The Child With Joint Pain Diagnostic Clues

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The Child With Joint Pain Diagnostic Clues

• Abraham Gedalia, M.D.
• Professor of Pediatrics
• Head, Division of Rheumatology
• Departments 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
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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
  200537704

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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 ?

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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 ?

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The Child With Pain
Multiple Joint Involvement
Single Joint Involvement
With Fever Septic arthritis/Osteomyelitis Sympathe
tic arthritis Foreign body with
infection Traumatic arthritis Soft Tissue
infection Rheumatic Diseases Reactive
arthritis Toxic synovitis Diskitis Sarcoidosis Hem
oglobinopathy 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 Lym
e Disease Fibromyalgia syndrome Chronic fatigue
syndrome Psychogenic pain Malignancies
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JRA Definition
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
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The Head of the femur is Slipping
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Reflex sympathetic dystrophy (RSD) Bone scan
with technetium 99m perfusion study
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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

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

• 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