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
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