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ILEG PAIN II LIMP. LEG PAIN. Possible causes for the kind of leg pain that often is referred to as “growing pains”. - PowerPoint PPT Presentation
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II LEG LEG PAINPAIN
IIII LIMP LIMP
LEG LEG PAINPAIN
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
I Idiopathic leg pain
(“Growing pains”)
II Trauma
III Leukemia & lymphoma
IV Bone tumors
V Infection & inflammation
VI Miscellaneous
3
LEG LEG PAINPAIN
10-20% of children may complain
sometimes in association with headaches and abdominal pains
vague leg pain on a recurrent basis
Idiopathic leg pains Idiopathic leg pains (1)(1)
4
LEG LEG PAINPAIN:
Pain 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 ׳
Idiopathic leg pains Idiopathic leg pains (2)(2)
5
LEG LEG PAINPAIN:
Etiology
- still to be determined
- not due to “growth” !
- excessive exercise, trauma
- hidden food allergy, emotional factors have been
suggested
6
Idiopathic leg pains Idiopathic leg pains (3)(3) LEG LEG PAINPAIN:
Trauma Trauma (1)(1)
most common cause
may be history of an episode of physical trauma
superficial clues: bruises, swelling
7
LEG LEG PAINPAIN:
muscle or bone bruises
pathological fractures
fractures
muscle injections
Trauma Trauma (2)(2)
8
LEG LEG PAINPAIN:
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
Bone Tumors Bone Tumors (1)(1)
9
LEG LEG PAINPAIN:
ROENTGENOGRAMS SHOULD BE OBTAINED IN
ANY CHILD COMPLAINING OF LOCALIZED
BONE PAIN
10
Bone Tumors Bone Tumors (2)(2)
LEG LEG PAINPAIN:
Osteomyelitis: localized, tenderness, swelling not always with
systemic signs
Bone scan !!
Tuberculosis: Limb pain without systemic symptoms !
Myositis: A. pyogenic infection
B. myositis as a result of a systemic infection
*Calf tenderness in influenza
Syphilis: periostitis - severe pain, pseudoparalysis
(in cong. infection)
Trichinosis: severe muscle pain, fever, periorbital edema,
eosinophilia. 11
Infection & InflammationInfection & InflammationLEG LEG PAINPAIN:
Shin splints (ant. & post. compartment synd.):
hypertrophy, swelling of muscle -
cramping pain on sudden resumption of
excessive exercise
Hypervitaminosis A - bony pain, symptoms of increased
cranial pressure
Scurvy Subperiosteal hemorrhages -
tenderness in limbs
12
Miscellaneous Causes Miscellaneous Causes (1)(1)LEG LEG PAINPAIN:
Caffey Disease - Infantile Cortical Hyperostosis
usually onset before 6 m.
Gaucher Disease - may suggest osteomyelitis !
severe pain, tenderness, swelling,
erythema, heat
Sickle-Cell Disease - black child, painful extremities and anemic
Melorheostosis - rare, longitudinal thickening of shaft of
long bone, usually one limb;
pain: severe, skin-tense, shiny, indurated
Miscellaneous Causes Miscellaneous Causes (2)(2)
13
LEG LEG PAINPAIN:
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
Miscellaneous Causes Miscellaneous Causes (3)(3)LEG LEG PAINPAIN:
LIMPLIMP
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
LIMPLIMP
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
LIMPLIMP
Painful causes
Non-painful causes
3
Painful CausesPainful Causes
I Trauma
II Inflammatory
III Infections
IV Aseptic necrosis & Osteochondritis
V Neoplasms
VI Hematologic
4
LIMP
Trauma Trauma (1)(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 bruisedtendon disorders
Achilles tendinitis: sudden acute pain, pain on palpation,
but strong plantar flexion
Achilles tendon rupture : lack of forceful plantar flexion
5
LIMP - Painful:
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
Trauma Trauma (2)(2)
LIMP - Painful:
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
Trauma Trauma (3)(3)LIMP - Painful:
Inflammatory Conditions Inflammatory Conditions (1)(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
findingsjuvenile rheumatoid arthritis: different presentations, one or
more joints, diagnosis by exclusion; pain: usually
not severe!
8
LIMP - Painful:
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
Inflammatory Conditions Inflammatory Conditions (2)(2)
LIMP - Painful:
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
Inflammatory Conditions Inflammatory Conditions (3)(3)
LIMP - Painful:
Infections Infections (1)(1)
osteomyelitis: localized pain, fever, ESR;
may mimic septic arthritis
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:
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 ilium12
Infections Infections (2)(2)LIMP - Painful:
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 2nd metatarsus, pain on palpation;
girls - 12 to 15 y.
Kohler dis.: tarsal navicular, mild limp; boys - 3 to 6 y.
13
Aseptic necrosis & Osteochondritis Aseptic necrosis & Osteochondritis (1)(1)
LIMP - Painful:
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:Aseptic necrosis & Osteochondritis Aseptic necrosis & Osteochondritis (2)(2)
NeoplasmsNeoplasms
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:
Hematologic ConditionsHematologic Conditions
hemophilia: 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 - Painful:
LIMPLIMP - - Non-painful CausesNon-painful Causes
I Neurologic disorders
II Muscle disorders
III Joint disorders
IV Bony deformities
V Functional state
17
NeurologicNeurologic
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
LIMPLIMP - - Non-painful:Non-painful:
Muscle DisordersMuscle 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
LIMPLIMP - - Non-painful:Non-painful:
Joint DisordersJoint 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
LIMPLIMP - - Non-painful:Non-painful:
Bony Deformities Bony Deformities (1)(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
LIMPLIMP - - Non-painful:Non-painful:
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
Bony Deformities Bony Deformities (2)(2)
LIMPLIMP - - Non-painful:Non-painful:
LIMPLIMP - - Non-painful: Functional StatesNon-painful: Functional States
hysteria: uncommon in young children
mimicry: likely to occur intermittently or to vary in form
23