Pediatrics_Nelson

Pediatrics_Nelson. Available @ StudentConsult.com In-Toeing, Out-Toeing, and Toe-Walking Metatarsus adductus is the most common foot disorder in infants. It is characterized by a convexity of the lateral foot (Fig. 201-2) and is caused by in utero positioning. It is bilateral in half of cases. Occurring equally in boys and girls, it is more common in first-born children because of the smaller primigravid uterus. Two percent of infants with metatarsus adductus have developmental dysplasia of the hip. The forefoot is adducted and sometimes supinated, but the midfoot and hindfoot are normal. The lateral border of the foot is convex, while the medial border is concave. Ankle dorsiflexion and plantar flexion are normal. With the midfoot and hindfoot stabilized, the deformity can be pushed beyond a neutral position (into abduction). Older children may present with an in-toeing gait.


Pediatrics_Nelson

Pediatrics_Nelson. True metatarsus adductus resolves spontaneously over 90% of the time without treatment, so reassurance is all that is needed. Metatarsus adductus that does not improve within 2 years needs evaluation by a pediatric orthopedist. Persistent cases may benefit from serial casting or bracing, and potentially surgery. The deformity is not associated with a disability. It is important to differentiate among metatarsus adductus, metatarsus varus, and skewfoot. Metatarsus varus looks like metatarsus adductus, but it is an uncommon rigid deformity that will need serial casting. Skewfoot is an uncommon deformity thatis characterized by hindfoot plantar flexion, midfoot abduction,and forefoot adduction, giving the foot a Z or serpentine appearance. This needs to be managed very carefully with serial castingand surgery to help reduce the risk of disability in adulthood.


Pediatrics_Nelson

Pediatrics_Nelson. The calcaneovalgus foot is another common foot disorder innewborns that is secondary to in utero positioning. It is characterized by a hyperdorsiflexed foot with forefoot abduction andheel valgus. It is usually unilateral. The appearance may be quitesevere dorsiflexion, but it is not a rigid deformity like congenital vertical talus. Simulated weight-bearing radiographs may benecessary for questionable diagnoses. The calcaneovalgus footwill appear normal or have minimal hindfoot valgus. This disorder requires no treatment beyond reassurance. Parents can be taught passive stretching exercises for their infant’s foot. Most affected infants realign by 2 years. A calcaneovalgus foot can be associated with bowing of the tibia, whichresolves spontaneously, but a leg length discrepancy may exist.


Pediatrics_Nelson

Pediatrics_Nelson. Hypermobile or pronated feet are seen in 15% of adults. Thechild with flatfeet is usually asymptomatic and has no activitylimitations. Newborn and toddler flatfoot is the result of ligamentous laxity and fat in the medial longitudinal arch. This iscalled developmental flatfoot and usually improves by 6 yearsof age. In older children, flatfoot is typically the result of generalized ligamentous laxity, and there is often a positive family history. Hypermobile flatfoot can be thought of as a normal variant.


Pediatrics_Nelson

Pediatrics_Nelson. In the non–weight-bearing position, the older child with a flexible flatfoot will have a medial longitudinal arch. When weight bearing, the foot pronates (arch collapse) with varying degrees of hindfoot valgus. Subtalar motion (essentially all ankle motion except plantar and dorsiflexion) is normal. Any loss of subtalar motion may indicate a rigid flatfoot, which can be related to tarsal coalition, neuromuscular disorders (cerebral palsy), and heel cord contractures. Radiographs of hyper-mobile flatfeet are usually not indicated. Hypermobile pes planus cannot be diagnosed until after 6 years ofage; before that, it is developmental pes planus. Reassurance thatthis is a normal variant is very important. Patients who are symptomatic with activity may require education on proper, supportivefootwear, orthotics/arch supports, and heel cord stretching.


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Pediatrics_Nelson. Patients with tarsal coalition will usually present with a rigid flatfoot (loss of inversion and eversion at the subtalar joint). Coalition is produced by a congenital fusion or failure of segmentation of two or more tarsal bones. The attachment may be fibrous, cartilaginous, or osseous. Tarsal coalition can be unilateral or bilateral and will often become symptomatic in early adolescence. The most common forms of tarsal coalition are calcaneonavicular and talocalcaneal. Available @ StudentConsult.com The patient will usually present with hindfoot pain, which may radiate laterally because of peroneal muscle spasm. Symptoms are exacerbated by sports, and young athletes can present with frequent ankle sprains. There is a familial component. Pes planus is usually present in both weight bearing and non–weightbearing positions. There is usually a loss of subtalar motion, and passive attempts at joint motion may produce pain.


Pediatrics_Nelson

Pediatrics_Nelson. Anteroposterior, lateral, and oblique radiographs should be obtained, but they may not always clearly identify the disorder. The oblique view often identifies the calcaneonavicular coalition. Computed tomography (CT) is the gold standard for diagnosis of tarsal coalition. Even patients with obvious calcaneonavicular coalition on plain radiographs should have a CT scan to rule out a second coalition. Coalitions that are asymptomatic (the majority) do not need treatment. Nonoperative treatment for patients with pain consists of cast immobilization for a few weeks and foot orthotics. The symptoms will often return, necessitating surgery. Surgical excision of the coalition and soft tissue interposition to prevent reossification can be very effective.


Pediatrics_Nelson

Pediatrics_Nelson. Cavus foot is characterized by increased height of the medial longitudinal arch (high arch) and frequently hindfoot varus. It can be classified as physiologic or neuromuscular. Most patients with physiologic cavus foot are asymptomatic. A thorough neurologic examination on all patients with a cavus foot is important. Patients with painful high arches have a high risk of neurologic (tethered cord) and neuromuscular disease, and there is a strong association with Charcot-Marie-Tooth disease, a familial neuropathy. The underlying disorder should be treated first. Nonoperative treatment using orthotics is usually not helpful. Progressive, symptomatic cavus foot will likely need surgical reconstruction. Available @ StudentConsult.com


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Pediatrics_Nelson. Available @ StudentConsult.com Kohler disease (tarsal navicular) and Freiberg disease (headof the second metatarsal) are uncommon and due to avascular necrosis. Patients will present with pain at the affected sitewith activity and weight bearing. Infection, fracture, and neoplasm should be excluded. Treatment consists of immobilization and activity restriction. The majority of the patients willimprove upon subsequent revascularization and re-formationof bone. Available @ StudentConsult.com Sever disease is a common cause of heel pain among active young people. The mean age of presentation for girls is about 9 years of age and for boys about 11 to 12 years. Approximately 60% of cases are bilateral. Sever disease is caused by the forces of the calf musculature through the Achilles tendon at the calcaneal apophysis, causing microfracture. As the child ages and the apophysis begins to close, the pain disappears.


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Pediatrics_Nelson. The common presentation is a young athlete who developsheel pain with activity that decreases with rest. Swelling is rare,but limping may be associated with Sever disease. The childwill have pain to palpation of the posterior calcaneus and oftentight heel cords. Radiographs are rarely indicated, but with persistent pain they should be done to exclude infection or tumor. Activity modification, icing, and anti-inflammatory medications can be helpful. A program designed to improve heel cord flexibility and overall ankle strength may decrease symptoms. Heel elevation using heel wedges or heel cups can be helpful.


Pediatrics_Nelson

Pediatrics_Nelson. Curly toes are the most common deformity of the lesser toes.The fourth and fifth toes are most commonly affected. Curlytoes are characterized by flexion at the proximal interphalangeal joint with lateral rotation of the toe. It is caused bycontractures of the flexor digitorum brevis and longus tendons. Some curly toes will spontaneously resolve by 3 to 4years of age. Persistent deformity may be treated by surgical tenotomy.


Pediatrics_Nelson

Pediatrics_Nelson. Polydactyly (extra toes) is usually found on the initial newborn physical examination. When the extra toe is adjacent to the fifth toe and attached by only a stalk of soft tissue or skin, simple ligation or amputation is effective. When the deformity involves the great toe or middle toes, or when the extra digit has cartilage or bone, delayed surgical intervention is indicated. Syndactyly (fusion of toes) is more common than polydactyly. It is usually a benign cosmetic problem. Both syndactyly and polydactyly may be associated with malformation syndromes (Table 201-2). Disorders Associated with Syndactyly and Polydactyly A simplified classification of the common spinal abnormalities, scoliosis and kyphosis, is presented in Table 202-1. Available @ StudentConsult.com


Pediatrics_Nelson

Pediatrics_Nelson. A simplified classification of the common spinal abnormalities, scoliosis and kyphosis, is presented in Table 202-1. Available @ StudentConsult.com Most patients will present for evaluation of an asymmetrical spine, which is usually pain free. A complete physical examination is necessary for any patient with a spinal deformity, because the deformity can indicate an underlying disease. The back is examined from behind (Fig. 202-1). First, the levelness of the pelvis is assessed. Leg-length discrepancy produces pelvic obliquity, which often results in compensatory scoliosis. When the pelvis is level, the spine is examined for symmetry and spinal curvature with the patient upright. Cutaneous lesions (hemangioma, skin dimple, or hair tuft) should be noted. The spine should be palpated for areas of tenderness.


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Pediatrics_Nelson. The patient is then asked to bend forward with the hands directed between the feet (Adams forward bend test). The examiner should inspect for asymmetry in the spine. The presence of the hump in this position is the hallmark for scoliosis. The area opposite the hump is usually depressed because of spinal rotation. Scoliosis is a rotational malalignment of one vertebra on another, resulting in rib elevation in the thoracic spine and paravertebral muscle elevation in the lumbar spine. With the patient still in the forward flexed position, inspection from the side can reveal the degree of roundback. A sharp forward angulation in the thoracolumbar region indicates a kyphotic deformity. It is important to examine the skin for café au lait spots (neurofibromatosis), hairy patches, and nevi (spinal dysraphism). Abnormal extremities may indicate Failure of formation Wedge vertebrae Hemivertebrae Failure of segmentation Unilateral bar Bilateral bar


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Pediatrics_Nelson. Failure of formation Wedge vertebrae Hemivertebrae Failure of segmentation Unilateral bar Bilateral bar Adapted from the Terminology Committee of the Scoliosis Research Society, 1975. skeletal dysplasia, whereas heart murmurs can be associated with Marfan syndrome. It is essential to do a full neurologic examination to determine whether the scoliosis is idiopathic or secondary to an underlying neuromuscular disease, and to assess whether the scoliosis is producing any neurologic sequelae. Estimating of rib hump and evaluation of curve unwinding as patient turns from side to side Measuring of rib hump with straight edge Measuring of leg length for Medial malleolus A B iliac spine A determination of pelvic obliquity AB = actual length A B = apparent leg length Figure 202-1 Clinical evaluation of a patient with scoliosis.


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Pediatrics_Nelson. Medial malleolus A B iliac spine A determination of pelvic obliquity AB = actual length A B = apparent leg length Figure 202-1 Clinical evaluation of a patient with scoliosis. Initial radiographs should include a posteroanterior and lateral standing film of the entire spine. The iliac crests should be visible to help determine skeletal maturity. The degree of curvature is measured from the most tilted or end vertebra of the curve superiorly and inferiorly to determine the Cobb angle (Fig. 202-2). Newer imaging modalities such as slot scanning or EOS provide the ability to obtain accurate measurements with much lower radiation than radiographs. Alterations in normal spinal alignment that occur in the anteroposterior plane are termed scoliosis. Most scoliotic deformities Figure 202-2 Cobb method of scoliotic curve measurement.


Pediatrics_Nelson

Pediatrics_Nelson. Alterations in normal spinal alignment that occur in the anteroposterior plane are termed scoliosis. Most scoliotic deformities Figure 202-2 Cobb method of scoliotic curve measurement. Determine the end vertebrae of the curve: They are at the upper and lower limits of the curve and tilt most severely toward the concavity of the curve. Draw two perpendicular lines, one from the bottom of the lower body and one from the top of the upper body. Measure the angle formed. This is the accepted method of curve measurement according to the Scoliosis Research Society. Curves of 0° to 20° are mild; 20° to 40°, moderate; and greater than 40°, severe. are idiopathic. Scoliosis may also be congenital, neuromuscular, or compensatory from a leg-length discrepancy.


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Pediatrics_Nelson. are idiopathic. Scoliosis may also be congenital, neuromuscular, or compensatory from a leg-length discrepancy. Idiopathic scoliosis is the most common form of scoliosis. It occurs in healthy, neurologically normal children. Approximately 20% of patients have a positive family history. The incidence is slightly higher in girls than boys, and the condition is more likely to progress and require treatment in females. There is some evidence that progressive scoliosis may have a genetic component as well.


Pediatrics_Nelson

Pediatrics_Nelson. Idiopathic scoliosis can be classified in three categories:infantile (birth to 3 years), juvenile (4 to 10 years), and adolescent (>11 years). Idiopathic adolescent scoliosis isthe most common cause (80%) of spinal deformity. The rightthoracic curve is the most common pattern. Juvenile scoliosis is uncommon, but may be underrepresented becausemany patients do not seek treatment until they are adolescents. In any patient younger than 11 years of age, there is agreater likelihood that scoliosis is not idiopathic. The prevalence of an intraspinal abnormality in a child with congenital scoliosis is approximately 40%. Idiopathic scoliosis is a painless disorder 70% of the time. A patient with pain requires a careful evaluation. Any patient presenting with a left-sided curve has a high incidence of intraspinal pathology (syrinx or tumor). Evaluation of the spine withmagnetic resonance imaging (MRI) is indicated in these cases.


Pediatrics_Nelson

Pediatrics_Nelson. Treatment of idiopathic scoliosis is based on the skeletalmaturity of the patient, the size of the curve, and whether the spinal curvature is progressive or nonprogressive. Initial treatment for scoliosis is likely observation and repeatradiographs to assess for progression. No treatment is indicated for nonprogressive deformities. The risk factors forcurve progression include gender, curve location, and curvemagnitude. Girls are five times more likely to progress thanboys. Younger patients are more likely to progress than olderpatients. Typically, curves under 25° are observed. Progressive curves between 20° and 50° in a skeletally immature patient are treated with bracing. A radiograph in the orthotic is important to evaluate correction. Curves greater than 50° usually require surgical intervention.


Pediatrics_Nelson

Pediatrics_Nelson. Abnormalities of the vertebral formation during the first trimester may lead to structural deformities of the spine that are evident at birth or early childhood. Congenital scoliosis can be classified as follows (Fig. 202-3):Partial or complete failure of vertebral formation (wedge vertebra or hemivertebra)Partial or complete failure of segmentation (unsegmented bars)Mixed


Pediatrics_Nelson

Pediatrics_Nelson. More than 60% of patients have other associated abnormalities, such as VACTERL association (vertebral defects, imperforate anus, cardiac anomalies, tracheoesophageal fistula, renal anomalies, limb abnormalities such as radial agenesis) or Klippel-Feil syndrome. Renal anomalies occur in 20% of children with congenital scoliosis, with renal agenesis being the most common; 6% of children have a silent, obstructive uropathy suggesting the need for evaluation with ultrasonography. Congenital heart disease occurs in about 12% of patients. Spinal dysraphism (tethered cord, intradural lipoma, syringomyelia, diplomyelia, and diastematomyelia) occurs in approximately 20% of children with congenital scoliosis. These disorders are frequently associated with cutaneous lesions on the back and abnormalities of the legs and feet (e.g., cavus foot, neurologic changes, calf atrophy). MRI is indicated in evaluation of spinal dysraphism.


Pediatrics_Nelson

Pediatrics_Nelson. The risk of spinal deformity progression in congenital scoliosis is variable and depends on the growth potential of the malformed vertebrae. A unilateral unsegmented bar typically progresses, but a block vertebra has little growth potential. About 75% of patients with congenital scoliosis will show some progression that continues until skeletal growth is complete, and about 50% will require some type of treatment. Progression can be expected during periods of rapid growth (before 2 years and after 10 years). Treatment of congenital scoliosis hinges on early diagnosis and identification of progressive curves. Orthotic treatment is not helpful in congenital scoliosis. Early spinal surgery should be performed once progression has been documented. This can help prevent major deformities. Patients with large curves that cause thoracic insufficiency should undergo surgery immediately.


Pediatrics_Nelson

Pediatrics_Nelson. Progressive spinal deformity is a common and potentially serious problem associated with many neuromuscular disorders, such as cerebral palsy, Duchenne muscular dystrophy, spinal Figure 202-3 Types of closed vertebral and extravertebral spinal anomalies that result in congenital scoliosis. A, Partial unilateral failure of formation (wedge vertebra). B, Complete unilateral failure of formation (hemivertebra). C, Unilateral failure of segmentation (congenital bar). D, Bilateral failure of segmentation (block vertebra).


Pediatrics_Nelson

Pediatrics_Nelson. muscular atrophy, and spina bifida. Spinal alignment must independent when they can sit in a wheelchair without exterbe part of the routine examination for a patient with neuro-nal support. Progressive curves can impair sitting balance, muscular disease. Once scoliosis begins, progression is usually which affects quality of life. Orthotic treatment is usually inefcontinuous. The magnitude of the deformity depends on the fective in neuromuscular scoliosis. Surgical intervention may severity and pattern of weakness, whether the underlying dis-be necessary with frequent fusion to the pelvis. ease process is progressive, and the amount of remaining musculoskeletal growth. Nonambulatory patients have a higher incidence of spinal deformity than ambulatory patients. Compensatory Scoliosis In nonambulatory patients, the curves tend to be long and Adolescents with a leg-length discrepancy (Chapter 200) may sweeping, produce pelvic obliquity, involve the cervical spine, have a positive


Pediatrics_Nelson

Pediatrics_Nelson. In nonambulatory patients, the curves tend to be long and Adolescents with a leg-length discrepancy (Chapter 200) may sweeping, produce pelvic obliquity, involve the cervical spine, have a positive screening examination for scoliosis. Before and also produce restrictive lung disease. If the child cannot correction of the pelvic obliquity, the spine curves in the stand, then a supine or seated anteroposterior radiograph of same direction as the obliquity. However, with identification the entire spine, rather than a standing posteroanterior view, and correction of any pelvic obliquity, the curvature should is indicated. resolve, and treatment should be directed at the leg-length dis-


Pediatrics_Nelson

Pediatrics_Nelson. The goal of treatment is to prevent progression and loss of crepancy. Thus, it is important to distinguish between a strucfunction. Nonambulatory patients are more comfortable and tural and compensatory spinal deformity. Available @ StudentConsult.com Kyphosis refers to a roundback deformity or to increased angulation of the thoracic or thoracolumbar spine in the sagittal plane. Kyphosis can be postural, structural (Scheuermann kyphosis), or congenital. Postural kyphosis is secondary to poor posture. It is voluntarily corrected in the standing and prone positions. The patient may also have increased lumbar lordosis. Radiographs are usually unnecessary if the kyphosis fully corrects. If not, radiographs will reveal no vertebral abnormalities. Treatment, if needed, is aimed at improving the child’s posture.


Pediatrics_Nelson

Pediatrics_Nelson. Scheuermann disease is the second most common cause of pediatric spinal deformity. It occurs equally in males and females. The etiology is unknown, but there may be hereditary factors. Scheuermann kyphosis is differentiated from postural roundback on physical examination and by radiographs.


Pediatrics_Nelson

Pediatrics_Nelson. A patient with Scheuermann disease cannot correct thekyphosis with standing or lying prone. When viewed fromthe side in the forward flexed position, patients with Scheuermann disease will have an abrupt angulation in the mid tolower thoracic region (Fig. 202-4), and patients with posturalroundback show a smooth, symmetrical contour. In bothconditions, lumbar lordosis is increased. However, half of patients with Scheuermann disease will have atypical backpain, especially with thoracolumbar kyphosis. The classic radiologic findings of Scheuermann kyphosis include the following:Narrowing of disk spaceLoss of anterior height of the involved vertebrae producing wedging of 5° or more in at least three consecutive vertebrae Irregularities of the vertebral endplatesSchmorl nodes


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Pediatrics_Nelson. Treatment of Scheuermann kyphosis is similar to idiopathic scoliosis. It is dependent on the degree of deformity, skeletal maturity, and the presence or absence of pain. Nonoperative treatment begins with bracing. Surgical fusion is done for patients who have completed growth, have a severe deformity, or have intractable pain. Congenital kyphosis is a failure of the formation of all or part of the vertebral body (with preservation of posterior elements) or failure of anterior segmentation of the spine, or both. Severe deformities are found at birth and tend to rapidly progress. Progression will not cease until the end of skeletal growth. A progressive spine deformity may result in neurologic deficit. Treatment of congenital kyphosis is often surgical. Figure 202-4 Note the sharp break in the contour of a child with kyphosis. (From Behrman RE: Nelson Textbook of Pediatrics, ed 14, Philadelphia, 1992, WB Saunders.)


Pediatrics_Nelson

Pediatrics_Nelson. Figure 202-4 Note the sharp break in the contour of a child with kyphosis. (From Behrman RE: Nelson Textbook of Pediatrics, ed 14, Philadelphia, 1992, WB Saunders.) Torticollis is usually first identified in newborns because of a head tilt. Torticollis is usually secondary to a shortened sternocleidomastoid muscle (muscular torticollis). This may result from in utero positioning or birth trauma. Acquired torticollis may be related to upper cervical spine abnormalities or central nervous system pathology (mass lesion). It can also occur in older children during a respiratory infection (potentially secondary to lymphadenitis) or local head or neck infection, and it may herald psychiatric diagnoses. Available @ StudentConsult.com


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Pediatrics_Nelson. Available @ StudentConsult.com Infants with muscular torticollis have the ear tilted toward the clavicle on the ipsilateral side. The face will look upward toward the contralateral side. There may be a palpable swelling or fibrosis in the body of the sternocleidomastoid shortly after birth, which is often the precursor of a contracture. Congenital muscular torticollis is associated with skull and facial asymmetry (plagiocephaly) and developmental dysplasia of the hip. After a thorough neurologic examination, anteroposterior and lateral radiographs should be obtained. The goal isto rule out a nonmuscular etiology. A computed tomography (CT) scan or MRI of the head and neck is necessary forpersistent neck pain, neurologic symptoms, and persistentdeformity.


Pediatrics_Nelson

Pediatrics_Nelson. Treatment of muscular torticollis is aimed at increasing the range of motion of the neck and correcting the cosmetic deformity. Stretching exercises of the neck can be very beneficial for infants. Surgical management is indicated if patients do not improve with adequate stretching exercises in physical therapy. Postoperative physical therapy is needed to decrease the risk of recurrence. Treatment in patients with underlying disorders should target the disorder.


Pediatrics_Nelson

Pediatrics_Nelson. Back pain in the pediatric population should always be approached with concern. In contrast to adults, in whom back pain is frequently mechanical or psychological, back pain in children may be the result of organic causes, especially in preadolescents. Back pain lasting longer than a week requires a detailed investigation. In the pediatric population, approximately 85% of children with back pain for greater than 2 months have a specific lesion: 33% are posttraumatic (spondylolysis, occult fracture), 33% are developmental (kyphosis, scoliosis), and 18% have an infection or tumor. In the remaining 15%, the diagnosis is undetermined. Available @ StudentConsult.com


Pediatrics_Nelson

Pediatrics_Nelson. The history must include the onset and duration of symptoms. The location, character, and radiation of pain are important. Neurologic symptoms (muscle weakness, sensory changes, and bowel or bladder dysfunction) must be reviewed. Medical history and family history should be obtained, with a focus on back pain, rheumatologic disorders, and neoplastic processes. The review of systems should include detailed questions on overall health, fever, chills, recent weight loss, and recent illnesses. Physical examination should include a complete musculoskeletal and neurologic evaluation. Spinal alignment, range of motion, areas of tenderness, and muscle spasm should be noted. Red flags for childhood back pain include persistent or increasing pain, systemic findings (e.g., fever, weight loss), neurologic deficits, bowel or bladder dysfunction, young age (under 4 is strongly associated with tumor), night waking, pain that restricts activity, and a painful left thoracic spinal curvature.


Pediatrics_Nelson

Pediatrics_Nelson. Anteroposterior and lateral standing films of the entire spine with bilateral oblique views of the affected area should be obtained. Secondary imaging with bone scan, CT scan, or MRI may be necessary for diagnosis. MRI is very useful for suspected intraspinal pathology. Laboratory studies, such as a complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and specialized testing for juvenile idiopathic arthritis and ankylosing spondylitis, may be indicated. The differential diagnosis of pediatric back pain is extensive (Table 202-2). Treatment depends on the specific diagnosis. If serious pathology has been ruled out and no definitediagnosis has been established, an initial trial of physicaltherapy with close follow-up for reevaluation is recommended. Diskitis (most common before the age of 6 years) Vertebral osteomyelitis (pyogenic or tuberculous) Spinal epidural abscess Pyelonephritis Pancreatitis


Pediatrics_Nelson

Pediatrics_Nelson. Diskitis (most common before the age of 6 years) Vertebral osteomyelitis (pyogenic or tuberculous) Spinal epidural abscess Pyelonephritis Pancreatitis Hip and pelvic abnormalities (sacroiliac joint dysfunction) Herniated nucleus pulposus (intervertebral disk) Overuse injuries (facet syndrome) Vertebral stress fractures (spondylolysis, spondylolisthesis) Vertebral compression fracture (steroid, sickle cell anemia) Upper cervical spine instability (atlantoaxial instability) Primary vertebral tumors (osteogenic sarcoma) Metastatic tumor (neuroblastoma) Primary spinal tumor (astrocytoma) Bone marrow malignancy (leukemia, lymphoma) Benign tumors (eosinophilic granuloma, osteoid osteoma)


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Pediatrics_Nelson. Spondylolysis is a defect in the pars interarticularis. Spondylolisthesis refers to bilateral defects with anterior slippageof the superior vertebra on the inferior vertebra. The lesions are not present at birth, but about 5% of children will have the lesion by 6 years of age. It is most common in adolescent athletes, especially those involved in sports that involverepetitive back extension. Classically, this was an injury seenin gymnasts and divers. However, with increased intensityand year-round sports, the incidence is increasing. Footballinterior lineman (extension while blocking), soccer players(extension while shooting), and basketball players (extension while rebounding) are examples of athletes at higherrisk. The most common location of spondylolysis is L5, followed by L4. Spondylolisthesis is classified according to the degree of slippage:Grade 1: less than 25% Grade 2: 25% to 50% Grade 3: 50% to 75% Grade 4: 75% to 99% Grade 5: complete displacement or spondyloptosis


Pediatrics_Nelson

Pediatrics_Nelson. The most common location of spondylolisthesis is L5 on S1. Available @ StudentConsult.com Patients will often complain of an insidious onset of low back pain persisting over 2 weeks. The pain tends to worsen with activity and with extension of the back and improves with rest. There may be some radiation of pain to the buttocks. A loss of lumbar lordosis may occur due to muscular spasm. Pain is present with extension of lumbar spine and with palpation over the lesion. Patients with spondylolisthesis may have a palpable step off at the lumbosacral area. A detailed neurologic examination should be done, especially because spondylolisthesis can have nerve root involvement.


Pediatrics_Nelson

Pediatrics_Nelson. Anteroposterior, lateral, and oblique radiographs of the spine should be obtained. The oblique views may show the classic Scotty dog findings associated with spondylolysis. The lateral view will allow measurement of spondylolisthesis. Unfortunately, plain radiographs do not regularly reveal spondylolysis, so advanced imaging may be needed. The most helpful form of advanced imaging among CT, bone scan, single-photon emission CT (SPECT), or MRI continues to be debated. MRI may be required in patients with neurologic deficits.


Pediatrics_Nelson

Pediatrics_Nelson. Painful spondylolysis requires activity restriction. Bracing iscontroversial but may help with pain relief. Patients benefit froman aggressive physical therapy plan to improve lower extremityflexibility and increase core strength and spinal stability. It is most beneficial to begin with flexion exercises and progress toextension exercises as tolerated. There is evidence that some patients with an acute spondylolysis can achieve bony unionand that these patients have a decreased incidence of low backpain and degenerative change in the low back as they age whencompared with spondylolysis patients with nonunion. Rarely,surgery is indicated for intractable pain and disability. Available @ StudentConsult.com Patients with spondylolisthesis require periodic evaluation for progression of their slippage. Treatment of spondylolisthesis is based on grading.


Pediatrics_Nelson

Pediatrics_Nelson. Available @ StudentConsult.com Patients with spondylolisthesis require periodic evaluation for progression of their slippage. Treatment of spondylolisthesis is based on grading. Grade 1: Same treatment as spondylolysis. Failure of nonoperative management may lead to surgical fusion.Grade 2: Reasonable to try nonoperative management, but if the slippage is progressing, surgical intervention may be needed. Any patient with neurologic symptoms requires surgical intervention.Grades 3 to 5: Spinal fusion is usually required to prevent further slippage or damage. Available @ StudentConsult.com Diskitis is an intervertebral disk space infection that does not cause associated vertebral osteomyelitis (see Chapter 117). The most common organism is Staphylococcus aureus. The infection can occur at any age but is more common in patients under 6 years of age.


Pediatrics_Nelson

Pediatrics_Nelson. Children may present with back pain, abdominal pain, pelvic pain, irritability, and refusal to walk or sit. Fever is an inconsistent symptom. The child typically holds the spine in a straight or stiff position, generally has a loss of lumbar lordosis due to paravertebral muscular spasm, and refuses to flex the lumbar spine. The white blood cell count is normal or elevated, but the ESR and CRP are usually high. Radiographic findings vary according to the duration of symptoms before diagnosis. Anteroposterior, lateral, and oblique radiographs of the lumbar or thoracic spine will typically show a narrow disk space with irregularity of the adjacent vertebral body end plates. In early cases, bone scan or MRI may be helpful, because they will be positive before findings are noticeable on plain radiographs. MRI can also be used to differentiate between diskitis and the more serious condition of vertebral osteomyelitis.


Pediatrics_Nelson

Pediatrics_Nelson. Intravenous antibiotic therapy is the mainstay of treatment. Blood cultures may occasionally be positive and identify the infectious agent. Aspiration and needle biopsy are reserved for children who are not responding to empirical antibiotic treatment. Symptoms should resolve rapidly with antibiotics, but intravenous antibiotics should be continued for 1 to 2 weeks and be followed by 4 weeks of oral antibiotics. Pain control can be obtained with medications and temporary orthotic immobilization of the back. The shoulder actually comprises four joints:Glenohumeral joint (commonly referred to as the shoulder


Pediatrics_Nelson

Pediatrics_Nelson. The shoulder actually comprises four joints:Glenohumeral joint (commonly referred to as the shoulder The glenohumeral joint has minimal geometric stability because the relatively small glenoid fossa articulates with the proportionately larger head of the humerus. The low level of intrinsic stability allows for a large range of motion. The rotator cuff muscles help give the glenohumeral joint more stability, but they need normal contact of the glenohumeral joint to be successful. The scapulothoracic movement also expands the range of motion of the shoulder, but like the glenohumeral joint, it requires strong, coordinated musculature to function efficiently.


Pediatrics_Nelson

Pediatrics_Nelson. Sprengel deformity is the congenital elevation of the scapula. There are varying degrees of severity; it is usually unilateral. There is restricted scapulothoracic motion (especially with abduction) so most of the shoulder motion is through the glenohumeral joint. There is usually associated hypoplasia of the parascapular muscles. Webbing of the neck and low posterior hairline can be associated problems. There is an association with congenital syndromes, such as Klippel-Feil anomaly, so a thorough history and examination are necessary. Mild forms with a cosmetic deformity and mild loss of shoulder motion do not need surgical correction. Severe forms may have a bony connection (omovertebral) between the scapula and lower cervical spine. Moderate and severe forms may need surgical repositioning of the scapula in early childhood to improve cosmesis and function.


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Pediatrics_Nelson. Obstetric brachial plexus palsy is discussed in Section 11. Brachial plexopathy is an athletic injury, commonly referred to as a stinger or burner. The symptoms are often likened to a dead arm. There is pain (often burning), weakness, and numbness in a single upper extremity. There are three mechanisms of injury:Traction caused by lateral flexion of the neck away from the involved upper extremityDirect impact to the brachial plexus at Erb’s pointCompression caused by neck extension and rotation toward the involved extremity


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Pediatrics_Nelson. Symptoms are always unilateral and should resolve within 15 minutes. It is paramount to assess the cervical spine for serious injury. Bilateral symptoms, lower extremity symptoms, persistent symptoms, or recurrent injury are all signs of more serious disease and may need a more extensive workup and cervical spine stabilization. Athletes may return to activity if there are no red flags on history or physical examination and the athlete has full pain-free range of motion and strength in the neck and affected extremity.


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Pediatrics_Nelson. Shoulder dislocation is uncommon in childhood but becomes more frequent in adolescence. The younger the patient is at presentation, the more likely it is that the patient will have recurrent dislocation. Anterior dislocation is the most common. If assessment of the neurovascular status of the affected extremity reveals any compromise, urgent reduction is needed to prevent further complications. Patients will need radiographs to assess for fractures of the glenoid (Bankhart lesion) and humeral head (Hill-Sachs lesion). Most patients will require a brief period of protection in a sling or shoulder immobilizer, as well as pain control. As symptoms resolve, a gentle range-of-motion program, followed by an aggressive strengthening program, should be done. Recurrence occurs in nearly 90% of athletes participating in contact sports, so orthopedists consider surgical intervention early rather than awaiting further dislocation.


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Pediatrics_Nelson. The incidence of overuse injuries is increasing because of increased opportunities for athletic participation as well as higher levels of intensity during sports. Overuse injuries are inflammatory responses in tendons and bursae that are subjected to repetitive motions and trauma (e.g., rotator cufftendinopathy in swimmers). These injuries are uncommon in children but may be seen in adolescents. Bony injury, such as physeal fractures and apophysitis, must be ruled out before making the diagnosis of a soft tissue overuse injury. Many overuse injuries in the shoulder, such as rotator cuff tendinopathy, are secondary to joint laxity.


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Pediatrics_Nelson. The patient will often present with discomfort over the affected area that worsens with activity. Physical examination usually reveals tenderness to palpation and often weakness of the associated muscles due to pain. It is important to assess for glenohumeral stability. Radiographs may be indicated for acute trauma or when symptoms are not improving. Treatment consists of activity modification, icing, anti-inflammatory medication, and a physical therapy program aimed at strengthening, increasing flexibility, and improving posture.


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Pediatrics_Nelson. Proximal humeral epiphysiolysis is commonly referred to as Little Leaguer’s shoulder. It most commonly occurs in 9to 14-year-olds who participate in overhead (tennis, volleyball) and throwing sports, particularly baseball pitchers. It is a stress injury that potentially can be a fracture (epiphysiolysis) of the proximal humeral physis. Most patients present with pain during or after throwing. There may be tenderness to palpation over the proximal humerus; if the athlete has been resting for a few days, examination may be normal. Radiographs should include comparison views to assess the physis. There may be widening of the proximal humeral physis in the affected arm, but the films may be normal. Treatment is rest from the offending activity, followed by a rehabilitation program designed to improve strength in the shoulder muscles. Pitchers should also be encouraged to follow youth pitching guidelines published by Little League baseball.


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Pediatrics_Nelson. The elbow consists of three articulations: Ulnar-humeral jointRadial-humeral jointProximal radioulnar jointCollectively, these joints produce a hinge-type joint that allows for supination (palm up) and pronation (palm down) positioning of the hand. The elbow has excellent geometric stability, and the musculature around the elbow primarily produces flexion and extension. Available @ StudentConsult.com


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Pediatrics_Nelson. Radial head subluxation is more commonly known as nursemaid’s elbow. Because the radial head is not as bulbous in infants and young children, the annular ligament that passes around it can partially slip off the radial head with traction across the elbow (Fig. 203-1). The subluxation is usually caused by a quick pull on the extended elbow when a child is forcefully lifted by the hand or when the child falls while holding hands with an adult. After a subluxation, the child usually holds the hand in a pronated position and will refuse to use the hand or move the elbow. Moving the hand into the supinated position while applying pressure to the radial head will usually reduce the injury. Usually, radiographs are not necessary unless reduction cannot be obtained or there is concern for fracture (swelling and bruising). Once the injury is reduced, the child will begin using the arm again without complaint. Parents should be educated about the mechanism of injury and encouraged to avoid that


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Pediatrics_Nelson. (swelling and bruising). Once the injury is reduced, the child will begin using the arm again without complaint. Parents should be educated about the mechanism of injury and encouraged to avoid that position. There is a high rate of recurrence for this injury. The problem generally resolves with


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Pediatrics_Nelson. Figure 203-1 Nursemaid’s elbow. The annular ligament is torn when the arm is pulled. The radial head moves distally, and when traction is discontinued, the ligament is carried into the joint. (From Rang M: Children’s Fractures, Philadelphia, 1974, JB Lippincott, p 121.) maturation, but some children with high recurrence rates may benefit from casting or, rarely, surgical intervention. Available @ StudentConsult.com


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Pediatrics_Nelson. Available @ StudentConsult.com Panner disease is an osteochondritis of the capitellum (lateral portion of distal humeral epiphysis) that occurs spontaneously in late childhood. Clinical features include elbow pain, decreased range of motion, and tenderness to palpation over the capitellum. Radiographs reveal fragmentation of the capitellum. Treatment is activity restriction and follow-up radiographs to demonstrate spontaneous reossification of the capitellum over several months. There is usually no need for further treatment or imaging studies. This is not to be confused with osteochondritis dissecans of the capitellum, which usually will occur in adolescents involved with throwing sports.


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Pediatrics_Nelson. The elbow is especially vulnerable to throwing injuries in theskeletally immature athlete. These occur from excessive andrepetitive tension forces across the radial aspect of the elbow andcompression forces across the lateral aspect of the elbow. Theseinjuries are commonly known as Little Leaguer’s elbow. Available @ StudentConsult.com


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Pediatrics_Nelson. Although this injury is most common in baseball players who throw frequently (pitcher, catcher, third base, and shortstop), it also occurs in football quarterbacks and tennis players. Patients will usually complain of pain over the medial elbow with throwing that may last for a few days afterward. There may be associated swelling and lateral or posterior elbow pain. Radiation of pain may be secondary to ulnar neuropathy. There is often a flexion contracture of the elbow when compared to the opposite side. Palpation of the medial epicondyle, radial head, capitellum, lateral epicondyle, and olecranon process often reveals tenderness. Ulnar (medial) collateral ligament stability should be assessed. Radiographs should include the contralateral elbow for comparison. Radiographic findings in Little Leaguer’s elbow can vary and may include normal anatomy, medial humeral epicondyle apophyseal avulsion fracture, osteochondritis dissecans of the capitellum, radial head abnormalities, and


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Pediatrics_Nelson. in Little Leaguer’s elbow can vary and may include normal anatomy, medial humeral epicondyle apophyseal avulsion fracture, osteochondritis dissecans of the capitellum, radial head abnormalities, and foreign bodies in the elbow. MRI may be helpful.


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Pediatrics_Nelson. Treatment depends on the underlying diagnosis but always includes pain control and rest from activity. Classic Little Leaguer’s elbow refers to medial humeral epicondyle apophysitis. These athletes benefit from rest, ice, anti-inflammatory medication, and a physical therapy program aimed at upper body strengthening. Throwing mechanics and the pitching guidelines published by Little League Baseball/Softball should be reviewed with these players. Switching players to a lower throwing position (e.g., first base) after rehabilitation, to avoid pitching for the remainder of the season, is often recommended.


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Pediatrics_Nelson. Multiple small joints, a delicately balanced intrinsic muscle system, a powerful extrinsic muscle system, dense sensory innervation, and specialized skin combine to make the hand a highlymobile and sensitive yet powerful anatomic part. The extrinsicmuscles originate in the forearm and the intrinsic muscles arelocated in the hand and coordinate small, delicate movements. The movements of opening the hand, extending and spreading the fingers, and then clenching the hand into a fist requirescoordinated function of the intrinsic and extrinsic muscles. Tenderness of direct palpation of the bones raises the concern for fracture. Scaphoid fracture is the most common carpal bonefracture in the pediatric population. It requires immobilizationin a thumb spica cast, whereas displaced fractures require surgical intervention. Salter-Harris fractures of the distal radius are also very common. In young gymnasts, there is increased riskfor injury at the distal radial physis from repetitive impact


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Pediatrics_Nelson. surgical intervention. Salter-Harris fractures of the distal radius are also very common. In young gymnasts, there is increased riskfor injury at the distal radial physis from repetitive impact andupper extremity weight bearing. This is commonly called gymnast’s wrist and requires absolute rest from impact and weightbearing to prevent premature closure of the growth plate.


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Pediatrics_Nelson. Ganglion cysts are synovial fluid-filled cysts about the wrist. The most common location is the dorsum of the wrist near the radiocarpal joint, followed by the volar radial aspect of the wrist. The defect is in the joint capsule, which allows synovial fluid into the soft tissues with wrist use, where it can become walled off with fibrous tissue. Often, in skeletally immature patients, the process is benign and disappears over time. Large ganglion cysts or cysts that are painful and interfere with function may require more aggressive therapy. Aspiration and steroid injection into the cyst may be helpful, but many will recur. Surgical excision will remove the tract that attaches to the wrist joint, so it is usually curative.


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Pediatrics_Nelson. Polydactyly (extra digits) occurs in simple and complex varieties (see Table 201-2). Skin tags and digit remnants that occur near the metacarpophalangeal joint of the fifth digit and thumb that do not have palpable bones or possess voluntary motion are simple varieties. These may be excised or ligated in the nursery. Complex deformities should be referred to a pediatric orthopedist for amputation. Syndactyly (fused digits) are concerning because of the possibility of shared structures and the tethering effects on bone growth (see Table 201-2). All patients with syndactyly should be referred for treatment options.


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Pediatrics_Nelson. Trigger thumb and trigger finger are secondary to isolated thickening of the flexor tendons. As the thickened nodule enlarges, it may catch in a bent position, then snap or triggerstraight as it passes through the first pulley that anchors the tendon. Ultimately, as it enlarges, it cannot pass through at all and produces a flexion deformity at the interphalangeal joints. The nodule may be palpable near the metacarpophalangeal joint. These children should be referred for surgical correction.


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Pediatrics_Nelson. Benign bone tumors and cystic lesions are common in childhood. Some represent fibrous dysplasia. Others are benign bone cysts (unicameral) or benign bone tumors (osteoid osteoma). Subacute osteomyelitis (Brodie abscess) and eosinophilic granulomas are lesions not associated with abnormal bone or cartilage growth. Some of these lesions can produce pain, limp, and pathologic fractures. Others can be incidental findings on radiographs. The prognosis is usually excellent. A brief differential diagnosis of bone tumors and their management is listed in Table 204-1. Malignant bone tumors are discussed in Section 21. Table 204-1 Benign Bone Tumors and Cysts DISEASE CHARACTERISTICS RADIOGRAPHIC FINDINGS TREATMENT PROGNOSIS Osteochondroma (osteocartilaginous exostosis) Common; distal metaphysis of femur, proximal humerus, proximal tibia; painless, hard, nontender mass Bony outgrowth, sessile or pedunculated Excision, if symptomatic Excellent; malignant transformation rare


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Pediatrics_Nelson. Multiple hereditary Osteochondroma of long bones; As above As above Recurrences exostoses bone growth disturbances Osteoid osteoma Pain relieved by aspirin; femur and Dense sclerosis surrounds small As above Excellent tibia; found predominantly in boys radiolucent nidus, <1cm Osteoblastoma (giant As above, but more destructive Osteolytic component; size As above Excellent osteoid osteoma) Table 204-1 Benign Bone Tumors and Cysts—cont’d DISEASE CHARACTERISTICS RADIOGRAPHIC FINDINGS TREATMENT PROGNOSIS Nonossifying fibroma Silent; rare pathologic fracture; late childhood, adolescence Incidental radiographic finding; thin sclerotic border, radiolucent lesion None or curettage with fractures Excellent; heals spontaneously Aneurysmal bone cyst As above; contains blood, fibrous Expands beyond metaphyseal Curettage, bone Excellent tissue cartilage graft Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4, Philadelphia, 2007,


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Pediatrics_Nelson. Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4, Philadelphia, 2007, Kliegman RM, Stanton BF, St. Geme JW, et al, editors: Nelson Textbook of Pediatrics, ed 19, Philadelphia, 2011, Saunders Miller MD, Thompson SR: DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practices, ed 3, Philadelphia, 2009, Saunders Sawyer JR, Kapoor M: The limping child: a systemic approach to diagnosis, Am Fam Physician 79:215–224, 2009 Shipman SA, Helfand M, Moyer VA, et al: Screening for developmental dysplasia of the hip: a systemic literature review for the U.S. Preventive Services Task Force, Pediatrics 117:e557–e576, 2006 Stein CJ, Micheli LJ: Overuse injuries in youth sports, Phys Sports Med 38:102–108, 2010 Wenger DR, Pring ME, Rang M: Rang’s Children’s Fractures, ed 3, Philadelphia, 2005, Lippincott Williams & Wilkins Wilson JC, Rodenberg RE: Apophysitis of the lower extremities, Contemporary Pediatrics 28:38–46, 2011