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Chapter 19 • Hoarseness 241
https://t.me/med1917
Laryngeal Papillomas
Patients with psychogenic hoarseness will have a low,
breathy voice caused by voluntarily abducting the
vocal cords during phonation. Physical examination
will be normal. Psychogenic hoarseness may follow a
traumatic event.
These are the most common laryngeal lesions that occur
during childhood. Most patients are between the ages of
2 and 7 and present with hoarseness. Occasionally papillomas, caused by the human papillomavirus, are seen in
newborns.
DIFFERENTIAL DIAGNOSIS OF Common Causes of Hoarseness
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Acute laryngitis Voice overuse, exposure to
environmental irritants,
recent URI
Acute
epiglottitis
Trauma Hoarseness after intubation;
Acute laryngeal edema History of food or drug allergy Edema of lips, tongue,
Laryngotracheobronchitis
(croup)
Chronic
laryngitis
Polyps History of allergy; voice abuse,
Neoplasm Smoking, airborne exposure,
Adults: rapid onset of sore
throat, dyspnea, hoarseness;
child: drooling, forwardleaning posture
direct throat trauma or
foreign body
Children 3 mo to 3 yr;
recent URI
Chronic history of smoking
and alcohol use; exposure
to environmental irritants;
chronic cough; duration of
hoarseness .3 wk
GERD, smoker; duration of
symptoms .3 wk;
progressive hoarseness,
worse at end of day, but near
normal in morning;
hoarseness may change
with position
chronic alcohol use, history
of chronic cough, hoarseness
for .3 wk
Voice quality: aphonia,
cervical lymphadenopathy;
pharyngitis; edema and
redness of vocal cords
Voice quality froglike;
fever, signs of respiratory
distress; drooling
Subluxation of
cricoarytenoid joint
and hypopharynx;
observe for respiratory
distress; voice quality
breathy
Barking cough, low-grade
fever, wheezing,
hoarseness; edema of
vocal cords; observe
for signs of respiratory
distress
Edema of vocal cords;
nodules may be present
Polyps visible on vocal
cords
Tracheal deviation; pain
with advanced tumor;
hoarseness may be
only sign
None, if duration of
hoarseness is ,3 wk
Possible airway support;
lateral and AP
radiographic views
of neck
Lateral and AP
radiographic views of
neck; laryngoscopy
Possible airway support
None initially, airway
support may be
necessary
Lateral and AP
radiographic views of
neck; laryngoscopy
ENT referral for biopsy
ENT referral for biopsy
Continued
242 Chapter 19 • Hoarseness
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Hoarseness—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
GERD History of upper GI burning;
cough especially at night;
chronic use of alcohol,
NSAIDs, or aspirin; history
of ulcer disease, smoker,
age ,45 yr; frequent throat
clearing
Hypothyroidism Presence of systemic symp-
toms, such as cold intolerance, weight gain, fatigue;
age .65 yr; postpartal
women; family history of
thyroid disease
Vocal cord paralysis Chronic cough; inspiratory
or expiratory stridor with
exertion
Psychogenic hoarseness History of psychiatric illness or
psychological trauma
Laryngeal
papillomas
AP, anteroposterior; CN, cranial nerve; DTR, deep tendon reflex; ENT, ear, nose, and throat; GERD, gastroesophageal reflux disease;
GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs; T4, thyroxine; TSH, thyroid-stimulating hormone; URI, upper respiratory tract
infection.
Children 2-12 yr and may
occur in infants; history of
maternal human
papillomavirus; may be
recurrent, progressive
May have epigastric
tenderness on palpation;
vocal cord inflammation
or ulcers
Normal or enlarged thyroid
gland, coarse hair, very
dry skin, prolonged DTR
recovery
Breathy, weak, soft voice;
abnormal movement
(usually unilateral) of
vocal cords; examination
may suggest specific CN
involvement
Breathy, low voice; larynx
will appear normal
Faint cry, severe stridor,
voice change, or
complete aphonia
Referral for endoscopy if
symptoms not relieved
with medication or
dietary alterations
TSH, free T4 index
Refer for ENT evaluation
As indicated to rule
out other causes
(i.e., lateral and AP
radiographic views of
neck); laryngoscopy
Refer for ENT evaluation
REFERENCES AND READINGS
Baneld G, Tandon P, Solomons N: Hoarse voice: an early symptom
of many conditions, Practitioner 244:267, 2000.
Dejonckere PH: Voice problems in children: pathogenesis and
diagnosis, Int J Pediatr Otorhinolaryngol 49:S311, 1999.
Garrett CG, Ossoff RH: Hoarseness, Med Clin North Am 83:115,
1999.
Hartnick CJ, Cotton RT: Congenital laryngeal anomalies: laryngeal
atresia, stenosis, webs, and clefts, Otolaryngol Clin North Am
33:1293, 2000.
McMurray JS: Disorders of phonation in children, Ped Clin North
Am 50:2, 2003.
Schwartz SR, Cohen SM, Dailey SH, Rosenfeld RM, Deutsch ES,
Gillespie MB et al: Clinical practice guideline: hoarseness (dysphonia), Otolaryngol Head Neck Surg 141:S1, 2009.
Sobol SE: Epiglottitis and croup, Otolaryngol Clin North Am
41:551, 2008.
Syed I, Daniels E, Blach NR: Hoarse voice in adults: an evidenced-
based approach to 12 minute consultation, Clin Otolarnygol
34:54, 2009.
Van der Goten A: Evaluation of the patient with hoarseness, Eur
Radiol 14:1406, 2004.
Wiatrak BJ: Congenital anomalies of the larynx and trachea,
Otolaryngol Clin North Am 33:91, 2000.
C H A P T E R
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20
Limb Pain
eports of pain in a limb present a diagnostic
challenge because of the many possible
R
broad range of differential diagnoses, it is best to use
a framework of differentiating the pain as a symptom
of musculoskeletal injury, musculoskeletal or joint
disease, systemic disease, or a mixture of factors.
Pain can be the result of a direct reaction in tissues,
secondary reaction in adjacent tissues, or referral
from a proximal or distal lesion or from organs
such as the heart or kidney. In children, aches and
pains in limbs are common; however, the presence,
location, and intensity of the pain are often difcult
to assess. Interpretation of pain is often made by the
parents.
affects the bones, muscles, and tendons and injury/
inammation of a joint that can affect surrounding
musculature, nerves, and blood vessels. For example,
lower extremity pain is often referred from the low
back and emanates from irritated nerve roots or is
secondary to myofascial syndromes of the low back,
pelvic, and hip musculature.
DIAGNOSTIC REASONING:
FOCUSED HISTORY
pathophysiological causes. Because of the
It is helpful to distinguish between limb pain that
Is the pain related to an urgent problem
that needs immediate treatment to avoid
disability or death?
Key Questions
n Have you had a recent injury?
n Can you describe exactly how the injury occurred?
n Do you have any other symptoms, such as fatigue,
fever, or swollen joints?
n What is the severity of the pain? Does it occur with
exercise or rest?
Injury
Injuries to the musculoskeletal system can range from
simple muscular strain to a signicant fracture associated with nerve or vascular injury. Therefore, when a
patient presents with a history of trauma, the priority is
to assess the vascular integrity of the limb. Neurological
integrity is next. Symptoms of coldness, severe pain, or
paresthesia are signals that physical examination should
begin immediately to assess the extent of injury and the
need for emergency treatment. Acute pain and swelling
that follow trauma usually indicate injury to a previously normal structure.
If the injury does not warrant urgent attention,
obtain further history. Ask questions that specify the
mechanism of injury, such as a direct blow or impact,
landing position after a fall, twisting, jumping, running, overstretching, or overuse. When discussing the
precipitating event, ask the patient to describe any
noise such as snapping, popping, or breaking that
may have occurred with the injury.
Constitutional Symptoms
The presence of generalized symptoms, such as
fever, weight loss, general malaise, or hot swollen
joints, suggests the presence of a systemic disorder
such as infection or rheumatic disease. In addition,
infection in a child causes systemic illness and the
child appears ill.
Fever related to joint problems can be the result of
hematogenous seeding by an organism, direct invasion as
a result of trauma or puncture, or migration from an adjacent area of infection. In rheumatic fever, a ß-hemolytic
streptococcal infection precedes the initial joint pain by 1
to 3 weeks. Often the hip joint may be the rst of many
joints affected before polyarticular migratory involvement occurs. The fever is sustained, not intermittent.
Fever spikes are seen with chronic forms of arthritis in
children.
243
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Other systemic infections associated with polyarthritis include bacterial endocarditis, Lyme disease,
syphilis, and such viruses as hepatitis B, rubella, cytomegalovirus, human immunodeciency virus (HIV),
Epstein-Barr virus, and varicella zoster.
Severity of Pain
Unrelenting diffuse pain, often occurring at night, is
an indication of bone involvement, either through bone
cancer or an infection such as osteomyelitis or septic hip.
Claudication and neurogenic pain increase with activity
and decrease with rest, more immediately for vascular
causes and more slowly for neurogenic causes.
Lack of spontaneous movement of a limb in a child
indicates pain and is often called pseudoparalysis.
What does the location of the pain tell me?
Key Questions
n Where does it hurt?
n Is the pain local or generalized?
Location
Location of pain provides a clue for identifying the site
where the pain originates. Local pain receptors signal the
site of irritation, and an increase in sensitivity (hyperesthesia) results. Referred pain generally involves the
muscle chains, nerve pathways, and vessels. Unilateral,
circumscribed limb or quadrant pain involves autonomic
nerve bers. Bilateral pain is more likely to originate
from systemic involvement. Diffuse pain with inconsistent distribution may be the result of psychosomatic
conditions such as depression and anxiety. Diffuse pain
over trigger points is indicative of bromyalgia. Collagen diseases and connective tissue diseases can affect
one or more joints. The more vaguely dened the boundaries of the pain, the deeper or more central is the location of the somatic irritation. The obturator nerve has
sensory branches that innervate the hip and skin on the
medial aspect of the thigh, causing pain that comes from
the hip to feel as though the pain is in the knee.
Could this be caused by a sprain or strain?
Strain
A strain involves injury to muscles and tendons, whereas
sprains involve injury to ligamentous structures. Both
types of injuries can produce a ripping or tearing sound
and range in severity from minor damage to a complete
tear. Injuries are generally classied as mild, moderate,
or severe. A moderate to severe strain/sprain may involve
some loss of joint or ligament stability. Strains may be
acute or chronic. Injury commonly occurs when lateral
stress is applied while the joint is plantar exed. This
position is the least stable position of the ankle, and the
overstretched ligaments are more susceptible to eversion
or inversion forces.
Sprain
Sprains cause minimal to moderate pain increasing 1 to
2 days after the trauma when the inammatory process
begins. A complete disruption that severs the sensory
nerve bers within the structure will cause little pain,
whereas a partial injury irritates sensory bers and may
produce intense pain.
In children, ligaments and joint capsules are two to
ve times stronger than the epiphysis; therefore, growth
plate injuries are more common than sprains.
Fracture
A fracture produces diffuse swelling around the injured
bone soon after injury. Deformity will be present if the
fracture is displaced. A patient may report hearing a
crack and being disabled by the increased severity of
pain with weight bearing or movement of the limb.
With stress fracture, there may be mild swelling and
tenderness and pain with weight bearing.
If there is no history of trauma or a
precipitating event, what else is causing
the pain?
Key Questions
n Can you describe your usual daily activities at
home, at work, and with hobbies?
n How does the pain affect your activities?
n Do you have other illnesses?
Key Questions
n Describe how the injury occurred.
n Did you hear a noise with the injury, such as a rip-
ping or cracking sound?
n Were you able to use the limb after the injury?
Overuse
Repetitive microtrauma results from cumulative injury
or overuse. This type of trauma most often affects the
ngers, wrists, and upper extremities. Persons who
work on keyboards for long periods may complain of
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paresthesia of the ngers and pain and soreness of the
wrists and ngers. Weekend hobbies or participation in
sports may result in overuse of certain muscle groups
associated with those activities.
Activities
A person may adapt to chronic musculoskeletal problems
by using an assistive device such as a cane or by limiting
activities. Rheumatic disorders produce symmetrical discomfort and pain with inactivity. Noninammatory conditions are often associated with asymmetrical pain after
extended use. Children will often avoid walking on a
limb that causes pain. Infants will have lack of movement of the limb as well as irritability and fussiness when
the limb is moved passively.
Other Illnesses
The presence of coronary artery disease increases the
risk of arterial insufciency and associated claudication pain. Peripheral neuropathy associated with diabetes can produce a burning pain or “pins and needles”
sensation, especially in the lower extremities.
In joint pain with injury, what do I need to
know about the specic joints involved?
Upper Extremity: Shoulder, Wrist, Elbow
Key Questions
n Is the pain in your dominant limb?
n Did you fall on an outstretched hand or arm?
n Did you overuse a joint?
Pain in the dominant hand may indicate repetitive microtrauma or overuse. Breaking a fall with an outstretched arm is a common mechanism of injury for a
fracture or dislocation of the hand or wrist.
Lower Extremity: Knee, Ankle
Key Questions
n How is the pain affected by weight bearing or activity?
n Did you feel a sense of “giving way”?
n Did you hear a pop, tear, or other sound?
n In what position was your leg when you hurt
your knee?
Continuing with an activity means the injury did not
totally disrupt any ligamentous structures. An inability
to straighten or bend the knee suggests a mechanical
blockage, such as a patellar dislocation or meniscus
tear. In chondromalacia, the patient can bend the knee,
but the movement is usually painful.
A loud pop is virtually diagnostic of an anterior
cruciate ligament (ACL) tear. A ripping sound suggests
a meniscus injury. A cracking sound may signify a
bony injury or dislocation of the patella.
A quick change in direction or a sudden stop may put
more force on the ligaments than they can dissipate,
resulting in acute rupture. A sudden twisting injury is
likely to represent a meniscus tear and a serious ligament disruption. Running or jumping activities are
commonly associated with knee and ankle injuries.
In children, 10% to 20% of knee symptoms are the
result of a problem in the hip joint.
Could this be musculoskeletal or joint disease?
Key Question
n Can you describe the pain?
In general, sharp, piercing, stabbing, cutting, pinching,
gnawing pain is most common with lesions of the
nerves and skin. Dull, tearing, boring, burning, and
cramping are common terms used to describe pain arising from deeper structures such as muscles, joints, and
internal organs. Pulsating, pounding, throbbing, and
hammering are common descriptions of vascular pain.
Gradually increasing sensations of pressure, tension,
heaviness, and calf pain indicate venous obstruction.
Severe pain that develops over 1 to 4 days is typical
of osteomyelitis or septic arthritis in children, which is
an emergency condition.
Muscle pain is caused by receptors located in bursa,
muscle bers, ligaments, and tendon attachments. It is
a diffuse, dull, gnawing, boring, or tearing pain that
increases with use and decreases with rest.
Intraarticular pain arises from receptors of the synovial membrane, joint capsule, or the brochondral layers
of the articular surfaces. Joint pain is either inammatory or degenerative. Inammatory joint pain radiates
diffusely to surrounding tissues. It is intense, sharp,
burning, boring, or pulsating (effusion) pain. It persists
during rest and is evident especially at night, worsening
in the morning with stiffness that lasts more than
45 minutes, and then improves throughout the day.
Degenerative joint pain radiates to the soft tissue
structures around the joint (i.e., muscles, ligaments, tendons). It is dull, boring, and gnawing when associated
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with muscle pain, or it can be a sharp, acute pain that
increases with overuse.
Bone lesions cause a dull ache; periosteal pain is
sharp and not well localized, and increases in intensity
with dependency of the extremity.
Neuralgic pain occurs in the distribution of a peripheral nerve or nerve root. The pain is stabbing or
cutting and can also present as pricking or lacerating.
What does the history of swelling tell me?
Key Questions
n Is there any swelling?
n When did the swelling begin?
Swelling
Swelling around a joint is always abnormal. Children
do not always recognize swelling; they often report
that they cannot squat down or ex their knee fully
because it feels “full or tight.”
Generally, swelling that develops immediately or
within 2 hours after an injury is the result of a fracture
or hemarthrosis and indicates a severe injury. Swelling
6 to 24 hours after an injury is usually of synovial origin, such as a meniscal tear, subluxation, dislocation,
or ligamentous damage. Swelling after 24 hours suggests an inammatory response.
Is this an acute or a chronic problem?
Key Questions
n When did the pain rst occur?
n When did you rst notice a problem?
dryer, opening jars, holding a pen, or handling eating
utensils.
How is activity affected?
Key Questions
n What are your usual activities?
n What activity makes the pain worse?
n What movements make the pain worse?
A large percentage of musculoskeletal injuries are caused
by repetitive motion that leads to microtrauma and eventually cumulative damage. Repetitive microtrauma in the
lower extremities from inappropriate rate and intensity of
training, shoe wear, or playing surfaces can cause stress
fractures of the weight-bearing bones of the lower limbs.
Pain is worse over the site of the fracture.
In children, pain in the groin or referred to the knee
and anterior thigh, occurring intermittently after activity and gradually becoming constant, may indicate
Legg-Calvé-Perthes disease (LCPD).
Intraarticular lesions usually worsen with joint motion and sports activities. Intraosseous tumors are less
sensitive to joint motion.
In children with a septic hip, pain increases with
movement.
What does joint stiffness or locking tell me?
Key Questions
n Have you had any joint stiffness?
n Does activity make the stiffness worse or better?
n Do you have locking of the knee?
Pain experienced hours after an injury or physical activity
is usually caused by acute extensor injury or overuse.
Severe ligament sprain is manifested as an immediately
disabling pain at the moment of the injury.
Determining if the complaint is acute or chronic
helps to differentiate the cause. Chronic joint problems
compound each other, whereas intermittent or episodic
pain is characteristic of diseases of the musculoskeletal
system. In children, limping or not using the extremity
may be a signal that the child is experiencing pain.
Parents will often note the loss of motion in an extremity or an awkward gait; they often report that the child
is unable to perform routine activities.
Patients may report noticing pain, weakness, or difculty in activities of daily living, such as using a hair
Joint Stiffness or Locking
Stiffness is felt after being in one position for a long time.
This complaint gets confused with locking of the knee,
which is an abrupt occurrence where the patient complains that something “gets in the way” and is unable
to fully extend the knee. Manipulation of the leg often
results in an equally abrupt unlocking. This is usually a
sign of a chronic unstable meniscus tear.
Stiffness is a common feature of any inammatory
arthropathy. It is important to know whether it is localized or generalized. The length of time the stiffness lasts
in the morning is a useful index of active synovitis in
disease states such as rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE). With most inammatory arthropathies, stiffness and pain are alleviated by
Chapter 20 • Limb Pain 247
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activity, whereas mechanical problems are aggravated
by activity. Musculoskeletal tumors commonly present
with mild joint stiffness because of muscle involvement
but rarely demonstrate instability.
What does the history of a limp tell me?
Key Questions
n Is there pain with the limp?
n Did the limp develop suddenly?
n Is the limp constant or intermittent?
n What is the effect of running or climbing stairs?
Limp
Limping is a pathological alteration of a smooth, regular
gait pattern and is never normal. Gait can be divided into
two phases: stance and swing. The stance phase starts
with the foot in contact with the ground and ends with
the toe being lifted off the ground; the limb supports all
the body weight. The swing phase begins with the toe
elevated from the ground and ends with the heel strike.
During the swing phase, the foot is not touching the
ground; the pelvis rotates forward and tilts slightly while
the trunk maintains a neutral position. Limp after strenuous running may indicate a stress fracture.
Quadriceps weakness causes difculty in climbing
stairs. During ambulation, this weakness causes the
knee to be unstable on heel strike, and assistance is
needed to push the knee manually into an extended
position.
Neuromuscular diseases can result in progressive
and painless muscle weakness or spasticity that affects
ambulation in a variety of ways.
Symptoms of pain and limping in children may
be incorrectly attributed to trauma instead of a more
serious problem such as neoplastic tumors or bone
infections.
Could this be caused by systemic disease?
Key Questions
n Have you been treated with antibiotics recently?
n Have you had any recent immunizations?
n Does the pain awaken you at night?
n Is the pain worse at night?
Medications
Certain antibiotics can cause serum sickness in children,
producing joint pain and fever.
Transient arthralgia may occur 6 to 8 weeks after
receiving MMR (measles, mumps, rubella) immunization. Recurrent or permanent arthritis may follow
rubella vaccination, especially in adult females.
In adults, uoroquinolone antibiotics can produce
tendinitis or tendon rupture.
Night Pain
Intense pain may occur at rest and during the night. At
rst the pain may occur only when the patient changes
position while sleeping; however, as the pain increases, it
will disrupt sleep. Report by an adolescent of night pain
is a red ag for the intraosseous pain of a bone tumor.
Pain in the lower limbs in children 6 to 12 who are in a
rapid linear growth period may awaken a child at night.
The cause of these “growing pains” is unknown, but they
are thought to result from muscle structures that have
to catch up with bone growth. The pains are usually
bilateral with no objective ndings.
Could the pain be caused by Lyme disease?
Key Questions
n Have you been camping or spending time in wooded
areas?
n Have you noticed any skin rash?
Lyme Disease
Lyme disease is an infection caused by the tick-borne
spirochete Borrelia burgdorferi. Early symptoms include diffuse arthralgias, myalgias, fever, chills, and
a characteristic targetlike rash. Although the arthralgia may involve multiple joints, usually the knee is
the affected joint. Joint manifestations occur 1 week
to 2 years following the initial illness. Patients may or
may not recall the antecedent tick bite or exposure.
What does the medical history tell me?
Key Questions
n Have you had anything like this before?
n Do you have a chronic disease?
n Could you have been exposed to any sexually trans-
mitted infection?
n Have you been treated with cortisone?
n Have you had a recent upper respiratory tract infection?
Chronic diseases, such as sickle cell anemia, inammatory bowel disease, Crohn disease, hypothyroidism
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and hyperthyroidism, and collagen vascular diseases,
are frequently associated with skin rashes, psoriasis,
and limb and joint pain.
Gonorrhea disseminates to the musculoskeletal system in 1% to 3% of individuals with the disease. Of
these, more than 80% develop arthritis.
Patients with chronic illness that requires long-term
administration of corticosteroids are at risk for cortisoneinduced necrosis of the hip. Sickle cell anemia can cause
hip pain during a sickle cell crisis. Viral infections may
cause diffuse myalgia.
Is this a mixed condition?
Consider the possibility that a patient may have a condition that is a mix of factors, such as a systemic disorder that has resulted in an acute injury. Clues to mixed
etiology might include an injury that seems out of proportion to the extent of the precipitating activity or the
presence of a chronic condition or other symptoms that
might point to an undetected chronic condition. It is
important to evaluate the limb pain in the context of the
whole person.
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
Evaluation of musculoskeletal injuries should include
examination of joint stability, deformity, and function.
Examination should be done as soon after an injury as
possible for an accurate diagnosis. Always observe for
symmetry, and then functionally assess limbs and joints
bilaterally, beginning with the unaffected side. Order the
examination so that the most painful tests will be done
last. See Figures 20-1 through 20-4 for anatomical landmarks of the shoulder, elbow, knee, and ankle.
Observe Patient Walking, Removing
Coat/Jacket, Getting Into a Seated
Position
Subtle clues of child abuse must be considered when
the patient history is not consistent with the type or
extent of injury. Abuse should always be considered in
an infant within the rst year when symptoms and history suggest a fracture, multiple injuries, rotational injuries, or multiple bruises in different states of healing.
Radiographs may show previous fractures.
Persons who have septic joints appear ill, and
movement of the joint will increase the pain. Inspect
the patient with minimal clothing obstructing your
AC
A
CA
R
B
FIGURE 20-1 Bones and ligaments of the shoulder. R,
Rotator cuff; B, long head of the biceps; AC, acromioclavicular
joint capsule; CC, coracoclavicular ligaments; A, acromion;
C, coracoid process; CA, coracoacromial ligaments. (From
Mercier LR: Practical orthopedics, ed 6, St Louis, 2008, Mosby.)
C
R
O
B
FIGURE 20-2 Bony and ligamentous anatomy of the elbow.
R, Radial collateral ligament; O, orbicular ligament; B, biceps
insertion; U, ulnar collateral ligament; C, capitellum; T, trochlea.
(From Mercier LR: Practical orthopedics, ed 6, St Louis, 2008,
Mosby.)
C
T
CC
U
view of movements. A child with a septic hip lies with
the thigh in a position of exion, abduction, and external rotation and cries when a lower limb is moved.
In adults, an internally rotated abducted leg is the
posture assumed with a posterior hip dislocation. An
externally rotated hip and shortened lower extremity
are signs of hip fracture.
General stiffness or limitation of motion of a single
joint forces the surrounding joints to accommodate by
Anterior cruciate
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ligament
Fibular (lateral)
collateral ligament
Tendon of
popliteus m.
Lateral
meniscus
Transverse
ligament
Fibular
head
Posterior
cruciate ligament
Medial condyle
Tibial (medial)
collateral ligament
Medial meniscus
Patellar
tendon
Patella
Semimembranous
tendon
Popliteus m.
Tibia
Chapter 20 • Limb Pain 249
Posterior
meniscus
femoral
ligament
Fibular
collateral
ligament
Lateral
condyle
Lateral
meniscus
Popliteus
tendon
Oblique
popliteal
ligament
Fibular
head
Anterior
FIGURE 20-3 Basic anatomy of the right knee joint. (From Mathers LH et al: Clinical anatomy principles,
St Louis, 1996, Mosby.)
IM
AITF
ATF
PTF
CF
FIGURE 20-4 The lateral ankle ligaments—anterior and pos-
terior talofibular (ATF and PTF, respectively) and calcaneofibu-
lar (CF). Also shown are the anterior inferior tibiofibular (AITF)
ligament and the beginning of the interosseous membrane (IM).
(From Mercier LR: Practical orthopedics, ed 6, St Louis, 2008,
Mosby.)
moving with greater excursion or range of movement
than usual. This makes the gait appear irregular or jerky.
Look for Limp
Pain, weakness, and deformity cause limping. Limping
will be accentuated if the patient is asked to walk on
the heels or tiptoes.
Posterior
Common abnormal gaits related to limping are
Trendelenburg gait, antalgic gait, and circumduction
gait. Trendelenburg gait is a ducklike gait that reects
unilateral weakness of the gluteus medius muscle. The
pelvis drops on the unaffected side during weight bearing on the affected side. In antalgic gait, there is an
acute one-sided limp because the patient takes quick
soft steps to shorten the period of weight bearing on
the involved extremity. Stance time on the affected
limb is decreased while stride length of the opposite
side is shortened, allowing a quicker return of weight
bearing to the unaffected limb. This is a reex response
to weight bearing on a painful limb.
Circumduction gait is seen with pathology of the
foot or ankle and reduces discomfort by limiting movement of the ankle. The gait is characterized by a circular outward swing of the leg and external rotation of
the foot that requires less ankle movement. External
rotation of the entire extremity is seen with slipped
capital femoral epiphysis.
Have the patient stand on one foot, and then the
other. When standing on one leg, the gluteus medius on
that side maintains the opposite side of the pelvis level,
balancing the trunk over the weight-bearing hip. If the
hip abductors are weak or painful, the opposite side of
250 Chapter 20 • Limb Pain
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the pelvis dips down during the stance phase. With
each step, the trunk shifts toward the side of a painful
or weak extremity to decrease the force transmitted
through the extremity to the hip.
Assessment of gait is best done either before or after
examination, when patients are less aware that they are
being observed.
Ankle plantar exion and dorsiexion are necessary for normal gait. If plantar exion is restricted,
there is no push-off and the forefoot and heel come off
the oor at the same time. The result is a higher knee
lift and the forefoot may slap against the oor. This
condition is seen with weakness from peroneal nerve
injury or with painful dorsiexors associated with shin
splints.
Observe the patient walking with and without shoes.
If a child walks without difculty with shoes off, the
shoes are probably the problem. Inadequate shoe width
is a common source of foot pain in children.
Have Patient Locate the Pain
Have the patient point to the area of pain. Location of
pain and actual area of pathology may not be consistent. Hip pain often is referred to the knee area because
the anterior branch of the obturator nerve passes close
to the hip joint and, if irritated, provides a painful sensation to the medial side of the knee. True hip joint
pain arises in the trochanteric bursa and is perceived in
the groin area.
Shoulder pain from rotator cuff tendinitis is felt
over the lateral aspect of the deltoid.
Swelling of the elbow may compress the ulnar
nerve, producing a tingling sensation in the fourth and
fth ngers.
Pain in the groin, lateral hip, or knee in a child may
indicate LCPD.
Pain in the groin, buttocks, or lateral hip in a child
may indicate slipped femoral capital epiphysis.
Vague, nebulous discomfort in the front of the
thighs, in the calves, and behind the knees located outside of the joints in a child may indicate growing pains.
spine, hips, knees, and rst metatarsophalangeal (MTP)
joints. Joints are enlarged with Heberden (DIP joints)
and Bouchard (PIP joints) nodes. (See Figure 20-5.)
Joints affected by RA include PIPs, metacarpophalangeal (MCP), wrists, knees, elbows, cervical spine,
and MTPs. Joints are swollen with a fusiform-shaped
swelling of the PIP joints. Subluxation, ankylosis, and
ulnar deviation may be observed as a result of joint
destruction from chronic inammation.
Assess Vital Signs
Elevated temperatures are seen with neoplastic, systemic, and infectious processes such as osteomyelitis,
septic arthritis and septic hip in children, and rheumatic disease. Neonates may not exhibit a fever with a
septic hip but may refuse to feed and will exhibit other
symptoms of septicemia, such as lethargy and subnormal temperature. Palpate for quality and presence of
pulses in any injured limb and compare to the opposite
side. Assess peripheral pulses for presence, rate, regularity, strength, and equality.
Inspect the Skin and Nails
Inspect the skin for redness and inammation. Chronic
venous obstruction in the lower extremities causes a
brownish coloring of the skin. Trophic skin changes
from arterial insufciency cause thin, shiny skin with
an absence of hair and brittle nails.
Lyme disease usually presents with a rash before
joint involvement; however, rash may occur concurrently. The rash, often characteristically found on the
trunk, is an erythematous papule that develops into an
Note Any Deformities
Fractures generally produce unilateral deformities or
swelling in the extremities. Inammatory and degenerative joint diseases produce observable joint swelling
and deformity that usually occurs bilaterally.
Osteoarthritis typically involves the distal interpha-
langeal (DIP) and proximal interphalangeal (PIP) joints,
FIGURE 20-5 Osteoarthritis of the hand. Heberden nodes are
shown at the DIP joints. (From Concannon MJ: Common hand
problems in primary care, Philadelphia, 1999, Hanley & Belfus.)
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