Lower Extremity Pain CLINICAL GUIDELINES for Workup

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Lower Extremity Pain CLINICAL GUIDELINES for Workup Definition Lower extremity musculoskeletal pain is common, the possible etiologies are broad, ranging from…
Lower Extremity Pain CLINICAL GUIDELINES for Workup Definition Lower extremity musculoskeletal pain is common, the possible etiologies are broad, ranging from benign to serious. The goal of this practice guideline is to present the tools for a provider to determine the diagnosis for a child with lower extremity pain in an efficient manner. This practice guideline is a reference for providers when caring for a patient with lower extremity musculoskeletal pain. Signs and symptoms The list of differential diagnoses’ for lower extremity pain is extensive and broad. A thorough history and physical exam will aid the provider in identifying the correct diagnoses. Always be familiar with the child’s medical history Focused History of Musculoskeletal Pain Timing of Pain Timing can aid in diagnosis. Acute onset of symptoms suggests a more acute diagnosis such as septic arthritis, osteomyelitis, fracture, or malignancy. In contrast, morning symptoms that improve through the day are more suggestive of a rheumatologic etiology. Pain after activities is suggestive of an overuse syndrome or stress fracture. Night waking pain can be a benign etiology such as growing pains or more serious etiologies such as malignancy or osteoid osteoma. Identify any preceding activities and/or sports played surrounding the symptoms. Sample questions: ã When did the pain start? What makes the pain better/worse? Rate pain on a scale ã Is the pain activity related? ã Is the pain bad enough to prevent the child from their activities, sports/play or school? ã How does the child feel after sports or play activities? ã Is the pain night waking versus in the AM or after naps? Associated Systemic Features Serious conditions will typically cause systemic symptoms. Be concerned by children who have stopped playing or teens who are limiting athletics or social activities. Sample questions: ã Presence and time of fevers. ã Association with any rashes, weight loss, change in activity, decreased appetite, lethargy and/or a change in sleep patterns . Approved By: Allison Duey‐Holtz, MSN Date: 5/31/12 Office Phone: 414‐337‐7322 Page 1 Nature & Location of Pain Children are often better at demonstrating the location of the pain. In verbal children it may be beneficial ask them to use their index finger to identify the point of maximum tenderness. Sample questions: ã Asking the patient to show them with their finger “the one pin point place that hurts the most, where would that be”? o If the child is unable to locate the area of maximum tenderness, ask them to draw a line with their finger demonstrating where the pain starts and stops. In non‐verbal children, rely on the parent’s perceptions of where the pain is. ã Can you describe the pain? Where does the pain start/stop? PHYSICAL EXAM A thorough musculoskeletal examination is important for diagnosis. The focused musculoskeletal examination includes pediatric orthopaedic, neurologic and rheumatologic aspects. Always start with a presumed non‐painful area, especially in small children, performing the examination of the painful area last. Musculoskeletal exam features ã Inspect and palpate both lower extremities o Identify the site of maximal tenderness ã Examine the joints for swelling and range of motion ã Evaluate range of motion to all upper and lower extremities including bilateral shoulders, elbows, wrists and fingers, hips, knees, ankles, and toes. o Be aware of the knee‐hip‐back triad. Often hip pain is referred to the knee. Back pain can refer to the hip or radicular pain from the spine will present with pain down the leg. o When evaluating knee pain always include evaluation of the hip. ã Include palpation of all extremities. o Assess for joint range limitation, warmth, and swelling. Neuromuscular exam ã Evaluate the undressed child through several gait cycles pay attention to each limb and joint. o Running may help uncover subtle gait abnormalities. o To minimize the affected limb’s pain, the amount of time spent in the stance phase decreases and that spent in the swing phase increases (Barkin, Barkin & Barkin, 2000; Herring, 2007; Laine, Kaiser & Diab, 2010; Leet & Skaggs, 2000; Renshaw, 1995; Wyndam, 2007). ã Examine deep tendon reflexes, tone, clonus, sensation, straight leg raise, muscle wasting, evaluation of the feet and toes for clawing or deformity (Herring, 2007; Leet & Skaggs, 2000; Morrissy & Weinstein, 2006; Wenger & Rang, 1993). o A positive exam finding from above is suggestive of an etiology from either the spinal cord or a nerve root. Approved By: Allison Duey‐Holtz, MSN Date: 5/31/12 Office Phone: 414‐337‐7322 Page 2 Causes The etiology of musculoskeletal pain, with or without a limp, is broad. Below are commonly seen etiologies for musculoskeletal pain. The diagnoses can be grouped into the following categories: ã Trauma: (i.e. strains/sprains, fractures, dislocations) ã Infection: septic arthritis, osteomyelitis, brodies abscess ã Immune‐mediated: toxic synovitis, juvenile rheumatoid arthritis, Lyme disease, Strep reactive arthritis, osteoid osteoma ã Acquired: slipped capital femoral epiphysis (SCFE), Legg‐Calve‐Perthes disease ã Neoplastic: leukemia/lymphoma, Ewing's sarcoma, osteosarcoma ã Referred: discitis, psoas abscess, spine or hip pathology ã Benign musculoskeletal: Growing pains, tendonitis/apophysitis Additional non‐painful etiologies that can cause a limp to consider include: ã Congenital: developmental dysplasia of the hip ã Non‐painful limp: leg length discrepancy, scoliosis ã Neurologic: cerebral palsy, myelomeningocele, or underlying neuromuscular pathology Risk Factors The vast majority of parents/care takers will identify a history of trauma for any source of musculoskeletal pain, especially in the young and non‐verbal. Most often the etiology of musculoskeletal pain is related to accidental injury. However, it is important for a provider to always remember the vast number of other causes of musculoskeletal pain. Complications While most musculoskeletal pain can be traced to a benign condition, one must remember infection and neoplastic processes can mimic many other diseases. The purpose of these guidelines is to provide the provider with the tools to work up patients with lower extremity pain in a timely manner, which in result will prevent further morbidity and medical complications Approved By: Allison Duey‐Holtz, MSN Date: 5/31/12 Office Phone: 414‐337‐7322 Page 3 Recommendations for Providers considering referral to Pediatric Orthopaedic specialist o Pre Work up Work‐up Algorithm History of Trauma Yes No Abnormal Exam with or Perform without constitutional ã Radiographs symptoms ã ã Perform Radiographs Differential Normal Abnormal Perform Labs ã Fracture/dislocation (Please refer to ã Soft Tissue lab section for ã ãã Overuse Apophysitis Sprain correct labs to ã Bone or Musculoskeletal Pain Joint Pain ã Accessory Navicular ã Legg Calve Perthes ã Tarsal coalition ã Slipped Capital Treatment options Bone or Musculoskeletal Pain Joint Pain +/‐ effusion ã Legg Calve Perthes Femoral Epiphysis ã Slipped Capital Femoral ã Osteochondritis ãã Treat and/or refer as ã Osteomyelitis, ã Transient synovitis Epiphysis dissecans appropriate ã Neoplasm ã ãã Consider further work up as ã Septic joint ã Kohlers Sacroilitis ã Reactive ã needed, ã Abscess Inflammatory ã Foreign body ã Treat as fracture if pt has ã Discitis Arthritis ã Rickets (+/‐ pain) ã physeal tenderness Adapted from Duey‐ ã Scoliosis (+/‐ pain) ã Spondylolysis/listhesis (+/‐ pain) Nonpainful + limp ã Developmental Dysplasia of the Hip Approved By: Allison Duey‐Holtz, MSN ã Leg length discrepancy Date: 5/31/12 Office Phone: 414‐337‐7322 Page 4 Imaging Location of Pain Radiographs Views to Obtain Other Imaging Tests Hip Pelvis AP, frog, lateral ‐MRI: Soft tissue and joints, large amounts of effusion; ex: stress fractures; infection; abscess; neoplasm; ligament injury; cartilage Femur Femur AP, lateral evaluation Knee Knee AP, lateral, sunrise, notch ‐CT: Boney abnormalities suspected but not definitive by x‐ray, ex: intra‐articular fracture Ankle Tibia AP, lateral ‐Ultrasound: Effusion of joints, vascular injuries suspected; ex: Ankle AP, lateral, mortise septic hip, infant DDH Foot Foot AP, lateral, oblique Laboratory Tests Test Condition Expected Finding CBC Infection Elevated WBC & Platelets Inflammation Elevated WBC & Platelets Malignancy Cytopenia CRP Infection Elevated Inflammation Elevated Malignancy Elevated ESR Infection Elevated Inflammation Elevated Malignancy Elevated ASO Acute rheumatic fever Markedly increased & usually very ill child Unresolved/undetected Group A Increased ASO, sore throat hemolytic strep AntiDNAse B Acute rheumatic fever Positive & usually very ill child Unresolved/undetected Group A Positive hemolytic strep Approved By: Allison Duey‐Holtz, MSN Date: 5/31/12 Office Phone: 414‐337‐7322 Page 5 Test Condition Expected Finding ANA SLE Markedly positive False positive Mildly positive Lyme Lyme disease Titer positive and Western Blot positive False positive titer (exposed but no disease) Synnovial Cell Count Septic arthritis Turbid fluid; WBC 50,000 to over 100K, PMNS 75% Transient synovitis Clear yellow synovial fluid; WBC 5, 000‐15K, PMNs 25% 25,000‐100,000K JIA Blood Cx Infection +/‐ positive Joint/Bone Cx Infection +/‐ positive Stool Cx Reactive arthritis with diarrhea Salmonella,Shigella, Yersinia, Campylocbacter Urine Cx Reactive arthritis Neisseria gonorrhoeae or Chlamydia Serum ferritin Restless Leg Syndrome Meet NIH RLS criteria Serum Ferritin 50mcg Adapted from Junnila & Cartwright, 2006a; Junnila & Cartwright, 2006b; Sawyer, J.R. & Kapoor, M. 2009, p. 220 Approved By: Allison Duey‐Holtz, MSN Date: 5/31/12 Office Phone: 414‐337‐7322 Page 6 Treatment and Referral of Pediatric Lower Extremity Pain Musculoskeletal complaints most commonly are from diagnoses’ treated by orthopedic and sports medicine providers. Occasionally, the underlying etiology causing musculoskeletal pain is from a problem not usually treated by orthopedic sub‐specialists. Below are common conditions that present with lower extremity pain and/or limp. Included are initial interventions orthopedic providers implement. Clinics at the CHW Orthopedic Center & Sports Medicine Program include: Cerebral Palsy Clinic Concussion Fracture General Orthopaedic Scoliosis Sports Medicine Trauma Well child lower extremity screening clinic Clinic locations: Children’s Hospital of Wisconsin‐Main campus; CHW‐Greenway; CHW‐New Berlin (concussion only) To schedule an appointment : Central Scheduling 414.607.5280 or toll free 877.607.5280 Orthopedic nurse line: 414.266.2513 Sports line 414.604.6512 Diagnosis History, Physical and Test findings Treatment and Referral Accessory navicular Medial foot pain ã conservative treatment with Non‐steroidal anti‐inflammatory drugs (NSAIDS) ã activity modification + x‐ray findings ã possible immobilization or orthosis ã referral to CHW Orthopedics or Sports Medicine with no improvement Apophysitis/ Tender to palpation over apophysis ã NSAIDS or Naproxen twice a day ã may consider short one to two week immobilization or bracing musculoskeletal conditions: +/‐ x‐ray findings ã physical therapy (PT) 1‐2 times per week for 6‐8 weeks to include range of motion of ‐Osgood‐ Schlatter affected joint(s), strengthening of lower extremities including hamstring/quadriceps/gluteus/calf muscles, with a return to sports program ‐Patella femoral pain Local options: CHW main campus and CHW Green Sports Medicine Physical Therapy ‐Sindig‐Larsen‐Johanssen Syndrome ã follow up in 6 weeks, consider referral to CHW Sports Medicine with no improvement of symptoms ‐Severs Approved By: Allison Duey‐Holtz, MSN Date: 5/31/12 Office Phone: 414‐337‐7322 Page 7 Cerebral palsy Neurology deficits with motor impairment ã Referral to CHW Multi Disciplinary Cerebral Palsy Clinic or CHW Physical Medicine and Rehabilitation Hypertonia Non painful limp Complex regional pain syndrome Pain after an injury, lower limb most ã NSAIDS or Naproxen twice a day common; pain to light touch that is ã begin PT for desensitization disproportionate to mechanism of injury; ã discontinuation of any bracing evaluate for autonomic symptoms (skin temp ã refer to CHW Pain & Palliative Care different; color changes, absence of sweating) Developmental dysplasia of hip Check history for female, first born, breech, ã refer to CHW Pediatric Orthopedics with positive exam findings or imaging studies and family history. (ultrasound or x‐ray) + Ortalani and Barlow, asymmetric thigh fold, + galeazzi, + klisic Discitis Back pain, +/‐fever, decreased spinal motion, ã Referral to CHW emergency room often systemic symptoms and systemically ill ã treat with IV antibiotic therapy with inpatient admission. ã involvement of CHW orthopedics ã consider LSO immobilization for pain control Foreign Body Possible history of foreign body, red, swollen, ã remove of foreign body +/‐ x‐ray findings ã antibiotic prophylaxis as needed ã if surgical excision required referral to CHW general surgery or orthopedics if bone involvement Fracture Swelling/pain with motion/palpation: + x‐ray ã splint and refer to CHW orthopaedics if non‐displaced and closed fracture findings: If tender over physis assume ã urgent care or emergency department if open fracture, displacement, or angulation fracture present Approved By: Allison Duey‐Holtz, MSN Date: 5/31/12 Office Phone: 414‐337‐7322 Page 8 Gonococcal/ + Sexual activity; arthritis of one or more ã involvement of local subspecialists as needed , (i.e. infectious disease and/or joints; sometimes accompanying dermatitis rheumatology), orthopaedics if septic joint Chlamydial arthritis and systemic signs and symptoms; +/‐ ã I&D and antibiotic treatment if septic joint positive nucleic acid amplification (NAAT) ã antibiotic treatment if aseptic joint and chlamydia likely plus pain management tests of synovial fluid, urine, vagina/cervix Growing Pains Late evening or night time lower extremity ã conservative management using symptomatic NSAIDS, massage, warmth, and other pains, usually bilateral, resolve with pain supportive measures until the syndrome resolves with time reliever/massage, not typically during day. ã may try a course of PT with muscle stretching and exercise ã Restless Leg Syndrome may present as growing pains. Consider referral to CHW X‐rays negative/Labs negative Juvenile inflammatory arthritis Morning pain, often multiple joint ã symptomatic relief can be obtained with NSAIDS involvement, chronic, younger than sixteen, ã referral to a CHW Pediatric Rheumatology +/‐CBC, ESR, ANA, AntiDNAse B, ASO Kohler’s disease Pain/swelling mid foot, limp, + x‐ray findings ã restrict weight bearing and splint (ie prowalker navicular bone ã consider refer to CHW orthopedics Legg‐Calve‐Perthes disease White males 4‐10yo, hip and groin pain, ã restrict activities and refer to CHW Orthopedics decreased internal hip rotation, x‐ray findings: flattening and fragmentation of femoral head Limb length discrepancy +/‐limp, not painful, + galeazzi, + AP leg ã refer to CHW Orthopedics length films Lyme Arthritis Exposure to endemic area, +/‐target rash, ã refer to cdc.gov for most recent treatment guidelines swelling/pain joints, +Lyme titer with OR +western blot, ã refer to Red Book: Report of the Committee on Infectious Disease (most recent edition) ã involvement of local subspecialists as needed (i.e. infectious disease and/or rheumatology) Approved By: Allison Duey‐Holtz, MSN Date: 5/31/12 Office Phone: 414‐337‐7322 Page 9 Neoplasm Progressive or intermittent, deep seated, ã expedited referral to CHW/Froedert pediatric musculoskeletal tumor specialist or gnawing pain, often worse at night, +/‐ pediatric oncologist constitutional symptoms, +/‐ elevated labs, +/‐ x‐ray findings Non accidental Trauma Injury doesn’t match story, child non‐ ã treat injuries and begin further workup to evaluate for non accidental trauma based ambulatory with high suspicion fractures, + x‐ upon CHW facility guidelines ray findings of affected area ã admit to hospital for safety of patient and further work up Osteochondritis dissecans Pain +/‐ swelling affected joint, increase with ã treat initially with activity restrictions, immobilization, and non weight bearing to activity, +/‐ catch/locking, + x‐ray findings or affected limb older child/teen ã NSAIDS ã refer to CHW Sports Medicine Osteomyelitis Local tenderness/swelling bone, limp,+/‐ fever, elevated CBC, ESR, and CRP ã refer to emergency room ã emergent Restless Leg Syndrome Sleep disturbance, normal physical exam, no ã Referral to pediatric sleep center systemic symptoms, meet NIH RLS guidelines criteria Rickets No supplemental vitamin d, darker skin, genu ã treatment of rickets by primary care provider with involvement of CHW endocrine varum and x‐rays findings: widening/cupping team as needed of the metaphysis; abnormal labs ã refer to CHW Orthopedics for treatment of genu varum Scoliosis Thoracic/lumbar prominence on Adams ã refer to CHW Orthopedics‐scoliosis/spine conditions clinic forward bend test/ asymmetric shoulders/pelvis; Rarely painful; x‐ray PA/lateral scoliosis shows scoliosis Approved By: Allison Duey‐Holtz, MSN Date: 5/31/12 Office Phone: 414‐337‐7322 Page 10 Septic joint Pain with joint motion, redness, swelling, ã emergent warmth, restricted joint motion, non‐weight ã ultrasound hip joints to evaluate for septic hip bearing or limp, fever, elevated CBC, CRP, ESR ã refer CHW Emergency room septic joint work up protocol +/‐blood cultures Slipped Capital femoral epiphysis Often seen 10‐14yo teens, M F, overweight, ã emergent groin/knee pain, pain internal hip rotation, ã strict non‐weight bearing limp, + AP/frog lateral Pelvis x‐ray ã refer to emergency room for surgical stabilization Spondylolysis / Spondylolisthesis Pain with back extension, AP/Lat/Oblique ã refer to CHW Orthopedics‐scoliosis/spine conditions clinic lumbar sacral spine films +/‐ findings ã NSAIDS as needed for pain ã consider activity limitations until seen by subspecialty providers Strain/sprain Tender to palpation over soft tissue, +/‐ ã NSAIDS laxity, swelling, no significant pain with ã range of motion brace weight bearing ã begin ambulation as tolerated ã refer to physical therapy if needed ã refer to CHW Orthopedics with recurrent sprains Tarsal coalition Pain in foot with activity, often flat foot and ã refer to CHW Orthopedics restricted subtalar foot motion, +/‐ x‐ray findings Toxic synovitis Mild pain with hip motion, ambulatory, If ambulatory, afebrile, no constitutional symptoms, normal CBC, ESR, CRP, provider afebrile, normal CBC, CRP, ESR comfortable ã NSAIDS Labs needs to be evaluated ã follow up in 2 to 3 days ã ambulation as tolerated ã limit sports If any of following symptoms refer to CHW Emergency for septic joint work up protocol ã Nonweightbearing ã Febrile or constitutional symptoms ã Moderate‐severe pain ã Elevated WBC, CRP or ESR Adapted from Herring, J.A., (2007); Junnila, J.L. & Cartwright, V.W., (2006a); Sawyer, J.R. & Kapoor, M. 2009; Duey‐Holtz et al (2012a), (2012b), (2012c) Approved By: Allison Duey‐Holtz, MSN Date: 5/31/12 Office Phone: 414‐337‐7322 Page 11 Reference American Academy of Pediatrics. (2009). Red Book: 2009 Report of the Committee on Infectious Diseases (28th ed.). Elk Grove Village, IL: American Academy of Pediatrics. American Academy of Orthopaedic Surgeons. (2011). Sprained Ankle. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=A00150 Armstrong, K., Kohler, W.C., & Lilly, C.M. (2009). Managing sleep disorders: From A to Zzzz… Contemporary Pediatrics, 6(3), 28‐35. Arthritis Foundation. (2009). Diagnosis and disease process. Retrieved from http://www.arthritis.org/ja‐diagnosis.php Asadi‐Pooya, A. A. & Bordbar, M.R. (2007). Are laboratory tests necessary in making the diagnosis of limb pains typical for growing pains in children? Pediatrics International, 39, 833‐835. Ashwal,
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