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Pediatric orthopedics is a unique area of pediatric emergency medicine as children are not “little adults.” The growth process of infants, children, and adolescents differentiates them from adults. Whether treating congenital, developmental, or injury-related problems in children, the constant change in structure and size of the skeletal system determines the plan of treatment. It is important to become familiar with the different appearance of growth plates, ossification centers, and appearance of bones at the various stages of development. This chapter focuses on non-traumatic orthopedic disorders encountered in the emergency department.



Torticollis, or wryneck, is stiff neck associated with muscle spasm in previously normal children. There are congenital causes but discussion will focus on acquired muscular torticollis, which is often seen in the emergency department. Most common symptoms are neck muscle pain, and inability to turn the head, holding the head in an awkward position with a slight chin tilt. The sternocleidomastoid and trapezius muscles are usually involved. Sleeping on the side, drafts (sleeping under a fan), and colds are commonly described historical factors but often there are no specific causes. The neck is usually “stiff” and pain is elicited with movement of the head. Patient will have complaint of pain with turning the head toward the side of the spasm. There is limited published data on the best treatment in the pediatric population; however, there are options. Muscle relaxers are often used in adults, but in children diazepam is a good medication choice because dose can be weight based. Nonsteroidal anti-inflammatory agents (NSAIDs) or narcotic pain medications may also be of benefit to alleviate discomfort. Physical ­therapists may advise heat or ultrasound (US) therapy. Patients and parents can be reassured that torticollis is usually a self-limiting process that will resolve in 1-4 weeks.

The immediate or life-threatening associated conditions could be atlantoaxial rotary subluxation, which is secondary to trauma. Posterior fossa tumors can cause torticollis and further investigation may be necessary if this is suspected. Infections in the posterior pharynx such as retropharyngeal abscess may also present with torticollis. A reported history of fever, sore throat, or difficulty swallowing may be an indication of a more serious etiology. Grisel syndrome, subluxation of the upper cervical joints can be a major cause. In neonates, a tightening and shortening of one sternomastoid muscle results in torticollis. Usually at 3 weeks of age, a visible palpable swelling develops, known as sternomastoid tumor. Treatment with physical therapy is often initiated.

Diagnostic testing such as cervical spine radiographs may need to be obtained to rule out bony abnormalities. Magnetic resonance imaging (MRI) should be considered if there is concern for structural problems or an infectious soft tissue process.


There are a number of open growth plates ...

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