M. Olivia Titus, MD

Case

A 2-year-old girl was carried into the ED after falling off her bed earlier in the evening. The parents did not see the child fall, but heard her crying in her room. On physical examination, the patient was in a lot of pain, would not move her left arm, and had a left elbow effusion. The radial pulse was strong, and she was able to move all of her fingers but would not move her elbow. A lateral X-ray taken of the left elbow is shown below (Figure 1).  

Supracondylar Fractures

Supracondylar fractures are the most common pediatric elbow injury and disposition can range from outpatient follow-up to urgent surgical intervention. The average age of presentation is between 3 to 10 years, and the injury typically results from a fall on an outstretched hand (FOOSH) with hyperextension of the elbow. Supracondylar fractures may also occur after a direct blow to the elbow or hyperflexion.¹

The supracondylar area in children,  the distal portion of the humerus, is thin and weak. The force transmitted to this region by a direct blow or FOOSH injury can fracture the humerus. The brachial artery runs along the anterior humerus and can easily sustain injury. Median, ulnar, or radial nerve injuries are also common and can result in permanent disability.² Immediate neurovascular examination is mandatory, and diminished or absent pulses, poor perfusion, and pallor are signs of ischemia. Examination should include assessment of the radial pulse and the sensory and motor function of the median, radial, and ulnar nerves.  To test the median nerve (via the anterior interosseous branch), ask the patient make an “OK” sign with his or her fingers; to test the radial nerve, instruct the child to make a “thumb’s up” sign; and to test the ulnar nerve, have  the child hold his or her fingers spread-out against resistance. In addition, sensation of the palmer and dorsal surfaces and in between the fingers should be confirmed.

Plain radiographs, including anteroposterior (AP), oblique, and true lateral views, should be obtained. Interpretation of pediatric elbow films can be difficult, and the stages of ossification must be considered. The helpful acronym for remembering the order of bone ossification is CRITOE (capitellum, radial head, internal [medial] epicondyle, trochlea, olecranon, and external [lateral] epicondyle) (Table 1).

If the anterior humeral line—a line drawn through the anterior cortex of the humerus—fails to intersect the capitellum in its middle third, fracture of the distal humerus is present (Figure 2). The radial head should be aligned with the capitellum. Close inspection for a posterior fat pad, or “sail sign” is imperative as it indicates hemorrhage, joint effusion, or occult fracture. The presence of an anterior fat pad can be a normal variant; however, if the pad is wide and creates a “sail sign” then fracture must be assumed.¹

Fracture Types

Pediatric supracondylar frac­tures are classified into three types (Table 2). Type I fractures may be subtle on X-ray, evident only by a posterior fat pad or only seen on an oblique view. These nondisplaced fractures may be splinted with a long-arm splint. Type II fractures are angulated yet the posterior cortex remains intact. Typically the anterior humeral line is displaced, anteriorly intersecting the anterior third of the capitellum or missing it entirely. These cases require urgent orthopedic consultation for either closed reduction with splinting or open reduction with percutaneous pin placement. 

Type III supracondylar fractures are completely displaced with a fracture through the anterior and posterior cortex. Since a high-risk of injury to the upper extremity vessels and nerves is associated with these very unstable fractures, routine neurovascular checks (while awaiting operative repair) are required. Supracondylar fractures are often associated with forearm or distal radius fractures; therefore, forearm radiographs should also be obtained.³

Diskitis

Diskitis is defined as inflammation or infection of the intervertebral disk. Though etiology is debated, Staphylococcus aureus is confirmed in up to 60% of cases.⁴ This infection has been described by some as being on the spectrum of vertebral osteomyelitis. Though rare, delayed diagnosis of diskitis can result in significant morbidity. Incidence peaks in early childhood between ages 3 to 5 years but may present at any age with back pain, limp, or refusal to walk. Most commonly, the lower lumbar disks are affected. Examination may reveal decreased muscle strength or reflexes, refusal to bend forward, hip pain, or tenderness of the spine. Although white blood cell (WBC) count is typically normal, more than 90% of patients with diskitis have an elevated erythrocyte sedimentation rate. X-rays usually appear normal until 2 to 3 weeks after symptoms begin, at which time narrowing of the joint space can be seen. Magnetic resonance imaging is required for diagnosis (Figure 3), and orthopedics should be consulted for possible aspiration for culture. Empiric antibiotic therapy includes an antistaphylococcal agent (eg, nafcillin/oxacillin, clindamycin, vancomycin) and a third-generation cephalosporin (eg, cefotaxime, ceftriaxone).⁵ 

 

Tumors

Back or bone pain can be a subtle early presenting symptom of cancer or tumors of the bone or bone marrow. The most common malignant bone tumors in children are osteosarcoma and Ewing sarcoma.⁶ Both types may present with intermittent pain or pain that worsens over weeks to months. Fever also may be present, which can lead to a misdiagnosis of osteomyelitis. Acute leukemia presenting with bone/back pain and a history of nighttime pain combined with low WBC, platelets, or hemoglobin is highly suggestive of this diagnosis. Physical examination should identify lymphadenopathy, hepatomegaly, or splenomegaly. The child with back pain in whom there is concern for mass should have laboratory evaluation, including a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, alkaline phosphatase, and lactate dehydrogenase. Plain radiographs may demonstrate “onion skinning” or the “sunburst” pattern, indicating periosteal reaction, and is highly suggestive of malignancy (Figure 4). Benign tumors of childhood may present initially as back pain as well. Osteoid osteoma is a common benign tumor which presents with pain that becomes worse at night and may respond to nonsteroidal anti-inflammatory drugs.⁷

Spondylolysis

Spondylolysis, also known as “pars defect,” is a unilateral or bilateral fracture of the vertebral pars interarticularis—typically of the lower lumbar vertebrae, most commonly L5. Spondylolysis occurs after repetitive microtrauma. Spondylolisthesis is the slipping of one vertebra over another one. These diagnoses should be suspected in adolescents, especially athletic patients presenting with acute low-back pain. The pain associated with these conditions often extends into the posterior thigh and is relieved by rest. Examination findings include lumbosacral tenderness, particularly with extension or lateral bending. Radiographs should include AP, lateral, and oblique views and may demonstrate fracture, displacement of the vertebrae, or the classic “Scotty dog” sign with the crack (collar) on the neck of dog (Figure 5). Treatment consists of immobilization, activity restriction, and physiotherapy. Referral to orthopedics is advised for follow-up X-rays and monitoring. If conservative treatment fails to relieve pain or if slippage progressively worsens, spinal fusion is necessary.⁸

Pediatric Cervical Spine Clearance

Thankfully, cervical spine injuries are rare, occurring in approximately 1% of children after blunt trauma.⁹ Left unrecognized, however, these injuries may result in permanent neurological disability. Children younger than 8 years of age are more likely to injure the upper cervical spine (C1 to C3) than older children and adults. This is because children have relatively larger heads than bodies and weaker cervical muscles and ligaments, making the upper cervical spine more mobile. The Emergency X-Radiography Utilization Study (NEXUS) criteria have been validated in adults; however, criteria for clearing the pediatric cervical spine are poorly studied. Because of limited data, there are few evidence-based guidelines for the clearance of the pediatric cervical spine. A study in 2001 found that the NEXUS guidelines where helpful in reducing imaging in 20% of children, but due to the low numbers of infants in this study, caution is advised when applying the NEXUS criteria to children under 2 years of age.⁹

Midline posterior cervical tenderness, evidence of intoxication, altered level of consciousness, abnormal neurological examination, or distracting painful injury are indications for AP, lateral, and odontoid X-rays. After blunt trauma, if a patient is receiving an urgent computed tomography (CT) scan for another area of injury such as the head or abdomen, he or she should also receive a CT scan of the cervical spine. Additionally, those with significant mechanism of injury, focal neurological findings, significant altered level of consciousness, and/or significant posterior midline neck pain should also have a cervical spine CT scan.¹⁰ Neurosurgical service consultation is necessary in cases of abnormal cervical spine radiographs (plain films and/or CT scan), abnormal neurological examination (focal neurological findings or altered level of consciousness), or continued significant posterior midline cervical spine pain/tenderness, history, and resolution of focal neurological findings despite normal radiographs. Clearance of the cervical spine is possible if the patient has no posterior midline cervical tenderness; has a normal neurological examination; is not intoxicated; has no altered level of consciousness; has no painful distracting injury and normal radiographs; and has resolution of significant midline tenderness and/or altered level of consciousness when either one of these was the criteria that necessitated the radiographs (Table 3).¹¹

Nonaccidental Trauma: Abuse

Orthopedic injury due to nonaccidental trauma (NAT) can be difficult to distinguish from normal childhood injuries. Identification of high-risk presentations is key in diagnosing these injuries and hopefully preventing further abuse. Femur fractures in children younger than age 1 year have a high likelihood of being nonaccidental, with between 60% to 80% of femoral shaft fractures resulting from abuse. No particular pattern of fracture is pathognomonic for NAT. The American Academy of Orthopaedic Surgeons recommends that children younger than age 36 months with a diaphyseal femur fracture be evaluated for child abuse.¹²

 

Spiral fractures and transverse fractures of long bones also raise suspicion for NAT. Injury to the metaphysis of long bones, especially in nonambulatory children, is considered highly suggestive of child abuse. The classic metaphyseal lesion, called a “corner” or “bucket-handle” fracture, occurs when the extremity (usually the forearm) is pulled or twisted forcibly, or the child is shaken. X-ray will demonstrate a disruption of the metaphysis with lucency. As the developing ribs are flexible and difficult to break with minor injuries, a child with a rib fracture and no history of severe trauma, such as a motor vehicle crash or fall from a significant height, has a high likelihood of being a victim of child abuse. Skull fractures caused from accidental injury and abuse may have similar presentations. The history and mechanism are important to correlate with physical examination findings for potential inconsistencies.¹³

Case Conclusion

The child in this case sustained a type II supracondylar fracture. Orthopedic surgery was consulted, and the patient was taken to the operating room for closed reduction and percutaneous pinning. She was placed in a cast, and pins were removed at follow-up 4 weeks later. No residual pain or deficits remained, and she regained full function of her arm.

Dr Hewett is a pediatric emergency medicine fellow, College of Medicine, Medical University of South Carolina, Charleston.
Dr Titus is vice chair, pediatric fellowships, and fellowship director, pediatric emergency medicine; and an associate professor of pediatrics, Medical University of South Carolina, Charleston.

Case

A 2-year-old girl was carried into the ED after falling off her bed earlier in the evening. The parents did not see the child fall, but heard her crying in her room. On physical examination, the patient was in a lot of pain, would not move her left arm, and had a left elbow effusion. The radial pulse was strong, and she was able to move all of her fingers but would not move her elbow. A lateral X-ray taken of the left elbow is shown below (Figure 1).  

Supracondylar Fractures

Supracondylar fractures are the most common pediatric elbow injury and disposition can range from outpatient follow-up to urgent surgical intervention. The average age of presentation is between 3 to 10 years, and the injury typically results from a fall on an outstretched hand (FOOSH) with hyperextension of the elbow. Supracondylar fractures may also occur after a direct blow to the elbow or hyperflexion.¹

The supracondylar area in children,  the distal portion of the humerus, is thin and weak. The force transmitted to this region by a direct blow or FOOSH injury can fracture the humerus. The brachial artery runs along the anterior humerus and can easily sustain injury. Median, ulnar, or radial nerve injuries are also common and can result in permanent disability.² Immediate neurovascular examination is mandatory, and diminished or absent pulses, poor perfusion, and pallor are signs of ischemia. Examination should include assessment of the radial pulse and the sensory and motor function of the median, radial, and ulnar nerves.  To test the median nerve (via the anterior interosseous branch), ask the patient make an “OK” sign with his or her fingers; to test the radial nerve, instruct the child to make a “thumb’s up” sign; and to test the ulnar nerve, have  the child hold his or her fingers spread-out against resistance. In addition, sensation of the palmer and dorsal surfaces and in between the fingers should be confirmed.

Plain radiographs, including anteroposterior (AP), oblique, and true lateral views, should be obtained. Interpretation of pediatric elbow films can be difficult, and the stages of ossification must be considered. The helpful acronym for remembering the order of bone ossification is CRITOE (capitellum, radial head, internal [medial] epicondyle, trochlea, olecranon, and external [lateral] epicondyle) (Table 1).

If the anterior humeral line—a line drawn through the anterior cortex of the humerus—fails to intersect the capitellum in its middle third, fracture of the distal humerus is present (Figure 2). The radial head should be aligned with the capitellum. Close inspection for a posterior fat pad, or “sail sign” is imperative as it indicates hemorrhage, joint effusion, or occult fracture. The presence of an anterior fat pad can be a normal variant; however, if the pad is wide and creates a “sail sign” then fracture must be assumed.¹

Fracture Types

Pediatric supracondylar frac­tures are classified into three types (Table 2). Type I fractures may be subtle on X-ray, evident only by a posterior fat pad or only seen on an oblique view. These nondisplaced fractures may be splinted with a long-arm splint. Type II fractures are angulated yet the posterior cortex remains intact. Typically the anterior humeral line is displaced, anteriorly intersecting the anterior third of the capitellum or missing it entirely. These cases require urgent orthopedic consultation for either closed reduction with splinting or open reduction with percutaneous pin placement. 

Type III supracondylar fractures are completely displaced with a fracture through the anterior and posterior cortex. Since a high-risk of injury to the upper extremity vessels and nerves is associated with these very unstable fractures, routine neurovascular checks (while awaiting operative repair) are required. Supracondylar fractures are often associated with forearm or distal radius fractures; therefore, forearm radiographs should also be obtained.³

Diskitis

Diskitis is defined as inflammation or infection of the intervertebral disk. Though etiology is debated, Staphylococcus aureus is confirmed in up to 60% of cases.⁴ This infection has been described by some as being on the spectrum of vertebral osteomyelitis. Though rare, delayed diagnosis of diskitis can result in significant morbidity. Incidence peaks in early childhood between ages 3 to 5 years but may present at any age with back pain, limp, or refusal to walk. Most commonly, the lower lumbar disks are affected. Examination may reveal decreased muscle strength or reflexes, refusal to bend forward, hip pain, or tenderness of the spine. Although white blood cell (WBC) count is typically normal, more than 90% of patients with diskitis have an elevated erythrocyte sedimentation rate. X-rays usually appear normal until 2 to 3 weeks after symptoms begin, at which time narrowing of the joint space can be seen. Magnetic resonance imaging is required for diagnosis (Figure 3), and orthopedics should be consulted for possible aspiration for culture. Empiric antibiotic therapy includes an antistaphylococcal agent (eg, nafcillin/oxacillin, clindamycin, vancomycin) and a third-generation cephalosporin (eg, cefotaxime, ceftriaxone).⁵ 

 

Tumors

Back or bone pain can be a subtle early presenting symptom of cancer or tumors of the bone or bone marrow. The most common malignant bone tumors in children are osteosarcoma and Ewing sarcoma.⁶ Both types may present with intermittent pain or pain that worsens over weeks to months. Fever also may be present, which can lead to a misdiagnosis of osteomyelitis. Acute leukemia presenting with bone/back pain and a history of nighttime pain combined with low WBC, platelets, or hemoglobin is highly suggestive of this diagnosis. Physical examination should identify lymphadenopathy, hepatomegaly, or splenomegaly. The child with back pain in whom there is concern for mass should have laboratory evaluation, including a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, alkaline phosphatase, and lactate dehydrogenase. Plain radiographs may demonstrate “onion skinning” or the “sunburst” pattern, indicating periosteal reaction, and is highly suggestive of malignancy (Figure 4). Benign tumors of childhood may present initially as back pain as well. Osteoid osteoma is a common benign tumor which presents with pain that becomes worse at night and may respond to nonsteroidal anti-inflammatory drugs.⁷

Spondylolysis

Spondylolysis, also known as “pars defect,” is a unilateral or bilateral fracture of the vertebral pars interarticularis—typically of the lower lumbar vertebrae, most commonly L5. Spondylolysis occurs after repetitive microtrauma. Spondylolisthesis is the slipping of one vertebra over another one. These diagnoses should be suspected in adolescents, especially athletic patients presenting with acute low-back pain. The pain associated with these conditions often extends into the posterior thigh and is relieved by rest. Examination findings include lumbosacral tenderness, particularly with extension or lateral bending. Radiographs should include AP, lateral, and oblique views and may demonstrate fracture, displacement of the vertebrae, or the classic “Scotty dog” sign with the crack (collar) on the neck of dog (Figure 5). Treatment consists of immobilization, activity restriction, and physiotherapy. Referral to orthopedics is advised for follow-up X-rays and monitoring. If conservative treatment fails to relieve pain or if slippage progressively worsens, spinal fusion is necessary.⁸

Pediatric Cervical Spine Clearance

Thankfully, cervical spine injuries are rare, occurring in approximately 1% of children after blunt trauma.⁹ Left unrecognized, however, these injuries may result in permanent neurological disability. Children younger than 8 years of age are more likely to injure the upper cervical spine (C1 to C3) than older children and adults. This is because children have relatively larger heads than bodies and weaker cervical muscles and ligaments, making the upper cervical spine more mobile. The Emergency X-Radiography Utilization Study (NEXUS) criteria have been validated in adults; however, criteria for clearing the pediatric cervical spine are poorly studied. Because of limited data, there are few evidence-based guidelines for the clearance of the pediatric cervical spine. A study in 2001 found that the NEXUS guidelines where helpful in reducing imaging in 20% of children, but due to the low numbers of infants in this study, caution is advised when applying the NEXUS criteria to children under 2 years of age.⁹

Midline posterior cervical tenderness, evidence of intoxication, altered level of consciousness, abnormal neurological examination, or distracting painful injury are indications for AP, lateral, and odontoid X-rays. After blunt trauma, if a patient is receiving an urgent computed tomography (CT) scan for another area of injury such as the head or abdomen, he or she should also receive a CT scan of the cervical spine. Additionally, those with significant mechanism of injury, focal neurological findings, significant altered level of consciousness, and/or significant posterior midline neck pain should also have a cervical spine CT scan.¹⁰ Neurosurgical service consultation is necessary in cases of abnormal cervical spine radiographs (plain films and/or CT scan), abnormal neurological examination (focal neurological findings or altered level of consciousness), or continued significant posterior midline cervical spine pain/tenderness, history, and resolution of focal neurological findings despite normal radiographs. Clearance of the cervical spine is possible if the patient has no posterior midline cervical tenderness; has a normal neurological examination; is not intoxicated; has no altered level of consciousness; has no painful distracting injury and normal radiographs; and has resolution of significant midline tenderness and/or altered level of consciousness when either one of these was the criteria that necessitated the radiographs (Table 3).¹¹

Nonaccidental Trauma: Abuse

Orthopedic injury due to nonaccidental trauma (NAT) can be difficult to distinguish from normal childhood injuries. Identification of high-risk presentations is key in diagnosing these injuries and hopefully preventing further abuse. Femur fractures in children younger than age 1 year have a high likelihood of being nonaccidental, with between 60% to 80% of femoral shaft fractures resulting from abuse. No particular pattern of fracture is pathognomonic for NAT. The American Academy of Orthopaedic Surgeons recommends that children younger than age 36 months with a diaphyseal femur fracture be evaluated for child abuse.¹²

 

Spiral fractures and transverse fractures of long bones also raise suspicion for NAT. Injury to the metaphysis of long bones, especially in nonambulatory children, is considered highly suggestive of child abuse. The classic metaphyseal lesion, called a “corner” or “bucket-handle” fracture, occurs when the extremity (usually the forearm) is pulled or twisted forcibly, or the child is shaken. X-ray will demonstrate a disruption of the metaphysis with lucency. As the developing ribs are flexible and difficult to break with minor injuries, a child with a rib fracture and no history of severe trauma, such as a motor vehicle crash or fall from a significant height, has a high likelihood of being a victim of child abuse. Skull fractures caused from accidental injury and abuse may have similar presentations. The history and mechanism are important to correlate with physical examination findings for potential inconsistencies.¹³

Case Conclusion

The child in this case sustained a type II supracondylar fracture. Orthopedic surgery was consulted, and the patient was taken to the operating room for closed reduction and percutaneous pinning. She was placed in a cast, and pins were removed at follow-up 4 weeks later. No residual pain or deficits remained, and she regained full function of her arm.

Dr Hewett is a pediatric emergency medicine fellow, College of Medicine, Medical University of South Carolina, Charleston.
Dr Titus is vice chair, pediatric fellowships, and fellowship director, pediatric emergency medicine; and an associate professor of pediatrics, Medical University of South Carolina, Charleston.

Case

A 2-year-old girl was carried into the ED after falling off her bed earlier in the evening. The parents did not see the child fall, but heard her crying in her room. On physical examination, the patient was in a lot of pain, would not move her left arm, and had a left elbow effusion. The radial pulse was strong, and she was able to move all of her fingers but would not move her elbow. A lateral X-ray taken of the left elbow is shown below (Figure 1).  

Supracondylar Fractures

Supracondylar fractures are the most common pediatric elbow injury and disposition can range from outpatient follow-up to urgent surgical intervention. The average age of presentation is between 3 to 10 years, and the injury typically results from a fall on an outstretched hand (FOOSH) with hyperextension of the elbow. Supracondylar fractures may also occur after a direct blow to the elbow or hyperflexion.¹

The supracondylar area in children,  the distal portion of the humerus, is thin and weak. The force transmitted to this region by a direct blow or FOOSH injury can fracture the humerus. The brachial artery runs along the anterior humerus and can easily sustain injury. Median, ulnar, or radial nerve injuries are also common and can result in permanent disability.² Immediate neurovascular examination is mandatory, and diminished or absent pulses, poor perfusion, and pallor are signs of ischemia. Examination should include assessment of the radial pulse and the sensory and motor function of the median, radial, and ulnar nerves.  To test the median nerve (via the anterior interosseous branch), ask the patient make an “OK” sign with his or her fingers; to test the radial nerve, instruct the child to make a “thumb’s up” sign; and to test the ulnar nerve, have  the child hold his or her fingers spread-out against resistance. In addition, sensation of the palmer and dorsal surfaces and in between the fingers should be confirmed.

Plain radiographs, including anteroposterior (AP), oblique, and true lateral views, should be obtained. Interpretation of pediatric elbow films can be difficult, and the stages of ossification must be considered. The helpful acronym for remembering the order of bone ossification is CRITOE (capitellum, radial head, internal [medial] epicondyle, trochlea, olecranon, and external [lateral] epicondyle) (Table 1).

If the anterior humeral line—a line drawn through the anterior cortex of the humerus—fails to intersect the capitellum in its middle third, fracture of the distal humerus is present (Figure 2). The radial head should be aligned with the capitellum. Close inspection for a posterior fat pad, or “sail sign” is imperative as it indicates hemorrhage, joint effusion, or occult fracture. The presence of an anterior fat pad can be a normal variant; however, if the pad is wide and creates a “sail sign” then fracture must be assumed.¹

Fracture Types

Pediatric supracondylar frac­tures are classified into three types (Table 2). Type I fractures may be subtle on X-ray, evident only by a posterior fat pad or only seen on an oblique view. These nondisplaced fractures may be splinted with a long-arm splint. Type II fractures are angulated yet the posterior cortex remains intact. Typically the anterior humeral line is displaced, anteriorly intersecting the anterior third of the capitellum or missing it entirely. These cases require urgent orthopedic consultation for either closed reduction with splinting or open reduction with percutaneous pin placement. 

Type III supracondylar fractures are completely displaced with a fracture through the anterior and posterior cortex. Since a high-risk of injury to the upper extremity vessels and nerves is associated with these very unstable fractures, routine neurovascular checks (while awaiting operative repair) are required. Supracondylar fractures are often associated with forearm or distal radius fractures; therefore, forearm radiographs should also be obtained.³

Diskitis

Diskitis is defined as inflammation or infection of the intervertebral disk. Though etiology is debated, Staphylococcus aureus is confirmed in up to 60% of cases.⁴ This infection has been described by some as being on the spectrum of vertebral osteomyelitis. Though rare, delayed diagnosis of diskitis can result in significant morbidity. Incidence peaks in early childhood between ages 3 to 5 years but may present at any age with back pain, limp, or refusal to walk. Most commonly, the lower lumbar disks are affected. Examination may reveal decreased muscle strength or reflexes, refusal to bend forward, hip pain, or tenderness of the spine. Although white blood cell (WBC) count is typically normal, more than 90% of patients with diskitis have an elevated erythrocyte sedimentation rate. X-rays usually appear normal until 2 to 3 weeks after symptoms begin, at which time narrowing of the joint space can be seen. Magnetic resonance imaging is required for diagnosis (Figure 3), and orthopedics should be consulted for possible aspiration for culture. Empiric antibiotic therapy includes an antistaphylococcal agent (eg, nafcillin/oxacillin, clindamycin, vancomycin) and a third-generation cephalosporin (eg, cefotaxime, ceftriaxone).⁵ 

 

Tumors

Back or bone pain can be a subtle early presenting symptom of cancer or tumors of the bone or bone marrow. The most common malignant bone tumors in children are osteosarcoma and Ewing sarcoma.⁶ Both types may present with intermittent pain or pain that worsens over weeks to months. Fever also may be present, which can lead to a misdiagnosis of osteomyelitis. Acute leukemia presenting with bone/back pain and a history of nighttime pain combined with low WBC, platelets, or hemoglobin is highly suggestive of this diagnosis. Physical examination should identify lymphadenopathy, hepatomegaly, or splenomegaly. The child with back pain in whom there is concern for mass should have laboratory evaluation, including a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, alkaline phosphatase, and lactate dehydrogenase. Plain radiographs may demonstrate “onion skinning” or the “sunburst” pattern, indicating periosteal reaction, and is highly suggestive of malignancy (Figure 4). Benign tumors of childhood may present initially as back pain as well. Osteoid osteoma is a common benign tumor which presents with pain that becomes worse at night and may respond to nonsteroidal anti-inflammatory drugs.⁷

Spondylolysis

Spondylolysis, also known as “pars defect,” is a unilateral or bilateral fracture of the vertebral pars interarticularis—typically of the lower lumbar vertebrae, most commonly L5. Spondylolysis occurs after repetitive microtrauma. Spondylolisthesis is the slipping of one vertebra over another one. These diagnoses should be suspected in adolescents, especially athletic patients presenting with acute low-back pain. The pain associated with these conditions often extends into the posterior thigh and is relieved by rest. Examination findings include lumbosacral tenderness, particularly with extension or lateral bending. Radiographs should include AP, lateral, and oblique views and may demonstrate fracture, displacement of the vertebrae, or the classic “Scotty dog” sign with the crack (collar) on the neck of dog (Figure 5). Treatment consists of immobilization, activity restriction, and physiotherapy. Referral to orthopedics is advised for follow-up X-rays and monitoring. If conservative treatment fails to relieve pain or if slippage progressively worsens, spinal fusion is necessary.⁸

Pediatric Cervical Spine Clearance

Thankfully, cervical spine injuries are rare, occurring in approximately 1% of children after blunt trauma.⁹ Left unrecognized, however, these injuries may result in permanent neurological disability. Children younger than 8 years of age are more likely to injure the upper cervical spine (C1 to C3) than older children and adults. This is because children have relatively larger heads than bodies and weaker cervical muscles and ligaments, making the upper cervical spine more mobile. The Emergency X-Radiography Utilization Study (NEXUS) criteria have been validated in adults; however, criteria for clearing the pediatric cervical spine are poorly studied. Because of limited data, there are few evidence-based guidelines for the clearance of the pediatric cervical spine. A study in 2001 found that the NEXUS guidelines where helpful in reducing imaging in 20% of children, but due to the low numbers of infants in this study, caution is advised when applying the NEXUS criteria to children under 2 years of age.⁹

Midline posterior cervical tenderness, evidence of intoxication, altered level of consciousness, abnormal neurological examination, or distracting painful injury are indications for AP, lateral, and odontoid X-rays. After blunt trauma, if a patient is receiving an urgent computed tomography (CT) scan for another area of injury such as the head or abdomen, he or she should also receive a CT scan of the cervical spine. Additionally, those with significant mechanism of injury, focal neurological findings, significant altered level of consciousness, and/or significant posterior midline neck pain should also have a cervical spine CT scan.¹⁰ Neurosurgical service consultation is necessary in cases of abnormal cervical spine radiographs (plain films and/or CT scan), abnormal neurological examination (focal neurological findings or altered level of consciousness), or continued significant posterior midline cervical spine pain/tenderness, history, and resolution of focal neurological findings despite normal radiographs. Clearance of the cervical spine is possible if the patient has no posterior midline cervical tenderness; has a normal neurological examination; is not intoxicated; has no altered level of consciousness; has no painful distracting injury and normal radiographs; and has resolution of significant midline tenderness and/or altered level of consciousness when either one of these was the criteria that necessitated the radiographs (Table 3).¹¹

Nonaccidental Trauma: Abuse

Orthopedic injury due to nonaccidental trauma (NAT) can be difficult to distinguish from normal childhood injuries. Identification of high-risk presentations is key in diagnosing these injuries and hopefully preventing further abuse. Femur fractures in children younger than age 1 year have a high likelihood of being nonaccidental, with between 60% to 80% of femoral shaft fractures resulting from abuse. No particular pattern of fracture is pathognomonic for NAT. The American Academy of Orthopaedic Surgeons recommends that children younger than age 36 months with a diaphyseal femur fracture be evaluated for child abuse.¹²

 

Spiral fractures and transverse fractures of long bones also raise suspicion for NAT. Injury to the metaphysis of long bones, especially in nonambulatory children, is considered highly suggestive of child abuse. The classic metaphyseal lesion, called a “corner” or “bucket-handle” fracture, occurs when the extremity (usually the forearm) is pulled or twisted forcibly, or the child is shaken. X-ray will demonstrate a disruption of the metaphysis with lucency. As the developing ribs are flexible and difficult to break with minor injuries, a child with a rib fracture and no history of severe trauma, such as a motor vehicle crash or fall from a significant height, has a high likelihood of being a victim of child abuse. Skull fractures caused from accidental injury and abuse may have similar presentations. The history and mechanism are important to correlate with physical examination findings for potential inconsistencies.¹³

Case Conclusion

The child in this case sustained a type II supracondylar fracture. Orthopedic surgery was consulted, and the patient was taken to the operating room for closed reduction and percutaneous pinning. She was placed in a cast, and pins were removed at follow-up 4 weeks later. No residual pain or deficits remained, and she regained full function of her arm.

Dr Hewett is a pediatric emergency medicine fellow, College of Medicine, Medical University of South Carolina, Charleston.
Dr Titus is vice chair, pediatric fellowships, and fellowship director, pediatric emergency medicine; and an associate professor of pediatrics, Medical University of South Carolina, Charleston.