Orthopedics - Oleksa A.P. 2006

Examination of the orthopedic patient
Development of the skeletal system

In the fetus, the bony Skeleton develops from mesenchymal tissue; specific skeletal segments appear during the 2nd month of fetal life. Tubular bones develop from Cartilage, whereas flat bones develop from Connective Tissue.

In the metaphysis and epiphysis, There is a layer (plate) of preparatory calcification, which is the site of longitudinal bone growth driven by the growth cartilage, while the plate itself plays a minimal role in this process. During growth, the periosteum models the bone, giving it the appropriate shape and width. Ossification centers refer to the areas within bones where bone-forming Cells lay down the first bone plates. All ossification centers appearing in the fetal tubular bones are called primary, whereas those appearing after birth are termed secondary and arise within the epiphyses. In various bones, the appearance of ossification centers correlates with the child's specific age. As the child grows, these centers enlarge, and The final stage of bone growth concludes with the fusion of the epiphysis and metaphysis, along with the disappearance (on radiographs) of the growth plate line (reminiscent of Risser's sign in Scoliosis).

Bone maturation depends on normal endocrine gland function, metabolic processes driving mineralization, and environmental factors. It has been proven that variations in the maturation of the Skeletal System are influenced by different climatic zones and genetic populations. Deviations from normal Bone Development and maturation may be caused by direct factors (such as inflammation or injury to the epiphyseal cartilage) or indirect factors (such as hormonal disorders). An objective assessment of a child's normal development relies on skeletal maturation indicators from birth until the completion of growth, i.e., up to 25 years of age. Radiographically, this is determined by the appearance, size, and shape of ossification centers, as well as the timing of epiphyseal plate closure. Concurrently, this can indicate deviations from normal bone growth—delayed, slowed, or accelerated growth. It is important to note that skeletal development differs between boys and girls. For this purpose, radiological standards of age-related skeletal development norms have been established. The examined child's age can be compared against the standard using a radiograph of a single skeletal site or multiple sites of the left skeletal half (HAND AND WRIST, elbow, shoulder, ankle, knee, hip joints, and scapula). The ossification centers of the left half of the skeleton are then counted and compared with the standard. This multi-site method (Sontag, Snell, and Anderson) exposes the child to significant radiation; therefore, as a rule, clinicians rely solely on a radiograph of the left hand and wrist (a single site) in one projection—the dorsopalmar view. Standards for the single-site method were developed by Todd from 3 months of life to 18.9 years for boys and from 3 months of life to 16.3 years for girls; Vogt and Vickers from birth to 6.5 years; and Greulich and Pyle from birth to 18 years, accounting for sex differences. Furthermore, the latter provide acceptable physiological deviations (plus-minus) in their standards.

Kopczynska J. (1961) developed standards for children in Poland and indicated that these physiological variations range from 9 to 15 months in girls and from 12 to 17 months in boys. Thus, standards developed in Europe are suitable for clinical use in Ukraine.

Figure 38 illustrates the timing of the appearance of secondary ossification centers in the BONES OF THE hand and FOOT, as well as the cessation of growth, according to Caffey J. (1946).

In a newborn infant, radiographs reveal only the diaphyses of the forearm, metacarpus, and Phalanges (primary ossification centers). The epiphyses and Carpal Bones are cartilaginous and not visible on radiographs. Secondary ossification centers (postnatal) in the carpal bones appear in the following sequence: During the first year of life, in the capitate and hamate bones; in the 2nd year, in the triquetrum and the distal radial epiphysis; at 4–5 years, in the lunate; at 5–6 years, in the trapezium, scaphoid, and the distal ulnar epiphysis; and at 12–13 years, in the pisiform bone. Ossification centers of the metacarpals and phalanges appear during years 1–4. Ossification centers form earlier in girls than in boys. The ossification process is completed by age 19. Anatomical Variants of the hand bones occasionally occur. The most frequent findings include an accessory ossification center in the 1st or 2nd metacarpal bone, a duplicated lunate, a multi-focal pisiform, or a separate ossification center in the ulnar styloid process. In the newborn's foot, ossification centers can be observed in the calcaneus, talus, and Metatarsal Bones. The ossification center in the cuboid bone appears at the end of the first year of life; in the lateral cuneiform, from 6 months to 2 years; in the medial cuneiform, from 1 to 3 years; and in the navicular bone, as well as the epiphyseal Regions of the metatarsals and phalanges, from 1 to 5 years. Foot bone growth is completed by the 22nd year of life. Anatomical variants include a separate ossification center of the proximal phalanx of the hallux, an accessory metatarsal ossification center, a fragmented calcaneal tuberosity, and a variable number of sesamoid bones.

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Fig. 38. Timing of the appearance of ossification centers in the Bones of the foot (a) and hand (b) (months and years of life).