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Ask Dr. Yogindra Vasavada Your Own Question
Dr. Yogindra Vasavada
Dr. Yogindra Vasavada, Pediatrician
Category: Pediatrics
Satisfied Customers: 3007
Experience:  M.D.(ped) passed at first attempt, in practice continuously for last 37 years. Certi. in Comp
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The question I have concerns a ten year old Russian girl

Customer Question

The question I have concerns a ten year old Russian girl called Marusya (M.) who has clear signs and symptoms of a potential entrapment of the peroneal nerve. 16 months ago a “hole” in one of the bones of her left knee was found by doctors in Moscow (where her father lives). M. complains of increasing pain in her left leg especially when walking long distances.
Medical history: In May 2015 M. visited her father in Moscow and while climbing on a playground her left knee felt somehow funny “as if there was soap inside”. She saw that her left knee was a bit swollen and purple on the inside but M. didn’t pay much attention to it because she could climb as usual. The knee felt strange but it didn’t hurt. Her father decided to take her to a doctor (in Moscow) the next day who took an x-ray. The doctor saw “something” but didn’t know what it was. The next day another doctor made an investigation that took 20 minutes (MRI?). With the results they went to another doctor who said: “I know what it is. It is a hole in the knee which everybody has somewhere in his/her body in the bones. You have it in an unlucky place close to a joint.” A week later M. went back to Scotland where her mother lives with a new husband. Over the next months M. had a little pain in her left knee from time to time which was more severe when she had to walk long distances. Then the pain felt sometimes like strokes or claps. During the last two months the pain got worse. A week ago M woke up early in the morning and her knee was hurting. Usually the knee starts hurting after walking for more than 5 minutes and is between 4 to 5 (on a scale of 0-10). Her mother is going back to Russia with M. and her little sister for four weeks in the middle of October. There is some talk about an operation. No further investigations have been done in the mean time and I am concerned for the well-being of my little friend.
I am a research physician (with little practical experience) but decide to make some simple basic investigations as M. is very dear to me and we are good friends.
The results of the investigation I did yesterday are:
Knee movements: The passive movements of M’s left knee are NOT painful and NOT restricted.
Sore point on the inside of the left knee: There is a sore point on the insight of M’s left knee. The area around the sore point is very slightly swollen and a slight brownish discoloration is visible.
Circumference of left middle thigh
The circumference of M’s left middle thigh is approx. 2 cm less than that of her right thigh.
Circumference of left middle calf
The circumference of M’s left middle calf is approx. 1.5 cm less than that of her right calf.
Walking on tiptoe
Walking on tiptoe is difficult for M. Her left leg feels somehow weak and she has to limp.
Walking on heels
M. has difficulties to lift her left forefoot.
Pronation and supination of the left foot
Supination does not hurt, pronation hurts a bit
Sitting cross-legged
M. has no problems sitting cross-legged
Pressing against the fore-foot
Pressing against the fore-foot induces pain in M.
Testing the sensitivity of the skin (lower leg - below the knee)
Very distinctive loss of sensitivity along the innervation of the superficial fibular nerve
What could potentially “entrap” the peroneal nerve and where would that be?
What are the most pressing investigations that would need to be done to get a clear picture?
Submitted: 29 days ago.
Category: Pediatrics
Expert:  Dr. David replied 29 days ago.

Hello, this is Dr. David. I am reviewing your question now and will be with you momentarily.

Expert:  Dr. David replied 29 days ago.

I think she most likely had a knee CT scan in Moscow.

I would get a copy of the CT scan report and see what that shows.

she could have a bone cyst or lytic lesion in her knee.

I'm not sure what her doctors there meant by "a hole" in the knee joint.

can her family get copies of the scan report from Moscow?

Customer: replied 29 days ago.
I have no access to any of the examination that have been done in Moscow and I do not know what the doctors meant by "a hole". That is how it was explained to her. From my current perspective it could have been a unicameral bone cyst (the most common bone cyst) or an aneurysmal bone cysts (less common). 94% of unicameral bone cysts occur however in the proximal humerus and proximal femur, not around the knee. An aneurysmal bone cyst seems to me more likely to me and might also explain the heamatoma (without any previous trauma) she had observed in Moscow.
What do you mean by lesion? What kind of lesion do you have in mind? Can this "lesion" have "grown" in the last 15 months and now compress a nerve? My main concern is the loss of sensitivity and motor functions of the peroneal nerve that developed in the last couple of weeks.
Expert:  Dr. David replied 29 days ago.

lesion is just a non specific word for an abnormality.

I agree with your differential at this point of the different types of bone cysts.

bone cysts can grow on their own

she needs another CT or MRI scan of the area in the UK or in Russia at this point.

MRI scan is better to check for nerves. CT scans of the knee don't see nerves at all.

without more scans and testing, all of this this discussion is rather moot and doesn't help the girl.

Customer: replied 29 days ago.
I don't think you are the right person for answering my questions. Thank you for trying.
Expert:  Dr. David replied 29 days ago.

you are welcome

let me know if you have other questions.