Musculoskeletal Disorders in Children

A big part of learning about pediatrics is understanding different musculoskeletal disorders in children. Rather than going through each of these using the full Straight A Nursing LATTE method, I’ve provided a concise summary of these conditions below. To review soft tissue injuries and fractures, check out this article, too!

Developmental dysplasia of the hip (DDH)

This condition involves abnormalities of the acetabulum or femoral head that can be caused by genetic, mechanical or physiological factors. Babies at higher risk for DDH are those with a family history, babies with congenital disorders such as spina bifida, those with breech presentation, babies who experienced crowding in utero, and babies who’ve had a difficult or prolonged delivery.

• Signs of DDH in infants are a positive Ortolani or Barlow maneuver, shorter limb on affected side, asymmetrical gluteal and thigh folds, and decreased abduction.
• Signs of DDH in older children are a shorter limb, telescoping mobility which is present in hip dislocation, a positive Trendelenburg sign, waddling and lordosis. Note that a Trendelenburg sign is positive when the patient places their weight on the affected side, the pelvis rises on that side and dips on the opposite side.
• Treatment for newborns and infants involves wearing a Pavlik harness for 22 to 24 hours a day for about six to twelve weeks, though some children may need surgical reduction. A key thing to know about a Pavlik harness is that it is considered a dynamic brace because it is not rigid and allows the child to move their legs. It holds the baby’s legs in a position that allows the hip joint to align properly so that it develops normally.
• Treatment in older infants and toddlers includes the child wearing an abduction brace, but they may need surgery and a spica cast. The cast is typically changed every six weeks to allow for growth and worn for three to six months. Once the cast is removed the child wears a hip abduction brace for several weeks as they build up their strength. A key teaching tip that could be on exams is to teach parents not to pick the child up by the waist as this puts all the weight of the cast on their lower body. Instead, pick the child up by the waist while supporting the thighs and trunk. It is also not recommended to use the crossbar of the cast as a handle as this could cause the cast to break.
• Treatment for older children usually means surgery, casting and extensive physical therapy.

Talipes equinovarus (TEV) aka “clubfoot”

In this condition the foot is pointed down and turned inward. It may be due to hereditary factors, position in utero or abnormal development. When the cause of the clubfoot is due to malposition, it generally responds well to stretching and serial casting which allows for gradual improvement. In some mild cases it may even resolve on its own. Congenital and teratologic TEV, however, usually require surgery and casting to prevent relapse. 

Metatarsus adductus (aka metatarsus varus)

This is the most common congenital foot deformity in children and involves abnormal adduction of the toes and forefoot. It often occurs with a kidney shaped lateral border due to intrauterine position or crowding. Treatment for this condition is often not needed as it may resolve on its own. However, it can be resolved more quickly with gentle manual manipulation. In cases of severe deformity, manipulation and serial casting may be needed.

Skeletal limb deficiency

Limb deficiency or abnormality usually refers to a congenital condition that involves a loss of function. 

• Amelia is a congenital defect that involves one or more missing limbs.
• Meromelia involves the partial absence of one or more limbs.
• Phocomelia is a condition in which a well developed hand or foot is near the location of the shoulder or hip, due to a deficiency in the long bones.

In cases where the skeletal limb deficiency is not hereditary, it may be due to exposure to certain medications, viruses, chemicals and smoking. An example of a medication that caused this abnormality is thalidomide, an immunosuppressant medication that is now used to treat multiple myeloma and leprosy. In the 1950s and 1960s, it was used for its sedative effects and to treat colds, flu, nausea, and “morning sickness.” As such, more than 10,000 children were born with phocomelia in what has now been deemed the “thalidomide tragedy.”

Treatments for skeletal limb deficiencies include prosthetics, splints, bracing and physical therapy and occupational therapy to maintain functional ability.

Osteogenesis imperfecta

Osteogenesis imperfecta, aka “brittle bone disease, is a genetic connective tissue disorder that causes bones to fracture easily. Patients with osteogenesis imperfecta have reduced type 1 collagen which leads to faulty bone mineralization, abnormal bone formation, and extreme fragility of the bones.

Signs and symptoms of osteogenesis imperfecta are:

• Bone deformities
• Fractures in various stages of healing
• Short stature (more notable at about 12 months of age and beyond)
• Blue sclera
• Conductive hearing loss due to abnormal bones of the ear
• Dental abnormalities
• Cardiac abnormalities such as aortic root dilation and valve insufficiency
• Frequent lung infections or respiratory difficulties due to reduced lung capacity, poor secretion clearance and ineffective cough

There is no cure for osteogenesis imperfecta and treatment is supportive. Fractures are treated as they occur and patients are prescribed bisphosphonates to increase bone density. Other medications may include anti-RANK ligand antibodies, parathyroid hormone and growth hormone. Surgery may be needed to correct deformities and prevention strategies include physical therapy, braces, splints, and dressing young children in multiple layers to provide additional padding. Because osteogenesis imperfecta is a hereditary condition, genetic counseling is advised in those with a family history.

Legg-Calvé-Perthes (LCP)

This is a self-limiting vascular necrosis of the femoral head that only affects children. It can occur at any age, though it most often occurs between the ages of  four and ten years old. The etiology of LCP is unknown but it is thought to be due to a temporary alteration in circulation or vascular supply to the femoral epiphysis. 

Signs and symptoms of LCP:

• Soreness or pain of the hip, thigh and/or knee of the affected side
• Achiness or stiffness of the affected side
• Intermittent limp
• Limited range of motion

Treatment for LCP involves rest, casting or surgery, depending on the age of the child and severity of the condition. The cast worn for LCP is a special cast that keeps the legs spread apart in a wide V, and is typically worn full time for a period of six months. Children with LCP have a higher risk of developing degenerative arthritis especially when there is significant damage to the femoral head.

Slipped capital femoral epiphysis

This is the most common hip disorder affecting adolescents. It involves a spontaneous displacement of the proximal femoral epiphysis and results in displacement and deformities of the femoral head. It usually develops during “growth spurts” and occurs secondary to weakness caused by collagen deficiencies. Additionally, obesity increases the risk for developing the condition and over 80% of children diagnosed with the condition are obese.

Treatment involves preventing further slipping until the physeal plate closes. The most common surgical procedure is screw fixation, which involves the use of screws to keep the ball of the femur from slipping out of position.

Scoliosis

Scoliosis is a lateral curvature of the spine that is greater than 10-degrees. In mild cases the individual may have no outward signs but more severe cases can cause asymmetrical shoulders, a visible curvature of the spine, rib deformities, cardiopulmonary complications and pain. 

A common method for scoliosis screening used in schools is the “Adam’s forward bend test.” However, the test is not conclusive for scoliosis and other diagnostics are utilized. The key diagnostics used for scoliosis are physical examination, spinal radiograph, CT scan, and MRI. Additionally, a scoliometer is a tool used to measure the angle of the spine, and it looks like a cross between a ruler and a level. The most widely used measurement to quantify the degree of spinal curvature is the Cobb angle:

• Less than 10 degrees is normal
• 10 to 25 degrees is mild scoliosis
• 26 to 45 degrees is moderate scoliosis
• Greater than 45 degrees is severe scoliosis

Mild to moderate scoliosis is typically treated with bracing. However, when the Cobb angle gets above 40 degrees, then surgery is typically recommended. 

Pectus excavatum

This is a congenital chest wall deformity caused by abnormal growth of the cartilage that connects the sternum to the ribs, resulting in a “sunken” chest. The severity of the deformity ranges from mild to severe. Those with moderate to severe pectus excavatum can experience respiratory difficulties such as shortness of breath, exercise intolerance and chest pain. Severe cases can even put pressure on the heart leading to cardiopulmonary impairment. The treatment for moderate to severe cases is surgery.

Kyphosis and lordosis

Kyphosis is an outward curvature (or hump) of the thoracic spine and is often related to posture. Lordosis (also known as “swayback”) is an inward curvature of the cervical and or lumbar spine that causes the abdomen to protrude forward and the buttocks to protrude outward.

Children with spinal curvature may have stiffness, tight hamstrings, and back pain. When significant, the curvature can lead to psychosocial issues regarding body image. 

Treatment involves managing the cause of the curvature. The plan may involve losing excess weight, postural correction, supportive garments, physical therapy and stretching. NSAIDS, heat, and cold may be used to address any pain that may be present. 

Osteomyelitis

This infection of the bone most often occurs in the pelvis, humerus, tibia, femur or foot. It can be related to an open fracture or puncture wound, nearby tissue infection, surgery, burns, pyelonephritis, otitis media and even respiratory infections. Signs and symptoms of osteomyelitis are pain, fever, tachycardia, swelling, limited ROM and reluctance to bear weight on the affected extremity.

Treatment involves IV antibiotics for an extended period of time (three weeks to four months). Surgery may be indicated in severe or chronic cases. 

Juvenile idiopathic arthritis

This is a chronic childhood arthritis that involves inflammation of the joint synovium and surrounding tissues. Over time it can develop into adhesions (bands of scar-like tissue) and ankylosis (an abnormal stiffening of a joint due to fusion of the bones). Both can cause pain and severely limit mobility and range of motion. 

There are several types of juvenile idiopathic arthritis and symptoms will vary depending on the type. However some commonalities among all types are joint swelling, joint pain, warmth and stiffness that are typically worse after periods of immobility. Additionally, other body systems can be affected leading to things like uveitis, rash, fevers and growth abnormalities. 

The treatment for juvenile idiopathic arthritis include pain medication, anti-inflammatory medications, DMARDs, glucocorticoids, heat therapy, physical therapy and occupational therapy. 

Achondroplasia

In achondroplasia, cartilage is unable to change into bone resulting in dwarfism. It is a genetic disorder with a wide range of symptoms, including disproportionate short stature, short limbs, macrocephaly (large head), hypotonia (which can affect motor skill development), bowing of the legs, a flat nose, prominent forehead, and a maximum height of four feet.

Potential complications associated with the condition include obesity, sleep apnea, recurrent ear infections, lordosis and/or kyphosis, and hydrocephalus.

There is no cure for achondroplasia itself, but patients may require treatment to manage complications. Patients may also receive growth hormone and a newer medication called vosoritide is being used to increase height in children with achondroplasia who are five years of age and older. 

Osteochondroma

Osteochondroma is the most common non-cancerous bone tumor in children. They are typically symptom free, but there may be a noticeable bump that could cause the child some discomfort or press on nerves leading to muscle weakness. They typically occur near a growth plate, especially around the upper arm and knee. The osteochondroma grows until puberty is complete and they’re more likely to be present in male children.

When the osteochondroma causes pain, affects growth or restricts range of motion, then surgical removal may be necessary. 

Osteosarcoma

Osteosarcoma is the most common malignant (cancerous) bone tumor in children, though it’s important to know it is rare overall. Signs and symptoms of osteoscarcoma include pain that progresses over time and may wake the child from sleep, tenderness, swelling, stiffness, difficulty walking, fractures, weight loss, anemia and fatigue. When the osteosarcoma is located near the spinal cord, the child may complain of back pain that radiates to the extremities.

Osteosarcoma is treated with chemotherapy and surgery. Some children may require joint replacement or an allograft with cadaver bone, while others may need to have the limb amputated. A highly specialized type of amputation surgery is a rotationplasty. In this procedure, the knee with the sarcoma is removed along with the surrounding tissues including the upper thigh. The nerves and blood vessels are preserved and the calf and foot are rotated 180 degrees and attached to the portion of the upper thigh that remains. The foot now points backwards, essentially allowing the ankle joint to serve as a knee joint. This allows for greater mobility when used with a prosthesis.

I hope this helps you understand musculoskeletal disorders in the pediatric population. For more pediatric articles, click here.

If you are passionate about pediatric nursing, please check out this incredible book, Nurse Papa. The author, David Metzger, is a pediatric nurse who shares his wisdom and insight about nursing and parenting in this beautiful and heartfelt collection. He also has a podcast, called Nurse Papa which you can explore on any podcast player or right here.

Review Pediatric Musculoskeletal Disorders for your exams, clinicals, and NCLEX while you’re on the go by tuning in to episode 283 of the Straight A Nursing podcast. Tune in wherever you get your podcast fix, or straight from the website here.

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