Acute and Non-acute Lower Extremity Pain in the Pediatric Population

Part III

Allison D. Duey-Holtz, MSN, RN, CPNP; Sara L. Collins, MSN, RN, CPNP; Leah B. Hunt, PA-C, MMSc; Polly F. Cromwell, MSN, RN, CPNP

Disclosures

J Pediatr Health Care. 2012;26(5):380-392.

Introduction

Lower extremity pain is common in childhood, with etiologies ranging from benign muscular conditions to systemic disease. We are presenting a three-part series of evidence-based practice guidelines to aid the provider in efficiently determining the diagnosis and treatment of a child with lower extremity pain. Part I focused on the history, physical examination, and diagnostic work up (Duey-Holtz, Collins, Hunt, Husske, & Lange, 2012; Duey-Holtz, Collins, Hunt, & Cromwell, 2012). Parts II and III have been divided to include comprehensive treatment guidelines, which are summarized in the Table. In general, the most common diagnoses for musculoskeletal pain can be categorized into the following etiologies:

Trauma: strains/sprains, fractures, dislocations, foreign body, non-accidental trauma
Infection: septic arthritis, osteomyelitis, diskitis
Immune-mediated: toxic synovitis, juvenile idiopathic arthritis, Lyme disease, reactive arthritis
Acquired/developmental: slipped capital femoral epiphysis, Legg-Calve-Perthes disease, Kohler disease, tarsal coalition, accessory navicular, osteochondritis desiccans
Neoplastic: leukemia/lymphoma, Ewing sarcoma, osteosarcoma
Referred: scoliosis, spondylolysis, spondylolisthesis
Benign musculoskeletal: growing pains, tendonitis/apophysitis
Neurologic: complex regional pain syndrome, restless leg syndrome
Metabolic: rickets

The following non-painful conditions can present with a limp or abnormal lower extremity examination results:

Developmental: developmental dysplasia of the hip, leg length discrepancy
Neurologic: cerebral palsy, syndromes that result in abnormal findings of neuromuscular examinations (Duey-Holtz et al., 2012)

Part III will cover the most common infectious, immune-mediated, acquired, neoplastic, and metabolic etiologies. Along with the following summary of each differential diagnosis, a reference table and algorithm are included (Table and Figure).

(Enlarge Image)

Figure.

Lower extremity pain differential diagnosis algorithm. Data from Gedalia, 2002; Junnilla & Cartwright, 2006; and Sawyer & Kapoor, 2009.

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Table. Diagnosis, treatment, and referral of pediatric lower extremity pain
Diagnosis	History, physical and test findings	Treatment and referral
Accessory navicular	Medial foot pain; + radiograph findings	• Conservative treatment with NSAIDs • Activity modification • Possible immobilization or orthosis • Referral to orthopedics with no improvement
Apophysitis/musculoskeletal conditions: • Osgood- Schlatter disease • Patella femoral pain • Sinding-Larsen-Johansson syndrome • Sever disease	Tender to palpation over apophysis; ± radiograph findings	• NSAIDs or naproxen twice a day • May consider short 1- to 2-wk immobilization or bracing • PT • Follow up in 6 wk, consider referral to orthopedics with no improvement
Cerebral palsy	Neurology deficits with motor impairment	Based on local referring pattern, refer to subspecialist who routinely cares for children with neuromuscular conditions (i.e., pediatric physical medicine and rehabilitation, pediatric neurology, and/or pediatric orthopedic surgery)
Complex regional pain syndrome	Pain after an injury, lower limb most common; pain to light touch that is disproportionate to mechanism of injury; evaluate for autonomic symptoms (skin temperature different; color changes; absence or increase of sweating)	Based on local referring pattern: • NSAIDs or naproxen twice a day • Begin PT for desensitization • Discontinuation of any bracing • Refer to pediatric pain specialty
Developmental dysplasia of the hip	Check history for female, first born, breech, and family history; + Ortolani and Barlow signs, asymmetric thigh fold, + Galeazzi sign, + Klisic sign	Refer to pediatric orthopedics with positive examination findings or imaging studies (ultrasound or radiograph)
Discitis	Back pain, ± fever, decreased spinal motion, often systemic symptoms and systemically ill	Based on the local referring pattern: • Treat with IV antibiotic therapy, typically with inpatient admission • Involvement of subspecialists who routinely care for bone/joint infections as necessary (i.e., infectious disease, orthopedic surgery, general pediatrics/hospitalists) • Consider immobilization for pain control
Foreign body	Possible history of foreign body, red, swollen, ± radiograph findings	• Remove foreign body • Antibiotic prophylaxis as needed • Referral to general surgery or orthopedics if bone involvement or surgical excision is required
Fracture	Swelling/pain with motion/palpation: + radiograph findings: if tender over physis, assume fracture	Splint and refer to emergency department or orthopedics within a few days if physeal, displaced, or angulated
Gonococcal/chlamydial arthritis	+ Sexual activity; arthritis of one or more joints; sometimes accompanying dermatitis and systemic signs and symptoms; ± positive nucleic acid amplification tests of synovial fluid, urine, vagina/cervix	• Involvement of local subspecialists as needed (i.e., infectious disease and/or rheumatology), especially if septic joint • Antibiotic treatment if septic joint (CDC, 2010) • Antibiotic treatment if aseptic joint and chlamydia likely plus pain management (Holmes et al., 2008)
Growing pains	Late evening or nighttime lower extremity pains, usually bilateral, resolve with pain reliever/massage, not typical during day; radiographs negative/laboratory results negative	• Conservative management using symptomatic NSAIDs, massage, warmth, and other supportive measures until the syndrome resolves with time • May try a course of PT with muscle stretching and exercise
Juvenile inflammatory arthritis	Morning pain, often multiple joint involvement, warmth and/or diminished range of motion, CBC, ESR, CRP (consider ANA, AntiDNAse B, ASO, Lyme serology, if clinically indicated)	Based on local referring pattern: • Symptomatic relief can be obtained with NSAIDs • Referral to a pediatric rheumatologist
Kohler disease	Pain/swelling mid foot, limp, + radiograph findings navicular bone	Restrict weight bearing and refer to orthopedics
Legg-Calve-Perthes disease	White boys ages 4–10 y, hip and groin pain, decreased internal hip rotation, radiograph findings: flattening and fragmentation of femoral head	Restrict activities and refer to orthopedics
Limb length discrepancy	± Limp, not painful, + Galeazzi sign, + AP leg length films	Refer to orthopedics
Lyme arthritis	Exposure to endemic area, ± target rash, swelling/pain joints, + Lyme titer with + Western blot	Based on local referring pattern: • Refer to cdc.gov for most recent treatment guidelines OR • Refer to Red Book: Report of the Committee on Infectious Disease (American Academy of Pediatrics [AAP], 2012) • Involvement of local subspecialists as needed (i.e., infectious disease and/or rheumatology)
Neoplasm	Progressive or intermittent, deep seated, gnawing pain, often worse at night, ± constitutional symptoms, ± elevated laboratory results, ± radiograph findings	Based on local referring pattern, expedited referral to pediatric tumor specialist or pediatric oncologist based on local referral pattern
Non-accidental trauma	Injury doesn't match story, child non-ambulatory with high suspicion fractures, + radiograph findings of affected area	Based on local referring pattern: • Treat injuries and begin further workup to evaluate for non-accidental trauma based on facility guidelines • Admit to hospital for safety of patient and further workup • Involvement of Child Protective Services and additional subspecialists as needed (i.e., social work, child advocacy teams, neurosurgery, general surgery or trauma teams)
Osteochondritis dissecans	Pain ± swelling affected joint, increase with activity, ± catch/locking, + radiograph findings for older child/teen	• Treat initially with activity restrictions, immobilization, and non–weight bearing to affected limb • NSAIDs • Refer to orthopedics
Osteomyelitis	Local tenderness/swelling bone, limp, ± fever, elevated CBC, ESR, and CRP	Based on local referring pattern: • ± order MRI • Refer to orthopedics/emergency department/admission to local hospital
Restless leg syndrome	Sleep disturbance, normal physical examination, no systemic symptoms, meet National Institutes of Health restless leg syndrome guidelines criteria	Based on local referring pattern, referral to pediatric sleep center
Rickets	No supplemental vitamin D, darker skin, genu varum and radiograph findings: widening/cupping of the metaphysis; abnormal laboratory findings	Based on local referring pattern: • Refer to orthopedics for treatment of genu varum • Treatment of rickets by primary care provider or endocrine team based upon provider
Scoliosis	Thoracic/lumbar prominence on Adams forward bend test; asymmetric shoulders/pelvis; radiograph shows scoliosis	Refer to orthopedics
Septic joint	Pain with joint motion, redness, swelling, warmth, restricted joint motion, non–weight bearing, fever, elevated CBC, CRP, ESR ± blood cultures	Based on local referring pattern: • Ultrasound hip joint or proceed with joint aspiration of small joints (if comfortable) • May refer to orthopedics, emergency department, or admission to hospital for joint aspiration and continued follow-up with positive cultures
Slipped capital femoral epiphysis	Often seen in 10- to 14-year-old teens, boys more than girls, overweight, groin/knee pain, pain internal hip rotation, limp, + AP/frog lateral pelvis radiograph	• Restrict weight bearing • Refer to emergency department or orthopedics for surgical stabilization
Spondylolysis/spondylolisthesis	Pain with back extension, AP/lateral/oblique lumbar sacral spine films ± findings	• Refer to orthopedics • NSAIDs as needed for pain • Consider activity limitations until seen by subspecialty providers
Strain/sprain	Tender to palpation over soft tissue, ± laxity, swelling, no significant pain with weight bearing	• NSAIDs • Range of motion brace • Begin ambulation as tolerated • Refer to physical therapy if needed • Refer to orthopedics with recurrent sprains
Tarsal coalition	Pain in foot with activity, often flat foot and restricted subtalar foot motion, ± radiograph findings	• Refer to orthopedics
Toxic synovitis	Mild/moderate pain with hip motion, ± limp, afebrile, normal CBC and CRP, ± hip effusion on ultrasound	• NSAIDs • Follow up in 2 to 3 days • Ambulation as tolerated • Limit sports • Refer to emergency department or orthopedics with increasing pain and/or fever

ANA, Antinuclear antibody; Anti-DNAse B, anti-deoxyribonuclease B; ASO, antistreptolysin; AP, anteroposterior; CBC, complete blood cell count; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; IV, intravenous; MRI, magnetic resonance imaging; NSAIDs, non-steroidal anti-inflammatory drugs; +, positive; PT, physical therapy.
Adapted from Herring, 2008; Junnilla & Cartwright, 2006; Sawyer & Kapoor, 2009.