A worried mother presents with her 4-year-old son for evaluation of lower extremity pain. She reports the boy has complained of some vague bilateral leg pains over the past several weeks after vigorous physical activities. She became alarmed after he had awakened the past two nights crying in pain. The boy reports the pain is hardly noticeable during the day. Recently, the pain has been in the bilateral distal thighs; however, his mother notes times of unilateral pain. The boy and his mother both deny constitutional symptoms now or over the past several weeks. Examination reveals an afebrile, well-developed male in no distress. The musculoskeletal examination is normal.
Question 12.6.1 The most likely diagnosis for the condition described above is?
E) Osteochondritis dissecans.
Answer 12.6.1 The correct answer is "B." Growing pain is a diagnosis of exclusion, although history and physical examination usually suffice for excluding more serious diagnoses. It is a condition of unknown etiology, but is thought by some to be a result of overuse/over activity on an immature musculoskeletal system. It is most frequently seen in otherwise healthy, active children aged 2 to 5, with some older children affected as well. Pain is commonly bilateral or/and localized to the calf, but may be felt at the ankle, knee, or thigh. Pain may be felt during the day after vigorous activities but is more common in the evening or causing awakening at night. Presentation with constitutional symptoms should lead to radiographic and/or metabolic evaluation.
Question 12.6.2 Which of the following should you entertain when a patient presents with typical growing pain?
C) Juvenile rheumatoid arthritis.
Answer 12.6.2 The correct answer is "D." It is important to consider other potential causes of what would otherwise appear to be growing pain. Although you may not find it necessary to perform any laboratory or radiologic studies, you should at least keep these and other diagnoses in mind when taking your history and performing your examination. Remember, growing pain is a diagnosis of exclusion.
Severe or persistent pain during the day is not "growing pain." By definition, "growing pain" occurs primarily at night and is better during the day.
Question 12.6.3 Treatment for growing pain includes:
A) Reassurance, rest, and short-term use of NSAIDs.
C) Chemotherapy and radiation.
D) Casting and bracing followed by physical therapy.
E) Staging of the disease is required prior to initiation of therapy.
Answer 12.6.3 The correct answer is "A." OK, so this was just a fun one. Do not do anything drastic for a benign condition! Those of you who chose "B," amputation, will find themselves in one of Dante's circles (or in court—which is worse?) … and clearly need a coffee break.
The same boy returns with his mother years later. He is now 12 years old and requires a physical examination for junior high school sports. You plan to evaluate him for scoliosis.
Question 12.6.4 Which of the following screening methods is the most sensitive for detecting scoliosis?
A) Observe the patient from the front with a loose-fitting shirt on. Measure the difference in shoulder height.
B) Observe the patient from behind, with shirt off, while he bends forward at the waist. Look for elevation of the ribs or paravertebral muscle mass on one side.
C) Observe the patient from the front, with shirt off, while he bends forward at the waist. Look for elevation of the ribs or paravertebral muscle mass on one side.
D) Observe the patient from the side, with shirt off, while he bends forward at the waist. Look for elevation of the ribs or paravertebral muscle mass on one side.
Answer 12.6.4 The correct answer is "B," which is known as the "forward bending test." This test is more sensitive than the other methods described. The forward bending test is accomplished by having the patient bend at the waist with feet together and hands hanging free. Observe the patient from behind and note any elevation of the ribs or paravertebral muscle mass on one side. The elevation should be measured in degrees (inclinometers are available), and an inclination of 5 degrees or more should be evaluated further. Options "A," "C," and "D" are not accepted methods of screening for scoliosis.
Routine screening for scoliosis is a recommendation "D" by the US Preventative Services Task Force. Routine scoliosis screening is not recommended. It may be appropriate in patients who have noticed pain or some other abnormality. Don't do it!
Scoliosis is a lateral curvature of the spine, usually accompanied by rotation and generally occurring in the thoracic or lumbar areas. It can occur with excessive kyphosis (posteriorly convex curvature) or lordosis (anteriorly convex curvature).
On forward bending test, you find slight elevation of the left paravertebral muscles mass, which you estimate to be 7 degrees. The remainder of the examination is normal. You decide to obtain radiographs that show 12 degrees of angulation (Cobb angle).
Question 12.6.5 This patient's scoliosis is most likely:
D) Secondary to infection.
Answer 12.6.5 The correct answer is "B." Most scoliosis that develops during adolescence is idiopathic. When there is no pain, fever, weight loss, or other warning signs (e.g., neurologic symptoms), the curvature is unlikely to be due to tumor or infection. "A," congenital scoliosis, typically presents earlier in life.
Question 12.6.6 The most appropriate initial management plan for this patient includes:
Answer 12.6.6 The correct answer is "B." In an otherwise healthy patient with a curvature measured at <25 degrees, observation is appropriate. "C" is incorrect because physical therapy and exercise regimens do not seem to limit the progression of scoliosis. "A" and "D" are incorrect because bracing and surgery are typically not warranted for this degree of scoliosis. Repeat examination and possibly repeat radiographs are warranted, but if the scoliosis remains stable and mild, the patient is not likely to experience any significant progression of disease with aging.
Bracing for scoliosis should be limited to those with idiopathic scoliosis and 25 to 45 degrees of angulation. Bracing is only effective if the child is still growing and <1 year past menarche if female.
The mother returns now with her 2-year-old daughter who is refusing to move her right arm. Earlier today she threw a tantrum at the store when her father refused to buy her the new "princess toy" (advertising hits them young). Dad was holding on to her arm when she flopped to the floor. She immediately began crying and refusing to move her right arm. In the office, she is well but holds her right arm adducted, flexed, and pronated. (The princess toy is in the other hand. Guilt is a powerful weapon.) Despite every trick you know, you can't get her to move that arm. You inspect and palpate the entire extremity and clavicle and find no crepitus, swelling, or tenderness.
Question 12.6.7 What is your next diagnostic step?
A) Obtain an x-ray of the elbow.
B) Actively supinate the forearm and flex the elbow while applying pressure over the radial head.
C) Actively twist the forearm at the elbow 360 degrees.
E) Perform a skeletal survey, mostly to bide time.
Answer 12.6.7 The correct answer is "B." This child has a "nursemaid's elbow" that is due to subluxation of the annular ligament rather than subluxation or dislocation of the radial head. It occurs in toddlers due to traction via pulling on a pronated and extended arm. Symptoms are immediate and care is sought due to child's refusal to move the arm. The diagnosis is clinical. Manual reduction may be done via supination/flexion or hyperpronation. Sedation is not needed. A palpable click may be felt. The child usually regains immediate movement of the arm and relief of discomfort. Immobilization is not needed but parents should be told that recurrent subluxations may occur and therefore pulling on the arm should be avoided. "A" would be correct if there was concern for a fracture based on findings of swelling, history of trauma, or focal tenderness. "C" is impossible: Can you really rotate a joint 360 degrees? "D" is incorrect as any primary-care provider may manage this. "E" is unnecessary as a nursemaid elbow is not a marker of abuse, although traumatic injuries in children should always make one consider abuse.
Reducing a nursemaid's elbow is gratifying. The patient with nursemaid's elbow should be using the arm normally within minutes. If the child still refuses to use the extremity after adequate observation, reconsider your diagnosis and whether the reduction was successful. Note that many will spontaneously reduce while radiographs are being done (therapeutic x-ray?). Both flexion and supination and extension and pronation have been used to reduce nursemaids elbow.
When dealing with pediatric orthopedics, always remember that child abuse is in the differential diagnosis. Be sure that the reported mechanism of the injury is consistent with the findings on examination and radiograph.
After successful reduction, you see the same 2-year-old child a month later presenting to your clinic with the parents who state that the child has been crying and has refused to walk since tripping over a toy a couple of hours ago. You look at the child and find no signs of abuse. The injured area is represented by the lower leg image in Figure 12-1.
Question 12.6.8 Your approach at this point is to:
A) Consult Child Welfare since this is almost always abuse
B) Consult orthopedics for casting and further treatment.
C) No treatment necessary for this particular fracture in a 2-year-old.
Answer 12.6.8 The correct answer is "B." This is a typical "toddler's fracture" that consists of a spiral fracture of the tibia usually from insignificant rotational trauma (e.g., running and falling with a twisting motion). There should not be an associated fibular fracture. "A" is incorrect because this type of fracture is not usually from abuse. A mid-shaft fracture would more likely be from abuse. "C" is incorrect because this fracture needs to be treated.
Objectives: Did you learn to…
Consider a broader differential diagnosis in a patient presenting with typical "growing pain?"
Initiate conservative treatment for a patient with growing pain?
Screen a patient for scoliosis?
Develop an approach to the adolescent with scoliosis?
Recognize the clinical presentation and treatment of a "nursemaid's elbow" (radial head subluxation)?
Recognize a toddler's fracture?" (tibial spiral fracture).