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Bukovinian State Medical University

Department of Developmental Pediatrics


to the practical class for medical students of 3-rd years

Modul 1: Child’s development

Submodul 2:

Topic 4:






It is completed by:

MD, MSc, PhD Strynadko Maryna

Chernivtsy – 2007

SUBJECT: Developmental Pediatrics.




BASIC LEVEL: Basic knowledge of pediatrics.


1. Care of the children. 2. Anatomy. 3. Histology. 4. Pysiology.



Growth of the cartilage and the bone

Growth of the skeleton follows a genetically programmed developmental plan that furnishes not only the best indicator of general growth progress, but also provides the best estimate of biologic age. Some degree of assessment can be achieved by observation of facial bone development (nasal bridge height, prominence of malar eminences, and mandibular size), but the most accurate measure of general development is the determination of osseous maturation by roentgenography. Skeletal age appears to correlate more closely with other measures of physiologic maturity (such as the onset of menarche) than with chronologic age or height. This "bone age" is determined by comparing the mineralization of ossification centers and advancing bony form to age-related standards. Skeletal maturation begins with the appearance of centers of ossification in the embryo and ends when the last epiphysis is firmly fused to the shaft of its bone.

In the healthy child skeletal growth and development consist of two concurrent processes: (1) the creation of new cells and tissues (growth), and (2) the consolidation of these tissues into a permanent form (maturation). Early in fetal life embryonic connective tissues begin to differentiate and become more closely packed to form cartilage. This cartilage is enlarged by cell division and expansion within the forming structures and by the laying down of successive layers on the surface of the mass. During the second month of fetal life, bone formation begins when calcium salts are deposited in the intercellular substance (matrix) to form calcified cartilage first and then true bone. There are some differences in this bone formation. In small bones, the bone continues to form in the center and cartilage continues to be laid down on the surfaces. Bones of the face and cranium are laid out in a tough membrane and directly ossified into bone during fetal life.

In long bones the ossification takes place in two centers. It begins in the diaphysis (the long central portion of the bone) from a "primary" center and continues in the epiphysis (the end portions of the bone) at "secondary" centers of ossification. Situated between the diaphysis and the epiphysis is an epiphyseal cartilage plate that is united to the diaphysis by columns of spongy tissue, the metaphysis (Fig. 7.1). It is at this site that active growth in length takes place, and interference with this growth site by trauma or infection can result in deformity. Under the influence of hormones, primarily pituitary growth hormone and thyroid hormone, bones increase in circumference by the formation of a new bone tissue beneath the membrane that surrounds the bone (periosteum) and in length by proliferation of the cartilage.

Epiphysis –

Metaphysis -

Diaphysis -

Secondary ossification


Epiphyseal plate

Primary ossification center

Fig.1. Model of a long bone.

Over the growth period of approximately 19 to 20 years, this development can be divided into three distinct but over-phases: (1) ossification of the diaphysis, (2) ossification of the epiphysis, and (3) invasion and subsequent replacement of growth cartilage plates with bony fusion of epiphysis and diaphysis. These changes do not take place in all bones simultaneously but appear in a specific order and at a specific time. Although the speed of bone growth and amount of maturity at specific ages vary from one child to another, the order of ossification is constant. The first center of ossification appears in the 2-month-old embryo, and at birth the number is approximately 400, about half the number at maturity. New centers appear at regular intervals during the growth period and provide the basis for assessment of "bone age." Postnatally, the earliest centers to appear (at 5 to 6 months of age) are those of the capitate and hamate bones in the wrist. Therefore, roentgenograms of the hand and wrist provide the most useful areas for screening to determine skeletal age, especially before age 6 years. A common rule of thumb is: age in years + 1 = number of ossification centers in the wrist. These centers appear earlier in girls than in boys.

Skeletal development advances until maturity through the growth of ossification centers and the lengthening of long bones at the metaphysis and cartilage plates. Linear growth can continue as long as the epiphysis is separated from the diaphysis by the cartilage plate; when the cartilage disappears,the epiphysis unites with the diaphysis and growth ceases. Epiphyseal fusion also follows an orderly sequence, thus the timing of epiphyseal closure furnishes another medium for measuring the skeletal age.

Investigation and assessment based on bone growth furnish a reliable index of growth rate in the individual child. In addition to the assessment of the general developmental and nutritional status of the child, the findings are of value in the diagnosis of many metabolic and endocrine disturbances affecting growth as well as some congenital conditions.


The course of dentition is sometimes divided into four major stages: (1) growth, (2) calcification, (3) eruption, and (4) attrition. The primary teeth arise as outgrowths of the oral epithelium during the sixth week of embryonic life and begin to calcify during the fourth to sixth months. Tooth buds form at 10 different points in each arch and eventually become the enamel organs for the 20 primary (deciduous) teeth. All the buds are present at birth, but the amount of enamel laid down varies with each set of teeth. Hard tissue formation generally occurs between 4 and 6 months of fetal life.

Teeth are divided into quadrants of the lower mandible and upper maxilla and are named for their location in each quadrant of the dental arch, such as central incisor, lateral incisor, and first and second molars. Teeth are also named after their specific function in the mastication of food. The central and lateral incisors, which have a knifelike, or scissorlike shape, cut the food. The cuspids, also called canines, tear the food. The term cuspid refers to the single point or cusp shape of the crown. The two premolars, or bicuspids because of their two-pointed crown, crush the food. The permanent molars, which have four or five cusps, grind the food.

About the middle of the first year the primary teeth begin to erupt, although calcification is not completed until sometime during the third year. The age of tooth eruption shows considerable variation among all children, but the order of their appearance is fairly regular and predictable (Fig. 7.2 A and B). The first primary teeth to erupt are the lower central incisors, which appear at approximately 6 to 8 months of age. This may vary from 4 months to 1 year in normal children, and infants may even be born with teeth. One incisor erupts, followed closely by the homologous incisor. The total of 20 primary teeth is acquired in characteristic sequence by 30 months of age. Calcification of the primary teeth is complete at this time. A quick guide to assessment of deciduous teeth during the first 2 years is: the age of the child in months — 6 = number of teeth that should be present.

The first permanent (secondary) teeth erupt at about 6 years of age. Before their appearance they have been developing in the jaw beneath the deciduous (primary) teeth. Meanwhile, the roots of the latter are gradually being absorbed so that at the time a deciduous tooth is shed, only the crown remains. At 6 years of age all the primary teeth are present and those of the secondary dentition are relatively well formed. At this time eruption of the permanent teeth begins, usually starting with the 6-year molar, which erupts posterior to the deciduous molars. The others appear in approximately the same order as eruption of the primary teeth and follow shedding of the deciduous teeth. The pattern of shedding primary teeth and the eruption of secondary teeth are subject to wide variation among children. To allow the larger permanent teeth to occupy the limited space left by shed primary teeth, a series of complicated changes must take place in the jaws. It is at this time that many of the difficulties created by crowding of teeth become apparent. With the appearance of the second permanent (12-year) molar, most of the permanent teeth are present. The third permanent molars, or wisdom teeth, may erupt from 18 to 25 years of age or later. A quick guide to assessment of permanent teeth is: the age of the child in years x 4 - 20 = number of teeth that should be present.



Average age of shedding (yr)



11.5 10.5 10.5


10 9.5 7 6


Fig.2. Sequence of eruption and shedding of A primary and В secondary teeth


Average age of eruption (yr)

Boys 7.5

8.7 11 7 10.4 11.2

6.4 12.7

Girls 7.2

8.2 11.0 10.0 10.9

6.2 12.2

Variable 17-21

12.1 6.2 11.5 10.8 10.8

7.7 65

11.7 5.9 10.9 10.2 9.9

7.3 6.3

Permanent dentition, as in other aspects of development, is somewhat more advanced in girls than it is in boys. The eruption of teeth is sometimes used as a criterion for developmental assessment, especially the 6-year molar, which seems to be the most universally consistent in timing. However, dental maturation does not correlate well with bone age and is less reliable as an index of biologic age. Retarded eruption is more common than accelerated eruption and may be caused by heredity or may indicate health problems such as endocrine disturbance, nutritional factors, or malposition of teeth.

^ Growth of the muscle

As skeletal development is responsible for linear growth, muscle growth accounts for a significant portion of the increase in body weight. The number of muscle fibers is established by the fourth or fifth month of fetal life and remains constant throughout life. Differences in muscle size between individuals and differences in one person at various times during a lifetime are the result of the ability of the separate muscle fibers to increase in size. The increase in muscle fiber length that accompanies growth is also associated with an increase in the number of nuclei in the fibers. This increase is most apparent during the adolescent growth spurt. At this time the increase in secretion of growth hormone and adrenal androgens stimulates the growth of muscle fibers in both sexes, but the growth in boys is further stimulated by the secretion of testosterone. At about 6 months of prenatal life, muscle mass constitutes approximately one sixth of the body weight; at birth, about one fourth, and at adolescence, one third. The variability in size and strength of muscle is influenced by genetic constitution, nutrition, and exercise. At all ages muscles increase in size with use and shrink with inactivity. Consequently maintaining muscle tone to minimize the amount of atrophy in skeletal muscle through active or passive range of motion exercises is an important protective nursing function.

^ Peculiarity of musculoskeletal the system in newborn

At birth the skeletal system contains larger amounts of cartilage than ossified bone, although the process of ossification is fairly rapid during the first year. The nose, for example, is predominantly cartilage at birth and is frequently flattened by the force of delivery. The six skull bones are relatively soft and not yet joined. The sinuses are incompletely formed in the newborn as well.

Unlike the skeletal system, the muscular system is almost completely formed at birth. Growth in the size of muscular tissue is caused by hypertrophy, rather than hyperplasia of cells.

^ Physiologicoanatomical peculiarities of the chest

Although the thoracic cavity houses two vital organs, the heart and lungs, the anatomic structures of the chest wall are important sources of the information concerning cardiac and pulmonary function, skeletal formation. The chest is inspected for size, shape, symmetry, movement and the presence of the bony landmarks formed by the ribs and sternum.

The doctor must become familiar with locating and properly numbering each rib, because they are geographic landmarks for palpating, percussing, and auscultating underlying organs. Normally all the ribs can be counted by palpating inferiorily from the second rib. The tip of the eleventh rib can be felt laterally, and the tip of the twelfth rib can be felt posteriorily. Other helpful landmarks include the nipples, which are usually located between the fourth and fifth ribs or at the fourth interspace and, posteriorly, the tip of the scapula, which is located at the level of the eighth rib or interspace. In children with thin chest walls, correctly locating the ribs is little difficult.

The thoracic cavity is also divided into segments by drawing imaginary lines on the chest and back: the anterior, lateral, and posterior divisions. The doctor should become familiar with each imaginary landmark, as well as with the rib number and corresponding interspace.

The size of the chest is measured by placing the tape around the rib cage at the nipple line. For the greatest accuracy at least two measurements should be taken, one during inspiration and the other during expiration, and the average recorded. The chest size is important mainly in comparison to its relationship with the head circumference. Marked disproportions are always recorded, because most are caused by abnormal head growth, although some may be the result of altered chest shape, such as barrel chest or pigeon chest.

As the child grows, the chest normally increases in the transverse direction, causing the anteroposterior diameter to be less than the lateral diameter. In an older child the characteristic barrel shape of an infant's chest is a significant sign of chronic obstructive lung disease, such as asthma or cystic fibrosis. Other variations in shape that are usually variants of the normal configuration are pigeon breast, or pectus carinatum, in which the sternum protrudes outward, increasing the anteroposterior diameter, and funnel chest, or pectus excavatum, in which the lower portion of the sternum is depressed. A severe depression may impair cardiac function, but in general neither condition causes pathologic dysfunction. However, these conditions often cause parents and children concern regarding acceptable physical appearance.

The doctor also notes the angle made by the lower costal margin and the sternum, which ordinarily is about 45 degrees. A larger angle is characteristic of lung diseases that also cause a barrel shape of the chest. A smaller angle may be a sign of malnutrition. As the rib cage is inspected, the junction of the ribs to the costal cartilage (costochondral junction) and sternum is noted. Normally the points of attachment are fairly smooth. Swellings or blunt knobs along either side of the sternum are known as the rachitic rosary and may indicate vitamin D deficiency. Another variation in shape that may either be normal or may suggest rickets (vitamin D deficiency) is Harrison's groove, which appears as a depression or horizontal groove where the diaphragm leaves the chest wall. Usually marked flaring of the rib cage below the groove is an abnormal finding.

Body symmetry is always an important notation during inspection. Asymmetry in the chest may indicate serious underlying problems, such as cardiac enlargement (bulging on the left side of rib cage) or pulmonary dysfunction. However, asymmetry is most often a sign of sсoliosis, lateral curvature of the spine. Asymmetry warrants further medical investigation.

Movement of the chest wall is noted. It should be symmetric bilaterally and coordinated with breathing. During inspiration the chest rises and expands, the diaphragm descends, and the costal angle increases. During expiration the chest falls and decreases in size, the diaphragm rises, and the costal angle narrows. In children under 6 or 7 years of age, respiratory movement is principally abdominal or diaphragmatic. In older children, particularly females, respirations are chiefly thoracic. In either type the chest and abdomen should rise and fall together.

Any asymmetry of movement is an important pathologic sign and is reported. Decreased movement on one side of the chest may indicate pneumonia, pneumothorax, atelectasis, or an obstructive foreign body. Marked retraction of muscles either between the ribs (intercostal), above the sternum (suprasternal), or above the clavicles (supraclavicular) is always noted, because it is a sign of respiratory difficulty.

Peculiarity of the chest in newborn The newborn's chest is almost circular because the anteroposterior and lateral diameters are equal. The ribs are very flexible, and slight intercostal retractions are normally seen on inspiration. The xiphoid process is commonly visible as a small protrusion at the end of the sternum. The sternum is generally raised and slightly curved.

^ Physiologicoanatomical peculiarities of the head in the newborn

General observation of the contour of the head is important, since molding occurs in almost all vaginal deliveries. In a vertex delivery the head is usually flattened at the forehead, with the apex rising and forming a point at the end of the parietal bones and the posterior skull or occiput dropping abruptly. The usual more oval contour of the head is apparent by 1 to 2 days after birth. The change in shape occurs because the bones of the cranium are not fused, allowing for overlapping of the edges of these bones to accommodate to the size of the birth canal during delivery. Such molding does not occur in infants born by cesarean section.

Six bones - the frontal, occipital, two parietals, and two temporals - comprise the cranium. Between the junctions of these bones are: bands of connective tissue called sutures. At the junction of the sutures are wider spaces of unossified membranous tissue called fontanels. The two most prominent fontanels in infants are the anterior fontanel formed by the junction of the sagittal, coronal, and frontal sutures, and the posterior fontanel, formed by the junction of the sagittal and lambdoidal sutures (Fig. 7.3). One can easily remember the location of the sutures because the coronal suture lierowns" the head and the sagittal suture "separates" the head.

Two other fontanels - the sphenoidal and mastoid - are normally present but are not usually palpable. An additional fontanel located between the anterior and posterior fontanels along the sagittal suture is found in some normal neonates but is also found in some infants with Down's syndrome.

The presence of this sagittal or parietal fontanel is always recorded.

Fig.3. Location of sutures and fontanel.

The doctor palpates the skull for all patent sutures and fontanels, noting size, shape, molding, or abnormal closure. The sutures are felt as cracks between the skull bones, and the fontanels are felt as wider "soft spots" at the junction of the sutures. These are palpated by using the tip of the index finger and running it along the ends of the bones.

The size of anterior fontanel is assessed between middle points of the opposite sides of the fontanel (between the frontal and parietal bones).

The anterior fontanel is diamond-shaped, measuring 2.5 cm (1 inch) by 3 cm (about 1.5 inches). The posterior fontanel is triangular-shaped, measuring between 0.5 and 1 cm (less than 1/2 inch) at its widest part. It is easily located by following the sagittal suture towards the occiput.

The fontanels should feel flat, firm, and well-demarcated against the bony edges of the skull. Frequently pulsations are visible at the anterior fontanel. Coughing, crying, or lying down may temporarily cause the fontanels to bulge and become more taut. However, a widened, tense, bulging fontanel is a sign of increased intracranial pressure. A markedly sunken, depressed fontanel is an indication of dehydration. Such findings are recorded and reported to the physician.

The doctor also palpates the skull for any unusual masses or prominences, particularly those resulting from birth trauma, such as caput succedaneum or cephalhematoma. Because of the pliability of the skull, exerting pressure at the margin of the parietal and occipital bones along the lambdoid suture may produce a snapping sensation similar to the identation of a Ping-Pong ball. This phenomenon is known as physiologic craniotabes and, although usually a normal finding, can be indicative of hydrocephalus, syphilis and ricket.

The degree of the head control in the neonate is also assessed. Although the head lag is normal in the newborn, the degree of the ability to control the head in certain positions should be recognized. If the supine infant is pulled from the arms into a semi-Fowler's position, a marked head lag and hyperextension are noted. However, as one continues to bring the infant forward into a sitting position, the infant attempts to control the head in an upright position. As the head falls forward onto the chest, many infants try to get to the erect position. If the infant is held in ventral suspension, that is, held prone above and parallel to the examining surface, the infant holds his head in a straight line with the spinal column. When lying on the abdomen, the newborn has the ability to lift the head slightly, turning it from side to side. A marked head lag is seen in Down's syndrome, hypoxic infants, and newborns with brain damage.

^ Examination of the spine

While the child is prone, the spine, extremities, joints, and muscles are inspected. However, they are also observed with the child sitting and standing.

The general curvature of the spine is noted. Normally the back of a newborn is rounded or C-shaped from the thoracic and pelvic curves. The development of the cervical and lumbar curves approximates the development of various motor skills, such as cervical curvature with the head control, and gives the older child the typical double-S curve.

Marked curvatures in posture are noted. Scoliosis, lateral curvature of the spine, is an important childhood problem, especially in females. Although scoliosis may be palpated as one feels along the spine and notes a sideways displacement, more objective tests include some aspects.

1. With the child standing erect, clothed only in underpants (and bra if an older girl), he is observed from behind, noting asymmetry of the shoulders and hips.

2. With the child bending forward so that the back is parallel to the floor, he is observed from the side, noting asymmetry or prominence of the rib cage.

A slight limp, a crooked hemline, or complaints of a sore back are other signs and symptoms of scoliosis.

The hack, especially along the spine, is inspected for any tufts of hair, dimples, or discoloration. A small dimple usually with a tuft of hair called a pilonidal cyst may indicate an underlying spina bifida occulta. The nurse palpates the spine to identify each spiny process of the vertebrae or lack of them. Any masses, which may be meningoceles, evidence of tenderness, and swelling are noted.

Mobility of the vertebral column is easily assessed in most children because of their propensity for constant motion during the examination. However, mobility can be specifically tested for by asking the child to sit up from a prone position or to do a modified sit-up exercise. Maintaining a rigid straightness when performing these maneuvers is considered abnormal and may indicate central nervous system infection or irritation. However, some individuals who are unable to relax, despite normal skeletal function, may also retain a rigid posture.

Movement of the cervical spine is an important diagnostic sign for neurologic problems, such as meningitis. Normally movement of the head in all directions is effortless. Hyperextension of the neck and spine, called opisthotonos, which is accompanied by pain if the nurse attempts to flex the head, is always referred for immediate medical evaluation.

Examination of extremities. Each extremity is inspected for symmetry of length and size; any deviation is referred for orthopedic evaluation. The fingers and toes are counted to be certain of the normal number. This is so often taken for granted that an extra digit (polydactyly) or fusion of digits (syndactyly).

The extremities are examined for symmetry, range of motion, and signs of malformation or trauma. The fingers and toes are counted, and supernumerary digits (polydactyly) or fusion of digits (syndactyly) is noted. A partial syndactyly between the second and third toes is a common variation seen in otherwise normal infants.

Range of motion of the extremities should be observed throughout the entire examination. Hyperflexibility of joints is characteristic of Down's syndrome. Eliciting the scarf sign may be helpful in identifying abnormal flexion of joints.

The fingernails are examined, and the nail beds should be pink, although slight blueness is evident in acrocyanosis. Persistent cyanosis of the nail beds indicates anoxia or vasoconstriction. Yellowing of the nail beds may indicate intrauterine distress, postmaturity, or hemolytic disease. Short or absent nails are seen in premature infants, whereas long nails, extending over the ends of the fingers, are characteristic of postmature newborns.

The palms of the hands should have the usual creases. A transverse palmar crease, called a simian crease, may suggest Down's syndrome. The full-term newborn usually has creases on the anterior two thirds of the sole of the foot. In postmature infants the sole is covered with deep creases, and in premature infants the creases are absent. The soles of the feet are flat with prominent fat pads.

The extremities are inspected for evidence of fractures from birth trauma. The clavicle, humerus, and femur are most commonly involved. Limitation of movement, visible deformity, asymmetry of reflexes, and malposition of the site are signs suggestive of a fracture. The hips are rotated to identify a congenital dislocation.

Muscle tone is also assessed. By attempting to extend a flexed extremity, the doctor determines if the tone is equal bilaterally. Extension of any extremity is usually met with resistance, and, when released, the extremity will return to its previous flexed position. Hypotonia suggests some degree of hypoxia. Asymmetric muscle tone may indicate a degree of paralysis from the brain damage. Failure to move the lower limbs suggests a spinal cord lesion or injury. Tremors, twitches, and myoclonic jerks characterize neonatal seizures or may be indicative of neonatal narcotic withdrawal syndrome. Quivering or momentary tremors are usually normal. Physiological hypertonus of flexed-muscle disappear by 2 month in infant.

Semiotics of the bone and muscle system lesions. Care for children with the diseases of bones and muscles


It is one of the most frequent deficiency diseases in infants, the main clinical symptoms of which are changes of the skeleton.

Etiology of rickets: the deficiency of vitamin D (D2 - ergo-calciferol, D3 - cholecalciferol).

Clinical symptoms.


a) delayed closure of fontanels;

b) deformed shape of the head:

1. the skull is flat and depressed toward middle;

2. a prominence of frontal bones = "Olympic forehead";

3. a prominence to the sides of the parietal bones = "caput quadratum";

4. prominence of parietal bones and depression toward middle the suture between these bones = "caput natiforme";

5. craniotabes (softening of cranial bones, feeling during palpation like pressing on ping-pong ball);

6. softening of cranial bones may lead to enlarging all the sizes of the head that is called macrocephalia).


a) rachitic rosary (enlargement of costochondral junction of ribs);

b) Harrison's groove (horizontal depression in the lower portion of the rib cage);

c) pigeon chest (depression to the middle of lower part of sternum);


kyphosis, scoliosis, lordosis.


a) bowing of the arms and legs;

b) knock-knee (X-shaped legs) (see Fig. 7.4-5);

c) saber shins;

d) instability of hip joints;

e) pelvic deformity;

f) enlargement of epiphysis at the ends of the long bones.

Fig. 4. Bowleg.

Fig. 5. Knock-knee.


a) delayed calcification, especially of permanent teeth;

b) maleruption of teeth.


potbelly, consti pation.

Rachitis tetany: seizures.

Symptoms of rickets are usually found in children less than 2 years of age, some of them in reduced form can persist for the whole life.

Laboratory diagnostics

1. Quantity of Ca2+ in the blood serum (normally: 2.25-2.5 mmol/1).

2. Sulkovich test (test for founding calcium in urine).

Nursing care plan

1. Encourage foods rich in vitamin D, especially fortified cow's milk.

2. In brest-fed infants encourage use of vitamin D supplements if maternal diet inadequate or infant exposed to minimal sunlight.

3. Emphasize the importance of exposure to the sun as the source of vit. D.

4. In caring for the child with rickets:

a) maintain a good body alignment;

b) reposition frequently to prevent decubiti and respiratory infection;

c) handle the child very gently and minimally;

d) instate seizure precautions;

e) have 10 % calcium gluconate available in case of tetany;

f) if prescribed, supervise proper use of orthopedic splints or braces.


A lateral curvature of the spine is usually associated with a rotary deformity.

Tests for scoliosis:

1. Have the child stand erect, observe from behind and note asymmetry of the shoulders and hips. (Normally shoulders, scapula, and iliac crests are symmetric).

Fig. 7.6. Spine disorders (A - normal spine, В - kyphosis, С - lordosis, D - Scoliosis I, II, III dg.)

2. Have the child bend forward at the waist until the back is parallel to the floor, observe from side and note asymmetry or prominence of rib cage.

Other signs of scoliosis include a slight limp, a crooked hem or a waistline, complaint of backache.

^ Congenital dislocation of the femur (hip)

Malformations of the hip with various degrees of deformity are present at birth.

Congenital displasia of the hip joint (acetabular displasia) - the mildest form, in which there is neither subluxation nor dislocation. The femoral head remains in the acetabulum.

In congenital hip subluxation the femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly over the fibrocartilaginous rim. The femoral head remains in contact with the acetabulum, but a stretched capsule and ligamentum teres cause the head of the femur to be partially displaced.

In dislocation the femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly over the fibrocartilaginous rim.

^ Clinical symptom

I. Dislocated or subluxated hip.

a) Limitation in hip abduction;

b) Unequal gluteal or leg folds;

c) Unequal knee height (Allis or Galeazzi sign);

d) Audible click on abduction (Ortolani sign) - if infant is under 4 weeks of age).

II. In older children.

a) Affected leg shorter than the other.

b) Telescoping or piston mobility of the joint (the head of the femur can be felt to move up and down in the buttock when the extended thigh is pushed first toward the child's head and then pulled distally).

c) Trendelenburg's sign (when the child stands first on one foot and then on the other (holding onto a chair or someone's hands) bearing weight on the affected hip, the pelvis tilts downward on the normal side instead of upward as it would with normal stability.

d) Greater trochanter is prominent and appears above a line from the anterior superior iliac spine to the tuberosity of the ischium.

e) Marked lordosis (bilateral dislocation).

f) Waddling gait (bilateral dislocation).

Paraclinic diagnostic procedures

- Radiography.

- Sonography.

Child caring plan

1.Improve the means of transportation of the child.

2.Devise the self-mobilization equipment.

3.If prescribed, supervise a proper use of orthopedic splints or braces.

Congenital clubfoot

A common deformity in which the foot is twisted out from its normal shape or position.

It must be described according to position of the ankle and foot:

a) talipes varus is an inversion or a bending inward;

b) talipes valgus is an eversion or bending outward;

c) talipes equines is a plantar flexion, in which toes are lower than the heel;

d) talipes calcaneus is a dorsiflexion, in which toes are higher than the heel;

e) talipes equinovarus is a composite deformity, in which the foot is pointed downward and inward in varying degrees of severity.

It is important to determine if the deformity can be passively corrected or is fixed.


Infection of the bones.

Manifestations of acute osteomyelitis

I. General:

a) History of the trauma of the affected bone (frequent).

b) Child appears very ill.

c) Irritability.

d) Restlessness.

e) Elevated temperature.

f) Rapid pulse.

g) Dehydration.

II. Local:

a) Tenderness.

b) Increased warmth.

c) Diffuse swelling over the involved bone.

d) Involved extremity is painful, especially on movement.

e) Involved extremity is held in semiflexion.

f) Surrounding muscles are tense and resist to passive movement.

Paraclinic diagnostic procedures:

Radiography, tomography, scintigraphy, blood culture, WBC (white blood count), erythrocyte sedimentation rate.

Child care plan

1. To administer antibiotics as prescribed, wound care, to maintain asepsis.

2. To cleanse the area as ordered, including irrigation if prescribed.

3. To apply appropriate medication and dress wound according to instructions.

4. To maintain immobilization with positioning or devices such as casts, splints, traction.

5. To ensure a nutrition diet.

6. To maintain integrity and sterility of venous access.

Duchenne muscular dystrophy

Inherited disorder is characterized by gradual degeneration of muscle fibers.

I. Manifestations of duchenne muscular dystrophy

1. Waddling gait.

2. Marked lordosis.

3. Frequent falls.

4. Gower sign (the child turns onto side and abdomen, flexes knees to assume a kneeling position, then with knees extended gradually pushes torso to an upright position by "walking" the hands up the legs).

5. Enlarged muscles (especially thighs and upper arms.

6. It is felt unusually firm or woody on palpation.

II. Later signs

1. Profound muscular atrophy.

2. Mental deficiency (common), usually mild.

3. Complications (contracture deformities of hips, knees and ankles, diffuse atrophy, obesity).

Paraclinic diagnostic procedures

4. Serum enzyme measurements (creatine phosphokinase, aldolase, glutamicoxaloacetic transaminase).

5. Electromyography.

6. Muscle biopsy.

Nursing care plan:

1. Help the child to develop self-help skills; to modify clothing for wheelchair wear, to fit over the contracted limbs; help the family to modify the environment to facilitate self-help.

2. Emphasize the importance to carry out physical therapy program.

3. Help the family to acquire the necessary equipment to promote mobility.

Muscles disorder syndromes

1. Pain syndrome (myalgia).

2. Syndrome of muscles atrophy.

3. Syndrome of muscles hypotonia.

4. Syndrome of muscles hypertonia.

5. Syndrome of muscles dystonia.

6. Syndrome of muscles hypertrophy.

7. Syndrome of myotonia.

8. Syndrome of myatonia.

9. Syndrome of myasthenia.

10. Syndrome of damage.

11. Syndrome of congenital malformation.

12. Syndrome of tetraplegia.

13. Syndrome of tetraparesis.

14. Syndrome of hemiplegia.

15. Syndrome of paraplegia.

16. Syndrome of paraparesis.

17. Syndrome of hemi paresis.

Bone disorder syndromes

1. Pain syndrome (ossalgia, artalgia).

2. Syndrome of hyperplasia of bone tissue.

3. Syndrome of osteomalacia (osteoporosis).

4. Syndrome of bone inflammation.

5. Syndrome of joint inflammation.

6. Syndrome of contracture.

7. Syndrome of congenital malformation.

8. Syndrome of bone damage.



Make a general conclusion on a theme of a class №1 and conducted practical work.



Situation tasks.


1. Nursing care of Infants and Children / editor Lucille F. Whaley and I. Wong. Donna L. - 2nd ed. - The C.V. Mosby Company. - 1983. - 1680 p.

2. Nykytyuk S.O. et al. Manual of Propaedeutic Pediatrics. – Ternopil: TSMU, 2005. – P. 6-22.

3. Pediatric Nurse Practitioner Certification Review Guide / editor, Virgina layng Milloing: contributing authors, Ellen Rudy Clore and all. - 2nd ed. - Health Leadership Associates,Inc.,1994. - 628 p.

4. Nelson Textbook of Pediatrics / edited by Richard E. Behrman, Robert M. Kliegman, Ann M. Arvin; senior editor, Waldo E. Nelson - 15th ed. - W.B.Saunders Company, 1996. - 2200 p.

5. Whaley L.F., Wong D.L.: Nursing care of infants and children, St. Louis, Toronto, London, 1983.


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