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, evaluat-ing 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 secon-dary 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 charac-teristics. 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.

The child with joint pain in primary care

“…These include primary and secondary malignancies, septic arthritis, osteomyelitis, inflammatory arthritis and non-accidental injury/child abuse. Only one in 10,000 children have MSK pain as the primary presenting feature of cancer [8], although around 20% of children with leukaemia and 2% of those with lymphoma have some MSK symptoms at diagnosis [9,10]. By far, the most common cause for MSK pain in children presenting to primary care in a Spanish study was trauma representing almost 44% of the presentations with mechanical causes/overuse being the next frequent at 24% [7].…”

Post traumatic septic arthritis of the elbow and osteomyelitis of the distal radius in a 12-year-old child

“…Joint pain is a common presenting complaint in children. The three main groups of differential diagnoses for joint pain include: trauma, malignancy [1] and arthritis either reactive, inflammatory or septic [2,3]. The presence of minor trauma does not exclude other causes.…”

Differenzialdiagnostik nicht-entzündlicher Gelenkschmerzen/-schwellungen bei Kindern und Jugendlichen

“…Maligne Erkrankungen im Kindesalter sind glücklicherweise einigermaßen selten, geschätzt etwa bei 1 von 10 000 Kindern mit muskuloskelettalen Beschwerden [4]. Trotzdem sollten sie in den differenzialdiagnostischen Erwägungen bis zum sicheren Ausschluss weit oben stehen [7] ren können, wie Neuroblastome, Rhabdomyosarkome und Ewing-Sarkome, können mit Knochenschmerzen einhergehen.…”

“…Allerdings kann das Erkennen bestimmter Muster den untersuchenden Arzt häufig rasch auf die richtige Fährte führen. Komplexe Algorithmen für das Vorgehen bei muskuloskelettalen Schmerzen sind an unterschiedlichen Stellen beschrieben worden [4][5][6]. ▶abb.…”