home Audience 1 What are marginal exostoses? Exostoses

What are marginal exostoses? Exostoses

What is exostosis

Exostosis is a bone or bone and cartilaginous growth of a non-tumor type on the surface of bones (a type of linear, spherical and other formation). Exostosis in its structure consists of cartilaginous tissue (ossified in similarity to normal cartilaginous tissue) and therefore the name “ cartilaginous"Exostosis does not accurately show the essence of the entire process.

The process of ossification during exostosis is usually accompanied by transformation into spongy bone, enclosed on the outside in a thin and dense bone shell. Surface bone exostosis- This is a layer covered with hyaline cartilage, the thickness of which is only a few millimeters. From such a cartilaginous head the growth of the entire exostosis subsequently results.

Causes of exostosis

The reasons for the formation of exostosis may be inflammatory process, bruise, incarceration, abnormalities of the periosteum and cartilage, such infectious diseases like syphilis, lack of function endocrine system or its individual glands. Exostosis is presented, in general, as a persistent formation, however, there are cases when the process of formation of exostosis decreases over time and the exostosis disappears forever.

Often, slowly increasing and not causing pain, exostosis is not observed clinical symptoms, remaining invisible to both the patient and the doctor. Exostosis is detected by X-ray examination, or by palpation of seals that are already visible during examination.

A large number of scientific works devoted to elucidating the causes of exostosis, their attention is directed to the study of heredity in this disease. However, even the presence in certain cases of family exostoses, which are inherited, does not yet provide any basis for explaining the occurrence of this disease.

Osteochondral exostosis

Osteochondral exostosis can continue to go unnoticed for a long time, since the growth of osteochondral exostosis is very often not accompanied by symptoms. Exostosis can be detected randomly, for example, with x-ray examination or when establishing growths or seals.

Often bone growths do not appear until age 8, but during active growth In the period from 8 to 16 years, the skeleton may become activated and exostosis may develop. Accelerated development of osteochondral exostosis is noted during puberty and is found on the fibula and tibia, as well as in the lower part of the thigh, on the shoulder blade and collarbone.

Osteochondral exostosis affects the hands and feet much less frequently and never affects the skull area. The number of growths with osteochondral exostosis can vary - from a few to dozens; the situation is similar with sizes - from a pea to a large orange. It is not always possible to palpate exostoses during research, therefore, to accurately determine their number, it is used radiography. This is the only way to obtain data on the size, shape and structure of osteochondral exostosis.

There are two types of osteochondral exostosis: solitary osteochondral exostosis And multiple exostotic chondrodysplasia. Both types of exostoses can affect any bone. The favorite localization is the metaphyses of the long tubular bone. 50% of all osteochondral exostoses involve the femur, proximal metaphysis of the shoulder joint and tibia. Osteochondral exostosis usually manifests itself in adolescence and childhood.

Clinical picture with osteochondral exostosis depends on the form of the disease, its localization, size of exostoses, shape and connection with nearby tissues and organs. Exostoses of enormous size can affect nerve trunks and blood vessels, causing painful sensations. Osteochondral exostosis in the spine, with further growth in the area spinal canal, may result in compression of the spinal cord.

Treatment of exostosis with surgery

Treatment of exostoses is only surgical. In the case of the formation of multiple exostoses, the first step is to remove overgrown areas of bone tissue that compress nerves and blood vessels. Treatment of exostosis with surgery is carried out by traumatologists-orthopedists under general or local anesthesia, depending on the size of the growths on the bone surface and their locations. During the operation, overgrown areas of bone tissue are removed, followed by smoothing.

When treating exostosis in our center of traumatology and orthopedics, an operation is performed with minimal tissue trauma and the use of modern technology, as well as with the application of internal cosmetic stitches, which allows you to return to active image life in the shortest possible time. Timely methods diagnosis of exostosis with further effective treatment(if necessary) help to avoid subsequent complications of this disease.

Exostosis (osteochondroma) is a benign osteochondral growth on the surface of the bone. It consists of cartilaginous tissue. This pathological condition bones, which is a complication of various diseases.

We can talk about an independent disease only in the presence of multiple exostoses.

Exostosis can have a variety of shapes: linear, spherical, spinous, mushroom-shaped, etc. Sizes also vary from a few millimeters to 10 centimeters in advanced cases.

Typically, the growth begins to form from the epiphyseal growth plate on long tubular bones. At first he is cartilaginous neoplasm, which ossifies over time. Exostosis turns into cancellous bone during ossification. On the outside, it is covered with a thin but very dense bone shell. The surface of the osteochondral growth is covered with thin hyaline cartilage, which gives rise to further growth of exostosis.

These osteochondral growths are persistent formations, however, there are cases when the size of these neoplasms decreased and they completely disappeared on their own.

The most typical appearance of these osteochondral growths is in children aged 8 to 20 years, during the period of skeletal growth. There have been rare cases of such pathological formations in adults.

Causes

These osteochondral growths can occur due to various reasons. They may appear:

during the regenerative process after injury;
for injuries;
with bruises;
with inflammation of the mucous membranes;
with osteomyelitis;
during inflammatory processes in fibrositis;
with bursitis;
when the periosteum is pinched;
as a consequence of chronic inflammatory processes in the bones;
later aseptic necrosis;
with insufficient function of the endocrine system organs;
when ligaments are torn at the place of their attachment;
as a concomitant complication of benign tumors;
after surgery;
as a consequence of chronic joint diseases;
with syphilis;
for congenital disorders and skeletal anomalies;
in cases of chondromatosis of bones.

Why multiple exostosis occurs has not been precisely established. It is definitely known that the basis for the formation of growths is a violation of the normal process of enchondral ossification. Clearly visible hereditary predisposition to such an occurrence of the disease.

Separately, we can distinguish exostosis, the origin of which is unknown.

After an injury, exostosis can form from a bone fragment or from an ossified hemorrhage.

Symptoms

Clinical manifestations of exostosis can be different. Sometimes they are completely asymptomatic and are discovered by chance during X-rays, or when they grow to a size that is visible to the naked eye.

In some cases, exostoses cause pain and discomfort, and sometimes limit the mobility of the injured limb.

Separately, we should highlight growths that over time turn into real malignant tumor.

Most often, osteochondral exostoses appear near the ends of long bones, near the joints. Their growth is directed in the opposite direction from the joint. The most susceptible to the formation of growths are the tibia and femur, bones of the forearm, pelvis, collarbone, scapula, ribs, and vertebrae.

Osteochondral formations on the phalanges of the fingers are quite rare. There they form subungual growths that grow up to 1 cm in diameter. Exostosis of this particular type most often causes pain if it leads to peeling and deformation of the nail.

Growths located in other parts of the body usually do not cause pain. If pain appears, this may serve as a signal of what is happening. malignant degeneration osteochondromas.

Multiple exostoses are usually located symmetrically along the long bones, near the ribs and collarbones. They can provoke skeletal deformation due to disorders correct height bones.

Separately, we should highlight exostoses of the vertebral bodies and knee joints. Vertebral exostosis may begin to grow inward, causing serious damage to the spinal cord.

Exostosis of the knee joint begins to grow with femur and grows under the quadriceps femoris muscle, putting pressure on it. This causes deformation and stretching of the muscle, and in some cases can provoke a fracture and the formation of a new pseudarthrosis.

Diagnostics (How does a doctor make such a diagnosis)

Exostosis is diagnosed during examination and palpation. To clarify the diagnosis, radiography is necessary. In some cases, when the disease is asymptomatic, its presence is determined by chance by taking an x-ray of the extremities.

Radiography gives a complete picture of the presence of exostoses, their quantity, size, location, shape, structure, stage of development, etc. The x-ray does not show the outer cartilage layer, so the actual size of the growths is always larger than visible.

Treatment

In cases where the exostosis is small in size, which does not change over time, has not become larger by the age of 20 and does not interfere normal life body, then it is periodically monitored. Therapy is not carried out in such cases.

It is important to consider that it is prohibited to use any physiotherapeutic methods on the places where exostoses are located. Since such an influence can provoke the degeneration of a growth into a malignant neoplasm.

If exostoses grow rapidly, cause inconvenience and discomfort, cause curvature of the spine or are cosmetic defect, then they are removed surgically.

The operation is performed by a traumatologist-orthopedist. Its type is selected depending on the size and location of the formation. This also determines the choice of anesthesia - local or general.

During the operation, not only the growth itself is removed, but also the periosteum adjacent to it is scraped off. This must be done in order to prevent the recurrence of exostoses.

Most often, a small incision is enough to perform surgery, which allows you to leave the clinic on the day of the operation. The rehabilitation period is 10-15 days.

An exception is the removal of exostoses from the knee joint. After the operation, the knee is immobilized with a plaster splint for 2 weeks, after which the load on the affected leg is limited for another 1-2 months to prevent possible fracture joint

If there are multiple exostoses, then only those that cause the development of deformities or compress nerves and blood vessels are removed.

At correct implementation After surgery, complete recovery occurs and no relapses are observed.

Prevention

Specific preventive measures does not exist. It is necessary to undergo periodic inspections and examinations, especially in childhood, when the risk of exostosis formation is quite high. In addition, it is imperative to carry out preventive examinations after injuries, as they can become trigger mechanism formation of exostosis.

Exostosis

What is exostosis?

The process of ossification during exostosis is usually accompanied by transformation into spongy bone, enclosed on the outside in a thin and dense bone shell. The surface of the bone exostosis is a layer covered with hyaline cartilage, the thickness of which is only a few millimeters. From such a cartilaginous head the growth of the entire exostosis subsequently results.

According to M.V. Volkov (1974), this disease accounts for 27% of all primary tumors and tumor-like skeletal dysplasias in children, and according to Adler (1983), osteochondral exostosis among benign tumors bones are found in 40% of cases.

The disease occurs in two forms: multiple exostotic chondrodysplasia and solitary osteochondral exostosis. Both solitary and multiple osteochondral exostoses can affect any bone. The favorite localization is the metaphyses of long tubular bones. In 48% of all osteochondral exostoses, lesions are detected in the distal metaphysis of the femur, proximal metaphyses of the humerus and tibia. The disease is usually detected in childhood and adolescence.

Clinical symptoms depend on the form of the disease, location, size of exostoses, their shape and relationship with surrounding organs and tissues.

With solitary lesions, as a rule, bone density, motionless relative to the bone, tumor-like formations of various sizes and shapes are detected; skin above them are usually not changed. Large osteochondral exostoses can put pressure on blood vessels or nerve trunks, causing pain. The location of exostoses in the spine with their growth towards the spinal canal can cause compression of the spinal cord.

With multiple forms of exostotic chondrodysplasia, symptoms such as short stature, club-handedness, and deformity of the knee joints often come to the fore. Large exostoses are often the cause of severe deformities caused by bulging of the exostosis beyond the bone, its pressure on the adjacent bone and its curvature, disruption of the epiphyseal growth zone and underdevelopment of the epiphysis. The latter often leads to the development of radial or ulnar clubhand (with underdevelopment of the epiphysis of the radial or ulna), hallux valgus or varus deformity.

X-ray picture. At the beginning of their development, exostoses are located in close proximity to the epiphyseal cartilaginous plate from the metaphysis. As the bone grows, moving away from the epiphysis, exostosis can be located in the diaphyseal part of the bone. By the distance of exostosis from the epiphysis, one can judge how long ago it appeared. Form of exostosis The growth of exostosis usually continues during the period of bone growth, but sometimes an increase in its size is noted after the closure of the growth zones.

One of the serious complications of osteochondral exostoses is their malignancy. According to different authors, such complications occur in 3-25% of cases. The cartilaginous coverings of exostosis undergo degeneration, pronounced proliferation and massive growths occur cartilage tissue. Malignancy is more often observed in adult patients. Degenerating exostoses are localized mainly on the pelvic bones, tibia, femur and humerus.

Treatment of osteochondral exostoses is only surgical. depends on their location.

Causes of exostosis

The reasons for the formation of exostosis may be inflammatory process, bruise, strangulation, abnormalities of the periosteum and cartilage, infectious diseases such as syphilis, insufficiency of the functions of the endocrine system or its individual glands. Exostosis is presented, in general, as a persistent formation, however, there are cases when the process of formation of exostosis decreases over time and the exostosis disappears forever.

Often, slowly increasing and not causing pain, exostosis is not marked by clinical symptoms, remaining invisible to both the patient and the doctor. Exostosis is detected by X-ray examination, or by palpation of seals that are already visible during examination.

A large number of scientific works are devoted to elucidating the causes of exostosis; their attention is directed to the study of heredity in this disease. However, even the presence in certain cases of family exostoses, which are inherited, does not yet provide any basis for explaining the occurrence of this disease.

Osteochondral exostosis

Osteochondral exostosis can continue to go unnoticed for a long time, since the growth of osteochondral exostosis is very often not accompanied by symptoms. Exostosis can be detected randomly, for example, during an X-ray examination or when growths or indurations are identified.

Often bone growths do not appear until the age of 8, however, during active skeletal growth in the period from 8 to 16 years, activation may occur and exostosis may develop. Accelerated development of osteochondral exostosis is observed during puberty and is found on the fibula and tibia, as well as in the lower part of the thigh, on the scapula and clavicle.

There are two types of osteochondral exostosis: solitary osteochondral exostosis And multiple exostotic chondrodysplasia. Both types of exostoses can affect any bone. The favorite localization is the metaphyses of the long tubular bone. 50% of all osteochondral exostoses affect the femur, proximal metaphysis of the shoulder joint and tibia. Osteochondral exostosis usually manifests itself in adolescence and childhood.

Diagnostic methods

The clinical picture of osteochondral exostosis depends on the form of the disease, its localization, size of exostoses, shape and connection with nearby tissues and organs. Exostoses of enormous size can affect nerve trunks and blood vessels, causing pain. Osteochondral exostosis in the spinal region, with further growth into the spinal canal region, can lead to compression of the spinal cord.

Diagnosis of exostoses is impossible without radiographic examination. Since in most cases, it is not possible to detect the formed growth upon palpation. X-ray imaging allows you to get an idea of the number of exostoses, the shape of the growths, their size, structure and development. It should be taken into account that the cartilaginous cover covering the growth from the outside is not visible on the x-ray. That is, the true size of exostosis is always larger than what is visible in the picture. This circumstance is especially pronounced in children, since the size of their upper cartilaginous growth often reaches 8-10 mm.

Treatment

There are no methods conservative treatment exostosis. It is only possible to carry out surgery. In what case is it necessary to perform surgery: If there is fast growth exostoses. If the growths put pressure on nerves or blood vessels. If the growth is so large that it appears visually. They try not to perform operations on children before they reach the age of 18, since they often experience spontaneous resolution of exostoses. However, if the growths cause discomfort or increase in size very quickly, then surgery is necessary. Surgical treatment exostosis can be performed under general or local anesthesia. The choice of pain relief method depends on the location of the growth and its size. The surgical technique involves removing the bone growth using a chisel. After which the bone is smoothed. In most cases, the operation is performed through a small incision. The rehabilitation period after surgery to remove exostosis takes no more than 14 days. If a single growth is removed, the patient can begin to stand up on the day of surgery. At the first stage after surgery, a gentle motor regimen is recommended. Then, after the swelling has reduced, a recovery-training regimen is prescribed. It is necessary to restore muscle strength and range of motion. It is very important that movements during training do not cause pain. Training at the first stage is carried out under the guidance of exercise therapy methodologist, then continue on their own.

Treatment of exostosis with surgery

Treatment of exostoses is only surgical. In the case of the formation of multiple exostoses, the first step is to remove overgrown areas of bone tissue that compress nerves and blood vessels. Treatment of exostosis with surgery is carried out by orthopedic traumatologists under general or local anesthesia, depending on the size of the growths on the bone surface and their location. During the operation, overgrown areas of bone tissue are removed, followed by smoothing.

When treating exostosis, our traumatology and orthopedics center performs surgery with minimal tissue trauma and the use of modern technology, as well as the application of internal cosmetic sutures, which allows you to return to an active lifestyle in the shortest possible time. Timely methods for diagnosing exostosis with further effective treatment (if necessary) help to avoid subsequent complications of this disease.

Complications of exostosis

With large exostoses, they may put pressure on neighboring bones, and bone defects and deformation of the bones of the extremities are sometimes observed. Very in rare cases Fractures of the exostosis stalk are observed. The most serious complication is the transformation of exostosis into a malignant tumor. Most often, malignant transition occurs with exostoses of the hip, scapula, pelvis, and vertebrae; Histologically, such osteogenic sarcoma can have the structure of chondrosarcoma, chondromyxosarcoma and spindle cell sarcoma, i.e., a malignant tumor of a very different morphological structure.

Prevention

The only prevention of exostosis is regular examination and preventive examination. It is especially important to carry it out among children, since the formation of exostosis can cause improper development of the skeleton and will cause a lot of trouble in the future.

Ministry of Education and Science of the Russian Federation

Federal State Budgetary Educational Institution of Higher Professional Education

in physical education

on the topic: Exostotic disease

Performed:

Art. gr. B445 Kan A. R.

Checked:

Batueva D.V.

Exostosis is a benign, dense, hard growth on the plane of the bone. It affects the oral cavity and gradually forms from hardened cartilage tissue. These neoplasms look like nodes, delimited by convolutions.

Their number varies from one to several at once. Aesthetically similar to pink to spiky mucosal compactions white flowers. Their size varies from a pea to the size of a large apple. Most often they settle near the molars on the side of the palate or on the bend of the lower jaw.

The duration of the disease is determined by significant pain of variable intensity and aching origin. Very often there is a malfunction normal condition joint, which stands next to the growth. Accumulation of pain in the appendages and epimetaphyses of long tubular bones is characteristic.

As the tumor grows, the cortex becomes thinner. Thinning and swelling of the endplate of the appendage is possible; sometimes formed periosteal layers appear in the area of the metaphysis of the bone.

Causes of exostosis

Typically exostosis refers to hereditary diseases, but it is sometimes difficult to determine its presence, since it develops without causing discomfort to the wearer and does not make itself known in any way for a long time. Although sometimes it is possible to probe it.

In addition to hereditary facts, there are inflammatory processes of different nature(flux, syphilis), injuries(improper fusion of bones leads to the formation of a growth), abnormalities of jaw development, some endocrine diseases.

It also happens that exostosis forms after complex removal tooth There is information that it can go away on its own, simply resolve.

Osteochondral exostoses are divided into 2 types:

Multiple exostotic chondrodysplasia (deviation of direction during growth in the territory of the cartilaginous plate and cartilage growth zone);
Solitary osteochondral exostosis (congenital benign education- osteochondroma).

Based on the origin of exostosis, conclusions can be drawn about its size, shape and location. If the growth occurs after an injury, then it may be located on the fusion of bones. In the case of an inflammatory process, the site of dislocation is located next to the source of pus.

Hereditary disease is detected in early age, its maximum growth occurs in puberty a child and most often does not need treatment, since by the age of 18 it tends to go away. The final diagnosis can be based on x-ray examination.

Symptoms

unknown origin;
There is a feeling that there is not enough space for the tongue;
Friction of the tongue in the gum area,
Aching pain in the jaw area.

Indications for removal of exostosis

The direct basis for removing exostosis is its fast growth. Also one of the indications for surgical intervention can serve the planned prosthetics(replacement of teeth or dentition with dentures).

An enlarged growth not only looks visually unacceptable, it dangerous to overall health and is fraught with complications, and belated surgery promises to be much more traumatic than timely. A person can simply complain about periodic pain, because there is pressure on the roots of the teeth.

A benign tumor in the lung can turn into a malignant tumor (cancer).

Removal is permissible only surgically; no local therapy will bring results. Extra bone tissue needs to be deleted.

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Exostosis removal technique

Before going under the surgeon's knife, you need to go through thorough examination. Determine the exact cause and know the consequences. The operation must be performed by a highly qualified specialist. Operation time is no more than 2 hours and general or local anesthesia is used (it all depends on the volume of removals performed).

There is an alternation of several stages. The doctor disinfects with special disinfectant compounds oral cavity. A small incision is made on the gum. The process of getting rid of using a chisel or laser.

That is, the bone formation is first removed and then smoothed by grinding with a drill. After the necessary insinuations stitches are placed and private bandage. With non-global interventions, the patient can leave medical institution on the same day.

The rehabilitation period lasts from 2 to 5 days. Sometimes after the procedure there remains slight swelling and pain at the operation site. In such a situation, you should take anesthetics and medications prescribed by your doctor to heal the wound. Of course, you should monitor the seams, prevent them from coming apart, and monitor the hardness of the food you eat. The prognosis in almost 100% of cases is good, the tissues quickly grow together and a speedy recovery occurs.

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Contraindications for removal

It is necessary to take into account existing contraindications to surgical intervention:diabetes (endocrine disease, increased level blood sugar) poor clotting blood(during surgery, the wound may not close and bleed), problems with the endocrine system ( hormonal imbalance), bad job adrenal glands, thyroid diseases.

After surgery, in rare cases, they worsen chronic diseases, especially the cardiovascular system.

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Complications that occur after surgery

Complications are often the responsibility of the patient. Dehiscence of sutures on a wound in most cases occurs due to the patient’s dishonest attitude towards his health. Active chewing of hard food is an almost absolute guarantee of a poor outcome from the operation.

Use not recommended alcoholic drinks, chewing gum and soft sweets, tobacco products. Should be excluded oral sex. Brush your teeth carefully. Physical activity jogging should be postponed Gym- will not be beneficial throughout the rehabilitation period.

The attending physician prescribes antibiotics and oral rinses. special compounds and solutions. The wound must be protected from any impact and infection. In the presence of low immunity And large quantity microbes in the mouth, the healing process is delayed up to a calendar month.

Prevention

The only prevention of exostosis may be constant and high-quality examination. Self checks oral cavity for foreign growths and discomfort, you need to palpate the gums and examine them for bleeding and any changes. If you take your health seriously - positive result will not keep you waiting.

You should not spare money and time to inspect and maintain normal functions your body and your loved ones. Work, study, household chores are important things, but compared to your well-being, they are secondary. Today a person will save on his health, and tomorrow he will spend a fortune on restoring it. Be carefull, do not let the disease defeat you. good health and cheers to you!

Exostosis

Exostosis is a benign bone or osteochondral growth on the surface of the bone. It has the appearance of linear, spiky, spherical or other formations.

Typically, during the process of ossification, exostosis turns into spongy bone, which is covered on the outside with a thin and dense bone shell. The surface of the bone exostosis is a layer covered with hyaline cartilage. Exostosis subsequently grows from this cartilaginous head.

Most often, exostosis is a persistent disease, but in some cases the process of its formation decreases over time and the formation disappears.

Causes

Exostosis may occur due to inflammatory process, bruise, incarceration, abnormalities of the periosteum and cartilage. The reasons for its formation may be infectious diseases (syphilis), disruption of the endocrine system or its individual glands.

Symptoms of exostosis

Typically, exostoses are not accompanied by clinical symptoms, but slowly and painlessly increase, remaining for a long time invisible to the patient and the doctor. They are discovered accidentally during an X-ray examination or after the appearance of a lump that can be felt under the skin or becomes noticeable during examination.

Most often, exostoses are formed on hip bones, shoulder joint, tibia, scapula, clavicle. Very rarely, the disease affects the feet and hands.

Diagnostics

In most cases, exostoses are not palpable enough when clinical trial. Therefore for full diagnostics(determining the shape, size, position, structure and other characteristics) it is necessary to conduct radiography.

Types of disease

Solitary osteochondral exostosis. Fixed bone spurs can be different sizes, the skin over them does not change. As they grow, they can put pressure on nerve trunks and blood vessels, causing severe pain in the field of finding education.
Multiple exostotic chondrodysplasia. This species is characterized by various deformities of the knee joints, short stature, and club-handedness. These deformities occur because the growth, as it grows, touches the adjacent bone, damaging and bending it.

Patient Actions

If exostosis is detected, the patient must agree to surgery to remove the growth. As you grow, the risk of complications increases, and the operation will be more traumatic.

Treatment of exostosis

Exostoses can only be treated surgically. Indications for removal of growths are their rapid growth, pain, big sizes, cosmetic defect.

The operation involves removing the bone formation using a chisel. The bone is then smoothed. In most cases, the operation is performed through a small incision. The rehabilitation period is up to 14 days.
The operation to remove exostosis is performed by orthopedic traumatologists under general or local anesthesia. The type of anesthesia depends on the size of the growths and their location.

In children under 18 years of age, exostoses often disappear on their own, so surgery is usually not performed in children. Surgery is needed if the growth causes pain or rapidly increases in size.

Complications

With the growth of exostosis located in the spine, compression of the spinal cord is possible.

Multiple exostosis in childhood threatens skeletal deformation.

With the rapid growth of exostosis, there is a risk of its malignant degeneration.

Prevention of exostosis

Prevention of exostosis is periodic examination and examination. This is especially important in childhood, since in children exostosis can cause skeletal deformation.

Another method is a preventive examination after an injury, since bruise and bone damage are one of the causes of the development of the disease.