Orthopedic Emergencies

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Chapter 47 Orthopedic Emergencies

Fred A. Fow, MD

1 Describe the presentation of osteomyelitis.

Fever, pain, and decreased use of the involved extremity are common manifestations of osteomyelitis. There may be accompanying signs of systemic illness, such as anorexia, malaise, and vomiting. Infants may exhibit decreased feeding, irritability, or listlessness. Pain may be manifested in neonates as pseudoparalysis. Examination findings include focal swelling, warmth, tenderness, and erythema, often metaphyseal in location. Neonates and younger children are more prone than older patients to present with secondary joint involvement. Proximal humerus and proximal femur infections involve the joint as a result of their intracapsular location. When there is limited soft tissue involvement tenderness may be out of proportion to the soft tissue findings. A patient may present with symptoms of severe illness, including signs of generalized sepsis and shock.

Other diagnoses to consider in the patient with suspected osteomyelitis include cellulitis, pyomyositis, necrotizing fasciitis, septic arthritis, toxic synovitis, thrombophlebitis, trauma, rheumatologic diseases, Ewing’s sarcoma, osteosarcoma, and leukemia.

Frank G, Mahoney HM, Eppes SC: Musculoskeletal infections in children. Pediatr Clin North Am 52:1083–1106, 2005.

Gutierrez KM: Bone and joint infections. In Long SS, Pickering LK, Prober CG (eds): Principles and Practice of Pediatric Infectious Disease, 2nd ed. Philadelphia, Churchill Livingstone, 2003, pp 467–474.

2 How are most cases of osteomyelitis acquired? Direct inoculation? Hematogenous spread? Contiguous spread?

The most common source for osteomyelitis is hematogenous spread. Direct inoculation into the bone is less common, as is local invasion from a contiguous infection.

Gutierrez KM: Bone and joint infections. In Long SS, Pickering LK, Prober CG (eds): Principles and Practice of Pediatric Infectious Disease, 2nd ed. Philadelphia, Churchill Livingstone, 2003, pp 467–474.

Kaplan SL: Osteomyelitis in children. Infect Dis Clin North Am 19:787–797, 2005.

3 What laboratory tests are helpful in the diagnosis of osteomyelitis?

Reasonable screening laboratory tests to obtain in suspected cases of osteomyelitis include complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). ESR and CRP are more sensitive indicators than white blood cell (WBC) count. ESR is elevated in up to 90% of cases of hematogenously acquired osteomyelitis. CRP is elevated in up to 98% of cases. Blood cultures should be obtained and are positive in 50–80% of cases of hematogenously acquired osteomyelitis. The highest yield for isolating a causative organism is achieved when bone aspirate, joint aspirate, and blood are collected for culture. With the exception of patients who are clinically unstable, these cultures should be obtained before initiation of parenteral antibiotics.

Look for emerging literature on the usefulness of polymerase chain reaction in identifying infections secondary to Bartonella henselae and Kingella kingae.

4 What imaging studies are indicated when osteomyelitis is suspected?

image Plain radiography is a reasonable initial imaging choice in the emergency department (ED) evaluation of a patient with suspected osteomyelitis. This may rule out fracture, tumor, or other concerns. Its usefulness is limited, however, because bony changes (lytic lesions, periosteal elevation, and periosteal new bone formation) may not appear until 10–20 days after symptoms begin. Changes to adjacent soft tissues (deep soft tissue swelling and loss of normal tissue planes) may occur much earlier, as early as several days after symptoms begin.

image Technetium 99 bone scanning is more sensitive in the early diagnosis of osteomyelitis than plain radiography, with reported sensitivities of 80–100%. However, results of bone scanning can be normal in up to 20% of cases in the first few days of illness. Its specificity in differentiating osteomyelitis from other differential diagnostic considerations (malignancy, soft tissue cellulitis, septic arthritis, trauma, fracture, and infarction) is also limited.

image Magnetic resonance imaging (MRI) (Fig. 47-1) appears to be the imaging study of choice for evaluating the patient with suspected osteomyelitis. Sensitivity ranges from 92% to 100%. MRI helps differentiate osteomyelitis from cellulitis and demonstrate myositis or pyomyositis contiguous to the site of bone involvement. As with bone scanning, malignancy, fracture, and infarction can appear similar to osteomyelitis on MRI.

image image

Figure 47-1 A. Plain radiograph of a knee with bone that registers normal. B. Magnetic resonance image of the same knee with a positive reading of osteomyelitis.

Special considerations apply for neonatal, pelvic, and vertebral osteomyelitis and osteomyelitis acquired in a nonhematogenous fashion.

Gutierrez KM: Bone and joint infections. In Long SS, Pickering LK, Prober CG (eds): Principles and Practice of Pediatric Infectious Disease, 2nd ed. Philadelphia, Churchill Livingstone, 2003, pp 467–474.

Kaplan SL: Osteomyelitis in children. Infect Dis Clin North Am 19:787–797, 2005.

5 Which organisms are commonly seen in osteomyelitis?

Staphylococcus aureus is the most common causative organism. Other common organisms include Streptococcus pneumoniae, Streptococcus pyogenes, and Kingella kingae. In addition to Staphylococcus aureus, group B streptococci and enteric gram-negative organisms are important organisms to consider in neonates with osteomyelitis. Other special considerations include Neisseria gonorrhoeae in sexually active adolescents; anaerobes in cases associated with sinusitis, mastoiditis, or dental abscess; Serratia spp. and Aspergillus spp. in patients with granulomatous disease; coagulase-negative staphylococci in patients who have undergone medical procedures; Salmonella spp. and gram-negative enteric organisms in patients with hemoglobinopathies; Pseudomonas aeruginosa in puncture wounds to the foot; Bartonella henselae in kitten exposures; and Coxiella burnetii in cases of exposure to farm animals. Haemophilus influenzae type B is only rarely seen since the advent of the H. influenzae type B vaccine but remains a consideration in an unimmunized child.

The increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) is worthy of particular attention and concern. MRSA can be particularly virulent and is associated with multiple sites of bone involvement, myositis, pyomyositis, intraosseous, and subperiosteal abscess formation, pulmonary involvement, and vascular complications (such as deep vein thrombosis and septic pulmonary emboli). These patients may be quite ill and require admission to the intensive care unit.

Mycobacterial and fungal infections are rare causes of osteomyelitis.

Frank G, Mahoney HM, Eppes SC: Musculoskeletal infections in children. Pediatr Clin North Am 52:1083–1106, 2005.

Gutierrez KM: Bone and joint infections. In Long SS, Pickering LK, Prober CG (eds): Principles and Practice of Pediatric Infectious Disease, 2nd ed. Philadelphia, Churchill Livingstone, 2003, pp 467–474.

Kaplan SL: Osteomyelitis in children. Infect Dis Clin North Am 19:787–797, 2005.

6 What historical features should raise suspicion for osteomyelitis (and/or septic arthritis) from Kingella kingae?

Kingella kingae plays an important role in osteomyelitis and septic arthritis in children. Infection with this organism typically occurs in children younger than 2 years of age and often follows an upper respiratory tract infection, pharyngitis, or stomatitis. It may be seasonal in occurrence (late summer through winter). An outbreak of invasive infections from this organism has been reported in a daycare population.

Frank G, Mahoney HM, Eppes SC: Musculoskeletal infections in children. Pediatr Clin North Am 52:1083–1106, 2005.

Gutierrez KM: Bone and joint infections. In Long SS, Pickering LK, Prober CG (eds): Principles and Practice of Pediatric Infectious Disease, 2nd ed. Philadelphia, Churchill Livingstone, 2003, pp 467–474.

Kaplan SL: Osteomyelitis in children. Infect Dis Clin North Am 19:787–797, 2005.

Yagupsky P, Dagan R, Howard CB, et al: Clinical features and epidemiology of invasive Kingella kingae infections in southern Israel. Pediatrics 92:800–804, 1993.

7 How should synovial fluid be handled to improve isolation of Kingella kingae?

Recovery of K. kingae is improved when synovial fluid aspirate or bone aspirate is collected in aerobic blood culture medium.

Kaplan SL: Osteomyelitis in children. Infect Dis Clin North Am 19:787–797, 2005.

Ross JJ: Septic arthritis. Infect Dis Clin North Am 19:799–817, 2005.

8 How is osteomyelitis treated?

Antibiotic treatment should be initiated as soon as appropriate cultures have been collected. Regardless of the patient’s age, treatment should address the likelihood of infection with Staphylococcus aureus. Given the increasing prevalence of MRSA in many communities, coverage of MRSA in particular is very important. Many MRSA isolates are susceptible to clindamycin. In children, adolescents, and infants over 2 months of age, clindamycin is a good choice for initial antimicrobial coverage. Isolate testing for inducible resistance to clindamycin should be performed, since isolates demonstrating inducible resistance may not respond to treatment. Vancomycin provides excellent coverage for MRSA. However, because of concerns about widespread use of vancomycin resulting in increasing antimicrobial resistance, it should be reserved for patients who are moderately to severely ill or who live in communities where significant resistance to clindamycin has been demonstrated. In infants younger than 2 months of age, additional antimicrobial coverage for Group B Streptococcus and enteric gram-negative becteria is important. In this age group clindamycin or vancomycin plus cefotaxime or gentamycin would be appropriate initial antimicrobial choices.

Special circumstances (noted in question 5) warrant consideration of antimicrobial coverage specific to the likely pathogens in such cases.

An orthopedic surgeon should be involved in cases of suspected or confirmed osteomyelitis. Surgical treatment is indicated in a number of circumstances. Moreover, surgical tissue is often helpful in identifying a causative organism to guide antimicrobial treatment.

Frank G, Mahoney HM, Eppes SC: Musculoskeletal infections in children. Pediatr Clin North Am 52:1083–1106, 2005.

Gutierrez K: Bone and joint infections in children. Pediatr Clin North Am 52:779–794, 2005.

Gutierrez KM: Bone and joint infections. In Long SS, Pickering LK, Prober CG (eds): Principles and Practice of Pediatric Infectious Disease, 2nd ed. Philadelphia, Churchill Livingstone, 2003, pp 467–474.

Kaplan SL: Osteomyelitis in children. Infect Dis Clin North Am 19:787–797, 2005.

9 Describe the signs and symptoms of septic arthritis.

Pain and decreased use of the involved limb are common symptoms of septic arthritis. Hip, knee, and ankle joints account for about 80% of cases of septic arthritis. Fever, malaise, and anorexia are seen in most patients. The involved joint is often held in a position of comfort. In the knee this is usually flexion. In the hip it is usually flexion, abduction, and external rotation. Passive range of motion away from the position of comfort is resisted and is painful. In joints other than the hip, tenderness, swelling, warmth, and erythema are usually seen and an effusion may be palpable. As in osteomyelitis, neonates may present with pseudoparalysis and tenderness of the affected limb.

Other diagnoses to consider in the patient with suspected septic arthritis include traumatic joint pain, transient synovitis (“toxic synovitis”), reactive arthritis, Lyme arthritis, juvenile rheumatoid arthritis, acute rheumatic fever, osteomyelitis, pyomyositis, necrotizing fasciitis, tumor, slipped capital femoral epiphysis, and Legg-Calvé-Perthes disease.

Frank G, Mahoney HM, Eppes SC: Musculoskeletal infections in children. Pediatr Clin North Am 52:1083–1106, 2005.

Gutierrez KM: Infectious and inflammatory arthritis. In Long SS, Pickering LK, Prober CG (eds): Principles and Practice of Pediatric Infectious Disease, 2nd ed. Philadelphia, Churchill Livingstone, 2003, pp 475–481.

Ross JJ: Septic arthritis. Infect Dis Clin North Am 19:799–817, 2005.

10 What laboratory tests help diagnose septic arthritis?

WBC counts, ESR, and CRP levels are usually elevated in cases of septic arthritis. The WBC count appears to be less useful than ESR in differentiating septic arthritis from transient synovitis. In cases of septic arthritis, the ESR is usually greater than 20 mm/hr. Mean ESR ranges from 44 to 65 mm/hr. The mean CRP level is 85 mg/L. Blood culture and synovial fluid analysis (cell count, Gram stain, and culture) are essential in the evaluation of children with suspected septic arthritis. Ideally, these tests should be performed before the administration of antibiotics. They yield an organism in up to 40% and up to 50–60% of cases, respectively, and when combined, they yield an organism in up to 60–70% of cases. The yield of synovial cultures may be improved by inoculation of the fluid into blood culture media. Typical synovial fluid WBC count is over 50,000 cells/mm3, with a predominance of polymorphonuclear cells (> 75–90%). Unfortunately, cell counts less than 50,000 cells/mm3 can be seen in cases of septic arthritis, and counts over 50,000 cells/mm3 are seen in juvenile rheumatoid arthritis. Synovial fluid glucose and protein levels are not reliable enough to differentiate septic arthritis from other infectious or inflammatory processes.

11 Which imaging studies can help make the diagnosis of septic arthritis?

The initial imaging choice in the ED is plain radiography. Soft tissue swelling, joint space widening, and changes suggestive of osteomyelitis may be seen. In the hip, capsular swelling and loss of the gluteal fat planes may be seen as early evidence of infection in the joint. If hip infection is suspected, ultrasonography may be performed and ultrasonographically guided joint aspiration performed. Bone scanning and MRI are both sensitive modalities for detecting joint infection. MRI has the added advantage of delineating changes in the adjacent soft tissues and bone.

Frank G, Mahoney HM, Eppes SC: Musculoskeletal infections in children. Pediatr Clin North Am 52:1083–1106, 2005.

Greenspan A, Tehranzadeh J: Imaging of infectious arthritis. Radiol Clin North Am 39:267–276, 2001.

Gutierrez KM: Bone and joint infections. In Long SS, Pickering LK, Prober CG (eds): Principles and Practice of Pediatric Infectious Disease, 2nd ed. Philadelphia, Churchill Livingstone, 2003, pp 475–481.

Hughes JG, Vetter EA, Patel R, et al: Culture with BACTEC Peds Plus/F bottle compared with conventional methods for detection of bacteria in synovial fluid. J Clin Microbiol 39:4468–4471, 2001.

Ross JJ: Septic arthritis. Infect Dis Clin North Am 19:799–817, 2005.

Zawin JK: Joint effusion in children with an irritable hip: US diagnosis and aspiration. Radiology 187:459–463, 1993.

12 Which organisms are commonly seen in septic arthritis?

The organisms commonly responsible for septic arthritis are much the same as those commonly associated with osteomyelitis (see question 5). Neisseria gonorrhoeae should be considered in neonates and in sexually active patients, especially those with multifocal joint involvement. Candida spp. should be considered in neonates. Antibiotic considerations for initial empiric treatment of septic arthritis are similar to those in osteomyelitis (see question 8).

Frank G, Mahoney HM, Eppes SC: Musculoskeletal infections in children. Pediatr Clin North Am 52:1083–1106, 2005.

Gutierrez K: Bone and joint infections in children. Pediatr Clin North Am 52:779–794, 2005.

Gutierrez KM: Bone and joint infections. In Long SS, Pickering LK, Prober CG (eds): Principles and Practice of Pediatric Infectious Disease, 2nd ed. Philadelphia, Churchill Livingstone, 2003, pp 475–481.

Ross JJ: Septic arthritis. Infect Dis Clin North Am 19:799–817, 2005.

13 What is the treatment for septic arthritis?

Optimal treatment involves antibiotics and joint drainage. Early consultation with an orthopedic surgeon is mandatory. Emergent surgical drainage of infected hip and neonatal shoulder infections is appropriate, whereas repeated nonsurgical aspiration may be reasonable for other joints. There is recent evidence that a short course of steroids may improve residual function and shorten the duration of acute symptoms.

Frank G, Mahoney HM, Eppes SC: Musculoskeletal infections in children. Pediatr Clin North Am 52:1083–1106, 2005.

Odio CM, Ramirez T, Arias G, et al: Double blind, randomized, placebo-controlled study of dexamethasone therapy for hematogenous septic arthritis in children. Pediatr Infect Dis J 22:883–888, 2003.

Ross JJ: Septic arthritis. Infect Dis Clin North Am 19:799–817, 2005.

14 Reactive arthritis is in the differential diagnosis for the patients described above. What are the common organisms responsible for reactive arthritis?

Salmonella, Shigella, and Campylobacter spp. and Yersinia enterocolitica from the gastrointestinal tract; N. gonorrhoeae and Chlamydia trachomatis from the genitourinary tract; and Streptococcus pyogenes, Mycoplasma pneumoniae, and N. meningitidis. Both Neisseria spp. and Streptococcus pyogenes can also cause septic arthritis.

Frank G, Mahoney HM, Eppes SC: Musculoskeletal infections in children. Pediatr Clin North Am 52:1083–1106, 2005.

Gutierrez K: Bone and joint infections in children. Pediatr Clin North Am 52:779–794, 2005.

15 Describe the typical presentation and evaluation of suspected pyomyositis.

Unfortunately, the diagnosis of pyomyositis is often not made until symptoms have been present for several weeks. Initial symptoms include crampy local muscle pain, most commonly involving the thigh, calf, buttock, upper extremity, and iliopsoas muscles. Early in the course of the infection local edema is present, although the overlying skin is often normal. The edema has been described as having a woody or rubbery feel. Over time, induration, edema, erythema, and tenderness increase. Fever, increasing constitutional symptoms, toxicity, and signs of sepsis may develop if the infection progresses and is untreated.

Leukocytosis and elevated CRP levels and ESR may develop as the infection progresses. Blood cultures should be collected. Creatine kinase level is often normal, however. Ultrasonography, computed tomography (CT), and MRI may demonstrate the presence of pyomyositis. MRI is more sensitive than CT.

Frank G, Mahoney HM, Eppes SC: Musculoskeletal infections in children. Pediatr Clin North Am 52:1083–1106, 2005.

Small LN, Ross JJ: Tropical and temperate pyomyositis. Infect Dis Clin North Am 19:981–989, 2005.

16 How is pyomyositis treated?

The organisms most commonly responsible for pyomyositis are Staphylococcus aureus and Streptococcus pyogenes (often associated with varicella infection). As is the case in osteomyelitis and septic arthritis, MRSA must be considered in these patients and antimicrobial treatment directed appropriately. When an identifiable abscess is present, drainage is indicated. In the interest of isolating an organism, consider delaying the initiation of antibiotics until drained fluid can be collected for culture, in stable patients. More extensive surgical intervention may be necessary if there is muscle necrosis.

Frank G, Mahoney HM, Eppes SC: Musculoskeletal infections in children. Pediatr Clin North Am 52:1083–1106, 2005.

Small LN, Ross JJ: Tropical and temperate pyomyositis. Infect Dis Clin North Am 19:981–989, 2005.

17 Describe the typical presentation and evaluation of suspected necrotizing fasciitis.

Patients with necrotizing fasciitis often have soft tissue swelling and pain near a site of trauma. Initially, pain with manipulation may be out of proportion to the skin findings seen. Induration and edema follow, then blistering and bleb formation. The skin becomes dusky and drains fluid. Subcutaneous pain and tenderness become severe, again often out of proportion to the appearance of the overlying skin. There is often high fever and signs of systemic illness. The process may be quite fulminant, accompanied by toxic shock syndrome and multiorgan failure.

Laboratory evaluation and imaging, particularly MRI, may be helpful in establishing the diagnosis. However, because of the rapidly progressive nature of necrotizing fasciitis, laboratory evaluation and imaging should not delay initiation of treatment. Collect wound, tissue, and blood cultures (aerobic and anaerobic).

Frank G, Mahoney HM, Eppes SC: Musculoskeletal infections in children. Pediatr Clin North Am 52:1083–1106, 2005.

18 What is the treatment for necrotizing fasciitis?

The most important aspect of treatment for necrotizing fasciitis is immediate surgical debridement. Seek surgical consultation as soon as possible. Antibiotic treatment should be directed at the likely causative organisms, including Streptococcus pyogenesand Staphylococcus aureus (including MRSA). A reasonable antibiotic choice would be clindamycin plus oxacillin. Add vancomycin in patients who are very ill. Ampicillin-sulbactam and piperacillin-tazobactam are other possible antimicrobial choices. In areas where MRSA is prevalent, treatment should also include vancomycin. It cannot be overemphasized, however, that antibiotic treatment alone is insufficient treatment for this severe, rapidly progressive, and often life-threatening infection.

Darmstadt GL: Subcutaneous tissue infections and abscesses. In Long SS, Pickering LK, Prober CG (eds): Principles and Practice of Pediatric Infectious Disease, 2nd ed. Philadelphia, Churchill Livingstone, 2003, pp 449–457.

Frank G, Mahoney HM, Eppes SC: Musculoskeletal infections in children. Pediatr Clin North Am 52:1083–1106, 2005.

Miller LG: Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med 352:1445–1453, 2005.

19 What concerns should the ED physician have when a child younger than 4 years presents with back pain?

Back pain is not a common symptom in young children, nor is it a particularly common expression of functional pain in young children. Concerning signs and symptoms in a young child with back pain include refusal to walk, limited range of motion in the back, persistent or increasing pain despite analgesics, anti-inflammatory agents and rest, fever, weight loss, signs of systemic illness, and abnormal neurologic signs. Serious causes to be considered in the young child include discitis, vertebral osteomyelitis, and tumors.

American Academy of Orthopaedic Surgeons: Slipped capital femoral epiphysis. In American Academy of Orthopaedic Surgeons: Orthopaedic Knowledge Update: Pediatrics. Rosemont, Illinois, American Academy of Orthopaedic Surgeons, 1996, pp 151–159.

Payne WK, Ogilvie JW: Back pain in children and adolescents. Pediatr Clin North Am 43:899–918, 1996.

Key Points: Orthopedic Emergencies

1 MRSA is an important organism to consider in bone, joint, and soft tissue infections. Provide adequate antimicrobial coverage if it is prevalent in your area.

2 Overlying skin findings may not be very remarkable early in the course of pyomyositis and necrotizing fasciitis.

3 Surgical debridement without delay is the most important aspect of the treatment of necrotizing fasciitis.

4 Back pain in a young child warrants serious consideration.

20 How do children with slipped capital femoral epiphysis present?

Slipped capital femoral epiphysis (SCFE) usually occurs during the rapid growth phase of adolescence and tends to occur more often in obese children. Males are affected almost twice as often as females. Black adolescents are affected about twice as often as white adolescents. SCFE may be chronic, acute, or acute superimposed on chronic in its presentation. Obesity is a risk factor in the development of SCFE. The presentation of SCFE is bilateral in approximately 20% of cases. Patients with SCFE will often have pain in the anterior hip, groin, medial thigh, or knee and will also demonstrate limitation of hip motion. Because SCFE can present with knee pain, the presence of knee pain in a child or adolescent mandates a thorough examination of the hip. Patients who are ambulatory have an antalgic gait with external rotation of the affected leg. Passive internal rotation of the hip is painful, and passive hip flexion is associated with compensatory external rotation.

American Academy of Orthopaedic Surgeons: Slipped capital femoral epiphysis. In American Academy of Orthopaedic Surgeons: Orthopaedic Knowledge Update: Pediatrics. Rosemont, Illinois, American Academy of Orthopaedic Surgeons, 1996, pp 151–159.

Canale ST: Fractures and dislocations in children. In Canale ST (ed): Campbell’s Operative Orthopaedics, 10th ed. Philadelphia, Mosby, 2003, pp 1481–1503.

Kienstra A; Macias C: Slipped capital femoral epiphysis: www.uptodate.com

21 What is the approach to the patient with suspected SCFE in the ED?

Plain radiography is the first step in the evaluation of patients with suspected SCFE. Films show displacement of the femoral capital epiphysis from the metaphysis through the growth plate. If the slip is chronic, metaphyseal remodeling may be seen. The anteroposterior view often demonstrates the presence of the slip. A line drawn tangent to the superior femoral neck should intersect the lateral aspect of the femoral head (Klein’s line). In SCFE this line passes more lateral on the capital epiphysis. Cross-table lateral radiography of the hip can help define the extent of posterior epiphyseal displacement. A frog-leg view of the pelvis may reveal a subtle slip, however, movement of the hip for radiography should be avoided as it may cause further slippage. Although a slip may be symptomatic on one side only, it is often present bilaterally on plain radiography. Because as many as 40% of patients have slips bilaterally, comparing sides on plain films may give false reassurance and result in failure to diagnose both slips.

Once the diagnosis is strongly suspected, the patient should avoid weight-bearing and an urgent orthopedic consultation should be obtained.

American Academy of Orthopaedic Surgeons: Slipped capital femoral epiphysis. In American Academy of Orthopaedic Surgeons: Orthopaedic Knowledge Update: Pediatrics. Rosemont, Illinois, American Academy of Orthopaedic Surgeons, 1996, pp 151–159.

Canale ST: Fractures and dislocations in children. In Canale ST (ed): Campbell’s Operative Orthopaedics, 10th ed. Philadelphia, Mosby, 2003, pp 1481–1503.

22 What is the etiology of “growing pains”?

Growing pains do not correlate with growth spurts and do not affect growth. They do not occur at the growth plate regions. Possible causes include fatigue, abnormal posture, restless legs syndrome, and overuse. Growing pains are often seen in children with other types of recurrent pain, such as headaches and abdominal pain. They are slightly more common in girls.

Wilking A: Growing pains. Available at: www.uptodate.com

23 What are some of the features of growing pains?

image Pain occurs most commonly in the lower extremities and is bilateral.

image Pain occurs in the evening hours and is often better by morning.

image Pain can become severe and is relieved by acetaminophen or ibuprofen.

image The physical examination is normal.

image There is often a family history of growing pains.

image Pain is chronic and may last for years.

Wilking A: Growing pains. Available at: www.uptodate.com

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