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Kathy BaileyConsultant Paediatric Rheumatologist
Coventry and Warwickshire
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Common
History and examination essential
Missed diagnosis permanent disability
Simple problems require confident
diagnosis
Will become part of curriculum!
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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
EXAMINATION◦ objective signs
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HISTORY!!!◦ Inflammatory◦ mechanical◦ non-organic/psychosomatic
◦ Acute or chronic
EXAMINATION◦ objective signs
TESTS◦ ???
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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
Associated features:◦ 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
Urinalysis
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www.arc.org.uk/arthinfo/emedia.asp
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LOOKgait
swelling
deformity
rash/colour changes
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FEELheat
swelling
tenderness
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MOVErestriction
+/- pain
muscle strength
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Inflammatory Mechanical Psychosomatic
Pain +/- + +++
Stiffness ++ +/- +
Swelling +++ +/- +/-
Sleep disturbance
+/- - ++
Instability +/- ++ +/-
Physical signs
++ + +/-
(or ++++)
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InflammatoryInflammatory MechanicalMechanical IdiopathicIdiopathic
InfectionInfection
ReactiveReactive
Post StrepPost Strep
JIAJIA
Connective Connective tissue diseasestissue diseases
- SLE- SLE
- JDMS- JDMS
- Scleroderma- Scleroderma
- Vasculitis- Vasculitis
HypermobilityHypermobility
OsteochondrosesOsteochondroses
- osgood-schlatter- osgood-schlatter
- Scheuermann’s- Scheuermann’s
- Perthes- Perthes
Chondromalacia Chondromalacia patellapatella
Osteochondritis Osteochondritis dissecansdissecans
Slipped upper Slipped upper femoral epiphysisfemoral epiphysis
Pain Pain amplification amplification syndromessyndromes
- Localised- Localised
- Generalised- Generalised
Growing painsGrowing pains
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Acute
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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
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Site %
Knee 39 Hip 25 Ankle 14 Elbow 12
Organisms
Staph Aureus
Tuberculosis
Salmonella in sickle cell disease
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•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
Neuroblastoma◦ Commonest solid tumour under infants◦ Bone pain from secondary spread◦ Urinary excretion of catecholamine metabolites
(VMA)
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Acute Lymphoblastic Leukaemia
Neuroblastoma
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
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5 of following1. Fever >5 days; unresponsive to Abx2. Non purulent conjunctivitis3. lymphadenopathy >1.5cm4. Rash - polymorphous5. mucosal changes6. extremities
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
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Chronic
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JIA Juvenile Idiopathic Arthritis
JRA Juvenile Rheumatoid Arthritis
JCA Juvenile Chronic Arthritis
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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
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
Persistence of arthritis ◦ 1 or more joints ◦ 6 or more weeks◦ Exclusion of other diagnoses
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Defined by clinical features in first 6 months
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Defined by clinical features in first 6 months◦ Oligoarthritis 1-4 joints
Persistent Extended
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Girls >boys Younger age Best prognosis
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Girls >boys Younger age Best prognosis
Associated with uveitis
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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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Defined by clinical features in first 6 months◦ Oligoarthritis 1-4 joints◦ Polyarthritis 5 or more joints◦ Psoriatic Arthritis
Arthritis AND psoriasisOR Arthritis plus 2 of:
Nail pitting Dactylitis First degree relative with confirmed psoriasis
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Defined by clinical features in first 6 months◦ Oligoarthritis 1-4 joints◦ Polyarthritis 5 or more joints◦ Psoriatic Arthritis◦ Enthesitis Related Arthritis
Arthritis AND enthesitisOR Sacroiliac pain and HLA B27
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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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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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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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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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Multidisciplinary team
◦ Paediatric rheumatologist
◦ Nurse specialist
◦ Occupational Therapist
◦ Physiotherapist
◦ Social worker
◦ Ophthalmologist
◦ Podiatrist
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Anti inflammatory drugs◦ NSAIDs◦ Glucocorticoids
“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 %
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Imaging:
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)
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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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Inappropriate history
Physical signs don’t match story
Other concerning features
Concerns raised by others
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Chondromalacia patella Adolescent girls Painful knees - kneeling
- going up stairs
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Osgood-Schlatter disease Adolescent boys Pain and swelling at tibial tuberosity Increased by exercise
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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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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
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
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Localised idiopathic pain eg RSD
CFS/ME
Fibromyalgia
Diffuse idiopathic pain
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History History History Examination Examination Examination
Investigations: targeted
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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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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