Inspection of the back should assess for normal alignment (e.g., abnormal kyphosis or lordosis), signs of local injury or rash In spondylolysis, there is excessive lumbar lordosis With Scheuermann kyphosis there is a fixed thoracic or lumbar kyphosis unaffected by patient position which is best observed from the side during trunk flexion It is noteworthy that idiopathic scoliosis typically does not cause back pain, so scoliosis found on inspection of a child with back pain may suggest a concomitant finding Palpation of the spine can isolate areas of tenderness Fractures, vertebral osteomyelitis, and discitis typically have tenderness over the affected areas, while muscular back pain may have tenderness to the paraspinal muscles Ranging the back can elicit pain with certain maneuvers Discitis will have pain with trunk flexion, as may certain spinal cord tumors Children with spondylolysis may have pain with hyperextension of the back A positive straight leg raise test suggests radiculopathy, possibly secondary to disc herniation or spondylolisthesis With sacroiliitis, there is a positive FABER (Flexion, Abduction, External Rotation) test With this maneuver, the supine patient’s leg is flexed at the knee while the ipsilateral hip is abducted and externally rotated so that the ankle rests over the contralateral knee Applying force on the flexed knee will produce pain at the contralateral, inflamed sacroiliac (SI) joint The physical examination should not be limited to the back and spine Flank tenderness suggests lateral muscle strain, renal inflammation, or infection A careful abdominal examination may reveal an intra-abdominal infection or mass A pelvic examination may identify an imperforate hymen or cervical motion tenderness A broader examination may reveal signs concerning for pneumonia, influenza, or other etiologies of back pain Table 54.2 lists historical and physical examination “red flags” for back pain that may suggest serious underlying pathology Figure 54.1 provides an algorithmic approach for diagnosis of etiologies of back pain in children FIGURE 54.1 Back pain algorithm Laboratory studies Laboratory investigation is not routinely required and should be directed by the history and physical examination A complete blood count, C-reactive protein, and erythrocyte sedimentation rate are indicated if there is suspicion for infectious, neoplastic, or rheumatologic process Blood cultures should be obtained if there is concern for infection Antinuclear antibody, HLAB27 and rheumatoid factor may help in determination of a rheumatologic process and a basic metabolic panel, liver tests, lactose dehydrogenase, and uric acid should be added if neoplasia is a concern If history and physical examination are suggestive of other etiologies, additional tests (e.g., urinalysis and urine culture, pancreatic enzymes, liver tests) may be indicated Imaging Imaging for evaluation of back pain should only be utilized if a specific disease process is suspected and confirmation on imaging would alter management Plain film radiographs are the starting point for most conditions that present with back pain which require imaging Anterior–posterior and lateral views of the spine will diagnose fractures, bony tumors, scoliosis, kyphosis, and lordosis Oblique views provide superior views of the pars interarticularis and can diagnose spondylolysis or spondylolisthesis However, given the low sensitivity of plain films, advanced imaging is often indicated if clinical suspicion is high Computed tomography is indicated for evaluation of acute, high-force trauma to the back, otherwise, MRI is often the study of choice The urgency of obtaining an MRI depends on the type and severity of symptoms, the presence of neurologic findings on examination, and concerning labs or plain films MRI is extremely sensitive for spinal cord lesions, osteomyelitis, discitis, and vertebral fractures Back pain in children deserves a careful and comprehensive evaluation Management of back pain in children and adolescents depends upon the specific etiology Nonsteroidal anti-inflammatory drugs are first-line treatment of nonspecific low back pain Because back pain is a relatively uncommon chief complaint and there is potential for significant pathology, close follow-up of patients, especially younger children, presenting with back pain should be ensured Suggested Readings and Key References Brooks TM, Friedman LM, Silvis RM, et al Back pain in a pediatric emergency department: etiology and evaluation Pediatr Emerg Care 2018;34(1):e1–e6 MacDonald J, Stuart E, Rodenberg R Musculoskeletal low back pain in schoolaged children: a review JAMA Pediatr 2017;171(3):280–287 Maher C, Underwood M, Buchbinder R Non-specific low back pain Lancet 2017;389(10070):736–747 Nahle IS, Hamam MS, Masrouha KZ, et al Back pain: a puzzle in children J Paediatr Child Health 2016;52(8):802–808 CHAPTER 55 ■ PAIN: CHEST ROBYN L BYER INTRODUCTION The complaint of chest pain rarely represents a life-threatening emergency in children, in contrast to the same complaint in adults Although heart disease is an uncommon source of chest pain in children, the fear of a cardiac origin for the pain may evoke anxiety in the child or in the parents There are a wide variety of etiologies for chest pain including diseases of the respiratory, cardiac, gastrointestinal (GI), neurologic, psychiatric, and musculoskeletal systems; however, it is most commonly due to idiopathic noncardiac origins Chest pain accounts for approximately 0.6% of all pediatric emergency department (ED) visits and affects boys and girls equally Clinicians need to take a careful approach to the patient even in the pediatric setting This chapter first briefly reviews the pathophysiology of chest pain, then outlines the differential diagnosis in children, and finally presents the evaluation, as appropriate in the ED PATHOPHYSIOLOGY To understand the possible origins of chest pain or discomfort, it is important to review how this sensation is transmitted Musculoskeletal pain is produced by irritation of tissues and is transmitted through the sensory nerves The stimulus is carried through the nerve in the dermatomal or intercostal distribution to the dorsal root ganglia, up the spinal afferents, and into the central nervous system (CNS) This local, peripheral sharp pain can also be produced by primary dorsal root irritation in the spine Because of overlap of nerve distribution, pain may be sensed in locations distal to the irritation For example, the third and fourth cervical nerves evoke pain as far caudally as the nipple line of the chest Tracheobronchial pain is transmitted by vagal afferents in the large bronchi and trachea to fibers in the cervical spinal column Dull, aching, or sharp pain is felt in the anterior chest or neck The irritation or sensation of cough is transmitted in a similar fashion Pleural pain arises in the pain-sensitive parietal pleura and then travels through the intercostal nerves in the chest wall, giving rise to sharp, welllocalized pain The visceral pleura is insensitive to pain The intercostal or phrenic nerves transmit diaphragmatic pain Peripheral diaphragmatic irritation may cause local chest wall pain because of the intercostal innervation Central ... approximately 0.6% of all pediatric emergency department (ED) visits and affects boys and girls equally Clinicians need to take a careful approach to the patient even in the pediatric setting This... Suggested Readings and Key References Brooks TM, Friedman LM, Silvis RM, et al Back pain in a pediatric emergency department: etiology and evaluation Pediatr Emerg Care 2018;34(1):e1–e6 MacDonald... CHEST ROBYN L BYER INTRODUCTION The complaint of chest pain rarely represents a life-threatening emergency in children, in contrast to the same complaint in adults Although heart disease is an