Musculoskeletal problems in children

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

18. Inflammatory Conditions Acute

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

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

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

22. Missed Septic Arthritis : Knee

23. Osteomyelitis of distal tibia

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

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

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

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

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

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

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

31. Malignancy

32. 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

33. Early features

34. Late features

35. Late features

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

37. Inflammatory Conditions Chronic

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

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

40. 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

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

42. Classification Defined by clinical features in first 6 months

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

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

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

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

47. 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

48. 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

49. 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

50. 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