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- Discussion:
    - most common malignancy of childhood;
    - usually affects young children;
    - most appear systemically ill;
     - dz can mimic JRA by skeletal and extraskelal manifestations;
    - joint disease is usually painful monoarticular (frequently hip) although it can be painful polyarticular
    - bone pain is common;
    - symptoms may last for months;

- Labs:
    - CBC w/ diff does not rule out exclude leukemia;
    - bone marrow examination is required for definative diagnosis;

- Radiographs:
    - changes appear in many areas of skeletal system but none is pathognomonic;
    - skeletal changes are most prevalent in long bones and skull;
    - generalized osteoporosis (almost always present)
    - in the skull, look for widening of the cranial sutures;
    - osteolytic lesions:
           - present in two thirds of pts;
           - usually in has a diffuse pattern in metaphyseal area;
           - lesions may vary in size;
           - appearance of new osteolytic lesions, may herald the onset of blastic bone marrow crisis;
    - metaphyseal leukemic lines:
           - more frequent in the older child;
           - occur in metaphysis adjacent to metaphyseal side of epiphseal plate;
           - lines are probably not caused by leukemic infiltration;
           - lines are a reflection of the metabolic demands on the patient;
           - lines represent a disturbance in endochondral bone formation, resulting in abnormally small trabeculae adjacent to epiphysis;
           - areas of growth arrest that appear as dense metaphyseal lines which are left behind as the bone continues to grow during remission;
                 - hence, periods of remission and exacerbation of disease will manifest radiographically w/ alternating dense and lucent areas representing various phases of activity of the disease;

- Bone Scan:  - may be useful in the dx

Orthopaedic manifestations of leukemia in children.

Skeletal scintigraphy and radiography at onset of acute lymphocytic leukemia in children

The gallium bone scan in acute leukemia.  

An unusual orthopaedic presentation of acute lymphoblastic leukemia.

Hyphenated history: Park-Harris growth arrest lines.

Musculoskeletal Manifestations in Pediatric Acute Leukemia

Avascular necrosis of the femoral head in children with acute lymphoblastic leukemia: a 4- to 9-year follow-up study.

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