ORTHOPEDICS FOR CHILDREN AND ADOLESCENTS
| BACK PAIN IN CHILDREN —Robert M. Bernstein, MD, Director of Pediatric Orthopaedic Surgery, Department of Surgery,
Cedars-Sinai Medical Center, Los Angeles, CA
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| Differential diagnosis: mechanical—trauma; pressure on posterior elements of spine; disc herniation; postural and
overuse injuries; syrinx or hydromelia; increase in fluid pressure in spinal cord; Scheuermann’s disease—abnormality
of growth plates of vertebral bodies; changes in disc spaces and endplates of vertebral bodies; wedging of vertebral
bodies; abnormal kyphosis (normal degree of kyphosis in thoracic spine 40º-45º for adults, 20º for children 2-5 yr of
age); inflammatory—rheumatologic disease; osteomyelitis; neoplastic—bone neoplasm (uncommon in children); spinal
cord and canal problems; meningioma; neurofibromatosis; muscle neoplasm; rhabdomyosarcoma; metastatic disease
(uncommon in children)
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| Diagnosis: patient history—infection; fever; recent ear infection; determine how pain started (eg, fracture); location of
pain; pain in back or limbs only at night consistent with infection or tumor; frequency, duration, and intensity of pain; response
to anti-inflammatory medications; determine whether pain interferes with play; pain with bending forward likely
disc herniation, pain with bending backward likely spondylolysis; weight loss; neurologic complaints; bowel and bladder
problems; weakness in legs; jumpy legs; gait changes; physical examination—examine standing patient; skin markings;
midline defects may suggest intraspinal anomaly; leg length discrepancies; flexion and extension of back; pain with palpation
or percussion indicates significant sensitivity to vibration; deep tendon reflexes; asymmetric abdominal reflexes
indicate intraspinal anomaly; motor and sensory examination; numbness; straight-leg raises to look for disc herniation;
press on sacroiliac (SI) joint to check for juvenile ankylosing spondylitis; anteroposterior (AP) and lateral x-rays; oblique
x-rays; bone scan; magnetic resonance imaging (MRI) and computed tomography (CT); complete blood count (CBC),
erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and antinuclear antibody (ANA) testing for suspected
infection, tumor, or rheumatologic disease
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| Discitis: pain in thoracolumbar region with kyphosis; pain with percussion; x-ray shows narrowing of disc spaces and
endplate changes; associated with endplate infection; toddlers do not walk; children may complain of abdominal pain,
adolescents complain of back pain; stiff posture; straight-leg raises sometimes positive; management—CBC; intravenous
(IV) and oral antibiotics; bracing; surgery rare
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| Questions and answers: differential diagnosis—muscle pull or disc herniation in adolescents 17 to 18 yr of age; depends
on physical activities in adolescents 12 to 13 yr of age, but consider spondylolysis; depends on presentation; if patient
has spondylolysis, treatment includes anti-inflammatory medication, changing activity level, and bracing; flexion/
extension radiographic views useful when considering surgery; postural roundback—slouching results in upper back
pain; physical therapy to strengthen back helpful; growing pains—eg, pain in shins or knees; typically in children 3 to 9
yr of age; pain at end of day or during night; massage, hot towel wraps, or anti-inflammatory medication helpful; pain in
>1 place (eg, both legs) unlikely to be serious
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| MUSCULOSKELETAL INFECTIONS —Deborah Lehman, MD, Associate Professor and Associate Director of Pediatric
Infectious Diseases, Department of Pediatrics, David Geffen School of Medicine at the University of California, Los Angeles
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| Differential diagnosis of osteomyelitis: trauma; septic arthritis; reactive arthritis; toxic synovitis; malignancy; rheumatic
fever if large joints inflamed; myositis; vasoocclusive crisis in children with sickle cell disease
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| Laboratory studies: white blood cell (WBC) count elevated; ESR elevated; chance of positive blood culture 30% to 40%;
plain film radiography; bone scan; knee puncture to rule out septic arthritis
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| Signs and symptoms: older children—pain and fever (suppressed with analgesics); limp; arthritis; infants—fewer
signs and symptoms; irritability; surface soft tissue changes; pseudoparalysis; multiple joint involvement
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| Work-up: patient history and physical examination; CBC frequently elevated, but normal CBC not uncommon; CRP—
expected to peak within first 2 days after initiation of treatment; returns to normal by end of first week; ESR—continues
to rise at end of first week of therapy; decreases to normal after 3 to 4 wk of therapy; checking ESR and CRP at initiation
of therapy and repeating 5 to 7 days into therapy helpful for determining effectiveness of therapy; children with delayed
normalization of CRP more likely to have complicated osteomyelitis or develop chronic osteomyelitis (consider longer
therapy); blood culture; bone aspiration; serum bactericidal levels; plain x-rays—not positive until second week following
onset of symptoms, but areas of soft tissue swelling and obliteration of flat planes seen early (subperiosteal elevation
seen later); bone scanning—sensitive early in course of disease; less sensitive in presence of soft tissue swelling; technetium-99
scan; 3-phase bone scan highly sensitive early in course of disease; less specific especially in patients with sickle
cell disease or trauma; allows visualization of entire skeleton; requires radiation dose; does not allow localization of abscess
that may or may not need to be drained; low sensitivity in newborns and patients with sickle cell disease; does not
require sedation; MRI—highly sensitive early on; localizes abscesses; does not involve ionizing radiation; good for areas
difficult to see on plain films and bone scan; small-area study; less specificity in areas of infarction and trauma; requires
sedation for young children
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| Microbiology: 70% to 90% of cases due to Staphylococcus aureus; group A β-hemolytic streptococci (especially after varicella
infection); gram-negative organisms in patients with sickle cell disease and Salmonella or Pseudomonas and IV drug
abusers; Pseudomonas in foot puncture wounds; group B streptococci in neonates; community-onset methicillin-resistant
S aureus (MRSA)—presents as cellulitis with necrotic center (pathognomonic); parents often report as spider bite (toxins
cause central necrosis; appearance similar to spider bite); reports of children with complicated courses of osteomyelitis or osteoarthritis;
Kingella kingae—mostly in children <2 yr of age; predilection for ankle joints; causes septic arthritis or associated
osteomyelitis; oropharyngeal colonizer in 15% of healthy toddlers; usually does not colonize in adults; difficult to grow
in culture; infections of coagulase-negative staphylococci and S aureus develop in children postcardiac or postthoracic surgery;
children with open fractures often have mixed infections; gram-negative rods in immunocompromised patients; patients
with chronic granulomatous disease predisposed to Serratia, S aureus, and Aspergillus; S aureus and coagulase-negative staphylococci
seen in patients with orthopedic prostheses; bite wounds usually polymicrobial; after varicella, patients at risk for
Streptococcus pyogenes; patients with hemoglobinopathies at risk for Salmonella; study found Salmonella more common
than S aureus in children with sickle cell disease and osteomyelitis
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| Chronic recurrent multifocal osteomyelitis (CRMO): more common in girls; mean age 11 yr; affects mostly long
bones and clavicles; associated with other autoimmune diseases; patients can have elevated acute phase reactants; reports of
unifocal nonrecurrent lesions (nonbacterial osteomyelitis); treatment—rule out malignancy; rest; immobilization; nonsteroidal
anti-inflammatory agents (eg, naproxen [Naprosyn])
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| Empiric therapy for osteomyelitis: due to high incidence of community-onset MRSA, vancomycin or clindamycin
added to first-generation cephalosporin; for foot puncture wounds, use piperacillin and tazobactam or third-generation
antipseudomonal penicillin to cover Pseudomonas; add cefotaxime to cover Salmonella in patients with sickle cell disease;
add cefotaxime and consider vancomycin for neonates, especially in neonatal intensive care unit (NICU); narrow
spectrum after isolating organism; start with IV therapy and transition to oral antibiotics; length of therapy 4 to 6 wk;
short (<3 wk) courses associated with 5 times higher rate of relapse; chronic osteomyelitis requires >6 wk of therapy;
consider changing to oral antibiotics when signs and symptoms resolving, laboratory markers improving (eg, 20% decline
in ESR), isolation of organisms sensitive to oral antibiotics, and administration of oral antibiotics reliable (give high
doses); complications—chronic osteomyelitis (areas of necrotic bone away from vasculature; require long and high
doses of antibiotics); spreading to joints; prolonged bacteremia; growth arrest; monitor for complications of drug therapy
(eg, neutropenia due to first-generation cephalosporins; check CBC weekly)
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| Arthritis: usually hematogenous in children; etiology—Mycobacteria; Lyme disease; gonococcus (GC); viral arthritides;
reactive arthritides; acute presentation of limb pain with motion; joint usually held in mild flexion and external rotation;
hip and shoulder joint arthritis must be managed emergently to avoid aseptic necrosis; on joint aspirate, look for high
WBC count (>50,000/µL); inoculating blood culture bottle best way to isolate fastidious organisms; perform concomitant
blood cultures; acute phase reactants important; imaging studies; septic arthritis—high WBC count and low serum glucose;
look at Gram’s stain; unusual organisms include Mycobacterium tuberculosis; arthritis as late manifestation can
cause concurrent arthritis of large joints; consider travel history
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| Questions and answers: puncture wounds—almost always need debridement; puncture usually causes osteochondritis
(difficult to treat); early debridement can shorten therapy from 6 wk to 2 to 3 wk for Pseudomonas osteochondritis (compared
to long bone osteomyelitis); S aureus—common; may resemble spider bite; obtain culture; nasopharyngeal carriage
in family members—common; treat with intranasal mupirocin or chlorhexidine baths; twice weekly bath with 1 tsp
of Clorox bleach per gallon of water shown effective
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| SPORTS INJURIES —William M. Hohl, MD, Co-Program Chair, and Associate Director of Pediatric Orthopaedics, Department
of Surgery, Cedars-Sinai Medical Center, Los Angeles
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| Acute fractures: children’s bones more porous and metabolically active than adult bones; children’s bones undergo sequential
partial failure under stress; pure bending fractures often seen in forearm of children; ligament injuries uncommon
in children, compared to adults; Salter-Harris fracture of distal fibular physis—childhood equivalent of lateral
ligament sprain of ankle; tenderness and swelling greatest at physis and not over ligament; fractures involving physis
more likely to occur during times of rapid growth or during puberty
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| Acute apophyseal injuries: muscle contracts violently and detaches tendon from bone; common in pelvis, tibial tubercle,
inferior pole of patella, and medial epicondyle (often associated with elbow dislocation)
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| Little league elbow: medial epicondyle chronic apophysitis; seen in throwing arm of children 8 to 16 yr of age; pain on
medial side of elbow exacerbated by throwing or full elbow extension; tenderness and swelling at medial epicondyle; pain
and instability with valgus stress; pain with full extension of elbow; check ulnar nerve; treatment—rest; ice; anti-inflammatory
drugs; stretching; strengthening; gradual return to throwing when patient pain-free and able to fully extend elbow
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| Inferior pole of patella: apophysitis; usually seen in jumping athletes (eg, basketball or volleyball players); pain and
swelling at inferior pole of patella; usually no specific moment of injury but sudden event may avulse patellar tendon attachment
from patella (patellar sleeve injury); treatment—rest; ice; anti-inflammatory agents; stretching quadriceps; gradual return
to activity
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| Osgood-Schlatter disease: pain in tibial tubercle with localized swelling and tenderness; fluctuating symptoms, depending
on activity; usually not due to specific injury; commonly seen in soccer players; bilateral 20% of time; physical
examination—tight quadriceps; no other symptoms of knee problems; plain radiography to rule out osteosarcoma of
proximal tibia; irregularities of ossification often seen; enlarged tibial tubercle; treatment—rest; ice; activity modification;
stretching quadriceps; patellar tendon strap
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| Sever’s apophysitis: heel pain; no specific injury; no swelling; tenderness at calcaneal apophysis; tight heel cords; sporadic
white appearance on radiography in asymptomatic children; treatment—gastrocnemius stretching; heel lift
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| Stress fracture: rate of accumulation of microscopic damage to bone exceeds rate of repair; often seen with sudden increase
in activity level; common in metatarsal bones in foot, tibia, and femur; pain with weight bearing; localized tenderness
and swelling over involved portion of bone; new bone formation seen on x-ray after 2 to 3 wk; earlier diagnosis with
bone scanning or MRI; treatment—rest; consider casting and crutches; gradual return to activity, using pain and tenderness
as guide
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| Anterior knee pain in adolescent female athletes: consider hip source, Osgood-Schlatter disease, and Sinding-
Larsen-Johannson disease; patellofemoral pain; contributing factors include ligamentous laxity, hyperpronation, abnormal
knee valgus or increased quadriceps (Q) angle, rapid growth, playing surfaces, poor shoes, and poor training program; physical
examination—ligamentous laxity; pronation and stance; increased Q angle; routine radiography (sunrise or Merchant’s
view often helpful); treatment—rest; ice; anti-inflammatory agents; physical therapy; expensive custom orthotics not immediately
recommended (less expensive alternatives available); taping
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| Meniscus tears: not common in young children; discoid lateral meniscus (congenital abnormality; symptoms can
present at age 7-8 yr); usually due to violent event (eg, high school football injury); pain and effusion after twisting injury;
mechanical symptoms (eg, locking or sensation of giving way); diagnosis—joint-line tenderness on medial or lateral
side; look for concomitant anterior cruciate ligament (ACL) injury; plain radiography normal; false-positive results
on MRI rare, but false-negative results occur; consequences of removing half of meniscus in young patients include premature
arthritis
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| Osteochondritis dissecans: lesion of bone and cartilage; etiology unknown, but may be due to repetitive microtrauma,
vascular insult, or incomplete fusion of ossification center; rare for children <10 yr of age to be symptomatic; male predominance
(at least 3:1); bilateral 20% of time; insidious onset of knee pain; aching; mechanical symptoms; plain radiography
usually diagnostic; MRI often helpful for determining prognosis and appropriate treatment; younger children can heal lesions
with rest, immobilization, and casting; arthroscopy; surgical intervention
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Educational Objectives
| The goal of this program is to educate the listener about orthopedic problems in children and adolescents. After hearing and
assimilating this program, the participant will be better able to:
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 | 1. List the differential diagnosis of back pain in children.
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| 2. Use patient history and physical examination to diagnose back pain.
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| 3. Perform appropriate laboratory and imaging studies for children with osteomyelitis.
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| 4. Select an effective treatment regimen for osteomyelitis.
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| 5. Identify common sports injuries in children and adolescents.
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Discussed on This Program
Cefotaxime sodium [Claforan]
Chlorhexidine gluconate (several trade names)
Clindamycin (several trade names)
Mupirocin (pseudomonic acid A) [Bactroban, Bactroban Cream, Bactroban Nasal]
Naproxen [Aleve, Anaprox, Anaprox DS, EC-Naprosyn, Naprosyn, Naprelan]
Penicillin G [Bicillin C-R, Bicillin C-R 900/300, Bicillin L-A, Permapen, Pfizerpen, Wycillin]
Penicillin V (phenoxymethyl penicillin) [Penicillin VK, Veetids]
Piperacillin sodium and tazobactam sodium [Zosyn]
Vancomycin [Vancocin, Vancoled]
Suggested Reading
Adirim TA et al: Overview of injuries in the young athlete. Sports Med33:75, 2003; Benjamin HJ et al: Little
league elbow. Clin J Sport Med 15:37, 2005; Bocchini CE et al: Panton-Valentine leukocidin genes are associated with
enhanced inflammatory response and local disease in acute hematogenous Staphylococcus aureus osteomyelitis in children.
Pediatrics 117:433, 2006; Devrim I et al: Atypical presentation of spondylitis in a case with sickle cell disease. Turk J
Pediatr 47:369, 2005; Dollard MD et al: Preconditioning principles for preventing sports injuries in adolescents and
children. Clin Podiatr Med Surg North Am 23:191, 2006; Duncan RA et al: Back pain in children: dig a bit deeper. Eur
J Emerg Med 12:317, 2005; Hestbaek L et al: The course of low back pain from adolescence to adulthood: eight-year
follow-up of 9600 twins. Spine 31:468, 2006; Kaplan SL: Osteomyelitis in children. Infect Dis Clin North Am 19:787,
2005; Maffulli N et al: The Epidemiology of Children's Team Sports Injuries. Med Sport Sci49:1, 2005; Pepper M et
al: The pathophysiology of stress fractures. Clin Sports Med 25:1, 2006; Sanpera I Jr et al: Bone scan as a screening
tool in children and adolescents with back pain. J Pediatr Orthop 26:221, 2006; Saphyakhajon P et al: Kingella kingae:
an emerging pathogen of acute osteoarticular infections in children. Pediatrics 117:249, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Dr. Lehman is on the Speakers’ Bureau for Aventis Pharmaceuticals, Inc. and Merck & Co.
Drs. Bernstein, Lehman, and Hohl spoke in Los Angeles, CA, on October 22, 2005, at Orthopaedic Aspects of the Growing
Child, presented by Cedars-Sinai Medical Center. The Audio-Digest Foundation thanks the speakers and Cedars-Sinai
Medical Center for their cooperation in the production of this program.
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