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. 

In This Article

Acquired Conditions

Accessory Navicular

Definition. An accessory navicular condition is an ossification center found on the medial side of the navicular bone. It is found in about 10% of the general population (Staheli, 2006).

History of Present Illness. Classification:

  • Type 1: Rarely symptomatic

  • Type 2: Disruption of the synchondrosis probably due to repetitive trauma and likely causing pain and swelling

  • Type 3: Bony prominence that can cause irritation with rubbing on shoes (Staheli, 2006)

Physical Examination.

Tenderness to palpation over the apophysis

Occasional tenderness to palpation over bony prominence

Diagnostic Tests.

  • Anterior-posterior (AP), oblique, and lateral foot radiographs may demonstrate extra bone adjacent to navicular bone

  • Consider magnetic resonance imaging (MRI), which may show edema at the insertion of the posterior tibial ligament

Treatment.

  • Symptomatic care

    • Nonsteroidal anti-inflammatory drugs (NSAIDs)

    • Physical therapy

    • Consider immobilizing in a brace, such as a short leg cast or Prowalker, for persistent symptoms

    • If no resolution is achieved with symptomatic care, surgical excision by an orthopedic surgeon may be required (Omey & Micheli, 1999; Staheli, 2006; Sullivan & Anderson, 2000))

Kohler Disease

Definition. Kohler disease is avascular necrosis of the navicular bone.

History of Present Illness.

  • Foot pain that might include a limp

  • May be preceded by a history of trauma

  • Most commonly seen in active boys

Physical Examination. Physical examination may show pain, swelling, and erythema at the unilateral midfoot.

Diagnostic Tests.

  • AP/lateral/oblique foot radiographs may show a fragmented, sclerotic navicular bone consistent with avascular necrosis

  • Bilateral AP/lateral/oblique radiographs of the feet may be needed for comparison of navicular bone size

Treatment.

  • Based on symptoms; Kohler disease is a self-limiting condition

  • Immobilize with a walking boot (e.g., Prowalker)

  • May be weight bearing if symptom free; if pain occurs with ambulation, should be non–weight bearing until symptom free

  • Scheduled NSAIDs as needed for symptoms (Herring, 2008; Sullivan & Anderson, 2000)

Legg-Calve-Perthes Disease

Definition. Legg-Calve-Perthes disease is idiopathic avascular necrosis of the unilateral femoral head.

History of Present Illness.

  • Legg-Calve-Perthes disease typically is three times more common in boys than in girls; it classically is found in small-for-age, very active children

  • Patients have unilateral knee, thigh, or hip pain

Physical Examination.

  • Antalgic (painful) gait/limp

  • Complaint of knee or thigh pain (hip pain often is referred to the knee)

  • Pain with hip internal rotation and abduction

  • May have positive Galeazzi sign due to a leg length discrepancy from the collapse of the femoral head

    • With the patient in a supine position with the knees flexed and the feet in a plantigrade position, the Galeazzi sign is positive if one knee height is higher than the other (Figure 1)

  • Limited abduction of symptomatic hip

  • Normal findings of a knee examination

Diagnostic Tests.

  • AP/frog pelvis radiographs reveal avascular necrosis to the femoral head

  • Occasionally in early stages, radiographs are normal; at that point, consider further workup for a septic joint (complete blood cell count [CBC], erythrocyte sedimentation rate [ESR], and C-reactive protein [CRP]) and, depending on the severity of symptoms and laboratory results, further imaging, including a bone scan (if the patient is young and cannot localize the pain) or magnetic resonance imaging (MRI) of the hip

  • If the patient presents with knee/thigh pain, include radiographs of the knee/femur

Treatment.

  • May be full weight bearing

  • Begin scheduled NSAIDs if the patient has symptoms

  • Limit all high-impact activities for the duration of the fragmentation and reossification stages (lasting up to 4 years)

  • Provide a referral to a pediatric orthopedist (Herring, 2008; Staheli, 2007; Staheli & Song, 2007)

Osteochondritis Desiccans

Definition. Osteochondritis desiccans is avascular necrosis of a bone.

History of Present Illness.

  • Most commonly seen in active, young persons

  • Most commonly affects the knee, elbow, and/or talus

  • Often the patient has no history of trauma

  • Symptoms typically occur with activities

  • Reports of swelling are common

Physical Examination. Physical examination should be performed to check for erythema, pain, joint swelling, and limitation of range of motion of the affected joint.

Diagnostic Tests.

  • AP/lateral radiograph of the affected joint

  • At some point likely will require MRI evaluation of the articular surface

Treatment.

  • Scheduled NSAIDs

  • Non–weight bearing on the affected joint

  • Activity restrictions

  • Provide a referral to orthopedics (Federico, Lynch, & Jokl, 1990; Herring, 2008; Sullivan & Anderson, 2000)

Slipped Capital Femoral Epiphysis

Definition. Slipped capital femoral epiphysis (SCFE) is displacement of the femoral head relative to the femoral neck and shaft through the physeal plate. It is one of the most common hip disorders of adolescence and occurs more frequently in boys. The exact etiology is unknown, although typically it is seen in children who are obese.

History of Present Illness.

  • The two most common features of the presentation of SCFE are pain and altered gait

  • SCFE occurs most frequently in obese 10- to 14-year-olds, male > female

  • SCFE also can be seen in children with trisomy 21 and hypothyroidism

  • The mean age of presentation is 12 years in girls and 13.5 years in boys, near the time of peak linear growth

  • Knee, thigh, or groin pain is present in 15% of patients

  • Children with SCFE may present with a limp

Physical Examination.

  • Pain with internal hip rotation or decreased range of motion

  • May have prodromal symptoms, that is, hip or knee pain, limp, or decreased range of motion

  • Limp

  • When knee pain is present, always examine the hip, because knee pain may be referred pain from the hip via the obturator nerve

    • Patients often hold their affected hip in passive external rotation

Diagnostic Tests.

  • Positive AP/frog and lateral pelvis radiographs

  • Thyroid-stimulating hormone and free T4 hormone in children with a normal body mass index

Treatment

  • Restrict weight bearing immediately

  • Refer to the emergency department or an orthopedic surgeon for surgical stabilization (Herring, 2008; Kienstra & Macias, 2011; Morrissy & Weinstein, 2006; Staheli, 2007; Staheli&Song, 2007)

Tarsal Coalition

Definition. A tarsal coalition is a fibrous, cartilaginous or bony connection between two or more bones of the hindfoot and midfoot.

History of Present Illness.

  • Pain in the foot with activity

  • May have a flat foot

Physical Examination.

  • Restricted subtalar foot motion

  • May have tenderness to palpation

Diagnostic Tests.

  • AP, lateral, and oblique radiographic views of the foot

  • Computed tomography scan of the foot for further diagnosis

Treatment. The patient should be referred to orthopedics for surgical treatment (Morrissy & Weinstein, 2006; Omey & Micheli, 1999; Staheli, 2007; Staheli & Song, 2007)..

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