Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs
   

 

 

Medical Problems - Orthopedics (B4)

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•Go to osgood-schlatter disease

•Go to patellofemoral syndrome
•Go to slipped capital femoral epiphysis
•Go to growing pains
•Go to back pain
•Go to scoliosis

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Text

This section reviews several common orthopedic problems in teens including Osgood-Schlatter disease, patellofemoral syndrome (chondromalacia patellae), slipped capital femoral epiphysis, "growing pains, scoliosis and back pain.

OSGOOD-SCHLATTER DISEASE

Osgood-Schlatter disease is a common problem in adolescents, especially active teen. It is a painful enlargement of the tibial tubercle at the insertion of the patellar tendon.

Etiology

During puberty and the development of significant muscle mass, there is significant traction stress from the patellar tendon on the small ossification center in the anterior tibial tubercle. This can result in actual small fragments of cartilage avulsing from the tubercle. Running and jumping can aggravate the condition.

Epidemiology

The condition has its peak prevalence with the timing of peak growth velocity and thus occurring on average about two years later in males than females (about 12 1/2 versus 10 1/2 years of age). The condition is more common in males.

Clinical Manifestations and Diagnosis

The condition is manifested by pain and swelling over the anterior tibial tubercle with point tenderness at that area. There is normal joint mobility and is more often unilateral. The condition lasts several months but can last longer. The diagnosis is usually made by history and examination and x-ray only necessary if something unusual on examination.

Therapy

This involves explanation of the condition to the adolescent and parents, restriction of activity if symptoms are severe. This might require immobilization in severe conditions for several weeks. In addition, nonsteroidal anti-inflammatory medications and ice can be helpful. The condition is usually self-limited but can reoccur with excessive activity.

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PATELLOFEMORAL SYNDROME (CHONDROMALACIA PATELLAE)

Patellofemoral syndrome, patellar malalignment syndrome, or chondromalacia patellae is a frequent cause of knee pain among adolescents. This condition can cause almost three-fourths of knee problems in adolescent females and one-third of problems in males. It is also a frequent problem in adolescent athletes.

Patellar malalignment syndrome is probably a better term as chondromalacia suggests damage to cartilage and this is not often the case.

Etiology

Usually the result of abnormal biomechanical forces across the patella. Abnormal forces can result secondary to quadriceps femoris muscle imbalance or weakness, altered patellar anatomy (e.g. small or high-riding patella), or increased femoral neck anteversion.

Epidemiology

More common in general population in females but higher prevalence in males in adolescents involved in sports.

Clinical Manifestations and Diagnosis

  • Peripatellar or retropatellar pain that increases with activity especially ascending or descending stairs. There may be crepitus felt in the knee. Usually a several month or more history of pain.
  • On examination, the teen may have retropatellar crepitation, patellae that are displaced anteromedially, tenderness of the undersurface of patella. Usually range of motion is normal and there is no joint effusion.
  • Diagnosis usually made by compatible history and examination. X-rays are generally of very limited help. Important to remember that hip disorders may have referred pain to the knee.

Treatment

Usually involves initial rest and avoidance of running, jumping and climbing plus non steroidal anti-inflammatory medications. In addition, teen should be enrolled in muscle strengthening program and graduated running exercises. After control of symptoms and improvement, teen should be in a maintenance program of exercises. Also important are using a good quality athletic shoe and occasionally custom orthotics. Surgery is usually not needed.

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SLIPPED CAPITAL FEMORAL EPIPHYSIS

Slipped capital femoral epiphysis is caused by a disruption of the epiphyseal plate between the femoral head and neck.

Etiology

In this condition, the femoral head slips posteriorly, inferiorly, and medially on the femoral metaphysis. The condition is secondary to the increased weight burden at adolescence particularly in an area that has not reached bony maturity. The condition occurs more often in adolescents during the time of peak weight velocity. The condition occurs as a chronic condition in about 80% of cases and less commonly as an acute problem more often secondary to trauma. Occasionally the condition can be related to an underlying endocrine disorder such as hypothyroidism or hypopituitarism.

Epidemiology

The condition is more common in males and more common in the African-American population. It usually occurs during the period of accelerated growth and is more common in the left hips of males. About 20% of those affected have bilateral involvement. In addition, the majority of those affected are overweight and often have a skeletal maturation that is 6 months or more delayed.

Clinical Manifestations and Diagnosis

  • The adolescent usually complains of pain that is localized to hip or groin and occasionally with a limp. There is also a limitation of internal rotation of the hip and decreased hip adduction and flexion. The leg may be held in slight external rotation and adduction.
  • The history and physical examination is critical. AP and frog leg lateral x-rays of the pelvis should be taken and may show the slip. In unusual cases a bone scan or MRI scan may be needed.

Treatment

Orthopedic referral is required, as surgery is the only reliable treatment.

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GROWING PAINS

Older children and younger adolescent may complain of pain in the lower extremities. Causes include trauma, fractures, infections (osteomyelitis, septic arthritis, abscess, cellulitis), vascular problems (e.g. hemophilia, sickle cell anemia, hemangioma), slipped femoral capital epiphysis, Osgood-Schlatter's disease, osteochondritis dissecans, chondromalacia patellae, arthritic conditions, and occasionally leukemia. Most of these are diagnosed through history, physical examination, and appropriate laboratory tests. However, sometimes limb pain may be secondary to "growing pains" which are difficult to define and diagnose and are a diagnosis of exclusion. There is even some question whether this is a "real" diagnosis.

Etiology

Unknown but possibly related to rapid growth, puberty, fibrositis, weather, and psychological factors.

Epidemiology

Reported between 4% and 50% of children and adolescents and increases after age 5 and peaks at about 13 in males and 11 in females.

Clinical Manifestations and diagnosis

  • The pain usually is a dull intermittent ache over the leg and thigh muscles especially on the anterior aspect of the thighs. Pain is usually bilateral and most frequently in late day or evening and night. There are no findings of loss of mobility, tenderness, erythema or swelling. There are no associated systemic diseases or abnormalities on any laboratory tests.
  • Diagnosis is usually by the consistent history and lack of symptoms of a systemic disease. Normal laboratory tests might include complete blood count, sedimentation rate and x-rays. Other tests would only be ordered based on the history.

Treatment

Involves reassurance and possibly massage and nonsteroidal anti-inflammatory medications.

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BACK PAIN

Back pain, especially low back pain, is one of the most common complaints among young adult and adult patients. While much less common in prepubertal and young adolescent patients, many middle and older teens experience back pain.

Prevalence

The prevalence increases with age but has been reported in 27% of Swiss school students and 26% of English school students. The annual incidence rose from 11.8% at age 12 to 21.5% at age 15. However, the majority of the teens did not seek medical attention.

Etiology

The prevalence of different etiologies varies with age as the younger the individual the more likely that the pain is NOT related to musculoskeletal strain.

Differential Diagnosis

  • Mechanical Disorders including overuse syndromes, herniated nucleus pulposus, slipped vertebral apophysis, postural disorders and vertebral compression fractures
  • Developmental disorders such as spondylolysis/spondylolisthesis and Scheuermann's Disease
  • Inflammation and Infections such as discitis/vertebral osteomyelitis, ankylosing spondylitis, reactive arthritis, sickle cell crisis or abscess
  • Neoplastic
  • Psychogenic

Evaluation

Usually the course is benign and self-limited. To rule out a significant underlying condition, a thorough history and physical examination should be conducted. This includes a history of the pain, history of trauma or athletic involvement, systemic symptoms, neurologic symptoms and family history of rheumatologic diseases. Severe back pain in adolescents suggests a possible underlying pathologic disorder other than muscular strain. The physical examination should include examination in the standing, sitting and supine positions. The examiner should check for leg length discrepancies, scoliosis, local tenderness, gait, range of motion, midline defects (might suggest underling spinal abnormality), knee and ankle reflexes, muscle strength or atrophy. In addition, the examiner should check for sensory changes and perform a straight leg-raising test. Systemic symptoms or signs, major focal neurologic signs and very limited range of motion are red flags for possible more serious condition. Radiological examination should be performed in teens with back pain over about 3 months or for those with history of significant trauma, focal findings or those with systemic symptoms.

Overuse syndromes/ Ligamentous strain :

This is most common in older adolescents and young adults. An increasing cause of this condition is the wearing of back packs. Most back pain related to ligamentous strain will resolve in two weeks to two months but most commonly over several weeks. Treatment involves back exercise, weight reduction, anti-inflammatory medications and sometimes a change in activities.

Spondylolysis/Spondylolisthesis :

Spondylolysis is a defect of the pars interarticularis and spondylolisthesis is the forward slippage of one vertebra on another, usually L5 on S1. These conditions commonly occur in teens with significant athletic involvement where there are large extension forces across the low back are at high risk (gymnasts, ballet dancers, wrestlers) There is usually a significant lordosis. The diagnosis of spondylolisthesis is by radiologic examination. Diagnosis of spondylolysis usually requires oblique films.

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SCOLIOSIS

Approximately 2-3% of adolescents are affected by scoliosis. The impact of the postural changes as well as treatment can have a significant psychological impact on a teen. One study actually showed higher rates of unemployment and lower rates of marriage in individuals with scoliosis.

Definition

Scoliosis is a lateral curvature of the spine of 11 degrees or greater associated with a rotational component. Structural scoliosis is a curve that does not correct with side bending toward the convex side of the curve. Nonstructural scoliosis will correct with side bending.

Etiology

Scoliosis may be secondary to

  • Nonstructural causes such as postural, hysterical, nerve root irritation, abdominal inflammation such appendicitis and leg length discrepancies.
  • Structural scoliosis includes idiopathic, congenital, vertebral causes (myelomeningocele, hemivertebrae), extravertebral (congenital rib fusions), neuromuscular causes from lower or upper motor neuron disease, myopathic diseases such as muscular dystrophy, rheumatoid disease, traumatic causes, bone tumors and other disorders such as Marfan syndrome, osteogenesis imperfecta, neurofibromatosis and osteochondrodystrophies

Idiopathic scoliosis

Adolescent idiopathic scoliosis presents from age 10 years until skeletal maturation and most commonly in females. Approximately 2% to 3% of adolescents have a curve greater than 10 degrees with about 0.5% having a curve greater than 20 degrees. The etiology is unknown but may be related to genetic factors, abnormal skeletal muscle and abnormal intervertebral disc composition. The risk of progression appears related to age of onset, gender, magnitude of the curve, skeletal maturity and pattern of the curve (d ouble curves are more likely to progress than single curves and thoracic curves are more likely to progress than lumbar curves).

Routine screening for scoliosis is controversial with the Canadian Task Force on the Periodic Health Examination and the U.S. Preventive Services Task Force's Guidelines for the Guide to Clinical Preventive Services finding insufficient evidence to make a recommendation while other groups such as the The Scoliosis Research Society, American Academy of Orthopedic Surgeons and the American Academy of Pediatrics recommending screening. Properly trained clinicians using an inclinometer can accurately evaluate adolescents for their need for scoliosis radiographs.

The clinical evaluation should include a history of age of onset, pain, cardiopulmonary symptoms, neurologic symptoms, and family history of spine disorders. Also any history of progression if known, age of menarche and any interventions. The exam should include neuromuscular exam, cardiopulmonary exam, skin for café-au-lait spots, leg length discrepancies, asymmetry of muscle mass, sexual maturity ratings and careful back examination. This should include a forward bending exam of spine. If indicated a standing A/P and lateral scoliosis radiographs should be taken.

Treatment options include observation, bracing and surgery. The choices often depend on degree and progression of curve, skeletal maturation and the location of the curve.

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Questions

Question #1
A 13-year-old adolescent male presents with knee pain for about 4 weeks. There is no history of trauma. He describes the pain as just below the right kneecap and worse with climbing stairs. On examination, there is full range of motion, no swelling or erythema but with some mild tenderness over anterior tibial tuberosity. What is the most likely diagnosis.

Answer
In a 13-year-old adolescent male with no history trauma and with an examination that only shows tenderness or some mild prominence of anterior tibial tuberosity, by far the most likely diagnosis is Osgood-Schlatter's disease. It is particularly common during peak growth and also in athletes. In this teen, an x-ray would not be indicated and observation with or without non-steroidal anti-inflammatory medication would be sufficient. Below is picture of an example of teen with Osgood-Schlatter's disease.

osgood-schlatter's disease
click for full-size image


Question #2
What factors predispose a teen to slipped capital epiphysis?

Answer:
Male sex, peak growth velocity, obesity, delayed skeletal maturation


Question #3
A 15-year-old teen who is advanced ballet dancer complains of severe lumbar back pain that has lasted for months. She is noted on exam to have significant lordosis. She also has localized tenderness in lumbar spine. What would be an important test to order?

Answer
While it is possible that the teen has musculoskeletal pain, the combination of months of back pain, localized tenderness and severe lordosis suggest the possibility of s pondylolysis or spondylolisthesis. It would be important to take lumbar spine films including oblique views.


Question #4
A 14-year-old adolescent female is examined and is found to have a moderate degree of scoliosis. What factors would be considered in her risk of progression of her curve?

Answer
Factors involved in progression include her age of onset, the degree of her curvature, her skeletal maturity and the pattern of her curve with double curves more likely to progress. In addition, pregnancy can be a risk for progression of the curve.

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Cases

A 13-year-old adolescent female presents with right knee pain for about one month. What would be the more significant items on history to be asking about?

Answer
It would be important to ask about:

  • Prior or recent trauma
  • Other joint pains and other systemic symptoms including fevers
  • What activities exacerbate the pain and what activities is she involved in
  • Her pubertal status or age of menarche
  • Location and radiation of the pain
  • History of joint swelling

The teen has no history of trauma. She is on the school track team and runs about one mile per day. The denies any teen swelling. She denies any other joint symptoms. Her review of systems is negative for any other symptoms. She states that running upstairs make the pain worse. Her menarche was at age 12. The pain she describes is around her right kneecap but she cannot localize it more than that.


Question
What would be important on the physical examination to check for?

Answer

  • On general examination, any signs of chronic/systemic diseases.
  • Joint exam: Any evidence of involvement of other joints, evidence of swelling, point tenderness, range of motion including knee and hip joints.
  • Posture: Evidence of medially placed knees or an increased Q angle. The Q angle is the angle found between a line drawn from the anterosuperior iliac spine through the center of the patella and a line from the center of the patella to the tibial tubercle (normal: <15 degrees). An increased angle is a predisposition to patellar malalignment syndrome.
  • Gait

Example of "Q" angle
example of 'Q' angle
click for full-size image

The teen's general examination is completely normal. She has a normal gait, although the pain increases when she squats. She does appear to have knees that are slightly medially placed and has an increased "q" angle. There is full range of motion of both her knees and hips. There is no swelling of either knee and no warmth. There is no tenderness or swelling over the anterior tibial tuberosity. There is moderate tenderness on the inferior medial aspect of the patella.


Question
What are the most common causes of knee pain in adolescents and what is the most likely in this teen?

Answer
The most common causes of knee pain in adolescents are trauma, overuse syndromes, Osgood-Schlatters and patellar malalignment syndrome. The most likely in this teen with no history of trauma and with increased Q angle and tenderness under the patella is patellar malalignment syndrome. Treatment should include some reduction in her training, nonsteroidal anti-inflammatory agents, muscle strengthening exercises including strengthening of the vastus medialis. After symptoms are controlled, a graduated running program and maintenance exercise program could be instituted.

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Web Sites

For Teenagers and Parents

http://familydoctor.org/handouts/135.html
Handout for parents or teens on Osgood-Schlatter disease

http://familydoctor.org/handouts/282.html
Handout for parents or teens on slipped capital epiphysis

Or go to http://familydoctor.org and search

Or to http://orth o info.aaos.org and search

http://www.scoliosis-assoc.org/
Scoliosis Association Inc. An international information and support organization

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References

Atar D, Lehman WB, Grant AD. Growing pains. Orthop Rev 1991;20(2):133.

Bunnell WA . Back pain in children. Orthop Clin North Am 1982;13: 587.

Burton AK , Clarke RD , McClune TD et al. The natural history of low back pain in adolescents. Spine 1996;21: 2323

Cordover AM, Betz RR, Clements DH et al. Natural history of adolescent thoracolumbar and lumbar idiopathic scoliosis into adulthood. J Spinal Disorders 1997;10:193.

Davidson K. Patellofemoral pain syndrome. Am Fam Physician 1993;48:1254-1262.

Deluca SA, Rhea JT. Slipped femoral epiphysis. Am Fam Physician 1984;29:159.

Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992;268:760.

Dickson RA. Spinal deformity--adolescent idiopathic scoliosis. Nonoperative treatment. Spine 1999;24:2601.

Dyment PG. Low back pain in adolescents. Pediatr Ann 1991;20:170.

Ecker ML. Back pain. In Drummond DS (ed) Spine: State of the art reviews: Strategies in the pediatric spine. 2000: 14:1:233.

Freeman BL. Scoliosis and Kyphosis. In Campbell 's Operative Orthopaedics, Canale. Ninth Edition,

Mosby, Inc.2849-2909, 1998.

Ginsburg GM, Bassett GS. Back pain in children and adolescents: Evaluation and differential diagnosis. J Am Acad Orthop Surgeons. 1997; 5:67.

King HA. Back pain in children. Orthop Clin North Am 1999;30: 467

LaBrier K, Oneill DB. Patellofemoral stress syndrome: current concepts. Sports Med 1993;16:449.

Lonstein JE. Spondylolisthesis in children. Cause, natural history, and management. Spine 1999;24: 2640

Manners P. Are growing pains a myth? Australian Family Physician. 1999;28:124.

Micheli LJ, Wood R Back pain in young athletes. Significant differences from adults in causes and pattems. Arch Pediatr Adolesc Med 1995;149:15.

Miller NH. Cause and natural history of adolescent idiopathic scoliosis. Orthopedic Clin North Am 1999;30:343.

Morrissy RT. Slipped capital femoral epiphysis. In: Morrissy RT, ed. Lovell and Winters Pediatric orthopaedics. 3rd ed. Philadelphia : JB Lippincott, 1990: 885-904.

Neinstein LS: Adolescent Health Care: A Practical Guide

Chapter 16: Scoliosis and Kyphosis: Joseph Chorley and Lawrence Neinstein

Chapter 17: Common Orthopedic Problems: Robert Bielski and Lawrence Neinstein

Chapter 18: Back Pain: Robert Bielski and Lawrence Neinstein

Noonan KJ, Dolan LA, Jaconson WC, et al. Long-term psychosocial characteristics of patients treated for idiopathic scoliosis. J Pediatr Orthop 17(6):712-717, 1997.

Olsen TL, Anderson RL, Dearwater SR et al. The epidemiology of low back pain in an adolescent population. Am J Pub Health 1992;82:606.

Oster J. Recurrent abdominal pain, headache, and limb pain in children and adolescents. Pediatrics 1972; 50:429.

Oster J, and Nielsen, A. Growing pains. Acta Paediatr Scand (suppl) 1972;61:329.

Reynolds RA. Diagnosis and treatment of slipped capital femoral epiphysis. Current Opinion in Pediatrics. 1999;11:80.

Roach JW. Knee disorders and injuries in adolescents. Adolescent Medicine 1998;9:589.

Roach JW. Adolescent idiopathic scoliosis. Orthopedic Clin North Am. 1999;30:353.

Selbst SM, Lavelle JM, Soyupak SK. Back pain in children who present to the emergency department. Clin Pediatr 1999;38:401.

Stanitski CL. Anterior knee pain syndromes in the adolescent. J Bone Joint Surg 1993;75:1407.

Tolo V Hip and thigh. In: Pine J, ed. Pediatric orthopaedics in primary care Baltimore : Williams & Wilkins, 1993:135-168.

Tolo V Knee. In: Pine J, ed. Pediatric orthopaedics in primary care Baltimore : Williams & Wilkins, 1993: 169-192.

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Copyright (©) 2004-2013 Lawrence S. Neinstein, University of Southern California . All rights reserved. Republication or redistribution of the text, table, graphs and photos is expressly prohibited. The University of Southern California shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.