# Orthopedic manifestations as presenting symptoms in children with neuroblastoma: a retrospective case series and clinical review

## TL;DR

About 20% of children with neuroblastoma first show orthopedic symptoms like hip or back pain, which can delay diagnosis if not properly evaluated.

## Contribution

This study highlights the importance of considering neuroblastoma in children with atypical musculoskeletal symptoms and abnormal blood markers.

## Key findings

- Seven out of 46 children (20%) initially presented with orthopedic symptoms.
- Three children had spinal involvement, and three had hip pain initially misdiagnosed as osteomyelitis.
- Six children had severe anemia and elevated inflammatory markers like ESR and CRP.

## Abstract

Neuroblastoma is the second most common childhood malignancy. Only a minority of children with metastatic disease present initially to orthopedic surgeons, despite musculoskeletal complaints such as back pain, limb pain, limp, extremity swelling, or findings mimicking osteomyelitis. These vague and nonspecific presentations increase the risk of delayed diagnosis.

To study orthopedic manifestations that present as the initial presenting symptoms of neuroblastoma in children and to characterize their clinical, radiological, and laboratory profiles.

Forty-six consecutive patients with neuroblastoma were retrospectively evaluated. Medical records were reviewed, with particular attention given to the presence of orthopedic manifestations preceding the diagnosis of neuroblastoma. The children who were presented primarily to the orthopedics department were identified. The details of musculoskeletal symptoms and radiological and laboratory investigations were analyzed.

Seven children (20%) presented initially with orthopedic complaints. Three patients had spinal involvement, including paraplegia from hydromyelia or vertebral metastasis with lytic–sclerotic lesions. Three children presented with persistent hip pain and limp and were initially diagnosed with osteomyelitis before biopsy confirmed neuroblastoma. One child presented with nontraumatic forearm swelling, initially presumed as osteomyelitis, with radiographs showing lysis of the ulnar metaphysis. A biopsy was used to establish the diagnosis. Six children had severe anemia with elevated ESR and CRP, and three had markedly elevated LDH levels.

Approximately one-fifth of children with neuroblastoma initially present to orthopedic surgeons. Persistent or atypical musculoskeletal complaints—especially hip pain or back pain accompanied by anemia, high ESR, or high CRP—should prompt the consideration of neuroblastoma and early histopathological evaluation to avoid diagnostic delays.