Remember that joint or limb pain, particularly in the lower extremities, may be referred pain from another location

Author: Michael Clemmens, MD

What to Do - Interpret the Data

Perform a thorough physical exam and consider radiographs of both the area in question, as well as those areas proximal and distal.

Lower extremity pain may be a sign of significant pathology in children. In toddlers, it often presents as a limp or refusal to bear weight. Infants may present with discomfort during diaper changes or refusal to move one extremity. Localizing the pathology may be difficult because young children are often unable to communicate the site of pain. Also, disease in one area may present as referred pain to another area. This happens most commonly with the hip, which may present as referred pain to the thigh or knee. However, limp and referred pain may also be secondary to spinal pathology or gastrointestinal disease, such as appendicitis. The clinician may be misled if the entire lower extremity and the adjacent body parts are not evaluated.

The differential diagnosis of lower extremity pain, or limp, is broad and depends on the age of the child. Table 230.1 lists some of the common etiologies of lower extremity pain for different age groups. A selection of diagnoses that require urgent recognition, evaluation, and treatment will be reviewed here. A more expanded differential diagnosis can be found in the references provided or in separate chapters on developmental dysplasia of the hip and fracture patterns in nonaccidental trauma. Generally, specific causes of limp fall into one of three categories: pain, weakness, or structural abnormality. A thorough history, a meticulous exam, and the judicious use of lab studies and x-rays will usually lead to the correct diagnosis.

Legg-Calvé-Perthesdisease (LCPD) and slipped capital femoral epiphysisarediseasesofthehip,thatifdiagnosed earlyleadto improvedoutcomes. LCPDisasyndromeofavascularnecrosisofthefemoralhead.PaininLCPD is generally not severe and may be referred to the anteromedial thigh or knee. Somecasespresentwithlimponly.Onexam,rangeofmotionmaybelimited. Slipped capital femoral epiphysis occurs from acute or repetitive trauma to a presumably abnormal femoral growth plate. It occurs most commonly in the early teenage years, just prior to the adolescent growth spurt, and it is associated with obesity. Along with external rotation of the affected limb, the presenting complaint is often limp with pain in the hip, thigh, or knee.

Theearlydiagnosisandtreatmentofsepticarthritis,abacterialinfection of the joint, is also critical to prevent morbidity from joint destruction. Although it can occur in any joint, it commonly affects the hip and knee. Fever is usually present, and the exam is most significant for severe pain upon passive range of motion of the joint. Serum inflammatory markers are elevated, and bacteria may be present in the synovial fluid of the affects joint or in the bloodstream. The most common mimicker of septic arthritis is transientsynovitis ofthe hip, a self-limited, temporary inflammatoryprocess of unclear etiology. Children with transient synovitis are not systemically ill and usually have normal laboratory values.

Childhood accidental spiral tibial (CAST) fractures, formerly called toddler's fractures, result from minor trauma such as twisting the ankle, tripping, or jumping from a low height. CAST fractures present with leg or foot pain, limp, or refusal to bear weight in children younger than 7 years. Swelling and deformity are often absent. The diagnosis is made by eliciting point tenderness over the fracture site, which is usually the lower third of the tibia. Pain may also be elicited by gently twisting the foot and the upper forelegin opposite directions. CAST fracturesarebestseenradiographically with an anterior oblique view. In many instances, however, the x-ray will be normal and the diagnosis made on clinical grounds alone.

Acute lymphoblastic leukemia is the most common childhood malignancy and frequently presents with long bone pain or limp. The diagnosis of acute lymphoblastic leukemia should be entertained in any child with lower extremity pain at night or persistent leg pain. A thorough history, physical examination, peripheral blood smear, and plain x-rays may lead to the diagnosis. Malignant tumors of the bone that arise in the distal femur or proximal tibia may also present with knee pain.

Suggested Readings

Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. J Bone Joint Surg Br. 1999;81:1029–1034.
Frick SL. Evaluation of the child who has hip pain. Orthop Clin North Am. 2006;37:133–140.
Mellick LB, Milker L, Egsieker E. Childhood accidental spiral tibial (CAST) fractures. Pediatr Emerg Care. 1999;15:307–309.
Singer JI. The cause of gait disturbance in 425 pediatric patients. Pediatr Emerg Care. 1985;1: 7–10.

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Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Williams & Wilkins.

More About Causes of Lower back pain

• Back to symptom: Lower back pain: Introduction (review 78 causes)
• Next Book Extract About Lower back pain: Back Pain (The 5-Minute Pediatric Consult)
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More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

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