Do Not Miss the Tumor: A Novel Presentation of Osteosarcoma
Antalgic gait is a common clinical presentation among pediatric patients and can have many different etiologies, with rare life-threatening etiologies including primary bone malignancies. Osteosarcoma is the most common primary malignancy of bone in pediatric and adolescent patients. The incidence rate of osteosarcoma has been reported as high as 5 to 7 per million among patients 19 years old or younger with males slightly more affected than females and African-Americans more than other racial groups. This report describes the case of a five-year-old African-American female who presented with an antalgic gait secondary to osteosarcoma in the left distal femur and follows her through treatment. In this case, the age is atypical as the peak incidence for osteosarcoma is around 16 years of age and is postulated to coincide with growth spurts. Osteosarcoma can have a range of presentations making it difficult to diagnose, which can cause delays in treatment and potential poor patient outcomes. Due to this, such a diagnosis must be included in the differential for patients presenting with an antalgic gait. Because primary-care physicians and pediatricians may be the first medical providers to encounter patients with osteosarcoma, it is imperative that such clinicians are familiar with the signs and symptoms associated with osteosarcomas in order to reduce the risk of metastasis and disease progression and prevent treatment delays. Additionally, we believe these clinicians should have a low threshold to refer patients to orthopedists or oncologic specialists in the cases of persistent pain or inconsistencies with history, physical exam, and diagnostic studies. Finally, direct communication and discussion between radiologists and referring clinicians help decrease delays in diagnosing osteosarcoma and other life-threatening conditions.

This case highlights the ambiguity of symptoms that can cloud such a diagnosis. This patient presented with an antalgic gait without a palpable mass. However, with further investigation, it was discovered the patient did have “red-flag” symptoms including pain at night and worsening pain inconsistent with the initial injury. Although radiographs were ordered, they were incorrectly read by both the attending radiologist and primary-care physician. This was an unfortunate occurrence but often occurs when the radiology read is “handed-off” to the patient and physicians neglect to look at the actual images. Therefore, although radiographs are the sensible first step in the diagnosis, in this instance, they were futile because they did not improve efficiency in diagnosis and treatment. Fortunately, this did not affect the overall outcome of the patient. It is well known that early detection and initiation of treatment is vital for patients with osteosarcoma because of the significant risk of metastases and associated poorer prognosis with increased tumor volume. Primary-care physicians encountering patients with an antalgic gait should have a low threshold for not only taking repeat imaging but also examining images themselves. These physicians should also have a low threshold for referral to an orthopedic surgeon should a patient's presenting complaint or history be inconsistent with their exam or diagnostic studies. It is imperative that such clinicians are familiar with the signs and symptoms associated with osteosarcomas in order to reduce the risk of metastasis and disease progression and prevent treatment delays.

Source:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137287/
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