I LEG PAIN II LIMP LEG PAIN Possible

I LEG PAIN II LIMP

LEG PAIN Possible causes for the kind of leg pain that often is referred to as “growing pains” Differentiation from “growing pains” by careful evaluation: history, physical examination (pain location, systemic symptoms) and few laboratory studies (X-rays, blood count, ESR) 2

LEG PAIN I Idiopathic leg pain (“Growing pains”) II Trauma III Leukemia & lymphoma IV Bone tumors V Infection & inflammation VI Miscellaneous 3

LEG PAIN: PAIN Idiopathic leg pains (1) 10 -20% of children may complain vague leg pain on a recurrent basis sometimes in association with headaches and abdominal pains 4

LEG PAIN: PAIN Pain Idiopathic leg pains (2) ׳ usually intermittent, bilateral, deep in legs ׳ commonly: thigh or leg ׳ joint pain: rare, points to other diagnosis!! ׳ may occur at any time, typically only at night (when child falling asleep or actually waking up) ׳ last about 1 hour ׳ may respond to rubbing, heat or analgesics ׳ systemic signs and symptoms: absent ׳ X-ray and ESR: normal 5

LEG PAIN: PAIN Idiopathic leg pains (3) - still to be determined - not due to “growth” ! Etiology - excessive exercise, trauma - hidden food allergy, emotional factors have been suggested 6

LEG PAIN: PAIN Trauma (1) most common cause superficial clues: bruises, swelling may be history of an episode of physical trauma 7

LEG PAIN: PAIN Trauma (2) muscle or bone bruises fractures pathological fractures muscle injections 8

LEG PAIN: PAIN Bone Tumors (1) Malignant - pain: persistent, increasing severity Benign tumors - more likely to be painless unless associated with pathological fracture or mechanical difficulties. Exceptions: Osteoid Osteoma Benign Osteoblastoma Eosinophilic Granuloma Metastatic tumors - more common: Neuroblastoma 9

LEG PAIN: PAIN Bone Tumors (2) ROENTGENOGRAMS SHOULD BE OBTAINED IN ANY CHILD COMPLAINING OF LOCALIZED BONE PAIN 10

LEG PAIN: PAIN Infection & Inflammation Osteomyelitis: localized, tenderness, swelling not always with systemic signs Bone scan !! Myositis: A. pyogenic infection B. myositis as a result of a systemic infection *Calf tenderness in influenza Tuberculosis: Limb pain without systemic symptoms ! Syphilis: periostitis - severe pain, pseudoparalysis (in cong. infection) Trichinosis: severe muscle pain, fever, periorbital edema, eosinophilia. 11

LEG PAIN: PAIN Shin splints Scurvy Miscellaneous Causes (1) (ant. & post. compartment synd. ): hypertrophy, swelling of muscle cramping pain on sudden resumption of excessive exercise Subperiosteal hemorrhages tenderness in limbs Hypervitaminosis A - bony pain, symptoms of increased cranial pressure 12

LEG PAIN: PAIN Miscellaneous Causes (2) Caffey Disease - Infantile Cortical Hyperostosis usually onset before 6 m. Sickle-Cell Disease - black child, painful extremities and anemic Gaucher Disease - may suggest osteomyelitis ! severe pain, tenderness, swelling, erythema, heat Melorheostosis - rare, longitudinal thickening of shaft of long bone, usually one limb; pain: severe, skin-tense, shiny, indurated 13

LEG PAIN: PAIN Miscellaneous Causes (3) Engelmann Dis. (Diaphyseal Dysplasia) rare, symmetric enlargement sclerosis of the shafts of major long bone and skull; difficult walking - limb pain Multiple Epiphyseal Dysplasia painful joints, enlarged in size; hips, knees or ankles: restriction in mobility, back pain: common, waddling gait Stickler Syn. (Hereditary Artho-ophthalmopathy) autosomal dominant, marfanoid habitus, large joints, hyperextensible knees, elbows and fingers, painful joints, morning stiffness, cong. myopia, conductive hearing loss 14

LIMP fairly straightforward in most children a thorough history, physical examination usually reveals the origin type of gait responsible for limp should be observed A. - by having the child walk unencumbered by clothing in the hallway B. - gait may suggest a foot, knee or hip problem 1

LIMP systemic symptoms indicate a more complex problem than simple trauma careful palpation of extremities: changes in temperature, coloration, swelling all joints put through range of motion 2

LIMP Painful causes Non-painful causes 3

LIMP Painful Causes I Trauma IV Aseptic necrosis & Osteochondritis II Inflammatory V Neoplasms III Infections VI Hematologic 4

LIMP - Painful: Trauma (1) local superficial lesions: skin irritation (tight shoe!!); lacerations or F. B. in foot, plantar warts ligamentous strains & sprains: ankle & knee injuries: common; may mimic fractures; joint swollen and sometimes bruised tendon disorders Achilles tendinitis: sudden acute pain, pain on palpation, but strong plantar flexion Achilles tendon rupture : lack of forceful plantar flexion 5

LIMP - Painful: Trauma (2) muscle bruising: history of trauma, purpura of skin; tenderness of affected muscle fractures must be considered in any painful limp!! PALPATION stress fractures: in joggers & athletes; pain: not severe toddler’s fracture: undisplaced, often spiral; radiology: may be normal early, typically tibia 6

LIMP - Painful: Trauma (3) child abuse: may be muscle bruising, sprains or fractures; history does not fit the injury, evidence of abuse: present infection: typically in toddlers after DPT booster, gluteal injections may irritate the sciatic nerve, thigh injections subluxation of patella: adolescent girls - commonly affected; suddenly knee gives away, joint swelling 7

LIMP - Painful: Inflammatory Conditions (1) toxic (transient) synovitis: hip - most common; may follow trauma or viral infection, fever; systemic signs - usually absent; painful abduction and internal rotation; predisposes to Perthes disease ? ? acute rheumatic fever: migratory joint pain or swelling, Jones criteria; pain is usually out of proportion to findings juvenile rheumatoid arthritis: different presentations, one or more joints, diagnosis by exclusion; pain: usually not severe! 8

LIMP - Painful: Inflammatory Conditions (2) systemic lupus erythematosus: arthritis, arthralgias and muscle weakness - common, other clues ! polyartheritis nodosa: diffuse symptoms; vasculitis dermatomyositis: proximal more than distal weakness, pain on muscle palpation, erythematous scaling papules over elbows, knees and knuckles Henoch-Schonlein Purpura: petechial or purpuric rash, abdominal pain, arthritis, nephritis, tissue swelling 9

LIMP - Painful: Inflammatory Conditions (3) serum sickness: urticaria, arthralgias or arthritis, fever and lymphoadenopathy; commonly associated with drug use ulcerative colitis, regional enteritis: arthritis, arthralgias lupoid hepatitis: arthritis or arthralgia with jaundice; hepatosplenomegaly - common 10

LIMP - Painful: Infections (1) osteomyelitis: localized pain, fever, ESR; may mimic septic arthritis: onset usually acute, generally monoarticular, very painful; gonococcal arthritis - may be migratory acute myositis: follows a viral illness (usually influenza); severe calves pain; CPK. pyomyositis: uncommon; localized muscle infection 11

LIMP - Painful: Infections (2) disc infection: back pain, hip referred pain; child may refuse to walk epidural abscess: extreme back pain, sensory changes in lower extremities acute appendicitis: psoas irritation may alter gait retroperitoneal masses: infection or inflammation, may be referred to hip; palpate for abdominal masses acute iliac adenitis: suppuration of lymph nodes; irritates hip capsule - limp; careful palpation along the ilium 12

LIMP - Painful: Aseptic necrosis & Osteochondritis (1) Perthes dis. : femoral epiphysis; boys - 4 to 8 y. ; may be totally asymptomatic Osgood-Schlatter dis. : painful tibial tuberosity, limping after heavy exercise; boys - 11 to 15 y. Freiberg dis. : head of 2 nd metatarsus, pain on palpation; girls - 12 to 15 y. Kohler dis. : tarsal navicular, mild limp; boys - 3 to 6 y. 13

LIMP - Painful: Aseptic necrosis & Osteochondritis (2) Sever’s dis. : calcaneal apophysitis, pain on heel palpation; primarily boys 8 to 12 y. Osteochondritis dissecans: knee - most common; history of joint locking and intermittent swelling Chondromalacia patella: pain - worse after exercise Larsen-Johansson dis. : pain & tenderness over lower pole of patella; swelling of adjacent soft tissue; boys - 10 to 14 y. ; limp + inability to kneel and run - typical Sinding-Larsen dis. : avulsion of patellar ligament, especially in CP 14

LIMP - Painful: Neoplasms leukemia: leg pain and limp may be presenting signs; may suggest arthritis malignant bone tus. : osteogenic sa. , Ewing, metastatic neuroblastoma, etc. benign bone tus. : osteoid osteoma, eosinophilic granuloma, fibrous dysplasia, etc. 15

LIMP - Painful: hemophilia: Hematologic Conditions hemarthrosis - usually obvious sickle-cell anemia: hand-foot syn. in toddlers; may be secondary to bone infection; painful symmetric swelling phlebitis: tenderness & local swelling of involved veins scurvy: limp secondary to periosteal hemorrhage hypervitaminosis A: bone pain may occur with intoxication; pseudotumor cerebri 16

LIMP - Non-painful Causes I Neurologic disorders II Muscle disorders IV Bony deformities V Functional state III Joint disorders 17

LIMP - Non-painful: Neurologic flaccid paralysis: limp due to weak muscle groups (poliomyelitis) spastic paralysis: jerky gait is accentuated on running; CP - most common (increased muscle tone, hyperreflexia) ataxia: due to drugs, infection or heredity; unsteady and broad based gait spinal involvement: intraspinal masses, diastematomyelia, cauda equina, lesions, herniated disc, spondylolisthesis CAREFUL NEUROLOGIC EXAMINATION IS MANDATORY ! 18

LIMP - Non-painful: Muscle Disorders muscular dystrophy: limp secondary to muscle weakness; pseudohypertrophy * numerous other primary muscle disorders with weakness may produce an abnormal gait arthrogryphosis: unclear etiology, neurogenic or muscular lack of full extension due to contracture 19

LIMP - Non-painful: Joint Disorders stiffness or contracture: may be seen in a number of inherited diseases (mucopolysaccharidoses) instability: CDH - waddling gait, +ve Trendelenburg; severe hyperextensibility - Ehlers - Danlos syn. ; severe pes-planus 20

LIMP - Non-painful: Bony Deformities (1) leg length discrepancies slipped femoral capital epiphysis: onset - insidious; adolescent - 11 to 15 y. ; obese coxa vara: congenital, waddling gait knock knees: severe, may cause unsteady gait 21

LIMP - Non-painful: Bony Deformities (2) Blount dis. : unilateral or bilateral bowing of tibia; beaking of proximal tibial epiphysis torsional deformities of lower extremities epiphyseal dysplasias: symptoms may mimic Perthes. Hereditary multiple epiphyseal dysplasia, Gaucher, hypothyroidism, sickle-cell disease - should be considered 22

LIMP - Non-painful: Functional States hysteria: uncommon in young children mimicry: likely to occur intermittently or to vary in form 23