W E HAVE recently seen two youngsters whose pnesenting complaints were highly suggestive of spinal cord disease but

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1 AMERICAN ACADEMY OF PEDIATRICS CLINICAL CONFERENCE BONY LESIONS OF THE LOWER EXTREMITIES SIMULATING CENTRAL NERVOUS SYSTEM DISEASE Irving H. Rozenfeld, M.D. W E HAVE recently seen two youngsters whose pnesenting complaints were highly suggestive of spinal cord disease but whose lesions were far removed from this area. We believe this deserves emphasis. right leg about 4 months previously but had not told anyone. Funthenmore, he reported Sarah Morris Hospital for Children, Chicago Case 1 CASE REPORTS The first patient was seen initially when he was 143k years old, complaining of vague pains in his night knee and thigh. This pain was intermittent, slightly worse at night, but did not interfere with the patient s activities. Physical examination was entirely negative. There was no local tenderness, limitation of motion or limp. Roentgenograms of the knee, thigh and hip were interpreted as negative, and the patient was advised to limit activity temporarily. Although he was subsequently seen for minor respiratory infections, there was no further mention of pain. Eighteen months later, the patient s mother called to say that she had just noticed that the right leg was thinner than the left. When seen, however, the patient, now 16 years old, reported that pain in the leg had continued during the 18-month period. There was no specific localization of the pain; it was worse at night and responded to heat, massage and aspirin. He had pain occasionally during the day and had limped for the preceding several months. This howeven did not stop him from playing football and baseball. He reported further that he first became aware of the thinness of the Fic. 1. Case 1. Atrophy of the right leg. Presented as part of a Clinical Conference for the Annual Meeting of the American Academy of Pediatrics, October, 1960, under Chairmanship of Dr. Jack Metcoff. ADDRESS: 29th Street and Ellis Avenue, Chicago 16, Illinois. PzrnmIcs, November

2 848 BONY LESIONS FIG. 2. Case 1. Tomograms, revealing a lesion in the upper part of the patella. an 11-lb weight loss during this 4-month period. On examination, there was marked atrophy of the entire right leg, as shown in Figure 1. The hamstring, quadriceps and gastrocnemius muscles were equally involved. The circumference of the right thigh, 8 in. above the patella, was 2 in. less than that of the left; the circumference of the right calf, 8 in. below the tibial tubercle, was almost 1 in. less than that of the left. Incidentally, the boy was night-handed. There was no local tenderness on palpation of the leg, but the patient complained of pain in the knee on extreme flexion of the knee joint. There was no limitation of motion. Neurologic examination revealed hyperactivity of the deep tendon reflexes and ankle clonus present on the right and an area of hypasthesia over the medial aspect of the right leg. There was no Babinski sign. Muscle strength was only slightly decreased, and the marked atrophy was cornpletely out of proportion to the minimal weakness present. Repeat roentgenognams of the knee, thigh, hip and back were again interpreted as negative. Lumbar puncture revealed nonma! fluid dynamics, and the protein and cellular components were with normal limits. Electromyography revealed no fibrillation potentials and a marked decrease in the total number of potentials. These findings were interpreted as compatible with upper neurone disease. Because of the persistent complaint of pain in the knee, associated with forced flexion of the knee, tomograms were taken; these revealed a lesion in the upper pole of the patella (Fig. 2). The central nidus with a surrounding area of sclerosis is typical of an osteoid osteoma. A hemipatallectomy was done, with complete subsidence of pain. Four months later the patient has a slight limp, complete range of motion and some return of muscle mass. The hemipatellectomy was done instead of a total pate!- lectomy for cosmetic reasons. The pathologic examination confirmed the diagnosis of osteoid osteoma. Case 2 A 16-year-old male was seen because the father, a physician, had noted atrophy of the left leg 2 weeks previously. History ne-

3 CLINICAL CONFERENCE 849 vealed the presence of mild pain of 6 months duration in the left knee. Upon further investigation it was found that the youngster s basketball coach had been aware of the atrophy and pain for approximately 6 months, but since the pain was relieved by the activity of playing basketball, and since the atrophy did not interfere with the boy s ability as a basketball player, the coach ignored the whole thing. Physical examination showed the atrophy of the left leg, and little else (Fig. 3). There was very little muscle weakness, and again the marked discrepancy between the degree of atrophy and the muscle weakness was noticable. There was no local tenderness in the leg and no limitation of motion. The circumference of the left thigh was 1i. in. less than that of the right, and the circumference of the left gastrocnemius was 1 in. less than that on the right. There were no pathologic reflexes. A roentgenognam of the knee revealed a flattening of the lateral tibia! condylar anticulating surface, with multicystic irnegulanities of the bone. A diagnosis of osteochondnitis dissecans was made. The patient is under therapy at the time of this writing. COMMENT These two cases are presented to demonstrate that relatively small lesions in and around the knee, with only slight pain, appanently can cause enough reflex splinting of the muscle groups around the knee to produce an atrophy of disuse. This occurred despite the fact that the patients not only walked but actively participated in FIG. 3. Case 2. Atrophy of the left leg. sports. If the reflex spasm of the muscle groups is great enough, abnormal neurologic signs such as ankle clonus and increased deep tendon reflexes may be demonstrated. This clinical situation is neither stressed nor mentioned in the standard pediatric, orthopedic or neurologic textbooks; yet it is striking when it occurs. Emphasizing this syndrome might increase ones index of suspicion, which is always important in terms of making a diagnosis.

4 CLINICAL CONFERENCE: BONY LESIONS OF THE LOWER EXTREMITIES SIMULATING CENTRAL NERVOUS SYSTEM DISEASE Irving H. Rozenfeld Pediatrics 1961;28;847 Updated Information & Services Permissions & Licensing Reprints including high resolution figures, can be found at: Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Information about ordering reprints can be found online:

5 CLINICAL CONFERENCE: BONY LESIONS OF THE LOWER EXTREMITIES SIMULATING CENTRAL NERVOUS SYSTEM DISEASE Irving H. Rozenfeld Pediatrics 1961;28;847 The online version of this article, along with updated information and services, is located on the World Wide Web at: Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, Copyright 1961 by the American Academy of Pediatrics. All rights reserved. Print ISSN: