Pretty much every individual symptom in children is likely to be something which is either normal or at very least will follow a benign course. Orthopaedic presentations are no exception. If you've already read part 1 (orthopaedic problems in children) and came away with the impression that almost all children with bow legs, knock knees, in-toeing etc are essentially normal and that the problem is likely to self-resolve, you're not wrong.
This is one of the wonderful things about paediatrics. Many concerning presentations are actually normal, allowing us to feel like we've done something great just by reassuring a parent that their child doesn't have anything wrong with them. Also, many problems self resolve allowing us to take a light touch approach, avoiding unnecessary tests or treatment, always remembering to act in the best interests of the child.
These factors are also one of paediatrics greatest difficulties. Everything is normal, except when it isn't and everything in children's health has an evil twin.
Let me give you some non-orthopaedic presentations as examples.
Paediatric orthopaedics is similarly riddled with presentations where the likelihood is that it is something that needs no intervention, while there always exists the possibility of a much more problematic pathology. Like the evil twin (often used as a complicated anti-hero in literature and film) concept, the pathology that we have to be wary of usually shares many characteristics with the more benign explanation for the symptoms. Since common things are common, the temptation is always to presume the more likely option. So how do we recognise the more dangerous orthopaedic problems, while avoiding over-investigation and over-referral?
First, it is important to know what is typical so that we can know what is atypical. For example, irritable hip is usually seen from the age of one to six years old. It can occur outside of that age range but is uncommon and so is diagnosed with an appropriate caution.
If a preschool child has a fall, the outcome is usually no injury or a fracture. Sprains are uncommon in this age group because they are too flexible to easily strain a ligament to the point of injury.
Once we are familiar with what is both normal and common, it is important to know what the signs are of the common and expected, we need to know what should alert us to the more significant yet less common pathologies. In other words, what are the red flags?
There are some red flags that are fairly reliable and these are listed here.
However some of the red flags that are listed elsewhere are rather contextual, proving the evil twin problem. For example, Arthritis Research UK lists nocturnal pains as a red flag symptom (1) while NHS choices lists nocturnal symptoms as a typical feature of growing pains (2). That is why red flags will only get you so far. Sometimes certain presentations are a set piece. Here are a few examples:
A 12 year old presents with bilateral knee pain, worse on the right. The pain is worse after sports and is particularly bad on stairs. He is limping. Both knees have full range of movement and no effusion. The tibial tuberosity is swollen and tender in both knees.
This is Osgood-Schlatters disease. Simple. This problem of adolescence is more a biomechanical problem than a true disease process. There is little that can be done for this problem apart from symptomatic treatment and a careful management of the balance between being active and being in pain. An orthopaedic surgeon can't fix this problem unfortunately.
A 7 year old presents with a limp and pain in the hip. There is no history of injury. They are not unwell or febrile. Simple analgesia has helped but the limp is still obvious. Examination is normal apart from a reduced internal and external rotation of one hip.
There are various possible explanations for this presentation, however index of suspicion for Perthe's disease has to be very high. The mysterious onset of symptoms that is typical of Perthe's diease makes it a difficult diagnosis. The early recognition of the disease is further hampered by the tendency that children have to reduce activity instead of increasing their complaining. Orthopaedic surgeons don't have a magic treatment for Perthe's but will do everything they can to reduce the progression of this difficult disease. X-ray or referral at presentation is recommended for a patient like this.
A 13 year old presents with what they think is a knee injury. They have had some left knee discomfort which was made much worse by running yesterday. Today, the pain is significant despite analgesia and they have a marked limp. The most notable clinical finding is that movements of the left hip are restricted by pain.
This could be a muscular or ligamentous injury. However it is also possible that this young person has a slipped upper femoral epiphysis. The growth plate in adolescents is at risk of fracture and the subsequent movement can cause permanent damage if not treated as soon as possible. These presentations are tricky as they come with a story that sounds more like a straightforward soft tissue injury. The important thing is to have a high index of suspicion and a low threshold for X-ray or same day referral.
Edward Snelson
@sailordoctor
Specialising in conjoined Meducaction
Disclaimer: Once again, many thanks to the team of orthopaedic surgeons at the Sheffield Children's Hospital. This concludes the planned mini series of paediatric orthopaedic posts but if you have further questions or simply wish to tell us your favourite orthopaedic surgeon joke, please post in the comments box below.
References
This is one of the wonderful things about paediatrics. Many concerning presentations are actually normal, allowing us to feel like we've done something great just by reassuring a parent that their child doesn't have anything wrong with them. Also, many problems self resolve allowing us to take a light touch approach, avoiding unnecessary tests or treatment, always remembering to act in the best interests of the child.
These factors are also one of paediatrics greatest difficulties. Everything is normal, except when it isn't and everything in children's health has an evil twin.
Let me give you some non-orthopaedic presentations as examples.
First, it is important to know what is typical so that we can know what is atypical. For example, irritable hip is usually seen from the age of one to six years old. It can occur outside of that age range but is uncommon and so is diagnosed with an appropriate caution.
If a preschool child has a fall, the outcome is usually no injury or a fracture. Sprains are uncommon in this age group because they are too flexible to easily strain a ligament to the point of injury.
Once we are familiar with what is both normal and common, it is important to know what the signs are of the common and expected, we need to know what should alert us to the more significant yet less common pathologies. In other words, what are the red flags?
There are some red flags that are fairly reliable and these are listed here.
A 12 year old presents with bilateral knee pain, worse on the right. The pain is worse after sports and is particularly bad on stairs. He is limping. Both knees have full range of movement and no effusion. The tibial tuberosity is swollen and tender in both knees.
This is Osgood-Schlatters disease. Simple. This problem of adolescence is more a biomechanical problem than a true disease process. There is little that can be done for this problem apart from symptomatic treatment and a careful management of the balance between being active and being in pain. An orthopaedic surgeon can't fix this problem unfortunately.
A 7 year old presents with a limp and pain in the hip. There is no history of injury. They are not unwell or febrile. Simple analgesia has helped but the limp is still obvious. Examination is normal apart from a reduced internal and external rotation of one hip.
There are various possible explanations for this presentation, however index of suspicion for Perthe's disease has to be very high. The mysterious onset of symptoms that is typical of Perthe's diease makes it a difficult diagnosis. The early recognition of the disease is further hampered by the tendency that children have to reduce activity instead of increasing their complaining. Orthopaedic surgeons don't have a magic treatment for Perthe's but will do everything they can to reduce the progression of this difficult disease. X-ray or referral at presentation is recommended for a patient like this.
A 13 year old presents with what they think is a knee injury. They have had some left knee discomfort which was made much worse by running yesterday. Today, the pain is significant despite analgesia and they have a marked limp. The most notable clinical finding is that movements of the left hip are restricted by pain.
This could be a muscular or ligamentous injury. However it is also possible that this young person has a slipped upper femoral epiphysis. The growth plate in adolescents is at risk of fracture and the subsequent movement can cause permanent damage if not treated as soon as possible. These presentations are tricky as they come with a story that sounds more like a straightforward soft tissue injury. The important thing is to have a high index of suspicion and a low threshold for X-ray or same day referral.
Edward Snelson
@sailordoctor
Specialising in conjoined Meducaction
Disclaimer: Once again, many thanks to the team of orthopaedic surgeons at the Sheffield Children's Hospital. This concludes the planned mini series of paediatric orthopaedic posts but if you have further questions or simply wish to tell us your favourite orthopaedic surgeon joke, please post in the comments box below.
References
