Child with a painless limp – An unusual presentation of a pelvic tumour.
Jayadeep Jayachandran, Lewys Peters
The presence of any disease process often presents with symptoms which are characteristic to that disease. Broad differentials are mperative when considering any disease processes. When the obvious diagnosis is not picked up with the clinical and diagnostic modalities the general practitioner should refer the case for specialist opinion.
We report a case of a child with a painless limp which the diagnosis was delayed as the initial investigation modality failed to diagnose a lesion in the affected pelvis.
A fit and well 12-year-old boy, with no history of any metabolic disorders or trauma had presented to the general practitioner with a limp which had been there for a few weeks. The parents had attributed this to increased sporting activity and had rested him for a week and when the symptoms failed to settle sought the GP consultation.
The GP after clinical evaluation requested a radiograph of the knee, as the knee was thought to be the culprit. The radiograph had been reported as normal. The GP had advised reduction of activity and analgesics. As the symptoms failed to settle, further review at the practice at about 2 months of the initial presentation was arranged,
At this stage a pelvic radiograph was performed and as this was reported as suspicious and the patient was referred to our Paediatric unit. Orthopaedic opinion was sought as a routine by the Paediatric team.
On examination he had a painless gait with no pain on palpation around the hip and abdomen, full range of movements of the hip.
Blood and urine tests were performed and did not reveal any abnormalities.
The radiographs were reviewed with a radiologist with special interest in musculo skeletal conditions. As the symptoms persisted, we made a provisional diagnosis of a ‘possible’ early slip capital epiphysis and requested an urgent MRI scan of the hip joint.
MRI of the hip revealed a large expansile lesion on the quadrilateral plate of the iliac bone.
Patient was referred to the Bone tumor unit in Birmingham. After a multi-disciplinary review the decision was made to perform a biopsy to confirm the diagnosis. He underwent a biopsy via a limited anterior approach.
The biopsy revealed the tumour as a giant cell tumour and further surgery was deemed to be appropriate in view of the child’s age and location of the lesion.
The tumour unit has arranged regular review of the patient and plans to deal with appropriately with serial clinical examination and imaging.
Painful limp in the age group commonly is attributed to either a slipped capital femoral epiphysis or late onset Perthes disease. Tumours are very rare and almost seldom in the differentials entertained. Lesions at this age group are usually aneurysmal bone cyst, with giant cell tumour and Ewing’s Sarcoma as differentials.
Limping child is a fairly common presentation in the paediatric patients and is usually due to transient synovitis. It is important to consider all possibilities and evaluate with MRI scans when the clinical and radiologic investigations are unremarkable and symptoms do not resolve in a few weeks.
GCT in the pelvis in paediatric age group is a rare occurrence. As a primary bone tumour GCT occurs in 5 % of cases and 20% of benign skeletal tumours. The prevalence of GCT is maximum in the third decade and about 80 % occurs in the age group 30 to 50. Less than 3 % of GCT occur in patients under 14.