EWMM Nederland - cursus Kiss 1 - · PDF fileEWMM Nederland - cursus Kiss 3 SynchondrosisC1 A normal C1 has in childhood 3 synchondroses: 1 in the posterior arch 2 in the anterior arch

EWMM Nederland - cursus Kiss 1

INFANT ANATOMY

UPPER CERVICAL

and

PELVIS REGION


Does the relation with the atlas remain after birth??

RECOVERY OF SKULL AFTER BIRTH

Vertebral ossification

Schinz 1979

Bone formation

6

There are 2 types of bone formation:

• desmale (direct) bone formation deriving from mesenchym – (skull – clavicula)

• enchondral bone formation – (spine – long bones) (osteoporosis)

Then in 3 stages;

• parenchyma stage (I)

• cartilage stage (II)

• calcification stage (III, IV en V)

Gutman


Synchondrosis C1

A normal C1 has in childhood 3 synchondroses:1 in the posterior arch2 in the anterior arch

Th i ibl h X

7

Swischuk

These are visible on the X‐rayand are not pathological!

C ‐ bone centers, atlas archof a fetus at 3 months

D ‐ synchondrosis betweenthe atlas arches* *

Bone formation of atlas in a 1 year old child

2 bone formation centers of the posterior arc (1 & 2)

1 in the anterior arc (3)

*Beware of the transverse processes they are not yet fully ossified


10

Transverse process is an osseous structure in childhood

Anomalies of the atlas

Synchondrosis C2

C2 contains 5 synchondroses in total

•1 between the corpus and the dens

•2 between the dens and the axis arch

•2 between the corpus and the axis arch

12

Swischuk


Ossification

13

Swischuk

The ossification of C2 takes place from within the dens.

Adherence of the lig.alaria

14

Neonatal

Red is bone formation

1 2

6

boneformation of the axis in new‐born (ventral view)boneformation of the arches (1 en 2)boneformation center of the corpus (3)advanced boneformation of the dens (6)

1 23


A ‐ corpus axis ‐ ossification begins in 4th fetal month

C ‐ neural arch appear in paired oss. centers by 6th fetal month

D ‐ fusion of arch (posterior) in 3rd and 4th year

F ‐ synchondrosis disappears when corpus & pediciles fuse between 4th and 7th year

H ‐ ossification top of dens between 2nd and 6th year

>

*

y

J ‐ synchondrosis between dens and arch disappears between 3rd & 7th year

L ‐ the same applies (J) for the dens & corpus

Neonatal

GENESIS ATLAS

•ATLAS ‐ 2 OR 3 BONE FORMATION CENTERS

•DEFINITIVE FUSION OF CORPUS + ARCH AT 7 9 YEARS7 – 9 YEARS


Chondrofication

C3 through C7

There are 6 centers that finally fuse together.

Note: The centers in the body lie in the

19

Note: The centers in the body lie in thesagittal plane.

Swischuk

Synchondrosis C3 – C7

Contains only 2 synchondroses, present

between the body and the vertebral arch.

20

Swischuk

Ossification

C3 through C7

Composed again

from 6 centers that fuse together.

Note: the centers in the body lie in

21

Note: the centers in the body lie inthe frontal plane.

Swischuk


Neonatal

!


desmal ossification from 9 weeks after conception and on

27


kiss‐I kiss‐Ikiss‐II

kiss‐I kiss‐I

Coupe in frontal planeof cerv. spine

compact structure C0‐C3

Coupe in frontal planeof spine

compact structure C0‐C3

Bio-mechanicsAngle of upper jointfacies articulares C1

occiput‐atlas:128o or less in adolescent

Unco‐vertebral joints

Dr.R.Sacher:1016 A/P- X pics


Abflachung des frontalen Kondylengelenkachsenwinkels C0/1

• bei Säuglingen durchschnittlich 153°

• bei Erwachsenen

durchschn.124°‐127°

vermehrt geändertes biomechanisches Verhalten des Atlas bei Kopfseitneige?

condylar angle in frontal plane

( 153° ‐ 128° )

Bio‐mechanics

Dr.R.Sacher:1016 A/P‐ X pics

condylar angle in frontal plane C0‐C1 in girl of 10 years old (128°)

Bio‐mechanics

Dr.R.Sacher:1016 A/P‐ X pics


condylar angle in frontal plane C0‐C1 in a 5 month old girl(153°)

Bio‐mechanics

Dr.R.Sacher:1016 A/P‐ X picx

135°

Vermehrte Keilform der WirbelkörperPhysiologische Kyphose der Säuglingswirbelsäule

Erhöhte dynamische Belastung C0/1 in Bauchlage

Statische Funktion des

Gelenks noch wenig ausgeprägt


zunehmende Denslordosierung

• zwischen 3. und 16. Lebensmonat Zunahme der Denslordosierung bis auf max. 25°

• Erwachsene durchschnittlich 12°

• bei maximal gehaltener• bei maximal gehaltener Dorsalextension Kompression des Myelondurchmessers bis auf die Hälfte

Koebke J, Kock C. Gelenke und Gelenkmechanik des Zerviko….

Saternus K-S, Koebke J. Inclination…

Stumpfer verlaufender Kondylengelenk‐achsenwinkel C0/1 in der Sagittalen

• halber Kondylenwinkel im Neugeborenenalter a=35°

• bei Erwachsenen ß=28°

Hinweise für eine dynamische Entwicklung der Atlaslateralität (N=1247)

• Prozentuale, altersspezifische Verteilung der ermittelten Atlaslateralität (AL /AR) sowie des durchschnittlichen Gelenkachsenwinkels C0/C1 (im Verhältnis zum

Erwachsenenalters = 100%) im Säuglingsalter

65

40

45

50

55

60

0-3 Mo 4-7 Mo 8-12 Mo

AlARC0/C1


change in average conylar angle C0/C1 in relation to age (N=1016)

140

145

150

155

160

nw

inke

l in

deg

rees

boys

girls

Bio-mechanics

120

125

130

135

0 2 years 4 years 6 years 8 years 10 years

Age

Gel

enka

chse

n


Discussion

• The condylar angle C0-C1 of newborn and infant (0-3 months) in the frontal plane is 153°.

• By the 10th year it is almost the same as in adults (128°).

The height of the occiput-condyle in the first month of life isabout 50% of the average height of the condyle in an adult.

Bio mechanics

Dr.R.Sacher:1016 A/P- pics


C0-C1 – Lateral flexion

•According to Penning, in lateral flexion C0-C2the atlas moves to the concave side.

•C0-C1 and C1-C2 move simultaneously in the same direction.

•Atlas Meniscus.

Penning

86% f b

adult newborn

lateral flexionin adults: in newborns:atlas shift to concave atlas shift to convex

86% of newborns

3% adultsBiedermann


Causes for the special morphological development?

• changes in stato-dynamics due to the extra taxation caused by new vertical position

(incl. the increase of differentiated head movement and the increasing necessity for stabilisation and balance)

Bio-mechanics

increasing necessity for stabilisation and balance)

• size and increasing weight in the head are relevant here


critical balanceC0 – C1

Flat articularfacet planes

C1 in childhood


Occipital portion

of alare ligament

Atlantal portion

of alare ligament

*Lateral flexion

(right)

(left)


C2 is still

Lateral flexionre C0

Li t l t bili ti C2 is still (in drawing)

Ligamental stabilisation

Left: atlas/axis facet stabilisation

C0 + C1- rotates relative to left posterior

Only at C2-C3 can the head be moved horizontally

in case asymmetrical position C0 C2 .

Function disturbances at this level have enormous consequences!

Labyrinth-reflex C2-C3 and total spine



Pelvis - Hip newborns


29-30 days

36 43 48

formation of cartilage skeleton after creation

of somites36-38 43-45

48-52

of somites

til f th t

In the foetal period the acetabulum is a deep structureover the head of the femur until the socket gets shallower

(after birth).

48 – 52 days

cartilage of the tarsus

cartilage of the metatarsal


At birth 1/3 of the caput is surrounded by acetabulum



After birth the acetabulum gets deeper;at 4 years maximum depth



Until 4th year the hip joint remains instableNEVER MANIPULATE!!




ilium


bone formationsacrumup to 18th year!up to 18th year!

OSSIFICATION SACRUM

• Sacral vertebrae are separated from each other by cartilage until the 18th year!

• Highest 3 sacral vertebrae• corpus has 1 bone formation centre• ossification begins around the 9th week• ossification begins around the 9th week• around the 6th year ossification arches with

corporae

• Bottom 2 sacral vertebrae• ossification begins between the 6th and 8th month• around 2nd year ossification bends with corpora

Growth of 5 sacral vertebrae begins post-natal and iscomplete around 18th-25th year.

Joint facets SIG have the same direction as thelumbal facets.

Conclusion: IMPULSE DIRECTION MOBILISATION

By forward movement the sacrum gets wider and th t f th j i t l b i t fthe curvature of the joint planes begins to form.

Conclusion: STOP SI jt-BLOCKAGE BEFORE CRAWLING STARTS.

AIM: TO PREVENT ASYMMETRY IN FORM AND FUNCTIONS!!!


UNTIL SCHOOL AGENEVER

MANIPULATE A HIP

SOFT MOBILISATION is OKSacrum however is not

a punctum fixum

05 9

20

during formation of the acetabulum, 3 bone centers grow towards each other


where to grip boneduring mobilisation


degree of inclination

(position) angle from valga to vara

ATTENTIONDURING THERAPY IMPULSES AND FIXATIONPAY ATTENTION TO

•THE STRUCTURE OF THE CARTILAGE

AND TO

•FINE STRUCTURES OF THE JOINTS under construction.


ATTENTIONDURING THERAPY IMPULSES AND FIXATIONPAY ATTENTION TO:

•THE CARTILAGE STRUCTURES OF THE SACRUM

NO SACRUM FIXATION !!!IMPULSES ON HIPS WITH 2 THUMBS

a: normal hip joint, the hip socket surrounds the ball

b: dislocation, the hip ball is no longer surrounded by the socket

Fig 45: shows a ball joint that is insufficiently covered by the socket.


Fig 44: birth joint deformities occur mostly during breech presentation, when overstretching of the knees occurs.

Fig 45: a dislocated hip that remains dislocated is a big source of pain, especially when a new socket has formed around it.

Fig 128: extra buttock fold by congenital hip dislocation

by SIG-problem Patrick pos.

Fig 46: when there is evidence of a congenital hip dislocation, the leg of the affected hip has restricted sideward movement.

Fig 47: at 3 months on the side of the dislocation (here right) an extra thigh fold appears, this is close to the crotch and not at the back of the upper leg.


Fig 48: with a dislocated hip, the upper leg is shorter than the other one (here right) the infant lays on his back, the knees and the hips are bent so that the feet are flat on the bed. The right knee is lower than the left

Fig 49: regardless of left or right, when the infant is standing a hollow back is very noticeable as the hips are pushed forward.

Congenital hip dislocationtest by Ortolani:

examine with thumbs on inside of knee

fingers on thigh bone

apply gentle traction and abduction, create pressure on the t h t jtrochanter major

resistance with abductionand exo-rotation occurs at 30-40o

test is positive when a“click” is felt

Hip dislocation:telescope test

90o hip flexion

pressure on femurtowards the table

lift the leg

a normal leg gives slight movement

on the side of the dislocation there is more movement


Classic orthopaedic approach:(bottom up)

“there is a difference in leg length…”

Functional approach:(top down)

“the head is out of alignment”the head is out of alignment

Documents

EWMM Nederland - cursus Kiss 1 - · PDF fileEWMM Nederland - cursus Kiss 3 SynchondrosisC1 A normal C1 has in childhood 3 synchondroses: 1 in the posterior arch 2 in the anterior arch