What Causes Bony Masses in the Foot?

Patient Presentation

A 10-year-old male came to clinic because of a ‘lump’ on the underside of his middle right toe that he had noted 3 days previously while washing his feet. It was not painful and had no swelling or tenderness. He denies any recent or distant past trauma including a foreign body.
He has had no problems walking and denies constitutional symptoms.
The past medical history shows that he has been healthy.
The family history includes diabetes in older family members. There are no cancer, bone or skin disorders in the family
The review of systems is non-contributory.
The pertinent physical exam shows a healthy male with growth parameters in the 25-50%. His skin examination is normal. He has shoddy anterior cervical and inguinal lymph nodes. On the ventral surface of his right middle toe is a 2-3 mm firm nodule that is slightly mobile and lying over the proximal phalynx. There is no discoloration, edema or tenderness. There is full range of motion in all joints of the toe and rest of the foot.
The physician’s differential diagnosis at this point included a gangion cyst, unrecognized foreign body, bony tumor, corn, bunion, or sesamoid bone. Because of the location, a corn, bunion and sesamoid bone were unlikely.
The radiologic evaluation of the toe was negative for a radioopaque foreign object, periosteal reaction or bony tumor.
The diagnosis of ganglion cyst was made based upon the physical examination and negative radiograph. The patient and his father were told the natural course of ganglion cysts which may remain stable in size for months to years. He was told that sometimes because of the location that the cysts are drained or removed. His father was also told
to report any symptoms of significant disease such as fever, bleeding, pain etc. in the unlikely event that they were to occur in the future.

Discussion
Ganglion cysts are benign synovial cysts that occur commonly in the wrist, knees or other joints. In the knees, they are commonly called Baker cysts.
In the wrist they are commonly called bible bumps because some people would take the largest book in the house, often the bible, and hit them to burst the cyst.
Ganglion cysts, are soft, semi-mobile, may transilluminate, and occasionally are painful. Most cysts will spontaneously remit over 2 years.
They may be drained or excised if they becomes extremely large, or become painful or cause a loss of function. Unfortunately there can be a high rate of recurrence.

Learning Point
A differential diagnosis of a bony mass often conjures up a malignant process. However, many bone masses are benign. The differential diagnosis includes:

Non-oncologic

  • Bunion
  • Corn
  • Foreign body
  • Ganglion cyst
  • Myositis ossificans
  • Sesimoid bone

Oncologic

  • Benign
    • Chondroblastoma
    • Aneuysmal bone cyst
    • Simple bone cyst
    • Enchondroma
    • Eosinophilic granuloma
    • Exostosis
    • Fibrous cortical defect and non-ossifying fibroma
    • Osteoblastoma
    • Osteochondroma
    • Osteoid osteoma
  • Malignant
    • Ewing’s sarcoma or primitive neuroectodermal tumor
    • Osteosarcoma
    • Metastatic tumor
    • Rhabdomyosarcoma

Questions for Further Discussion

1. What is the current standard initial evaluation for children with a malignant bone tumor?
2. What are indications for referral to a podiatrist?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

To view current news articles on this topic check Google News.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2249-2250, 2453-2454.

Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:134.

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Date
September 26, 2005

Acute Abdominal Pain Through the Ages. What Causes It?

Patient Presentation
A 13-year-old male came to the clinic with a 6 hour history of lower abdominal pain. He complained that his left testicle hurt especially when he coughed.
The abdominal pain began with the left testicle and moved to the lower abdomen. He described it as like being kicked. It slightly improved before he came to the clinic.
The past medical history and family history are negative.
The review of systems shows no trauma, emesis, or fever. He has had normal urination and stooling.
The pertinent physical exam reveals a male in moderate distress from pain with slight tachycardia. His right testicle is normal but his left testicle shows severe edema and discoloration (i.e. red/blue). He has no left-sided cremasteric reflex, and elevation of the testicle does not improve the pain. The entire testicle is exquisitely tender.
His abdominal examination is normal.
The diagnosis of presumed tesicular torsion was made. The urologist was called and an emergency ultrasound was performed which showed no arterial or venous blood flow.
He was taken to the operating room where the torsion was confirmed. After detorsion, there was minimal improvement in the color of the testicle. It was decided to take him to the recovery room and carefully monitor him.
Unfortunately, he continued to have pain and another ultrasound again showed no blood flow. At re-operation there was obvious necrosis and an orchiectomy was performed.

Discussion
Testicular torsion is a surgical emergency. It occurs in 1:4000 boys and men under age 25 years. Peak incidence is in the preadolescent age group. Acute onset of pain with emesis is common. Scrotal edema, redness and loss of the cremasteric reflex, in a high-lying, horizontal testes are often seen on physical examination.
As edema increases it is often more difficult to differentiate from other causes of acute scrotal pain. Time is of the essence as irrevesible changes can occur within 4-6 hours. After 24 hours infarction is the general rule.

Learning Point
Acute abdominal pain has a large differential but its characteristics makes one suspect an urgent need for diagnosis and management. History should include onset, location and nature of pain and the progression. A child with sudden onset of severe, well-localized pain that is worsening makes a healthcare provider quite worried.
Areas to emphasize on the physical examination include the general appearance including hydration, chest (looking for pulmonary or musculoskeletal pathology), and the abdomen and genitourinary examinations.

The differential diagnosis of acute abdominal pain by ages includes:

  • Infants

    • Anatomic abnormalities of gastrointestinal tract
    • Colic
    • Necrotizing enterocolitis
    • Pyloric stenosis
    • Volvulus/malrotation
  • Toddler/Preschooler

    • Hernia
    • Intussusception
    • Plumbism
  • School Ager

    • Appendicitis
    • Diabetes mellitis
    • Hemolytic-uremic syndrome
    • Henoch-Schonlein purpura
    • Mesenteric lymphadenitis
    • Psychogenic abdominal pain
  • Pre-teen/Teenager

    • Abdominal epilepsy
    • Crohn’s disease
    • Diabetes mellitis
    • Mononucleosis
    • Ovarian cyst
    • Ovarian/testicular torsion
    • Pelvic inflammatory disease
    • Psychogenic abdominal pain
    • Pregnancy
    • Ulcerative colitis
  • Any Age

    • Anatomic abnormalities of gastrointestinal tract
    • Child abuse
    • Constipation
    • Cystic fibrosis
    • Foreign body/bezoar
    • Gallstones/gallbladder disease
    • Gastritis/peptic ulcer disease
    • Gastroenteritis
    • Hepatitis
    • Hirschsprung’s Disease
    • Mumps
    • Obstruction – gastrointestinal, nephrogenic, gall bladder, etc.
    • Pancreatitis
    • Pinworms
    • Perforation/peritonitis
    • Pneumonia
    • Sickle cell anemia
    • Trauma
    • Tumor
    • Urinary tract infection
    • Urolithiasis

Questions for Further Discussion
1. Should the contralateral testes be explored and an orchipexy performed in a child with testicular torsion?
2. How common is prenatal testicular torsion?
3. What evaluation should be performed for acute abdominal pain?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Acute Abdominal Pain.

To view current news articles on this topic check Google News.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1740.

Woodhead JC. Pediatric Clerkship Guide. Mosby. St. Louis MO, 2003:121-130.

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
September 19, 2005

What is the Differential Diagnosis of Localized Hair Loss?

A 14 year-old male came to clinic with a history of a round area of hair loss on the back of his head for a few days. There is itchiness and some flaking.
He denies hair loss or pruritis elsewhere on his body, and denies hair pulling. He finished wrestling season 2 weeks ago.
The past medical history is negative for chronic medical conditions or psychological stressors.
The family history is positive for androgenetic baldness. There are no immunologic diseases in the family.
The pertinent physical exam shows a healthy male. On the left side of the occiput there is a 3.5 centimeter in diameter, well circumscribed lesion with incomplete hair loss.
There are some broken hairs in the lesion and there is scaling at the ends of the lesion. There are no other areas on his scalp or body.
The diagnosis of of tinea capitus was made and he was placed on Griseofulvin for 6 weeks. He is to return if the scaling has not resolved and if the hair has not begun to grow back.

Discussion
Hair is an epidermal apendage. There are 3 types of hair:

    Lanugo hair – soft, fine hair shed at ~ 36-37 weeks of fetal gestation.
    Vellus hair – fine, short hair covering most of the body. It replaces lanugo hair.
    Terminal hair – long, course hair mainly in the scalp, pubic and axillary areas.

Hirsuitism is when vellus hair turns more into terminal hair. Androgenetic baldness is when terminal hair turns more into vellus hair. Some areas of the body remain free of hair such as palms, soles, mouth, and genitals.

Normal hair loss is ~50-100 hairs lost/day on the scalp. Normal hair grows about 2.5 mm/week.

Learning Point
The differential diagnosis of localized hair loss includes:

  • Congenital syndromes – such as congenital triangular alopecia which has frontotemporal areas of alopecia.
  • Alopecia areata – localized hair loss, usually round or oval in shape with no inflammation, often found on the scalp or beard, but also eyelashes, eyebrows, etc. Immune mediation may be the cause. Most resolves in a few months but may have more than one attack and subsequent attacks have less chance of complete resolution.
  • Androgenetic alopecia – diffusely thinner scalp hair especially in the center of the scalp, sometimes with frontal accentuation. Course may be gradual or rapid. The cause is genetic but inheritance mode is unclear. Treatment includes wigs, hair transplants, medication such as Minoxidil or Finasteride or antifungal medication. Many people simply ignore it.
  • Trichotillomania – irregular hair that is broken, bent and of variable length. Caused by conscious or subconscious plucking or pulling of the hair. Usually this is a minor comfort habit. Treatment is through stress control, possibly with psychiatric help if severe.
  • Traction alopecia – irregular areas of short broken hair. It is caused by pulling or stress the hair with grooming including straightening, rolling, clipping, etc. of the hair. Treatment involves changing styling habits.
  • Friction alopecia – generally rounded area that is prone to rubbing. This commonly occurs on the occiput of infants who lie on their backs. Treatment involves placing the infant in other positions.

  • Tinea capitus – roundish area with scaling of the lesion, possibly with central clearing. Broken hairs may be seen.
    It is caused by fungal infection of the scalp and hair, often seen in children 2-10 years old.
    A Wood’s lamp examination may show fluorescence with Microsporum species (often associated with dogs and cats). Tinea caused by Trichophytons species do not fluoresce.
    Treatment is a systemic antifungal such as Griseofulvin, Terbinafine or Intraconazole, as the fungus is in the bulb of the hair shaft and cannot be effectively treated topically.

Questions for Further Discussion
1. What are the side effects of Griseofulvin?
2. What is the differential diagnosis of non-localized hair loss?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

To view current news articles on this topic check Google News.

Hurwitz S. Clinical Pediatric Dermatology, 2nd Edit. W.B. Saunders and Co. 1981:481-495.

American Academy of Pediatrics. Tinea Capitus, In Pickering LD, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2003;617-618.

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
September 12, 2005

When Helping to Develop A Palliative Care Plan, What Should be Considered?

Patient Presentation
A phone call came from a nurse about a 3-year-old male. She was calling to inform the physician that the child had died quietly in the early hours of the morning with his family.
The funeral home had already been called and would be contacting the physician to sign the death certificate. The funeral arrangements were not completed at this time.
The past medical history reveals that this child was diagnosed with lissencephaly at age 9 months after he had a seizure. The parents also noted he was behind in his development.
Because of aspiration and subsequent pneumonias, he had a fundoplication and gastrostomy tube placed. His general overall health declined over time and after a long hospitalization a few months ago, it was decided with the family and the medical team, that
in the future he would be treated at home. His family’s home health agency had worked with several palliative care agencies including one for children.
The palliative care agency worked with the family, neurologist, general pediatrician, and home health agency to develop a comprehensive plan for treatment including pain management, nutrition, treatment for medical contingencies such as another infection, bereavement support for the patents and older children, end of life arrangements, and medical insurance.
About 1 week ago, he had increased respiratory distress and a fever. He received oral antibiotics and oxygen. He also appeared to have some pain and this was controlled by injected morphine sulfate. Last evening his breathing began to be more shallow and his heart rate decreased. He died in the early morning.

Discussion
Lissencephaly is caused by abnormal migration of cortical neuroblasts and the cerebrum fails to sulcate properly. Children may have micro- or macrocephaly, seizures and mental retardation. Other migration problems include pachygyria, where the cerebrum has large, broad gyri with too few sulci, or polymicrogyria where the cerebral surface has many small crevices. All can exist in the same brain. All three disorders have cortical lamination abnormalities.

When many people think of palliative care for children, they often think of children with cancer. Almost every pediatric specialty has a need for pallative care for some of their patients. For example, children with congenital heart disease, cystic fibrosis, short bowel syndrome, chronic renal disease, muscular dystrophy, thalessemia, etc. all may need pallative care at some time.

According to the American Academy of Pediatrics, palliative care “seeks to enhance quality of life in the face of an ultimately terminal condition. Palliative treatments focus on the relief of symptoms (e.g. pain, dyspnea) and conditions (e.g. loneliness) that distress and detract from the child’s enjoyment of life. It also seeks to ensure that bereveaved families are able to remain functional and intact.”Hospice care is a group or package of palliative care services that is provided by a multispecialty team which often includes physicians, nurses, chaplains, health aids, and bereavement counselers. Hospice care is generally provided for a limited per day rate.

Learning Point
The palliative care plan that is right for each child and family is absolutely unique. The plan also may change with time as the child and family go through the dying process. Active listening to the child and family is required to develop and modify a plan focusing on what interventions will be the most beneficial. The child can participate to the extent that their developmental capability, illness and level of consciousness allow. Listed below are areas which should be addresed in a pallative care plan and some examples. The full table can be found in To Learn More below.

Palliative Care Essential Elements include:

  • Physican Concerns
    • Identify pain and other symptoms
    • Examples
      • Have pain and emergency medication available
      • Have oxygen available
  • Psychosocial Concerns
    • Identify fears and concerns
    • Identify coping and communication styles
    • Discuss previous experiences with death, dying
    • Assess resources for bereavement support
    • Examples
      • Adjust plan to blend with child and family’s copying and communication style
      • Assure child and family they will not be abandoned
  • Spiritual Concerns
    • Spiritual assessment including understanding child’s hopes, dreams, life meaning, etc.
    • Examples
      • Consider referring child and family to culturally appropriate spiritual advisor
  • Advance Care Planning
    • Identify decision makers
    • Discuss illness trajectory
    • Identify goals of care
    • Think about issues regarding care or concerns near end of life
    • Examples
      • Communication decision-making with entire team
      • Identify probable time of death
      • Provide anticipatory guidance about physical changes around time of death
  • Practice Concerns
    • Communication and coordination with health care team
    • Establish preferences for location of care
    • Become familiar with child’s home/school
    • Address child’s current and future functional status
    • Inquire about financial burdern
    • Examples
      • Create plan for location of death, contacts at time of death, pronouncement of death
      • Visit care sites such as school to provide education and support
      • Order medical equipment such as commode, wheelchair, etc.
      • Offer financial assistance

Questions for Further Discussion
1. What are some of the problems with access to pediatric palliative care?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Grief.

To view current news articles on this topic check Google News.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2176.

Himelstein BP, Hilden JM, Boldt AM, Weissman D. Pediatric Palliative Care. NEJM. 2004;350;1752-1762. Available from the Internet at: http://content.nejm.org/cgi/content/full/350/17/1752 cited 6/30/2005).

American Academy of Pediatrics Policy Statement. Palliative Care for Children. Pediatrics 2000:106;351-357. Available from the Internet at: http://pediatrics.aappublications.org/cgi/content/abstract/106/2/351?ijkey=998090f579fcd0b281de95222f76b49d19e9c4de&keytype2=tf_ipsecsha (cited 6/30/2005).

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
September 6, 2005