Doernbecher Children’s Hospital
Musculoskeletal Pain from Birth to AdolescenceOHSU
PRESENTED BY: Scott Yang MD, Assistant Professor, Pediatric Orthopaedic Surgery Doernbecher Children’s Hospital, OHSU OHSUNo disclosures
2 Agenda
• Identify common musculoskeletal (MSK) causes of pain in pediatric patients • Case Based • Broken down by age group / anatomy • Tips for examination • OHSUFocus on can’t miss items
3 General Principles
Three things not to miss (time sensitive) - Trauma - Usually history obvious, except infants/young children
- Infection - Fever, malaise - Limb splinting with or without history of minor trauma
- Tumor - Persistent symptoms OHSU- constitutional symptoms - Night pain
4 Case #1 History
HPI: 8 month old male presents with fevers, fussiness, and guarding of his right leg
PEX TMax 102.5 GuardsOHSU right leg, Resists hip/knee ROM
5 Case #1 Imaging
Normal Radiographs
Trace right hip OHSUeffusion
6 Case #1 Imaging & Diagnosis
MRI right femur w/ w-out contrast
Extensive myositis & muscle abscess
SurgeryOHSU with > 75 mL of pus; MRSA
Learning Point: In very young children, advanced imaging can be extremely helpful for accurate diagnoses 7 Case #2 History
HPI: 10 y/o M with 1 month left atraumatic knee pain. Hurts at rest, wakes him at night, and painful every time he walks.
PEX: Full range of motions left knee, no palpable masses AntalgicOHSU gait, walks with clear limp Learning Point: Persistent pain, frequent night pain, that is ALWAYS reproduceable, with limping = something is wrong!!
8 Case #2 Imaging & Diagnosis OHSU Further workup & biopsy = Cancer Osteosarcoma
9 Age 0-2 Principles:
- Young children don’t know any better - Non-accidental or accidental
- Some genetic conditions may manifest early
- Examination in this age group = observation - Relative guarding of extremity can reflex injury anywhere from the OHSUproximal or distal part of the extremity
10 Case #3 History HPI: 2 month old F brought in to ED for not moving left arm. Mother unclear on traumatic event. Conflicting history with Father.
Exam: GuardsOHSU left arm Moves other limbs spontaneously. No major swelling or bruising 11 Case #3 Imaging & Diagnoses
Skeletal Survey: 1) Multiple healing rib fractures 2) Left acute humerus fracture 3) Left 1st metatarsal fracture 4) Right healing femur OHSUfracture
12 Case #3 Treatment
• Hospitalize, Report to Social Work/DHS ASAP • Treat injuries as appropriate, remove from current situation
Learning Point: Very young non mobile children (< 1 year old) cannot easily hurt themselves
If presenting with pain or extremity splinting, they need you to advocate for them to look for injury, for which you OHSUmay find many.
13 Case #4 History
HPI: 2 year old female playing in yard, now unable to walk. Unwitnessed.
PEX: MildOHSU Swelling of left leg Image Credit: By Jamie Campbell from Emsworth (nr Portsmouth), U.K - Falling Holds left leg off the ground, down, CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=6693997 doesn’t allow examination
14 Case #4 Imaging & Diagnosis
Toddler’s Fracture - Common cause of pain in active toddlers - Accidental injuries quite common in age >1.5 years
Learning Point: A keyOHSU risk for child abuse is patient age; accidental injuries leading to fractures are more common as children start walking
15 Case #5 History
HPI: 5 year old female with multiple lower extremity pain crises starting at age 2. unable to walk during crises for few days. Multiple hospitalizations
Image Credit: www.kidspot.com.au PEX:OHSU Overall lower extremities without swelling Walks with clear limp on right leg 16 Case #5 Imaging
Multiple bone infarcts in femurs
Right hip avascular necrosisOHSU
17 Case #5 Imaging HepatosplenomegalyOHSU
18 Case #5 Diagnosis
Diagnoses: Gaucher’s Disease (lysosomal storage disorder) - Autosomal recessive GBA Gene mutation leads to buildup of glucocerebroside - Accumulates in organs, bones Image credit: Nature.com OHSUleading to infarcts & damage
19 Case #5 Discussion
Learning Point: Young children, Age 0-5 can manifest recurrent MSK pain symptoms due to genetic or metabolic conditions that lead to progressive or recurrent tissue damage / pain
Other Examples: 1) Other lysosomal storage disease (mucopolysaccharidoses) 2) Sickle cell disease 3) OHSUSkeletal dysplasias
20 Age 3-9 Principles
Most kids are resilient, and want to play. Look for consistency in symptoms, and functional differences
Exam Tips: - Children can express themselves more, but still need much guidance to get accurate diagnosis - OHSUPhysical exam should focus on tasks. - Jump? Walk? Run? High Five? Squat?
21 Case #6 History HPI: 5 year old male presents with intermittent limping, and mild hip pain for past 6 months. No fevers/malaise. Able to jog with a limp -Otherwise plays well, can go to school, no malaise
PEX: Well appearing SlightOHSU trendelenburg limp Difficulty running / jumping Slightly decreased left hip abduction range of motion
22 Case #6 Imaging
Initial Presentation OHSU6 months later
23 Case #6 Pearls & Treatment
Legg-Calve-Perthes disease ● Avascular necrosis of the hip in childhood (Age 3-9 typically)
● Unclear etiology Learning Point: The limp is persistent and frequent. Think ● Treatment is Perthes as cause of mild to moderate OHSUpersistent hip pain in young child supportive care, sometimes surgery
24 Case #6 Perthes Disease Treatment
• Limited activity / stretching / PT
• Abduction Orthosis or OHSUCasting
Image: 1) Orthoinfo, AAOS.org 25 2) Weinstein & Flynn, Lovell and Winters Pediatric Orthopaedics 7th Ediition Case #6 – Perthes Surgical Treatment in Children
• Some children (often > 8 years old) may benefit from hip surgery
OHSU7 y/o 8 y/o 47 y/o
Image: 1) Shohat et al, JBJS 2016 26 Case #6 Discussion
Learning point: Know basics of school age child hip pain conditions! OHSU
27 Case #7 History
HPI: • 4 year old female presents with left knee swelling and limp, worse in the mornings x 1 month. Stiffness improves through day.
PEX: • Left knee 10 degree flexion contracture, moderate swelling OHSUImage Credit: Shenoi S, Pediatrics in Review • Able to walk, subtle limp, no severe pain with knee range of motion
28 Case #7 Diagnosis
Labs: Normal CBC, ESR, CRP + ANA Xrays: Negative
Juvenile Idiopathic Arthritis - OHSUBroadly Defined: Arthritis > 6 weeks, < 16 years of age
29 Case #7 Diagnosis Pearls
• Oligoarthritis: ≤ 4 joints, knees/ankles/elbows, can be unilateral, Most common • Polyarthritis: >5 joints, often bilateral joints, small joints too. Affects about 25% of children with JIA. • Systemic: Whole body (joints, skin and internal organs). High Fever & Rash can occur. • OHSUUveitis can occur, check the eyes
Image Credit: Pediatrics in Review
30 • Learning point: – Inflammatory conditions should be on differential for school aged child as a cause of MSK pain – Acute conditions include post-viral transient synovitis; post- streptococcal arthritis OHSU– Chronic conditions include JIA
31 Age 10-16 Principles
Always think about the growth plate in preteen/teen - Child is rapidly growing in adolescence - Skeletal growth plate is weakest part of the skeleton during OHSUthis time
32 Age 10-16 Principles
Sporting or activity demands may lead to stress injuries - Year-round sports common - More competition / Image Credit: Lariatonline OHSUintensity
33 Case #8 History
HPI: 13 year old competitive soccer star complains of activity related anterior right > left knee pain Worse with jumping or after soccer practice
PEX: - OHSUTenderness along bilateral tibial tubercle - Pain with resisted knee extension, pain with squat jumps
34 Case #8 Diagnosis
Osgood Schlatter Disease - Inflammation along tibial apophysis due to overuse - Apophysitis: Traction injury to growth plate Treatment:OHSU – Rest, Rest, Rest Image Credit: NEJM
35 Case #8 Discussion
Other common areas of apophysitis: OHSU
Image Credits: AAFP 36 Case #8 Discussion
Learning Point: • Overuse injuries are very common in adolescents in the OHSUGROWTH PLATE (weakest part of bone)
37 Case #9
History: 12 year old female competitive gymnast complains of 1 month of severe activity limiting low back pain. Worse with gymnastics, prolonged standing
PEX:OHSU ++ Pain with lumbar hyperextension Image Credit: AAOS Normal neurologic examination
38 Case #9 imaging OHSU
Image Credit: 1) Cavalier at al, JAAOS 2006 39 Case #9 – Spondylolysis Pearls
• Stress fracture of the par interarticularis of the spine – L5 common – Cause: Repetitive hyperextension exercises in children/adolescents (football lineman, gymnast, swimmers, etc)
• Often athletes (up to 47% in adolescent athletes w/ low back pain) (Micheli et al, Arch Ped Adolesc Med 1995, Nitta et al, Orthopedics 2016) OHSU– Difficult to due to active patient population
Image Credit: http://www.massgeneral.org/ortho-childrens/conditions- treatments/spondylolysis.aspx 40 Case # 9 - Spondylolysis
• Unfavorable OHSUenvironment to heal
41 Case # 9 – Spondylolysis Treatment • Treatment: – Non-surgical: • Anti-lordotic bracing, physical therapy, core exercises • If caught early, treat to heal (~50% success) • If chronic, symptomatic control – Surgical: • Persistent symptoms > 6 months after nonsurgical rx OHSU• Direct repair of fracture (L1- L4) • Limited fusion (L5)
Image Credit: 1) Cheung et al, JAAOS 2006 2) Menga et al, Spine 2014 42 Case #10 History
HPI: 13 year old M with 6 months right knee pain. No trauma. Severe limp 2 weeks ago, improved, but persistently painful
PEX: BMI: 31 Normal right knee exam RightOHSU hip: Limitation of flexion & internal rotation compared to left side. ++ pain with hip flexion & internal rotation Image Credit: AAOS
43 Case #10 Imaging
- OHSUDiagnosis: Slipped capital femoral epiphysis
44 Case 10 – SCFE Discussion
• Proximal femoral epiphysis is disrupted from the metaphysis at the growth plate – Leads to 3D deformity of the hip – Can occur gradually over OHSUtime or associated with a sudden event
45 Image: OrthoInfo.aaos.org Case 10 - SCFE Epidemiology
• Age 9-13 • 10.8/100,000 children annually in USA • Associated with obesity – >50% of SCFE patients are OHSU>95th percentile for weight
46 Case 10 – SCFE Clinical Pearls
• Groin / thigh / knee pain – 90% - Several weeks-months of pain, insidious limp – 10% - Sudden acute severe pain without prodromal symptoms • Range of motion – Loss of hip internal rotation OHSU– Excessive hip external rotation
Learning Point: An overweight pre-teen / teen complaining of frequent knee pain Needs a thorough and TIMELY HIP exam
47 Image: OrthoInfo.aaos.org Case 10 - SCFE Treatment
• In-Situ screw fixation as soon as possible • Prevent further OHSUdeformity!
48 Summary
Always think Trauma, Tumor, or Infection first (Most common)
0-2: Non accidental / accidental injuries; Genetic Conditions
3-9: Perthes disease / Hip conditions, Inflammatory conditions, GeneticOHSU Conditions
10-16: Growth plate / overuse / stress injuries
49