1 / 37

I LEG PAIN II LIMP

I LEG PAIN II LIMP. LEG PAIN. Possible causes for the kind of leg pain that often is referred to as “growing pains”.

tale
Download Presentation

I LEG PAIN II LIMP

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. I LEG PAIN II LIMP

  2. 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 laboratorystudies (X-rays, blood count, ESR) 2

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

  4. LEG 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

  5. LEG PAIN: Idiopathic leg pains (2) 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 5

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

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

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

  9. LEG 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

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

  11. LEG 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

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

  13. LEG 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

  14. LEG 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

  15. 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

  16. 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

  17. LIMP Painful causes Non-painful causes 3

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

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. LIMP - Painful: Infections (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

  26. 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

  27. 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 2nd metatarsus, pain on palpation; girls - 12 to 15 y. Kohler dis.: tarsal navicular, mild limp; boys - 3 to 6 y. 13

  28. 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

  29. 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

  30. LIMP - Painful: Hematologic 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

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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

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

More Related