Diskitis is an intervertebral disk space infection that does not cause associated vertebral osteomyelitis (see Chapter 117). The most common organism is Staphylococcus aureus. The infection can occur at any age but is more common in patients under 6 years of age.
Children may present with back pain, abdominal pain, pelvic pain, irritability, and refusal to walk or sit. Fever is an inconsistent symptom. The child typically holds the spine in a straight or stiff position, generally has a loss of lumbar lordosis due to paravertebral muscular spasm, and refuses to flex the lumbar spine. The white blood cell count is normal or elevated, but the ESR and CRP are usually high.
Radiographic findings vary according to the duration of symptoms before diagnosis. Anteroposterior, lateral, and oblique radiographs of the lumbar or thoracic spine will typically show a narrow disk space with irregularity of the adjacent vertebral body end plates. In early cases, bone scan or MRI may be helpful, because they will be positive before findings are noticeable on plain radiographs. MRI can also be used to differentiate between diskitis and the more serious condition of vertebral osteomyelitis.
Intravenous antibiotic therapy is the mainstay of treatment. Blood cultures may occasionally be positive and identify the infectious agent. Aspiration and needle biopsy are reserved for children who are not responding to empirical antibiotic treatment. Symptoms should resolve rapidly with antibiotics, but intravenous antibiotics should be continued for 1 to 2 weeks and be followed by 4 weeks of oral antibiotics. Pain control can be obtained with medications and temporary orthotic immobilization of the back.
The shoulder actually comprises four joints:Glenohumeral joint (commonly referred to as the shoulder
The glenohumeral joint has minimal geometric stability because the relatively small glenoid fossa articulates with the proportionately larger head of the humerus. The low level of intrinsic stability allows for a large range of motion. The rotator cuff muscles help give the glenohumeral joint more stability, but they need normal contact of the glenohumeral joint to be successful. The scapulothoracic movement also expands the range of motion of the shoulder, but like the glenohumeral joint, it requires strong, coordinated musculature to function efficiently.
Sprengel deformity is the congenital elevation of the scapula. There are varying degrees of severity; it is usually unilateral. There is restricted scapulothoracic motion (especially with abduction) so most of the shoulder motion is through the glenohumeral joint. There is usually associated hypoplasia of the parascapular muscles. Webbing of the neck and low posterior hairline can be associated problems. There is an association with congenital syndromes, such as Klippel-Feil anomaly, so a thorough history and examination are necessary. Mild forms with a cosmetic deformity and mild loss of shoulder motion do not need surgical correction. Severe forms may have a bony connection (omovertebral) between the scapula and lower cervical spine. Moderate and severe forms may need surgical repositioning of the scapula in early childhood to improve cosmesis and function.
Obstetric brachial plexus palsy is discussed in Section 11. Brachial plexopathy is an athletic injury, commonly referred to as a stinger or burner. The symptoms are often likened to a dead arm. There is pain (often burning), weakness, and numbness in a single upper extremity. There are three mechanisms of injury:Traction caused by lateral flexion of the neck away from the involved upper extremityDirect impact to the brachial plexus at Erb’s pointCompression caused by neck extension and rotation toward the involved extremity