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)

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I Idiopathic leg pain

(“Growing pains”)

II Trauma

III Leukemia & lymphoma

IV Bone tumors

V Infection & inflammation

VI Miscellaneous

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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)

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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)

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LEG LEG PAINPAIN:

Etiology

- still to be determined

- not due to “growth” !

- excessive exercise, trauma

- hidden food allergy, emotional factors have been

suggested

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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

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LEG LEG PAINPAIN:

muscle or bone bruises

pathological fractures

fractures

muscle injections

Trauma Trauma (2)(2)

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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)

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LEG LEG PAINPAIN:

ROENTGENOGRAMS SHOULD BE OBTAINED IN

ANY CHILD COMPLAINING OF LOCALIZED

BONE PAIN

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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

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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)

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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

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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

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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

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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

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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!

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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

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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

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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

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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.

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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

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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.

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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

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LIMP - Painful:

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:

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:

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:

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:

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:

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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