Musculoskeletal system

The bony skeleton provides the framework or the structure for the body’s various organ systems,
as well as the mechanisms for movement and locomotion. Additionally, bone is also the site for mineral
metabolism and homeostasis, as well as a site for hematopoiesis. Development of the skeleton, or
morphogenesis, begins in the fourth week of life in utero. Bone forms by either the process of
endochondral ossification (long bones) or intramembranous ossification (flat bones and clavicles). The
continued development and remodeling of the bone are a function of osteoblasts (bone-forming cells),
osteocytes (mature bone cells), and osteoclasts (bone-breakdown cells). Osteoblasts are modified
fibroblasts which have collagen fibres deposited round them, calcium salts then accumulate here to
increase bone size. Osteoclasts, developed from the bone marrow stem cells, then continually shape
bone by removing excess material.
Bone is involved in the mineral homeostasis of calcium, phosphorous, parathyroid hormone,
vitamin D, and calcitonin. Bones are composed of an organic and inorganic matrix (the noncellular
material surrounding cells within a tissue). The organic matrix is proteinaceous and consists largely of
collagen. The inorganic matrix is a calcium phosphate salt known as hydroxyapatit. About 99% of the
calcium within the body and 90% of the phosphorus are deposited in bones and teeth. These minerals
give bone its rigidity, and they account for approximately two thirds of the weight of bone. In infants
bones contain more water and less minerals then in adults. The blood supply and vascularisation of
bones is well developed.
Enormous changes in the musculoskeletal system occur during infancy. Much of the newborn
musculoskeletal exam focuses on detection of congenital abnormalities, particularly in the hands,
spine, hips, legs, and feet. Musculoskeletal examination often must be combined with the neurologic
and developmental examination.
The infant’s head shows the skull bones to be thin and the facial bones small. The jaw is small at birth
with usually no teeth, but grows until puberty when adult proportions are apparent. The shape of the
head, its symmetry, and the presence of abnormal faces should be observed and head circumference
measured in children under 3 years. At birth, a baby’s head may seem relatively large. A newborn’s
head accounts for one fourth of the body length and one third of the body weight; these proportions
change, so that by adulthood the head accounts for one eighth of the body length and about one tenth of
the body weight. The bones of the skull are separated from one another by membranous tissue spaces
called sutures The areas where the major sutures intersect in the
anterior and posterior portions of the skull are known as
fontanelles. On palpation, the sutures feel like ridges and the
fontanelles like soft concavities. The anterior fontanelle at birth
measures 4 cm to 6 cm in diameter and usually closes until 18
month. The posterior fontanelle measures 1 cm to 2 cm at birth
and usually closes by 2 months. An enlarged posterior fontanelle
may be present in congenital hypothyroidism. A bulging, tense
fontanelle is observed in infants with increased intracranial
pressure, which may be due to central nervous system infections,
neoplastic disease, or hydrocephalus (obstruction of the
circulation of cerebrospinal fluid within the ventricles of the
brain). A depressed anterior fontanelle may be a sign of
dehydration. Overlap of the cranial bones at the sutures at birth,
called molding, results from passage of the head through the birth
canal; it disappears within 2 days.
Dilated scalp veins are indicative of long-standing increased intracranial pressure. It is best to palpate
the fontanelle while the baby is sitting quietly or being held upright.

1
 A newborn’s scalp is often swollen from localized subcutaneous edema over the occipitoparietal
region, called caput succedaneum, caused by distension of capillaries and extravasation of blood and
fluid resulting from the vacuum effect of rupture of the amniotic sac. This swelling often crosses over
suture lines and resolves in 1 to 2 days. Another type of localized swelling of the scalp is a
cephalohematoma, due to subperiosteal hemorrhage from the trauma of birth. This swelling does not
cross over suture lines and resolves within 3 weeks. As the hemorrhage resolves and calcifies, there
may be a palpable bony rim with a soft center. Premature closure of one or more cranial sutures causes
craniosynostosis, with an abnormally shaped skull. Palpation may reveal a raised bony ridge at the
suture line. Craniotabes can be due to increased intracranial pressure as in hydrocephaly, metabolic
disturbances such as rickets, and infection (e.g., congenital syphilis). The premature infant’s head at
birth is relatively long in the occipitofrontal diameter and narrow in the bitemporal diameter
(dolichocephaly). Usually the skull shape normalizes within 1 to 2 years.
At birth, only the ethmoid sinuses are developed. Maxillary sinuses are noted on x-rays by age 4
years, sphenoid sinuses by age 6, and frontal sinuses by age 6 to 7.
Teeth should be examined for r the timing and sequence of eruption, number, character,condition,
and position. Abnormalities of the enamel may reflect local or general disease. As in most
developmental changes of childhood, there is a predictable progression of tooth eruption and also a
wide variation in the age of eruption. A rule of thumb is that the infant will have one tooth for each
month of age between 6 and 26 months, up to the full complement of 20 primary teeth. In general,
lower teeth erupt a bit earlier than upper teeth. Staining of the teeth may be intrinsic or extrinsic.
Intrinsic stains may be due to tetracycline use prior to 8 years (yellow, gray, or brown stain). Iron
preparation (black stain) is an example of extrinsic stain. Extrinsic stains can be polished off; intrinsic
stains cannot. Dental caries are caused by bacterial activity. Caries are more likely among young
children who have prolonged bottle-feeding
The infant’s thorax is more rounded than that of older children and adults. Also, the chest wall in
infancy is thin, with little musculature, and therefore lung and heart sounds are transmitted quite
clearly. The bony and cartilaginous rib cage is very soft and pliant. In infants and young children ribs
lie horizontal, making it difficult for small children to breathe thoracically; they persist with
diaphragmatic movement.The tip of the xiphoid process is often seen protruding anteriorly immediately
beneath the skin at the apex of the costal angle. Two types of chest wall abnormalities noted in
childhood include pectus excavatum, or “funnel chest,” and pectus carinatum, or “chicken breast
deformity”
The infant head circumference is the same as the chest; that of the abdomen is greater than both.
The normal young child has increased lumbar concavity and decreased thoracic convexity compared
with the adult, and often a protuberant abdomen, until the age of two years when the pelvic bones grow
and allow abdominal contents to drop down into it.
The vertebral spine has two primary curves present at birth, but normally by
adolescence four vertebral curves are evident; the cervical (lordotic), the thoracic
(primary curve), the lumbar (lordotic) and the sacral (primary curve

The spine should be examined

carefully. While major defects
of the spine such as
meningomyelocele are obvious
and often detected by ultra-
sound prior to birth, subtle
abnormalities may include
pigmented spots, hairy patches,
or deep pits. These abnor-
malities, if present within 1 cm
or so of the midline, may
overlie external openings of

2
sinus tracts that extend to the spinal canal. Palpation of the the spine, particularly in the lumbosacral
region, gives possibility to notise any deformities of the vertebrae. Inspection for scoliosis is
nessassary. The child bend forward with the knees straight (Adams bend test) and examiner evaluates
any asymmetry. Scoliosis in a young child is unusual and abnormal; mild scoliosis in an older child is
not uncommon
Examination the newborn and infant’s hips at must be conducted at each examination for signs of
dislocation. There are two major techniques, one to test for the presence of a posteriorly dislocated hip
(Ortolani test), and the second to test for the ability to sublux or dislocate an intact but unstable hip
(Barlow test). The baby should be relaxed for the next two techniques, som,times it' is usefull bottle or
pacifier. For the Ortolani test, place the baby supine with the legs pointing toward you. Flex the legs to
form right angles at the hips and knees, placing your index fingers over the greater trochanter of each
femur and your thumbs over the lesser trochanters. Abduct both hips simultaneously until the lateral
aspect of each knee touches the examining table. A palpable movement of the femoral head back into
place constitutes a positive Ortolani sign. With a hip dysplasia, you feel a “clunk” as the femoral head,
which lies posterior to the acetabulum, enters the acetabulum.
For the Barlow test, place your hands in the same position as for the Ortolani test. This time, press
in the opposite direction with your thumbs moving down toward the table and outward. Feel for any
movement of the head of the femur laterally. Normally there is no movement and the hip feels “stable.”
If you feel the head of the femur slipping out onto the posterior lip of the acetabulum, this constitutes a
positive Barlow’s sign. If you do feel this dislocation movement, abduct the hip by pressing with your
index and middle fingers back inward and feel for the movement of the femoral head as it returns to the
hip socket. A positive Barlow’s sign is not diagnostic of a dysplastic hip, but it indicates laxity and a
dislocatable hip progressively, and the baby needs to be reexamined in the future Children older than 3
months may have a negative Ortolani or Barlow sign and still have a dislocated hip due to tightening of
the hip muscles and ligaments.
Skeletal age is best measured at the left wrist and hand. An individual is compared to standard
radiography (TW2 method). This is a score of the stage of development of the twenty bones of the wrist
and hand. The score is relatively subjective and depends on the presence of bones and epiphyses, and
the relationship of their size, shape and markings.