MUSCULAR SYSTEM

Muscular system includes more than 600 muscles, most of which is involved in the various
movements.

The anatomic and physiological features of the

muscular system
By the time of birth of the muscles in a child is almost the same as an adult, but there are
significant differences with regard to weight, size, structure, biochemistry and physiology
of muscles and neuromuscular units.

Skeletal muscle newborn anatomically formed and relatively well developed, their total
mass is 20-22% of body weight. By 2 years of relative muscle mass decreases slightly (to
16.6%), and then in connection with the increase in motor activity of the child and
increases again to 6 years up to 21,7%, to 8 - 27-28% and by 15 - 32 -33%. In adults, it
averages 40-44% of body weight. A total mass of muscles during the period of childhood
increases 37 times.

The structure of skeletal muscle tissue in children of different ages has some
differences. Newborn muscle fibers arranged loosely, their thickness is 4-22 microns. In
postnatal muscle growth is mainly due to thickening of the muscle fibers, and 18-20 years
of their diameter is 20-90 microns. In general, the muscles in young children are more thin
and weak, and muscle relief becomes smoother and is usually pronounced only 5.7 years of
life.

Fascia newborn thin, loose, easily separated from the muscles. Thus, the weak
development of tendinous helmet and a loose connection with its periosteum calvarial
bone predispose to bruising when the child passes through the birth canal. Maturation
fascia begins with the first months of life and is associated with functional activity of the
muscles. In the muscles of the newborn on a lot hoc interstitial tissue. In the first years of
life is an absolute increase in loose intramuscular connective tissue, and the relative
number of cellular elements per unit area decreases. Along with the development of muscle
fibers are being formed and endomysium perimiziya. His differentiation ends to 8.10 years.

The nervous apparatus of the muscles at the time of birth is not fully formed, that is
combined with the immaturity of the contractile apparatus of skeletal muscles. As the child
is maturing as a phase motor innervation of skeletal muscle fibers (change polineyronnoy
innervation on mononeyronnuyu, decrease of sensitivity to acetyl-tilholinu in mature
neuromuscular synapses dedicated only to the postsynaptic membrane), and the definitive
formation of neuromuscular units. There is also the formation of new proprioretsepto-ing
with their concentration in the muscle areas experiencing the greatest strain.
 Skeletal muscle in neonates is characterized by lower content of contractile proteins
(newborn to 2 times less than in older children), the presence of fetal form of myosin that
has little ATPase activity. As the child grows, fe-tal myosin is replaced by definitive myosin
increases content of tropomyosin and sarcoplasmic proteins, decreases the amount of
glycogen, lactic acid and water.

Muscles of the child are characterized by several functional features. Thus, the children
noted an increased sensitivity of muscles to some humoral agents (in particular, to
acetylcholine). During the intrauterine period skeletal muscle are low excitability. Muscle
reproduces only 3-4 reduction in the second. With age, the number of reductions comes to
60-80 per second. Maturation of the neuromuscular synapse leads to greatly accelerate the
transition of excitation from nerve to muscle. Newborn muscles do not relax, not only
during wakefulness, but in the dream. Permanent explain their activity involving the
muscles in the heat (so-called contractile thermogenesis) and metabolic processes of the
organism, stimulation of muscle tissue itself. Muscle tone may be a guide in determining
gestational -

the third age of the newborn. Thus, in healthy children during the first 2-3 months of life
note the increased muscle tone of flexors, the so-called physiologic hypertonicity
associated with the peculiarities of the functioning of the central nervous system and leads
to some limitation of mobility in joints. Hypertonicity in the upper limbs disappears in 2-
2,5 months, and in the lower - in 3-4 months. Very preterm children (gestational age less
than 30 weeks) are born with the general muscular hypotonia. A child born at 30-34-th
week of gestation, the lower limbs bent at the hip and knee joints. Flexion of the upper
extremities appears only in children born after 34 th week of gestation. After 36-38-th
week mark flexor position as the lower and upper extremities.

Growth and development of muscles in children is uneven and depends on their functional
activity. Thus, newborn underdeveloped facial and chewing muscles. They are noticeably
stronger after the eruption of deciduous teeth. Clearly expressed in age-related features
diaphragm. Its dome newborns more convex, tendinous center occupies a relatively small
area. As the convexity of the light aperture decreases. In children under 5 years of the
diaphragm is high, which is associated with a horizontal course of the ribs.

Newborn poorly developed muscles, aponeuroses and fascia of the abdomen, resulting in a
convex shape of the anterior abdominal wall, continuing up to 3-5 years. Umbilical ring in
the newborn has not yet been formed, especially in its upper part, in connection with which
the formation of umbilical hernias. Superficial inguinal ring forms a funnel-shaped
protrusion, more pronounced in girls.

Newborn dominates the mass of muscles of the trunk. In the first years of life in connection
with the increase in motor activity of the muscles of the limbs are growing rapidly, with the
development of the muscles of the upper extremities in all phases of development ahead of
the muscles of the lower extremities. In the first place to develop large muscles of the
shoulder, forearm, much later - the muscles of the hand, which leads to difficulties in
performing fine manual work to 5 or 6 years of age. Up to 7 years in children under-
developed leg muscles, and therefore they do not carry long loads. At the age of 2-4 years
intensively grow large gluteal muscles and the longissimus dorsi. The muscles that provide
the vertical position of the body, the most intensively grow after 7 years, especially among
adolescents 12-16 years old. Improving the accuracy and coordination of movements is the
most intense after 10 years, and the ability to fast movements developed only for 14 years.

The intensity of the gain in muscle mass and muscle strength associated with the
floor. Thus, indicators of dynamometry boys higher than girls. The exception is the period
from 10 to 12 years, when it becomes the power of the girls higher than boys. The relative
strength of the muscles (for 1 kg of body weight) up to 6-7 years varies slightly, and then to
the age of 13-14 years is rapidly increasing. Muscular endurance with age is also rising and
a 17-year-old twice that of 7-year-old children.

Method of investigation of the muscular system

Inquiries

The most frequent complaints with the defeat of the muscular system - muscle pain
(myalgia), and reduced muscle strength. In gathering medical history should be possible to
clarify the time of appearance of these complaints, triggers, relationship with other
pathological symptoms, available to the child, family and ancestral history.

Inspection and palpation

When inspection and palpation primarily assess the degree of muscle development. It is
also necessary to evaluate such important indicators of the muscular system, as the tone,
strength and motor activity of muscles.

The development of muscles. In healthy children the muscles of the elastic to the touch,
similar to the symmetric parts of the body and limbs. There are 3 degrees of muscle
development.

Good - the contours of the muscles of the trunk and limbs alone are clearly visible, the
stomach is drawn or slightly protruding forward, shoulder blades pulled to the chest, when
a voltage increases the relief of muscle contraction.

Medium - moderately developed muscles of the trunk and limbs - well, at a voltage clearly
changed their shape and volume.

Weak - at rest the muscles of the trunk and limbs badly konturiruyutsya, at a voltage of
muscles varies barely noticeable, the lower part of the belly hang down, lower angles of the
blades apart and behind the rib cage. Insufficient development of muscles can occur in
children, leading a sedentary lifestyle, with dystrophy caused by malnutrition, the presence
of chronic somatic diseases, pathology of the nervous system, the generalized destruction
of joints, etc. The extreme degree of weak

muscle development - atrophy. In this state the mass of muscle tissue sharply reduced, and
belly muscles in its thickness and consistency is similar to the tendon. If muscle atrophy is
reversible or irreversible violations trophics muscles with the development of thinning and
degeneration of muscle fibers, weakening or loss of their contractile capacity. Asymmetry
of muscle mass involves varying degrees of homologous muscle groups. To reveal the
asymmetry consistently compare similar muscles of both halves of the face, trunk and
limbs. For a more accurate assessment of a centimeter tape measure and compare the
circumference of the left and right limbs at the same levels. Muscle asymmetry may be due
to hypoplasia, trauma, pathology of the nervous system of some rheumatic diseases (
gemiskle-rodermii, Jurassic), etc.

Palpation identify local or widespread pain, as well as seals along the muscles that may be
associated with inflammatory changes, focal or diffuse deposition of calcium in them.

Muscle tone. Muscle tone - a reflex muscle tension, controlled by the CNS and also
depending on what happens in muscle metabolic processes. Reduction or absence of tone
is called hypotonia or atony of muscles, respectively, a normal tone - normotoniey muscles,
a high tone - muscular hypertension.

The preliminary view of the state of muscle tone can be obtained by visual assessment of
posture and position of the limbs of the child. For example, the posture of a healthy
newborn (arms bent at the elbows, knees, hips and pulled her abdomen) indicates the
presence of his physiological hypertonus flexors. With a decrease in muscle tone newborn
lying on a table with arms outstretched and legs. In older children, reduced muscle tone
leads to disturbances of posture, wing-shoulders, excessive lumbar lordosis, increased
abdominal and others

Muscle tone investigating, evaluating the resistance of muscles that occurs during passive
movements in the respective joints (of course this should be as relaxed).

Increased tone may be of two kinds.

-- Spasticity - the resistance movement is expressed only in the beginning of passive flexion
and extension, then the obstacle as it decreases (the phenomenon of "folding knife").There
is a break in the central influence on the cells of the anterior horn of the spinal cord and
disinhibition of the segmental reflex apparatus.

-- Muscle rigidity - hypertonicity is constant or increases with the repetition of movements

(the phenomenon of "wax" or "lead pipe"). In the study of muscle tone may be
discontinuous, steplike resistance (the phenomenon of "gear"). Sure you can freeze in that
position, which she attached - plastic tone. Occurs when the defeat of the extrapyramidal
system.

When hypomyotonia reveal the lack of resistance during passive movements, flabby
texture muscles, increase

movements in the joints (for example, pererazgibanie). There are a few samples for judging
the state of muscle tone in children.

-- Symptom back - legs baby, lying on his back, unbend, straighten and pressed to the table
for 5 s, then released. If a newborn physiological hypertonus legs immediately returned to
its original position, with reduced tone full refund does not happen.

-- The test of the traction - lying on your back take the child by the wrists and try to
translate into a sitting position. Child unbend first hand (first phase) and then bends them,
his whole body tightened to investigating (second phase). When hypertonicity missing the
first phase, while gipotonuse - the second phase.

-- The symptom of "strings" - the researcher, standing face-to-child, takes him into his own
hands and performs rotational motion alternately in one or the other side, while
appreciating the degree of active muscle resistance.

-- Symptom "flabby shoulders" - a child grasping her shoulders from behind with two
hands and actively raise up. When muscle hypotonia, this movement comes easy, with the
shoulders relate earlobes.

Volume movements. Assess the volume of both active and passive movements.

Active movements are studying the process of monitoring the child during the game,
walk, perform those or other movements (squats, bending, lifting hands and feet, stepping
over obstacles, ascent and descent of stairs, etc.). Restriction or lack of movement in
various muscle groups and joints indicates a lesion of the nervous system (paresis or
paralysis), muscle, bones and joints.

Passive motion of exploring, consistently producing bending and straightening of the

joints: elbow, hip, ankle, etc. In newborns and children the first 3-4 months of life note the
restriction of joint movement due to physiological hypertonicity. Limitation of passive
movements in older children, indicates an increase in muscle tone or failure of the joints.

The strength of muscles. Muscle strength assessed by the degree of force necessary to
overcome the active resistance of a particular muscle group. Young children are trying to
take away their toy snatched. Older children are asked to provide resistance with
unbending bent arm (leg). Status of muscle strength can be indirectly judged by how a child
performs squatting, climbing and descending stairs, getting up from the floor or bed,
dressing and undressing, etc. Muscle strength clearly increases with age. Typically, the
leading arm is stronger, and in general muscle strength in boys than in girls. More
objectively judge the muscle strength can be on the testimony of the dynamometer (manual
and become).

Laboratory and instrumental investigations

In diseases of the muscular system exploring the biochemical blood indices [the activity of
creatine, the muscle fraction of lactate dehydrogenase (LDH), transaminases, the
concentration of amino acids and creatine in blood and urine myoglobin content in blood
and urine], determine the autoantibodies. To refine the diagnosis of conduct genetic and
morphological studies of muscle biopsy.

Among the instrumental methods to determine the causes for the decline of muscle
strength in clinical practice most often use electromyography (EMG) - a method of
registration of bioelectrical activity of muscles, allowing, for example, to differentiate
primary muscle pathology of their lesions in diseases of the nervous system. Muscular
excitability was assessed using chronaximetry, muscle performance - ergograph and
ergometer.

Semiotics of lesions of the musculoskeletal system

MAJOR SYNDROMES OF DESTRUCTION OF MUSCLE

Wasting and atrophy of muscles

Muscular hypotrophy or atrophy can be congenital and acquired, primary and secondary.

Hypotrophy of muscles occurs occasionally in healthy children, leading a sedentary life,

while limiting the mobility in the postoperative period or severe somatic pathology.

Muscle atrophy is accompanied by flaccid paralysis, in particular, arising out of the

paralytic form of polio. Muscle atrophy develops gradually with hereditary degenerative
diseases of the musculoskeletal system, chronic infections occurring, violations of
metabolic processes, trophic disorders of the nervous system, long-term use of
glucocorticoids and other local muscle atrophy may formed during prolonged immobility
associated with diseases of joints, damage tendons, nerves or muscles themselves.

Violation of muscle tone

Muscle hypotonia in newborns may be due to CNS lesions, hyperbilirubinemia,

prematurity, some congenital diseases. In infants decrease in muscle tone occurs in rickets,
malnutrition (II and III degree), they are older - in rheumatic chorea, lesions of the
cerebellum and other muscle tone decreases with hypokalemia. The reason for this may be
vomiting, diarrhea, prolonged use of diuretics, treatment of cardiac glycosides, as well as
the defeat of the endocrine glands (pituitary, thyroid, adrenal glands).

Muscular hypertension occurs with lesions of the pyramidal tract (eg, Little's disease,
injury, spinal cord and brain, encephalitis), some infectious diseases (eg, tetanus), myo-
tonii Thomsen and others

Myalgia

Myalgia can be caused by spasm, compression, inflammation or ischemia of the muscles.

g

Severe pain in the muscles of the extremities often occur when infectious diseases such as
leptospirosis, brucellosis, tularemia, relapsing fever.

Pain at rest and muscle soreness are peculiar disease occurring with muscle necrosis and
myoglobinuria.

Pain during or after physical activity observed in hereditary metabolic miopatiyahili

ischemia (eg, scleroderma).

Aching muscles, combined with their seal indicates their inflammatory injury (myositis,
dermatomyositis, trichinosis).

Foci density in the rocky strata muscles are formed by deposition of calcium salts
(ossification), arises in hyperparathyroidism, talk soplazmoze, dermatomyositis, and
cavalry.

Muscle contractions

Muscle contractures often occur in diseases affecting the joints and muscles surrounding
the joint, often flexors.

Reduced muscle strength

Muscle weakness in the proximal limb is more typical for myopathy, the distal - for
polyneuropathy, as well as mioto-ethnic dystrophy, distal muscular dystrophy.

Increase of weakness after the load may indicate a disorder of neuromuscular

transmission or metabolic myopathies (in violation of utilization of glucose or lipid
metabolism).
 Among endocrine diseases muscle weakness often cause gipokortitsizm,
hyperthyroidism, hypothyroidism, hyperparathyroidism, acromegaly.

The overall decline in muscle strength occurs with severe debilitating disease, chronic
lung disease, heart, liver and chronic renal failure (CRF).

MAJOR diseases accompanied by muscular lesions

Myopathy

Myopathy - generic name of a heterogeneous group of diseases of the musculoskeletal

system (mainly skeletal muscle), caused by violation of the contractile capacity of muscle
fibers and manifested muscle weakness, decrease in volume of active movements, reduced
tone, atrophy, and sometimes psevdogipertrofiey. Myopathy may be either primary
(muscular dystrophy) and secondary (inflammatory, toxic, metabolic, etc.).

Muscular dystrophy - inherited myopathy, manifesting progressive muscle weakness

caused by destruction of muscle fibers. Update muscle tissue while greatly disturbed. In
Duchenne's disease and related disorders is disturbed synthesis dystrophy-on, which leads
to disruption of cytoskeleton connections with intercellular matrix Rieks. Muscle fibers lose
their structural integrity and die, while muscle tissue is replaced by fat.

The group of inflammatory myopathy include the following diseases.

-- Infectious Diseases etiology: bacterial (streptococcal necrotizing myositis, gangrene),

viral (influenza, rubella, en terovirusnaya infection, HIV infection), parasitic
(toxoplasmosis, chi-stitserkoz, trichinosis), spirochetal (Lyme disease).

-- Idiopathic autoimmune diseases (dermato-and polymyositis, SLE, juvenile polyarteritis

etc.).

Medicinal myopathy may occur while taking various medicines: cimetidine, penicillamine,
procainamide (neo-kainamida), chloroquine, colchicine, cyclosporine, glucocorticoids,
propranolol, etc.

Myotonia

Myotonia - a condition in which muscle contraction occurs after the tonic stiffness lasting
several seconds. Myotonia characteristic of myotonic dystrophy, congenital myotonia
(Thomsen disease) and congenital paramyotonia, in which muscular rigidity provoked
cooling.

Myasthenia
Myasthenia - a disease characterized by increasing muscle weakness and abnormal fatigue
of skeletal muscles caused by a violation of neuromuscular transmission. The basis of
myasthenia gravis often is immune damage (formation of AT to the acetylcholine receptor
postsynaptic membrane of the neuromuscular synapse). Myasthenia can occur in children
of any age and is manifested ptosis, diplopia, bulbar symptoms, increasing weakness of the
muscles.

Neonatal myasthenia gravis occurs in infant for not more than 2 months after birth due to
passive transplacental transfer of AT by a pregnant woman, suffering from myasthenia, the
fetus.

Congenital myasthenia gravis - a disease manifested ptosis, external ophthalmoplegia,

fatigue. It is caused by genetic defects of neuromuscular synapses with the development of
resistance to inhibitors of cholinesterase. The disease can occur in utero in the newborn
period or during the first years of life.

Paralysis and paresis

Paralysis (paresis) is called the state with the loss (decrease) the ability of muscles to
decrease due to random destruction of the nervous system. There are central and
peripheral paralysis (paresis).

When flaccid paralysis muscles become flabby, dull and passive movements of the joints
redundant.

Central paralysis is usually accompanied by spastic hypertonicity. Muscles become

compacted, intense, distinctly con-turiruyutsya, passive movement difficult and limited.

Congenital muscular

The most common congenital anomaly of muscles - hypoplasia sternoclavicular-mastoid

muscle, resulting in torticollis.

Often, there are anomalies in the structure of the diaphragm with the formation of
hernias.

Hypoplasia or absence of a large chest or deltoid muscle leads to strain the shoulder
girdle.