The Child With Joint Pain Diagnostic Clues

Abraham Gedalia, M.D.

Professor of Pediatrics

Head, Division of RheumatologyDepartments of Pediatrics, Louisiana State University Health Sciences

Center and Children's Hospital of New Orleans

New Orleans, LA

Objectives: At the conclusion of this activity, the participants should be able to: 1. Discuss the approach to the child with joint pain or arthritis

2. Recognize the diagnostic clues of the different arthropathies 3. Develop strategy for the diagnosis

The Child With Joint Pain

IMPORTANT FACTS

• Musculoskeletal pain during childhood is common

• According to population surveys, 16% of school-aged children reported to have limb pain٭

• Joint Pain has multiple etiologies

• Early diagnosis and treatment is critical to prevent

complications

Cassidy Textbook of Pediatric Rheumatology 2005;37:704 ٭

The Child With Joint Pain

IMPORTANT QUESTIONS

• How many joints are involved, is it one joint or many ?

• Any associated fever ?

• Any joint swelling ?

• What is the duration of symptoms ?

• Any associated morning stiffness, rash, mouth ulcers ?

• Any associated muscle weakness ?

• Any associated chest pain, abdominal pain, diarrhea ?

• Any weight loss, skin bruises, and/or night pain ?

• Any associated migraines and or sleep disturbances ?

• Any associated eye problem ?

• Any associated Trauma ?

The Child With Joint Pain

IMPORTANT QUESTIONS

• How many joints are involved, is it one joint or many ?

• Any associated fever ?

• Any joint swelling ?

• What is the duration of symptoms ?

• Any associated morning stiffness, rash, mouth ulcers ?

• Any associated muscle weakness ?

• Any associated chest pain, abdominal pain, diarrhea ?

• Any weight loss, skin bruises, and/or night pain ?

• Any associated migraines and or sleep disturbances ?

• Any associated eye problem ?

• Any associated Trauma ?

The Child With Pain

Single Joint Involvement

Multiple Joint Involvement

With Fever

Septic arthritis/Osteomyelitis

Sympathetic arthritis

Foreign body with infection

Traumatic arthritis

Soft Tissue infection

Rheumatic Diseases

Reactive arthritis

Toxic synovitis

Diskitis

Sarcoidosis

Hemoglobinopathy

Malignancies

Without Fever

Trauma

Mechanical derangement

Rheumatic Diseases

Toxic synovitis

Avascular necrosis

Subacuteosteomyelitis

Diskitis

Hemoglobinopathy

Reflex sympathetic

dystrophy

Malignancies

Psychogenic pain

With Fever

Bacterial infections

Sepsis

Viral infections

Lyme disease

Reactive arthritis

Rheumatic diseases

Post immunization

Immune deficiencies

Serum sickness

Inflammatory bowel

disease

Sarcoidosis

Familial Mediterranean fever

Malignancies

Without Fever

Rheumatic diseases

Joint hypermobility

Growing pains

Post immunization

Immune deficiencies

Guilain-Barre

Lyme Disease

Fibromyalgia syndrome

Chronic fatigue syndrome

Psychogenic pain

Malignancies

1

SINGLE JOINT INVOLVEMENT WITH FEVER

1. Infection; joint, bone or soft tissue

2. Sympathetic Arthritis

3. Traumatic Arthritis

4. Rheumatic disease; JRA, SLE, RF

5. Vasculitis (HSP & KD)

6. Reactive arthritis

7. Toxic synovitis

8. Diskitis

9. Sarcoidosis

10. Hemoglobinopathy

11. Malignancy

1

SINGLE JOINT INVOLVEMENT WITH FEVER

1. Infection; joint, bone or soft tissue

2. Sympathetic Arthritis

3. Traumatic Arthritis

4. Rheumatic disease; JRA, SLE, RF

5. Vasculitis (HSP & KD)

6. Reactive arthritis

7. Toxic synovitis

8. Diskitis

9. Sarcoidosis

10. Hemoglobinopathy

11. Malignancy

1

SINGLE JOINT INVOLVEMENT WITH FEVER

1. Infection; joint, bone or soft tissue

2. Sympathetic Arthritis

3. Traumatic Arthritis

4. Rheumatic disease; JRA, SLE, RF

5. Vasculitis (HSP & KD)

6. Reactive arthritis

7. Toxic synovitis

8. Diskitis

9. Sarcoidosis

10. Hemoglobinopathy

11. Malignancy

a. Chronic pediatric arthropathies

b. Onset before 16 years of age

c. Presence of objective arthritis (in one or more joints) for at least 6 weeks

Arthritis: Defined by swelling or effusion of joints, increased warmth and/or painful limited movement with or without tenderness

JRA: Definition

1

SINGLE JOINT INVOLVEMENT WITH FEVER

1. Infection; joint, bone or soft tissue

2. Sympathetic Arthritis

3. Traumatic Arthritis

4. Rheumatic disease; JRA, SLE, RF

5. Vasculitis (HSP & KD)

6. Reactive arthritis

7. Toxic synovitis

8. Diskitis

9. Sarcoidosis

10. Hemoglobinopathy

11. Malignancy

1

SINGLE JOINT INVOLVEMENT WITH FEVER1. Infection; joint, bone or soft tissue

2. Sympathetic Arthritis

3. Traumatic Arthritis

4. Rheumatic disease; JRA, SLE, RF

5. Vasculitis (HSP & KD)

6. Reactive arthritis

7. Toxic synovitis

8. Diskitis

9. Sarcoidosis

10. Hemoglobinopathy

11. Malignancy

1

SINGLE JOINT INVOLVEMENT WITH FEVER

1. Infection; joint, bone or soft tissue

2. Sympathetic Arthritis

3. Traumatic Arthritis

4. Rheumatic disease; JRA, SLE, RF

5. Vasculitis (HSP & KD)

6. Reactive arthritis

7. Toxic synovitis

8. Diskitis

9. Sarcoidosis

10. Hemoglobinopathy

11. Malignancy

1

SINGLE JOINT INVOLVEMENT WITH FEVER

1. Infection; joint, bone or soft tissue

2. Sympathetic Arthritis

3. Traumatic Arthritis

4. Rheumatic disease; JRA, SLE, RF

5. Vasculitis (HSP & KD)

6. Reactive arthritis

7. Toxic synovitis

8. Diskitis

9. Sarcoidosis

10. Hemoglobinopathy

11. Malignancy

1

SINGLE JOINT INVOLVEMENT WITH FEVER

1. Infection; joint, bone or soft tissue

2. Sympathetic Arthritis

3. Traumatic Arthritis

4. Rheumatic disease; JRA, SLE, RF

5. Vasculitis (HSP & KD)

6. Reactive arthritis

7. Toxic synovitis

8. Diskitis

9. Sarcoidosis

10. Hemoglobinopathy

11. Malignancy

1

SINGLE JOINT INVOLVEMENT WITH FEVER

1. Infection; joint, bone or soft tissue

2. Rheumatic disease; JRA, SLE, RF

3. Kawasaki disease

4. Reactive arthritis

5. Trauma

6. Toxic synovitis

7. Diskitis

8. Sarcoidosis

9. Hemoglobinopathy

10. Malignancy

1

SINGLE JOINT INVOLVEMENTWITHOUT FEVER

1. Trauma

2. Rheumatic disease

3. Toxic synovitis

4. Aseptic necrosis

5. Diskitis

6. Infection

7. Hemoglobinopathy

8. Malignancy

9. Musculoskeletal pain syndrome

10. Psychogenic pain

The Head of the femur isSlipping

1

SINGLE JOINT INVOLVEMENTWITHOUT FEVER

Slipped Capital Femoral Epiphysis (SCFE)

1. Incidence 1/100,000

2. Male / Female = 3:1; Age 12-15 year

3. Obesity in 75% of cases

4. Bilateral in 25% of cases

5. Can be triggered by trauma

1

SINGLE JOINT INVOLVEMENTWITHOUT FEVER

1. Trauma

2. Rheumatic disease

3. Toxic synovitis

4. Aseptic necrosis

5. Diskitis

6. Infection

7. Hemoglobinopathy

8. Malignancy

9. Musculoskeletal pain syndrome

10. Psychogenic pain

1

SINGLE JOINT INVOLVEMENTWITHOUT FEVER

1. Trauma

2. Rheumatic disease

3. Toxic synovitis

4. Aseptic necrosis

5. Diskitis

6. Infection

7. Hemoglobinopathy

8. Malignancy

9. Musculoskeletal pain syndrome

10. Psychogenic pain

1

SINGLE JOINT INVOLVEMENT WITHOUT FEVER

Legg-Calve-Perthes- Disease

1. Age 2 - 12 years

2. Male / Female = 4:1

3. Unknown cause

4. Knee pain is very common initial symptom

5. The younger the patient at onset the better the outcome

1

SINGLE JOINT INVOLVEMENTWITHOUT FEVER

1. Trauma

2. Rheumatic disease

3. Toxic synovitis

4. Aseptic necrosis

5. Diskitis

6. Infection

7. Hemoglobinopathy

8. Malignancy

9. Reflex Sympathetic Dystrophy

10. Psychogenic pain

Reflex sympathetic dystrophy(RSD)

Bone scan with technetium 99m

perfusion study

1

SINGLE JOINT INVOLVEMENTWITHOUT FEVER

1. Trauma

2. Rheumatic disease

3. Toxic synovitis

4. Aseptic necrosis

5. Diskitis

6. Infection

7. Hemoglobinopathy

8. Malignancy

9. Musculoskeletal pain syndrome

10. Psychogenic pain

1

MULTIPLE JOINT INVOLVEMENTWITH FEVER

1. Infection; bacterial and/or viral

2. Rheumatic disease

3. Vasculitis (HSP & KD)

4. Lyme disease

5. Reactive arthritis

6. Postimmunization

7. Immune deficiency syndromes

8. Serum sickness

9. Inflamatory bowel disease

10. Sarcoidosis

11. Familial Mediterranean fever12. Malignancy

1

MULTIPLE JOINT INVOLVEMENTWITH FEVER

1. Infection; bacterial and/or viral

2. Rheumatic disease

3. Vasculitis (HSP & KD)

4. Lyme disease

5. Reactive arthritis

6. Postimmunization

7. Immune deficiency syndromes

8. Serum sickness

9. Inflamatory bowel disease

10. Sarcoidosis

11. Familial Mediterranean fever12. Malignancy

1

MULTIPLE JOINT INVOLVEMENTWITH FEVER

1. Infection; bacterial and/or viral

2. Rheumatic disease

3. Vasculitis (HSP & KD)

4. Lyme disease

5. Reactive arthritis

6. Postimmunization

7. Immune deficiency syndromes

8. Serum sickness

9. Inflamatory bowel disease

10. Sarcoidosis

11. Familial Mediterranean fever12. Malignancy

1

MULTIPLE JOINT INVOLVEMENTWITH FEVER

1. Infection; bacterial and/or viral

2. Rheumatic disease

3. Vasculitis (HSP & KD)

4. Lyme disease

5. Reactive arthritis

6. Postimmunization

7. Immune deficiency syndromes

8. Serum sickness

9. Inflamatory bowel disease

10. Sarcoidosis

11. Familial Mediterranean fever12. Malignancy

1

MULTIPLE JOINT INVOLVEMENTWITH FEVER

1. Infection; bacterial and/or viral

2. Rheumatic disease

3. Vasculitis (HSP & KD)

4. Lyme disease

5. Reactive arthritis

6. Postimmunization

7. Immune deficiency syndromes

8. Serum sickness

9. Inflamatory bowel disease

10. Sarcoidosis

11. Familial Mediterranean fever12. Malignancy

1

MULTIPLE JOINT INVOLVEMENTWITH FEVER

1. Infection; bacterial and/or viral

2. Rheumatic disease

3. Vasculitis (HSP & KD)

4. Lyme disease

5. Reactive arthritis

6. Postimmunization

7. Immune deficiency syndromes

8. Serum sickness

9. Inflamatory bowel disease

10. Sarcoidosis

11. Periodic Fever Syndromes (FMF, TRAPS, HIDS, CAPS)

12. Malignancy

1

MULTIPLE JOINT INVOLVEMENTWITH FEVER

1. Infection; bacterial and/or viral

2. Rheumatic disease

3. Vasculitis (HSP & KD)

4. Lyme disease

5. Reactive arthritis

6. Postimmunization

7. Immune deficiency syndromes

8. Serum sickness

9. Inflamatory bowel disease

10. Sarcoidosis

11. Familial Mediterranean fever12. Malignancy

The Child With Joint Pain IMPORTANT DIAGNOSTIC CLUES

• 11 y/o Female with 4 week H/O joint pain & swelling (elbows & R wrist). ESR: 93 mm/h; CRP: 5.8 mg/dl Uric acid: 7.4 mg/dl; LDH: 1522 U/L

• A bone scan with abnormal increase of tracer activity in both fibulas and left tibia

• Bone marrow biopsy shows near total replacement of the marrow with leukemic cells

1

MULTIPLE JOINT INVOLVEMENTWITHOUT FEVER

1. Rheumatic Disease

2. Joint hypermobility

3. Growing pains

4. Fibromyalgia syndrome

5. Chronic fatigue syndrome

6. Lyme disease

7. Immune deficiency syndrome

8. Postimmunization

9. Guillain-Barre

10. Psychogenic pain

11. Malignancy

1

MULTIPLE JOINT INVOLVEMENTWITHOUT FEVER

1. Rheumatic Disease

2. Joint hypermobility

3. Growing pains

4. Fibromyalgia syndrome

5. Chronic fatigue syndrome

6. Lyme disease

7. Immune deficiency syndrome

8. Postimmunization

9. Guillain-Barre

10. Psychogenic pain

11. Malignancy

Diagnosis of benign joint hypermobility is confirmed if three of the five signs are present

1

MULTIPLE JOINT INVOLVEMENTWITHOUT FEVER

1. Rheumatic Disease

2. Joint hypermobility

3. Growing pains

4. Fibromyalgia syndrome

5. Chronic fatigue syndrome

6. Lyme disease

7. Immune deficiency syndrome

8. Postimmunization

9. Guillain-Barre

10. Psychogenic pain

11. Malignancy

1

MULTIPLE JOINT INVOLVEMENTWITHOUT FEVER

1. Rheumatic Disease

2. Joint hypermobility

3. Growing pains

4. Fibromyalgia syndrome

5. Chronic fatigue syndrome

6. Lyme disease

7. Immune deficiency syndrome

8. Postimmunization

9. Guillain-Barre

10. Psychogenic pain

11. Malignancy

Suspected Rheumatic Conditions: DIAGNOSTIC TESTS

Body fluids

• CBC, ESR, CRP, CMP

• Rheumatoid factor

• ANA / ANA Profile

• Quantitative Immunoglobulins

• HLA Typing

• Muscle enzymes

• ACE

• Von Wllibrand factor antigen

• ANCA

• Genetic Mutations

• Urine (UA, Prot / Creat)

• Synovial Fluids

• Ophthalmology (Slit lamp)

Other tests

• CXR, CT, MRI, MRA, Bone scan, Angiogram

• EKG, ECHO

• Tissue Biopsy

• Bone marrow aspiration