Different Causes for Leg Pain in Children

There are many different causes and diagnoses for leg pain in children. Developmental stage or age groups many of these causes. Some, however, can occur at any age.

The numerous causes of leg pain in children include Legg-Calve-Perthes disease, sports injuries, toddler’s fractures, Slipped Capital Femoral Epiphysis(here forward referred to in the medical jargon of SCFE), and leg length differences.

Legg-Calve-Perthes is also referred to as Legg-Perthes, here forward to be referred to as LCP. LCP is rare, and in the United States only occurs at the ratio of 1:1200 children under the age of 15. The developmental stage when LCP becomes clinically evident is between the ages of 3-12 years of age, with 7 yrs being the median age.1 However, other sources site the specified age range as between 4-8 years, which actually is a representation of the median 7 years stated earlier.

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LCP is characterized not just by developmental age, but by sex, familial, and racial factors as well. Most LCP patients are Caucasian; in addition, most have a parent or close relative who suffered from the disease as well. Males are affected 4-5 times more frequently than females, but this is not a sex-linked trait. A genetic factor is implied, but with no identifiable gene as of yet.

LCP is defined “as the idiopathic avascular osteonecrosis of the capital femoral epiphysis of the femoral head.”

What happens in the case of LCP is this: due to unknown etiology, the head of the femur, which contains the epiphysis and epiphysial plate, becomes necrotic. Necrosis, meaning dead or dying tissue, in this case means that no further bone growth can occur, owing to the fact that blood supply has been cut off.

Since new bone cells are produced primarily at the epiphysial plate, no bone growth in the affected leg means that, until treated, it will become shorter than the unaffected leg. Soon afterward, a noticeable limp occurs due to pain and compensation for the self same pain. Children suffering from LCP may also have pain in the groin, knee, and thigh as well.

Necrosis in the femoral head leads to inflammation, thus being the initial cause of pain. Activity, especially excessive hip-leg activity such as running or jumping, will irritate the femoral head and increase the pain level. The pain can be relieved or lessened by rest.

X-ray films arrive at definitive diagnosis, but doctors suspecting the problem will look for clinical signs that LCP is present. These clinical signs include difficulty rotating the knee. If LCP has existed for some time and gone undiagnosed, other clinical signs will be indicative of its presence, such as atrophy of the buttocks, calf, or thigh muscle.

Those afflicted with LCP receive a myriad of treatments. The treatment plan is most likely individualized for each child depending on the severity of pain, atrophy, and gait difficulties.

The treatments used most commonly are “leg exercises, crutches, casts, bracing, and occasionally traction and surgery. With proper treatment, the bone will grow back and the child will be able to walk normally without pain.”

Toddler’s fractures can occur quite easily with a simple fall. Signs to look for are irritability of the child, persistent complaints of pain, and refusal to walk. These should be relied on heavily as a parent’s diagnosis of a problem, for inflammation and redness are minor at the site above the break.

The bone fractured in these cases is typically the tibia. The above-mentioned symptoms warrant immediate medical attention and typically reflect that a fracture has occurred if the child is between 2-4 years old.

Sports injuries can occur at any age of the active child. When a sports injury has occurred, pain and limping may result due to , i.e., ankle and knee sprains, or muscle strains. However, if limping persists after a few days of rest, or if the child refuses to bear weight on the leg, immediate medical attention is warranted.

Slipped Capital Femoral Epiphysis, with the medical acronym of SCFE, “is a common hip disorder in overweight adolescents…” The symptoms resulting from the slipped epiphysis are severe pain occurring in the hip and knee. This, in turn, results in limited movment of the affected hip, and limping. Diagnosis is by x-ray.

Treatments would include pain relief as prescribed by the doctor; a usual program of alternating Tylenol and Ibuprophen might be prescribed. Included in the treatment plan would be immediate counseling of the family and adolescent on proper diet, and allowable exercise considering the ailment.

Sickle Cell Disease(SCD) is the severest form of the sickling syndromes; this is because it is homozygous recessive. In other words, the child carries both recessive alleles on the chromosome. In all sickling syndromes, the problem results from the genetic error of the red blood cell design. In the United States, it is estimated that 1:12 Blacks are carriers of the sickle cell trait, and 1:65 develop sickle cell anemia. Though predominantly affecting Blacks in the U.S., other races are susceptible as well: people from the Mediterranean, India, Asia-Minor, and the Caribbean.

Rather than the normal shape of RBC’s, the genetic disorder causes sickle-shaped cells that do not allow oxygen to attach to the protein heme in an effective manner. This reduces oxygen available in the blood.

The prognosis for children with SCD is poor, in that death occurs during the middle-aged years. “Anemia usually is severe, chronic and hemolytic.” Both acute and chronic exacerbations will occur, the frequency of which is most likely tied to emotional and environmental factors. These environmental factors include emotional upset, situations that lead to dehydration, change of oxygen tension in the body(by infection, which is common, i.e.,), and weather changes – in particular cold. Environmental factors that can be eliminated altogether to help reduce the recurrence or severity of attacks are alcohol and tobacco.

The worst-case scenario, which does occur with these patients, is vaso-occlusive episodes. In these episodes, circulation is greatly hampered, resulting in pain concentrated in areas of localized necrotizing bone marrow, i.e., the sternum, ribs, long-bones, spine and pelvis. The occlusion is from clumped, sickle cells that cannot flow out of the area.

No specific therapy exists for SCD. However, depending on the type of crisis, be it the need to lower Hb S during an infarction, too little oxygen and RBC’s, severe dehydration, etc., transfusion is a frequent treatment – usually packed red blood cells are the blood component used.

“Transial Synovitis of the hip is a cause of hip pain in children.” The adjective ‘transial’ is used because the condition does not last long – approximately a week. Symptoms of pain occur in one hip, but pain may also be felt in the medial aspect of the knee and thigh. The pain occurs in the tissue surrounding the hip, not in the bones themselves.

The pain increases with different rates in children; some are in the doctor’s office within 1-3 days of onset, some a few days later as the pain peaks. The child may have a limp, or have trouble standing and walking by the time he’s seen. Once again, boys are affected more than girls. The age range affected is from 3-10 years of age.

Treatment is bed rest for 3-4 days and use of non-steroidal anti-inflammatories for pain relief, reduction of inflammation and swelling. The child returns to normal after this time period. If a temperature is present, the doctor may order x-rays and blood tests to rule out other hip conditions.

Leg Length Differences. The name is self-explanatory. “Some children are either born with or develop a difference in the length of the bones in their legs.” No etiology is given for either scenario, and both situations receive the same set of treatment choices. Differences in leg length between 0-2cm require no treatment most of the time, but shoe lifts may be used. If the length difference is between 5-15cm, surgery to lengthen one leg or to shorten the other is necessary, unless a prosthesis is chosen for the shorter limb.

In summary, there are many conditions and diseases that add to the suffering and cause of leg pain in children. The hip disorders and diseases discussed that are accompanied by knee and/or thigh pain, can be misdiagnosed as injuries originating in the knee, other than compensational pain as the symptoms really are. Though many affect children at different stages of life and bear different severity of diagnosis and prognosis, all are significant.

Bibliography

1. www.mrsci.com/Orthopedics/Perthes_disease.php, 10/26-27/06
2. www.hopkinsmedicine.org/orthopedicsurgery/perthes.html, 10/26-27/06
3. Hall & Brody:  Therapeutic Exercise:  Moving Toward Function, 2nd Edition c 2005, Lippincott, Williams, and Wilkins.
4. www.keepkidshealthy.com/symptoms/legpainlimping.html, 10/26-27/06
5. Phipps, Cassmeyer, Sands, Lehman, Medical-Surgical Nursing, Concepts and Clinical Practice, c 2005, Mosby. Shiel, Jr., William C., MD,
6. www.medicinenet.com/ankylosing_spondylitis/article.html, 10/26-27/06
7. www.familydoctor.org/181.xml, 10/26/06

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