right leg about 4 months previously but had not told anyone. Funthenmore, he reported
Fic. 1. Case 1. Atrophy of the right leg.
PzrnmIcs, November 1961
AMERICAN
ACADEMY
OF
PEDIATRICS
847
CLINICAL
CONFERENCE
BONY
LESIONS
OF
THE
LOWER
EXTREMITIES
SIMULATING
CENTRAL
NERVOUS
SYSTEM
DISEASE
Irving H. Rozenfeld, M.D.
Sarah Morris Hospital for Children, Chicago
W
E HAVE recently seen two youngsters whose pnesenting complaints werehighly suggestive of spinal cord disease but
whose lesions were far removed from this
area. We believe this deserves emphasis.
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 ac-tivities. Physical examination was entirely
negative. There was no local tenderness,
limitation of motion or limp.
Roentgeno-grams of the knee, thigh and hip were
in-terpreted 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 how-even did not stop him from playing football
and baseball. He reported further that he
first became aware of the thinness of the
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.
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.
848 BONY LESIONS
On
examination,
there was markedat-rophy of the entire right leg, as shown in
Figure 1. The hamstring, quadriceps and
gastrocnemius muscles were equally
in-volved. 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
mo-tion.
Neurologic examination revealed
hyper-activity of the deep tendon reflexes and
ankle clonus present on the right and an
area of hypasthesia over the medial aspect
as negative. Lumbar puncture revealed
non-ma! 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 typ-ical of an osteoid osteoma. A
hemipatallec-tomy 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
hemipatel-lectomy was done instead of a total
FIG. 3. Case 2. Atrophy of the left leg.
CLINICAL CONFERENCE 849
vealed the presence of mild pain of 6 months
duration in the left knee. Upon further
in-vestigation 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
de-gree of atrophy and the muscle weakness
was noticable. There was no local
tender-ness 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
cir-cumference 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 an-ticulating surface, with multicystic irnegu-lanities of the bone. A diagnosis of
osteo-chondnitis dissecans was made. The
pa-tient is under therapy at the time of this
writing.
COMMENT
These two cases are presented to
demon-strate that relatively small lesions in and
around the knee, with only slight pain,
ap-panently can cause enough reflex splinting
of the muscle groups around the knee to
produce an atrophy of disuse. This
oc-curred despite the fact that the patients not
only walked but actively participated in
sports. If the reflex spasm of the muscle
groups is great enough, abnormal
neuro-logic signs such as ankle clonus and
in-creased deep tendon reflexes may be
dem-onstrated.
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
