{"id":6131,"date":"2025-06-04T00:01:00","date_gmt":"2025-06-04T08:01:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=6131"},"modified":"2025-10-02T13:52:04","modified_gmt":"2025-10-02T21:52:04","slug":"pance-question-of-the-day-right-leg-pain","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-right-leg-pain","title":{"rendered":"PANCE\u00ae Question of the Day: Right leg pain"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-right-leg-pain\/#The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\" >The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-right-leg-pain\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-right-leg-pain\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-right-leg-pain\/#Major_Takeaway\" >Major Takeaway<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-right-leg-pain\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-right-leg-pain\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Prepare for the PANCE with this challenging clinical scenario on right leg pain in a child. Explore the clinical details to make an informed decision.<\/em><\/strong> <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 3-year-old boy is brought by his parents to the emergency department for evaluation of right leg pain. The patient had multiple episodes of watery diarrhea and low-grade fevers five days ago, which have fully resolved. However, over the past two days, the patient began complaining of right leg pain, and today he was limping. The patient has no significant past medical history and does not take any medication. Parents deny dysuria or hematuria. He is up-to-date on his vaccinations. Temperature is 37.9\u00b0C (100.2\u00b0F), blood pressure is 95\/58 mmHg, pulse is 135\/min, respiratory rate is 20\/min, and oxygen saturation is 97% on room air. On physical examination, the patient is in no acute distress and is well-appearing. There is limited range of motion at the right hip secondary to pain, but active and passive movement is possible. There is no obvious erythema or warmth over the hip. All other joints are within normal limits. Laboratory results are shown below. Hip ultrasound shows an effusion. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following is the <em>best <\/em>next step in management?&nbsp;&nbsp;<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td><strong>Laboratory value<\/strong>&nbsp;&nbsp;<\/td><td><strong>Result<\/strong>&nbsp;&nbsp;<\/td><\/tr><tr><td>Hemoglobin&nbsp;&nbsp;<\/td><td>12.5 g\/dL&nbsp;&nbsp;<\/td><\/tr><tr><td>Leukocyte count&nbsp;&nbsp;<\/td><td>16,100\/mm<sup>3<\/sup>&nbsp;&nbsp;<\/td><\/tr><tr><td>Platelet count&nbsp;&nbsp;<\/td><td>344,000\/mm<sup>3<\/sup>&nbsp;&nbsp;<\/td><\/tr><tr><td>C-reactive protein (CRP)&nbsp;&nbsp;<\/td><td>&nbsp;&nbsp;&nbsp; 1mg\/dL&nbsp;&nbsp;<\/td><\/tr><tr><td>Erythrocyte sedimentation rate (ESR)&nbsp;&nbsp;<\/td><td><strong>&nbsp;&nbsp;&nbsp;<\/strong> 15 mm\/h&nbsp;&nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Perform hip arthrocentesis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Order hip x-ray<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Order hip magnetic resonance imaging (MRI)<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Order Borrelia burgorferi enzyme immunoassay (EIA)<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">E. Obtain urinalysis&nbsp;<\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em><strong>Scroll down to find the answer!&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<\/strong><\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Perform hip arthrocentesis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before we get to the Main Explanation, let&#8217;s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The incorrect answers to today&#8217;s PANCE\u00ae Question are&#8230;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Order hip x-ray<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> An x-ray of the hip may identify fracture, osteomyelitis, or other causes of pain and swelling, but is not the best next step in management. This patient\u2019s history is concerning for transient synovitis, However, there is elevation of laboratory studies warranting further evaluation of arthrocentesis to rule out septic arthritis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Order hip magnetic resonance imaging (MRI)<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> An MRI may identify effusions or abnormalities of the bone and soft tissues, but it is not the best next step for this patient. This patient\u2019s history is concerning for transient synovitis, but there is elevation of laboratory studies warranting further evaluation with arthrocentesis to rule out septic arthritis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Order Borrelia burgorferi enzyme immunoassay (EIA)<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Lyme arthritis often presents as monoarthritis of the knee with effusion. This patient has an effusion in the hip and a history of recent gastrointestinal illness, making transient synovitis more likely. However, this patient has elevations in laboratory studies, making arthrocentesis the best next step to rule out septic arthritis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Obtain urinalysis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Urinalysis may be indicated if there is concern for reactive arthritis or urinary tract infection causing pelvic discomfort. This patient has an effusion in the hip and no urinary symptoms. This patient\u2019s history is concerning for transient synovitis, but there is elevation of laboratory studies warranting further evaluation with arthrocentesis.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"975\" height=\"536\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/06\/image_022713.png\" alt=\"\" class=\"wp-image-6134\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/06\/image_022713.png 975w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/06\/image_022713.png?resize=300,165 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/06\/image_022713.png?resize=768,422 768w\" sizes=\"auto, (max-width: 975px) 100vw, 975px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">This pediatric patient presents for assessment of right leg pain and limping and is found to have limited range of motion of the right hip due to pain. He has had a recent viral illness, which, along with the other clinical features, is suggestive of transient synovitis. Hip effusion is seen on ultrasound. Given that the patient has a white blood cell count over 15,500 and a slightly elevated c-reactive protein, he should have an arthrocentesis on this joint to formally rule out septic arthritis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Septic arthritis refers to a bacterial infection of the synovium and joint space. Transient synovitis (toxic synovitis) is noninfectious synovial inflammation and can present similarly. Differentiating the two is important since the treatment is different. Transient synovitis is a benign and self-limited illness, whereas septic arthritis requires drainage of the joint and antibiotics to prevent permanent bone, joint damage, and multisystem involvement.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">If there is enough suspicion, formal diagnosis of septic arthritis or transient synovitis is confirmed via joint aspiration, with evaluation of synovial fluid cell count with differential, gram stain, and culture. In patients with septic arthritis, synovial fluid analysis will typically reveal bacterial growth, cloudy or purulent fluid, as well as a cell count &gt; 50K WBC\/mm3. Patients can also have positive blood cultures. In contrast, patients with transient synovitis will have a negative gram stain and culture, clear or yellow fluid, and a cell count of 5K &#8211; 15K WBC\/mm3.&nbsp;&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Arthrocentesis should be performed in any patient with a suspected septic joint. Patients with clinical features consistent with transient synovitis who have findings that are concerning for septic arthritis should also have an arthrocentesis to rule out septic arthritis.&nbsp;<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch this Osmosis video:&nbsp;<a href=\"https:\/\/www.osmosis.org\/learn\/Septic_arthritis_and_transient_synovitis_(pediatrics):_Clinical_sciences\">Septic arthritis and transient synovitis (pediatrics): Clinical sciences<\/a><\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">John J, Chandran L. Arthritis in children and adolescents [published correction appears in Pediatr Rev. 2012 Mar;33(3):109]. <em>Pediatr Rev<\/em>. 2011;32(11):470-480. doi:10.1542\/pir.32-11-470&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Arvikar SL, Steere AC. Diagnosis and treatment of Lyme arthritis. <em>Infect Dis Clin North Am<\/em>. 2015;29(2):269-280. doi: 10.1016\/j.idc.2015.02.004&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Horowitz DL, Katzap E, Horowitz S, Barilla-LaBarca ML. Approach to septic arthritis. <em>Am Fam Physician<\/em>. 2011;84(6):653-660.&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Kliegman, RM, St Geme, JW, Blum, NJ, et al, eds. <em>Nelson Textbook of Pediatrics.<\/em> 21st ed. Elsevier; 2020.&nbsp;&nbsp;<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\/pa\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/06\/Blog_Display_Ads_MD1_2023.png?w=700\" alt=\"\" class=\"wp-image-4438\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/06\/Blog_Display_Ads_MD1_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/06\/Blog_Display_Ads_MD1_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><em>Want more PANCE\u00ae-style practice questions? Try Osmosis by Elsevier today! Access your&nbsp;<a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>&nbsp;and discover why millions of current and future clinicians and caregivers love learning with us.<\/em><\/strong><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Explore today\u2019s PANCE\u00ae question on a pediatric case of right leg pain and learn the critical next step in managing this fascinating case!<\/p>\n","protected":false},"author":204,"featured_media":6133,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[20,38,1371,37],"tags":[796,215,799,800,148,280,797,717,798,795],"class_list":["post-6131","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-exam-prep","category-pance","category-pance-questions","category-pa","tag-clinical-management","tag-healthcare-education","tag-joint-pain","tag-medical-scenarios","tag-medical-training","tag-pance","tag-pediatric-assessment","tag-pediatric-care","tag-septic-arthritis","tag-transient-synovitis"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>PANCE\u00ae Question of the Day: Right leg pain - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-right-leg-pain\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"PANCE\u00ae Question of the Day: Right leg pain - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"Explore today\u2019s PANCE\u00ae question on a pediatric case of right leg pain and learn the critical next step in managing this fascinating case!\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-right-leg-pain\" \/>\n<meta property=\"og:site_name\" content=\"Osmosis Blog\" \/>\n<meta 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