CHAPTER 16 Helen Foster1 and Lori Tucker2 1 Newcastle University; Great North Children’s Hospital; Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK 2 British Columbia’s Children’s Hospital, Vancouver, Canada Musculoskeletal (MSK) presentations in childhood are common, with a spectrum of causes (Box 16.1), the majority of which are benign and self‐limiting. It must be remembered, however, that severe, potentially life‐threatening conditions such as malignancy, sepsis, vasculitis and non‐accidental injury may also present with MSK complaints. Furthermore, MSK features are common in association with chronic conditions other than rheumatic disorders, such as inflammatory bowel disease and cystic fibrosis. Diagnosis relies on competent MSK clinical skills, with the minimum of pGALS as a basic MSK examination (Foster et al., 2006), appropriate knowledge of normal variants (Box 16.2), ‘red flags’ to raise suspicion of malignancy or sepsis and clinical scenarios at different ages (Box 16.3). The approach to MSK assessment in children is different to that of adults; as young children may have difficulty in localizing or describing symptoms, the history is often given by the parent/carer, and complaints may be non‐specific, such as ‘my child is limping’. Clinical assessment usually distinguishes between mechanical and inflammatory problems and an approach to assessment (Table 16.1) incorporates potential diagnoses according to whether pain is localized or diffuse, whether the child is ‘well’ or not and the presence or absence of ‘red flags’. The presence of multisystem features broadens the differential to include connective tissue diseases. Table 16.1 A strategy for characterizing musculoskeletal pain in children Source: Adapted from Malleson and Beauchamp (2001). **Associated with one or more ‘red flags’, such as fever, anorexia, weight loss, malaise and raised inflammatory markers. JIA, juvenile idiopathic arthritis; SLE, systemic lupus erythematosus. This is a common presentation, with a spectrum of age‐related causes (Box 16.4), and the site of the problem may be broad (from a foreign body in the sole of the foot to a tumour in the spine). Orthopaedic conditions at the hip are common and often present acutely, with a well (albeit limping) child, with possible diagnoses including slipped upper femoral epiphysis (usually the older, often overweight, child) and Perthes’ disease (Figure 16.2) (which may follow a transient synovitis or ‘irritable hip’ in the younger child). The hip joint is unusual as a monoarthritis in juvenile idiopathic arthritis (JIA), and in isolation, sepsis (including mycobacterial infection) needs to be considered. The concept of referred pain from the hip or thigh, for example, must be sought in situations where the child has knee pain but there is no evidence of localized disease at the knee. Figure 16.2 Perthes’ disease, showing avascular necrosis of the right hip Back pain is a common complaint, and is frequently mechanical with contributory factors such as poor posture, physical inactivity, overweight or abnormal loading (such as carrying heavy school bags on one shoulder). Certain sporting activities such as cricket, bowling or gymnastics pose increased risk of back pain, with possible consequences such as spondylolysis and spondylolisthesis. ‘Red flags’ for referral for a child with back pain include a painful scoliosis, neurological symptoms suggestive of nerve root entrapment or cord compression and systemic findings to suggest malignancy or sepsis. Isolated back pain in a child under the age of 5 years is very unusual, and should warrant a referral for investigation. Inflammatory back pain may be a feature of enthesitis‐related arthritis (a subtype of JIA), often presenting in late adolescence and with a strong association with expression of HLA‐B27; however, it is important to note that few children or adolescents with JIA present solely with back pain as a presentation. Osteochondritis of the knee (Osgood–Schlatter disease) is common, especially in adolescent boys who are physically active (particularly those who play football or basketball). Sever’s disease (osteochondritis of the calcaneum) may present with a painful heel, and is also common in adolescent boys who play football or other running sports. Flat feet (Figure 16.3) are common, and standing on tiptoe should create a normal medial longitudinal arch; inability to do so or painful fixed flat feet warrant further investigation to exclude tarsal coalition. High fixed arches, or pes cavus, may suggest neurological disease. Figure 16.3 Normal variant: mobile flat feet are common Non‐specific mechanical MSK pain in children is often labelled as ‘growing pains’. Making a diagnosis of ‘growing pains’ requires careful assessment, and Box 16.5 suggests when alternative diagnoses need to be sought. Many children and adolescents with non‐specific aches and pains, including growing pains, are found to have joint hypermobility, which is suggested by symmetrical hyperextension at the fingers, elbows and knees (genu recurvatum), and flat pronated feet. It is important, however, to consider and exclude ‘non‐benign’ causes of hypermobility (e.g. Marfan’s, Stickler’s and Ehlers–Danlos syndromes), which are rare but important, as these children are at risk of retinal and cardiac complications.
Musculoskeletal Disorders in Children and Adolescents
Localized pain
Diffuse pain
‘Well’ child
‘Unwell’** child
‘Well’ child
‘Unwell’ child
Strains and sprains
Bone tumours
JIA (oligoarticular subtype)
Localized idiopathic pain syndromes
‘Growing pains’
Septic arthritis
Osteomyelitis
Hypermobility
Diffuse idiopathic pain syndromes
Leukaemia
Neuroblastoma
JIA (systemic and polyarticular onset subtypes)
SLE
Juvenile dermatomyositis
Vasculitis
The ‘limping child’
Back pain
Mechanical pain
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