History

CHAPTER 3

History

• Musculoskeletal issues may result from a wide range of possible etiologies (Table 3-1).

• History is an important aspect of the musculoskeletal evaluation and may alone yield the diagnosis in 75% of cases.

• The most common musculoskeletal issues are injury, pain, deformity, and change in function.

Mechanism of Injury

• Ask the child and family to provide a detailed account of how the injury occurred.

• The mechanism of injury is very important—it may identify injured structures and injury types.

— An inversion injury to the ankle commonly results in sprain of the lateral ligaments.

— A fall on an outstretched arm commonly results in a humerus or radius fracture.

Table 3-1. Categories of Etiologies of Musculoskeletal Issues

Etiology	Examples
Trauma Acute Chronic	Fracture, tendon rupture Stress fracture, tendinopathy
Inflammation	Juvenile idiopathic arthritis
Infection	Osteomyelitis
Neoplasm Malignant Benign	Osteosarcoma, leukemia Unicameral bone cyst, exostosis
Congenital abnormality	Clubfoot, amniotic band syndrome
Neurodevelopmental disorder	Cerebral palsy, hereditary motor and sensory neuropathy
Endocrine disorder	X-linked hypophosphatemic rickets
Hematologic disorder	Osteonecrosis
Genetic disorder	Osteogenesis imperfecta, trisomy 21

• If the trauma was not witnessed, knowing what type of activity the child was participating in at the time of the suspected injury may suggest a mechanism.

• Trauma is common in active children, but it may not always be the cause of the symptoms.

• When the mechanism does not match the symptoms, or when the timing of the trauma does not coincide closely with the onset of symptoms, consider a coinci-dental condition such as neoplasm or infection, or nonaccidental trauma.

Pain

• Pain expression depends on the patient’s age.

— Neonates and infants usually refuse to move the painful area (pseudoparalysis) and cry or are fussy.

— Children will avoid using the painful part, alter its function, or report pain. They may be able to localize pain but are rarely able to characterize it.

— Adolescents will report pain and can localize and characterize it.

• Pain location can be determined by asking the patient to point with one finger “where you feel the pain,” or by asking the patient to indicate where they hurt on a corresponding drawing of a human figure (Figure 3-1). Keep in mind that pain may occur along dermatomal distributions or be referred from another site in addition to occurring at areas of peripheral nerve innervation.

Figure 3-1. Human -figure-marked-by-patient to indicate location of pain.

• Severity can be rated by using a numeric scale (1 to 10) or by using a pain face scale such as the Wong-Baker FACES^® Pain Rating Scale (Figure 3-2).

• Quality (eg, sharp, dull, aching, throbbing, burning), onset, frequency, and duration can be assessed using open-ended questions and may reveal patterns suggestive of potential pathologies.

• Timing of pain and factors that aggravate or relieve the pain may assist in diagnosis and guide treatment.

— Mechanical causes worsen with activity.

— Inflammatory causes worsen after rest.

— Progression over time can indicate whether the condition is static, episodic, improving, or worsening.

— Malignancies and infections frequently cause pain at rest, awaken children from sleep, or both.

— Night pain relieved by nonsteroidal anti-inflammatory medication is classic for osteoid osteoma.

• Presence of associated symptoms may suggest involvement of specific systems (Box 3-1).

• Chronic pain is less common in children than in adults, but it still is a difficult problem to diagnose and treat.