Limb, Heel, and Foot Pain

Question 1

What (5) conditions should be on the differential diagnosis for hip pain in a child?

Answer 1

Infection, tumor, transient synovitis, Legg-Calve-Perthes disease, and slipped capital femoral epiphysis.

Question 2

What is the initial workup, after H&P, for a limping child?

Answer 2

Blood culture, CBC, CRP, ESR, and muscle enzymes. Get an AP and lateral x-ray of a suspect joint. Do entire lower extremity x-rays if there are no focal findings on physical exam.

Question 3

What are “growing pains”?

Answer 3

Recurrent, self-limited, benign limb pains of unknown etiology (not actually due to growing).

Question 4

What are the characteristics of growing pains?

Answer 4

They are typically bilateral, described as deep, sharp, aching pain in the muscles of the legs. Pain usually occurs late in the day or during the night and resolves by morning. There is no joint involvement or inflammation.

Question 5

Osteoid osteoma does not respond to which common analgesic?

Answer 5

Osteoid osteoma often presents with severe nighttime pain that responds to salicylates and NSAIDs but not acetaminophen.

Question 6

What is an osteoid osteoma?

Answer 6

Osteoid osteoma is a benign bony lesion that produces prostaglandins and is commonly located in the proximal femur or tibia.

Question 7

What are the typical imaging findings associated with osteoid osteomas?

Answer 7

On x-ray, it typically presents as a sharp, round or oval lesion <2 cm in diameter with a 1-2 mm peripheral radiolucent zone surrounding a homogenous dense center.

Question 8

What is the recommended treatment for osteoid osteoma?

Answer 8

For those with mild or tolerable pain, treat with NSAIDs and observe with serial exams and x-rays every 4-6 months. Most spontaneously resolve within several years. In patients with severe pain or limp, surgical resection or radiofrequency ablation of the lesion is sometimes needed.

Question 9

What is Osgood-Schlatter disease?

Answer 9

A repetitive stress injury to the patellar tendon insertion at the tibial tuberosity.

Question 10

What is transient synovitis?

Answer 10

It is thought to be a post-infectious arthritis characterized by hip pain, limp, or refusal to walk.

Question 11

In what age range is transient synovitis most common?

Answer 11

It typically presents between 3 and 10 years of age, with median age of presentation being 6 years old.

Question 12

What is the treatment for transient synovitis?

Answer 12

Ibuprofen

Question 13

What is Legg-Calve-Perthes disease?

Answer 13

A partial or complete idiopathic avascular necrosis of the femoral head.

Question 14

In what patient population is Legg-Calve-Perthes disease most common?

Answer 14

It occurs most often in boys between the ages of 3 and 12 years, with a peak incidence at 5-7 years.

Question 15

How does Legg-Calve-Perthes disease typically present?

Answer 15

Patients present with hip pain and a limp. The pain is insidious and worsens with activity. Physical exam reveals reduced hip movement and pain with passive range of motion.

Question 16

What are some (4) conditions which can lead to the development of avascular necrosis?

Answer 16

Renal failure, corticosteroid use, collagen vascular disease, and sickle cell disease.

Question 17

How is Legg-Calve-Perthes disease treated?

Answer 17

Treat by maintaining the femur in an internally rotated and abducted position so that the femoral head is held within the acetabulum. This can be accomplished with activity modification, abduction exercises, or bracing. The disorder should resolve with time, but surgical intervention may be used to speed recovery.

Question 18

What is slipped capital femoral epiphysis?

Answer 18

It is characterized by posterior and inferior slippage of the epiphysis off the metaphysis, causing hip, groin, or knee pain in conjunction with a limp. It can be unilateral or bilateral.

Question 19

What are some (4) risk factors for slipped capital femoral epiphysis?

Answer 19

SCFE is more likely to occur in an obese child during early adolescence and near the time of peak linear growth. The incidence is higher among males, African Americans, obese children, and those with endocrine dysfunction (especially hypothyroidism and GH deficiency).

Question 20

What would you expect to find on physical exam in a patient with SCFE?

Answer 20

There is pain with movement of the hip and impaired internal rotation and flexion.

Question 21

What is the treatment in patients with SCFE?

Answer 21

Immediate nonweightbearing status, emergent orthopedic referral, and surgical repair.

Question 22

When should imaging be performed in a patient who presents with a plantar puncture wound?

Answer 22

If there is any suspicion of a retained foreign body, evaluate with x-ray or US (depending on whether you suspect radioopaque or radiolucent foreign body). If the initial imaging is negative for FB but clinical suspicion is high, follow with CT or MRI.

Question 23

What is achilles tendonitis?

Answer 23

An overuse injury from prolonged or intense running or hiking.

Question 24

What would you expect to see on physical exam in a patient with Achilles tendonitis?

Answer 24

Tenderness and swelling over the Achilles tendon at the back of the ankle.

Question 25

Where would you expect a patient to report pain if they have plantar fasciitis?

Answer 25

The pain and tenderness generally occurs along the plantar surface of the foot and commonly over the calcaneal tubercle or origin of the plantar fascia at the anterior portion of the calcaneus.

Question 26

In which patients would a diagnosis of plantar fasciitis be more common?

Answer 26

Adolescents who participate in sports or jobs with repetitive standing, running, or walking.

Question 27

How would one differentiate between plantar fasciitis and heel contusions on exam?

Answer 27

Heel contusions are typically localized to the midheel, and the tenderness does not vary. The pain in plantar fasciitis is more diffuse along the plantar surface of the foot.

Question 28

What physical exam findings would make one concerned for the presence of a calcaneal fracture?

Answer 28

The heel would be very swollen and tender, and weightbearing would be intolerable.