compensation strain other parts of the spine, lower extremities, proximal thighs.
Scoliotic posture characterized by a shift toward the spine, physiological curves in all departments in the sagittal plane indicated. Determine the head tilt to the side, shoulder asymmetry, triangles waist. Most deformation happens in December hrudnynno-lumbar. At right (symmetric) investing baby on his stomach, scoliotic posture is not defined. This occurs even when the child is actively straining muscles examined standing, leaning doperedu that eliminates static load on the spine. Scoliotic posture in children is primarily concerned with the different tone of the back muscles, or asymmetric development. When X-ray examination in the horizontal plane, the deviations from the normal range is not defined.
Prevention of posture is to create a normal growth of the child:
• maximum environmental sanitation;
• respect for the day;
• true, balanced diet high in vitamins, trace elements, appropriate age requirements;
• Physical Education (morning gymnastics, doing all kinds of sports) quenching;
• compliance with sanitation in areas where there is a child.
Formation of posture should begin at an early age - teach the child right to sit, stand, walk, work out the correct working posture during class seating. Parents of kindergarten teachers, school teachers should pay attention to this. Preventive measures should be carried out primarily among debilitated children, those who are under medical supervision, especially supervision of a physician, physical therapist, podiatrist, pediatrician.
Treatment of posture is the prescribing exercise therapy (continuously for a minimum of 20-40 minutes per day), massage - a rate of 10-15 sessions, depending on the state of the muscles on both sides and the difference in tone symmetrical muscle groups of the body. Appointed multivitamins, especially in autumn and winter, calcium gluconate, calcium glycerophosphate, drugs that improve metabolism and normalize them, especially mineral metabolism. In determining violations of posture depending on the strain displays, children have examined children's orthopedist 1 every 3-6 months. X-ray examination is intended to confirm the diagnosis and in cases of disease progression (1 per year for medical reasons - often).
Kyphosis is a curvature of the spine in the sagittal plane bending backwards. More often observed in breast, less often - other parts of the spine.
Define the following types of kyphosis:
• congenital;
• acquired;
• rickety.
Congenital kyphosis observed in malformations of the spine and back muscles (wedge-shaped vertebrae, ribs and vertebrae more and so on.). Increased kyphosis may occur in infants, but too often in 5-6 months of age. When your child grows deformation may significantly worsen, leading to zatrymnnya growth.
Treatment. The child with congenital kyphosis preventive measures, warning increased strain. Designed corrective exercises, gypsum beds in the maximum position correction. If conservative treatment methods are ineffective, the disease progresses, the question arises about the surgical correction of defects of the spine and chest.
Lessons kyphosis - occurs as a result of diseases in which the deformation of the vertebrae (spinal injury, osteochondropathy, rickets, tuberculous spondylitis, etc..).
Rachitic kyphosis - often seen in children due to rickets or rahitopodibnyh diseases. Rapidly developing this pathology when the child begins to sit independently.
Treatment of rachitic kyphosis in infants is especially complex preventive measures. When clinical signs of disease should be applied orthopedic measures: do not put the child too early, often spread on the abdomen, strengthen the muscles of the trunk. Be sure to give the specific treatment vitamins "D" and drugs that normalize mineral metabolism, exercise therapy, massage trunk, extremities, ultraviolet radiation, maintaining a daily regimen, a full and balanced diet. In the summer, the recommended spa treatment, rehabilitation.
Osteohondropatychnyy or adolescent kyphosis - occurs primarily in disease Sheyyermana Mau lies in osteochondropathy apophysis vertebrae. Observed in boys 12-17 years old, girls - 11-15 years. Boys suffer more.
Disease Calvet - it osteochondropathy vertebral body or vertebra plana detected in children aged 3 to 15 years. Most often seen in children 5-7 years.
Scoliosis - a persistent lateral curvature of the spine, which is determined by the torsion, which is caused by pathological changes in the spine and paravertebral tissues, accompanied by progression of deformation with static-dynamic disturbances and functional changes of internal organs (Yu.F.Isakov, 1998).
The most common neurogenic, muscle hypothesis and innate origin of scoliosis.
Congenital scoliosis occurs from malformation of the spine, ribs, chest. Deviation of the spine can contribute to the physical, chemical and biological factors and diseases affecting 5-10 weeks of embryogenesis. In certain periods formed odnotypovi defects. Progression of deformation always depends on the issues and options for its combination with other changes.
Idyopatychnyy scoliosis is the most common form of disease, its etiology is not definitively proven. Pathological changes consist in the occurrence of degenerative changes in the vertebrae, muscles, ligaments, and so on.
Acquired scoliosis develop on the background of various diseases, the effects of damage.
Scoliosis neurogenic damage observed in diseases of the nervous system malformation (miyelodysplaziya, neurofibromatosis, the effects of spinal, brain injury, especially in infants, children spastic paralysis, etc.)..
Myopathic origin of scoliosis is associated with the development of muscles and ligaments, degenerative processes disabilities. In children, a common group of scoliosis myopathic origin on the basis of rickets and rahitopodibnyh diseases.
Scoliosis can be simple, with one side arc curvature, complex, when a few arcs and total distortion when all spine injuries.
Scoliotic posture can be functional as a consequence flap kyphotic posture. In the horizontal position and pulling the child up clinical signs (asymmetry angle blades, shoulder, waist different triangles, etc.) disappear, if they remain, indicating the torsion of the vertebrae, which is a manifestation of early forms of scoliosis. On examination, the child must determine:
• the lower corners of the blades;
• symmetrical blades relative to the spine;
• the shoulder on both sides;
• symmetry collarbone;
• location of the head and face symmetry;
• symmetry of the chest;
• symmetry of the pelvis (the location of the propeller iliac both sides, buttocks position);
• functional limb shortening;
• symmetrical triangles waist;
• mobility of the spine in different departments;
• location barbate processes of vertebrae (better identify with paint);
• Identify muscular ridges on both sides, or rib hump (with sloping doperedu);
• symmetry of the buttocks and the gluteal folds.
The child should be viewable in a bright room, the light falling on the front or rear, standing in position children inspect the front, back, sides and in the supine position.
Suspicion of scoliosis prescribed x-ray, which can determine the type of distortion, the degree of deformation, detect defects, as well as the changes that are the result of disease, to assess the maturity of the bones of the spine, depending on the age of the child.
X-ray study performed in the upright position in the front and side projections, lying - in front of a projection of the teaching position in the most probable correction.
Violation of posture in the supine position on the radiograph is not defined violation axis spine in scoliosis - is a violation. For accurate diagnosis of scoliosis radiography is desirable to carry out a review of the pelvic bones. In older children, when not possible to cover all research spine radiographs performed separately cervico-thoracic, lumbar-hrudnynno.
The degree of deformation is determined by Ferguson, matching centers of the vertebral bodies at the apex curvature and neutral vertebrae above and below the main arc. These lines connect the angle of intersection will fit size distortions.
For the Cobb method on radiographs determine neutral vertebrae above and below the main arc, conduct parallel lines according to these vertebrae. Cross-section perpendicular to these lines will be largest deformation.

Podiatrists often use classification proposed VD Chaklin:

I degree - small lateral curvature of the spine with initial manifestations of torsion vertebrae. The angle of the main arc deformation is not more than 10 at.
Second degree - a marked deviation axis spine with significant implications torsion vertebrae. On top of the main arc is defined deformation of the vertebrae. Clinically there is muscle spindle, later - a slight rib hump. The angle of the main arc 20o-25o;
Third degree - curvature of the spine from vertebral torsion, deformation of the chest, rib hump. On top of wedge deformity of the vertebrae. The angle of the main arc 40o;
Fourth degree, the most severe deformity with significant changes: torsion of the vertebrae and their wedge deformation, the presence of anterior and posterior rib humps (often formed thoracic kyphoscoliosis). Due to the complex deformation of the spine occurs rigidity of movement, dysfunction of internal organs. The angle of the main arc more than 40o, the most severe deformities can be 75o or more.

Intensive increase in deformation occurs primarily during active growth of the child, reaching a maximum manifestation of puberty and ends with the cessation of growth.

The most unfavorable course of scoliosis in children with revealing the first signs of the disease in 4-6 years, more favorable when the strain was first diagnosed after 10-12 years of life.
Type of scoliosis is determined on the radiograph by lokadizatsiyi top corner of the main arc. This is important because it determines the course of the disease, treatment and prognosis. Define the following main types of scoliosis: cervico-thoracic (verhnohrudnyy), thoracic, lumbar, thoracic, lumbar, lumbosacral, combined.
In connection with dysfunction of internal organs in scoliosis III-IV degree, patients prescribed a study to determine respiratory function, cardiovascular system, and others.
In X-ray examination children prescribed a comprehensive study: clinical examination (complete blood count, urinalysis, biochemical studies), electromyography of back muscles, limbs, chest, studies of the nervous, cardiovascular and endocrine systems, and so on. Patients with scoliosis should be examined by experts every year for the advent of complaints - before, must be taken on clinical supervision orthopedic (surgeon).
Treating children with posture and scoliosis begin after diagnosis. Conservative treatment of this group of children difficult and not completely solved problem. Great attention should be paid to work with parents who need to familiarize with the orthopedic regime, which the child must adhere permanently, complex physical therapy and general characteristics of education, nutrition in this pathology.
Patients with early forms of scoliosis under stable compensation are treated in outpatient departments, athletic clinics. If rapid progression of deformity, children prescribed stays in specialized medical institutions (kindergartens for children with diseases of the musculoskeletal system, boarding schools for children with abnormal posture and scoliosis). With a significant increase strain in a short period of time, the patient is directed to orthopedic hospitals (Orthopedic department, motels, etc.)
Conservative treatment is always complex, aimed at strengthening the muscles of the trunk, limbs, forming a child's correct posture and consists of the following steps:
• continued compliance orthopedic regime aimed at unloading the spine; jobs prepared according sanitation requirements (height chairs, lighting, space, etc.) equal to bed (with wooden base, or orthopedic mattress), with progressive forms II-IV century. lessons at home, at school lying with orthopedic devices, and continued wearing corsets, correcting posture;
• Formation of correct posture in compliance with individual static-dynamic mode, aimed at correcting abnormal posture, which contribute to strengthening m'ziv, hardening of the child, forming stereotype adherence correct posture in a state of maximum correction;
• general strengthening, rehabilitation of the child, balanced nutrition (sufficient number of physiological norms of proteins, fats, carbohydrates, minerals, vitamins, etc.), adherence of the day (including the child's age, physiological characteristics); sports - swimming, skiing, basketball and other species that do not contribute to the load on the spine;
• fiziofunktsionalne treatment: exercise, massage, taking into account the type and strain of muscles, exercise therapy;
• sanitary-educational work among children and their parents;
• constantly carry out activities of medical, social and vocational rehabilitation of children with scoliosis.
One of the main methods of conservative treatment of scoliosis is physiotherapy which has features and should be done under medical supervision in physical therapy clinics and offices athletic clinics. We must adhere to the basic principle: constant corrective influence over time, the systematic implementation of regular exercise (every day, or 2 times a day). Various methods of strengthening muscles to hold the spine in trimmed state have their own characteristics depending on the child's age, shape, type and level scoliosis disease (stable compensation or stage progression). Given this set of exercises should be chosen only individually, shall include the location, extent and stability distortions.
Under the supervision of physical therapist child explore complex gymnastic exercises and controlled the quality of their performance. Home gymnastics done under the supervision of parents who are familiar with the proper execution of exercises, their sequence length. Classes are encouraged to perform at home 2 times a day for 30-50 minutes., Depending on the age and physical characteristics of the child.
Children with scoliosis I degree is not recommended restriction of movement in his spare time. Useful exercises and such sports that improve muscle strength of the trunk (swimming, cycling, volleyball, winter, skiing, skating). Prohibited those sports in which there is a load on the spine (gymnastics, wrestling, weightlifting, etc.).
Scoliosis second degree requires the most careful treatment, the main element of which is gymnastics. Along with exercises and self-correction samovyrivnyuvannya used by those who develop the strength and endurance of muscles. These exercises are symmetric or asymmetric resistance and encumbrance. We must always pay attention to the fact that the exercises are aimed at mobilizing the spine without fixation may lead to increased distortion.
When scoliosis III-IV stages gymnastics aimed at the general strengthening of the child. Uses exercises that improve respiratory function and raise the habit of keeping the body in proper condition possible correction, corrective exercises are less important. Children with scoliosis III-IV degree primarily require prosthetic and orthotic devices.
Along with therapeutic exercises for children assigned massage binding the individual characteristics, the degree of curvature and condition muscles in areas of protrusion and bending. Improper execution massage can exacerbate the disease and strengthen the strain. It is advisable to appoint 10-15 massages per course of treatment that can be repeated every 2-3 months.
Children with scoliosis appointed medications that improve immunity (Immunal, vitamins), mineral metabolism (calcium supplements, phosphorus, vitamins «D»), and so on. When scoliosis III-IV degree assigned symptomatic treatment at the impact of curvature on the function of the abdominal and thoracic cavity.
Physiotherapy (EFO with minerals, electrical, etc.) should be carefully under the supervision of the muscles of the trunk and spine bone.
Conservative treatment does not always make it possible to obtain satisfactory results. The younger the child at the time of detection of scoliosis, the more opportunities to progression of deformation. Increasing angle distortions 150-250 in the short term (1-2 years) is a bad sign. With disease progression decide on the need to perform surgery. Recently revised approach to surgical treatment for children of all ages, developed and implemented new methods of intervention based on pathogenesis, age, individual characteristics of the organism.
Surgical treatment is not provided when:
• slowly progressive scoliosis and II degree scoliosis neprohresuyuchyy (stable compensation);
• scoliosis whiplash from defects;
• scoliosis from progressing myopathy, neuromuscular diseases;
• children with developmental disabilities, lung, heart, internal organs, the central nervous system in the stage of decompensation;
• in diseases of other systems in the stage of decompensation;
• scoliosis with significant deformity of the chest, and changes in the internal organs of the occurrence of decompensation, especially the lungs, heart.
Indications for surgical treatment in children with scoliosis:
• progressive scoliosis III-IV degree angle of curvature greater than 400-500 with initial impaired cardiovascular and respiratory system. Progressive scoliosis is the one in which the angle of curvature for the year increased by more than 150-200
• scoliosis, which quickly porohresuyut, congenital scoliosis from birth defects of the spine, thorax;
• progressive kyphoscoliosis with possible or imaginary paresis, paralysis from scoliotic deformity;
• scoliosis with the emergence of nephrologic disorders (pain, paralysis, paresis);
• insufficient support from scoliosis of the spine.
At the dispensary children with I-IV degree of scoliosis are to complete the process of growth. When stable compensation children orthopedist examined 1-2 times a year, other experts 1 per year, with the progression - often.
Among patients should be continuously measures of medical, rehabilitation, teens need help

Materials for self-

Situational task.
Task 1. The girl months of age, born from the second pregnancy and childbirth in the gluteal peredlozi during orthopedic medical examination revealed: right limb shortening of 1 cm, asymmetric leather folds on the thighs and buttocks, positive symptom "click" on the right. The mother of the child was treated at the hip dysplasia.
1. Which major clinical signs (likely) and secondary of the disease in a child should be defined?
2. What is the nature of this disease? Substantiate.
3. Methods for diagnosing defects in the child rest of this age, justify.
4. Treatments malformations.

Task 2. In divchynky 3 years vidmichayetsya soft tissue density in the region of the neck, tension sternocleidomastoid muscle nipple-areolar from left, asymmetry of the face. Head tilted vlivo, chin - right. The girl born in the gluteal peredlozi of first births weighing 4 kg 800 g with spinal trauma and perinatal hypoxic-damage to the nervous system. Within one year treated in orthopedic and neurologist, then the doctors did not apply.

1. Put diagnosis in this child.
2. Etiopatohenez disease.
3. What is the conservative treatment of a child under 3 pokiv?
4. Treatment after 3 pokiv principles of surgical treatment.
5. Relapse prevention, rehabilitation of the child.

Problem 3. In the outpatient department filed a podiatrist to have a child at the age of 4 months with complaints of head tilt to the left and return to the right side. When viewed vidmichaetsya shortened sternocleidomastoid soskopodibnyy m 'lang left and tight formations in the lower third, painless during palpation.

1. Your diagnosis. To the differential diagnosis.
2. Aetiopathogenesis.
3. Additional research techniques.
4. Principles of conservative treatment
5. Prevention of relapse.

Problem 4. In child 3 months parents viewed asymmetry cutaneous folds on the thighs and buttocks. When ohlyadi - asymmetry of skin folds on the thighs and buttocks, thighs vidvedennya restriction in hip joints more pronounced on the left, the left limb shortening to 1 cm in ultrasound hip joints No kernel skosteninnya heads thighs, skewness roofs, left hip joint angles are not measured. The mother of the child was treated at the hip dysplasia.

1. Identify symptoms FOLLOWING child.
2. Put diagnosis justification.
3. Ultrasound diagnosis of developmental disorders of the hip joints.
4. X-ray diagnosis.
5. Method of treatment of congenital hip dislocation in a child.

Problem 5. In newborn boy aged 3 days, born in gluteal peredlozi, during passive hip abduction is a symptom of "clicks" in the hip joint. From history we know that is not burdened heredity, illness during pregnancy, the mother was, but there was oligohydramnios.

1. Formulate a preliminary diagnosis, justify.
2. Which additional research techniques necessary to execute child?
3. Principles of treatment of a child in the hospital.
4. Principles of conservative treatment to 3 months.
5. Prevention of complications tactics child.

Problem 6. A child 5 years of age determined deformation expressed as a reduction of the anterior feet, varus position, corns on the outer surface of the foot. From history we know: one year child was treated at the Orthopaedic department was made orthopedic shoes in which the boy began to walk independently, with the birth occurs neurologist. From the age of two to doctors not treated, the child is not being treated in a podiatrist, wore ordinary shoes.

1. Formulate a preliminary diagnosis diagnosis.
2. Which additional research techniques necessary to accomplish?
3. The reason for relapse in a child.
4. Principles of conservative treatment and rehabilitation.
5. The method of surgical treatment and rehabilitation in the postoperative period. Weather.

Problem 7. Inspect newborn boy who was born from the first pregnancy, during which the 21 weeks observed oligohydramnios and labor in the home peredlozi. Mother during pregnancy is not ill. Postpartum Neonatal found the child varus deformity of the feet, which is easily corrected, the father of the child was treated at the clubfoot, operated.

1. Put diagnosis.
2. Aetiopathogenesis.
3. Spend the differential diagnosis.
4. Principles of conservative treatment in hospital.
5. Principles of conservative treatment in infants.

Task 8. The child is 12 years old, who was treated at the posture to 5 years, during a medical examination determined asymmetry and shoulder blades, marked rib hump thing asymmetry triangles waist. Radiologically angle distortion in the way Cobb is 10o.

1. Formulate a preliminary diagnosis diagnosis.
2. Which additional research techniques necessary to perform.
3. The reason for relapse in a child.
4. Principles of conservative treatment and rehabilitation.
5. Indications and principles of surgical treatment.

Problem 9. Newborn to 5 days, weighing at birth - 4 kg 500 g defined tumor formation on the anterior surface of the neck right. Formation painless, color over it is not changed, dense consistency. Determined little sustained head tilt to the right.

1. Formulate a preliminary diagnosis.
2. With what diseases one must conduct differential diagnostics.
3. Tactics treatment of a child in the hospital.
4. Conservative treatment in young children.
5. Complications and prevention of complications.

Problem 10. The child is 10 years old, during a medical examination determined asymmetry and shoulder blades, triangles waist asymmetry, kyphosis in the thoracic spine in supine deformity corrected. The child has been tennis. At the dispensary is not worth it.

1. Put diagnosis.
2. Methods for screening children.
3. Aetiopathogenesis.
4. Principles of conservative treatment of the child.
5. Prevention of complications.
Tests
1. The most common congenital malformations of the musculoskeletal system in children with clinical and statistical indicators include:
A. arthrogryposis.
V. Congenital dislocation of the hip.
S. Syndaktiliyu.
D. Polydactyly.
E. torticollis.

2. Congenital muscular torticollis in infants is associated with a defect or injury and is determined during the inspection. The child may show the following symptoms.

A. steady shortening of sternocleidomastoid muscle soskopodibnoho formation of dense, painless on palpation.
B. Asymmetry of the face.
S. spinal deformity.
D. Chronic myositis sternocleidomastoid muscle soskopodibnoho.
E. Spastic paralysis yyynyh muscles.

3. Have a 3-month baby turned to the doctor with a complaint that a child lame foot. OBJECTIVE: both feet bent down supinovani, reduced anterior feet, correction impossible. The diagnosis - congenital clubfoot. What method of treatment should be used in a child

A. Staging redresatsiya in plaster bandages
B. Surgery on tendons
C. Surgery on bones
D. Wrapping the feet by Fincom-Etinhenom
E. Therapeutic exercise.

4. Have a 1-month old girl noticed asymmetry of folds on the thighs of a child. OBJECTIVE: left limb shortening, external rotation, limited dilution legs bent at the hip joints. The diagnosis: hip dysplasia, hip subluxation left. What treatment strategy should be used.

A. Surgical treatment after 6 years
B. Surgical treatment
C. Closed reduction subluxation
D. Skeletal traction hip
E. Putting strementsiv Pavlik

5. In Grade 6 student during routine inspection revealed asymmetry blades, triangles asymmetrical waist, back determined muscle spindle, angle curvature of the thoracic spine partially corrected by straining back muscles, curves in all parts saved. What disease musculoskeletal occurs?

A. Lordotychna posture
B. Violation of posture
C. Kyphotic posture
D. Scolliosis
E. Back flap

6. Neonatologists, examined the girl, who was born in gluteal peredlozi, revealed limitations hip abduction, asymmetry leather folds on the thighs and buttocks, a symptom of "click" on both sides the same length limbs Which symptom is intrinsic in congenital dislocation of the hip?

A. Limitation of hip abduction
B. Birth in gluteal peredlozi
C. Symptom "click"
D. Asymmetry leather folds
E. Different length of limbs
7. The girl 1 year orthopedist showed kyphosis of the thoracic spine, which was diagnosed at the age of 7-8 months. By this time the child was treated on rickets and active phases. Several months ago, suffered bronchopneumonia, urinary tract infection, a manifestation of exudative diathesis. What disease is the cause of kyphosis in children?
A. Congenital scoliosis
B. Urinary Tract Infection
C. Bronchopneumonia
D. Exudative diathesis
E. Rickets

8. Girl 15 years engaged in artistic gymnastics from 7 years. Asked the doctor complaining of tiredness in the evening and after exercise, back pain, deformity of the spine and chest. Was diagnosed: S - shaped scoliosis thoracic and lumbar spine I-II degree. What are the clinical signs of the disease?

A. Deformation of the chest
B. Asymmetry shoulder, shoulder blades, waist triangles
C. Curvature of the spine and muscular "cushion" when bending forward
D. Pain in the lumbar spine
E. Fatigue after exercise

9. In the hospital in the newborn during the inspection found symptom "click" left asymmetry leather folds, shortened limbs left. Diagnosed congenital dislocation of the hip. Who is more likely signs of congenital dislocation of the hip in newborns.

A. External rotation of limbs
B. Limitation of abduction
C. Shortening of limb
D. The asymmetry of skin folds
E. Symptom "click"

10. The girl suffers from '10 S-shaped scoliosis I degree for one year, neurological disorders is not. What are the main therapeutic measures should be given to patients first?

A. Vitamin
B. Massage
C. Shaping Corset
D. Correcting gymnastics and massage
E. Sleep in a plaster bed

11. The baby was born prematurely. Examination: observed proportionality child asymmetry leather folds of the buttocks and thighs, restriction removal of limbs, a symptom of "mouse" is not defined, the same length of limbs. Your diagnosis?

A. Achondroplasia
B. Congenital dislocation of the hip
C. Dyshondroplaziya
D. Hip Dysplasia
E. Hip fracture

12. After the birth of baby parents viewed shortening of the right lower limb and its external rotation. Physician during examination revealed positive symptom "slippage" right thigh, limb withdrawal limit to 600, increased muscle tone. Put the correct diagnosis.

A. Right hemiparesis
B. Hip Dysplasia
C. Congenital dislocation of the hip
D. Fracture of the proximal femur
E. Arthritis of the hip joint

13. The child is 5 years old, pronounced head tilt right asymmetry of the facial skull, right sternocleidomastoid muscle nipple dramatically tense, head movements restricted right shoulder higher than the left, normal cervical spine. When X-ray examination revealed no pathology. Put the correct diagnosis.

A. Disease Grisel
B. Scoliosis whiplash
C. Disease Klippel - feil
D. Congenital torticollis
E. Congenital scoliosis

14. The baby was born prematurely in the gluteal peredlozi. The examination revealed asymmetry leather folds on the thighs, restriction removal of limbs, slight hypotrophy gluteal muscles on the left. What method of examination can help confirm the diagnosis of dysplasia?

A. Ultrasound
B. X-ray
C. Clinical examination
D. Teplovizorna diagnosis
E. Computer tomographic study

15. To the doctor asked parents 2 year old child complaining hitch, shortened limbs. A child born in the gluteal peredlozi began to walk at 1 year 5 months. When radiography was defined skewness Acetabular roof, breaking lines Shenton, lateropozytsiyu head of the femur, which is at the upper edge of the acetabulum. Put the correct diagnosis.

A. Congenital limb shortening
B. Varus deformity of the femoral neck
C. Congenital dislocation of the hip
D. Fracture of the femoral neck
E. Hip Dysplasia

List of theoretical questions

1. What are the main clinical symptoms of hip dysplasia.
2. What are the main clinical symptoms of congenital dislocation of the hip.
3. What are the main clinical symptoms of congenital torticollis.
4. What are the main clinical symptoms of congenital clubfoot.
5. What are the main clinical symptoms of posture, scoliosis in children.
6. Identify medical tactics in violation of formation of the hip joints.
7. Identify treatment strategy for congenital torticollis.
8. Identify medical tactics in congenital clubfoot.
9. Identify treatment strategy for scoliosis in children.
10. Identify surgical tactics in congenital dislocation of the hip.
11. Identify surgical tactics in congenital torticollis.
12. Identify surgical tactics in congenital clubfoot.
13. Identify surgical tactics in scoliosis in children.
14. Identify the rehabilitation of children with congenital musculoskeletal system.

Practical skills:

1. Definition symtomu "click" in newborns and measurement of absolute and relative length of limbs
2. Wide swaddling newborns dressing preventive pants and strementsiv Pavlik.
3. Overview of a child in violation of posture and scoliosis.