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The adolescent with back pain in the ED

Adolescent with back pain


  • traumatic:
    • muscle strain or tendinitis
    • crush fracture Tx vertebrae from compressive injury or hyperflexion injury (eg. fall from pushbike over handlebars onto head or fall from height onto feet)
    • fracture transverse process Lx spine from high impact direct blow or tearing injury from muscle injury
    • renal trauma
    • pyelonephritis
  • thoracic kyphosis:
    • Scheuermann's disease - esp. males early adolescence, upper Tx spine resulting in wedging & kyphosis
    • post-traumatic thoracic spine fracture
    • habitual
    • ankylosing spondylitis (10% start before puberty, peak onset 15-25yr olds; always causes sacro-iliitis as well)
  • scoliosis:
    • postural - curve disappears when bend to touch toes
    • compensatory - due to pelvic tilt from unequal leg length
    • spasmodic - due to acute muscle spasm as in acute disc prolapse, pyelonephritis or appendicitis
    • structural:
      • congenital - eg. hemivertebrae
      • neuropathic - eg. polio, neurofibromatosis
      • myopathic - eg. muscular dystrophy
      • idiopathic
  • hyperlordosis of lumbar spine:
    • racial (eg. negro women)
    • secondary to large abdomen (obesity, pregnancy) which throws centre of gravity forwards & pt compensates by angling upper trunk backwards
    • secondary to thoracic kyphosis
    • spondylolisthesis - posterior elements of L4/5 usually, fail to hold two vertebral levels in place allowing the upper body to slip forward on the lower body & occurs in 3-7% of the population.
    • congenital structural defect (spondylolysis)
    • post-trauma or surgery
    • sports with high shear loads in flexion, esp. in adolescents - gymnastics, rugby, diving, javelin-throwing, wrestling, weightlifting, golf
  • uncommonly:
    • gynae. causes such as imperforate hymen, miscarriage, endometriosis
    • lumbar disc prolapse
  • rarely:
    • sacro-ileitis:
      • ankylosing spondylitis (10% start before puberty, peak onset 15-25yr olds)
      • psoriasis (5% of pts with psoriasis)
      • Reiter's disease - males mainly; non-specific urethritis, polyarthritis (esp. sacro-iliac, lower limbs), conjunctivitis
      • discitis (loss of disc space on Xray) eg. TB, idiopathic (usually lumbar)
      • osteomyelitis spine
      • tumour

essentials of ED Mx:

  • avoid Xrays unless absolutely necessary as high radiation dose to gonads & then ensure not pregnant, and yield is not high unless major trauma or a compressive trauma such as landing on head or severe hyperflexion such as a MVA lap belt injury or fall from height resulting in an unstable Chance fracture
  • urinalysis
  • if pubertal amenorrhoeic female, consider imperforate hymen
  • if scoliosis:
    • 1. are legs equal length - palpate ASIS whilst standing - if not then compensatory scoliosis
    • 2. is it just postural - ie. it corrects on bending to touch toes
    • 3. otherwise, neuro exam, Xray whole spine & refer to paed. orthopaedics
  • if thoracic kyphosis, Xray Tx spine to demonstrate Scheuermann's disease & refer to paed. orthopaedics
  • if febrile, unwell with normal urinalysis, and spine tenderness, suspect osteomyelitis of spine.
  • if sacro-ileitis, check skin, nails for psoriasis, consider Xray for ankylosing spondylitis features, if male, ask about features of Reiter's
backpain_adol.txt · Last modified: 2016/12/20 06:23 by

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