Progressive Limp In A 5-year-old Boy - Page #4
 

Working Diagnosis:
Stress fracture of the right inferior pubic ramus and right ischium and hematoma of the corpus cavernosum

Treatment:
He was restricted from any contact sports and running. Pediatric Urology was consulted and agreed with the diagnosis of corpus cavernosum hematoma. Urinalysis was normal. Rest was advised.

Outcome:
His Mother took time off from work to keep him home from daycare to rest. While playing in the driveway she observed him dropping forcibly into the hockey butterfly/W position onto the concrete. When questioned he said he was practicing to be a hockey goalie and did this all of time. His grandmother who babysits him often confirmed he does this maneuver frequently. Direct blunt trauma to the perineum was felt to be the primary mechanism for the pelvic stress fracture and hematoma. After several weeks of rest, his limp resolved.

Editor's Comments:
This case is interesting because it highlights the importance of obtaining a thorough history. This is especially true in pediatrics as communication barriers are usually present. Often, the initial story may not reveal all the details and the true story may come to light only after subsequent questioning (in my experience it is usually the medical student who obtains the "real" history in a relaxed setting away from rounds). When obtaining a thorough history in pediatrics, obviously the child should be a source if sufficiently developmentally mature, but also parents, guardians, siblings and caregivers are important sources of potentially useful information.

This story also reveals the broad differential diagnosis of limp in a preschool child, a fairly common presentation in a pediatric or family medicine clinic. Remember that when evaluating a painless limp in a 4-10 year old, it is important to include Legg-Calve-Perthes disease on the list. LCP is fairly uncommon but crucial not to miss as it can lead to osteoarthritis of the hip joint if inadequately treated or discovered late.

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