Bone problems are a frequent complaint in adolescents. More common problems including fractures, posture issues and injuries are reviewed in other sections. Several other bone disorders including tumors, spondylolysis and spondylolisthesis and infection are discussed in this section.
Bone tumors
Fortunately malignant bone tumors are unusual in children and adolescents. The annual incidence of malignant bone tumors in this age group is 5.6 cases per million white children; the incidence is slightly lower in African-American children.
Osteosarcoma is the most common primary bone tumor in adolescents usually diagnosed in the second decade of life during the period of increased bone development. It is slightly more common in boys; about 1.5 boys are affected for each girl. This difference is thought to be due to the longer period of bone growth in boys. Osteosarcoma usually is found in the long bones including the upper part of the humerus, lower section of the femur and upper aspect of the tibia. The tumor spreads by metastasizing to the lungs and other bones.
Who is likely to develop osteosarcoma?
While it is very unlikely for any individual to be at risk for osteosarcoma, teens who have a history of radiation therapy or retinoblastoma may have a modestly increased risk. There may be a genetic predisposition to osteosarcoma in familial cancer syndromes including the Li-Fraumeni syndrome.
What are the symptoms of osteosarcoma?
Most teens with osteosarcoma present with bone pain and swelling over the tumor. The pain may awaken the teen at night. If the tumor has spread, there may be weight loss, fever and pallor. Occasionally a teen may develop a pathologic fracture through the area of the tumor. This type of fracture occurs secondary to weakness of the bone due to disease.
How is osteosarcoma evaluated?
A bone tumor should be suspected in any teen with persisting deep bone pain, swelling and an abnormal x-ray of the area. If osteosarcoma is suspected, the teen should be referred to a center that specializes in the care of bone tumors. A biopsy will be performed for pathological, molecular and biologic studies. An MRI of the tumor will likely be performed, as well as blood tests and imaging studies to detect lung and bone metastases.
How is osteosarcoma treated?
For teens with nonmetastatic osteosarcoma of an extremity, the five-year disease-free survival rate is sixty-five to seventy-five percent. The current treatment is to provide preoperative chemotherapy followed by surgery to remove the tumor. Some limbs can be saved, while other teens require amputation of the limb. Patients with lung metastases usually have a thoracotomy to remove tumors in the lungs. This is followed by chemotherapy postoperatively.
How is osteosarcoma prevented?
There is no prevention for osteosarcoma.
Benign bone tumors are more common than osteosarcoma. Many of these are diagnosed after the teen sustains a pathologic fracture. An osteochondroma, which is a bony outgrowth, develops from long bones particularly the femur, humerus and tibia. A unicameral bone cyst can occur at any age. These are fluid-filled collections that occur in the medullary canal of the bone and expand to the outer layer or cortex of the bone. The outer layer of the bone may be thinned, and this may lead to a pathologic fracture. An aneurysmal bone cyst is characterized by spaces in the bone filled with blood and fibrous tissue. Primarily seen in adolescents and children under age twenty years, there is a slightly increased prevalence in females.
Who is likely to develop benign bone tumors?
There is no particular group at increased risk for these tumors.
What are the symptoms of benign bone tumors?
There may be no symptoms from osteochondroma. The teen may feel a lump under the skin, but pain is usually not present. Most unicameral bone cysts have no symptoms, and come to the attention of the patient after a pathologic fracture. These fractures could occur after a relatively minor injury including throwing or catching a ball. An aneurysmal bone cyst usually has pain and swelling over the cyst. If the spine is involved there could be neurological symptoms including loss of some function.
How are benign bone tumors evaluated?
Referral to an orthopedic surgeon is usually needed in the initial states of evaluation. X-rays or MRI imaging is needed to evaluate these tumors.
How are benign bone tumors treated?
If the teen has discomfort or joint immobility from an osteochondroma, then removal by excision may be performed. Some adolescents seek excision of the tumor due to cosmetic concerns. A unicameral bone cyst may be treated by aspiration of the contents followed by injection of steroids into the cyst. Sometimes repeated injections, curettage and bone grafting are necessary to treat recurrences of the cyst. Aneurysmal bone cysts are treated by curettage and bone grafting or excision of the cyst.
How are benign bone tumors prevented?
There is no prevention.
Spondylolysis and spondylolisthesis
Significant low back pain in adolescents may be due to spondylolysis in up to ½ of adolescents. Those engaged in gymnastics are at increased risk. Spondylolysis refers to a crack or separation between the front and back of the vertebra at a section termed the pars interarticularis. The cause is unknown but is felt to be secondary to physical stressors. This occurs typically in a lumbar vertebra, usually number five. The crack allows the affected vertebra to slip onto the adjacent vertebra.
Who is likely to develop spondylolysis and spondylolisthesis?
About five percent of adolescents may develop this condition. Symptoms are more likely to develop in athletes who hyperextend their back including gymnasts. Dancers, ballet dancers and acrobats may be at increased risk for these conditions.
What are the symptoms of spondylolysis and spondylolisthesis?
Most teens with this condition develop back pain. The pain is usually worse with extension of the back, and it increases with activity and diminishes with rest.
How are spondylolysis and spondylolisthesis evaluated?
Initial x-rays may demonstrate spondylolysis and spondylolisthesis. If so, then referral to an orthopedic surgeon for treatment is usually indicated.
How are spondylolysis and spondylolisthesis treated?
For teens who have a modest amount of vertebral slippage without any symptoms, there may be no need to limit sports participation. However, gymnastics or other activities that involve extension of the back may cause pain. For those teens who have persisting pain and a more significant degree of slippage, then physical activities may to be curtained, physical therapy may be needed and a brace may be prescribed.
How are spondylolysis and spondylolisthesis prevented?
There is no prevention.
Osteomyelitis
Osteomyelitis is an infection of the bone that is not common in adolescents, but of great importance because of the potential to cause permanent disability. It is especially important if the growth plate of the bone is affected. Osteomyelitis is most commonly caused by Staphylococcus aureus, but other organisms including Streptococcus and Pseudomonas may be implicated. This type of infection may occur after a penetrating injury or less commonly after joint surgery or other orthopedic procedures. There also may be spread of bacteria through the bloodstream although this is much more common in younger children.
What is likely to develop osteomyelitis?
At least for younger children, boys are at higher risk than girls for bone infections by a factor of 2:1. This may be due to a predisposition of boys to injuries due to their lifestyle. There appears to be no particular predilection based on race.
What are the symptoms of osteomyelitis?
The first symptoms of the infection may be subtle. These include redness and swelling of the skin and soft tissues that are overlying the site of the infection. This may be followed by fever and increasing pain as well as fatigue and other constitutional symptoms.
How is osteomyelitis evaluated?
A clinician will probably order blood tests including a complete blood count and blood culture to look for the presence of bacterial infection. X-rays of the affected bone are usually ordered. It also may be necessary to remove some material from the bone by needle to test for the presence of infection.
Other diseases may also present with similar symptoms. These include leukemia, neuroblastoma and slipped capital femoral epiphysis. Arthritis may also have some symptoms in common with osteomyelitis.
How is osteomyelitis treated?
Optimal treatment involves the use of a team that consists of a primary care clinician, orthopedic surgeon and physiatrist. Antibiotic therapy is a mainstay in order to treat the infection. Hospitalization may be necessary in certain cases since the antibiotics are often given by vein at least for the first week. Following inpatient treatment, the teen is sent home on oral antibiotics. An orthopedic surgeon will assess the need for needle aspiration or surgery. A physiatrist will determine if physical therapy should be performed to prevent limitations that could develop from limited use of the affected area.
How is osteomyelitis prevented?
There is no prevention.
An increasingly recognized complication of eating disorders is osteopenia. This is a condition where a patient’s bone mineralization is decreased in comparison to normal patients. This is usually determined by a DEXA scan. Treatment for osteopenia includes weight gain, multivitamins, calcium and possible medication intervention through an approved medication trial. Women athletes who lose weight and their menstrual periods are also at particular risk for osteopenia.
Related topics:
Athletic injuries, back pain, bowed legs, exercise, foot injuries, growing pains, hip displacement, knee disorders, musculoskeletal disorders, osteoporosis, stress fractures
