First Aid for the Pediatrics Clerkship, 3 Ed.

Musculoskeletal Disease

 

NORMAL SKELETAL MATURATION

Image The growth plate in the newborn is generally not constituted as an effective structure until 12–24 months.

Image The metaphysis is the most metabolically active area.


Image

Children with sickle cell disease are prone to Salmonella osteomyelitis (but remember, the most common cause even in these children is Staphylococcus aureus).


PEDIATRIC SKELETON

Image The anatomy, biomechanics, and physiology of the child’s skeleton are very different when compared to adults, Image differences in fracture pattern, diagnostic problems, and treatment regimens.

Image Bone is more porous and elastic.

Image The most obvious anatomic differences in the pediatric bones are the presence of growth plates and the thick periosteum.

Image The physis (growth plate) is the weakest site in a child’s bone.

Image A thick periosteal sleeve makes fractures more stable.

Image Remodeling capabilities and rapid healing.


Image

In addition to S aureus, young infants may develop osteomyelitis caused by Streptococcus agalactiae or enteric gram-negative bacteria.


OSTEOMYELITIS

Image

A previously ambulatory 18-month-old girl refuses to walk. She has marked tenderness over the distal left femur. The child has a temperature of 101.6°F (38.7°C), erythrocyte sedimentation rate (ESR) of 72 mm/hr, and white blood cell count (WBC) of 18.5. Radiographs reveal no bony abnormalities. Think: Osteomyelitis.

The initial signs and symptoms are often nonspecific. Refusal to walk, limping, or reluctance to move the affected extremity is common presentation. Fever is usually present. Focal tenderness over a long bone may be an important clue for diagnosis. The WBC count is usually Image and ESR is elevated. Initial plain radiograph may be normal or show only soft tissue swelling. Radionuclide bone scans usually are positive within 48–72 hr of onset of illness. Bone aspiration may reveal an etiologic agent.


Image

Consider Kingella kingae in children who attend day care. (Remember, K kingae is a fastidious organism found in normal respiratory flora.)


DEFINITION

Image Inflammation of the bone caused by infection.

Image Can be acute (< 2 weeks) or chronic.


Image

Cultures for K kingae may need to be incubated longer than usual laboratory protocol.


EPIDEMIOLOGY

Image Preschool-age children (50%).

Image Male preponderance.

Image More common in African-American children.


Image

Puncture wounds to the foot may result in osteomyelitis caused by mixed flora, including Pseudomonas.


ETIOLOGY

Image Most often bacterial.

Image See Table 19-1 for causes of osteomyelitis by age group.

Image Overall, Staphylococcus aureus is the most common bug.

TABLE 19-1. Causes of Osteomyelitis by Age

Image

PATHOPHYSIOLOGY

Image Primarily hematogenous.

Image Spread from contiguous infected structures.

Image Direct inoculation.


Image

The most common site for osteomyelitis is the rapidly growing end (metaphysis) of long bones.


SIGNS AND SYMPTOMS

Image Infants and young children:

Image Fever, irritability, and lethargy.

Image Refusal to walk or bear weight.

Image Older children:

Image May localize pain

Image Limping

Image Physical examination:

Image Painful local swelling

Image Point tenderness

Image Local warmth

Image Erythema


Image

Nearly 50% of hematogenous osteomyelitis occurs in the tibia or femur.


DIAGNOSIS

Image Leukocytosis.

Image Elevated ESR: Sensitive marker for osteomyelitis, mean ∼70 mm/hr. Peaks 3–5 days.

Image Elevated C-reactive protein (CRP): peaks at 48 hr.

Image CRP typically returns to normal 7–10 days after appropriate therapy but the ESR may remain elevated for 3 or 4 weeks, even with appropriate therapy.

Image Growth on blood culture.

Image Radiographic findings (see Figure 19-1):

Image Lucent areas in bone represent cortical destruction.

Image Periosteal elevation. Periosteal and lytic changes in the bone may not be seen until substantial bone destruction has occurred.

Image Plain films may be normal for 7–10 days in up to two-thirds of children.


Image

Consider osteomyelitis in any child with Image use of a limb and fever.



Image

Every attempt should be made to establish a microbiologic diagnosis.


Image

FIGURE 19-1. Acute hematogenous osteomyelitis of the proximal humerus.

Mottling and patchy radiolucencies are present in the metaphyseal region. (Reproduced, with permission, from Wilson FC, Lin PP. General Orthopedics. New York: McGraw-Hill, 1997.)

Image Radionuclide scintigraphy (bone scan):

Image Common isotopes used include technetium, gallium, and indium.

Image Can detect osteomyelitis within 24–48 hr of onset with ∼90% sensitivity.

Image Caution: Radionuclide scans may be positive in other illnesses that result in Image osteoblastic activity, including malignancy, trauma, cellulitis, postsurgery, and arthritis.

Image Magnetic resonance imaging (MRI):

Image Provides anatomic detail not seen with bone scan.

Image Useful for visualizing soft tissue abscess associated with osteomyelitis, bone marrow edema, and bone destruction.

Image Contrast enhancement with gadolinium.

DIFFERENTIAL DIAGNOSIS

Image Septic arthritis (can coexist).

Image Fracture.

Image Cellulitis.

Image Transient synovitis.

Image Acute leukemia or neuroblastoma.

Image Slipped capital femoral epiphysis (SCFE).


Image

The ESR and CRP can be followed to assess response of osteomyelitis to therapy. They should Image if treatment is working.


TREATMENT

Image Admit all children with osteomyelitis.

Image Orthopedic consultation.

Image Parenteral antibiotics pending cultures (obtain blood, bone, and joint aspirate cultures before antibiotic administration).

Image Infants and children: Penicillinase-resistant penicillin (oxacillin) and cephalosporin (cefotaxime).

Image Older children (> 5 yr): nafcillin or vancomycin.

Image Consider surgical drainage if:

Image Pus is obtained from aspirate.

Image No response to 24–48 hr of antibiotics.


Image

Osteomyelitis without radiographic change should not be treated with antibiotics until an osseous specimen is obtained.


COMPLICATIONS

Image Pathologic fractures.

Image Chronic osteomyelitis.

Image Leg length discrepancy.

SEPTIC ARTHRITIS

Image

A 14-year-old boy presents to the emergency department (ED) because of right knee pain for the past 2 days. Three days prior to the onset of the pain, he hit his knee on a pool table. Vitals: Temperature 100.6°F (38.1°C), pulse rate 100, respirations 24. On physical exam, the knee is slightly swollen and tender and is held in flexion. Think: The most important initial diagnostic procedure is aspiration of the knee for smear and culture.

Although more common in children, it can occurs in all ages. Trauma can be the precipitant of infection. Staphylococcus aureus is the most common cause of septic arthritis. Physical examination may show local erythema, warmth, and swelling. The key to the diagnosis is the detection of bacteria in the synovial fluid either by Gram stain or by a culture; therefore, synovial fluid aspiration should be performed.


Image

Most common cause of polyarticular septic arthritis is Neisseria gonorrhoeae.


Image

A 5-year-old boy who has a definite history of penicillin allergy develops osteomyelitis. Smear of the aspirate shows gram-positive cocci in clusters. Think: Treat child with vancomycin.

Vancomycin is directed against gram-positive organisms and can be given to patients who can not receive penicillins and cephalosporins.

DEFINITION

A microbial invasion of joint space.


Image

Adolescent intravenous (IV) drug abusers are at risk for gram-negative septic arthritis.


ETIOLOGY

Image Neonates:

Image S aureus (most common cause of septic arthritis in all ages).

Image S agalactiae.

Image Gram-negative enteric bacilli (K kingae has replaced Haemophilus influenzae type b [Hib] as the most common gram-negative arthritis in the child 2 months to 5 years old).

Image Older children (very similar to osteomyelitis):

Image S aureus: Remember—infection with community-acquired methicillin-resistant S aureus (CA-MRSA) is becoming more common.

Image S pyogenes.

Image S pneumoniae.

Image Gonococcus.


Image

Candida albicans must also be considered in neonates and premature infants with septic arthritis.


EPIDEMIOLOGY

Relatively common in infancy and childhood; can occur in all ages.

PATHOPHYSIOLOGY

Organisms may invade the joint by:

Image Direct inoculation.

Image Contiguous spread.

Image Bacteremia (most common route).


Image

Septic arthritis is an orthopedic emergency.


SIGNS AND SYMPTOMS

Image Pain.

Image Joint stiffness.

Image Erythema.

Image Edema.

Image Limp and unable to bear weight.


Image

Two-thirds of cases of septic arthritis occur in weight-bearing (hip or knee) joints and involve a single joint (monoarticular).


LABORATORY

Image Complete blood count (CBC)—a normal WBC does not rule out diagnosis.

Image Elevated ESR.

Image Blood culture.

Image Joint aspiration.

MANAGEMENT

Image Admit all children with septic arthritis.

Image Orthopedic consultation (it is an orthopedic emergency)

Image Joint aspiration.

Image Parenteral antibiotics immediately after joint aspiration.


Image

The knee is the most frequently infected pediatric joint, but the hip is known to have the most severe consequences.


COMPLICATIONS

Potential for severe complications:

Image Spread—results in osteomyelitis.

Image Avascular necrosis.

Image Angular deformities.

Image Leg length discrepancy.


Image

Fever is not necessary for diagnosis of septic arthritis.


TRANSIENT SYNOVITIS

Image

An 18-month-old infant develops a temperature of 105°F (40.6°C) and refuses to bear weight on her right leg. Physical exam reveals a swollen and warm right knee that the infant will not allow to be flexed or extended. The infant was diagnosed with varicella 3 weeks prior to the onset of this illness. Think: The most appropriate diagnostic test would be a synovial fluid analysis.

This patient has a high suspicion for septic arthritis. Joint aspiration is the gold standard for diagnosing septic arthritis and should be performed whenever septic arthritis is suspected. Septic arthritis (due to group A β-hemolytic streptococcus) can occur after a viral infection such as varicella. Children with septic arthritis usually have a history of high fever and restriction of movements.

DEFINITION

Image A reactive arthritis.

Image The most common cause of hip pain in childhood.

Image Predominates in children 5–10 years old.

ETIOLOGY

Image Cause remains uncertain.

Image Often follows an upper respiratory infection (URI).


Image

Most common mimic of septic arthritis is transient synovitis. Examining the joint aspirate can differentiate.


SIGNS AND SYMPTOMS

Image Unilateral hip or groin pain is the most common complaint.

Image Painful limp.

Image Usually afebrile and nontoxic appearance.

DIAGNOSIS

Image Diagnosis of exclusion. Transient synovitis must be distinguished from septic arthritis. The two disorders present on a continuum and may overlap. Where doubt exists, ultrasound-guided or fluoroscopically guided diagnostic aspiration should be performed.

Image Radiographs are usually normal.

Image Plain films do not diagnose or exclude a hip effusion.

Image The appearance of a septic arthritis of the hip may be identical.

MANAGEMENT

Image First, rule out septic arthritis.

Image Supportive therapy.

Image Nonsteroidal anti-inflammatory drugs (NSAIDs).

Image Complete recovery occurs within a few weeks.

OSGOOD-SCHLATTER DISEASE

Image

A 16-year-old boy complains of right knee pain. On examination, there is significant tenderness and swelling over the tibial tuberosity. He is otherwise healthy. Think: Osgood–Schlatter disease; treat with activity restriction. Osgood-Schlatter disease is a chronic overuse injury and a common cause of knee pain. It occurs due to forceful contraction of the extensor mechanism in sports such as jumping. It is a clinical diagnosis. Tenderness over the proximal tibial tuberosity at the site of patellar insertion is often present. However, plain radiographs are helpful to rule out other causes of knee pain.


Image

Pain is most pronounced over the tibial tubercle in Osgood-Schlatter disease.


DEFINITION

Image An inflammatory disorder of the proximal tibial physis where the patellar tendon inserts on the tibia.

Image Benign, self-limited extra-articular disease.


Image

Typical history: Nonspecific aching knee pain exacerbated by exercise.


ETIOLOGY

Image Traction apophysitis/repetitive trauma.

Image Chronic microtrauma to the tibial tuberosity secondary to overuse of the quadriceps muscle.


Image

Osgood-Schlatter disease is a common cause of knee pain in the adolescent.


RISK FACTORS

Image Boys between ages 11 and 18 yr.

Image Rapid skeletal growth.

Image Involvement in repetitive jumping sports.


Image

Septic arthritis may coexist with osteomyelitis at sites where the metaphysis lies within the joint capsule:

Image Proximal femur–hip joint

Image Proximal humerus– shoulder joint

Image Distal lateral tibia–ankle joint

Image Proximal radius–elbow joint


SIGNS AND SYMPTOMS

Image Knee pain (tibial tuberosity pain).

Image Reproduced by extending the knee against resistance.

Image Knee joint examination is normal.

Image Tibial tuberosity swelling.

Image Absence of effusion or condylar tenderness.

DIAGNOSIS

Image Diagnosis is primarily clinical.

Image X-ray of the knee may show evidence of fragmentation of the tibial tubercle (see Figure 19-2). Compare with opposite side.

TREATMENT

Image Relative rest.

Image Restriction of activities as tolerated (patients can still engage in activities even with pain; they will eventually grow out of it).

Image Knee immobilizer only for severe cases.

Image Complete resolution through physeal closure.


Image

The major consequence of bacterial invasion of a joint is permanent damage to joint cartilage.


Image

FIGURE 19-2. Osgood-Schlatter disease.

Note the elevation and irregularity of the tibal tubercle. (Reproduced, with permission, from Wilson FC, Lin PP. General Orthopedics. New York: McGraw-Hill, 1997.)

LEGG-CALVÉ-PERTHES DISEASE

Image

A 6-year-old boy presents with hip and knee pain. He has been limping. On examination, he is unable to abduct or internally rotate his hip. Think: Legg-Calvé-Perthes disease.

Legg-Calvé-Perthes disease is osteonecrosis of the capital femoral epiphysis of the femoral head. It is due to vascular changes within the proximal femur. Limping is the most common symptom. Pain may be poorly localized in the groin or referred to the thigh or knee joint. It is therefore important to recognize that thigh or knee pain in the child may be due to hip pathology. Plain x-rays of the hip are helpful in making the diagnosis. It occurs at an earlier age than slipped capital femoral epiphysis (SCFE).

DEFINITION

Avascular necrosis of femoral head (occurs when blood supply to the proximal femoral epiphysis is disrupted).


Image

Toxic synovitis is the most common cause of limping and acute hip pain in children aged 3–10 yr.


ETIOLOGY

Image Idiopathic.

Image Some precipitants include sickle cell disease, steroids, trauma, and infection.

EPIDEMIOLOGY

Image Male-to-female ratio: 4:1.

Image Highest incidence is during periods of rapid growth of the epiphyses (ages 4–8 yr).

SIGNS AND SYMPTOMS

Image Insidious onset. Symptoms generally begin with minor trauma.

Image Limp with or without pain.

Image Pain (activity related and relieved by rest).

Image Limited hip motion, particularly abduction and medial rotation.

Image Image range of motion.

Image Knee pain is common.


Image

Classic presentation of Legg-Calvé-Perthes disease is a “painless limp.”


RADIOLOGY

Image Anteroposterior (AP) and frog-leg lateral position. X-ray findings correlate with the progression and extent of necrosis (see Figure 19-3).

Image Early: Effusion of the joint, widening of the joint space and periarticular swelling.

Image Few weeks: Image bone density around the joint, collapse of the femoral head (affected side appears smaller than the unaffected femoral head).

Image Late: New bone replaces necrotic bone.

MANAGEMENT

Image Pediatric orthopedic consultation.

Image Protect joint.

Image Abduction orthoses to “contain” the femoral head on the acetabulum.

Image Rest and NSAIDs.

Image Surgery for 6- to 10-year-olds with large areas of necrosis.

COMPLICATIONS

Limb length discrepancy.

Image

FIGURE 19-3. Radiograph of pelvis demonstrating changes of Legg-Calvé-Perthes disease.

Note the sclerotic, flattened, and fragmented right femoral head.

SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE)

Image

An obese 14-year-old boy has pain in the left anterior thigh for 2 months. On physical exam, there is limited passive flexion and internal rotation of his hip. Think: The most likely diagnosis is SCFE.

SCFE is the most common hip disorder of adolescence and occurs at the time of the pubertal growth spurt. Referred pain (groin, thigh, or knee pain) is a common presentation. AP and frog-leg lateral views of the pelvis should be obtained.


Image

Knee pain in a child warrants a complete hip examination.


DEFINITION

Image Type of Salter I fracture of the proximal femoral growth plate.

Image Disruption of the proximal femoral epiphysis through the physeal plate.

Image Epiphysis is usually displaced medially and posteriorly.


Image

SCFE is the second most commonly missed time-sensitive pediatric orthopedic problem (fracture is most common).


ETIOLOGY

Image Most cases are idiopathic.

Image Weak growth plate (physis is weak prior to closure).

Image Local trauma.

TYPES

Image Acute (< 3 weeks).

Image Chronic (> 3 weeks).


Image

Remember, slips can occur in children of normal weight.


RISK FACTORS

Image Obesity.

Image Hypothyroidism.

Image Hypogonadism.

Image Growth hormone (GH) administration.

Image Renal osteodystrophy.

Image Radiation therapy.


Image

MRI can reveal avascular necrosis, whereas conventional radiographs may appear normal.


SIGNS AND SYMPTOMS

Image Pain can be located anywhere between the groin and medial knee.

Image Limping.

Image Internal rotation, flexion, and abduction are lost.

Image Painful limp.

Image Leg tends to roll into external rotation.


Image

SCFE is the most common orthopedic hip disorder occurring in adolescence.


DIAGNOSIS

Image AP and frog-leg lateral of both hips (Figure 19-4).

Image Ice cream scoop (epiphysis) falling off its cone.

Image The frog-leg lateral film demonstrates subtle displacement more clearly.

Image Earliest sign is widening of epiphysis.

Image Always examine and obtain x-ray of the contralateral hip.

Image A diagnosis of a preslip can be made with bone scintigraphy.


Image

In the presence of suspicion for SCFE, both hips should be imaged.


COMPLICATIONS

Image Avascular necrosis of capital femoral epiphysis.

Image Chondrolysis.

Image

FIGURE 19-4. Hip radiographs in a 13-year-old girl with mildly slipped capital femoral epiphysis (SCFE) on the right.

Note on the AP view that a line drawn along the superior border of the femoral neck (Klein line) shows less femoral head superior to the line on the right than it does in the normal hip on the left.

Image Nonunion.

Image Premature closure of the epiphyseal plate.


Image

Fifteen percent of children who have SCFE have mostly knee or distal thigh pain.


TREATMENT

Image Orthopedic consultation.

Image Removal of weight bearing from the affected limb (crutches or wheelchair in overweight patients).

Image Internal fixation using central percutaneous pin fixation with one or more cannulated screws is the treatment of choice (Figure 19-5).


Image

Bilateral SCFE is common.


Image

FIGURE 19-5. SCFE after screw fixation (same patient as Figure 19-4).

TENOSYNOVITIS

DEFINITION

Inflammation of the tendon and tendon sheath.

ETIOLOGY

Image Trauma

Image Overuse


Image

Klein line: On the AP view of the hip, a line drawn along the superior border of the femoral neck should pass through a portion of the femoral head. If not, consider SCFE.


TYPES

Image de Quervain tenosynovitis of the wrist (ie, abductor pollicis longus and extensor pollicis brevis tendons).

Image Volar flexor tenosynovitis (ie, trigger finger).

MANAGEMENT

Image Rest.

Image NSAIDs.

Image Thumb spica wrist splint.

THE LIMPING CHILD

Image Thorough history and physical.

Image Assess gait with patient barefoot based on age.

Image Plain-film radiographs typically initial study.

Image Consider lab work based on differential diagnosis (ie, CBC, ESR).

DIFFERENTIAL DIAGNOSIS

Image

JUVENILE RHEUMATOID ARTHRITIS (JRA)

DEFINITION

Chronic disease characterized by inflammation of the joints.

ETIOLOGY

Unknown.


Image

Seek help from your radiology and orthopedic colleagues if clinical suspicion for SCFE is high but the films are negative.


CLASSIFICATION

Image Polyarticular (35%):

Image Five or more joints.

Image Symmetric distribution.

Image Both large and small joints.

Image Pauciarticular (50%):

Image Fewer than five joints.

Image Asymmetric distribution.

Image Often large weight-bearing joints.

Image Iridocyclitis (50%).

Image Systemic (20%):

Image Fever, rash, arthritis, and visceral involvement.

Image Also known as Still disease.


Image

The most common cause of chest pain in children is idiopathic.


DIAGNOSTIC CRITERIA

Image Age of onset under 16 yr.

Image Arthritis in one or more joints.

Image Duration ≥ 6 weeks.

Image Exclusion of other causes.

Image See Table 19-2 for diagnosis based on joint fluid analysis.


Image

Rheumatoid factor (RF) tends to be negative in early childhood in JRA. RF is positive in about 15% of patients, usually when onset of polyarticular disease occurs after the age of 8 yr.


SIGNS AND SYMPTOMS

Image Polyarticular:

Image Symmetric, chronic pain and swelling of joints.

Image Systemic features are less prominent.

Image Long-term arthritis; symptoms wax and wane.

Image Pauciarticular:

Image Asymmetric chronic arthritis of a few large joints.

Image Systemic features are uncommon.

TABLE 19-2. Joint Fluid Analysis

Image

Image Systemic:

Image Salmon-pink macular rash.

Image Systemic symptoms: Arthritis, hepatosplenomegaly, leukocytosis, and polyserositis.

Image Episodic, remission of systemic features within 1 yr.

TREATMENT

The goal of treatment is to restore function, relieve pain, and maintain joint motion.

Image NSAIDs.

Image Range-of-motion and muscle-strengthening exercises.

Image Methotrexate, anti–tumor necrosis factor (TNF) antibodies, or antipyrimidine medication for patients who do not respond to NSAIDs.


Image

A normal ESR does not exclude the diagnosis of JRA.


REITER SYNDROME

DEFINITION

Triad of asymmetric arthritis, urethritis, and uveitis.

ETIOLOGY

Thought to be a reactive arthritis after infection with gram-negative (Salmonella, Shigella, Yersinia, Campylobacter, Chlamydia, Mycoplasma, and Ureaplasma) in persons with human lymphocyte antigen (HLA)-B27.


Image

The presence of HLA-B27 is a major determinant of disease severity in Reiter’s syndrome and a predictor of recurrence.


DIAGNOSIS

Image Bone density is preserved.

Image Proliferative bone formation is present.


Image

Routine ophthalmologic screening should be performed every 3–6 months for 4 yr for all children with arthritis to look for iridocyclitis.


CHILDHOOD FRACTURES (NOT RELATED TO ABUSE)

Torus Fracture (Figure 19-6)

Image Latin torus = buckle.

Image Buckle fracture: A buckle in the concave cortex of malleable bone under compression.

Image Impaction injury in children in which the bone cortex is buckled but not disrupted.

Image Stable fracture.

Greenstick Fracture (Figure 19-7)

Image Definition: A break in the convex cortex under tension caused by the bending of malleable bone.

Image Angulation beyond the limits of plastic deformation.

Image Incomplete fracture in which cortex is disrupted on only one side.

Image Represents bone failure on the tension side and a plastic or bend deformity on the compression side.


Image

Reiter syndrome: Can’t pee, can’t see, can’t climb a tree.


Image

FIGURE 19-6. Torus fracture.

Toddler Fracture (Figure 19-8)

Image Nondisplaced spiral fracture of the tibia.

Image Symptoms include pain, refusal to walk, and minor swelling.

Image There is often no history of trauma, or a history of a twisting motion of the leg with a planted foot.

Image Differential diagnosis: Should include nonaccidental trauma.

Image Treatment: Immobilization for a few weeks to protect the limb and to relieve pain.

Salter-Harris Fracture Classification

See Figure 19-9.

Image

FIGURE 19-7. Greenstick fracture.

Image

FIGURE 19-8. Toddler fracture.

(Reproduced, with permission, from Schwartz DT, Reisdorff BJ. Emergency Radiology. New York: McGraw-Hill, 2000: 602.)

Image

FIGURE 19-9. Salter-Harris fracture classification.

SPRAINS

DEFINITION

Image Sprain: Injury to ligament.

Image Strain: Injury to muscle-tendon unit.

Ankle Sprain

Image Inversion: Injury to lateral ligament (85%).

Image Anterior talofibular injures first.

Image Posterior talofibular—severe pain.

Image Eversion: Injury to medial ligament (15%).

Image Deltoid ligament injury most common.

Image More severe than inversion.


Image

Sprain is a diagnosis of exclusion in children.


SIGNS AND SYMPTOMS

Image Grade I: Pain/tenderness without loss of motion.

Image Grade II: Pain/tenderness, ecchymosis with some loss of range of motion.

Image Grade III: Ligament is completely disrupted; pain/tenderness, swelling and ecchymosis, joint instability, and complete loss of range of motion.

MANAGEMENT

Image The goal of treatment is to Image local edema and residual stiffness.

Image RICE therapy—rest, ice, compression, elevation.

Image Protection includes joint immobilization at a right angle, elastic (Ace) bandage wrap, and Jones’s dressing for more severe injuries. Splinting the affected joint protects against injury and relieves swelling and pain.

Image Crutches and crutch gait training.

Image NSAIDs as needed for analgesia.

Image Early use of joint and appropriate rehabilitation is key to healing process.

SUBLUXATION OF RADIAL HEAD

Image

A 2-year-old boy complains of left arm pain. He holds his arm in a flexed, pronated position and refuses to supinate his forearm during examination. His mother remembers pulling him by the arm yesterday. Think: Subluxation of the radial head (nursemaid’s elbow).

Subluxation of the radial head is a common traumatic elbow injury in children. Average age is between 2 and 4 yr. It is due to a sudden longitudinal pull on the forearm while the child’s arm is in pronation. Child keeps his arm in passive pronation, with slight flexion at the elbow. Radiographs are not required if the history suggestive of this injury.

DEFINITION

Subluxation of the radial head.

ETIOLOGY

Image Slippage of the head of the radius under the annular ligament.

Image Most common cause is axial traction.

Image Sudden longitudinal pull on the forearm while the child’s arm is in pronation.

Image Stretching of the annular ligament allows fibers to slip between the capitellum and the head of the radius.

EPIDEMIOLOGY

Image Common age: 1–4 yr.

Image More frequent under 2 yr.

Image Left arm predominance.

Image Rare after the age of 6 yr (annular ligament becomes thick and strong by age 5 yr).

SIGNS AND SYMPTOMS

Image Child suddenly refuses to use an arm.

Image Elbow fully pronated/inability of the child to supinate the arm.

DIAGNOSIS

Image Diagnosis is made primarily by history.

Image Imaging studies are unnecessary.

MANAGEMENT

Image Elbow is placed in full supination and slowly moved to full flexion.

Image Alternatively, overpronation of the forearm is also effective.

Image A click at the level of the radial head signifies reduction (see Figure 19-10).

Image Relief of pain is remarkable.

Image

FIGURE 19-10. Reduction of nursemaid’s elbow.

OSTEOSARCOMA

Image

A patient has had dull, aching pain for several months that has suddenly become more severe. Think: Osteosarcoma.

Osteosarcoma is a common cancer in adolescence. Symptoms may be present for a significant period of time before it is diagnosed. Pain, particularly with activity, is a common symptom. Distal femur and proximal tibia are commonly involved bones. On examination, palpable mass may be present. Since osteosarcoma is not radiosensitive, surgery may be needed.

DEFINITION

Malignant tumor arising from osteoblasts.


Image

Osteosarcoma is the sixth most common malignancy in children and the third most common in adolescents.


EPIDEMIOLOGY

Image The most frequent sites of origin are the metaphyseal regions.

Image Most osteosarcomas develop in patients 10–20 years of age.

Image Osteosarcomas most frequently occur during periods of maximal growth.

SIGNS AND SYMPTOMS

Image Bone pain.

Image Typically long bones (distal femur and proximal tibia) and flat bones (pelvis 10%).


Image

Osteosarcoma is the most common primary malignant neoplasm of bone (60%).


Image

FIGURE 19-11. Osteosarcoma of proximal humerus.

Note disorganized appearance of bony cortex (arrow).

RADIOLOGY

Radiographs show mixed sclerotic and lytic lesion arising in the metaphyseal region, often described as a sunburst pattern (Figure 19-11).


Image

All patients with osteosarcoma should undergo computed tomographic (CT) scanning to detect metastatic pulmonary disease.


MANAGEMENT

Image Bone tumors generally are sensitive to radiation and chemotherapy.

Image Amputation and limb salvage are effective in achieving local control.

PROGNOSIS

Image Seventy-five percent survival in nonmetastatic disease.

Image Death is usually due to pulmonary metastasis.

Image Widely metastatic disease carries poor prognosis.

EWING’S SARCOMA

Image

A 10-year-old boy complains of pain in his left leg. On examination, there is localized swelling and pain in the middle of his left femur. His temperature is 100.8°F (38.2°C), and ESR is elevated. Further questioning reveals a 2-month history of increasing fatigue and weight loss. Think: Ewing’s sarcoma.

Ewing’s sarcoma is a common malignant bone tumor in young patients. Most patients present with either pain or a mass. Most common site for metastases is lung. Periosteal reaction and new bone formation with an onion-skin appearance are suggestive of Ewing’s sarcoma. Most tumors are considered radiosensitive.

DEFINITION

Malignant tumor of bone arising in medullary tissue.


Image

Primary site is split almost evenly between the extremities and central axis.


EPIDEMIOLOGY

Image Most common bone lesion in first decade.

Image Second to osteosarcoma in second decade.

Image However, still rare—only 200 new cases/yr.

Image Very strong Caucasian and male predilection, hereditary.


Image

Bone pain is a presenting symptom of Ewing’s sarcoma in 80–90%.


SIGNS AND SYMPTOMS

Image Bone pain.

Image Systemic signs: Fever, weight loss, fatigue.

RADIOLOGY

Image Calcified periosteal elevation, termed onion skin.

Image Radiolucent lytic bone lesions in the diaphyseal region.

Image Evaluation of patients with Ewing’s sarcoma should include a CT to define the extent of metastatic disease.

TREATMENT

Image Radiotherapy.

Image Chemotherapy.

Image Surgical resection.

Image Autologous bone marrow transplant for high-risk patients.


Image

Metastasis is present in 25% of patients with Ewing’s sarcoma at diagnosis. The most common sites of metastasis are the lungs, bone (spine), and bone marrow.


PROGNOSIS

Image Patients with a small localized tumor have a 50–70% long-term disease-free survival rate.

Image Patients with metastatic disease have a poor prognosis.

BENIGN BONE TUMORS

Osteoid Osteoma

DEFINITION

Reactive lesion of bone.

SIGNS AND SYMPTOMS

Image Pain (evening or at night), relieved with aspirin.

Image Point tenderness.

Image Predominantly found in boys.


Image

Osteoid osteomas are most common in the femur and tibia.


RADIOLOGY

Osteosclerosis surrounds small radiolucent nidus.

MANAGEMENT

Image Salicylates relieve pain.

Image Surgical incision of the nidus is curative.

PROGNOSIS

Prognosis is excellent. There have been no known cases of malignant transformation, although the lesion has been known to reoccur.

Enchondroma

DEFINITION

Cartilaginous lesions.

SIGNS AND SYMPTOMS

Image Tubular bones of hands and feet.

Image Pathologic fractures.

Image Swollen bone.

Image Ollier disease (if multiple lesions are present).


Image

Enchondromas have a predilection for the phalanges.


RADIOLOGY

Image Radiolucent diaphyseal or metaphyseal lesion.

Image Often described as “fingernail streaks in bones.”

MANAGEMENT

Surgical curettage and bone grafting.


Image

Mafurci syndrome is multiple enchondromas and aniomas of the soft tissue.


PROGNOSIS

Prognosis is excellent. Malignant transformation may occur, but is very rare in childhood.

Osteochondroma (Exostosis)

DEFINITION

Image Most common bone tumor in children.

Image Disturbance in enchondral growth.

Image Benign cartilage-capped protrusion of osseous tissue arising from the surface of bone.

SIGNS AND SYMPTOMS

Image Painless, hard, nontender mass.

Image Distal metaphysis of femur, proximal humerus, and proximal tibia.

Image Grows with child until skeletal maturity

RADIOLOGY

Pedunculated or sessile mass in the metaphyseal region of long bones.


Image

Baker cysts are the most common mass in the popliteal fossa.


MANAGEMENT

Excision if symptomatic.

PROGNOSIS

Prognosis is excellent. Malignant transformation is very rare.


Image

It is important to exclude deep vein thrombosis (DVT) in patients with a popliteal cyst and leg swelling.


Baker’s Cysts

DEFINITION

Image Herniation of the synovium in the knee joint into the popliteal region.

Image A Baker’s cyst is lined by a true synovium, as it is an extension of the knee joint.

SIGNS AND SYMPTOMS

Image Popliteal mass

Image Commonly transilluminates

DIAGNOSIS

Aspiration of mucinous fluid from popliteal fossa.

MANAGEMENT

Image Baker’s cysts are benign.

Image Nearly always disappears with time in children.

Image Avoid surgery (only for significant pain).

DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)

Image

While doing a physical exam on a 3-month-old female infant, the physician notices that her left knee is lower when her hips are flexed. The infant was born to a P1G1 mother via a breech vaginal delivery. Think: DDH.

It is called Galeazzi’s sign, which is an apparent shortening of the femur on the side of the dislocated hip and is noted by placing both hips in 90 degrees of flexion and comparing the height of the knees. Screening examination should include the Ortolani test and the provocative maneuver of Barlow. Risk factors include female gender, breech presentation, and positive family history for DDH. Ultrasound can be obtained in infants younger than 6 months. It is a treatable condition with successful treatment if intervention starts early. Pavlik harness is the treatment of choice in the first 6 months of life.


Image

Associated anomalies with DDH:

Image Torticollis

Image Clubfeet

Image Metatarsus adductus


DEFINITION

Abnormal growth and development of the hip resulting in an abnormal relationship between the proximal femur and the acetabulum.


Image

Ortolani test: Slowly abduct flexed hip. The femoral head will shift into the acetabulum producing a clunk.


EPIDEMIOLOGY

Image One in 1000 live births.

Image Tenfold Image risk in sibling of child with DDH.

Image Female > male. Breech female is at highest risk.


Image

Barlow test: Dislocate the hip by flexing and adducting the hip with axial pressure.


PATHOPHYSIOLOGY

Image At birth there is a lack of development of both acetabulum and femur.

Image Progressive with growth.

Image Reversible if corrected in first few days or weeks.


Image

Forced abduction of the hips in DDH is contraindicated because of risk of avascular necrosis.


SIGNS AND SYMPTOMS

Image Newborn:

Image Ortolani: Reduction maneuver.

Image Barlow: Provocative test Image potential for dislocation of a nondisplaced hip.

Image Asymmetric skin folds (40%).

Image 3–6 months:

Image Limited abduction.

Image Allis’s or Galeazzi’s sign: Knee is lower on affected side when hips are flexed.

Image 12 months (unilateral dislocation): Trendelenburg sign—painless limp and lurch to the affected side with ambulation. When the child stands on the affected leg, there is a dip of the pelvis on the opposite side, due to a weakness of the gluteus medius muscle.

Image 12 months (bilateral dislocation):

Image Waddling gait.

Image Lumbar lordosis due to flexion contractures.


Image

Signs of instability are more reliable than x-ray in DDH.


IMAGING

Image < 6 months: Ultrasound (acetabulum and proximal femur are predominantly cartilaginous).

Image > 6 months: Radiographs (proximal femoral epiphysis ossifies by 4–6 months).


Image

In DDH, after 3–6 months, muscle contractures develop, and the Barlow and Ortolani tests become negative.


TREATMENT

Image Newborn to 6 months: Pavlik harness (flexion and abduction of the hip).

Image 6 months to 3 years: Skin traction for 3 weeks to relax soft tissues around the hip prior to closed or open reduction. After 6 months of age, the failure rate for the Pavlik harness is > 50%.

Image > 3 yr: Operations to correct deformities of the acetabulum and femur.


Image

Triple diapers have no place in the treatment of DDH.


OSTEOGENESIS IMPERFECTA (OI)

Image

A 2-year-old child is brought in with a right radial fracture after lightly bumping his arm. An x-ray shows multiple healing fractures. On examination, the child has blue sclera, thin skin, and hypoplastic teeth. Think: OI. OI is also called brittle bone disease. Triad: fragile bones, blue sclerae, and early deafness. The teeth frequently have dentinogenesis imperfecta. The enamel is normal, but the dentin is dysplastic. Radiographic appearance may vary according to the type of disease and its severity and include osteopenia and fractures. In infancy, these features may result in evaluation for nonaccidental injury.


Image

Double or triple diapers are not adequate to obtain a proper position and are no longer indicated treatment of DDH.


DEFINITION

Image Rare, inherited disorder of connective tissue, characterized by multiple and recurrent fractures.

Image OI is an autosomal-dominant disorder that occurs in all racial and ethnic groups.


Image

X-ray is not helpful in the newborn. After 6–8 weeks, x-rays begin to show signs of dislocation (lateral displacement of the femoral head).


ETIOLOGY

Image Molecular genetics have identified more than 150 mutations in the genes that encode for type 1 collagen.

Image There are four types of OI: Types I and IV are mild and present with an Image risk of fractures. Type II is lethal in the newborn period, and type III is a severe form causing significant bony deformity secondary to multiple fractures.

Image Ten percent of OI patients have the severe neonatal form of the disease.


Image

OI is the most common osteoporosis syndrome in children.


SIGNS AND SYMPTOMS

Image Bone fragility.

Image Easy bruising.

Image Repeated fracture after mild trauma.

Image Deafness.

Image Blue sclera.

Image Hyperextensibility of ligaments.

Image Normal intelligence.


Image

Type I collagen fibers are found in bones, organ capsules, fascia, cornea, sclera, tendons, meninges, and the dermis.


DIAGNOSIS

Radiographic findings:

Image Osteopenia.

Image Wormian bones.

Image Thin cortices.

Image Bowing.

Image Normal callus formation.

Image Collagen synthesis analysis.

TREATMENT

Image Bisphosphonates.

Image Surgical correction of long-bone deformities.

Image Trauma prevention.

PROGNOSIS

Prognosis is poor, and most patients are confined to wheelchairs by adulthood.

GENETIC COUNSELING

Image Genetic counseling should be offered.

Image Risk of an affected individual passing the gene to his or her offspring is 50%.

KLIPPEL-FEIL SYNDROME

DEFINITION

Congenital fusion of a variable number of cervical vertebrae.


Image

Children with Klippel-Feil syndrome are at risk for:

Image Atlantoaxial instability

Image Neurologic impairment


ETIOLOGY

Failure of normal segmentation in the cervical spine.

SIGNS AND SYMPTOMS

Image Classic clinical triad:

Image Short neck.

Image Low hairline.

Image Limitation of neck motion.

Image Associated with:

Image Renal anomalies.

Image Scoliosis.

Image Spina bifida.

Image Deafness.

DIAGNOSIS

Children with Klippel-Feil syndrome should have the following tests performed:

Image Renal ultrasound.

Image Hearing test.

Image Lateral flexion-extension radiographs of cervical spine.

TREATMENT

Image Annual evaluation.

Image Avoid violent activities.

Image Close evaluation of immediate family members.

TORTICOLLIS

DEFINITION

Twisted or wry neck.


Image

Torqueo = to twist; collum = neck


ETIOLOGY

Image Congenital: Injury to the sternocleidomastoid muscle during delivery.

Image Acquired: Rotatory subluxation of the upper cervical spine.

MANAGEMENT

Image Congenital: Physical therapy for stretching.

Image Acquired:

Image Warm soaks.

Image Analgesics.

Image Mild anti-inflammatory agents.

Image Soft cervical collar.

Image Passive stretching.


Image

Torticollis is the most common cause of neck muscle strain.


MUSCULAR DYSTROPHIES

Duchenne’s Muscular Dystrophy (DMD)

Image

A 3-year-old boy must use his hands to push himself up when rising from a seated position. Think: Gower’s maneuver.

The Gower test indicates proximal muscle weakness, which is described as Image in the ability to rise from the floor without assistance of the upper extremities. DMD is a sex-linked recessive inherited trait that occurs in males. Since children with DMD usually reach early motor milestones at appropriate times, diagnosis may be delayed. However, the diagnosis becomes evident between 3 and 6 years of age. Creatine kinase (CK) should be obtained, which is elevated (50–100 times normal). DNA analysis confirms the diagnosis.

DEFINITION

Degenerative disease of muscles. DMD is characterized by early childhood onset, typically within the first 5 yr.

INHERITANCE

Image X-linked recessive.

Image One in 3600 males.

SIGNS AND SYMPTOMS

Image Clumsiness.

Image Easy fatigability.

Image Symmetric involvement.

Image Axial and proximal before distal.

Image Pelvic girdle, with shoulder girdle usually later.

Image Rapid progression.

Image Loss of ambulation by 8–12 yr.

Image Pseudohypertrophy of calves.

Image Cardiomegaly—varied severity.


Image

DMD is the most common muscular dystrophy.


DIAGNOSIS

Image Serum CK is markedly elevated.

Image Muscle biopsy is pathognomonic—degeneration and variation in fiber size and proliferation of connective tissue. No dystrophin present.


Image

DMD is associated with:

Image Mental retardation

Image Cardiomyopathy


MANAGEMENT

Image Encourage ambulation.

Image Prevent contractures with passive stretching.


Image

Death in patients with DMD occurs through cardiac or respiratory failure.


Becker’s Muscular Dystrophy (BMD)

DEFINITION

Milder form of muscular dystrophy.

INHERITANCE

X-linked recessive.

SIGNS AND SYMPTOMS

Image Late childhood onset, typically between 5 and 15 yr.

Image Slow progression.

Image Proximal muscle weakness.

Image Prominence of calf muscles.

Image Inability to walk occurs after 16 yr.

DIAGNOSIS

Muscle biopsy shows degeneration of muscle fibers. Dystrophin is reduced or abnormal.

Myotonic Muscular Dystrophy (MMD)

INHERITANCE

Autosomal dominant.

SIGNS AND SYMPTOMS

Image Congenital MMD affects infants and is more severe than the adult form.

Image Adult-onset MMD has a variable onset, typically in the teens to adulthood.

Image Muscle weakness of voluntary muscles in the face, distal limbs, and diaphragm.

Image Involuntary clenching of hands and jaw, ptosis, and respiratory difficulty.

Limb Girdle Muscular Dystrophy

DEFINITION

Two types:

Image Pelvifemoral (Leyden-Möbius).

Image Scapulohumeral (Erb’s juvenile).

INHERITANCE

Autosomal recessive, with high sporadic incidence.

SIGNS AND SYMPTOMS

Image Variable age of onset; childhood to early adult (present in second or third decade).

Image Pelvic girdle usually involved first and to greater extent.

Image Shoulder girdle often asymmetric.

DIAGNOSIS

Muscle biopsy shows dystrophic muscle changes. Dystrophin is normal.

MANAGEMENT

Image Promote ambulation.

Image Physiotherapy.

Image Mildly progressive, life expectancy mid to late adulthood.

Facioscapulohumeral Muscular Dystrophy

INHERITANCE

Autosomal dominant.

SIGNS AND SYMPTOMS

Image Variable.

Image Slow progression.

Image Diminished facial movements: inability to close eyes, smile, or whistle.

Image Weakness of the shoulder girdle: Difficulty raising arms over head.

Image Normal life span.

DERMATOMYOSITIS/POLYMYOSITIS

DEFINITION

Image Polymyositis primarily affects skeletal muscle.

Image Dermatomyositis: Skin eruption + myopathy.

EPIDEMIOLOGY

Image Female > male.

Image Age 5–14 yr.


Image

In adults, dermatomyositis and polymyositis are associated with malignancy and rheumatic disease. Myositis is not associated with cancer in children.


SIGNS AND SYMPTOMS

Image Symmetric proximal muscle weakness.

Image Violaceous rash—symmetric, erythematous rash on extensor surfaces, upper eyelids, and knuckles. Rash around eyes called heliotrope rash.

Image Worrisome triad (not common):

Image Dysphagia

Image Dysphonia

Image Dyspnea


Image

Dermatomyositis affects proximal muscles more than distal muscles, and weakness usually starts in the legs. An inability to climb stairs may be the first warning sign.


DIAGNOSIS

Image ESR, serum CK, and aldolase reflect the activity of the disease.

Image Electromyography (EMG) is used to distinguish myopathic from neuropathic causes of muscle weakness.

TREATMENT

Image Prednisone.

Image Intravenous immune globulin (IVIG), cyclosporine, or methotrexate in refractory cases.

PROGNOSIS

Most children will recover in 1–3 yr.

CONNECTIVE TISSUE DISEASES

Marfan Syndrome

DEFINITION

Genetic defect of genes coding for the connective tissue protein fibrillin.


Image

The most worrisome complications of Marfan syndrome are aortic dilation, aortic regurgitation, and aortic aneurysms.


INHERITANCE

Autosomal dominant.

SIGNS AND SYMPTOMS

Image Musculoskeletal:

Image Tall stature.

Image Long, thin digits (arachnodactyly).

Image Hyperextensible joints.

Image High arched palate.

Image Cardiac: Dilation of the aorta.

Image Ocular: Ectopia lentis—lens dislocation (which progresses over time).

Ehlers-Danlos Syndrome (EDS)

DEFINITION

Group of genetically heterogenous connective tissue disorders.

ETIOLOGY

Image Quantitative deficiency of collagen causing poor cross-linking of collagen.

Image Autosomal dominant.


Image

Type IV EDS is associated with a weakened uterus, blood vessels, or intestines. It is important to identify patients with EDS type IV because of the grave consequences of the disease. Women with EDS type IV should be counseled to avoid pregnancy.


SIGNS AND SYMPTOMS

Image Children with EDS are normal at birth.

Image Skin hyperelasticity.

Image Fragility of the skin and blood vessels.

Image Joint hypermobility.

Image Propensity for tissue rupture.

MANAGEMENT

Image Symptomatic.

Image Preventive.

Image Prolonged wound fixation.

Image Genetic counseling.

Scoliosis

DEFINITION

More than 10-degree curvature of spine in the lateral plane due to the rotation of the involved vertebrae (see Figure 19-12).

Image

FIGURE 19-12. Radiograph of spine demonstrating marked scoliosis.

ETIOLOGY

Image Eighty percent of cases are idiopathic.

Image Scoliosis is associated with:

Image Neurofibromatosis.

Image Marfan syndrome.

Image Cerebral palsy.

Image Muscular dystrophy.

Image Poliomyelitis.

Image Myelodysplasia.

Image Congenital vertebral anomalies (hemivertebrae, unilateral vertebral bridge).

EPIDEMIOLOGY

Image Four to five times more common in girls.

Image Age of onset: 9–10 yr for girls, 11–12 yr for boys.

SIGNS AND SYMPTOMS

Image Usually asymptomatic.

Image Severe curvature may Image impairment of pulmonary function.

DIAGNOSIS

Image X-ray of entire spine in both the AP and lateral planes.

Image To examine children, have the patient bend forward 90 degrees with the hands joined in the midline. An abnormal finding consists of asymmetry of the height of the ribs or paravertebral muscles on one side.


Image

Thirty percent of family members of patients with scoliosis are also affected. Siblings of affected children should be carefully examined.


MANAGEMENT

Treatment depends on the curve magnitude, skeletal maturity, and risk of progression:

Image Curve < 20 degrees: Physical therapy and back exercises aimed at strengthening back muscles.

Image Curve 20–40 degrees in a skeletally immature child: Orthopedic back brace. A back brace does not Image the curve, but prevents further curve progression.

Image Curve > 40 degrees: Spinal fusion to correct deformity.


Image

Screening for scoliosis should begin at age 6–7 yr.


PROGNOSIS

Image Curve > 60 degrees: Associated with poor pulmonary function. Large thoracic curves are associated with a shortened life span.

Image Curve < 40 degrees: Usually do not progress. Small curves are well tolerated.

Image Risk of progression higher in younger childhood.

Kyphosis

DEFINITION

Posterior curvature of the spine.

ETIOLOGY

Scheuermann thoracic kyphosis is a structural deformity of the thoracic spine.

SIGNS AND SYMPTOMS

Image Pain

Image Progressive deformity

Image Neurologic compromise

Image Cardiovascular complaints

Image Cosmetic issues

RADIOLOGY

Image Diagnosis is confirmed on lateral radiographs.

Image X-ray shows anterior wedging of at least 5 degrees of three or more adjacent thoracic vertebral bodies.

Spondylolysis

DEFINITION

Fracture of the pars interarticularis due to repetitive stress to this area.

ETIOLOGY

Spondylosis occurs as a result of new bone formation in areas where the annular ligament is stressed.

TYPES

Image Congenital: Cervical.

Image Acquired: Lumbar, most often at L5 (85% of cases).


Image

Spondylolysis is the most common cause of low back pain in adolescent athletes. This injury is most commonly seen in gymnasts, dancers, and football players.


SIGNS AND SYMPTOMS

Image Cervical pain.

Image Low back pain, worse during the adolescent growth spurt and with spine extension.

Image Radicular symptoms are not common.

DIAGNOSIS

Oblique x-ray view of the spine will show the characteristic “Scottie dog sign.”

TREATMENT

Image NSAIDs.

Image Strength and stretching exercises.

Image Lumbosacral back brace.

Spondylolisthesis

DEFINITION

Anterior or posterior displacement of one vertebral body on the next due to bilateral pars interarticularis injury.

SIGNS AND SYMPTOMS

Image A palpable “step-off” at the lumbosacral area.

Image Limited lumbar flexibility.

DIAGNOSIS

Lateral x-ray views show displacement of one vertebral body from another.


Image

Grade 1: < 25% displacement

Grade 2: 25–50%

Grade 3: 50–75%

Grade 4: 75–100%

Grade 5: Complete displacement


MANAGEMENT

Treatment depends on grade of lesion:

Image < 30% displacement: No restrictions on sports activities, but requires routine follow-up.

Image > 50% displacement: In situ posterior spinal fusion or bracing.


Image

Children at highest risk for diskitis:

Image Immunocompromised

Image Systemic infections

Image Postsurgery


COMPLICATIONS

Image Deformity

Image Disability

Diskitis

DEFINITION

Image Pyogenic infection of the intervertebral disk space.

Image An uncommon primary infection of the nucleus pulposus, with secondary involvement of the cartilaginous end plate and vertebral body.


Image

The lumbar spine is the most common site of involvement for diskitis.


ETIOLOGY

Image Most present prior to 10 years of age.

Image Spontaneous.


Image

S aureus is the most common organism causing diskitis.


SIGNS AND SYMPTOMS

Image Moderate to severe pain.

Image Pain is localized to the level of involvement and exacerbated by movement.

Image Radicular symptoms.

LABS

Image MRI is the radiographic study of choice.

Image Elevated ESR.


Image

Plain radiographs are usually not helpful for early diagnosis of diskitis.


MANAGEMENT

Image Intravenous antibiotics.

Image Surgery is often not necessary.

RENAL OSTEODYSTROPHY

DEFINITION

Bone diseases resulting from defective mineralization due to renal failure.

SIGNS AND SYMPTOMS

Image Growth retardation

Image Muscle weakness

Image Bone pain

Image Skeletal deformities

Image Slipped epiphyses

DIAGNOSIS

Image Normal to Image serum calcium.

Image Normal to Image phosphorus.

Image Image alkaline phosphatase.

Image Normal parathyroid hormone (PTH) levels.

Image Radiographs of the hands, wrists, and knees show subperiosteal resorption of bone with widening of the metaphyses.


Image

In children, renal osteodystrophy resembles rickets.


TREATMENT

Image Low-phosphate formula.

Image Enhance fecal phosphate excretion with oral calcium carbonate, an antacid that also binds phosphate in the intestinal tract.

Image The goals of treatment include normalization of the serum calcium and phosphorus levels and maintenance of the intact PTH level in the range of 200–400 pg/mL.

OSTEOCHONDRITIS DISSECANS

DEFINITION

Avascular necrosis of bone adjacent to articular cartilage.

SIGNS AND SYMPTOMS

Image Vague pain (typically in the knee or ankle).

Image With joint flexed, may be able to palpate defect below articular cartilage.

Image May present as a loose body in the joint.

Image Most common in the lateral portion of medial femoral condyle.

DIAGNOSIS

Image X-rays show characteristic appearance of subcondylar osteonecrosis.

Image MRI may be useful to confirm diagnosis.

TREATMENT

Image Children < 11 years—typically observed with serial radiographs to assess healing.

Image Adolescents—excision of loose fragments if small. Replacement with fixation if large. Sometimes area can be drilled to promote revascularization and healing.

PROGNOSIS

Typically good with appropriate intervention.



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