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I I LEG LEG PAIN PAIN II II LIMP LIMP

ILEG PAIN II LIMP

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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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Page 1: ILEG PAIN II        LIMP

II LEG LEG PAINPAIN

IIII LIMP LIMP

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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)

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I Idiopathic leg pain

(“Growing pains”)

II Trauma

III Leukemia & lymphoma

IV Bone tumors

V Infection & inflammation

VI Miscellaneous

3

LEG LEG PAINPAIN

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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)

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LEG LEG PAINPAIN:

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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)

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LEG LEG PAINPAIN:

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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:

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Trauma Trauma (1)(1)

most common cause

may be history of an episode of physical trauma

superficial clues: bruises, swelling

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LEG LEG PAINPAIN:

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muscle or bone bruises

pathological fractures

fractures

muscle injections

Trauma Trauma (2)(2)

8

LEG LEG PAINPAIN:

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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)

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LEG LEG PAINPAIN:

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ROENTGENOGRAMS SHOULD BE OBTAINED IN

ANY CHILD COMPLAINING OF LOCALIZED

BONE PAIN

10

Bone Tumors Bone Tumors (2)(2)

LEG LEG PAINPAIN:

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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:

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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

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Miscellaneous Causes Miscellaneous Causes (1)(1)LEG LEG PAINPAIN:

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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)

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LEG LEG PAINPAIN:

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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:

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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

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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

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LIMPLIMP

Painful causes

Non-painful causes

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Painful CausesPainful Causes

I Trauma

II Inflammatory

III Infections

IV Aseptic necrosis & Osteochondritis

V Neoplasms

VI Hematologic

4

LIMP

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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:

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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:

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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:

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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!

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LIMP - Painful:

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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

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Inflammatory Conditions Inflammatory Conditions (2)(2)

LIMP - Painful:

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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

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Inflammatory Conditions Inflammatory Conditions (3)(3)

LIMP - Painful:

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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:

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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:

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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:

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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

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LIMP - Painful:Aseptic necrosis & Osteochondritis Aseptic necrosis & Osteochondritis (2)(2)

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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.

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LIMP - Painful:

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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

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LIMP - Painful:

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LIMPLIMP - - Non-painful CausesNon-painful Causes

I Neurologic disorders

II Muscle disorders

III Joint disorders

IV Bony deformities

V Functional state

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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:

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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

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LIMPLIMP - - Non-painful:Non-painful:

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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

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LIMPLIMP - - Non-painful:Non-painful:

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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

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LIMPLIMP - - Non-painful:Non-painful:

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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

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Bony Deformities Bony Deformities (2)(2)

LIMPLIMP - - Non-painful:Non-painful:

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LIMPLIMP - - Non-painful: Functional StatesNon-painful: Functional States

hysteria: uncommon in young children

mimicry: likely to occur intermittently or to vary in form

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