Pain Syndromes in Childhood Flashcards
Headache
Most common recurrent pain syndrome in children
Average onset for headaches is 7 years old
Migraine
Migraines must have occured at least 5 times prior
Each episode lasts 1-72 hours without an identifiable cause
Generally a positive family history of migraines
The pain is associated with nausea, vomiting, photophobia, or photophobia
Must meet 2 of the following:
- Pain on one side
- Pulsating/throbbing
- Moderate to severe intensity
- Increasing severity with activity
Basilar artery migraine
occurs more commonly in adolescent girls
presents with vertigo, syncope, visual alterations, and dysarthria
When to get CT/MRI in child with headache
Recent school failure or behavioral change
Change in type of headache
Recent onset of severe headache
Abnormal neurological sign
Fall off in growth
Headache that awakens a child from sleep
Early morning headache with increase in frequency and severity
Headache with focal seizure
Migraine headache, followed by seizure
Focal neurologic findings
Tension Headache
Tension headaches are the most common cause of headaches
Caused by muscle contraction
Tends to be more severe as the day goes on
Pressing, dull, tightness that is described as a band around the head
Pain is bilateral
Organic Headache
May be caused by structural abnormalities, metabolic disease, or infectious etiologies
Common Characteristics:
- Sleep related headaches
- nocturnal awakening from headache
- pain worse by cough micturition or defecation,
- recurrent and localized headache
- lack of response to medical therapy
- pulsatile tinnitus
Cluster Headaches
Occurs up to several times per day for the a few weeks before disappearing
Headaches occur at the same time each day
Pain is unilateral and retro or periorbital
May get ipsilateral lacrimation, eye redness, and nasal congestion
Children tend to be restless during attacks
Common in children ages 10-20 years old
Responds to treatment with oxygen: 6L/min x 15 mins-inactivates the trigeminocervical complex
Prophylactic treatment: Verapamil
Chronic Headaches
Defined as headaches that is present for more than 15 days a month for more than 3 months without any identifiable pathology Risk factors:
- Females
- major depression
- medication overuse
Basilar Skull Fracture
associated with CSF leak and cranial nerve damage
See Raccoon eyes, Battle sign, Hemotympanum
Temporal bone fracture
Bleeding from external auditory canal, CSF from nose, hearing loss, and facial paralysis
When to get a head CT in head traumas
History of LOC for >1minute
Seizure after event
Persistent/progressive vomiting
Depressed mental status
Focal neurological signs
Signs of skull fracture: battle sign, raccoon eyes, cranial nerve palsies Irritability
Bulging fontanel
Recurrent abdominal pain
At least 3 times in 3 or more months
Peak incidence of abdominal pain is 7-10 years old in girls
Not associated with eating or defecation
Stress can all influence the rapidity and duration of the pain
Pain may affect daily living but growth and development are normal
Abdominal pain does not wake child up from sleep
Generally in the periumbilical region
Only 5% of children with recurrent abdominal pain have true organic etiology
Irritable Bowel Syndrome
History of change in stool frequency or consistency-diarrhea alternating with constipation
Relief of pain after defection
Benign limp pain
Bening nocturnal pains of childhood
Most common recurrent musculoskeletal problem in children
Bilateral Deep aching pain in the muscles of the legs
Pain occurs late in the day or middle of the night and resolves by morning
usually awakens child from sleep
No morning symptoms
Not associated with limping or mobility problems
No joint involvement or inflammation
Treatment: disappears by 13 years of age
Osteoid osteoma
Benign lesion that produces prostaglandins
Severe nighttime pain in the proximal femur or tibia (involvement of long bones)
Responds to salicylates and NSAIDS but not acetaminophen
X-Ray reveals a sharp round or oval lesion
Osgood-Schlatter disease
Repetitive stress injury to the patellar tendon at its insertion into the tibial tubercle
Most common in children 10-15 years
Swollen tibial tubercle
See fragmentary ossification of the tibial tubercle on X-Ray
Transient synovitis
Pain, limp, and limitation of motion at the hip
History of upper respiratory infection
Patients appear nontoxic but may refuse to walk
Septic Arthritis
Lack of weight bearing
Fever
Elevated CRP and ESR
Elevated WBC
Aspiration of joint necessary
May result in destruction of a joint if left untreated
Legg-Calve-Perthes disease
Partial or complete idiopathic avascular necrosis of the femoral head
Boy between 4 and 8 years old
Refer to orthopedist
Limping for 3-6 weeks, aching in the leg or thigh
X Ray shows misshapen appearance of the left femoral head
TX: bracing for 12-18 months, bed rest, and traction for months
Slipped Capital Femoral Epiphysis
Slipping of the epiphysis off the metaphysis
Obese adolescent
TX: Surgery
Nursemaid’s Elbow/Radial Head Subluxation
Girls more affected than boys
Usually ages 1-4 years, peaks at 2-3 years of age
Sudden traction on extended, pronated arm, annular ligament moved from radial head and becomes trapped
Affected arm position: arm held close to body, elbow flexed, forearm pronated, supination is restricted, non-tender, non-swollen elbow
TX: Reduction: apply pressure on the radial head, grasp wrist and apply slight traction, supinate wrist while flexing elbow to 90 degrees
Developmental Dysplasia of the Hip
Disruption of contact between the proximal femur and acetabulum
Barlow: sign of exit
Ortolani test: sign of relocation
Risk factors: females, positive family history, and breech presentation
Ultrasound of joint space: Preferred if infants are less than 6 months
X Ray: after 8 months of age
TX: Pavlik Harness
Sprains
Injury to ligament around a joint
Tenderness with swelling and bruising
TX: Rest, Ice, Compression, and Elevation
Grades of Fractures
Type 1: epiphysis slips or separates from metaphysis
Type 2: metaphyseal bone separates with the epiphysis
Good prognosis, growth disturbances are uncommon, requires immobilization with cast
Type 3: Fracture through epiphysis extending to epiphyseal plate
Type 4: fracture that extends from the articular surface
Orthopedic consult, growth disturbance and functional impairment more likely
Type 4: crush injury to the epiphysis
Poor prognosis due to disruption of blood supply to epiphysis
Greenstick Fracture
Uncommon in children
Incomplete fracture
Torus (buckle) Fracture
Buckle of the metaphysis
Most common in the distal radial metaphysis
Heals in 3 weeks of immobilization
Spiral Fracture
Fracture that has curvilinear coarse
Generally found in the tibia
Clavicular Fracture
History of falling on shoulder, blunt trauma, or difficult vaginal delivery
Generally affects the middle and lateral portion of the clavicle
Child cannot lift arm due to pain
May see skin tenting
TX: slight or figure 8-clavicle strap for 4-6 weeks
Congenital Torticollis
Injury to sternocleidomastoid muscle
Chin rotated towards unaffected side
May feel palpable mass on the affected side
TX: stretching exercises
Distal Humerus/Elbow Fracture
Supracondylar fracture most commonly occurs after fall on outstretched hand or elbow
Has a high risk of complication
Evaluate for damage to the brachial artery, median nerve, or radial nerve
Compartment syndrome
Most common in tibial and supracondylar fractures
Pain is out of proportion to the fracture and remote to the fracture
Acromioclavicular separation
Occurs most commonly in adolescents
Generally results in direct blow to the shoulder
Tenderness over the AC joint
Should dislocation
Occurs in adolescents
Abducted, externally rotated shoulder is pushed posterior during contact sports
Swelling and deformity occurs over the shoulder anteriorly
Traction and counter traction can replace the shoulder
Immobilize with sling and refer to orthopedics because of high rate of recurrence
Scoliosis
More common in girls
Refer to orthopedics if the curve is 10 degrees or greater
