Musculoskeletal problems in children

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Musculoskeletal problems in children

• Kathy Bailey
• Consultant Paediatric Rheumatologist
• Coventry and Warwickshire

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Why is it important?

• Common
• History and examination essential
• Missed diagnosis permanent disability
• Simple problems require confident diagnosis
• Will become part of curriculum!

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How do children present?
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How do children present?

• Limp
• stiffness
• swelling
• pain
• restriction of movement

• change in activities
• not using limb
• colour change in limb
• fever
• rash
• unwell

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Whats wrong with them?

• HISTORY!!!
• Inflammatory
• mechanical
• non-organic/psychosomatic

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Whats wrong with them?

• HISTORY!!!
• Inflammatory
• mechanical
• non-organic/psychosomatic
• Acute or chronic

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Whats wrong with them?

• HISTORY!!!
• Inflammatory
• mechanical
• non-organic/psychosomatic
• Acute or chronic
• EXAMINATION
• objective signs

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Whats wrong with them?

• HISTORY!!!
• Inflammatory
• mechanical
• non-organic/psychosomatic
• Acute or chronic
• EXAMINATION
• objective signs
• TESTS
• ???

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History

• Age of child
• Duration
• Symptoms
• Impact on activities
• Joints affected
• Family History
• Antecedents
• infection/trauma/
• illness

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History

• Associated features
• Constitutional
• Fever
• Rash
• Muscle weakness
• Eyes
• Weight loss
• GI
• bruising
• LN/mucusitis
• ....etc

• Age of child
• Duration
• Symptoms
• Impact on activities
• Joints affected
• Family History
• Antecedents
• infection/trauma/
• illness

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Examination

• Height and weight
• Temp/pulse/BP
• General observations
• Rash
• Systems examination
• Urinalysis

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Musculoskeletal examination

• PaediatricGaitArmsLegsSpine
• www.arc.org.uk

www.arc.org.uk/arthinfo/emedia.asp
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Examination - musculoskeletal

• LOOK
• gait
• swelling
• deformity
• rash/colour changes

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Examination

• FEEL
• heat
• swelling
• tenderness

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Examination

• MOVE restriction
• /- pain
• muscle strength

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Differential Diagnosis
Inflammatory Mechanical Psychosomatic
Pain /-
Stiffness /-
Swelling /- /-
Sleep disturbance /- -
Instability /- /-
Physical signs /- (or )
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Inflammatory Mechanical Idiopathic
Infection Reactive Post Strep JIA Connective tissue diseases - SLE - JDMS - Scleroderma - Vasculitis Hypermobility Osteochondroses - osgood-schlatter - Scheuermanns - Perthes Chondromalacia patella Osteochondritis dissecans Slipped upper femoral epiphysis Pain amplification syndromes - Localised - Generalised Growing pains
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Inflammatory Conditions

• Acute

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Septic Arthritis

• Fever
• Localised tenderness
• hot
• Painful to move
• Raised inflammatory markers

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Septic Arthritis

• Fever
• Localised tenderness
• hot
• Painful to move
• Raised inflammatory markers
• JOINT ASPIRATION

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Septic Arthritis Joint Distribution

• Site
• Knee 39
• Hip 25
• Ankle 14
• Elbow 12

• Organisms
• Staph Aureus
• Tuberculosis
• Salmonella in sickle cell disease

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Missed Septic Arthritis Knee
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Osteomyelitis of distal tibia
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Reactive Arthritis

• May be history of recent infection
• Single or multiple joints
• No systemic features
• Resolves by 6 weeks
• Important to consider alternative diagnoses

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Henoch Schonlein Purpura

• Reactive Vasculitis (small vessel)
• Palpable Purpura
• Arthralgia/Arthritis
• Abdominal pain
• Nephritis
• Headaches

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Malignancy

• 1 of patients referred to paediatric
  rheumatology have underlying malignancy

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Malignancy

• Acute Lymphoblastic Leukaemia
• Bone pain and arthralgia in 20-40
• Suspect from history, exam, or blood count
• Bone Marrow aspirate

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Malignancy

• Acute Lymphoblastic Leukaemia
• Neuroblastoma
• Commonest solid tumour under infants
• Bone pain from secondary spread
• Urinary excretion of catecholamine metabolites
  (VMA)

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Malignancy

• Acute Lymphoblastic Leukaemia
• Neuroblastoma
• Primary Bone tumour
• Osteoid osteoma benign
• osteosarcoma

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Malignancy

• Features to raise concern
• Bone pain (night time)
• Weight loss
• Night sweats or fevers
• Abnormal bloods
• Xray changes

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Malignancy
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Kawasaki Disease

• 5 of following
• Fever gt5 days unresponsive to Abx
• Non purulent conjunctivitis
• lymphadenopathy gt1.5cm
• Rash - polymorphous
• mucosal changes
• extremities
• early - swelling/palmar erythema
• late peeling
• OR 4 plus coronary artery aneurysms

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Early features
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Late features
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Late features
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KD - management

• Prevent late sequel of coronary artery aneurysms
• Intravenous IVIG
• Aspirin
• initially high, anti inflammatory
• then low dose, anti platelet

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Inflammatory Conditions

• Chronic

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Whats in a name?

• JIA Juvenile Idiopathic Arthritis
• JRA Juvenile Rheumatoid Arthritis
• JCA Juvenile Chronic Arthritis

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Whats in a name?

• JIA Juvenile Idiopathic Arthritis
• JRA Juvenile Rheumatoid Arthritis
• JCA Juvenile Chronic Arthritis

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Juvenile Idiopathic Arthritis

• JIA commonest rheumatic condition in childhood
• 30 150 per 100,000
• 10 years follow up
• 1/3 achieve remission
• 30 have severe functional limitations
• Fantini et al, ACR 1996

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Definitions

• Disease of childhood onset
• under 16 years
• Persistence of arthritis
• 1 or more joints
• 6 or more weeks
• Exclusion of other diagnoses

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Classification

• Defined by clinical features in first 6 months

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Classification

• Defined by clinical features in first 6 months
• Oligoarthritis 1-4 joints
• Persistent
• Extended

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Oligoarthritis

• Girls gtboys
• Younger age
• Best prognosis

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Oligoarthritis

• Girls gtboys
• Younger age
• Best prognosis
• Associated with uveitis

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Classification

• Defined by clinical features in first 6 months
• Oligoarthritis 1-4 joints
• Polyarthritis 5 or more joints
• RF positive
• RF negative

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Classification

• Defined by clinical features in first 6 months
• Oligoarthritis 1-4 joints
• Polyarthritis 5 or more joints
• Psoriatic Arthritis
• Arthritis AND psoriasis
• OR
• Arthritis plus 2 of
• Nail pitting
• Dactylitis
• First degree relative with confirmed psoriasis

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Classification

• Defined by clinical features in first 6 months
• Oligoarthritis 1-4 joints
• Polyarthritis 5 or more joints
• Psoriatic Arthritis
• Enthesitis Related Arthritis
• Arthritis AND enthesitis
• OR
• Sacroiliac pain and HLA B27

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Classification

• Defined by clinical features in first 6 months
• Oligoarthritis 1-4 joints
• Persistent
• Extended
• Polyarthritis 5 or more joints
• RF positive
• RF negative
• Psoriatic Arthritis
• Enthesitis Related Arthritis
• Systemic Arthritis

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Systemic Arthritis

• Daily fever for at least 2 weeks duration
  (quotidian for 3 days)
• Plus one or more of
• Evanescent rash
• Generalized lymphadenopathy
• Hepatosplenomegaly
• Serositis
• Arthritis
• EXCLUSION OF OTHER DIAGNOSES

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Quotidian Fever Systemic Arthritis
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Evanescent salmon pink rash Systemic Arthritis
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Prognosis

• Poor indicators
• Polyarticular onset and course
• Rheumatoid factor positive girls
• Systemic disease with persistent features
• Delay in starting effective treatment
• Good indicators
• Oligoarticular disease

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Treatment

• Goals
• Disease remission
• Symptomatic improvement
• Stiffness
• Pain
• Joint range of movement
• Prevent joint damage
• Normal growth and development
• Education and normal adolesence
• Prevent eye damage from Uveitis

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Therapeutic approach

• Multidisciplinary team
• Paediatric rheumatologist
• Nurse specialist
• Occupational Therapist
• Physiotherapist
• Social worker
• Ophthalmologist
• Podiatrist

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Drug treatments

• Anti inflammatory drugs
• NSAIDs
• Glucocorticoids
• Disease modifying drugs
• Methotrexate
• Etanercept
• New biologic agents for recalcitrant disease

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Mechanical conditions
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Perthes(Legg-Calve Perthes)

• Avascular necrosis of the femoral head
• usually 2-10 (peak 4-6) yrs.
• 3-5 boysgirls
• Bilateral 30

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PerthesLegg-Calve Perthes

• Imaging
• Asymmetry in femoral heads
• Consider MRI or Nuclear medicine if clinical
  suspicion is high

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Slipped Upper Femoral Epiphysis

• 10-13 years old
• Overweight boys
• 25 bilateral within 18/12
• Slip of femoral head through growth plate
• (posteriorly and inferiorly)

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Slipped Upper Femoral Epiphysis

• Imaging
• AP and (frog) lateral films needed
• CT/ MRI in cases of difficulty

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Klein line should intersect femoral head
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Non - Accidental Injury

• Inappropriate history
• Physical signs dont match story
• Other concerning features
• Concerns raised by others

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Anterior knee pain

• Chondromalacia patella
• Adolescent girls
• Painful knees - kneeling
• - going up stairs

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Anterior knee pain

• Osgood-Schlatter disease
• Adolescent boys
• Pain and swelling at tibial tuberosity
• Increased by exercise

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Anterior knee pain

• Osgood-Schlatter disease
• Adolescent boys
• Pain and swelling at tibial tuberosity
• Increased by exercise
• Tenderness /- swelling of tibial tuberosity
• Pain on resisted extension of knee

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Osgood Schlatter - Radiology

• Clinical diagnosis
• DO NOT XRAY

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Hypermobility

• Very common
• May be generalised or localised
• Frequently responsible for musculoskeletal pain

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Flat feet

• Common cause of lower limb pain
• If symptomatic correct with good footware and
  insoles

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Idiopathic Musculoskeletal pain
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Growing pains

• 25-40 of children!
• 3-5 years and 8-12 years
• Typical history

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Growing pains - history

• Wake during night with pain
• Eased with massage
• May be worse after active day
• No daytime symptoms
• No abnormal physical signs

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Idiopathic pain syndromes

• No identifiable inflammatory or mechanical
  condition
• Chronic pain
• Impact on daily activities
• Average age 9 12 years
• Girls gt boys
• Disease of the developed world

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Spectrum of condition
Localised idiopathic pain eg RSD
CFS/ME Fibromyalgia
Diffuse idiopathic pain
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Evaluation of musculoskeletal symptoms
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Evaluation of musculoskeletal symptoms

• History
• History
• History
• Examination
• Examination
• Examination
• Investigations targeted

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Investigations

• Blood Count
• ? Appropriate to clinical features
• Inflammatory markers
• Usually mirror clinical features
• Not always raised in inflammatory conditions
• Blood and synovial fluid cultures
• ANA/Rh Factor
• Not helpful in making a diagnosis
• Imaging
• Need to use best modality and ask the right
  question

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Summary

• Musculoskeletal complaints are common in
  childhood
• Serious pathology leads to long term disability
  if not appropriately managed
• Diagnosis is dependant on good history and
  examination