Definition of the Complaint
Back, joint, and extremity pain are worrisome symptoms in children. Although benign musculoskeletal disease accounts for many cases, more sinister diagnoses should be ruled out. The inability of young children to clearly describe the location and nature of the pain contributes to diagnostic difficulties. Since the diverse complaints of back, extremity, and joint pain frequently share a common etiology, a uniform approach to such symptoms facilitates accurate diagnosis.
Complaint by Cause and Frequency
Back pain, or discomfort anywhere along the spinal and paraspinal area, reflects potential pathology in a wide range of organ systems, including musculoskeletal, central nervous system, pulmonary, vascular, and intraabdominal or retroperitoneal structures (Table 5-1). Young children who cannot accurately localize pain require indirect symptom assessment. For example, refusal to walk, irritability with repositioning, and reluctance to participate in specific activities often provide the earliest clues to identifying back pain.
Table 5-1. Causes of back pain in childhood by etiology. |Favorite Table|Download (.pdf)
Table 5-1. Causes of back pain in childhood by etiology.
Spinal epidural abscess
Scheuermann (juvenile) kyphosis
Intravertebral disk herniation
Juvenile ankylosing spondylitis
Juvenile rheumatoid arthritis
Sickle cell disease
Alteration in gait or changes in the use of a limb also suggest an underlying extremity or joint disorder (Table 5-2). Examining one joint above and below the site of the chief complaint can prevent missing a diagnosis in cases of referred pain. For example, knee pain may be the presenting symptom for hip pathology. Joint and extremity symptoms can also represent referred pain from a spinal or paraspinal process. The radicular symptoms of nerve root entrapment in the lumbar spine may present as foot pain.
Table 5-2. Causes of Joint or Extremity Pain in Childhood by Etiology. |Favorite Table|Download (.pdf)
Table 5-2. Causes of Joint or Extremity Pain in Childhood by Etiology.
Disseminated Neisseria gonorrhoeae
Acute rheumatic fever
Systemic juvenile idiopathic arthritis
Systemic lupus erythematosus
Bone/soft tissue tumors
Sickle cell disease
Evaluation of back, extremity, and joint pain requires an understanding that extensive interplay of symptoms, findings, and etiologies exists among these diagnostic groups. Any patient with pain that interferes with activity, has associated neurologic symptoms (weakness, changes in reflexes, or bowel/bladder control), or has worrisome associated symptoms (weight loss, fever, worsening pain over time) should prompt a diagnostic evaluation.