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Musculoskeletal problems in children

Musculoskeletal problems in children. Kathy Bailey Consultant Paediatric Rheumatologist Coventry and Warwickshire. Why is it important?. Common History and examination essential Missed diagnosis permanent disability Simple problems require confident diagnosis

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Musculoskeletal problems in children

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  1. Musculoskeletal problems in children Kathy Bailey Consultant Paediatric Rheumatologist Coventry and Warwickshire

  2. Why is it important? • Common • History and examination essential • Missed diagnosis permanent disability • Simple problems require confident diagnosis • Will become part of curriculum!

  3. How do children present?

  4. How do children present? • change in activities • not using limb • colour change in limb • fever • rash • unwell • Limp • stiffness • swelling • pain • restriction of movement

  5. What’s wrong with them? • HISTORY!!! • Inflammatory • mechanical • non-organic/psychosomatic

  6. What’s wrong with them? • HISTORY!!! • Inflammatory • mechanical • non-organic/psychosomatic • Acute or chronic

  7. What’s wrong with them? • HISTORY!!! • Inflammatory • mechanical • non-organic/psychosomatic • Acute or chronic • EXAMINATION • objective signs

  8. What’s wrong with them? • HISTORY!!! • Inflammatory • mechanical • non-organic/psychosomatic • Acute or chronic • EXAMINATION • objective signs • TESTS • ???

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

  10. 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

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

  12. Musculoskeletal examination PaediatricGaitArmsLegsSpine • www.arc.org.uk www.arc.org.uk/arthinfo/emedia.asp

  13. LOOK gait swelling deformity rash/colour changes Examination - musculoskeletal

  14. FEEL heat swelling tenderness Examination

  15. MOVE restriction +/- pain muscle strength Examination

  16. Differential Diagnosis

  17. Inflammatory Conditions Acute

  18. Fever Localised tenderness hot Painful to move Raised inflammatory markers Septic Arthritis

  19. Fever Localised tenderness hot Painful to move Raised inflammatory markers JOINT ASPIRATION Septic Arthritis

  20. Site % Knee 39 Hip 25 Ankle 14 Elbow 12 Organisms Staph Aureus Tuberculosis Salmonella in sickle cell disease Septic Arthritis : Joint Distribution

  21. Missed Septic Arthritis : Knee

  22. Osteomyelitis of distal tibia

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

  24. Reactive Vasculitis (small vessel) Palpable Purpura Arthralgia/Arthritis Abdominal pain Nephritis Headaches Henoch Schonlein Purpura

  25. Malignancy • 1% of patients referred to paediatric rheumatology have underlying malignancy

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

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

  28. Malignancy • Acute Lymphoblastic Leukaemia • Neuroblastoma • Primary Bone tumour • Osteoid osteoma – benign • osteosarcoma

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

  30. Malignancy

  31. Kawasaki Disease 5 of following • Fever >5 days; unresponsive to Abx • Non purulent conjunctivitis • lymphadenopathy >1.5cm • Rash - polymorphous • mucosal changes • extremities • early - swelling/palmar erythema • late – peeling OR 4 plus coronary artery aneurysms

  32. Early features

  33. Late features

  34. Late features

  35. KD - management • Prevent late sequel of coronary artery aneurysms • Intravenous IVIG • Aspirin – • initially high, anti inflammatory • then low dose, anti platelet

  36. Inflammatory Conditions Chronic

  37. What’s in a name? JIA Juvenile Idiopathic Arthritis JRA Juvenile Rheumatoid Arthritis JCA Juvenile Chronic Arthritis

  38. What’s in a name? JIA Juvenile Idiopathic Arthritis JRA Juvenile Rheumatoid Arthritis JCA Juvenile Chronic Arthritis

  39. 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

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

  41. Classification Defined by clinical features in first 6 months

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

  43. Oligoarthritis • Girls >boys • Younger age • Best prognosis

  44. Oligoarthritis • Girls >boys • Younger age • Best prognosis • Associated with uveitis

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

  46. 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

  47. 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

  48. 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

  49. SystemicArthritis • 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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