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Diagnosis and Management of Pediatric Primary Bone Tumors in the Emergency Department
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Publication Date: July 2021 (Volume 18, Number 07)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 07/01/2024.

Authors

Mahnoosh Nik-Ahd, MD, MPH, FAAP
Pediatric Emergency Medicine Fellow, UCSF Benioff Children’s Hospital Oakland, Oakland, CA
Anurag K. Agrawal, MD
Associate Professor, Division of Oncology, Department of Pediatrics, UCSF Benioff Children’s Hospital Oakland, Oakland, CA
Melissa Zimel, MD, FAAOS
Assistant Professor, Division of Orthopaedic Surgical Oncology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA

Peer Reviewers

Jeffrey T. Neal, MD
Assistant in Medicine, Division of Emergency Medicine, Boston Children’s Hospital; Instructor of Pediatrics, Harvard Medical School, Boston, MA
Elysha Pifko, MD
Pediatric Emergency Medicine Attending Physician, Nemours/AI duPont Hospital for Children, Wilmington, DE

Abstract

Musculoskeletal pain is a common chief complaint of children in the emergency department. Although nonspecific and typically benign, musculoskeletal pain should be investigated thoroughly with consideration for an underlying bone tumor, especially when it is a recurrent visit for pain. This issue reviews the specific signs, symptoms, and unique presentations the emergency clinician should know when evaluating a pediatric patient with musculoskeletal pain. Additionally, assessment of relevant radiographic findings to assist in differentiating bone tumors and guide further management are discussed.

Case Presentations

CASE 1
An 8-year-old previously healthy girl presents to the ED with pain in her left leg that is worse at night...
  • She is a gymnast and has been practicing more intensely for an upcoming competition, but she denies any significant falls or other trauma to her leg. She had a cold last week and had fevers at that time, but otherwise denies new fevers, swelling, weight loss, night sweats, or pain in her other joints. The pain is not waking her from sleep, and she has only needed to take ibuprofen occasionally for the pain.
  • On examination, she is afebrile and all of her vital signs are within normal limits. She localizes the pain to the proximal third of her tibia, and there is mild tenderness to palpation over this area. There is no erythema, swelling, or other skin changes overlying this area, and she has full range of motion of all of her joints in the lower extremity, with a normal gait.
  • You wonder whether an x-ray and laboratory studies are truly indicated, as her history and physical examination appear relatively benign...
CASE 2
A 13-year-old girl with a history of asthma presents to the ED with a painful, swollen lesion on the anterior chest wall…
  • She first pointed this out to her mother a few days ago, and they did not think much of it. Since that time, it appears to have enlarged significantly. The patient is now uncomfortable, and she is sometimes short of breath when she lays flat. The girl denies fevers, weight loss, or night sweats. Her mom says that the girl had complained of chest pain several times a few months ago, but those instances occurred during upper respiratory infections and asthma exacerbations.
  • On examination, the girl is afebrile. Her vital signs are: heart rate, 133 beats/min; blood pressure, 119/75 mm Hg; respiratory rate, 38 breaths/min; and oxygen saturation, 98% on room air. She appears uncomfortable but nontoxic, prefers to be sitting up, and has a quarter-sized erythematous swollen lesion on her right anterior chest wall that is tender to very soft palpation, with no obvious crepitus or surrounding erythema.
  • You wonder whether this presentation is infectious in etiology or potentially malignant. Regardless, you are concerned about her airway and breathing. Other than a chest x-ray and screening laboratory studies, you wonder what other workup would be immediately helpful and which consultants you should involve urgently.

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