Thigh Pain In A Football Player

Abstract

HISTORY: 15 year old football player presenting with left thigh pain for 2 weeks. No acute injury. Pain first noticed with running. Pain is sharp, rated 8/10 at rest. Despite relative rest, no improvement in symptoms; symptoms now present at rest. Does have nighttime pain. Denies radicular symptoms, fever, recent infection, weight loss. PHYSICAL EXAMINATION: MSK: Left Lower Extremity-Inspection: No swelling, deformity, ecchymosis. Antalgic gait. -Palpation: Tenderness over length of rectus femoris. There is no tenderness over the knee, hip, tibia, fibula. -Range of motion: Limited exam due to pain. -Neurovascular: Strength is 4+/5 in flexion. Distally neurovascularly intact with brisk pulses, 2 second capillary refill, and sensation intact to light touch. DIFFERENTIAL DIAGNOSIS: 1. Ewing Sarcoma 2. Osteosarcoma 3. Osteomyelitis 4. Langerhans Cell Histiocytosis TEST AND RESULTS: XR Left Femur:Findings: Focal area of cortical destruction at medial aspect of proximal tibial diaphysis. Adjacent cortex abnormal. Corresponding periosteal reaction, hyperdense soft tissue mass. No pathologic fracture. Impression:Aggressive lesion of proximal femoral diaphysis. Further evaluation with contrast-enhanced MRI recommended. Labs: CRP 2.9- > 8.9-> > 0.1, ESR 117- > 130-> > 2, WBC 8.9, Hgb/Hct 14/41.6, Plt 407CXR: negativeMRI Left Lower Extremity with/without contrast:Impression:1. Aggressive marrow replacing lesion of left femoral diaphysis with anterior projecting soft tissue component. Differential includes Ewing's sarcoma versus osteosarcoma. 2. No additional lower extremity osseous lesion or adenopathy identified. LEFT FEMUR BIOPSY:SPECIMEN: Fragments of reactive bone with mixed inflammation, compatible with osteomyelitis. REPEAT LEFT FEMUR BIOPSY: I&D; obtained additional tissue to r/o malignancy.Specimen: Findings consistent with acute and chronic osteomyelitis. No features of malignancy seen. FINAL/WORKING DIAGNOSIS: Acute on Chronic MRSA Osteomyelitis TREATMENT& OUTCOMES: 1. Admission for IV antibiotics. Febrile on admission; fever curve improved. 2. ID: Oral Antibiotics x 6 weeks. Improving pain, downtrending inflammatory markers until wnl. 3. Ortho: Toe Touch Weightbearing x 6 weeks - > PWB - > WBAT. Completed PT. Cleared for high impact/contact activities.