Volume 1, Case 4 Answers

Films:

This follow-up radiograph showed progressive demineralization and multiple compression fractures of the thoracic and lumbar vertebral bodies. This is not obvious initially if your attention is directed at the abdominal soft tissue. Upon close inspection, you can appreciate multiple vertebral compression fractures of her thoracic and lumbar vertebrae. Note that the vertebral bodies appear to be flatter than normal. It is remarkable that her clinical symptoms pointed to the abdomen rather than her spine. Some hepatomegaly is also noted on one of the views. These vertebral fractures were felt to be most consistent with acute leukemia. Bone marrow studies confirmed the diagnosis of acute lymphocytic leukemia.

A lateral view of her lumbar spine makes these fractures easier to appreciate. The vertebral bodies are obviously flatter than they should be on this view.

Lateral

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Teaching Points:

Abdominal radiographs are generally non-diagnostic for the vast majority of cases. However, when they reveal significant findings, they are often difficult to appreciate. Abnormalities of the bony structures include vertebral fractures, pelvic fractures, rib fractures, congenital dislocated hips, other hip injuries, etc. If one is not paying careful attention to the bony structures, these findings can be easily overlooked, although they may appear obvious once the abnormalities are identified. Soft tissue findings include fecaliths, intussusception, pneumoperitoneum, subtle obstructions, volvulus, mass effects, etc.

Abdominal pain is a non-specific presentation for many serious diagnoses, but abdominal pain is most often the result of a benign cause. It is often useful to observe the patient ambulating since this can provide significant clues to the patient's severity. Patients who cannot walk upright easily should be taken more seriously than those who can ambulate normally. Coughing and jumping are useful peritoneal signs for children since this tends to distract them away from the abdomen. When the patient is walking, ask the child to jump and challenge them to jump higher if possible. Then ask them if jumping hurt their tummy. Ask the child to cough and then ask them if the cough hurt their tummy. Negative findings on jumping and coughing make the likelihood of peritoneal irritation extremely remote.

In this case, if the examiners had observed the patient ambulating, they may have noted some difficulty since she did complain of pain with standing. If the examiners asked her to jump, it is likely that she would have complained of pain in her back, though in this instance, such a maneuver may have worsened her compression fractures. Hopefully, the patient would be able to appreciate this and refuse to jump. It is difficult to conceive that this patient with so many vertebral compression fractures could tolerate ballet practice the previous day and that she presented with such non-specific findings. Often children can be extraordinarily stoic despite being in substantial pain. This can be deceiving for the examiners. A good practice is to palpate all parts of the abdomen and all parts of the back in patients with abdominal pain.

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Loren Yamamoto, MD, MPH 
Associate Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine
loreny@hawaii.edu