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    Pain With A Limp

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    Emily Eresuma
    An 11-year-old female presented with 3 weeks of right leg pain and swelling, as well as 2 days of fever. Imaging showed an extensive right pelvic and thigh mass. Biopsy revealed a small round blue cell tumor, consistent with primitive neuroectodermal tumor (PNET)/Ewing sarcoma. She will receive chemotherapy before surgery to resect the tumor, followed by additional chemotherapy and radiation therapy.

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    Pain With A Limp

    Uploaded by

    Emily Eresuma
    278 views21 pages
    An 11-year-old female presented with 3 weeks of right leg pain and swelling, as well as 2 days of fever. Imaging showed an extensive right pelvic and thigh mass. Biopsy revealed a small round blue cell tumor, consistent with primitive neuroectodermal tumor (PNET)/Ewing sarcoma. She will receive chemotherapy before surgery to resect the tumor, followed by additional chemotherapy and radiation therapy.

    Original Description:

    Pediatric Morning Report. Primary Children's Hospital.

    Original Title

    Pain With a Limp

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    An 11-year-old female presented with 3 weeks of right leg pain and swelling, as well as 2 days of fever. Imaging showed an extensive right pelvic and thigh mass. Biopsy revealed a small round blue cell tumor, consistent with primitive neuroectodermal tumor (PNET)/Ewing sarcoma. She will receive chemotherapy before surgery to resect the tumor, followed by additional chemotherapy and radiation therapy.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    278 views21 pages

    Pain With A Limp

    Uploaded by

    Emily Eresuma
    An 11-year-old female presented with 3 weeks of right leg pain and swelling, as well as 2 days of fever. Imaging showed an extensive right pelvic and thigh mass. Biopsy revealed a small round blue cell tumor, consistent with primitive neuroectodermal tumor (PNET)/Ewing sarcoma. She will receive chemotherapy before surgery to resect the tumor, followed by additional chemotherapy and radiation therapy.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 21

    Morning Report Pain with a Limp

    MEGHAN EDMUNDSON

    H&P
    HPI: 11Y 9M female with PMH of hypothyroidism presents for right upper leg pain and limp for 3 weeks and 2 days of fever.

    HPI Details
    Pain is described as aching and burning radiating from the

    superior aspect of the right knee to the proximal femur. Patient can bear weight on her leg and ambulate. Pain is worse at the end of the day. Pain wakes her up at night. Ibuprofen provides minimal relief. No prior URI or GI symptoms but patient does develop diarrhea in the hospital. Patient is obese. No weight loss, pallor, bruising or bleeding. Aunt thought leg felt warm and brought her to ED.

    Additional Details
    PMH: hypothyroidism on Synthroid PSH: none IUTD except for Flu Medications: Synthroid NKDA Normal diet FH: Mom-hypothyroidism MGGM-"bone marrow cancer" PGF-adult onset leukemia SH: father passed away 3 weeks ago from unknown causes

    PE
    T 38.4. HR 88. RR 20. BP 123/70. SaO2 95% on Room Air. WEIGHT - 71.1 Kg GENERAL: alert, smiling and cooperative, well developed and nourished girl in no acute distress HEAD: normocephalic, atraumatic. EYES: normal pupillary reflexes bilaterally, extraocular movements intact, no conjunctival injection. EARS: normally placed NOSE: no discharge or obstruction. OROPHARYNX: moist mucus membranes, tonsils 1+ without exudate, no pharyngeal erythema or lesions. NECK: supple without lymphadenopathy or tenderness to palpation. CARDIOVASCULAR: normal rate, rhythm, and S1/S2, without murmur or gallop. Pulses appropriate. Capillary refill time <2-3 seconds. LUNGS: clear to auscultation bilaterally, good air flow, no retractions. ABDOMEN: obese, soft, non-tender, non-distended with active bowel sounds and no masses or hepatosplenomegaly. EXTREMITIES: all extremities warm and well perfused. No cyanosis, clubbing, or edema. Full range of motion in left hip and left knee. Right hip - pain with internal and external rotation, no redness or obvious swelling. Full range of motion in right knee. NEUROLOGIC: awake and alert, cranial nerves II-XII grossly intact, moving four extremities equally with normal tone, no focal deficits.

    Now what?

    LABS? IMAGING? CONSULTS?

    Labs
    BMP- 143/3.8/103/26/11/0.64/83 AG- 14 Ca- 9.8 CBC with diff- 12.2/11.9/36.7/458 N- 60.4 L-24.1 M-14.0 E- 7 B- 0.6 ESR- 60 CRP- 5.7 Blood cultures obtained

    Imaging
    XR Knee- Normal radiographs of the right knee. XR Hip- Normal radiographs of the right hip. Asymmetric positioning of the patient precludes comparison of bilateral fat planes surrounding the hip joint to assess for hip joint effusion. This should be correlated with known clinical information.

    Differential Diagnosis?

    Differential Diagnosis
    SCFE

    Legg Calve Perthes


    Septic Joint Transient Synovitis Osteomyelitis Osteosarcoma Leukemia, Lymphoma Psoas Abscess Post Infectious/Reactive Arthritis Benign Bone Tumors

    Further Work Up
    MRI of the Pelvis with and without contrast: Impression: 1. Extensive right pelvic and proximal thigh mass with encasement and infiltration of right pubic bone and medial right ischium. Small round blue cell tumor is favored. Osteogenic sarcoma is an additional consideration. Neurogenic tumor or lymphoma thought less likely. 2. Signal abnormality involving inferior right ilium and lateral ischium, peritumoral edema versus tumor involvement. 3. Enlargement and signal abnormality right obturator externus and adductor musculature of proximal right thigh, peritumoral edema versus tumor involvement. 4. Pathologically enlarged right external iliac lymph node, smaller right common iliac chain nodes.

    Heme Onc Consult


    Ortho for tissue biopsy Chest Ct for pulm mets Bilateral BM Aspirates Surgical path report Port placed Follow up for outpatient Cxs, prelim path-small

    round blue cell tumor Normal No evidence of leukemia or lymphoma Consistent with PNET/Ewing Sarcoma

    chemo treatment

    Future Plan
    Chemo before surgery: vincristine, doxorubicin,

    cyclophosphamide, ifosfamide, and etoposide Resected tissue studied for necrosis >90-95% indicated good response Post op chemo and radiotherapy

    Clues
    Pain and swelling not responding to conservative

    therapy Deep bone pain Nighttime awakening Palpable mass X-ray showing a lesion Ewings is more likely to be associated with systemic findings

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