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Epiglottis
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Vestibular fold
(false vocal cord)
Chapter 21 • Hoarseness
Base of tongue
Vocal folds
(true vocal cords)
249
Trachea
FIGURE 21-1 View of the interior of the larynx. (From Christensen B, Kockrow E: Foundations and adult
health nursing, ed. 6, St. Louis, 2011, Mosby.)
Progression
Progressive hoarseness usually indicates a lesion such
as a laryngeal or hypopharyngeal cyst.
What does the onset of hoarseness tell me?
Key Questions
l
How did the hoarseness develop?
l
Is there any history of trauma to the throat?
l
Have you had any recent surgery around the throat
or neck?
Onset
Acute onset of hoarseness is usually the result of infec-
tion or trauma. The trauma can be from direct injury
(foreign body, accidents) or overuse from screaming.
The overuse can be gradual, resulting in progressive
hoarseness and vocal cord changes. This hoarseness is
worse in the afternoon or evening.
Hoarseness from birth may indicate a congenital
problem, such as laryngeal web, cyst, palsy, or angioma. Newborns with aphonia, or a hoarse cry that does
not resolve, may have a congenital anomaly, papilloma, or vocal cord paralysis.
Trauma
External trauma to the throat is rarely a cause of
hoarseness, but it can result in hematoma formation in
the laryngeal soft tissues. There can also be mucosal
lacerations, arytenoid cartilage dislocation, or fracture
of the laryngeal cartilage. Internal trauma can occur
with endotracheal intubation associated with surgery
Arytenoid cartilage
Cuneiform cartilage
Corniculate cartilage
when an endotracheal tube catches on laryngeal structures and is pushed against resistance.
Surgical History
Hoarseness or voice change is a sign of the vagus nerve
(cranial nerve [CN] X). Surgery such as tonsillectomy,
thyroidectomy, or rhinoplasty can alter the quality of
the voice secondary to structural change and scarring.
Damage to CN X can also be the result of hormone
imbalance, bacterial infection, or tumor.
Does the presence of risk factors help narrow
the diagnosis?
Key Questions
l
Have you had a recent cold or upper respiratory tract
infection?
l
Do you have allergies or asthma?
l
Do you smoke? How long have you been a smoker?
l
How much alcohol do you drink?
l
Can you describe your voice habits, such as singing,
talking, and shouting?
l
Are you frequently exposed to dust, fumes, or loud
noise?
l
Are your immunizations up to date?
Upper Respiratory Infection
Acute laryngitis, epiglottitis, and acute laryngotracheobronchitis (croup) are sequelae from a viral upper respiratory infection (URI) that can result in vocal cord
inammation. Postnasal discharge that is thick and
purulent may pool around the larynx and cause chronic
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Chapter 21 • Hoarseness
secondary edema. Nasal congestion that leads to mouth
breathing produces laryngeal dryness, with resultant
hoarseness on arising in the morning.
Children who have epiglottitis are not hoarse, but as
the epiglottis swells, the voice becomes mufed and
drooling is observed.
Allergies and Asthma
Poorly controlled or undiagnosed asthma can result in
a chronic cough with subsequent hoarseness. Allergies can cause chronic or recurrent irritation and
swelling of both the upper and lower airways. Children who have a history of asthma and/or allergies
can develop vocal cord edema, inammation, and
hoarseness.
Smoking
Cigarette smoking is the most signicant risk factor for
laryngeal cancer. Smoking is also a risk factor for acute
or chronic laryngitis because smoke irritates all mucous membranes and impairs ciliary function, causing
pooling of secretions around the larynx.
Alcohol Consumption
Chronic consumption of hard liquor is a direct irritant
to the throat and is associated with laryngeal cancer.
Voice Habits
Voice misuse occurs when the true vocal cords are
forced to vibrate under undue stress and tension. Voice
abuse is exuberant overuse and can lead to inammation and edema of the larynx, hemorrhage, or vocal
cord polyps. A gradual progression of hoarseness
may go unnoticed by the patient. Often a precipitating
incident (such as shouting, excessive speaking, or
singing) produces acute laryngitis. Specic questions
may need to be asked to make the patient aware
of conditions that lead to voice abuse, such as the
following:
l
Have others noticed a change in the quality of your
voice?
l
Do you talk frequently to people who are hard of
hearing?
l
Do you yell at children?
l
Do you work in an environment that is noisy or con-
tains dust and fumes?
l
Have you recently attended a sporting event?
Exposures
Patients who are chronically exposed to work environments that contain dust, fumes, or a high noise level
that leads to chronic voice abuse are at increased risk
for laryngeal cancer.
Immunizations
Laryngeal diphtheria should be considered in patients
who have failed to update their diphtheria immunizations. For adults, the tetanus, diphtheria, and acellular
pertussis (Td/Tdap) vaccination is recommended
once and then tetanus-diphtheria (Td) boosters every
10 years; pregnant women are advised to have a
Tdap during each pregnancy (www.cdc.gov/vaccines/
schedules/hcp/adult.html). Laryngeal diphtheria usu-
ally develops as a downward progression of the tonsillar pharyngeal membrane.
What other clues will help narrow the diagnostic
possibilities?
Key Questions
l
Does the hoarseness change during the day?
l
Is it painful?
l
What other symptoms are present?
l
Do you have a neurological disorder?
Timing
Hoarseness that is altered by a position change suggests a mobile lesion, such as a pedunculated polyp.
Patients with myasthenia gravis have a normal voice in
the morning with progressive hoarseness throughout
the day.
Pain
Pain may be associated with an inammatory process,
such as a viral URI or GERD. Pain occurs late in laryngeal cancer. Neurological and hormonal causes do not
usually produce pain.
Associated Symptoms
The presence of cough, shortness of breath, weight
loss, dysphagia, ear pain, or throat pain should raise
concerns about neoplasm, systemic disease, or neurological causes. Hormonal disorders, such as hypothyroidism, will also produce signs and symptoms that
vary in severity according to the duration and degree
of hormone deciency. Early symptoms of hypothyroidism include cold intolerance, heavy menses, weight
gain, dry skin, fatigue, and constipation. Later signs
and symptoms include hoarseness, very dry skin, hair
loss of lateral eyebrows, and neurological symptoms,
such as delayed deep tendon reex recovery, depression, and mental confusion.
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251
Neurological Disease
Patients with parkinsonism, myasthenia gravis, or
amyotrophic lateral sclerosis have progressive dysarthria and dysphagia. As neurological disease progresses, patients will develop a chronic cough and
throat clearing caused by microaspiration of pooled
secretions.
Gastroesophageal Reflux Disease
Reux of gastric contents causes inammation of the
posterior larynx, especially the arytenoid mucosa. The
patient may also report a habit of frequent throat clearing and a sensation of a lump in the throat. Chronic
cough or throat clearing further damages already irritated vocal folds. Generally patients have hoarseness in
the morning and coughing at night. In children, GERD
presents with dysphagia, hoarseness, vomiting, and
chronic cough.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Listen to the Quality of Voice
Acoustic evaluation criteria for voice include range
(monotonic to extremely variable), loudness (soft to
loud), pitch (low-pitched voice requires more effort to
produce adequate volume; sudden changes in pitch),
register (temporary loss of voice because of abductor
spasm), and quality (roughness, breathiness, and
hoarseness). Table 21-1 lists common criteria used in
evaluating the voice.
Examine the Respiratory System
Assess the airway. Stridor, a high-pitched inspiratory
sound caused by turbulent air passing through a narrowed
glottis secondary to inammation or tumor, indicates an
immediate referral to a specialist. If the patient is able
to cough and laugh but cannot speak, this indicates a
functional problem, because coughing and laughing
require total adduction of the vocal cords. Auscultate the
lungs for quality of breath sounds, asthmatic wheezing,
and signs of consolidation.
Note any associated stridor in children. Inspiratory
stridor may indicate an extrathoracic problem, such as
supraglottic collapse or vocal fold paralysis. An intrathoracic lesion may cause an expiratory stridor.
Perform a General Inspection
Note hair distribution, especially signs of hair loss over
lateral eyebrows and hair loss on scalp, to assess thyroid function. Look for the placement of the trachea
and thyroid gland. Bulges or asymmetry of the neck
suggest a tumor. A head and neck hemangioma or
lymphangioma increases the possibility of a similar
laryngeal lesion as the source of hoarseness.
Examine the Head and Neck
Examine the oral, pharyngeal, and nasal mucosa for
signs of excessive dryness, inammation, or infection.
Excessive mucosal dryness, including the conjunctiva,
may be secondary to use of medications such as decongestants and antidepressants or may be a symptom of
an autoimmune disorder such as Sjögren syndrome.
Otoscopy may indicate otitis media with effusion
contributing to hearing loss, a factor to be considered in voice abuse. Inspect the nasal mucosa for
color, edema, and purulent discharge, and examine
the nasal septa for deviation that may cause obstruction. Hypertrophic tonsils and severe dental abnormalities (malocclusion, cleft palate) can contribute
to hoarseness.
Any indication of airway obstruction associated
with hoarseness is a potentially life-threatening situation. Do not perform a physical examination of the
pharynx if you suspect acute epiglottitis. Examination
may trigger laryngospasms and airway obstruction.
Refer immediately for emergency treatment and
airway support.
Table 21-1
ACOUSTIC QUALITY MEASUREMENT DISORDER
Range Monotonal to extremely variable Monotonal: Parkinson disease, depression
Loudness Soft to loud Environmental, psychological, systemic disease
Pitch Low to high; glottal, raspy to falsetto Variable: Puberty
Register Presence of voice Vocal fatigue, overuse
Quality Breathy to resonant Vocal cord mass, paresis, bowing, atrophy
Diagnostics Used in Evaluating Voice
Low: Male gender, overuse
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Chapter 21 • Hoarseness
EVIDENCE-BASED PRACTICE
Are Specialists More Accurate Than Primary Care Providers
in Diagnosing Voice Disorders?
Accurate diagnosis of a voice disorder is an essential first
step in choosing appropriate treatment. The objective of this
study was to examine differences in laryngeal diagnosis over
time in outpatients evaluated by primary care physicians
(PCPs) and/or otolaryngologists. The study retrospectively
analyzed data from a large, national, administrative U.S.
claims database. Participants were patients with a laryngeal
disorder diagnosis from 2004 to 2008, with at least two
outpatient visits by a PCP and/or otolaryngologist and continuously enrolled for 12 months; 29,501 individuals met the
inclusion criteria. The initial and final laryngeal diagnoses
were tabulated. Results showed that more than half the
patients in the PCP-to-otolaryngology group (referred) and
Data from Cohen SM, Dinan MA, Roy N, et al: Diagnosis change in voice-disordered patients evaluated by primary care and/or otolaryngology: A
longitudinal study. Otolaryngol Head Neck Surg, 150:95, 2014.
Examine the larynx indirectly using a laryngeal
mirror. Patient cooperation is critical. Ask the patient
to open the mouth wide and extend the neck while
protruding the tongue. The mirror is advanced to contact and lift the uvula while the patient breathes
through the mouth. Focus the light on the mirror after
the mirror is angled to visualize the larynx. Ask the
patient to say “e” or “a” to observe movement. Sometimes the epiglottis obscures visualization. Direct
examination of the larynx with a laryngoscope
requires the skill and experience of a specialist.
Observe the larynx for the presence of secretions
and evidence of ulcers, polyps, masses, edema, or redness. Observe for vocal cord motion, especially adduction and abduction of vocal cords, and the presence of
spasm or tremor.
Assess Cranial Nerve Function
Most of the cranial nerves (CNs) play a part in speech
and voice production, and any disease process that
affects neurological function, especially vocal cord
paralysis, may affect the voice. Specically examine
CNs V, VII, VIII, IX, X, XI, and XII.
Assess Hearing (Cranial Nerve VIII)
Voice or whisper testing for hearing acuity is the
rst level of hearing screening. An audible whisper
is approximately 20 decibels (dB), and normal
speech is about 50 dB. Patients with neurosensory
hearing loss may speak at an abnormally loud
volume.
one third of the otolaryngology-to-otolaryngology group had
different laryngeal diagnoses over time. Three fourths of
patients with an initial acute laryngitis diagnosis in the PCP–
to-otolaryngology group and half of patients in the otolaryngology-to-otolaryngology group had a different final laryngeal
diagnosis. Of patients with a final diagnosis of laryngeal cancer, one fourth of the otolaryngology-to-otolaryngology group
had an initial diagnosis of nonspecific dysphonia, and one
fifth of the PCP-to-otolaryngology group had an initial diagnosis of acute laryngitis.
Conclusion: Differential diagnosis of voice disorders often
evolves over time, and the impacts on treatment and health
care use are important areas of future study.
Palpate Lymph Nodes
Palpate the cervicofacial lymph nodes. Tender nodes
indicate inammation; nontender nodes may indicate
neoplasm. Enlarged nodes in the deep cervical chain in
the absence of other symptoms may indicate laryngeal
cancer.
Palpate Thyroid
Palpate the thyroid for size, tenderness, and crepitus
by moving the thyroid cartilage across the cervical
spine.
LABORATORY AND DIAGNOSTIC STUDIES
Flexible Fiberoptic Laryngoscopy
Laryngoscopy allows direct examination of the hypopharynx and larynx. A local anesthetic is applied to the
oral or nasal mucosa, and the instrument is passed
through the nose or oral cavity for excellent visualization of laryngeal structures. Laryngoscopy is also
performed using a general anesthetic.
Radiography
Lateral view radiographs of soft tissues of the neck are
used to evaluate structures for abnormalities.
Barium Esophagram
This contrast radiographic technique can be used to
differentiate between mechanical lesions and motility
disorders, providing important information about
the latter in particular. For patients with esophageal
Chapter 21 • Hoarseness
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253
dysphagia and a suspected motility disorder, barium
esophagram should be performed rst.
DIFFERENTIAL DIAGNOSIS
Acute Laryngitis
Acute laryngitis is a self-limiting condition caused by
a viral infection, environmental irritants, postnasal
drainage secondary to poorly controlled allergic rhini-
tis, or voice overuse. The loudness and quality of voice
are affected, and the patient may report a sore throat.
Hoarseness often progresses throughout the course of
the day. Indirect examination of the larynx reveals red-
ness and edema of the vocal cords. Physical pathology
may be absent in mild cases.
Acute Epiglottitis
Adults will report severe and rapidly progressing
symptoms of sore throat, dyspnea, and hoarseness.
In children, there is no cough or hoarseness, but
drooling with a forward leaning posture is observed.
This condition is most commonly associated with
Haemophilus inuenzae infection. Voice quality is
froglike. The patient will also have a high tempera-
ture and will be anxious, fearful, and restless with
respiratory distress.
Trauma
Any swelling in response to trauma, directly to the
larynx or indirectly to the throat, will cause hoarseness.
Swelling might be secondary to head and neck surgery
such as dental surgery, tonsillectomy, or thyroidec-
tomy. Postintubation trauma may be acute if secondary
to inammation, or chronic if neurological or structural
damage is irreversible. Mucosal abrasion or ulcer may
be caused by direct trauma to the larynx and is associ-
ated with painful phonation and a breathy voice.
Acute Laryngeal Edema
Laryngeal edema may be one symptom in a general-
ized allergic response that involves the lips, tongue,
and other hypopharyngeal structures. Drug reactions
and food allergies, especially to seafood and nuts,
often precipitate this response. This condition is a
medical emergency because of the high risk of airway
obstruction.
3 months to 3 years and is more prevalent in the fall
and winter. It is associated with a barking cough, dyspnea, wheezing, low-grade fever, and hoarseness. Inspiratory stridor occurs abruptly because of narrowing
of the passage, causing negative pressures generated
on inspiration. Physical examination can determine the
degree of respiratory distress such as color, stridor,
nasal aring, and level of consciousness.
Chronic Laryngitis
This condition is associated with a combination
of chronic exposure to working conditions with high
levels of dust, fumes, or noise; hard liquor consumption; cigarette smoking; and a history of frequent and
persistent cough. Physical examination reveals edema
or nodules of the vocal cords.
Polyps
Vocal cord polyps develop as a result of chronic
inammation from voice abuse, allergies, or GERD.
The voice quality is breathy. With dependent polyps,
the patient may report that symptoms of hoarseness
change with position.
Neoplasm
Laryngeal cancer usually occurs in patients who have
a long history of cigarette smoking and alcohol consumption. Hoarseness is characterized by a raspy or
harsh voice. Physical examination may reveal leukoplakia or a white scaly appearance of the vocal cords.
Patients do not usually report pain until carcinoma
is advanced. Pain secondary to ulceration is late
and is often perceived as ear pain, especially when
swallowing.
Gastroesophageal Reflux Disease
Patients with GERD will report retrosternal burning
(heartburn) that radiates upward. The regurgitation of
gastric acid is exacerbated by consuming large meals,
lying in a supine position, or bending over. Patients
may describe a sour taste, experience salivary hypersecretion, have painful swallowing, or have a chronic
cough or habit of throat clearing. Physical examination
will be normal or epigastric tenderness may be elicited
by abdominal examination. Inammation or ulceration
may be visible on the vocal cords.
Laryngotracheobronchitis (Croup)
Subglottic edema is caused by a viral infection, most
often parainuenza virus 1 that can obstruct the airway.
This condition is most common in children ages
Hypothyroidism
One symptom of hypothyroidism is a low, gravelly
voice. The degree of hoarseness depends on the severity of thyroid deciency. Usually hypothyroidism is
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Chapter 21 • Hoarseness
suspected when other symptoms are present such as
cold intolerance; rough, scaly skin texture; weight
superior mediastinum or carcinoma of the thyroid or
esophagus.
gain; and signs such as bradycardia and prolonged
deep tendon reex recovery. Risk factors for hypothyroidism include increased age, postpartum status, and
a family history of thyroid disease. The thyroid
gland may be nonpalpable or enlarged. Examination
of the larynx may reveal edema or polyps. An elevated
serum thyroid-stimulating hormone (TSH) level will
Psychogenic Hoarseness
Patients with psychogenic hoarseness will have a
low, breathy voice caused by voluntarily abducting the
vocal cords during phonation. Physical examination
will reveal no abnormalities. Psychogenic hoarseness
may follow a traumatic event.
conrm the diagnosis.
Laryngeal Papillomas
Vocal Cord Paralysis
Paralysis is usually unilateral and produces a weak,
breathy voice. Unilateral abductor paralysis on the left
side is caused by pressure on the vagus or recurrent
laryngeal nerve by a mass of malignant glands in the
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Acute laryngitis Voice overuse, exposure to
Acute epiglottitis Adults: Rapid onset of sore
Children: Drooling, forward-
Trauma Hoarseness after intubation;
Acute laryngeal edema History of food or drug allergy Edema of lips, tongue, and
Laryngotracheobronchitis
(croup)
Chronic laryngitis Chronic history of smoking
Polyps
Children 3 mo to 3 yr;
History of allergy; voice abuse,
Common Causes of Hoarseness
environmental irritants,
recent URI
throat, dyspnea, hoarseness
leaning posture
direct throat trauma or
foreign body
recent URI
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
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 papil-
lomavirus, are seen in newborns.
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
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 ENT referral for biopsy
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
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255
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Hoarseness—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Neoplasm Smoking, airborne exposure,
chronic alcohol use,
history of chronic cough,
GERD History of upper GI burning;
Hypothyroidism Presence of systemic
Vocal cord paralysis Chronic cough; inspiratory
Psychogenic
hoarseness
Laryngeal papillomas Children 2-12 yr and may
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.
hoarseness for .3 wk
cough especially at night;
chronic use of alcohol,
NSAIDs, or aspirin; history
of ulcer disease, smoker,
age ,45 yr; frequent throat
clearing
symptoms, such as cold
intolerance, weight gain,
fatigue; age .65 yr;
postpartum; family history
of thyroid disease
or expiratory stridor with
exertion
History of psychiatric illness,
or psychological trauma
occur in infants; history
of maternal human
papillomavirus; may be
recurrent, progressive
Tracheal deviation; pain
with advanced tumor;
hoarseness may be
only sign
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
ENT referral for biopsy
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.
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 50:363, 2003.
Schwartz SR, Cohen SM, Dailey SH, 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, Otolar-
yngol Clin North Am 33:91, 2000.
CHAPTER
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22
useful framework for differentiating limb pain
A
involves determining whether symptoms are
caused by musculoskeletal injury, musculoskeletal or
joint disease, systemic disease, or a combination of
factors. Pain can result from 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. For example, lower extremity pain is
often referred from the low back and emanates from
irritated nerve roots, or pain is secondary to myofascial
syndromes of the low back, pelvic, and hip musculature. In children, aches and pains in limbs are common.
However, the presence, location, and intensity of the
pain are often difcult to assess, and interpretation of
pain is often made by the parents.
Lower Extremity Limb Pain
DIAGNOSTIC REASONING: FOCUSED
HISTORY
Is the pain related to an urgent problem that needs
immediate treatment to avoid disability or death?
Key Questions
l
Have you had a recent injury?
l
Can you describe exactly how the injury occurred?
l
Do you have any other symptoms such as fatigue,
fever, or swollen joints?
l
What is the severity of the pain? Does it occur with
exercise or rest?
Injury
Injuries to the musculoskeletal system can range from
simple muscle strain to a signicant fracture associated
with nerve or vascular injury. Therefore, when a patient has 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. Compartment syndrome is an injury
that involves both vascular integrity and neurological
functioning. This condition develops when trauma to
an extremity causes swelling and pressure that compromises blood ow to the affected muscles and
nerves. Surgical decompression is needed, and prompt
diagnosis is crucial to avoid amputation and other
complications.
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. A severe crush
injury puts the patient at high risk for developing
compartment syndrome—among other complications—
in the crushed limb. 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. 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 b-hemolytic streptococcal
infection precedes the initial joint pain by 1 to
3 weeks. Often the hip joint may be the first 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.
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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, arthritis,
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.
Severe nontraumatic pain that occurs with pallor,
paresthesia, or paralysis in a cold limb may be the
result of acute limb ischemia, which requires emergent treatment to avoid amputation. Acute limb ischemia is often the result of worsening atherosclerotic
peripheral vascular disease, in which a narrowed artery becomes occluded secondary to thrombosis or
embolism. On examination, the affected limb will
have diminished or absent peripheral pulses. Acute
limb ischemia requires urgent consultation with a
vascular surgeon for possible revascularization.
In young children, failure to spontaneously move
an arm or leg can be a sign of pain and is called pseudoparalysis.
What does the location of the pain tell me?
Key Questions
l
Where does it hurt?
l
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 actually comes from the hip to feel
as though the pain is in the knee.
Could this be caused by a sprain or strain?
Key Questions
l
Describe how the injury occurred.
l
Did you hear a noise with the injury, such as a
ripping or cracking sound?
l
Were you able to use the limb after the injury?
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 or sprain may involve some loss of joint or ligament stability. Strains
may be acute or chronic. Ankle 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 a 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
l
Can you describe your usual daily activities at home,
at work, and with hobbies?
l
How does the pain affect your activities?
l
Do you have other illnesses?
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Chapter 22 • Lower Extremity Limb Pain
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 with 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.
History of Injury
In joint pain with injury, what do I need to know about
the specic joints involved?
Key Questions
l
Is the pain affected by weight bearing or activity?
l
Did you feel a sense of “giving way”?
l
Did you hear a pop, tear, or other sound?
l
In what position was your leg when the injury
occurred?
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 an 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
l
Can you describe the pain?
In general, sharp, piercing, stabbing, cutting, pinching, and 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 and is an emergency
condition.
Muscle pain is caused by receptors located in
bursa, muscle fibers, ligaments, and tendon attachments. It is a diffuse, dull, gnawing, boring, or
tearing pain that increases with use and decreases
with rest.
Intra-articular 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 improving
throughout the day.
Degenerative joint pain radiates to the soft tissue
structures around the joint (i.e., muscles, ligaments,
tendons). It is a dull, gnawing sensation associated
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, 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
l
Is there any swelling?
l
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
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