Childhood Orthopaedic Problems

Review article published in Update Magazine - 2000

Author Dr Gordon Cameron

Childhood abnormalities

Case scenario 1

Lesley is a thirteen-year-old ballet dancer who has pain behind the kneecaps.She has consulted four times in the last year – always with her highly assertive mother. "Something must be done!" says mum.Entrance exams for ballet school are only weeks away and Lesley's knees are too sore to dance. She feels like they might give way at times and broke down in tears in a recent class.There are no problems with Lesley's general health and no other joints trouble her. Her knees do not become swollen or hot.

Examination reveals a sulky girl but the joints are unremarkable and X-rays are normal.

Changes in child health surveillance programs seem to have altered the type of orthopaedic ailments GP's see.Ten years ago children with over-riding toes, knock-knees and bow-legs consulted regularly. Now, even with a special interest in orthopaedics I rarely see a single case.GP's today are more familiar with the orthopaedic problems of later childhood and adolescence. Major abnormalities like talipes equinovarus or hip dislocation are dealt with in the neonatal unit and minor ailments are the province of the health visitor or the community paediatric team.This article concentrates on the "tricks of the trade" to ease the orthopaedic diagnostic process and discusses those conditions seen most commonly.

Major orthopaedic pathology can be devastating in a child's life and all GP's should be alert to the relevant signs. But we will see fifty cases of anterior knee pain for every one of slipped upper femoral epiphysis and this article reflects that fact.

Anterior knee pain

Lesley's case (above) will be familiar to most GP's and to all members of the hospital orthopaedic team. Anterior knee pain is extremely common and almost universally benign.Pain behind the kneecap can herald the onset of underlying pathology such as tumour or juvenile arthropathy but this is rare and simple clinical alertness should identify such cases without difficulty.Beware the child with an exclusively unilateral presentation; with progressively worsening pain or with pain when in bed at night. Pain at rest is always suspicious. If in doubt, arrange an X-ray and check the ESR. If doubt persists, refer early to a specialist.Don't forget the principles of referred pain – even experts get caught out at times!

Pain felt in the knee could be referred from the hip since both joints derive from the same embryological segment.The term chondromalacia patella was once common but is no longer used. Arthroscopy shows that cartilage texture is normal in most patients.Biomechanical abnormalities of the feet and anteversion of the femur can predispose towards retropatellar pain. Poor bulk and tone in the quadriceps muscles is commonly found – particularly in the oblique part of vastus medialis - and this responds well to physiotherapy treatment.Girls are much more commonly afflicted than boys are and, in my experience, family dynamics are important.

Try to examine the child in the absence of their parents or coach - at least for part of the time. A frank discussion to explore motivation can be very useful in planning management. Many youngsters seem to want to use knee pain as an excuse to stop competing in sport – often to the dismay of their parents. Pain behind the kneecap is certainly uncomfortable but a desire to swap the discus for the disco may also be a factor!Common symptoms in anterior knee pain cases include a sense of the knee almost giving way (pseudo-giving) or being about to lock up (pseudo-locking) – although never actually doing so.

Many patients complain of discomfort on stairs, often worse on the way down. The cardinal symptom of retropatellar problems is the knee cap "getting stuck" when sitting and then giveing a painful "jerk" or "jump" when the patient gets up to walk. American specialists call this "movie-goers-knee" and the description seems apt.

A simple examination routine

• Start with the patient standing facing you and look for obvious quadriceps wasting or the "squinting patellae" of femoral anteversion. Look from the side for the backward bowed recurvatum knee, which suggests underlying hypermobility and predispose to knee pain.
• Lie them down and use the dorsum of your hand to check for warmth – compare one knee to the other. Is there an effusion present? This would be very uncommon in simple anterior knee pain.
• Palpate along the joint lines for tenderness or for obvious swelling
• Examine the patella – does it seem smaller than you would expect? Is it sitting unusually high up the femur? These are normal variants but both predispose to patellofemoral pain.
• Keep the palm of your hand on the patella while you passively bend and straighten the knee - this allows you to feel whether the kneecap moves in a smooth alignment.
• Gently press the patella against the femur. This is tender in everyone but more so in a patient with anterior knee pain – if in doubt compare with the other knee.
• Lastly – and this test may not be required since it will cause pain if positive – sit your patient on the edge of the couch with the knee flexed to ninety degrees. Resist the foot as they try to extend the knee in a kicking motion.

Don't forget that anterior knee pain can be a manifestation of other knee pathology. A thorough examination should finish by palpating the knee joint line for tenderness and by testing the stability of the cruciate and collateral ligaments.Having made the diagnosis, reassure your patient strongly and refer them to physiotherapy. There is little to be gained by sending them to an orthopaedic surgeon unless the features are atypical. Many sporting youngsters simply seek an escape from the pressure of an overbearing parent and an open, frank discussion can be dramatically therapeutic.

Osgood Schlatter's disease

This condition shows what happens to young bones when the development of muscle power exceeds the bone's ability to cope - typically in the early teenage years – before the tibial tubercle apophysis has properly fused to the tibia.

Repetitive overuse causes an inflammatory reaction around the apophysis and in severe cases the tibial tubercle can be lifted away from the underlying bone.The patient complains of well-localised pain at the tibial tuberosity. In the early stages there is local heat but this usually subsides in time - leaving a prominent bump. Pain lasts for as long as the provocative activity continues but quickly settles with rest. Ibuprofen will releive any acute inflammatory change. Don't arrange X-rays – the diagnosis can be made clinically.Strongly reassure the parents and the child that a few months of rest now will allow full resumption of sporting activity later.

Case scenario – 2: outcome

Under intense parental pressure you refer Lesley to a local orthopaedic surgeon. A diagnosis of anterior knee pain is made and arrangements made for physiotherapy treatment.

Six months later you see Lesley again with tonsillitis. She has given up dancing and never gets knee pain now. She is a livelier outgoing girl than you remember

A pain in the hip

The question most GP's ask when faced with hip pain is "should I refer and if so when?" Here's how I approach a child or adolescent with hip pain.

First – make sure you're "talking the same language!" The word "hip" means different things to different patients. Many say the pain is in their hip when they mean in the buttock or lateral thigh. In fact groin pain is the cardinal feature of hip problems.

The pain of hip disease may radiate down the medial thigh towards the knee and sometimes below. The more inflamed the lesion, the further the pain will spread. Sometimes pain in the same side upper buttock is a feature although I find this more often in adults with osteoarthritis than in children.

Explore the history and discover how long the symptoms have been present. Was the onset sudden or gradual? Is the child sporty? Was there recent trauma? Are there symptoms of systemic upset? Is there pain at rest?

Try to watch your patient walk. Do they limp? Is there a trendelenburg gait? Are they standing on a flexed hip?

Check the temperature – the febrile child with hip pain needs investigated urgently.

Undress your patient and look at the spine. Check for obvious deformity. Next lie them supine. Look at the posture of the affected leg. Acute hip pathology may cause spasm in the psoas muscle and this pulls the joint into flexion at rest.An inflamed hip loses its ability to rotate medially and the leg may lie in an externally rotated posture for that reason. This is often exaggerated when the examining doctor flexes the hip and it tends to rotate externally and abduct away from the midline.

Palpate the inguinal region for tenderness over the joint – the head of the femur lies immediately deep to the femoral pulse. Check for lymphadenopathy and palpate the scrotum and testes in a boy – this may give clues to other causes for the pain. Examine the abdomen – acute appendicitis can also cause spasm in psoas and pain in the groin.

If the clinical examination features do point to hip disease then refer urgently if:

• There is a history of systemic upset or fever
• Recent trauma has occurred
• The onset was sudden or dramatic

The first of the above features suggests osteomyelitis or septic arthritis and the latter two could point towards slipping of the capital femoral epiphysis – particularly in an older child.

Perthes' disease and transient synovitis present with a more gradual onset of pain. Most will still need assessed by an orthopaedic specialist but the referral is less urgent. Some of them will improve spontaneously without treatment.

Acute wry neck or torticollis

Acute torticollis or "wry neck" can occur at any age from infancy to late teens but is uncommon beyond the age of twenty. The cause is uncertain but may relate to prolapse of the nucleus pulposis from a cervical disc.There may be a preceding febrile illness with cervical lymphadenopathy but the onset is often unheralded. Many patients simply wake up in the morning with a "stuck neck."Although the pain is often severe it is only provoked by movement and use of a soft collar can provide dramatic relief. Severe spasm limits most neck movement but the patient can often obtain rotation in one direction. Sleeping is a problem but can be made more comfortable by using only one pillow and supporting the neck in a neutral position with a rolled up small hand towel.In theory the diagnostic possibilities include meningitis or other serious neck pathology but in practice it is rarely hard to come to differentiate.

The condition resolves spontaneously in seven to ten days. In the meantime reassure your patient strongly and persuade them to wear a collar. Encourage gentle movements from an early stage and provide as much analgesia as they need. Moist heat (a warm damp towel) is often very soothing and if physiotherapy can be accessed quickly then the results can be rapidly gratifying.

Practice points:

• Hip disease causes mainly groin pain
• Knee pain can be referred from the hip joint

• Exclusively unilateral patellar pain is unusual and may need further investigation

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