ILEG PAIN II LIMP
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Transcript of ILEG PAIN II LIMP
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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
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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
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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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muscle or bone bruises
pathological fractures
fractures
muscle injections
Trauma Trauma (2)(2)
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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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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:
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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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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
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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
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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
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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
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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
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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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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
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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.
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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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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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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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