How Common Are Bone Spurs in Young Athletes?

Patient Presentation
An 18-year-old female came to clinic after twisting her knee during her varsity soccer practice 3 days previously. She had planted her foot and then turned her body causing pain in the lateral and anterior area of the left knee. She had stopped practice and iced the area. She did not hear a popping sounds, nor felt the joint catch. She had pain with walking but was improving. She had a soccer tournament the following weekend and wanted to return to play. The past medical history showed previous muscle strains, and a right sided ankle sprain. She had been playing high-intensity soccer for many years.

The pertinent physical exam revealed a medium-build female with a mild gait abnormality when walking. She had mild tenderness near the lateral joint line but her collateral and cruciate ligament tests were normal. She had mild pain during the maneuvers but nothing significant.

The diagnosis of a left lateral ligamentous injury was made but because of the high level of participation a radiograph was taken. The radiologic evaluation of the knee showed no bony abnormalities other than a tiny right notch osteophyte. The patient had not had any problems with her knee previous so it was felt this was an incidental finding. She was counseled about working with her athletic trainer and returning to play when pain free.

Discussion
The terminology of abnormal calcification of soft tissues and uses of the terms is often muddied. Especially as the causes may be similar and multiple adjacent tissues may be involved.

  • An exostosis is an abnormal proliferation of bone from the joint. They can appear in various forms and in many locations.
  • An osteophyte is also known as a bone spur and is type of exostosis. Osteophytes are thought to be periosteal or synovial mesenchymal stems cells that become calcified. They usually have a more narrow or pointed projection from the joint. Osteophytes are a very common feature of osteoarthritis.
  • Enthesophytes are abnormal bony projections at the attachment of a tendon or ligament. These are often due to trauma and examples commonly occur at the knee or heel, such as Osgood Schlater disease.

Exostosis variants include:

  • Osteochrondroma – usually a solitary, non-tender, slow-growing mass in long bones (more commonly lower extremity). Radiographically they can be sessile or stalked in appearance.
    This is the most common skeletal tumor (10-15%). They occur especially during the bony growth period. Complications occur in about 4% of patients and include fractures, bony deformation, and compression causing neurovascular problems.
  • Hereditary multiple exostosis – an autosomal dominant disorder with multiple masses in all parts of the body except the head. They are very common in the lower extremity particularly the knee. Short stature may also be seen.
  • Trevor’s disease – usually affects the tarsal bones or epiphyses of long bones. More common in lower extremities and usually unilateral.
  • Nora’s lesion – also known as bizarre parosteal osteochondromatous proliferation seen in the hands and feet. Generally seen in adults.
  • Subungual exostosis – these occur in both the hands and feet with feet more commonly affected particularly the great toe. These are felt to be traumatically related and the bony projection comes from the nail bed. These are usually seen in teens and adults.

Normal variations or congenital anomalies can be mistaken for exostoses such as the supracondylar process of the humerus, os intermetarsale or even the bony projection within the central spinal canal that tethers and splits the spinal cord in half in diastematomyelia. Periosteal reactions can also appear similar to exostoses and include entities such as osteomyelitis, osteoid osteoma, or osteosarcoma. Myositis ossificans from trauma can cause calcification of the muscle but if deep can also show abnormal ossification of the periosteum.

Learning Point
Risk factors for osteophytes include age (older), body mass index (heavier), physical activity (heavy physical activity), diet (low amounts of various nutrients) and genetic factors.

Osteophytes or bone spurs are usually thought of in older people who have osteoarthritis. However they can occur in young people. A cross-sectional, case-controlled study of young adults (<18-36 years) found that being an athlete had a higher risk of radiographic evidence of osteophytes in the knee (odds-adjusted ratio = 2.8) and if a patient had anterior cruciate ligament surgery (odds adjusted ratio = 7.0). While this study isn’t representative of the general population, it does show that young athletes are at risk for development of osteophytes even at a young age. While this study didn’t find a difference in males and females overall for osteophytes, young female athletes are at higher risk for knee injuries particularly in sports with “cutting” type activities such as basketball or soccer.

Questions for Further Discussion
1. What are common benign bone tumors? A review can be found here
2. What is the long-term outcome of ACL repair? A review can be found here
3. What are the positive aspects of organized sports activities?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Bone Diseases and Osteoarthritis.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Richardson RR. Variants of exostosis of the bone in children. Semin Roentgenol. 2005;40(4):380-390. doi:10.1053/j.ro.2005.01.020

DaCambra MP, Gupta SK, Ferri-de-Barros F. Subungual exostosis of the toes: a systematic review. Clin Orthop Relat Res. 2014;472(4):1251-1259. doi:10.1007/s11999-013-3345-4

Roemer FW, Jarraya M, Niu J, Silva J-R, Frobell R, Guermazi A. Increased risk for radiographic osteoarthritis features in young active athletes: a cross-sectional matched case-control study. Osteoarthr Cartil. 2015;23(2):239-243. doi:10.1016/j.joca.2014.11.011

Nasr B, Albert B, David CH, Marques da Fonseca P, Badra A, Gouny P. Exostoses and vascular complications in the lower limbs: two case reports and review of the literature. Ann Vasc Surg. 2015;29(6):1315.e7-1315.e14. doi:10.1016/j.avsg.2015.02.020

Wong SHJ, Chiu KY, Yan CH. Review Article: Osteophytes. J Orthop Surg (Hong Kong). 2016;24(3):403-410. doi:10.1177/1602400327

Perez-Palma L, Manzanares-Cespedes MC, de Veciana EG. Subungual Exostosis Systematic Review and Meta-Analysis. J Am Podiatr Med Assoc. 2018;108(4):320-333. doi:10.7547/17-102

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What are Potential Problems Associated with Helicobacter pylori?

Patient Presentation
Two pediatricians were talking about the coincidence of each having a family who were concerned about the transmission and testing for H. pylori. Both families had young, asymptomatic children and in one family the mother was affected and in the other family the father was affected. Both parents were being given their initial treatment for H. pylori. Both pediatricians had independently read the recent guidelines for management and had concluded that the children in each family should not be tested currently but be monitored for possible problems.

Discussion
Helicobacter pylori (H. pylori) is a microaerophilis, spiral bacterium that is a prevalent human pathogen. How this infection affects individuals is different in adults and children. Overall seroprevalence rate in children world-wide was estimated to be ~33%, but this seroprevalence rate is decreasing in the developed world for both adults and children. It is acquired in childhood and can persist through colonization throughout life if untreated. Fortunately, it often is asymptomatic and generally does not cause serious disease in children.

Some serotyping data shows that within families children acquire it more often from mothers than from fathers.

Learning Point
H. pylori causes gastritis (chronic), peptic ulcer disease (PUD), gastric adenocarcinoma and MALT (mucosal-associated lymphoid tissue lymphoma) in adults. Many of the studies have been conducted in adults and extrapolating to children is not appropriate. Potential clinical problem may not be caused by H. pylori but rather may only be associated with it in children. Many of those listed below are certainly not specific to H. pylori.

  • PUD can cause upper abdominal pain and potential gastrointestinal bleeding but is not common in children. Testing is recommended if PUD is identified.
  • Functional abdominal pain – testing is not recommended
  • Iron deficiency anemia – testing is not recommended for initial investigation, but may be appropriate for refractory anemia
  • Chronic immune thrombocytopenic purpura – testing may be considered
  • Short stature and failure to thrive – testing is not recommended
  • Henoch-Schonlein purpura – testing is not recommended
  • Obstructive sleep apnea – testing is not recommended
  • Diabetes mellitus – testing is not recommended
  • Asthma/atopic dermatitis – testing is not recommended
  • Celiac disease (having H. pylori possibly has a protective effect)

Guidelines for management for children and adolescents from Europe and North America were published in 2017 (see To Learn More below). Testing of relatives with gastric cancer that were previously included in guidelines have been removed from this iteration. Test and treat strategy for children is not recommended as the clinical goal is to identify the cause of the upper abdominal pain and/or other symptoms rather than identifying H. pylori infection. Patients should have appropriate diagnostic testing (i.e. endoscopy with biopsy, urea breath hydrogen testing, stool antigen testing) with antimicrobial susceptibility testing to guide treatment. Even with biopsies, H. pylori can be an incidental finding. Treatment depends on age, antibiotic susceptibility testing and include antibiotics and proton pump inhibitors for 7-14 days depending on the protocol. Adherence to protocol has been shown to be a key to treatment success and more than 90% adherence is recommended. The main cause of treatment failure is clarithromycin resistance and non-adherence. Post treatment re-testing for treatment success or failure is recommended at least 4 weeks after treatment. There has been a vaccine trial in China with children. The efficacy rate was “…71% and 55% at 12 months and 3 years after vaccination.” One problem was “…that 20% of younger children in the study were not protected [from H. pylori].”

Questions for Further Discussion
1. How common are gastric ulcers? A review can be found here
2. What are the ROME criteria for functional abdominal pain? A review can be found here
3. What causes abdominal pain? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Helicobacter Pylori infections

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Jones NL, Koletzko S, Goodman K, et al. Joint ESPGHAN/NASPGHAN Guidelines for the Management of Helicobacter pylori in Children and Adolescents (Update 2016). J Pediatr Gastroenterol Nutr. 2017;64(6):991-1003. doi:10.1097/MPG.0000000000001594

Kalach N, Bontems P, Raymond J. Helicobacter pylori infection in children. Helicobacter. 2017;22 Suppl 1. doi:10.1111/hel.12414

Kotilea K, Kalach N, Homan M, Bontems P. Helicobacter pylori Infection in Pediatric Patients: Update on Diagnosis and Eradication Strategies. Paediatr Drugs. 2018;20(4):337-351. doi:10.1007/s40272-018-0296-y

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Distinguishes Childhood Masturbation from Other Potential Diagnostic Entities?

Patient Presentation
A 3-year-old female came to clinic for followup after seeing an urgent care provider for possible urinary tract infection 3 days previously. The parent had complained that the child had been putting her hands in her genital area more frequently or “holding herself.” The provider had noticed some vulvar and vaginal irritation and had started her on antibiotics for possible urinary tract infection. Her mother had continued to see the behavior and was concerned. During the visit the child sat on a child-sized chair and would put her hand in her genital area and did some rocking back and forth. The mother said that this was the behavior she was worried about and had also videotaped it. The video showed the child at a table during a meal performing the same behavior. The pediatrician noted that the child did not seem distressed or worried when performing the behavior. The mother agreed and said that she seemed calmer. The mother noted that she was always aware/awake during the episodes as well and would stop the behavior her name was called out, a hand was put on her arm or otherwise distracted. The mother denied any concerns for child maltreatment. The past medical history was negative for any renal problems and the family history was negative for genital or renal problems. The review of systems showed no specific urinary frequency or dysuria, fever, or malodorous urine or vaginal discharge. Stooling was normal.

The pertinent physical exam showed a healthy female with normal vital signs and growth parameters. She had some mild vaginal irritation. The hymen was intact and no other lesions including bruises or rashes were noted in the genital area, abdomen or legs.

The diagnosis of vaginal irritation and childhood masturbation was made. “It can be difficult to tell if there was irritation which started her touching herself which then continued, or if she was touching herself which caused some irritation,” the pediatrician explained. “Either way, improving her hygiene will help the irritation,” she explained. The pediatrician also went on to explain the normal self exploration and stimulation that young children perform, and how the mother could explain to the child that this is normal but people don’t do this in public. The antibiotics were also stopped.

Discussion
Childhood masturbation (CM) is defined as self-stimulation of the genitalia in a prepubescent child.” CM is normal sexual behavior and can be noted at all ages including infancy. It becomes very common after puberty. It is one of the most common sexual behaviors. CM can resemble the same adult masturbatory activity including flushing, sweating, muscular contracting and breath holding or tachypnea. However in younger children these changes are not recognized, are interpreted differently or infants and young children may also have different activities. “…(1)stereotyped posturing of the lower extremities and/or mechanical pressure on the perineum or suprapubic area, (2) associated intermittent (quiet) grunting, irregular breathing, facial flushing and diaphoresis, (3) variable duration of the episode (lasting from a few seconds to several hours) and variable frequencies of episodes (range form once in a while to almost continuously), (4) no alteration of consciousness, (5) cessation with distraction, (6) the episodes cannot be explained by abnormalities on physical and other diagnostic (technical, laboratory) examinations.”

In young children CM is part of their curiosity of the world and in this case in exploring their own and other’s bodies (i.e. viewing genitalia) and in discovering pleasurable sensations. Sexual behaviors in puberty and post-pubertal youth and adults is more intentional with sexual arousal and/or orgasm as goals. Some parents especially worry that the behaviors are abnormal or excessive. There is no specific definition of normal or excessive and these are left to interpretation. Normative behavior is based on cultural, group or societal expectations with the idea that they support health or at least do not hinder it. For example, as children mature and reach school age, they are less likely to do CM activities in public as they have learned that certain behaviors are not acceptable in public. If the CM causes distress for the child, is outside the developmental range for the child’s age, or there are concerns for child maltreatment, or there are multiple behavioral problems, then simple normative CM may not be the only diagnosis to consider. In children with psychological stress, CM can be a regulating mechanism. It can also be a stimulatory activity for children with severe lack of external stimulation in their lives.

CM can occur in children who are victims of abuse. No specific behavior is pathognomonic of abuse and for many victims there are no symptoms at all. However sexualized behavior is one of the common symptoms of child abuse. Examples of inappropriate sexual behaviors include:

  • Putting mouth on breasts or genitals
  • Masturbating with objects
  • Inserting objects into vagina/anus
  • Inserting tongue while kissing
  • Imitating sexual sounds
  • Undressing with other people
  • Wanting to participate in sexual acts or imitating sexual intercourse including with dolls or toys
  • Wanting to see inappropriate video or television

Parental and societal views of CM are different and should be respected. Discussing normal growth and development of the child including their own sexuality usually normalizes the behavior and understanding for families. Based on the family’s beliefs, the child’s age and education, the child (and family) can be educated about their sexuality and taught to masturbate in a private location similar to other private activities such as elimination. Some people have strong feelings about the term masturbation and alternatives include self-stimulation or gratification.

Reasons that CM comes to attention can be attributing it to abdominal pain, seizures, dystonia, movement disorders, urinary tract infections, vaginal discharge or vaginitis, diaper rash, phimosis, balanitis, pinworms, eczema and lichen sclerosus. Sometimes it can be difficult to tell if the CM caused genital trauma which in turn leads to the child complaining of pain or holding or rubbing their genitals, or if it is the other way around. Videotaping the behavior can help with diagnosis as the behavior can be reviewed by the clinician and family together.

Learning Point
The key element which distinguishes CM from other differential diagnostic entities is that it ceases with distraction. Children are awake during the behavior.

Questions for Further Discussion
1. Describe common sexual behaviors in young children. A review can be found here
2. What is differential diagnosis of vulvovaginitis? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sexual Health and Child Behavior Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Mallants C, Casteels K. Practical approach to childhood masturbation – a review. European Journal of Pediatrics. 2008;167(10):1111-1117. doi:10.1007/s00431-008-0766-2

Strachan E, Staples B. Masturbation. Pediatr Rev. 2012;33(4):190-191. doi:10.1542/pir.33-4-190

Wilkinson B, John RM. Understanding Masturbation in the Pediatric Patient. J Pediatr Health Care. 2018;32(6):639-643. doi:10.1016/j.pedhc.2018.05.001

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Are the Oral Equivalents of Milia of the Face?

Patient Presentation
A 2-week-old male came to clinic for his health supervision visit. The family had many first-time parent questions and were adapting to the infant and his needs. The past medical history showed a term male born without difficulties.

The pertinent physical exam he was 3.645 kg, and was past birth weight of 3.380 kg. His length and head circumference were 75%. On physical examination he showed a few lesions of erythema toxicum on his cheeks. On his alveolar ridge he had some fluid-filled inclusions on the palate mid-line and posterior. The rest of his examination was normal.

The diagnosis of a healthy male with erythema toxicum and Epstein’s pearls was made. The family had not noticed the Epstein’s pearls and became concerned. The physician noted how these were a normal variation and would resolve as would the erythema toxicum.

Discussion
Milia are small, usually < or = to 3 mm, benign, white, superficial keratinous cysts. They can arise spontaneously (are defined as primary) or because of other conditions (are defined as secondary). Milia can occur at any age but are common in adult patients. However, primary care providers for neonates see it commonly as well as congenital milia occurs in 40-50% of newborns.

Milia occurs more often on the face (especially the nose), but also scalp, neck/upper parts of the trunk and upper extremities. They usually resolve spontaneously in a few weeks, but patient and parent preference may dictate treatment. Treatment options include simple extraction by nicking and lateral pressure to extract the keratin. Other options include topical retinoids, electrocautery, or electrodissection. The differential diagnosis for congenital milia usually includes molluscum contagiosum which has a central umbilication, miliaria crystallinia which has pin-point clear vesicles, sebaceous hyperplasia which is usually more yellow than white in color, transient neonatal pustular melanosis where the vesicles present at birth rupture in a couple of days and heal with hyperpigmentation or candidal or bacterial lesions.

Various images of milia can be seen in “To Learn More” below.

Benign primary milia in children and adults occur spontaneously but are more likely to involve the eyelids and cheeks.

Other milia variations include:

  • Milia en plaque which is rare but has an erythematous plaque lesion with multiple milia lesions contained within it.
  • Nodular grouped milia are also uncommon and are similar but have a nodule with multiple milia contained within it.
  • Generalized milia with nevus depigmentosus where multiple milia are found in the area of hypopigmentation.
  • There are multiple genetic syndromes which also include milia as part of their syndrome. For example hereditary vitamin D dependent rickets, or basal cell nervus syndrome.
  • Secondary milia are localized milia but associated with disease, trauma or medications. They can resolve spontaneously but are less likely.

Learning Point
Oral equivalents of congenital milia are seen with the oral inclusion cysts called Epstein’s pearls on the palate near the midline raphe or Bohn’s nodules on the alveolar ridge and lateral palate.

Questions for Further Discussion

1. What are some options for oral thrush treatment? A review can be found here
2. What causes leukoplakia? A review can be found here
3. What are some of the skills dentists bring to overall pediatric health?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Common Infant and Newborn Problems.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Berk DR, Bayliss SJ. Milia: a review and classification. J Am Acad Dermatol. 2008;59(6):1050-1063. doi:10.1016/j.jaad.2008.07.034

Kansal NK, Agarwal S. Neonatal milia. Indian Pediatr. 2015;52(8):723-724.

Wang AR, Bercovitch L. Congenital Milia En Plaque. Pediatr Dermatol. 2016;33(4):e258-259. doi:10.1111/pde.12888

Zaouak A, Chamli A, Ben Jennet S, Hammami H, Fenniche S. Milia en plaque. La Presse Medicale. 2019;48(12):1589-1590. doi:10.1016/j.lpm.2019.09.001

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa