Diagnosis |
History, physical and test findings |
Treatment and referral |
Accessory navicular |
Medial foot pain; + radiograph findings |
• Conservative treatment with NSAIDs • Activity modification • Possible immobilization or orthosis • Referral to orthopedics with no improvement |
Apophysitis/musculoskeletal conditions: • Osgood- Schlatter disease • Patella femoral pain • Sinding-Larsen-Johansson syndrome • Sever disease |
Tender to palpation over apophysis; ± radiograph findings |
• NSAIDs or naproxen twice a day • May consider short 1- to 2-wk immobilization or bracing • PT • Follow up in 6 wk, consider referral to orthopedics with no improvement |
Cerebral palsy |
Neurology deficits with motor impairment |
Based on local referring pattern, refer to subspecialist who routinely cares for children with neuromuscular conditions (i.e., pediatric physical medicine and rehabilitation, pediatric neurology, and/or pediatric orthopedic surgery) |
Complex regional pain syndrome |
Pain after an injury, lower limb most common; pain to light touch that is disproportionate to mechanism of injury; evaluate for autonomic symptoms (skin temperature different; color changes; absence or increase of sweating) |
Based on local referring pattern: • NSAIDs or naproxen twice a day • Begin PT for desensitization • Discontinuation of any bracing • Refer to pediatric pain specialty |
Developmental dysplasia of the hip |
Check history for female, first born, breech, and family history; + Ortolani and Barlow signs, asymmetric thigh fold, + Galeazzi sign, + Klisic sign |
Refer to pediatric orthopedics with positive examination findings or imaging studies (ultrasound or radiograph) |
Discitis |
Back pain, ± fever, decreased spinal motion, often systemic symptoms and systemically ill |
Based on the local referring pattern: • Treat with IV antibiotic therapy, typically with inpatient admission • Involvement of subspecialists who routinely care for bone/joint infections as necessary (i.e., infectious disease, orthopedic surgery, general pediatrics/hospitalists) • Consider immobilization for pain control |
Foreign body |
Possible history of foreign body, red, swollen, ± radiograph findings |
• Remove foreign body • Antibiotic prophylaxis as needed • Referral to general surgery or orthopedics if bone involvement or surgical excision is required |
Fracture |
Swelling/pain with motion/palpation: + radiograph findings: if tender over physis, assume fracture |
Splint and refer to emergency department or orthopedics within a few days if physeal, displaced, or angulated |
Gonococcal/chlamydial arthritis |
+ Sexual activity; arthritis of one or more joints; sometimes accompanying dermatitis and systemic signs and symptoms; ± positive nucleic acid amplification tests of synovial fluid, urine, vagina/cervix |
• Involvement of local subspecialists as needed (i.e., infectious disease and/or rheumatology), especially if septic joint • Antibiotic treatment if septic joint (CDC, 2010) • Antibiotic treatment if aseptic joint and chlamydia likely plus pain management (Holmes et al., 2008) |
Growing pains |
Late evening or nighttime lower extremity pains, usually bilateral, resolve with pain reliever/massage, not typical during day; radiographs negative/laboratory results negative |
• Conservative management using symptomatic NSAIDs, massage, warmth, and other supportive measures until the syndrome resolves with time • May try a course of PT with muscle stretching and exercise |
Juvenile inflammatory arthritis |
Morning pain, often multiple joint involvement, warmth and/or diminished range of motion, CBC, ESR, CRP (consider ANA, AntiDNAse B, ASO, Lyme serology, if clinically indicated) |
Based on local referring pattern: • Symptomatic relief can be obtained with NSAIDs • Referral to a pediatric rheumatologist |
Kohler disease |
Pain/swelling mid foot, limp, + radiograph findings navicular bone |
Restrict weight bearing and refer to orthopedics |
Legg-Calve-Perthes disease |
White boys ages 4–10 y, hip and groin pain, decreased internal hip rotation, radiograph findings: flattening and fragmentation of femoral head |
Restrict activities and refer to orthopedics |
Limb length discrepancy |
± Limp, not painful, + Galeazzi sign, + AP leg length films |
Refer to orthopedics |
Lyme arthritis |
Exposure to endemic area, ± target rash, swelling/pain joints, + Lyme titer with + Western blot |
Based on local referring pattern: • Refer to cdc.gov for most recent treatment guidelines OR • Refer to Red Book: Report of the Committee on Infectious Disease (American Academy of Pediatrics [AAP], 2012) • Involvement of local subspecialists as needed (i.e., infectious disease and/or rheumatology) |
Neoplasm |
Progressive or intermittent, deep seated, gnawing pain, often worse at night, ± constitutional symptoms, ± elevated laboratory results, ± radiograph findings |
Based on local referring pattern, expedited referral to pediatric tumor specialist or pediatric oncologist based on local referral pattern |
Non-accidental trauma |
Injury doesn't match story, child non-ambulatory with high suspicion fractures, + radiograph findings of affected area |
Based on local referring pattern: • Treat injuries and begin further workup to evaluate for non-accidental trauma based on facility guidelines • Admit to hospital for safety of patient and further workup • Involvement of Child Protective Services and additional subspecialists as needed (i.e., social work, child advocacy teams, neurosurgery, general surgery or trauma teams) |
Osteochondritis dissecans |
Pain ± swelling affected joint, increase with activity, ± catch/locking, + radiograph findings for older child/teen |
• Treat initially with activity restrictions, immobilization, and non–weight bearing to affected limb • NSAIDs • Refer to orthopedics |
Osteomyelitis |
Local tenderness/swelling bone, limp, ± fever, elevated CBC, ESR, and CRP |
Based on local referring pattern: • ± order MRI • Refer to orthopedics/emergency department/admission to local hospital |
Restless leg syndrome |
Sleep disturbance, normal physical examination, no systemic symptoms, meet National Institutes of Health restless leg syndrome guidelines criteria |
Based on local referring pattern, referral to pediatric sleep center |
Rickets |
No supplemental vitamin D, darker skin, genu varum and radiograph findings: widening/cupping of the metaphysis; abnormal laboratory findings |
Based on local referring pattern: • Refer to orthopedics for treatment of genu varum • Treatment of rickets by primary care provider or endocrine team based upon provider |
Scoliosis |
Thoracic/lumbar prominence on Adams forward bend test; asymmetric shoulders/pelvis; radiograph shows scoliosis |
Refer to orthopedics |
Septic joint |
Pain with joint motion, redness, swelling, warmth, restricted joint motion, non–weight bearing, fever, elevated CBC, CRP, ESR ± blood cultures |
Based on local referring pattern: • Ultrasound hip joint or proceed with joint aspiration of small joints (if comfortable) • May refer to orthopedics, emergency department, or admission to hospital for joint aspiration and continued follow-up with positive cultures |
Slipped capital femoral epiphysis |
Often seen in 10- to 14-year-old teens, boys more than girls, overweight, groin/knee pain, pain internal hip rotation, limp, + AP/frog lateral pelvis radiograph |
• Restrict weight bearing • Refer to emergency department or orthopedics for surgical stabilization |
Spondylolysis/spondylolisthesis |
Pain with back extension, AP/lateral/oblique lumbar sacral spine films ± findings |
• Refer to orthopedics • NSAIDs as needed for pain • Consider activity limitations until seen by subspecialty providers |
Strain/sprain |
Tender to palpation over soft tissue, ± laxity, swelling, no significant pain with weight bearing |
• NSAIDs • Range of motion brace • Begin ambulation as tolerated • Refer to physical therapy if needed • Refer to orthopedics with recurrent sprains |
Tarsal coalition |
Pain in foot with activity, often flat foot and restricted subtalar foot motion, ± radiograph findings |
• Refer to orthopedics |
Toxic synovitis |
Mild/moderate pain with hip motion, ± limp, afebrile, normal CBC and CRP, ± hip effusion on ultrasound |
• NSAIDs • Follow up in 2 to 3 days • Ambulation as tolerated • Limit sports • Refer to emergency department or orthopedics with increasing pain and/or fever |