This document discusses the musculoskeletal system in children. It notes that the high growth and bone development in children makes this system prone to issues. The goal is to study the anatomy and physiology of bones and muscles at different ages, and recognize common symptoms of problems. Key areas covered are the composition and investigation of the bone and muscle systems, common musculoskeletal issues in children, and how to objectively examine the head, chest, spine, pelvis and extremities. The student should learn examination techniques and be able to identify typical complaints and evaluate objective findings related to this system in children.

1. SKIN AND SUBCUTANEOUS FAT
The current relevance of a research: Due to its anatomic and physiological
peculiarities concerning children subcutaneous fat and skin take an active part in all the
exchange and immune processes, they are treated as tissues that are characterized by the
fast development in childhood. That is why skin and subcutaneous fat affections may be
the evidences of the affected organism.
The aim of the lesson: To study the anatomic and physiological peculiarities of
skin and subcutaneous fat among children of different ages, as well as with symptoms of
their affection.
As the result of the self-training the student must know the following:
1. Anatomic and physiological peculiarities of skin and subcutaneous fat.
2. The skin and subcutaneous fat functions in age aspect.
3. The peculiarities of skin and subcutaneous fat for newborns, physiological and
transitory states of skin and subcutaneous fat within the period of newborns.
4. The methods of skin and subcutaneous fat investigation.
5. The skin and subcutaneous fat affection semiotics.
As the result of topic covering the student must be able to:
1. Collect the anamnesis, to analyse the complaints typical for the skin and subcutaneous
fat affection.
2. Evaluate the skin colour, its humidity, temperature, the skin fold thickness, skin
elasticity, dermatographism, the state of capillaries; in case of eruption pserence one
must be able to find out its nature.
3. Evaluate the skin and subcutaneous fat state (turgor, oedemata, infiltration, tha state of
development).
Skin glands in age aspect:
Oil glands may be found on all the skin districts, except for palms, feet and dorsal
side of feet. Their ducts open to the hair follicle, except for lips skin, preputial bags and

2. small (lower) lips of pudendum, where they open on the surface directly. The oil glands
activity depends on androgenic stimulation (the mother’s androgens stimulation for
foetus).
Apocrine glands are located at axillary sockets, perianal and privy parts districts,
near umbilicus. They produce the milk-like odourless secret. It is pushed out under the
androgen stimulators action to the surface. Under the influence of bacteria it becomes
smelly, this smel is connected with perspiration. These glands are “sleeping” up to the
pubertal period.
Eccrine (merocrine) glands are spread over the whole body’s surface. They
response to the temperature on hair districts and regulate the body’s temperatutre by
means of water transportation to the skin surface where it is turned into a vapour. Their
ducts are opened to the skin surface. The glands are provided with sympathetic nerve
endings.
Skin eruption elements:
Primary: appear in visually unchanged skin.
Spot (makula) – primary non-cavernous skin eruption element which changes
the skin colour only, it disappears when pressed. May be of inflammation and non-
inflammation genesis. According to its size is divided into roseolas (less than 5 mm in
size), proper spots and erythema (more than 20 mm in size). Among the spots of non-
inflammation genesis hemorrhagic ones are the most frequent to meet; they are divided
into petechia, purpura (2-5 mm in size), linear (vibices), ecchimozes (“bruises” >5 mm),
big formless spots – sugilation (???),haematoma. The spots can be dypigmented (vitiligo,
albinism), hyper pigmented (freckles, chloasma, birthmarks). Typhoid maculopapular
rash is present in case of typhoid, syphilis, measles and German measles. Punctate (finely
papular) rash is typical for scarlet fever and measles. Telangiectasia (vessels units having
the star form) are also treated as spots. They are the evidence of liver affection.
Papule (papula) - is the vessel knit, non-cavernous element which changes the
skin consistence and relief. Appears as the result of different pathological processes
taking place in epidermis and skin upper layers (infiltrate skin accumulation, skin tissues
hypertrophy, protein products precipitations. Depending on the size the following types

3. are distinguished: miliary, lenticularis (up to 0, 5 cm), numeral (???) (1-2 cm). they may
be of inflammation and non-inflammation (warts) genesis. Papule is most frequent in
case of scab, lichen pilaris, measles, German measles and purpura rheumatica).
Hunch (tuberculum) - is the non-cavernous element located in a gauze layer of
derma, up to 1 cm in diameter, prominent on the skin surface. May be of inflammation
and non-inflammation nature. Is noticed in case of syphilis, wolfish herpes, leprosy and
leishmaniasis.
Nodule (nodus) - is the non-cavernous element located in derma. May be of
non-inflammation (atheroma, lipoma) and inflammation (strophuloderma, leprosy,
rubber, furuncle, carbuncle, nodal eryterma).
Vial (vesicula) – is the primary non-cavernous element having a bottom, cover
and content. If it is less than 1 cm in size, it is vial; if it is more than 1 cm in size, it is
bulb (bulla). The content may be serum, hemorrhagic and purulent. May be located either
in epidermis ar below epidermise. It is typical for eczema, chicken pox, shingles. The
bulb is typical for burns.
Pustule (pustula) – is the non-cavity element with the purulent content located in
epidermis, derma or subcutaneous. May be connected (osteofolliculitis, folliculitis, acne
and hydradenitis) and disconnected (impetigo) with the skin appendages; deep and
superficial.
Bulb (urtica) – is the non-cavernous element (stands between the cavernous and
non-cavernous ones), form as the result of temporary surface blood vessels widening and
liquid blood components release. The examples: nettle-rash, insects bites, nettle burns,
allergic dermatosis).
Secondary: is the stage of primary and secondary elements development.
Secondary pigmentation: - the skin colour change on the place of the previously
existing element.
Peel (squama) – the element consisting of the surface epidermis layers, skin fat,
dust and bacteria.
Erosion (erosio) – the defect in the epithelium boundaries. Ulcer (uslus) – is the
deep defect of skin which reaches the cellar layer, is formed of the deep primary
elements.

4. Excoriation (excoriatio) – scratch, abrasion. Is the linear skin defect caused in
mechanic way.
Crack (rhagades) – is the linear skin defect formed as the result of the skin
wholeness and elasticity.
Crust (crustae) – exudation which is dry; appears on the places of all the
cavernous lements or at the places of secondary elements accompanied by the skin
wholeness affection.
Cicatrice (cicatrix) - conjunctive tissue replaces skin.
Atrophy – all the skin layers get thinner.
Lichenification (lichenificatio) – all the skin layers get thicker, the underlined
picture is present (neurodermatitis, eczema). The skin is wholeness, coarse, the picture is
enforced, there is a lot of furrows, practically cannot be taken to folds.
The ambiguity of skin eruption elements is called polymorphism. The real (true)
polymorphism is represented by several different primary elements, while the false one is
represented by the one primary element on different stages of its development.
The normotrophia, hypotrophy and paratrophy finding out and the
sequence of precipitation and disappearance for children:
Normotrophy – is the normally developed subcutaneous fat.
Paratrophy – is overdeveloped subcutaneous fat among infants. As for eldery
children, the same symptoms stand for adiposity.
Hypotrophy – is the disappearing or lowering of subcutaneous fat (SCF). There
are three detected grades of hypotrophy:
I grade – SCF disappears on stomach, lowers on body and extremities. The body
mass compromise stands for 11-20%.
II grade – SCF disappears on stomach, lowers on body and extremities, but
remains on a child’s face. The body mass compromise stands for 21-30%.
III grade – SCF disappears even on face. The body mass compromise stands for
more than 30%.
SCF precipitation: face, neck and shoulders, body, extremities, stomach.
SCF disapearance: stomach, hip internal surface, body, extremities, cheeks
(Bish’s heaps).

5. Sclerema, scleredema:
Sclerema (focal or diffusive) – is the process of SCF infiltration. Is noticed
among the prematurely born and weak full-term children. Most frequently appears on
cheeks, hips, buttocks, body with the following spread on the neighbouring sound skin
zones. The skin of these zones is cold, tense, pale or with hyperemia.
Scleredema is the process of infiltration or oedema of the definite SCF zone
which spreads over the neighbouring body zones.
Tests:
1. The following elements are treated as the primary skin eruption elements except for:
1.1. Spot;
1.2. Papule;
1.3. Vial;
1.4. Hunch;
1.5. Ulcer;
1.6. Pustule.
2. The following elements are treated as the secondary eruption elements except for:
2.1. Cicatrice;
2.2. Peel;
2.3. Atrophy;
2.4. Hunch;
2.5. Lichenification.
3. Point out the skin zones free of oil glands:
3.1. Lips;
3.2. Palms;
3.3. Neck;
3.4. Shoulders;
3.5. Stomach.
4. What of the given below is not typical for the child’s skin epidermis?
4.1. Epidermis is thin, delicate and light;

6. 4.2. The glittering epidermis layer is noticed on palms and feet only;
4.3. The melanin pigment is absent in growth layer up to the age of 6 months;
4.4. The cambial layer where the epithelium cellars growth takes place is almost
undeveloped.
4.5. All the intercellar connections are very weak, that is why the superfacial
layer cells are easily pilled and traumas are usual.
5. “Thrush” is the following:
5.1. The patch on tonsil as the result of diphtheria;
5.2. The white pellicle in the infant’s mouth cavity left after feeding;
5.3. The fungus affection of the mouth cavity, mostly among infants;
5.4. White dots often appearing on the infants’ faces, the result of the temporary
oil glands ducts closing.
6. The following statements have nothing to do with the childrens’ derma peculiarities:
6.1. The quantity of collagenous (white) fibers is small, they are thin and joined
into the light fascicle.
6.2. The elastic derma fibres are well developed, they are the prevaling ones
during the childish age;
6.3. The papillary derma layer is not enough exposed;
6.4. The water quantity in derma is sufficiently biger for children than for adults;
6.5. The derma’s biochemical composition helps the increased skin penetration.
7. Which of the given below skin peculiarities helps the newborns pemphigus
development:
7.1. Collagenous (white) fibers are thin and joined into the light fascicle;
7.2. Children’ skin contains more water than that of adults;
7.3. Child’s skin is delicate and easilly injured;
7.4. The basic (basement) membrane is undeveloped;
7.5. All given above.
8. Dermatographism is:
8.1. The corresponding skin vessels response on mechanic stimulation by the
blunt item;

7. 8.2. The skin response on the environment temperature change;
8.3. One of the SCF characteristics;
8.4. All given above.
9. What do the jam syndrome positive reaction says:
9.1. Of the increased skin vessels fragility;
9.2. Of the periferal vessels hypo tonus;.
9.3. Of the periferal vessels hyper tonus;
9.4. Of the skin lowered turgor;
9.5. This is the physiological state for the newborn’s skin.
10. The following substances sre prevailing in children’ skin:
10.1. Croton and oleic acids;
10.2. Stearic and arachidonic fat acids;
10.3. Oleic and palmitinic fat acids;
10.4. Capric and linoleic fat acids;
10.5. Palmitinic and stearic fat acids.
Answers: 1.5; 2.4; 3.2; 4.4; 5.3; 6.2; 7.4; 8.1; 9.1; 10.3;
MUSCULOSKELETAL (APPARATUS) SYSTEM
The current relevance of a research: the high growth and bone stock (bone
tissue) reconstruction tempo which take place while a lot of organs and systems are
functionally imperfect, especially for children of early age, may lead to the high
frequency of apparatus affection.
The aim of the lesson: to study the composition peculiarities and functions of
bones and muscles of children of different ages, to evaluate the state of this system and to
recognize the most spread symptoms of its affection in childish age.
As the result of the self-training the student must know the following:
1. The peculiarities of histological composition and chemical composition of children’
bone tissue.
2. The peculiarities of skull, backbone, chest and extremities among children.

8. 3. The most frequent skeleton affection semiotics.
4. The order of teeth coming out.
5. The methods of bone system investigation.
6. The peculiarities of histological composition and muscles tonus for children of
different ages.
7. The muscles affection semiotics for children.
8. The methods of muscular system investigation.
As the result of topic covering the student must be able to:
1. Point out complaints typical for musculoskeletal system affection; collect the
family and individual anamnesis.
2. Conduct the objective bones and muscles investigation for children of different
ages.
3. Evaluate the data obtained as the result of the objective investigation of the given
system.
4. Work out the plan for the laboratory and instrumental musculoskeletal system
investigation and evaluate the data obtained.
The methodology of the musculoskeletal system investigation for children.
During the children’ investigation it is necessary to exinine the anamnesis data
which have the importance for the musculoskeletal system, static and motility
development (mother’s state of health within the pregnancy period, the character of her
feeding, the child’s state of health, the child’s feeding and the brining up regime); as well
as the typical complaints (pain in bones, muscles and joints; joints configuration change
and mobility limiting).
During the examination one must pay attention on the following aspects: the
head’s form and size changes (microcephalia, macrocephaly, acrocephaly, buttocks-like,
saddle-like, scaphocephaly, steeple (tower) skull, flat occiput); the upper and lower laws
development, the peculiarities of occlusion, teeth quantity, their character (milk
(deciduous, baby, first, primary, temporary) teeth, permanent (succedaneous) teeth); the
chest form (conical, cylindric, flat) and its form (Harrison’s trench, keeled chest, funnel

9. breast, barrel (emphysematous) chest, cardiac hump, one side flattening or one side
outpouching); the backbone form (the pathological kyphosis presence, lordosis, scoliotic
angulation) and child’s pelvis (plano- rachitic, Otto’s pelvis); extremities configuration
(acromegalia, bradydaktylia, adactylia, aphalangia, etc.); the joints form (edema,
deformation), their mobility and the skin and surronding tissues state (eruption presence,
knots and other formations); muscles trophism (weak, middle and best state of
development, atrophy, hypertrophy, hypotrophy); the state of muscles tonus (hypo tonus
and hyper tonus).
By means of musculoskeletal system palpation the wholeness of skull bones,
sutures state and crown is detected (craniotabes, crown sides pliability, crown’s size); the
breaks and deformation presence; osteoid tissue hyperplasia signs (rickety thickening of
wrists and ankles, rachitic rosaries, “beads”); the skin temperature over the joints, pain in
bones, muscles and joints; the muscles power and tonus; the infiltration presence.
The muscles trophism and power finding out.
The muscles trophism which characterises the level of exchange (metabolism)
processes is detected by the degree and symmetry of the development of certain muscles
groups. The evaluation is made in the state of calm and in the state of physical loading.
The following development states are distinguished: low, middle, good. In case of a low
body and extremeties muscles development they are not well exposed in the state of
calm, in case of physical loading their volume is not significanly changed, the lower part
of stomach is drooping, the shoulder-blades lower corners are separated from the chest.
In case of a middle development, the body muscles mass is moderately exposed
in the state of calm, the same of extremities are well exposed, their volume andform are
changed when physically loaded. In case of a good state of development the body and
extremities muscles are well developed, and their relief enlargement is visually noticed
when physically loaded.
The muscles power evaluation is made according to the special scale by 5
points’ system: 0 points – movements are absent; 1 point – active mopvements are
absent, but muscular tension is detected by means of palpation; 2 points – passive
movements are possible in case of slight resistance overcoming; 4 points – passive

10. movements are possible in case of moderate resistance overcoming; 5 points – the
muscles power is within the normal indexes.
Additional methods of investigation: a) calcium, phosphorus, alkaline
phosphatase content finding out in blood serum; b) X-ray examination of cells; c)
electromyography; d) chronaximetry; e) for eldery children the dynamometry; f) muscles
biopsy; g) densitometry.
Osteoid tissue hyperplasia signs
Rickety thickening of wrists and ankles, rachitic rosaries, “beads”, frontal tubers
enlargement.
Osteomalacia signs
Craniotabes (occipital bone’s softening), Краніатабес (пом’якшення
потиличної кістки), back of the head’s flattening, Harrison’s trench, X-like and O-like
shanks (genu varum).
The normal rate of Ca and P in blood serum (Doskin V.A., 1997).
Usual calcium in blodd cerum 2,5 – 2,87 milli gram-molecule per liter
ммоль/л
Ionized calcium 1,25 – 1,37 milli gram-molecule per liter
Phosphorus inorganic in blood serum 0,65 – 1,62 milli gram molecule per liter
Arthritis symptoms.
There is a skin oedema, it aches: edemas of the surrounding tissues near joints,
the mobility is limited in joints as well as the active movements are also limited.
Muscles tonus violation types.
Hypotonia – is the muscles tonus lowering (as the result of rachits, hypotrophy,
chorea, congenital acromicria (trisomy 21 (Down's) syndrome, mongolism, Down's
disease), hypothyroidism, Hoffmann's muscular atrophy, peripheral paralysis).

11. Hypertension – the muscles tonus increasing (it is typical for the sound child for
the first 3-4 months of life, central paralysis, meningitis, correcting).
Muscles trophism violation types.
Atrophy – is the muscles extreme degree of the low development or
undevelopment (simple form) or degeneration (degenerative form).
The simple form is met in cases of cerebral palsy, muscles diseases (muscles
progressive dystrophy, inborn myodystrophy) and joints (juvenile rheumatoid arthritis,
tuberculous coxitis). Degenerative form is the result of peripheral paralysis,
poliomyelitis, and others.
Hypertrophy – is the process of muscles thickening and mass enlargement. Most
frequently is found among children going infor sports or practicing physical labour. In
case of pseudohypertrophy fat accumulation simulates the well exposed muscles.
Tests:
1. The big parietal region of a sound child is closed at the age of:
1.1. 4 - 6 months
1.2. 6 - 8 months
1.3. 9 - 11 months
1.4. 1 - 1,5 years
2. The newborn’s chest is of the following form:
2.1. Cylindrical
2.2. Barrel
2.3. Funnel
2.4. Conical
3. Which of the given below symptoms is not the sign of rachitis?
3.1. Craniotabes
3.2. Crown sides pliability
3.3. Rachitic rosaries
3.4. Bandy (boomerang) legs
4. Which of the given below signs is not the evidence of osteomalacia?

12. 4.1. Craniotabes
4.2. Caput quadratum
4.3. Genu varum
4.4. Back of the head’s flattening
5. Which of the given below symptoms is not the sign of osteoid tissue hyperplasia?
5.1. Rachitic rosaries
5.2. Rickety thickening of wrists and ankles
5.3. Harrison’s trench
5.4. Frontal tubers enlargement
6. Flat feet is the physiological state for children up to the age of:
6.1. Before 6 months
6.2 First 2-3 years of life
6.3. Up to 5 years
6.4. Up to 7 years
7. Physiological chest kyphosis is formed for :
7.1. 2 - 3 months
7.2. 6 - 7 months
7.3. 10 - 12 months
7.4. 1,5 - 2 years
8. The flexors hypertonus of the upper extremities is preserved for children up to:
8.1. 1 month
8.2. 2 - 3 months
8.3. 3 - 4 months
8.4. 4 - 5 months
9. The flexors hypertonus of the lower extremities disappears at the age of:
9.1. 1 month
9.2. 2 - 3 months
9.3. 3 - 4 months
9.4. 4 - 5 months
10.Which of the given below additional methods is used for the muscular system
investigation?

13. 10.1. Electromyography
10.2. Chronaximetry
10.3. Dynamometry
10.4. Scanning
Answers: 1.4; 2.2; 3.4; 4.2; 5.3; 6.2; 7.2; 8.2; 9.3; 10.4.