How does the nurse practitioner decide the extent of the diagnostic work-up in a child with extremity pain?



  1. What are three differential diagnoses of leg pains in school-age children? Include the pathophysiology of the three differentials.

Growing Pains

This medical condition is defined as a throbbing pain in the legs. It more specifically occurs in the front of thighs, calves, or behind the knees. It tends to impact both legs and occurs during nighttime. It may also awaken the child from sleep (Lehman & Carl, 2017). The mechanism of disease is unclear. However, research suggests that an increased level of physical activity can cause growing pains and growth spurts. It commonly occurs in children between the ages of four and twelve. A heating pad, stretching, and massages help relieve the symptoms.


Leukemia refers to the cancer of the blood-producing tissues of the body. These include the lymphatic system and the bone marrow. Among patients with leukemia, the bone marrow generates an additional amount of dysfunctional white blood cells. As a result, among leukemia’s common signs and symptoms are bone pain and tenderness (Kolivand et al., 2018). The mechanism by which leukemia causes a cancerous transformation of pluripotent hematopoietic stem cells, leading to the growth of both myeloid and lymphoid precursors (Kolivand et al., 2018). In acute leukemia, these cancerous cells are usually immature and poorly distinguished. Abnormal leucocytes also referred to as blasts, can be either myoblasts or lymphoblast (Imai, 2017). In addition, they may go through clonal growth and multiplication. This interferes with the production and functioning of healthy blood products and replaces them with cancerous cells, causing clinical symptoms.

Restless Legs Syndrome (RLS)

This condition is characterized by an uncontrollable compulsion to move legs, generally due to a painful sensation. It typically occurs during the evening or night when the patient is resting. It may disrupt sleep that eventually disrupts daytime activities. Patients generally define RLS as uncomfortable and abnormal sensations in their legs or feet. These sensations are described as aching or throbbing. A positive history of dominant inheritance is reported among 40% of the cases of RLS. This suggests a genetic foundation as a mechanism by which RLS is caused (Didato et al., 2020). The symptomatic reaction with levodopa and dopamine agonists paves the path to ascertain that dysfunction of the dopaminergic system possibly contributes to the pathophysiology of RLS. This system is proximal to the hypothalamus’ circadian control centers, which could explain the indicative alteration of RLS diagnosis based on circadian patterns (Didato et al., 2020). The metabolism of iron in the brain could also play a role in the pathogenesis of RLS. This is mainly because iron is a tyrosine hydroxylase cofactor. This refers to a rate-limiting phase in the alteration of dopamine from levodopa. This suggests that a decline in iron levels can affect dopamine levels. In addition, circadian variations have been reported in the tyrosine hydroxylase’s activity (Didato et al., 2020). This could suggest the aggravating of RLS during the nighttime.

  1. What laboratory or radiographic studies are appropriate for children with leg pains? Explain

Laboratory studies appropriate for children with leg pain may include a negative antinuclear antibody (ANA) test, an erythrocyte sedimentation rate (ESR), and a complete blood count. The results of these tests may help diagnose or rule out the possibility of infection, cancer, and complete lupus erythematous (Lizano, 2019). It is recommended that plain radiography must be the initial choice of radiologic study. It generally supports the exclusion of certain conditions such as cancer. They can be further supportive concerning fracture or bony lesions. Magnetic resonance imaging (MRI) has been reported to have the highest sensitivity levels when an inflammatory cause is suspected for the leg pain (Lizano, 2019).

  1. How do musculoskeletal injuries in children differ from those in adults? In terms of injury type and location?

Differences between musculoskeletal injuries in children and adults are mainly attributed to the variance in the physiology of the growing bones. For instance, the elasticity of the metaphysis is reported to be higher among children than adults. This suggests that fractures are usually incomplete in children (Locquet et al., 2019). Also, the origin of the tibia of the anterior cruciate ligament (ACL) in children possibly avulse a fragment of bone. On the other hand, a similar mechanism of injury in the adult tend to disrupt it mid-substance (Locquet et al., 2019). This suggests significant variance between musculoskeletal injuries in children and adults.

  1. How does the nurse practitioner decide the extent of the diagnostic work-up in a child with extremity pain?

The nurse practitioner can decide the range of diagnostic work-up in a child with extremity pain based on the clinical features presented by the child. For instance, identifying if the pain is out of proportion to clinical findings, it is recommended to order ESR (Lizano, 2019). When a severe rheumatic cause is suspected, the nurse practitioner must thoughtfully utilize the laboratory test. For instance, ANA can be utilized for a patient suspected to be suffering from juvenile rheumatoid arthritis (Lizano, 2019). The nurse practitioner can determine the need for appropriate laboratory tests based on patient history and findings of the physical exam. These may include atypical symptoms or abnormal findings during the physical exam of a child with extremity pain. Radiologic studies are warranted in such cases (Lizano, 2019).

  1. What fractures are common in pediatric patients, and what are the ages associated with them?

The most common fractures among children up to 24 months include 25% of supracondylar or distal humerus fractures and 29% of distal radial buckle fractures (Baig, 2017). The most common fractures among children aged three to six include 10% of ulnar metaphysis or radial fractures and 32% of distal radial/buckle fractures and supracondylar or distal humerus fractures each (Baig, 2017). For children between seven to 12 years, the most common fractures include nine percent of ankle fractures, 12% of supracondylar fractures, and 37% of buckle or radial fractures (Baig, 2017).

  1. Choosing one of the diagnoses you’ve come with; how would you treat the condition?

Growing pains have been identified not to have any particular treatment. It often improves without treatment in a year or two. The intensity of pain reduces after a year (Lehman & Carl, 2017). During this time, growing pains are managed through easing associated discomfort by self-care measures. These may include gently massaging the affected leg and using the heating pad to soothe sore muscles. Medication treatment may consist of administering a pain-relieving medication such as children’s Motrin, Advil, or Tylenol (Lehman & Carl, 2017). In addition, parents can be guided to take their child to a physiotherapist to learn about exercise that helps muscles stretch. Performing stretching exercises in the day may provide pain relief during the nighttime.

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