Kathy Bailey
Consultant Paediatric Rheumatologist
Coventry and Warwickshire
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Common
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History and examination essential
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Missed diagnosis
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Simple problems require confident diagnosis
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Will become part of curriculum!
permanent disability
Limp
 stiffness
 swelling
 pain
 restriction of
movement

change in
activities
 not using limb
 colour change in
limb
 fever
 rash
 unwell
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HISTORY!!!
◦ Inflammatory
◦ mechanical
◦ non-organic/psychosomatic
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HISTORY!!!
◦ Inflammatory
◦ mechanical
◦ non-organic/psychosomatic
◦ Acute or chronic
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HISTORY!!!
◦ Inflammatory
◦ mechanical
◦ non-organic/psychosomatic
◦ Acute or chronic
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EXAMINATION
◦ objective signs
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HISTORY!!!
◦ Inflammatory
◦ mechanical
◦ non-organic/psychosomatic
◦ Acute or chronic
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EXAMINATION
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TESTS
◦ objective signs
◦ ???
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Age of child
Duration
Symptoms
Impact on activities
Joints affected
Family History
Antecedents
◦ infection/trauma/
◦ illness
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Age of child
Duration
Symptoms
Impact on activities
Joints affected
Family History
Antecedents
◦ infection/trauma/
◦ illness
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Associated features:
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◦
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Constitutional
Fever
Rash
Muscle weakness
Eyes
Weight loss
GI
bruising
LN/mucusitis
....etc
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Height and weight
Temp/pulse/BP
General observations
Rash
Systems examination
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Urinalysis
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Paediatric
Gait
Arms
Legs
Spine
 www.arc.org.uk
www.arc.org.uk/arthinfo/emedia.asp
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LOOK
gait
swelling
deformity
rash/colour
changes
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FEEL
heat
swelling
tenderness
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MOVE
restriction
+/- pain
muscle strength
Inflammatory Mechanical Psychosomatic
Pain
+/-
+
+++
Stiffness
++
+/-
+
Swelling
+++
+/-
+/-
Sleep
disturbance
Instability
+/-
-
++
+/-
++
+/-
Physical
signs
++
+
+/(or ++++)
Inflammatory
Infection
Reactive
Post Strep
JIA
Connective
tissue diseases
- SLE
- JDMS
- Scleroderma
- Vasculitis
Mechanical
Idiopathic
Hypermobility
Pain
Osteochondroses amplification
syndromes
- osgood-schlatter
- Scheuermann’s
- Perthes
- Localised
- Generalised
Growing pains
Chondromalacia
patella
Osteochondritis
dissecans
Slipped upper
femoral epiphysis
Acute
Fever
 Localised
tenderness
 hot
 Painful to move
 Raised
inflammatory
markers
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Fever
Localised
tenderness
hot
Painful to move
Raised
inflammatory
markers
JOINT ASPIRATION
Site
%
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Knee
Hip
25
Ankle
Elbow
Organisms
39
14
12
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Staph Aureus
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Tuberculosis
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Salmonella in
sickle cell
disease
•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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Reactive Vasculitis
(small vessel)
Palpable Purpura
Arthralgia/Arthritis
Abdominal pain
Nephritis
Headaches
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1% of patients referred to paediatric
rheumatology have underlying malignancy
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Acute Lymphoblastic Leukaemia
◦ Bone pain and arthralgia in 20-40%
◦ Suspect from history, exam, or blood count
◦ Bone Marrow aspirate
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Acute Lymphoblastic Leukaemia
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Neuroblastoma
◦ Commonest solid tumour under infants
◦ Bone pain from secondary spread
◦ Urinary excretion of catecholamine metabolites
(VMA)
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Acute Lymphoblastic Leukaemia
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Neuroblastoma
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Primary Bone tumour
◦ Osteoid osteoma – benign
◦ osteosarcoma
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Features to raise concern:
◦ Bone pain (night time)
◦ Weight loss
◦ Night sweats or fevers
◦ Abnormal bloods
◦ Xray changes
5 of following
1.
Fever >5 days; unresponsive to Abx
2.
Non purulent conjunctivitis
3.
lymphadenopathy >1.5cm
4.
Rash - polymorphous
5.
mucosal changes
6.
extremities
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early - swelling/palmar erythema
late – peeling
OR 4 plus coronary artery aneurysms
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Prevent late sequel of coronary artery
aneurysms
◦ Intravenous IVIG
◦ Aspirin –
 initially high, anti inflammatory
 then low dose, anti platelet
Chronic
JIA
Juvenile Idiopathic Arthritis
JRA
Juvenile Rheumatoid Arthritis
JCA
Juvenile Chronic Arthritis
JIA
Juvenile Idiopathic Arthritis
JRA
Juvenile Rheumatoid Arthritis
JCA
Juvenile Chronic Arthritis
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JIA commonest rheumatic condition in
childhood
◦ 30 – 150 per 100,000
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10 years follow up
◦ 1/3 achieve remission
◦ 30% have severe functional limitations
Fantini et al, ACR 1996
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Disease of childhood onset
◦ under 16 years
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Persistence of arthritis
◦ 1 or more joints
◦ 6 or more weeks
◦ Exclusion of other diagnoses
Defined by clinical features in first 6 months
Defined by clinical features in first 6 months
◦ Oligoarthritis
 Persistent
 Extended
1-4 joints
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Girls >boys
Younger age
Best prognosis
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Girls >boys
Younger age
Best prognosis
Associated with
uveitis
Defined by clinical features in first 6 months
◦ Oligoarthritis
1-4 joints
◦ Polyarthritis 5 or more joints
 RF positive
 RF negative
Defined by clinical features in first 6 months
◦ Oligoarthritis
◦ Polyarthritis
◦ Psoriatic Arthritis
1-4 joints
5 or more joints
 Arthritis AND psoriasis
OR
 Arthritis plus 2 of:
 Nail pitting
 Dactylitis
 First degree relative with confirmed psoriasis
Defined by clinical features in first 6 months
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Oligoarthritis
1-4 joints
Polyarthritis
5 or more joints
Psoriatic Arthritis
Enthesitis Related Arthritis
 Arthritis AND enthesitis
OR
 Sacroiliac pain and HLA B27
Defined by clinical features in first 6 months
◦ Oligoarthritis
1-4 joints
◦ Polyarthritis
5 or more joints
 Persistent
 Extended
 RF positive
 RF negative
◦ Psoriatic Arthritis
◦ Enthesitis Related Arthritis
◦ Systemic Arthritis
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Daily fever for at least 2 weeks duration
(quotidian for 3 days)
Plus one or more of:
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Evanescent rash
Generalized lymphadenopathy
Hepatosplenomegaly
Serositis
Arthritis
EXCLUSION OF OTHER DIAGNOSES
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Poor indicators
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Polyarticular onset and course
Rheumatoid factor positive girls
Systemic disease with persistent features
Delay in starting effective treatment
Good indicators
 Oligoarticular disease
Goals
◦ Disease remission
◦ Symptomatic improvement
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 Stiffness
 Pain
 Joint range of movement
Prevent joint damage
Normal growth and development
Education and normal adolesence
Prevent eye damage from Uveitis
Multidisciplinary team
◦ Paediatric rheumatologist
◦ Nurse specialist
◦ Occupational Therapist
◦ Physiotherapist
◦ Social worker
◦ Ophthalmologist
◦ Podiatrist
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Anti inflammatory drugs
◦ NSAIDs
◦ Glucocorticoids
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“Disease modifying drugs”
◦ Methotrexate
◦ Etanercept
◦ New biologic agents for recalcitrant disease
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Avascular necrosis of the femoral head
usually 2-10 (peak 4-6) yrs.
3-5 boys:girls
Bilateral 30 %
Imaging:
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Asymmetry in femoral heads
Consider MRI or Nuclear medicine if clinical
suspicion is high
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10-13 years old
Overweight boys
25% bilateral within 18/12
Slip of femoral head through growth plate
(posteriorly and inferiorly)
Imaging:
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AP and (frog) lateral films needed
CT/ MRI in cases of difficulty
Klein line should intersect femoral head
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Inappropriate history
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Physical signs don’t match story
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Other concerning features
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Concerns raised by others
Chondromalacia patella
 Adolescent girls
 Painful knees - kneeling
- going up stairs
Osgood-Schlatter disease
 Adolescent boys
 Pain and swelling at tibial tuberosity
 Increased by exercise
Osgood-Schlatter disease
 Adolescent boys
 Pain and swelling at tibial tuberosity
 Increased by exercise
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Tenderness +/- swelling of tibial tuberosity
Pain on resisted extension of knee
Clinical
diagnosis
DO NOT XRAY
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Very common
May be generalised
or localised
Frequently
responsible for
musculoskeletal
pain
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Common cause of
lower limb pain
If symptomatic –
correct with good
footware and
insoles
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25-40% of children!
3-5 years and 8-12 years
Typical history
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Wake during night with pain
Eased with massage
May be worse after active day
No daytime symptoms
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No abnormal physical signs
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No identifiable inflammatory or mechanical
condition
Chronic pain
Impact on daily activities
Average age 9 – 12 years
Girls > boys
Disease of the developed world
CFS/ME
Fibromyalgia
Diffuse idiopathic
pain
Localised
idiopathic
pain eg RSD
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History
History
History
Examination
Examination
Examination

Investigations:
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targeted
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Blood Count
◦ ? Appropriate to clinical features
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Inflammatory markers
◦ Usually mirror clinical features
◦ Not always raised in inflammatory conditions
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Blood and synovial fluid cultures
ANA/Rh Factor
◦ Not helpful in making a diagnosis
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Imaging
◦ Need to use best modality and ask the right
question
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Musculoskeletal complaints are common in
childhood
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Serious pathology leads to long term
disability if not appropriately managed
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Diagnosis is dependant on good history and
examination