Musculoskeletal Pain: A New Algorithm for Differential Diagnosis of a Cardinal Symptom in Pediatrics

Abstract

Musculoskeletal pain (MSP) is a common childhood complaint associated with multiple differential diagnoses, including cancer. Considering the expanding spectrum of diagnostics, evaluat­ing a young patient with MSP is a challenge today, particularly for non-specialists in a primary care setting. Since childhood cancer is rare and most cardinal symptoms mimic rather non-serious diseases, misdiagnosis is not uncommon, but of significant prognostic relevance. To build the appropriate bridge between primary and secon­dary care for a child presenting with MSP, thereby preventing treatment delay and longterm sequelae, initial evaluation should follow a comprehensive, multidisciplinary, systematic and stepwise approach, which unites the patient’s individual anamnestic, psychosocial, and clinical charac­teristics. After a systematic review of the literature, we generated multidisciplinarily quality-assured recommendations for efficient, rational and cost-effective primary care assessment of pediatric MSP. The algorithm promotes the identification and structured interpretation of the patient’s individual clinical clues. It should serve the primary care physician to recognize when further intervention, rather than reassurance and follow-up, is needed using the minimum amount of testing to make an appropriate, prompt diagnosis in the clinical situation “child presenting with MSP”. A German version of this algorithm has been published in the Guideline-Portal of The Association of the Scientific Medical Societies (“Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften”, AWMF) in November 2013.

Zusammenfassung

Muskuloskelettale Schmerzen (MSS) sind bei Kindern und Jugendlichen häufig und mit einem breiten Spektrum an Differenzialdiagnosen, auch Krebs, assoziiert. Durch kontinuierliche Optimierung von Diagnostik und Behandlung wurden die Überlebensraten von Kindern und Jugendlichen mit Krebserkrankungen in den letzten Jahrzehnten auf über 80% gesteigert. Für die erstversorgenden Ärzte tritt ein gezielter, kostenbewusster Umgang mit den diagnostischen Verfahren zunehmend in den Vordergrund. Aufgrund der Seltenheit von Krebs bei Kindern und Jugendlichen wird bei unspezifischen Symptomen wie MSS oft nicht gleich an ein Malignom als Ursache gedacht. So kommt es einerseits regelmäßig zu Fehldiagnosen mit prognostischer Relevanz. Andererseits belastet unnötige invasive und kostspielige Diagnostik sowohl die Patienten als auch das Gesundheitssystem. Ziel dieser Übersichtsarbeit ist die Verbreitung eines Algorithmus zur symptomorientierten Differenzialdiagnostik in der Situation „Kind/Jugendliche(r) mit MSS“ in der Primärversorgung. Damit soll zur Verbesserung der Prognose von Kindern und Jugendlichen mit MSS und entsprechender Grunderkrankung beigetragen werden. Der Algorithmus wurde von Mitgliedern der Gesellschaft Pädiatrische Onkologie und Hämatologie (GPOH) in Zusammenarbeit mit der Deutschen Gesellschaft für Kinder- und Jugend­medizin (DGKJ) und dem Bundesverband für Kinder- und Jugendmedizin (BVKJ) entwickelt. Es wird eine Vorgehensweise zur sofortigen und richtigen Diagnosestellung empfohlen, die die individuelle anamnestische, psychosoziale und klinische Befundkonstellation des Patienten systematisch erfasst und schrittweise miteinander vereinigt.

Key words

children and adolescents - musculoskeletal pain - epidemiology - etiology - differential diagnosis - primary care

Schlüsselwörter

Kinder und Jugendliche - muskuloskelettale Schmerzen - Epidemiologie - Ätiologie - Differenzialdiagnose - Primärdiagnostik

• References

• 1 Asadi-Pooya AA, Bordbar MR. Are laboratory tests necessary in making the diagnosis of limb pains typical for growing pains in children?. Pediatr Int 2007; 49: 833-835
• 2 Barbosa CM, Nakamura C, Terreri C et al. Musculoskeletal manifestations as the onset of acute leukemias in childhood. J Pediatr (Rio J) 2002; 78: 481-484
• 3 Barrios Lopez M, Casado Picon R, de Inicencio Arocena J et al. Burkitt’s lymphoma presenting as an intermittent limp. Reumatol Clin 2011; 7: 139-140
• 4 Borzutzky A, Stern S, Reiff A et al. Pediatric chronic nonbacterial osteomyelitis. Pediatrics 2012; 130: 1190-1197
• 5 Bürk G, Frosch M, Zernikow B. Muskuloskelettale Schmerzen. Schmerz 2000; 14: 340-345
• 6 Cabral DA, Trucker LB. Malignancies in children who initially present with rheumatic complaints. J Pediatr 1999; 134: 53-57
• 7 Clarke NM, Page JE. Vitamin D deficiency: a paediatric orthopaedic perspective. Curr Opin Pediatr 2012; 24: 46-49
• 8 Connelly MA, Schanberg LE. Evaluating and managing pediatric musculoskeletal pain in primary care. In: Walco GA, Goldschneider KR. (eds.) Pain in children. A practical guide in primary care. Humana Press as part of Springer Science and Business Media. LLC: Chapter 19, 2008. [ISBN: 9781934115312]
• 9 Deere KC, Clinch J, Holliday K et al. Obesity is a risk factor for musculoskeletal pain in adolescents: findings from a population-based cohort. Pain 2012; 153: 1932-1938
• 10 Diepenmaat AC, van der Wal MF, de Vet HC et al. Neck/shoulder, low back and arm pain in relation to computer use, physical activity, stress and depression among Dutch adolescents. Pediatrics 2006; 117: 412-416
• 11 Dorronsoro Martin I, Merino Munos R, Sastre-Urguelles A et al. Malignant disease presenting as rheumatic manifestations. An Pediatr (Barc). 2004. 61. 393-397
• 12 Duey-Holtz AD, Collins SL, Hunt LB et al. Acute and non-acute lower extremity pain in the pediatric population: part I. J Pediatr Health Care 2012; 26: 62-682
• 13 Duey-Holtz AD, Collins SL, Hunt LB et al. Acute and non-acute lower extremity pain in the pediatric population. part II J Pediatr Health Care 2012; 26: 216-230
• 14 Duey-Holtz AD, Collins SL, Hunt LB et al. Acute and non-acute lower extremity pain in the pediatric population: part III. J Pediatr Health Care 2012; 26: 380-392
• 15 Forgie SE, Robinson JL. Pediatric malignancies presenting as a possible infectious disease. BMC Infectious Diseases 2007; 7: 44-50
• 16 Gonzalves M, Terreri MT, Barbosa CM et al. Diagnosis of malignancies in children with musculoskeletal complaints. Sao Paulo Med J 2005; 123: 21-23
• 17 Gupta D, Singh S, Suri D et al. Arthritic presentation of acute leukemia in children: experience from a tertiary care centre in North India. Rheumatol Int 2010; 30: 767-770
• 18 Haas JP. Chronische muskuloskelettale Schmerzen bei Kindern und Jugendlichen. Monatsschr Kinderheilkd 2009; 157: 647-654
• 19 Halama D, Hierl T, Wickenhauser C et al. Psammomatoid Juvenile Ossifying Fibroma of the Maxilla: Radical Surgery with Maxillary Resection in a 7-year-old Girl. Klin Padiatr 2013; 225: 418-419
• 20 Harel L. Growing pains: myth or reality. Pediatr Endocrinol Rev 2010; 8: 76-78
• 21 Hempfing A, Placzek R, Göttsche T et al. Primary subacute epiphyseal and metaepiphyseal osteomyelitis in children. Diagnosis and treatment guided by MRI. J Bone Joint Surg 2003; 85-B: 559-564
• 22 Hill D, Whiteside J. Limp in children: Differentiating benign from dire causes. J Family Practice 2011; 60: 193-197
• 23 Jackson C, McLaughlin K, Teti B. Back pain in children: a holistic approach to diagnosis and management. J Pediatr Health Care 2011; 25: 284-293
• 24 Jansson A, Golla A, Plewig G et al. Chronisch rezidivierende multifokale Osteomyelitis und andere nichtbakterielle Osteitiden. Dtsch Arztebl 2004; 101: A-584/B-483/C-475-
• 25 Jansson A, Reinhardt D. Knochenschmerzen. Monatsschr Kinderheilkd 2009; 157: 645-646
• 26 Jeske M, Lohse P, Kallinich T et al. Genotype-Phenotype and Genotype-Origin Correlations in Children with Mediterranean Fever in Germany – an AID-Net Study. Klin Padiatr 2013; 225: 325-330
• 27 Jones OY, Spencer CH, Bowyer SL et al. A multicenter case-control study on predictive factors distinguishing childhood leukemia from juvenile rheumatoid arthirits. Pediatrics 2006; 117: 840-844
• 28 Jordan KP, Kadam UT, Hayward R et al. Annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study. BMC Musculoskelet Disord 2010; 11: 144
• 29 Junnila JL, Cartwright VW. Chronic musculoskeletal pain in children: Part I. Initial Evaluation. American Family Physician 2006; 74: 115-122
• 30 Junnila JL, Cartwright VW. Chronic musculoskeletal pain in children: Part II. Rheumatic causes. American Family Physician 2006; 74: 293-300
• 31 Karmazyn B. Ultrasound of pediatric musculoskeletal disease: from head to toe. Semin Ultrasound CT MR 2011; 32: 142-150
• 32 Keitzer R. Acute rheumatic fever (ARF) and poststreptococcal reactive arthritis (PSRA) – an update. Z Rheumatol 2005; 64: 295-307
• 33 Konijnenberg AY, De Graeff-Meeder ER, Kimpen JL et al. Pain of Unknown Origin in Children Study Group . Children with unexplained chronic pain: do pediatricians agree regarding the diagnostic approach and presumed primary cause?. Pediatrics 2004; 14: 1220-1226
• 34 Lowe RM, Hashkes PJ. Growing pains: a non inflammatory pain syndrome of early childhood. Nat Clin Pract Rheumatol 2008; 4: 542-549
• 35 MacKenzie JD, Vasanawala SS. State-of-the-art in pediatric body and musculoskeletal magnetic resonance imaging. Semin Ultrasound CT MR 2010; 31: 86-99
• 36 Malleson PN, Beauchamp RD. Diagnosing musculoskeletal pain in children. CMAJ 2001; 165: 183-188
• 37 Nathrath M, Teichert I. Onkologische Ursachen von Knochenschmerzen. Monatsschr Kinderheilkd 2009; 157: 655-660
• 38 O’Sullivan P, Beales D, Jensen L et al. Characteristics of chronic non-specific musculoskeletal pain in children and adolescents attending a rheumatology outpatient clinic: a cross-sectional study. Ped Rheumatology Online 2011; 9: 3
• 39 Oztuerkmen S, Akyay A, Bicakci Z et al. Delayed diagnosis of acute leukemia in a patient with bone pain and fracture. Turk J Pediatr 2010; 52: 552-555
• 40 Paladino C, Eymann A, Llera J et al. Estimated prevalence of musculoskeletal pain in children, who attend a community hospital. Arch Argent Pediatr 2009; 107: 515-519
• 41 Patel DR, Moore MD, Greydanus DE. Musculoskeletal diagnosis in adolescents. Adolesc Med State Art Rev 2007; 18: 1-10
• 42 Peitz J, Schoenau E. Knochenschmerzen aus endokrinologischer Sicht. Monatsschr Kinderheilkd 2009; 157: 661-663
• 43 Picchietti D, Allen RP, Walters AS et al. Restless legs syndrome: prevalence and impact in children and adolescents – the Peds REST Study. Pediatrics 2007; 120: 253-266
• 44 Redlich A, Wechsung K, Boxberger N et al. Extra-appendiceal Neuroendocrine Neoplasms in Children – Data from the GPOH-MET 97 Study. Klin Padiatr 2013; 225: 315-319
• 45 Reinehr T, Buerk G, Andler W. Spondylodiscitis in childhood. Klin Padiatr 1999; 211: 406-409
• 46 Riccio I, Marcarelli M, Del Regno N et al. Musculoskeletal problems in pediatric acute leukemia. J Pediatr Orthop B 2013; 22: 264-269
• 47 Schilling F, Coerdt W, Eckardt A et al. Pelvic type of recurrent multifocal osteomyelitis. Klin Padiatr 2001; 213: 277-284
• 48 Sinigaglia R, Gigante C, Bisinella G et al. Musculoskeletal manifestations in pediatric acute leukemia. J Pediatr Orthop 2008; 28: 20-288
• 49 Suri D, Ahluwalia J, Sachdeva MU et al. Arthritic presentation of childhood malignancy: beware of normal blood counts. Rheumatol Int 2011; 31: 827-829
• 50 Tamashiro MS, Aikawa NE, Campos LM et al. Discrimination of acute lymphoblastic leukemia from systemic-onset juvenile idiopathic arthritis at disease onset. Clinics (Sao Paulo) 2011; 66: 1665-1669
• 51 Trueworthy RC, Templeton KJ. Malignant bone tumors presenting as musculoskeletal pain. Pediatr Ann 2002; 31: 355-359
• 52 Trapani S, Grisolia F, Simoninni G et al. Incidence of occult cancer in children presenting with musculoskeletal symptoms: a 10-year survey in a pediatric rheumatology unit. Semin Arthritis Rheum 2000; 29: 348-359
• 53 Uebbing K, Körber F, Urban R et al. Continued Child Welfare Endangerment by Misinterpretation of Paediatric Injuries. Klin Padiatr 2012; 224: 274-275
• 54 Uziel Y, Hashkes PJ. Growing pains in children. Pediatric Rheumatology 2007; 5: 5-9
• 55 Valovich McLeod TC, Decoster LC, Loud KJ et al. National Athletic Trainers’ Association Position Statement: Prevention of Pediatric Overuse Injuries. J Athl Train 2011; 46: 206-220
• 56 Weiser P. Approach to the patient with noninflammatory musculoskeletal pain. Pediatr Clin North Am 2012; 59: 471-492
• 57 Weller F. Knochen- und Gelenkschmerzen im Kindesalter. Kinder- und Jugendmedizin 2009; 5: 254-260
• 58 Windschall D, Jaeger-Roman E, Niewerth M. Wachstumsschmerzen. Häufige Diagnose unklarer Aetiologie. Monatsschr Kinderheilkd 2009; 157: 670-674
• 59 Winkelmann S, Hirsch W, Burdach S et al. Therapy of osteoid osteomas – always surgically?. Klin Padiatr 2003; 215: 35-39
• 60 Wong KO, Bond K, Homik J et al. Antinuclear Antibody, Rheumatoid Factor, and Cyclic-Citrullinated Peptide Tests for Evaluating Musculoskeletal Complaints in Children. Rockville (MD) 2012; Agency for Healthcare Research and Quality (US), Report No.: 12-EHC015-EF, AHRQ Comparative Effectiveness Reviews; PMID: 22514802 [PubMed]
• 61 Young G, Toretzsy JA, Campbell AB et al. Recognition of common childhood malignancies. Am Fam Phys 61: 2144-2154 2000;
• 62 Zapata AL, Moraes AJ, Leone C et al. Pain and musculoskeletal pain syndromes related to computer and video game use in adolescents. Eur J Pediatr 2006; 165: 408-414
• 63 Zapata AL, Moraes AJ, Leone C et al. Pain and musculoskeletal pain syndromes in adolescents. J Adolesc Health 2006; 38: 769-717
• 64 Zernikow B, Gerhold K, Bürk G et al. Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften. Definition, diagnosis and therapy of chronic widespread pain and so-called fibromyalgia syndrome in children and adolescents. Systematic literature review and guideline. Schmerz 2012; 26: 318-330