An interesting case of limping in a child with autism

Key Points

Preface: When you are a pediatrician who also happens to be a father of a child with autism, your understanding of autism reaches beyond the patient-pediatrician relationship. Indeed, your interest and experience with autism may even result in a larger number of children within the autistic spectrum to be a part of your practice. Some of the insight and discovery you gain from this is that when a child with autism is sick, you need to be a bit more selective about testing and possible hospitalization, since this will prove very disruptive to your patient.

You receive a call on a Friday afternoon from a parent relating the last three weeks of events that have led to your 5-year-old patient's symptoms. Your patient with severe autism had a minor fall while on an escalator at Disney World, and one day later had developed a mild limp.

When he returned home several days later, his parents noticed the limp had worsened. They decided to take him directly to an orthopedic surgeon, bypassing you the gatekeeper while you were away on vacation. The parents profusely apologize for not calling earlier, and state that they are now just finishing a bone scan. You realize that there must be more to the history, so you suggest that they come to your office when the bone scan is finished. You call the orthopedic surgeon in the interim to clarify the details.

In the following week, the limp persists, as does the pain localized to the right distal femur; no fever or other new systemic symptoms develop. Over the course of the week, the parents relate that their child gradually refuses to walk or bear weight. Repeated radiographs of the lower extremities are normal. Although there is no fever, the orthopedic surgeon is worried about osteomyelitis and orders a bone scan. The bone scan results are normal, essentially making fracture or osteomyelitis very unlikely.

What's going on?