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Virtual Pediatric Hospital: Virtual Pediatric Patients: Case 3

Virtual Pediatric Patients

Case 3 - An Adolescent With Leg Pain

Donna M. D'Alessandro M.D., Tamra E. Takle M2
Peer Review Status: Internally Peer Reviewed


The Patient
Leg Pain icon gif

"I'm a 14-year-old athlete going into 9th grade. I play football, basketball, track, baseball, and wrestling. Football is my favorite sport and I play linebacker or tackle. On the weekends, I like to hunt and fish, and do competitive bow-shooting. I live with my mom, step-dad and my half-brother in a 2-story house out in the country."

The Problem / Clinical Presentation
"I came to the doctor because my right leg's been bothering me for a while and I haven't been able to run or play sports as much. He took a look at my leg and made me get an x-ray. Then he sent me to the University of Iowa to see the cancer doctors."

Rick arrived at the pediatric oncology clinic with his outside x-rays on a particularly busy day. To expedite the clinic visit, Rick's films were taken by the pediatric oncologist to the pediatric radiologist for review. The outside films were of poor technical quality, and it was decided to repeat them. The findings on the x-ray could be consistent with several diagnoses, and it was decided to obtain a complete history and physical before issuing a final x-ray interpretation.

Rick was somewhat quiet and only after extensive questioning did he reveal that he had been accidentally hit during track practice by a shot put a month earlier. Leg Pain icon gifHe said that it hurt at first, so he put some ice on it and took ibuprofen. Since it never bruised, he forgot about it and never told his parents.

His activity decreased the next few weeks since the track season was finished, and it wasn't until baseball practice began three weeks after the incident that his right leg began bothering him again.

Rick complains of pain mainly when he tries to bend his right knee that he describes as a tearing sensation. He is unable to run quickly.

Clinical Physical Exam
Leg Pain icon gif

On physical exam, Rick is a cooperative, quiet adolescent male. As Rick rests on an exam table that is too short for him, his left leg dangles off the end and he holds his right leg in a straightened position . There is an obvious 12 cm x 9 cm area of tenderness and swelling on the right thigh that is without erythema or warmth. Rick has passive flexion motion to approximately 90 degrees, and actively to 45 degrees from a straight line. There was full range of motion in the right hip and ankle. All other extremities show full muscle strength and range of motion. When asked to walk, Rick limped slightly, holding his right leg rigid. There was no lymphadenopathy or organomegaly and he was hemodynamically stable. The rest of the physical exam is unremarkable.

Clinical Differential Diagnosis

Clinical Labs
No clinical labs were done.

Laboratory Differential Diagnosis
Not applicable

Imaging Findings
Leg Pain icon gifAmorphous calcification is seen in the soft tissues of the right thigh that is separated from the bone. No abnormal periosteal reaction is seen and there is normal bony mineralization and bony structure.

Imaging Differential Diagnosis
Myositis ossificans, osteosarcoma, hypercalcemia, collagen vascular disease.

Operative Intervention
No operative intervention was done.

Pathological Findings
Not applicable

Pathological Diagnosis
Not applicable

Treatment Course, Prognosis and Follow-up
"After the cancer doctors looked at my x-rays, they asked me a lot of questions, and I remembered to tell them about the shot put. They told me that I had bleeding in my muscle and now the calcium in my body is making a hard shell around the blood. They told me I couldn't play sports until I can bend my leg all the way and I don't have any more pain. I have to do exercises to make my leg bend better. They also told me my x-rays would look different for 2-4 years until the calcium goes away but I should be able to play sports pretty soon." Leg Pain icon gif


The Approach to the Adolescent With Leg Pain

Extremity pain is a common problem in all age groups. It may be difficult to distinguish between bone, muscle, joint or referred pain. A younger child may not even be able to localize the pain.

Differential Diagnosis
The differential diagnosis changes with the age, history and physical examination of the patient.

In infancy and toddlerhood (see also childhood and adolescence)

In childhood (see also infancy and toddlerhood and adolescence)

In adolescence (see also infancy and toddlerhood and childhood)

History and Physical
History should include onset of the symptoms, severity, intermittent or constant pain, and associated symptoms such as limp, refusal to bear weight, fever and rash. A history of preceding upper respiratory infections or trauma (especially minor trauma such as a toddler fall or even new shoes that have rubbed the feet). A close physical examination of the entire affected limb and proximal areas to the affected site (looking for sources of referred pain) such as the shoulder, neck, lower abdomen, pelvis and spine is important. Inspection for swelling and erythema should be done with palpation of muscle and bone and notation of localized heat. Additionally, range of motion of all joints should be noted. A neuromuscular examination including gait should be assessed. A general physical examination for signs of systemic infection is also indicated.

Evaluation
The laboratory evaluation could be quite extensive but should be guided the clinical situation and differential diagnoses being entertained. Tests to consider are:

Blood

CBC, Differential, Platelet - for infections, malignancy
Blood culture - for bacteremia
ESR - for evidence of inflammation

Imaging

Extremity radiographs - for trauma, primary malignancy
Computed tomography - for better delineation of a bone or soft tissue lesion

Other

ANA, Rheumatoid Factor - for connective tissue diseases
Total Protein, albumin - for inflammatory bowel disease, neoplasia
Alkaline Phosphatase, uric acid - for neoplasia
Urethral and cervical cultures - for Neisseria gonorrhea
RPR - for syphilis

Consultation

Orthopaedic Surgery for possible surgical management

Treatment
Most children usually have a self-limited, localized disease process such as transient synovitis or trauma. These can be treated with conservative management including rest, limited immobilization, thermotherapy, and pain relief. More complicated orthopaedic disease such as Legg-Perthes, and SCFE need orthopaedic management. If an infectious disease is suspected, appropriate antibiotics should be administered. Systemic diseases such as connective tissue disease, inflammatory bowel disease, and neoplasias require a team approach to the evaluation and management.


Myositis Ossificans Discussion

Clinical Presentation
The most common presentation of Myositis ossificans is in young athletes after an incident of trauma, but it can be seen at any age. Minor trauma can result in this benign condition; therefore a complete history as well as physical is essential to make the diagnosis. It initially presents as a lesion in the proximal extremities that is tender and swollen, and later becomes more well-circumscribed to form a hard but painless mass.

Pathophysiology
Myositis ossificans is heterotopic bone formation. There are several theories that attempt to explain the development of Myositis ossificans, but none has been conclusively proven. These include implantation of periosteum into the muscle, osteogenic cells that escape the periosteum into the muscle, ossifying hematoma, or metaplasia of the connective tissue. Myositis ossificans is preceded by injury that necessitates proliferative repair, and the majority of these injuries are to the elbow or thigh.

Lab Findings
There are no lab findings commonly associated with the diagnosis of Myositis ossificans.

Imaging Findings
On plain radiographs, Myositis ossificans appears to be an irregularly contoured mass that is calcified, with the calcification becoming initially more dense before beginning to resolve. Although often in close relationship to bone, there is a radiolucent zone towards the bone, and no clear connection between the lesion and the bone. There is no associated periosteal reaction. Computed tomography will show the lesion to be calcified solely around its periphery, which allows it to be distinguished from an osteosarcoma which is completely calcified.

Pathology
A biopsy of the lesion would reveal degenerative necrosis of the tissue, followed by the invasion of histiocytes. Three zones of maturity (first described by Ackerman) develop. Zone 1 (central) has cells with occasional mitotic figures, resembling sarcoma. Zone 2, the intermediate zone, has immature osteoid formation against a fibromuscular background. Zone 3, the peripheral zone, consists of mature peripheral bone with fibrous stroma. Biopsy and histological examination are not frequently done because at different stages the specimen may closely resemble osteo-, fibro- or myosarcoma.

Differential Diagnosis

Treatment
After a traumatic injury, steps should be taken to prevent the onset of Myositis ossificans. This includes limiting range of motion initially (24-48 hours), as any mobilization of the affected muscle can worsen the development of Myositis ossificans. The next step is to restore flexion and extension through passive range of motion exercises. Finally, progressive resistance exercises should be performed until full range of motion is restored. Mature calcified masses should be excised if the origin or insertion of the tendon or muscle is involved, if function is impaired, or if it is a large lesion that can easily be reinjured.

Prognosis
Myositis ossificans is a benign condition, so with proper treatment prognosis is excellent.

References
Berkowitz, Carol D, Pediatrics A Primary Care Approach. W.B. Saunders and Co. Philadelphia, PA, 1996. pp. 320-324.

Cushner FD, Morwessel RM. Myositis Ossificans Traumatica. Orthopaedic Review 1992. pp. 1319-1326.

Illingworth, RS, Common Symptoms of Disease in Children. Blackwell Scientific Publications. 1988. pp. 271-284.

Robbins SL, Cotran RS, Kumar V. Pathologic Basis of Disease. W.B. Saunders Co. Philadelphia, PA. 3rd Edit. 1984. pp. 1312.

Sheldon, Stephen H. and Levy, Howard B. Pediatric Differential Diagnosis. Raven Press. 1985. pp. 110-113, 118-121.

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