Growing pains? Or something else? Seminar highlights underdiagnosed musculoskeletal problems

Oct. 17, 2002

ASSEMBLY EDITION • SAN DIEGO

Growing pains? Or something else?
Seminar highlights underdiagnosed musculoskeletal problems

BY ROBERT CARLSON

The label "growing pains" is commonly used to explain many musculoskeletal aches in children, but it might mistakenly be applied to far more significant problems. Children with joint infection, structural abnormalities, neuromuscular disease and even neoplasia might first be seen by a family physician for vague bone-pain complaints that don't respond to over-the-counter painkillers.

"Conditions such as developmental dysplasia of the hip are often missed, chalked up to growing pains or muscle pain from fever associated with influenza," said Kenneth Taylor, M.D., co-presenter in the clinical seminar "Children's Potpourri: Commonly Missed Musculoskeletal Problems in Children" on Wednesday. Taylor is clinical instructor of family medicine at the University of California, San Diego, and co-director of sports medicine there.

A missed diagnosis of developmental dysplasia of the hip is the fourth-leading cause of malpractice suits in pediatrics, said co-presenter Suraj Achar, M.D., clinical instructor of family medicine at UCSD and assistant director of sports medicine.

In his presentation, Achar said pediatric patients with musculoskeletal complaints are often seen by family physicians rather in than the emergency department if there is no acute or traumatic injury.

"A child with osteochondritis dissecans might come into the office with mild pain in the knee, a little bit of limping, minimal effusion or swelling," Achar said.

Achar's take-home points were:

Limping is always abnormal.
Only a few musculoskeletal cases require emergency surgery (such as slipped capital femoral epiphysis).
Temperature is the critical vital sign.
Age stratification can help differentiate infectious causes of limping abnormalities, more likely in younger children, from structural causes more likely in older children.
Think systematically for treatment.
Refer patients to other specialists if you are not sure of the diagnosis.

The primary differential is pain, Achar said. In musculoskeletal complaints, it might be due to infection, inflammatory disorders, trauma, neoplasia or hip disease.

And don't forget child abuse, he advised.

Onset of pain might be delayed, so that is not always helpful, Achar said, and a history of trauma can be misleading if child abuse is involved.

Location of pain can also be misleading since this type of pain can be referred.

"Knee and thigh pain is often from the hip," Achar said.

A plain X-ray series is suitable for diagnosing most cases of limp or trauma, Achar said, though he recommended getting at least two views, 90 degrees apart.

Achar said a positive joint exam, which finds swelling, limited range of motion, warmth, tenderness or erythema, will help rule out growing pains.

"Tylenol^® takes care of growing pains," Achar said. "And growing pains are bilateral or symmetrical, not focal or unilateral, and they usually hurt at night but don't interfere with daytime activities."

An orthopedic disorder should be suspected if the patient has a positive joint exam but a normal temperature and a normal erythrocyte sedimentation rate, Achar said.

In his presentation, Taylor said physicians should think about physeal injuries before ligament injuries in the older child playing sports. Ligaments are tough by that age, while growth plates are still weak, he said.

Some conditions such as slipped capital femoral epiphysis will require surgery, but Seaver's disease, Little League Elbow and Salter-Harris type-I and typeII fractures could heal with just a few weeks' rest, Taylor said.

"If you catch these early, the kids can get back to sports very quickly," he said.

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