Inability to Bear Weight
Presentation
A young previously healthy female presents with her father for evaluation of right upper leg pain. The pain originated after the patient was hit by a lacrosse ball on her right knee at school one month prior to arrival. Initially, she was seen by her PCP, and knee X-rays were negative. Due to persistent symptoms, an MRI was scheduled for the upcoming week. However, the patient's pain had been progressively worsening, described as originating in the distal thigh and radiating up to the hip. She now reports difficulty straightening her leg unless manually arranged, and says external rotation provides some relief. Patients’ father denies fevers, joint redness, skin discoloration/bruising, or recent illnesses, but he has observed increased swelling in the distal thigh region.
Upon examination, mild fullness was observed in the distal right thigh without any signs of skin compromise. Tenderness was present in the distal anterior thigh, with no tenderness during palpation along the knee or proximal tibia. The patient struggled to bear weight, which was only possible after rotating her leg in an extended position.
Workup
X-ray of femur:
Results
Radiology impression:
Expansile permeative lesion in the distal femur lacking benign features, with periosteal new bone formation and possible soft tissue component. Findings are highly concerning for neoplasm such as ewing sarcoma, osteosarcoma among other etiologies.
After consultation with pediatric orthopedic surgery and hematology/oncology, the patient was made non-weight bearing and urgent outpatient follow-up with MRI imaging was arranged.
Takeaway Points
"Cannot bear weight" is a significant chief complaint!
Perform a comprehensive physical examination for orthopedic injuries, including areas proximal and distal to the painful region.
While not all orthopedic tumors necessitate admission, arranging appropriate follow-up prior to discharge is crucial.
