Back, Joint, and Extremity Pain
Samir S. Shah, Jacqueline Owusu-Antwi, and Lisa B. Zaoutis
Approach to the Patient with Back, Joint, and Extremity Pain
I. Definition of the Complaint
Back, extremity, and joint pain are worrisome symptoms in children. The
inability of young children to clearly describe the location and nature of the
pain contributes to diagnostic difficulties. Because the diverse complaints of
back, extremity, and joint pain frequently share a common etiology, a uniform
approach to such symptoms facilitates accurate diagnosis.
II. Complaint by Cause and Frequency
Back pain, or discomfort anywhere along the spinal and paraspinal area, reflects
potential pathology in a wide range of organ systems, including
musculoskeletal, central nervous system (CNS), pulmonary, vascular, and
intraabdominal or retroperitoneal structures (Table 5-1). Young children who
cannot accurately localize pain require indirect symptom assessment. For
example, refusal to walk, irritability with repositioning, or reluctance to
participate in specific activities often provides the earliest clues to
underlying infectious, inflammatory, or neoplastic disorders.
Alteration in gait or changes in the use of a limb also suggest an underlying
extremity or joint disorder (Table 5-2). Examination of one joint above and one
below the site of the chief complaint can prevent missing a diagnosis in cases
of referred pain. For example, knee pain may be the presenting symptom for hip
pathology. Joint and extremity symptoms can also represent referred pain from a
spinal or paraspinal process. The radicular symptoms of nerve root entrapment
in the lumbar spine may manifest as foot pain.
The evaluation of back, extremity, and joint pain requires an understanding that
extensive interplay of symptoms, findings, and etiologies exists among these
diagnostic groups.
III. Clarifying Questions
Routine inquiry into the onset, location, duration, character, radiation, and
intensity of the pain may clarify the diagnosis. Caretaker observations may
supplement the history, especially in nonverbal patients. Special mention
should be made regarding the onset of pain in relation to trauma. Many children
with nontraumatic abnormalities first notice a previously underappreciated
symptom after an insignificant injury. For example, a child with a spinal tumor
may fall off a bicycle and complain of leg pain, when in fact the tumor had
been present for weeks and it was the progressive paresis that caused the child
to fall from the bike. Incidental injuries are present in almost all children
's recent history; they may be associated with the underlying problem, but they
may not necessarily be the primary cause. Beware of the red herring of trauma.
The following questions can be particularly helpful.
• What is the age of the patient?
— In younger children, especially those younger than 5 years of age, back pain is
often a manifestation of a serious underlying disorder. In contrast, older
adolescents are more likely to have nonspecific musculoskeletal disorders,
similar to adults with back pain.
• What is the timing of the pain?
— Mechanical strains and stresses are often improved at night and resolve within
several weeks. However, spondylolysis, spondylolisthesis, and Scheuermann
disease may also improve with rest. Pain that worsens at night is more typical
of tumors or infections.
• Are there systemic symptoms?
— Fever, malaise, and weight loss are more suggestive of an inflammatory,
neoplastic, or infectious etiology.
• Are there any neurologic findings?
— Bowel or bladder dysfunction and skin lesions such as café-au-lait spots, sacral dimples, or hairy patches may be useful clues to spinal
pathology. Some examples are syringomyelia, tethered cord, ruptured disc,
spinal cord tumor, or unrecognized spinal dysraphism.
• Is there decreased range of motion of the back?
— Stiffness of the spine is an unusual finding in young children and may indicate
infection, inflammation, or tumor. In adolescents, muscle spasm from overuse
injuries can limit the range of motion, but this resolves quickly.
• Is a deformity of the back noticeable?
— Deformity of the normal spinal curvature may represent primary spinal
pathology, a congenital or idiopathic process, or muscular abnormalities that
contribute to progressive scoliosis or kyphosis. Splinting during acute
pneumonia leads to transient abnormal lateral curvature of the thoracic spine.
Pictures
Book Source Details
- Book Title: Pediatric Complaints and Diagnostic Dilemmas
- Author(s): Samir S Shah MD; Stephen Ludwig MD
- Year of Publication: 2003
- Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright Details: Pediatric Complaints and Diagnostic Dilemmas, Copyright © 2008 Williams & Wilkins.
More About Causes of Lower back pain
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