Endgames Picture Quiz

“It’s just a muscle sprain”

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2503 (Published 30 April 2013) Cite this as: BMJ 2013;346:f2503
  1. Rej Bhumbra, locum consultant orthopaedic surgeon,
  2. William Aston, consultant orthopaedic surgeon ,
  3. Rob Pollock, consultant orthopaedic surgeon
  1. 1London Sarcoma Service, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
  1. Correspondence to: R Bhumbra bhumbra{at}hotmail.com

A 10 year old boy presented to his general practitioner with a four week history of left mid-thigh pain with no associated history of systemic symptoms. He had no memory of a preceding trauma and no history of infection, locally or systemically. The pain was relapsing and remitting in its extent and frequency. It was also activity related, with occasional night waking and pain at rest. His GP took a full history, conducted a complete hip examination, and at initial presentation decided that the pain was caused by a muscle sprain.

Two months later the pain has not abated and the child re-presented to his GP, who requested a plain radiograph of the hip, the results of which were normal. A further three months later, his father noticed an associated distal thigh mass and immediately took the boy to the emergency department. On presentation to hospital, he was walking pain free but had an obvious mass, which did not limit his range of movement.

He did not have a fever; his C reactive protein was 6 mg/L, erythrocyte sedimentation rate was 4 mm in the first hour, and total white blood cell count was 8×109/L. The on-call orthopaedic team requested anterioposterior and lateral radiographs of the thigh (figs 1 and 2).

Fig 1 Anterioposterior radiograph of the distal femur

Fig 2 Lateral radiograph, midshaft femur


  • 1 Are there any red flag symptoms in the initial presenting history?

  • 2 Given this history, what other examination findings would be relevant?

  • 3 Would femoral radiography and its related radiation exposure have been warranted at an earlier stage?

  • 4 What do the anterioposterior and lateral radiographs taken six months after the onset of pain show?

  • 5 What would be the next stage in this boy’s management?


1 Are there any red flag symptoms in the initial presenting history?

Short answer

The four week …

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