the painful limb, knee & back

growing pains
1. aka nocturnal idiopathic pain
2. =episodes of generalised pain in lower limbs
3. common in preschool & school-aged kids
4. pain often wakes child from sleep
5. pain settles w/ massage or comforting
6. features needed for diagnosis
  1. age range 3-12 years
  2. pains symmetrical in lower limbs & not limited to joints
  3. pains NEVER present @ start of day after waking
  4. physical activities not limited; NO LIMP
  5. physical exam normal & otherwise
    1. except for some w/ joint hypermobility
hypermobility
1. older kids or teens
  1. MSK pain confined mainly lower limbs
    1. worse after exercise
  2. joint swelling absent/transient
2. distribution
  1. generalised
  2. limited to peripheral joints
    1. hands & feet
3. upper limb findings
  1. symmetrical hyperextension of thumbs
  2. fingers that can be hyperextended onto forearms
  3. elbows that can be hyperextended beyond 10 deg
  4. palms can be placed flat on floor w/ knees straight
4. lower limb finding
  1. knees that can be hyperextended beyond 10 deg
  2. flat feet w/ normal arches on tip toe
    1. feet over-pronated secondary to ankle hypermobility
5. mild degrees are a normal finding in younger female kids
6. many are asyptomatic
  1. helps for dancing & gymnastics
7. some experience recurrent mechanical joint & activity-related mm pain
  1. specialist assessment needed
  2. advice about
    1. footwear
    2. exercises
    3. orthotics
8. a feature of other conditions
  1. chromosomal disorders
    1. Down syn
  2. inherited collagen disorders
    1. Marfan syn
    2. Ehlers-Danlos syn
complex regional pain syndromes
1. aka idiopathic pain syndromes
2. localised or generalised
  1. localised
    1. clinical features
      1. extreme & incapacitating pain
        trigger= minor trauma, can be w/o clear precipitant
      2. foot & ankle involvement
        often unlit
        cool to touch
        swelling & mottling
        held in flexion w/ minimal (if any) active movement
        normal range of passive movements possible w/ distraction
        bizarre posturing
      3. hyperaesthesia (increased sensitivity to stimuli)
      4. allodynia (pain from a stimulus that doesn't normally cause pain)
    2. present in a wheelchair
  2. generalised
    1. clinical features
      1. severe widespread pain
      2. disturbed sleep patterns
      3. feeling exhausted
      4. extreme tenderness over soft tissues
      5. absent or fewer tender points like those found in adults with fibromyalgia
3. usually present in teen females
4. otherwise well
  1. physical exam otherwise normal
5. unknown cause
  1. but pts often have sig stresses in lives
6. need to exclude organic pathology
7. MDT approach needed
  1. mostly physical therapy based
    1. community or inpt
acute-onset limb pain
1. osteomyelitis
  1. infection of metaphysis of long bones
  2. commonest sites
    1. distal femur
    2. proximal tibia
  3. route
    1. usually due to haematogenous spread of pathogen
    2. direct spread from infected wound
  4. swollen skin directly over affected site
  5. can spread to cause septic arthritis
    1. in areas where joint capsule is inserted distal to epiphyseal plate- e.g. hip, elbow, shoulder
  6. causative pathogens
    1. Staph .aureus
      1. causes most infections
    2. in the unimmunised
      1. H. influenzae
      2. TB
    3. Streptococcus
    4. if sickle cell anaemia
      1. Staph
      2. Salmonella
  7. presentation
    1. markedly painful immobile limb (pseudoparesis) in child w/ acute febrile illness
    2. swelling & exquisite tenderness over infected site
    3. erythematous & warm over infected site
    4. moving limb causes severe pain
    5. possible sterile effusion of adj joint
    6. more insidious presentation in infants
      1. swelling & reduced limb movement
        initial sign
    7. outside infancy
      1. back pain
        vertebral infection
      2. groin pain
        pelvic infection
      3. multiple foci
        disseminated Staph or H. influenze infection
  8. Ix
    1. blood cultures usually +ve
    2. raised WCC
    3. ESR/CRP raised
    4. X-rays
      1. normal
        takes 7-10 days for subperiosteal new bone formation & localised bone refraction to be visible
      2. may show soft tissue swelling
      3. characteristic changes (chronic osteomyelitis)
        periosteal rxn along lateral shaft of tibia
        multiple hypodense areas within metaphyseal regions
    5. US
      1. periosteal elevation @ presentation
    6. MRI
      1. allow IDn of subperiosteal pus & purulent debris (i.e. infection) in bone
    7. radionuclide bone scan
      1. helpful if site of infection unclear
  9. Rx
    1. parental Abx promptly for several weeks
      1. prevention of
        bone necrosis
        chronic infection w/ discharging sinus
      2. iv Abx given until clinical recover & ESR/CRP normal
        fb oral therapy for several weeks
    2. aspiration or surgical decompression of subperiosteal space
      1. if atypical px
      2. if immunodef kid
    3. surgical drainage
      1. if not responding quickly to Abx
    4. affected limb initially rested in splint
      1. then subseq mobilised
2. malignant disease
  1. acute lymphoblastic leukaemia
    1. bone pain in kids
      1. sometimes primarily @ night
    2. frank arthritis
  2. neuroblastoma
    1. usually young kids
    2. presentation of mets- sx hard to localise
      1. systemic arthritis
      2. bone pain
  3. bone tumours
    1. osteogenic sarcoma
    2. Ewing tumour
    3. rare
    4. present w/ swelling or pathological fracture
3. osteoid sarcoma
  1. benign tumour
  2. affects teens
    1. esp boys
  3. involves femur or tibia or spine
  4. presentation
    1. pain more severe @ night
      1. improves w/ NSAIDs
    2. involves femur or tibia or spine
    3. if near a joint
      1. localised tenderness
      2. soft tissue swelling
      3. joint effusion
    4. scoliosis if in spine
  5. X-ray
    1. usually diag
    2. sharply demarcated radiolucent nidus of osteoid tissue w/ sclerotic bone around it
    3. if normal, CT or MRI
  6. Rx- surgical removal
the painful knee
1. hip pain often referred to knee
2. Osgood-Schlatter disease
  1. osteochondritis of the patellar tendon insertion @ knee
  2. often affects physically active teen males
    1. esp football or basketball
  3. presentation
    1. knee pain after exercise
    2. localised tenderness over knee
    3. swelling over tibial tuberosity
  4. Mx
    1. reduced activity
    2. physiotherapy for quadriceps mm strengthening
    3. hamstring stretches
    4. orthotics
    5. knee immobiliser splint
3. chondromalacia patellae
  1. softening of articular cartilage
  2. often teen females
  3. causes pain when patella tightly apposed to femoral condyles i.e.
    1. standing up from sitting
    2. on walking up stairs
  4. assoc w/ hypermobility & flat feet
    1. suggests biomechanical component to aetiology
  5. Rx
    1. rest
    2. physiotherapy for quadriceps mm strengthening
4. osteochondritis dissecans (segmental avascular necrosis of subchondrial bone)
  1. presents as knee pain in physically active teen
    1. w/ localised tenderness over femoral condyles
    2. pain caused by separation of bone & cartilage from medial femoral condyle ff avascular necrosis
      1. complete separation of articular fragments may -> loose body formation & sx of knee locking or giving way
  2. Rx
    1. rest & quadriceps exercises
    2. arthroscopic surgery
5. subluxation & dislocation of patella
  1. subluxation
    1. produces feeling of instability/giving way of knee
    2. often assoc w/ general hypermobility
  2. dislocation
    1. usually laterally
    2. sudden
    3. rare
    4. severe pain
    5. reduction occurs spontaneously or on gentle extension of knee
    6. Rx
      1. quadriceps exercises
      2. surgery to realign pull of quadriceps on patellar tendon
6. injuries
  1. contact sports -> acute knee inj
    1. inj to menisci & ligaments common in teens
      1. MRI to determine extent of damage
      2. conservative mx
      3. these inj in infants & young kids-> fractures
        cos ligaments stronger than their bone
  2. non-contact sports w/ sustained activity-> chronic inj &over syndromes
back pain
1. concerning in very young & pre-teen girls
  1. cause can often be IDed (unlike adults)
    1. mechanical causes
      1. muscle spasm or soft tissue pain
        from sports-rel in
        poor posture
        abnormal loading
    2. tumours: benign or malignant
      1. spine is common site for osteoid osteoma
      2. spine can be primary site for many tumours
    3. vertebral osteomyelitis or discitis
      1. localised tenderness
      2. infants
        reluctance to walk or bear weight
        pain on spine flexion
      3. fever
      4. systemic upset
      5. plain x-ray +/- MRI
      6. Rx= iv Abx
    4. spinal cord or nerve root entrapment
      1. from tumour
      2. or prolapsed iv disc
      3. often assoc w/ trauma or heavy lifting
    5. Scheuermann disease
      1. osteochondrosis of vertebral body
      2. may present w/ fixed thoracic kyphosis +/- back pain
      3. diag on X-ray
        radiographic changes often incidental finding & pt often asymptomatic
    6. complex regional pain syn
      1. diagnosed when no physical cause found
      2. exacerbated by psychological stress
    7. spondylolysis/spondylolisthesis
      1. stress fracture of pars interarticularis of vertebra
      2. increased risk w/ certain sports
        bowling in cricket
        gymnastics
      3. if bilat-> spondylolisthesis
        forward slip of vertebral body
        & potential cord or nerve root compression
      4. X-ray + CT
2. red flag clinical features
  1. young age
    1. pathology more likely
  2. high fever
    1. infections
  3. night waking, persistent pain
    1. osteoid sarcoma
    2. tumours
  4. painful scoliosis- infection or malignancy
  5. focal neuro signs- suggest nerve root/spinal cord compression
    1. nerve root irritation
    2. loss of bladder/bowel control
  6. assoc weight, systemic malaise- malignancy

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the painful limb, knee & back

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	Creado por v.djabatey hace casi 11 años