Journal of Urgent Care Medicine

Practice Management

4-Year-Old With Right-Sided Pelvic Pain

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XR 2 - Right-sided pelvic pain, Lytic lesion on medial iliac bone, mass circled

Differential Diagnosis

Benign:

  • Most occur before the age of 40
  • Osteochondroma
  • Osteoblastoma
  • Giant cell tumor
  • Fibrous dysplasia
  • Aneurysmal bone cyst
  • Chondroblastoma

Malignant:

  • Osteosarcoma
  • Chondrosarcoma
  • Chordoma
  • Ewing’s
  • Metastases
  • Plasmacytoma
  • Lymphoma
  • Post-radiation sarcoma

Malignancy Mimics:

  • Hemophilic pseudo tumor
  • Osteomyelitis
  • Insufficiency fracture
  • Particle disease

Diagnosis

The imaging reveals a large lytic lesion on the medial right iliac bone with ill-defined lateral margins (cortical destruction) and likely adjacent soft tissue mass. This either represents an aggressive malignancy (ie Ewings Sarcoma, Osteosarcoma, metastatic disease such as Neuroblastoma) or an aggressive benign lesion (ie Langerhans Cell Histiocytosis (LCH), Osteomyelitis, Osteoblastoma, Aneurysmal Bone Cyst).

What to Look For

  • Age of the patient (4 years old), and painful lesion
  • Appearance of the lesion: Fully lytic lesion with wide zone of transition (ill-defined margins) and loss of medial cortex indicating an aggressive lesion, with likely adjacent soft tissue mass.
  • Look for additional lesions elsewhere in the body.

Pearls for Urgent Care Management

  • Given the appearance in this case, you would be concerned about adjacent soft tissue mass with bony invasion and/or erosion.
  • Pediatric orthopedic consultation with a specialist in pediatric bone tumors is recommended. 
  • Advanced imaging (MRI) and biopsy is indicated as directed by the pediatric orthopedic oncologist.

References

  1. McCarville MB. The child with bone pain: malignancies and mimickers. Cancer Imaging. 2009 Oct 2;9 Spec No A(Special issue A):S115-21. doi: 10.1102/1470-7330.2009.9043. PMID: 19965301; PMCID: PMC2797463.
  2. Trueworthy RC, Templeton KJ. Malignant bone tumors presenting as musculoskeletal pain. Pediatr Ann. 2002 Jun;31(6):355-9. doi: 10.3928/0090-4481-20020601-07. PMID: 12073739.
  3. Nik-Ahd M, Agrawal AK, Zimel M. Diagnosis and management of pediatric primary bone tumors in the emergency department. Pediatr Emerg Med Pract. 2021 Jul;18(7):1-20. Epub 2021 Jul 2. PMID: 34196516.

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4-Year-Old With Right-Sided Pelvic Pain
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