Pediatric Orthopedics

Educational Objectives

The goals of this program are to improve evaluation and management of pediatric back pain and sports injuries. After hearing and assimilating this program, the clinician will be better able to:

1.   Recognize red flags in the child with back pain that may indicate serious pathology.

2.   Choose appropriate imaging studies for pediatric back pain and sports injuries.

3.   Explain the role of exercise and stretching in treatment of pediatric back pain.

4.   List the most common sports injuries in pediatric patients.

5.   Identify pediatric sports injuries that require surgical intervention.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Drs. Brown and Weiss and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Brown spoke on May 16, 2008, in Boston, MA, at Current Surgical Perspectives for the Pediatric Primary Care Provider, presented and jointly sponsored by Boston Medical Center and Boston University School of Medicine.  Dr. Weiss spoke on May 14, 2008, in Los Angeles, CA, at the Annual Spring Meeting and Parmelee Lecture, Office Or­thopedics for the Pediatrician, presented and sponsored by the Los Angeles Pediatric Society. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Back Pain in Children

T. Desmond Brown, MD, Assistant Professor of Orthopaedic Surgery, Boston University School of Medicine, Director of Pediatric Orthopaedics, Boston Medical Center, Boston, MA

Initial approach: determine severity of back pain; goal to restore function and have patient return to normal activi­ties; utilize team approach; consider psychosocial aspects and appropriate referral; possible role for manipulation

Development of back pain: byproduct of bipedal and upright posture; present over spectrum of life; back pain in adults significant economic cost; ideal to prevent childhood back pain from continuing into adulthood; most prob­lematic between 12 and 15 yr of age

Growth: rapid growth in height and weight from 12 to 15 yr of age causes increased stress to structures; bones act as engines of growth by stretching muscles, arteries, and nerves; magnetic resonance imaging (MRI) reveals early de­generative disc disease in young teenagers; x-ray and MRI findings not always correlated with presence of back pain in adulthood; however, adolescent who complains of back pain more likely to experience it as adult; back pain occurs earlier and more frequently in girls

Origins of back pain: not all pain originates from vertebral bodies; discs — function as cushions to dampen applied forces; similar to jelly doughnut with firm annular ring outside and soft interior (nucleus pulposus); periphery of disc well-innervated, so peripheral tears common source of pain; facet joints  —  connection point between vertebral bodies; well–innervated, but difficult to prove as origin of pain; injections to facet joints for relief of pain not effec­tive; herniated disc  —result of nucleus pulposus extruding from annular tear and pressing on peripheral disc nerves; pain radiating down leg classic presentation of herniated disc; muscular and ligamentous strains  —  difficult to prove, probable common cause of nonspecific pain

Initial evaluation: age of child narrows focus of examination and diagnosis; consider psychosocial factors to deter­mine ability to cope with pain and contribution to chronicity of pain; gradual or sudden onset; if sudden, ask whether motor vehicle accident or sports injury occurred; recent onset greater cause for concern than duration over several years; location of pain; timing and severity, especially when worse at night; overall health and activity level; presence of fever; appetite or weight changes; presence of bowel or bladder impairment; weakness; ability to go up and down steps; ability to do normal activities; ambulation without limp

Physical examination: overall appearance and state of health; presence of scoliosis or kyphosis; forward flexion; range of motion testing and provocation of pain; note history of recent growth spurt; observe walking; test reflexes and muscle strength

Age at presentation: back pain not uncommon in adolescents; however, in children <10 yr of age (and especially if <8 yr of age), or with abnormal physical findings (eg, abnormal gait, weakness, impairment in activities) at any age, consider serious causes

Initial imaging: order x-rays if systemic symptoms, abnormal findings, or deformities present, or if child points di­rectly to area of pain

Leukemia: child systemically ill with musculoskeletal pain in legs and back, particularly younger children; osteope­nia may develop, then compression fractures

Osteogenesis imperfecta: x-rays helpful; causes osteopenia and resulting compression fractures

Corticosteroids: high doses lead to osteopenia and compression fractures

Discitis: vertebral osteomyelitis begins in endplate of vertebral body adjacent to disc; typically, children 3 to 7 yr of age complain of leg pain or abnormal gait and look ill, with fever and decreased appetite; white blood cell (WBC) count normal; elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP); x-rays typically normal; bone scan or MRI identifies infection site (bone scan more specific); blood cultures identify organism, typically Staphylococcus or Streptococcus; in children with sickle cell anemia, may see rare case of Salmonella; intravenous antibiotics shorten duration of symptoms; utilize brace if child has problems with standing or walking

Sacroiliac joint infection: pain in vicinity of lower back and pelvis; fever; elevated ESR; joint aspiration typically bloody, but cultures almost always contain gram-positive cocci

Spinal cord tumor: consider in very young child, especially if scoliosis present; do neurologic examination; if ab­normality found, consider MRI

Eosinophilic granuloma or Langerhans cell histiocytosis: vertebra plana typical x-ray finding; self-limited inflam­matory process; rule out other possibilities (eg, infection or tumor); bone scan identifies location; MRI gives best image; support spine with orthosis to reduce pain; condition resolves over time

Spondylolysis: defect or fracture of pars interarticularis (ridge of bone between superior and inferior facet joints); area of maximal stress secondary to bipedal locomotion; typically at fifth lumbar vertebra (L5); common defect; older studies showed »4% of population has pars defects by 4 to 5 yr of age; usually asymptomatic until adoles­cence, and majority remain asymptomatic; however, back pain develops in significant proportion; hamstrings tight and forward flexibility limited; unclear whether tight hamstrings contribute to pars defect or vice versa; difficult to detect on anteroposterior or lateral x-rays, but visible on oblique views; typical patient 12 to 15 yr of age and able to localize pain precisely at L5, often unilaterally; helpful to diagnose in pre-stress fracture state; if bone scan posi­tive, initiate trial of immobilization and limited activity to decrease back pain and avoid true spondylolysis; treat­ment same as for nonspecific back pain (stretching, analgesics); most patients can continue sports; counsel patient about condition and about higher risk for back pain in adulthood

Spondylolisthesis: rare; develops secondarily to spondylolysis; defect at L5 allows it to slip forward on sacrum; more severe back pain, spasm, and hamstring tightness; occasional neurologic deficit; follow spondylolysis patients until skeletal maturity to rule out slippage at L5; slippage less likely in adulthood

Herniated discs: relatively common by 30 to 40 yr of age; rare in childhood, but do occur; child can develop acute episode immediately after incident, but often insidious; typically, child complains of leg pain originating in buttock and radiating down leg; positive straight leg raise (SLR) test and possible positive contralateral SLR test; good prognosis in children, often without surgery

Herniated endplate: seen in adolescents, but not adults; poor prognosis for resolution without surgery; large frag­ments cause severe back and radiating pain; possible bowel and bladder abnormalities; requires surgical removal

Scheuermann’s kyphosis: severe kyphosis with complaints of pain and perceived deformity; x-ray criteria include wedging of vertebral bodies; typically seen in tall heavy children; boys and girls affected; tight hamstrings; pain of­ten below apex of curve, in upper lumbar region; cosmetic appearance and pain significant issues; few good treat­ment options; physical therapy useful for stretching and postural exercises; consider brace for those still growing; surgery rarely done and  of unclear benefit

Adolescent idiopathic scoliosis: considered painless condition, but many with scoliosis do have back pain; studies found more back pain in adolescents with scoliosis than in controls; pain not related to magnitude of curve; patients given diagnosis of scoliosis may think they must also have pain; speaker recommends asking about back pain in “neutral way”; some children point to apex of curve as site of pain, even though unaware of scoliosis or x-ray find­ings; speaker believes scoliosis and back pain probably related, but should be considered and treated as separate problems

Backpacks and school children: one study found heavier backpacks led to more back pain; use caution with leading questions; studies recommend maximum backpack weight »12% to 14% of body weight; no evidence of epidemic of back pain secondary to heavy school backpacks

Psychosocial factors: child’s overall approach to life; higher depression scores in children with back pain; child liv­ing with adult with back pain more likely to have same complaint; unknown whether genetic, physiologically linked, or learned behavior; emotional or behavioral disorders in childhood associated with back pain in young adulthood; more common with lower levels of parental education, but back pain seen in  all socioeconomic strata

Strength and activity: exercise often prescribed, although increased strength not associated with decreased inci­dence of back pain; no correlation between level of activity or inactivity and pain

Nonspecific back pain: most children do not have identifiable source of pain; give reassurance (not likely serious); can attribute to muscle strain; educate about possible recurrences; limited activity not necessarily indicated; use common sense and avoid potentially harmful activities (eg, lifting weights); treat symptomatically with acetamino­phen or ibuprofen

Back pain patient profile: two types; inactive out-of-shape child needs to increase aerobic exercise and lose weight; athletic well-muscled child needs to stretch and reduce activity level

Back pain exercises: at minimum, teach and encourage hamstring stretches; best results seen with increase in overall aerobic activity level

Conclusions: teach and encourage hamstring stretching; recognize psychosocial components; physical activity raises mood, improves well–being and fitness, and reduces back pain; intervention in childhood can prevent lifelong back pain

Pediatric Sports Injuries

Jennifer M. Weiss, MD, Assistant Professor of Clinical Orthopedic Surgery, Childrens Hospital Los Ange­les/USC Keck School of Medicine, and Director, Sports Medicine Program, Childrens Orthopedic Center, Chil­drens Hospital Los Angeles, CA

Shoulder dislocations: often traumatic and dramatic; many shoulder reduction maneuvers available; Stimson technique  —easiest to do; patient lies prone, with arm off side of table; weight hangs from wrist or held in hand for 10 min; Hill-Sachs lesion often visible as divot of bone on humerus; surgery possibly necessary if soft tissue sepa­rating from bone; traditional treatment immobilizes shoulder in sling; newer methods place shoulder into external rotation (achieves better healing of soft tissue to bone and lower incidence of future dislocations); United States Military Academy at West Point study showed young patients treated with sling alone had 80% chance of repeat dislocation; those treated operatively had lower risk for repeat injury

Multidirectional instability: shoulder clicks, pops, and is hypermobile; atraumatic; often bilateral; best treated with rehabilitation (physical therapy) to increase core muscle, scapular and rotator cuff strength; rarely consider surgery; may also present with hyperextension of elbows and wrists and ligamental laxity; child can reach opposite shoulder freely; humerus translates easily in glenoid; apprehension test positive

Elbow injuries: review anatomy of elbow; capitellum and radius lateral, trochlea and ulna medial; rest first treatment for children who throw or pitch and complain of elbow pain; early phase of throwing places tension on inner elbow and stretches structures medially; late phase brings arm through throw and stresses lateral elbow; acceleration or follow-through phase puts pressure on posterior elbow; older patients with elbow pain due to throwing typically have bone spurs on posterior elbow and issues with late phase throwing; “little leaguer’s elbow” affects skeletally immature pitchers £10 yr of age

Traction apophysitis: pulling on piece of bone over growth plate of medial elbow; affects origin of flexor-pronator muscles; many patients exceed recommended pitching time due to involvement in multiple teams and leagues; treat with rest and gradual return to activities, regardless of whether stress fracture present; consider surgery only if non­operative treatment fails, acute fracture present, or athlete high level

Osteochondritis dessicans: piece of bone tries to pull out of capitellum; if bone separates, pitching career ended; ob­tain x-rays and possibly MRI; patient complains of localized pain; overuse injury; treat with rest; operate if conser­vative treatment fails or bone separates

Panner’s disease: symptoms similar to those of osteochondritis dessicans; transient and self-limiting avascular ne­crosis; consider orthopedic consultation to differentiate from osteochondritis dessicans

Avulsion fractures of pelvis: soft tissue separates and breaks off pieces of bone (eg, hamstrings separate from ischial tuberosity, rectus femoris separates from iliac spine); treat with rest; if tenderness present, obtain x-rays to rule out avulsion fracture; no change in management if fracture present; helpful for parents to know

Labrum of hip: functions as meniscus does in knee; athletes with frequent external rotation (eg, dancers, gymnasts) complain of clicking, popping, and pain; diagnose by stressing hip to reproduce clicking; arthrography with dye raises sensitivity of MRI from 45% to 96%; treat initially with rest, and follow with arthroscopy if pain persists

Snapping hip: iliotibial band snaps over greater trochanter; hamstring snaps over ischial tuberosity; iliopsoas snaps over iliopectineal line; treat with activity modifications, stretching, and anti-inflammatory medications; look for slipped capital femoral epiphysis in adolescents with hip pain, especially larger patients

Anterior cruciate ligament (ACL) tears: increasing frequency in skeletally immature athletes; unclear whether due to better recognition of injury or increased participation at competitive levels; ACL tears diagnosed by history and physical examination; MRI not always necessary but confirms diagnosis; patient reports history of pop, then swell­ing; positive Lachman test (pull tibia anteriorly and feel increased translation); poor prognosis for nonoperative management (develop meniscal tears and cartilage damage); nonoperative management only with consistent rest; warn patients about long-term consequences of torn ACL; classic surgery permanently damages growth plate; newer surgical repairs bypass growth plate

Meniscal tears: complaints of knee swelling, locking, popping, and catching; knee tender to palpation along joint line; positive McMurray sign when knee moved slowly from flexion to extension; external rotation during McMur­ray examination for evaluation of medial meniscus, and internal rotation to check lateral meniscus; in patients <12 yr of age, physical examination found to give more reliable diagnosis of tears than MRI; typically treated with sur­gery

Discoid meniscus:  meniscus develops with excess tissue and deviation from normal C-shape; extra tissue “gets stuck” and locks; if asymptomatic, no treatment indicated; with knee complaints, surgery recommended to remove excess meniscal tissue

Suggested Reading

Arciero RA et al: Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder disloca­tions. Am J Sports Med 22:589, 1994; Bernstein RM, Cozen H: Evaluation of back pain in children and adolescents. Am Fam Physician 76:1669, 2007; Caine D et al: Epidemiology of injury in child and adolescent sports: injury rates, risk fac­tors, and prevention. Clin Sports Med 27:19, 2008; Emery KH: Imaging of sports injuries of the upper extremity in chil­dren. Clin Sports Med 25:543, 2006; Freire M et al: Functional capacity and postural pain outcomes after reduction mammaplasty. Plast Reconstr Surg 119:1149, 2007; Kocher MS et al: Diagnostic performance of clinical examination and selective magnetic resonance imaging in the evaluation of intraarticular knee disorders in children and adolescents. Am J Sports Med 29:292, 2001; Kocher MS, Tucker R: Pediatric athlete hip disorders. Clin Sports Med 25:241, 2006; LaBella C: Common Acute Sports-Related Lower Extremity Injuries in Children and Adolescents. Clin Pediatr Emerg Med 8:1, 2007; Macias BR et al: Asymmetric loads and pain associated with backpack carrying by children. J Pediatr Orthop 28:512, 2008; Micheli LJ, Curtis C: Stress fractures in the spine and sacrum. Clin Sports Med 25:75, 2006; Skaggs DL et al: Back pain and backpacks in school children. J Pediatr Orthop 26:358, 2006; Wall EJ et al: Backpacks and back pain: where's the epidemic? J Pediatr Orthop 23:437, 2003; Wang RY, Arciero RA: Treating the athlete with anterior shoulder instability. Clin Sports Med 27:631, 2008.