Child Presenting With Joint Pain

8/7/2019 Child Presenting With Joint Pain

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Arthritis


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Arthritis or Arthralgia ?

Painful

PainfulRed

Red

Swollen

Swollen

Warm

Warm

Lowmobility

Lowmobility

Painful


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Child with Arthritis

y Monoarthritis y Pol arthritis

y Oligorthritis


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Monoarthritis- Aetiology


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Traumay Exclude trauma from the history

y Hx of trauma ?

y Fall

y Direct injury

y

Blowy Commonest cause of Monoarthritis in paediatric age

group


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Septic Arthritis

y Hx :

y Joint pain and swelling (single, but neonates Polyarticular )

y Pseudoparalysis

y Fevery Thompson Aet al.Acute pediatric monoarticular arthritis: distinguishing lyme arthritis

from other etiologies. Pediatrics. Mar 2009;123(3):959-65. [Medline]

HaematogenousDirect innoculation

Adjacent osteomyelitis


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yEx:y Signs of inf lammation

y Hip :

y Flexed

y Abducted and

y Externally rotated

y Knee, ankle and elbow

y

Partially flexedy Shoulder

y Adducted and

y Internally rotated


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Septic Arthritis - Organisms

< 2 / 12 2 / 12 5 Y > 5 Y

Staphylococcus aureus Haemophilus influnzae

type B

Neisseria gonorrhoeae

E. coli Staphylococcus aureus

GBS Gp A Streptococci

Other Gram negativeorg.

Strep. pneumoniae

Communityacquired

MRSA


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Gonococcal Arthritis

FeverFeverChillsChills

RashRash

Tenos novitisTenos novitis

Migratorpol arthritisMigrator

pol arthritis

MonoarticularinfectionMonoarticularinfection


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Possibilities

y Gp A streptococcus reported in children with active VZV infection

y Salmonella in SCA

y Mycobacterium tuberculosis - rare cause of chronic pyogenicarthritis

y Kingella kingae - noted to cause septic arthritis in children < 5years

in Israel and is an emerging pathogen in the USy Rarely, fungi or anaerobes may cause SA

y Borrelia burgdorferi - common cause of reactive arthritis

y monoarthritis without fever, weeks to months after being bitten by a tick


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Septic Arthritis - Investigationsy S novial fluid for:

y WBC - > 50k/ml withPMNL

y Glucose 30% ofRBS

Uniquey Gram stain

y Culture Low senitivity(60-70%)

y B

lood for:y Culture Poor yield

y WBC/DC Elevated

y ESR Elevated

y CRP Elevated Moresensitive

y Imaging:

y Radiography

y Effusions and widenedjoint space

y Exclude other causes

y USS

y Diagnostic &Therapeutic

y Sensitive

y Scintigraphy

y Multifocal disease inneonates

y ?Associated OM


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y Independent variables that distinguished septic

arthritis from transient synovitisy History of fever

y Difficulty of bearing weight on a limb

y ESR> 40 mm/h and

y WBC count > 12,000 / ml

y The probability of septic arthritis was 99.6% forchildren with all 4 factors

y Probability was 93.1% for those with an 3 factors

y (Kocher MS et al.1999)

y Luhmann et alapplied these 4 criteria to their

population and discovered 59

% predicted probability


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Septic Arthritis - Managementy Medical:

y Empirical Antibiotics aftercollecting specimens

y Splint joint in functional

positiony Early passive movements

y Surgical:

y Uncomplicated SA Serial

arthrocentesis until fluid no

longer reaccumulates

y I0 Urgent Arthrotom

y Hip & Shoulder SA

y No response to Rx after

72 h with Antibiotics

y Large amount of pus and

debris in arthrocentesis

Age Antibiotic

Neonate without

meningitis

Cloxacillin &

Gentamycin

Neonate with

meningitis

Vancomycin &

Ceftriaxone

Others Cloxacillin

ClindamycinCeftriaxone


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Transient Synovitis

y Most common cause of acute hip pain in children

between 3-10years & highest incidence of non-traumatic

hip painyArthritis IIryto a Transient Inflammation of the synovium

y Hx

y Unilateral hip or groin pain

y Some may report medial thigh or knee pain

y Recent hx of URTI+ in 50% patients


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Transient Synovitis

y Ex

y Hip

y

Hold hip in flexion with slight abduction and external rotation

y Mild restriction of motion, esp to abduction and internal rotation

y Painful - even with passive movement

y

Tender to palpation

y Log roll Most sensitive. Shows involuntary guarding of

Muscles on affected side


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Transient Synovitis

y Causes

y No definitive cause

y Ix:

y Usually Ix do not reveal any abnormality

y Imaging may show Joint Effusion

y

Arthrocentesis and further Ix help to differentiate TS from otherserious causes of Monoarthritis


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Transient Synovitis

y Mx

y Bed rest x 7 10 days

y Advice not to bear weight on affected joint for few days

y Apply heat and massage

y Skin traction at 450 hip flexion to reduce intra capsular pressure

y NSAID reduce the duration of symptoms


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Haemarthrosis

y Usually follows trauma

y Feature in bleeding disorders

y Clotting factor deficiency Haemophilia

y Thrombocytopaenia

y Anticoagulant therapy

y Differentiate Haemarthrosis from SA

y Both are extremely painful

y Both usually involves single joint

y Both are usually associated with degree of Pyrexia

y Haemarthrosis Fever >38.50 C is rare


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Polyarthritis - AetiologyInfection Bacterial - Septicaemia

Viral - Rubella, Mumps, Adeno virus, Coxsakie B, HSVOthers - Mycoplasma, Lyme disease, Rickettsia

Reactive GI infections

Streptococcal infectionsIBD Crohns disease

Ulcerative colitis

Vasculitis HSPKawasaki

Haematological SCALeukaemia

Connective tissuedisorder

JIASLEPAN


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Child Presenting With Joint Pain