Evaluation of The Child With Joint Pain and - or Swelling - UpToDate

30/9/2016
Evaluationofthechildwithjointpainand/orswellingUpToDate
OfficialreprintfromUpToDate
www.uptodate.com.scihub.bz2016UpToDate
Evaluationofthechildwithjointpainand/orswelling
Authors: YukikoKimura,MD,TauntonRSouthwood,MD,FRACP,FRCPA,FRCP,FRCPCH
SectionEditor: RobertSundel,MD
DeputyEditor: ElizabethTePas,MD,MS
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Aug2016.|Thistopiclastupdated:Aug16,2016.
INTRODUCTIONJointpainandswellingarecommonmanifestationsofmanymusculoskeletaland
rheumatologicdiseases.Asaresult,thedifferentialdiagnosisofchildhoodjointpainandswellingislargeand
includesbothbenignandseriousconditions.Theassessmentofachildwithjointpainand/orswellingneedsto
differentiatebetweenconditionsofvaryingseverity,especiallythosethatrequireurgentmedicalintervention[1].
Theevaluationofachildwithjointpainorswellingisreviewedhere.Althoughthereisoverlapamongthecauses
oflimping,hippain,andjointswellingandpain,thecausesandapproachestoassessingachildwithlimpand/or
hippainarediscussedseparately.(See"Approachtothechildwithalimp"and"Overviewofthecausesoflimpin
children"and"Overviewofhippaininchildhood".)
DIFFERENTIALDIAGNOSISThedifferentialdiagnosisofchildhoodjointpainorswellingisbroad,ranging
frombenigntoseriousconditions,someofwhichcanhavedevastatingconsequences(eg,septicarthritis)(table
1).Thecategoriesofpossiblediseasethatmaypresentwithjointpainand/orswellingareincludedinthe
followingmnemonic,ARTHRITIS:
Avascularnecrosisandepiphysealdisorders(see"Overviewofhippaininchildhood",sectionon'Legg
CalvPerthesandsecondaryavascularnecrosis'and"Evaluationandmanagementofslippedcapital
femoralepiphysis(SCFE)",sectionon'Osteonecrosis')
Reactiveandpostinfectiousarthritis(see"Acuterheumaticfever:Clinicalmanifestationsanddiagnosis")
TraumaAccidentalandnonaccidental,includinghypermobilityassociatedwithmicrotrauma
HematologicLeukemia,bleedingdiatheses,andhemoglobinopathies
Rickets,metabolicandendocrinedisorders(see"Overviewofricketsinchildren")
InfectionSepticarthritisandosteomyelitis,aswellasothertypesofinfections,suchasLymearthritisand
parvovirusassociatedarthritis(see"Bacterialarthritis:Clinicalfeaturesanddiagnosisininfantsand
children",sectionon'Clinicalfeatures'and"MusculoskeletalmanifestationsofLymedisease"and"Specific
virusesthatcausearthritis"and"ClinicalmanifestationsanddiagnosisofparvovirusB19infection"and
"Hematogenousosteomyelitisinchildren:Clinicalfeaturesandcomplications",sectionon'Clinicalfeatures')
TumorMusculoskeletalneoplasia(eg,osteosarcoma),lymphoma,andneuroblastoma(see
"Osteosarcoma:Epidemiology,pathogenesis,clinicalpresentation,diagnosis,andhistology")
Idiopathicpainsyndromes,suchascomplexregionalpainsyndrome(CRPS)type1andfibromyalgia(see
"Fibromyalgiainchildrenandadolescents:Clinicalmanifestationsanddiagnosis"and"Complexregionalpain
syndromeinchildren")
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Systemicrheumatologicdiseases(see"Kawasakidisease:Clinicalfeaturesanddiagnosis"and"Systemic
lupuserythematosus(SLE)inchildren:Clinicalmanifestationsanddiagnosis"and"Classificationofjuvenile
arthritis")
Notethatthegroupofdiseasesincorporatedunderthegroupingofjuvenileidiopathicarthritis(JIA)doesnot
appearonthisdifferentialdiagnosislist.ThediagnosisofJIArequirestheexclusionofalloftheabovediagnoses.
INITIALEVALUATIONAthoroughhistoryandphysicalexaminationaretheinitialstepsindeterminingthe
diagnosisofachildwithjointpainand/orswelling.Inparticular,signsandsymptomsthatarecauseforconcern
(ie,redflagsordangersignsthatsuggestanunderlyingseriouscondition)shouldbesought.
WorrisomefindingsTherearecertainsignsandsymptomsinthechildwhopresentswithjointpainand/or
swellingthatmayindicatethepresenceofamoreseriousconditionrequiringurgentmedicalattention(table2).
Thesefindingsaretypicallyuncoveredduringtheinitialhistory(see'History'below)andphysicalexam.(See
'Physicalexamination'below.)
HistoryThehistoryneedstodifferentiatebetweenbenignandpathologicconditions,especiallythosethat
requireurgentmedicalattention,andhelpsprovideafocusforthephysicalexaminationanddiagnosticstudies.
Theimportantelementsofthehistoryinclude(table3):
Presenceoffever.
Paincharacterization,includingthesite,numberofjointsinvolved,andtheseverity,frequency,duration,and
patternofpain.Thecharacterizationofswellingisalsoimportantandincludesmanyofthesameelements
asthoseforpain,aswellasthepresenceofassociatedfindingsofwarmthanddiscoloration.
Presenceofprecipitatingfactors,suchasahistoryoftrauma.
Reviewofsystemsfocusingonhistoryofrash,weightloss,abdominalpain,andocularabnormalities.
Othermedicalconditionsassociatedwitharthritisorarthralgias.Theseincludeceliacdisease,inflammatory
boweldisease,chroniclungorcardiacdiseasewithhypoxia,uveitis,psoriasis,andcysticfibrosis.
FamilyhistoryItisimportanttoaskaboutthepresenceofpsoriasis,hypermobilitysyndromes,
inflammatoryboweldisease,spondyloarthropathies,uveitis,and/orbonydysplasiasincloserelativesas
theseconditionshaveageneticbasisandmaybeassociatedwitharthritisinthechild.Thelikelihoodthat
jointpainisduetoanautoimmuneconditionisincreasedifafamilymemberhassufferedfroman
autoimmunediseaseand/orimmunedeficiencysyndrome.Thislikelihoodfurtherincreasesiffamily
membersonbothmaternalandpaternalsidesareaffected.Thehealthandmedicalhistoryofthepatient's
siblingsmayalsobeinformative.
FeverThepresenceoffevernarrowsthedifferentialdiagnosissignificantly.Ifthereisahistoryoffever,itis
importanttoascertainthetimingandpatternoffeverandtheheightofelevatedtemperature.
Fevermayprecedeorpresentatthesametimeasjointsymptomsinchildrenwhosediseaseisduetobacterial
infection.Highfever(temperaturegreaterthan38C)inapatientwithmonoarticulardiseaseistypicalofa
bacterialinfectionofthejointorbone.However,subacuteorpartiallytreatedinfectionmaynotbeaccompanied
bysignificantfever.Feveralsomighthavebeenpresentduringanantecedentillnessthatprecededthe
developmentofreactivearthritis.(See'Antecedentinfection'belowand"Reactivearthritis".)
Feverisalsoassociatedwithnoninfectiousdiseasesincludingjuvenileidiopathicarthritis(JIA),Kawasakidisease,
vasculitis,andsystemiclupuserythematosus(SLE).Insomeconditions,thepatternoffeverisanimportantclue
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tothediagnosis,asdemonstratedinthefollowingexamples:
SystemicJIAisassociatedwithaquotidianfeverpattern.Adailyspikeofhighfeveroftenoccursinthe
afternoonorevening,withareturntonormalorevensubnormaltemperaturebetweenfevers,typicallyinthe
earlymorning.(See"Systemicjuvenileidiopathicarthritis:Clinicalmanifestationsanddiagnosis",sectionon
'Fever'.)
Periodicfeversyndromes,suchasfamilialMediterraneanfever,haveacharacteristicpatternofirregular,
intermittentepisodesoffever.Theselastforafewdaysorlonger,resolvespontaneously,andgivewayto
weeksofnormaltemperature.Duringthefebrileepisodes,patientsmayhavejointpainandswelling.(See
"Periodicfeversyndromesandotherautoinflammatorydiseases:Anoverview".)
ThefeverinpatientswithSLEhasagradualonsetandistypicallylowgradeandintermittent.(See
"Systemiclupuserythematosus(SLE)inchildren:Clinicalmanifestationsanddiagnosis".)
Pain,swelling,andstiffnesscharacterizationPainandswellingarecharacterizedbytheirlocation,
severity,frequency,duration,andfactorsthateitherexacerbateorrelievethefinding(table3).Jointstiffnessis
alsoacommonfeaturebut,likepain,issubjectiveandmaybedifficulttoquantify.
Thefollowingquestionshelptocharacterizethechild'sjointpainandswelling:
Howsevereisthepain,swelling,orstiffness?
Whereisthelocation(s)ofthepain,stiffness,orswelling?
Howmanyandwhichjointsareinvolved?
Whenandforhowlonghavethejoint(s)beenpainful,stiff,orswollen?
Howquicklydidthepain,swelling,orstiffnessappear?
Whatmakesthepain,swelling,orstiffnessbetterorworse?
SeverityAlthoughtheseverityorintensityofpainorstiffnessshouldbeassessed,onemustbecareful
nottoequateseverityofpainorstiffnesswithseverityofillness,becausetheperceptionofpainissubjective.
However,painsevereenoughtocausethechildtorefusetoputanyweightontheaffectedlimbisa"redflag"for
seriousillness,suchasbacterialinfectionofthejointorbone(eg,septicarthritisandosteomyelitis)ormalignancy
(eg,leukemiaandosteosarcoma).Incontrast,JIA,LeggCalvPerthesdisease,slippedcapitalfemoral
epiphysis,OsgoodSchlatterdisease,andtransientsynovitisareoftenassociatedwithlimping,butthepainis
generallynotsevereenoughforachildtorefusetobearweight.(See"Approachtothechildwithalimp".)
Youngchildrenandinfantsmayhavedifficultyarticulatingthepresenceofpainandmaynotcomplainofjointpain
evenwhenthereareobvioussignsofjointinflammationandswelling[2].Incasesthatinvolvethelower
extremities,theyoungchildmaymanifestpainasarefusaltowalkorwalkingwithalimp,and,inthosethat
involvetheupperextremities,thepatientmaylimitthemovementanduseoftheinvolvedarm.
Inanadolescentwhocomplainsofexcruciatingpain,oftenaccompaniedbyinabilitytowalk,butdoesnotseemed
tobeparticularlybotheredbytheproblem("labelleindifference"),apaindisordersuchascomplexregionalpain
syndrome(CRPS)type1orfibromyalgiamaybethelikelydiagnosis.(See"Complexregionalpainsyndromein
children"and"Fibromyalgiainchildrenandadolescents:Clinicalmanifestationsanddiagnosis".)
Painthatwakesachildinthemiddleofthenightisgenerallysevereandisausefuldiagnosticclueasitismore
commonlyseeninpatientswithbonypainduetobenigntumors,suchasosteoidosteoma,ormalignancies,such
asleukemia.Althoughotherbenignconditionssuchasgrowingpainsalsooccurtypicallyatnight,thesechildren
arealwaysentirelywellduringtheday.(See"Growingpains".)
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Significantjointsymptomsarelikelytointerferewithdailyactivities,suchaswalkinglongdistances,participating
insportsorphysicaleducation,andplayingmusicalinstruments.Involvementofthesmalljointsofthehandmay
interferewithwriting,buttoningclothes,andopeningjarsandbottles.
LocationandnumberofinvolvedjointsDeterminingthesite(s)ofthepain/swellingisimportantto
developarationallistofdifferentialdiagnosesandtodirectsubsequentevaluationandtreatment.Involvementof
asinglejointismoreconcerningforanacuteprocessandwarrantsmoreurgentevaluationthaninvolvementof
multiplejoints.
Itmaybechallengingtohavechildrenlocalizepainaccurately,especiallyyoungerchildren.Childrenshouldbe
askedtotellortopointtothepainfularea(s).Forthenonverbalchild,familymembersareaskedwhatledthemto
thinkthatthechildhasajointproblemandwhethertheynotedanyunusualwarmthorswellingofthejoint(s).
Thereisoverlapbetweencausesofmonoarticularandpolyarticularpainandswelling(table1).However,itis
importanttodeterminethenumberofinvolvedjointsbecauseinfectionisarelativelycommoncauseofacutepain
andswellinginasinglejoint,whichcanresultincartilagedestructionwithinafewdaysifnottreated.Asaresult,
patientswithmonoarticularinvolvementneedtobeassessedurgentlytoensurethattherapycanbeinitiatedas
quicklyaspossibleinthosesuspectedofhavingabacterialinfectionasthecauseoftheirsymptoms.
SinglejointinvolvementBacterialinfections(eg,septicarthritisandosteomyelitis)andsignificanttrauma
(eg,fractureorhemarthroses)areimportantcausesofpaininasinglejointthatmustbeconsideredwithout
delay,asdiscussedabove.Othercommoncausesofmonoarticularpainand/orswellinginclude
osteonecrosis(ie,LeggCalvPerthesdisease),oligoarticularJIA,Lymearthritis,andsomecasesof
reactivearthritis.
MultiplejointinvolvementAsbacterialinfectionandsignificanttraumararelyaffectmultiplejoints,thereis
lessurgencytoevaluateachildwithpolyarticularinvolvement[3].Causesofmultiplejointpainand/or
swellingincludeconnectivetissuedisorders,suchasSLE,JIA,andinflammatoryboweldiseaseassociated
arthritis.
Frequency,duration,andpatternPainandswellingcanbecharacterizedbasedupontheirfrequency,
duration,andpattern:
Persistent,intermittent,andmigratorypain/swellingPersistentpainischaracteristicofinflammationofthe
jointspacecommonlyseeninpatientswitharthritisthatisduetoinfectionorarheumatologicdisorderor
bonypainduetoaneoplasticprocess.
Intermittentpain,particularlyassociatedwithactivity,ismorelikelyduetoamechanicalproblem(eg,
patellofemoralsyndrome,meniscalorligamentousinjuriesoftheknee,orrotatorcuffimpingementdisorder
intheshoulder).Inaddition,recurrentpainandswellingofoneortwolargejointsfollowedbyspontaneous
resolution,particularlyintheknees,ischaracteristicofLymearthritis.
Migratoryjointpainispainthatlastsforseveraldaysinoneormorejointsandthenresolveswhileother,
previouslyunaffectedjointsbecomepainful.Itcanbeseeninpatientswithacuterheumaticfever(ARF)or
poststreptococcalreactivearthritis,HenochSchnleinpurpura(immunoglobulinA[IgA]vasculitis),and
childhoodleukemiaorlymphoma.(See"Acuterheumaticfever:Clinicalmanifestationsanddiagnosis"and
"HenochSchnleinpurpura(immunoglobulinAvasculitis):Clinicalmanifestationsanddiagnosis"and
"Overviewofthepresentationanddiagnosisofacutelymphoblasticleukemiainchildrenandadolescents".)
TimeofdayDiurnalvariationisanimportantdistinguishingfeatureofmanydifferentcausesofjointpain
thataidsinidentifyingtheunderlyingdiagnosis.Jointpainduetoarthritis,suchasJIA,isusuallyworseatthe
beginningofthedayandimprovesthroughoutthedaywithmovementandactivity.Incontrast,paindueto
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traumaormechanicalcauses(eg,hypermobility,tornmeniscus,patellofemoralsyndrome,orLeggCalv
Perthesdisease)isusuallymildornonexistentinthemorningandworsenswithactivityormayonlyoccur
afterincreasedphysicalactivity.Growingpainstypicallyoccurinawellchild,withpainthatmayaffectthe
jointusuallybeginningattheendofthedayandintothemiddleofthenight,butnotduringthedaytime[4].
Althoughbonetumorscancausenocturnalpain,thechildalsohaspainduringtheday.(See"Overviewof
hippaininchildhood",sectionon'LeggCalvPerthesandsecondaryavascularnecrosis'and"Growing
pains"and"Clinicalpresentation,staging,andprognosticfactorsoftheEwingsarcomafamilyoftumors"and
"Osteosarcoma:Epidemiology,pathogenesis,clinicalpresentation,diagnosis,andhistology".)
AcuityofonsetRapidonsetoffindingswithinoneortwodaysisoftenassociatedwithsepticarthritis,
osteomyelitis,andvasculitis(suchasHenochSchnleinpurpura),whereasmanyoftheothercausesof
childhoodjointpainandswellingaremoreinsidious.
OtherjointsymptomsThepresenceofawarmorredjointindicatesinflammationofthejoint(arthritis).
Thesefindingsincreasetheconcernforaninfectiousorinflammatorycauseforjointpainandswelling.Lockingor
"givingway"ofthejointaresuggestiveofamechanicaljointdisorder.
PrecipitatingfactorsThefollowingfactorsmaybeassociatedwiththeinitiationand/orworseningofjoint
symptoms.Theirpresencemaybehelpfulindeterminingthepossiblecauseofjointsymptoms.
AntecedenttraumaTraumamaybethedirectcauseofjointpain,aswithfracturesorligamentous
injuries,orindirect,aswithsomecasesofosteomyelitis.Judgingthedegreeoftraumaanddeterminingthe
temporalrelationbetweenthetraumaandthechild'spresentationareimportantindecidingwhethertraumacan
bethecauseoracontributingfactortoachild'sjointsymptoms.Inasignificanttraumaticinjury,theprecipitating
eventisusuallyassociatedwiththeimmediateonsetofpain,swelling,andsometimesbruising.Insomecases,
however,anepisodeofminortraumamaysimplybringtoattentionapreexisting,butasyetundiagnosedand
unrelated,condition.
AntecedentinfectionRecentinfections,especiallywithentericpathogens(Salmonella,Shigella,
Yersinia,andCampylobacter),viruses(eg,parvovirusB19andvaricella),GroupAStreptococcus,and
immunization(eg,rubellaimmunization),maybeassociatedwithreactivearthritis,acommoncauseofacute
arthritisinchildren[5].Asanexample,thearthritisofARF,asequelofagroupAstreptococcalpharyngeal
infection,typicallyoccurstwoweeksaftertheprecipitatinginfection.(See"Acuterheumaticfever:Clinical
manifestationsanddiagnosis".)
Reactivearthritisisbroadlydefinedasanarthritisthatdevelopssoonafterorduringaninfectionelsewhereinthe
bodybutinwhichthemicroorganismscannotberecoveredfromthejoints.Inthemostrestrictivedefinition,
reactivearthritishasbeenusedtorefertothetriadofpostinfectiousarthritis,urethritis,andconjunctivitis,formerly
calledReitersyndrome.(See"Reactivearthritis".)
InactivityJointpainorstiffnessthatisworsenedbyperiodsofinactivity(calledarticularorinactivity
gelling)istypicalofchronicinflammatoryarthritis,suchasseeninsomecasesofJIAorSLE.Animportant
questiontoaskiswhetherthechildappearsstiffinthemorningwithgradualresolutionorimprovementduringthe
day'sactivity.Someparentswillvolunteerthattheirchild"lookslikeanoldman"aftergettingupinthemorning.
Veryyoungchildrenmaysimplybeirritableuponawakeningandasktobecarrieduntiltheyfeelbetter.Affected
childrenmayhavesimilarcomplaints/findingslaterinthedayafteranap,aperiodofinactivity(suchasalongcar
ride),orevensittingatadeskinclass.
IncreasedphysicalactivityChildrenwithmechanicalcausesofjointpain,suchashypermobility
syndrome,patellofemoralsyndrome,andosteochondroses,willoftenhavepainthatissignificantlyworseoronly
occursafterincreasedphysicalactivity.Growingpainsarealsooftenreportedtobemorefrequentafteranactive
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day.(See"Jointhypermobilitysyndrome"and"Approachtochronickneepainorinjuryinchildrenorskeletally
immatureadolescents",sectionon'Patellofemoralpainsyndrome'and"Overviewofthecausesoflimpin
children",sectionon'Osteochondrosisandapophysitis'and"Growingpains".)
ReviewofsystemsAthoroughreviewofsystemsdetectsthepresenceofothersymptomsthatmayaidin
theidentificationofthecorrectdiagnosis.Clinicalfeatures,suchasrash,weightloss,abdominalpain,andeye
abnormalities,incombinationwithjointfindingsaresuggestiveofspecificdiseasesbaseduponpattern
recognition(table4).
PhysicalexaminationAbnormalitiesdetectedbythephysicalexaminationareimportantcluestothe
diagnosisandhelpdifferentiatesevereconditionsrequiringurgentmedicalinterventionfrommorebenign
disorders.
Inadditiontoathoroughgeneralexamination,acompletemusculoskeletalexaminationincludes:
Generalappearanceincludingmeasurementofgrowthparametersandvitalsigns.
Specialattentiontotheheart,lung,skin,andeyessincetheseorgansystemsareoftenaffectedinchildren
withjointpainorswelling.Inmanycases,abnormalitiesoftheseorgansmaysuggestanunderlyingetiology.
Screenoftheentiremusculoskeletalsystemwithafocusedexaminationofthepainfulorswollenjoint(s).
Evaluationofmotorstrength(bothproximalanddistal)sinceneuromuscularconditionsandinflammatory
myopathiesmaybeaccompaniedbyjointsymptoms.
Performingameticulouspediatricmusculoskeletalexamination,especiallyinyoungchildren,requiresapatient
andpersistentapproach.Itmayeventakemorethanonesessiontocompleteifthechildisfractious.Withouta
thoroughandsystematicexamination,however,subtlesignsofcriticalimportancetothediagnosisofthe
conditionmaybemissed.
GeneralappearanceAgeneralinspectionofthepatientshoulddeterminewhetherthechildisillorwell
appearing.Heightandweightmeasurementsarecomparedwithreferencerangesandpriorvalues.Achangein
thepatient'sgrowthcurveorrecentweightlossmaybeindicativeofaseriousorchronicdisorder,suchas
systemicorpolyarticularJIA,SLE,inflammatoryboweldisease,oramalignancy(eg,leukemia).
Vitalsignsincludedeterminationofbloodpressure,whichmaybeelevatedinSLEoraprimaryvasculitis,and
temperature.(See'Fever'above.)
MusculoskeletalscreeningThePediatricGaitArmsLegsSpine(pGALS)examinationisasimplescreen
formusculoskeletalabnormalitiesthatcanbeperformedinminutes(figure1andfigure2andfigure3andfigure
4)[6,7].Itisascreenthatusessimplephysicalmaneuvers,includingobservationofthegait,toassessfor
musculoskeletalabnormalities.
FocusedjointexaminationIfanaffectedjointisextremelypainful,itsassessmentshouldbereserved
untiltheendtoencouragecooperationwiththerestoftheevaluation.
Thejointexaminationbeginswithinspectionandproceedstopalpationandestimationofactiveandpassive
rangeofmotion(ROM)(table5).
InspectionObservationisthefirststepinjointexamination.Ifthejointpainlocationisasymmetricalor
worseononesidethantheother,comparebothextremities,lookingfordifferencesinsizeandshape.Doesthe
childholdanaffectedjointinaparticularpositionofcomfort?Ifajointappearsbiggerthanthecorresponding
contralateralarticulation,furtherassessmentwillneedtodetermineifjointeffusion,synovialthickening,edemaof
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thesofttissueoverlyingthejoint,bonyovergrowth,orsomecombinationoftheseabnormalitieshasledtothe
increaseinjointsize.(See'Palpation'below.)
Evenifonlyasinglejointispainful,theentireextremityshouldbeexaminedtodetectthepresenceofmuscle
atrophy,discrepanciesoflength,and/orgeneralizedasymmetry.Therearetwocommonlyusedclinicalmethods
formeasuringanapparentleglengthdiscrepancy.Themostaccurateistocorrectanypelvictilt(observedfrom
behind)byaskingthechildtostandwiththefootoftheshorterlegonanobjectofmeasurableheight,suchasa
book,magazine,orevenaspecificallyfashionedwoodenblock(a"lift").Alternatively,eachleglengthcanbe
comparedaftercarefulmeasurementfromtheanteriorsuperioriliacspinetothemedialmalleolus,althoughthis
methodissubjecttoconsiderableobservererror.
Theskinoverlyingthejointshouldbeinspectedforevidenceofscars,bruises,anddiscoloration,whichcouldbe
causedbyarashorinflammation.
PalpationThefirststepistoassessanydifferencesinthetemperatureoftheskinoverlyingtheaffected
joint.Increasedwarmthoftheaffectedjointcomparedwiththeunaffectedsidecanindicateinflammationdueto
infectionorrheumatologicdisorder.ExtremitiesaffectedbyCRPStype1canbeeithercoolerorwarmerthanthe
unaffectedside.
Palpationincludesassessmentforthepresenceandlocationoftenderness.Jointtendernessmaybesecondary
todisordersofthebone,suchasosteomyelitis,bonetumor,othercausesofperiostitis,orOsgoodSchlatter
diseasesynovialdisease,suchasarthritisorabnormalitiesoftheligaments,tendons,andmenisci.Palpationof
the"entheses"(pointsofinsertionofligament,tendon,orjointcapsuleintobone)isofparticularimportancein
determiningthesubtypeofJIA(usuallyassociatedwithenthesitisrelatedarthritisorspondyloarthritis)and
occasionallyinothermusculoskeletalandrheumaticdiseases.Inflammationatthesepointsofinsertionisreferred
toas"enthesitis."
Ifosteomyelitisissuspected,acarefulpalpationoftheboneshouldbeperformed,anditshouldstartawayfrom
thepainfulareaandmovetowardsitslowly.Inafebrilechild,severepaininalocalizedareaofbone("point
tenderness")isindicativeofpossibleosteomyelitis.Inanonfebrilechild,thereisawidedifferentialdiagnosisfor
pointbonetenderness,includingfracture,periostitis,benignormalignantneoplasia,andenthesitis.Subacute
osteomyelitisisalsopossibleintheafebrilechild[8,9].
Ifswellingispresent,palpationmayhelpdeterminethenatureoftheenlargement.Acysticorfluctuantqualityto
theswellingsuggestsafluidcollectionthatmaybeindicativeofajointeffusion,ganglion,meniscalcyst,bursal
swelling,orabscess.Adoughyorrubberyconsistencysuggestssynovialthickening,whereas,ahard,bonyfeel
mayindicateosseousovergrowth(eg,bonetumororexostosis).(See"Benignbonetumorsinchildrenand
adolescents:Anoverview",sectionon'Examination'.)
RangeofmotionROMisanimportantpartoftheexaminationofachildwithjointpainhowever,if
thereisseverepain,particularlyifthereisahistoryoftraumaand/oranobviousdeformity,itisprudenttosplint
theinvolvedjointandproceedtoobtainradiographstoruleoutafractureordislocation.
Intheabsenceofseverepain,deformity,and/orahistoryofsignificanttrauma,jointfunctionisassessedwiththe
followingquestionsinmind:
IstheROMlimitedand,ifso,towhatdegree?Whilemostjointsarelimitedinmovementtoflexionand
extension,afewjointsmoveinotherplanes,resultinginagreaterROM.Theseincludethehips,shoulders,
spine,wrists,andankles.ActiveandpassiveROMshouldbenotedinabductionandwithinternaland
externalrotationofthehipsandshoulders.Aparticularlyvaluabletechniqueistoassessthedegreeof
relaxedpassiveextensionofthekneesbyraisingbothlegsusingthefeetwhilethepatientissupineand
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askingthepatienttorelax.Thekneesshouldhaveupto10degreesofrecurvatum(hyperextension),and
anyasymmetrymayindicateasubtlebutsignificantlossofjointrange.
Ofnote,oneofthebiggestmistakesthatnonspecialistsmakewhentestingpassiveROMisnotpushingthe
jointtothelimitsofitsROM.Frequentlyinarthritisandotherinflammatoryconditions,theremaybevery
subtleabnormalitiesthataremissedwhenthisisnotdone.Asanexample,intheknee,wherelossofthe
normalfewdegreesof"relaxedpassiveextension"maybetheonlyindicationofkneepathology,afew
degreesofmotionmaybethesoledistinguishingfeaturebetweenanarthriticjointandanormalone.To
demonstratethisfinding,whilethechildliessupineandrelaxedwiththelegsextended,thefeetaregently
liftedoffthebedbytheexaminer(asdescribedintheprecedingparagraph).Ifthereisasymmetryofthe
expected5to10degreeshyperextensionoftheknees,pathologyisgenerallyfoundinthesidethathas
"lost"relaxedpassiveextension.
Isthereexcessivejointmobility[10]?Excessivemobilityofthejoint,whichmaybeassociatedwithjointpain,
canbeseeninbenignhypermobilitysyndrome,whichmaybeassociatedwithincreasedmusculoskeletal
painandinpathologicjointlaxitysyndromes,suchasEhlersDanlosorMarfansyndrome.(See"Joint
hypermobilitysyndrome"and"Genetics,clinicalfeatures,anddiagnosisofMarfansyndromeandrelated
disorders".)
Istherepainwithmotion?Ifpalpationandmovementofthepainfuljointdonotreproduceorexacerbatethe
pain,thenreferredpainshouldbesuspected.Asanexample,kneepainmayarisefromaproblematthe
hip.Ifthehipandkneearenormalonexamination,consideranevenmoreproximalsite,suchasthespine
orretroperitoneum.Forexample,pyomyositisofthepsoas(psoasabscess)typicallypresentswithhippain
andflexiondeformity[3].
Ismusclestrengthnormal?Muscleweakness,especiallyproximalweakness,maybeanindicationof
myopathy,suchasdermatomyositisormusculardystrophy.Theinflammatorymyopathiesinparticularmay
beassociatedwithjointsymptoms,aswellasmusclepainandweakness.
SpecificjointsThereareseparatetopicsthatreviewthepediatricevaluationofpainandinjuryofspecific
joints.
Neck(see"Approachtothechildoradolescentathletewithneckpainorinjury")
Footandankle(see"Footandanklepainintheactivechildorskeletallyimmatureadolescent:Evaluation")
Knee(see"Approachtoacutekneepainandinjuryinchildrenandskeletallyimmatureadolescents"and
"Approachtochronickneepainorinjuryinchildrenorskeletallyimmatureadolescents")
Hip(see"Overviewofhippaininchildhood",sectionon'Commoncausesofhippaininchildren')
REFERRALIfthecauseofachildscomplaintsremainselusivedespiteacomprehensivehistoryandphysical
exam,orifadiseaseordisorderrequiringaspecialist'sexpertiseisdiscoveredorsuspected,referraltoa
pediatricrheumatologistororthopedistisoftenamoreefficientapproachthanperformingnumerousimagingand
laboratorystudies.
DIAGNOSTICSTUDIESTheadditionofselectiveimagingandlaboratorytestingtoacompleteandthorough
historyandphysicalexaminationmayhelptoestablishthecauseofjointabnormalities.Diagnosticstudiesshould
bedonejudiciouslyandchosenonthebasisoflikelydiagnoses[11].Infact,mostrheumatologicdisorders
affectingchildrenarediagnosedbaseduponthehistoryandphysicalexamination,andimagingandlaboratory
studiesareusedtoconfirmorgradethepathology.Someofthemostcommonrheumaticdiseasesofchildren,
suchasjuvenileidiopathicarthritis(JIA),mayhavefewornoassociatedlaboratoryabnormalities.Diagnostic
studiesmayhelptoexcludeotherconditionsorsupportone'sclinicalimpression,butrarelydotheyreveala
previouslyunsuspecteddiagnosis.Aparticulardangerfortheinexperiencedclinicianisfindinganddealingwith
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irrelevantorinconsequential"abnormalities"asaresultofperforminganoverenthusiasticbatteryof
investigations.
JointaspirationJointaspirationandexaminationofthesynovialfluidshouldbeperformedinanychildwith
clinicalfeaturessuggestiveofsepticarthritis(table6)toeithermakethediagnosisorruleitout.Acuteonsetof
feverwithjointpain,swelling,andlimitedrangeofmotion(ROM)inasinglejointofthelowerextremityisthe
classicpresentationforbacterialarthritis.However,thepresentationvariesdependingupontheageofthechild,
thesiteofinfection,andthecausativeorganism.Asexamples,theclassicalsignsofsepsismaybemissingina
childwithtuberculousarthritis,anindolentconditionthatusuallypresentsasmonoarthritis,andwithKingella
kingaeinfection,whichistypicallyinsidious,indolent,andwithlowgradeornofever[1214].(See"Bacterial
arthritis:Clinicalfeaturesanddiagnosisininfantsandchildren"and"Skeletaltuberculosis",sectionon
'Infectious'.)
Jointaspirationisnotnecessaryformostchildrenwithjointswellingandpainwholackfeaturesofsepsis(ie,
fever,illappearance,refusaltobearweightoruseanextremity),sincethisinvestigationrarelyaddsuseful
informationinthisgroupofchildren.Thisisunlikethesituationinadults,inwhomotherillnesses,suchasgout,
makearthrocentesisamoreimportantdiagnostictool.Inaddition,theprocedureisprobablymorepainfuland
traumatictoapediatricpatient.
Ifitisnecessary,olderchildrenusuallycantoleratejointaspirationwiththeuseoflocalanesthetics.Younger
childrenandthoserequiringaspirationofashoulderorhipmayrequireproceduralsedationorgeneral
anesthesia.Hipjointaspirationshouldbeperformedwithultrasonographicguidancebysomeoneskilledinthis
procedure.(See"Jointaspirationorinjectioninchildren:Indications,technique,andcomplications".)
Thefollowingtestingtoassessthepresenceofsepticarthritisisperformedroutinelyonsynovialfluid,although
Gramstainandcultureareundoubtedlythemostuseful:
CellcountanddifferentialHighwhitecellcountisindicativeofaninflammatoryprocesssuchasJIAor
septicarthritis
Gramstain
Glucose
Protein
Microbiology(aerobicandanaerobicbacterialcultures)
Examinationofthejointfluidforcrystalsisrarelyinformativeinchildren.Goutyarthritisisveryrarebefore
puberty,eveninchildrenwithLeschNyhansyndrome(hypoxanthineguaninephosphoribosyltransferase
deficiency)[15].
ImagingVariousimagingmodalitiesareusedtoevaluatethechildwithjointpainand/orswelling.Indications
forthesestudiesdependuponthediagnosessuspectedandthejoint(s)involved.
EvaluationofconditionswithpresentationssimilartoJIAPlainradiographsoftheaffectedjointareuseful
inrulingoutseveralofthedifferentialdiagnosesofJIA,includingfractures,periostitis,avascularnecrosis,
hematologicmalignancies,bonetumors,andbonedysplasias,andshouldbeperformedoneverychildin
whomthereisconcernforoneofthesediseases.Magneticresonanceimaging(MRI)isusuallyreservedfor
instanceswhenboneinfection,traumaticjointinjury,ortumorisofconcernandcomputedtomography(CT)
forfracturesthatarenotevidentonplainradiographs.
Plainradiographsarealmostalwaysthebestinitialimagingtesttoperformwhenevaluatingthesechildren.
Decisionsregardingmoreadvancedimagingshouldbediscussedwithanexperiencedradiologist.Onthe
otherhand,contrastenhancedMRIandjointultrasoundscanstodemonstratejointeffusionsandsynovitis
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aremorecommonlyusedthanplainradiographsintheevaluationandmanagementofJIAoncethe
diagnosisismade.IncasesofpolyarticularJIA,themostseverelyaffectedjoint(s)aretypicallyimagedto
monitorforevidenceofchronicchangesindicativeofdiseaseprogression,suchascystformation,cartilage
thinning,orbonyerosions.
Simultaneousimagingofthecontralateraljointmaybeperformedtoallowforcomparisonofgrowthand
development.Unilateralaccelerationmaybeasignofchronicinflammationassociatedwithlongstanding
arthritis.
HippainofunclearetiologyInpatientswithhippainofunclearetiology,ultrasonographyorMRIis
particularlyusefulindetectingthepresenceorabsenceofajointeffusionorastructuralproblemsuchas
avascularnecrosisorslippedupperfemoralepiphysis.Aneffusionassociatedwithseverepainand/orfever
suggestssepticarthritisofthehip.(See'Jointaspiration'above.)
Suspectednoninflammatoryconditions(trauma,infections)CTscansaregenerallyreservedforevaluating
noninflammatoryconditions,suchastraumaticboneandsofttissueinjuries,backpain,tumors,and
infections(osteomyelitis),andshouldbediscussedwiththeappropriateradiologistpriortoorderingthe
study.MRImaybeusefulinidentifyingthepresenceofinfectiousarthritisandespeciallyosteomyelitiswith
boneandmarrowinvolvement[16].However,inflammatoryarthritisandsepticarthritiswithoutbone
involvementmayhavesimilarMRIfindings.
SepticarthritisversusosteomyelitisTechnetiumbonescanscanbehelpfulindifferentiatingsepticarthritis
fromosteomyelitiswhentheclinicalexaminationisnothelpfulindistinguishingbetweenthetwo.
Osteomyelitistypicallypresentswithisolatedbonepainandfever,whilesepticarthritispresentswithsevere
jointpain,highlyrestrictedrangeofjointmovement,andswellingaswellasfever.However,osteomyelitisis
occasionallyassociatedwithasterile"sympathetic"effusionoftheadjacentjoint.Thetwoconditionsmay
coexist,particularlyinjointswherethemetaphysisiswithinthejointcapsule(suchastheankleinprepubertal
children).TheextentofboneinvolvementinosteomyelitiscanbeevaluatedbyMRI,butMRIisnotalways
availableandmaybedifficulttoperformwithoutgeneralanesthesiainayoungchild[17,18].
DetectionofskeletaltumorsortraumainpatientswithlocalizedbonepainandnoclearetiologyBone
scansarealsousedfordetectingunsuspectedskeletaltraumaandtumors,suchasosteoidosteoma,which
maypresentwithlocalizedbonepain,especiallyatnight.Perhapsthemostcommonuseofbonescansis
attemptingtolocalizesymptomsinanonacutesituationwhenthesourceorlocationofthepatient'spain
remainsunclearaftertheclinicalexamination.However,imagingisseldomasusefulastheexaminationof
anexperiencedpractitionersincebonescansprimarilydetectabnormaltraceruptakebyosteoblasts,atype
ofcellnotaffectedbypotentialcausesofjointsymptoms.Thus,referraltoapediatricrheumatologistor
orthopedistpriortoobtainingabonescaninthesepatientsisadvised.(See"Benignbonetumorsinchildren
andadolescents:Anoverview",sectionon'Radiologicevaluation'and"Imagingtechniquesforevaluationof
thepainfuljoint",sectionon'Bonescan'.)
LaboratorytestingThefollowinglaboratorytestsshouldbeobtainedinanychildwithacuteorchronicjoint
painwithoutanimmediatelyobviouscauseorinwhomoneofthespecificdiagnoseslistedforeachlaboratory
testissuspected(table1andtable4):
Completebloodcountanddifferentialtodetectabnormalitiesofbloodcelllinesthatmaybeassociatedwith
systemiclupuserythematosus(SLE),systemicJIA,bacterialandviralinfections,andleukemia[19,20].
Acutephasereactants(erythrocytesedimentationrateorCreactiveprotein).Whenelevated,thesetests
arenonspecificmarkersofinflammationthatdonotnecessarilyreflectjointpathology.Conversely,children
withinflammatorydiseases,suchasJIA,canhavenormalacutephasereactants.
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Serumchemistries,especiallyliverandkidneyfunctiontests.Abnormalvaluesmaybeindicativeofa
possiblesystemicdisorder,suchasSLEorvasculitis.Elevatedlevelsofcreatinekinase(CK)maybe
indicativeofmyositis.
Serumlactatedehydrogenase(LDH).Elevatedlevelsmaybeindicativeofthepresenceofmalignant
neoplasm[1921].
UrinalysistodetecturinaryabnormalitiesthatmaybeseeninsomerheumatologicdisorderssuchasSLE,
vasculitis,andHenochSchnleinpurpura(immunoglobulinA[IgA]vasculitis).
Furtherevaluationisdependentuponwhetherthejointsymptomsareacuteorchronic.
AcutejointpainAcutejointpain,eitherasasolitarymanifestationorwhenaccompaniedbysystemic
symptoms,maybedirectlyorindirectlyrelatedtoaninfectiousprocess.Thus,thefollowingtestsareindicated:
Culturesofthethroat,blood,stool,and/orurineinpatientswithlocalizingclinicalfindingsandinflammationof
multiplejointsleadingtosuspicionforareactivearthritis
SerologictestingforLymediseaseforchildrenwholiveinorhavevisitedanendemicareasinceoneofthe
mostcommonlateorchronicmanifestationsofLymediseaseisanacutepauciarthritis
AntistreptolysinO(ASO)titerorsimilarstudieslookingforevidenceofarecentstreptococcalinfectionina
childsuspectedofhavingacuterheumaticfever(ARF)
ChronicjointpainChronicjointpainisunlikelytoberelatedtoaninfectiousprocess,theprimary
exceptionsbeingthearthritisofLymediseaseortuberculosis.
Thefollowingtestsareindicatedinchildrenwithchronicjointpainandadditionalfeaturesthatsuggestspecific
diagnoses[2224]:
Quantitativeimmunoglobulinstodetectimmunedeficienciesinchildrenwithahistoryofunusuallynumerous
orsevereinfectionssinceimmunedeficienciesincludinghypogammaglobulinemiamaybeassociatedwitha
varietyofautoimmunemanifestations[25].Elevatedlevelsofimmunoglobulinssimilarlymaybeindicativeof
anautoimmunecondition[26].(See"Autoimmunityinpatientswithprimaryimmunodeficiency"and
"Approachtothechildwithrecurrentinfections"and"Laboratoryevaluationoftheimmunesystem".)
SerologictestingforLymediseaseforchildrenwholiveinorhavevisitedanendemicarea.
Antinuclearantibody(ANA)forachildsuspectedofhavingamultisysteminflammatorydiseasesuchasSLE.
HigherANAtitersaremorecommonlyseeninchildrenwithautoimmunedisease[24,27].However,thisisnot
asensitiveorspecificenoughtesttouseforgeneralscreeningpurposes.MostchildrenwithJIAhave
negativeautoantibodytests,andmanyhealthychildrenhavelowtitersofANAnotassociatedwithpathology.
Rheumatoidfactor(RF)andanticitrullinatedpeptideantibodies(ACPA)aremarkersforpotentiallymore
severediseaseandpooroutcomeinJIAbutshouldonlybeperformedinpatientswithanestablished
diagnosisofJIA.
Humanleukocyteantigen(HLA)B27forchildrensuspectedofhavingcertainformsofarthritis.Whilethe
presenceofthisantigenisassociatedwithanincreasedriskofenthesitisrelatedarthritis,juvenileankylosing
spondylitis,psoriaticarthritis,arthritisassociatedwithinflammatoryboweldisease,andreactivearthritis,itis
apoorgeneralscreeningtest.NinepercentofCaucasianscarrythisgeneandarealmostallhealthyand
neverdeveloparthritis,whilethereareothers(especiallythoseofAfricandescent)whodonothaveHLA
B27butstillgoontodevelopankylosingspondylitisandrelatedconditionsinassociationwithdifferent
geneticmarkers.
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SUMMARY
Thedifferentialdiagnosisforjointpainandswellingisbroad,rangingfrombenigntoseriousconditions,
someofwhichcanhavedevastatingconsequences(table1).(See'Differentialdiagnosis'above.)
Acompletehistorymaydifferentiatebetweenbenignandpathologicconditions,especiallythosethatrequire
immediatemedicalattention,andhelpsdirectthephysicalexaminationandworkup.(See'Initialevaluation'
aboveand'Worrisomefindings'above.)
Theimportantelementsofthehistoryincludecharacterizationofthepainand/orswelling(ie,site,severity,
frequencyanddurationofsymptoms,andthenumberofjointsinvolved)(table3)presenceofotherjoint
findings(instability,warmth,andredness)andprecipitatingfactors(antecedentinfectionortraumaandlevel
ofactivity)reviewofotherassociatednonmusculoskeletalsymptoms(eg,feverandrash)(table4)andthe
presenceofothermedicalconditionsassociatedwitharthritis.(See'History'above.)
Abnormalitiesdetectedbythephysicalexaminationmaybeimportantcluestothediagnosisandhelp
differentiatesevereconditionsrequiringurgentmedicalinterventionfrommorebenigndisorders.Athorough
physicalexaminationandgeneralinspectionshouldbeconducted,includingmeasurementofgrowth
parametersandvitalsigns,screeningoftheentiremusculoskeletalsystem(figure1)aswellasafocused
examinationoftheaffectedjoint(s)(table5),andevaluationofmotorstrengthtodetectanyneuromuscular
conditionsthatmaybeaccompaniedbyjointsymptoms.(See'Physicalexamination'above.)
Selectiveimagingandlaboratorytestingaredirectedbythehistoryandphysicalexamination.(See
'Diagnosticstudies'above.)
Referraltoapediatricrheumatologistororthopedistisadvisedifthecauseofjointpainorswellingremains
elusivedespiteacomprehensiveevaluationorifadiseaseordisorderrequiringaspecialist'sexpertiseis
discoveredorsuspected.(See'Referral'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1.FosterH,KimuraY.Ensuringthatallpaediatriciansandrheumatologistsrecognisesignificantrheumatic
diseases.BestPractResClinRheumatol200923:625.
2.SherryDD,BohnsackJ,SalmonsonK,etal.Painlessjuvenilerheumatoidarthritis.JPediatr1990116:921.
3.FinkCW,NelsonJD.Septicarthritisandosteomyelitisinchildren.ClinRheumDis198612:423.
4.UzielY,HashkesPJ.Growingpainsinchildren.PediatrRheumatolOnlineJ20075:5.
5.RiiseR,HandelandKS,CvancarovaM,etal.IncidenceandcharacteristicsofarthritisinNorwegian
children:apopulationbasedstudy.Pediatrics2008121:e299.
6.FosterHE,KayLJ,FriswellM,etal.Musculoskeletalscreeningexamination(pGALS)forschoolage
childrenbasedontheadultGALSscreen.ArthritisRheum200655:709.
7.www.arc.org.uk/arthinfo/medpubs/6535/6535.asp(AccessedonAugust13,2008).
8.CeroniD,BelaieffW,CherkaouiA,etal.Primaryepiphysealorapophysealsubacuteosteomyelitisinthe
pediatricpopulation:areportoffourteencasesandasystematicreviewoftheliterature.JBoneJointSurg
Am201496:1570.
12/26
30/9/2016
9.BenGhozlenH,KazizH,AbidF,etal.Managementofsubacuteacetabularosteomyelitisinachild.Arch
Pediatr201522:861.
10.SmitsEngelsmanB,KlerksM,KirbyA.Beightonscore:avalidmeasureforgeneralizedhypermobilityin
children.JPediatr2011158:119.
11.AnsellBM.Rheumaticdiseasemimicsinchildhood.CurrOpinRheumatol200012:445.
12.deGrootR,GloverD,ClausenC,etal.BoneandjointinfectionscausedbyKingellakingae:sixcasesand
reviewoftheliterature.RevInfectDis198810:998.
13.YagupskyP,PorschE,StGemeJW3rd.Kingellakingae:anemergingpathogeninyoungchildren.
Pediatrics2011127:557.
14.WilliamsN,CooperC,CundyP.Kingellakingaesepticarthritisinchildren:recognisinganelusivepathogen.
JChildOrthop20148:91.
15.TreadwellBL.Juvenilegout.AnnRheumDis197130:279.
16.KirkhusE,FlatB,RiiseO,etal.DifferencesinMRIfindingsbetweensubgroupsofrecentonsetchildhood
arthritis.PediatrRadiol201141:432.
17.ConnollyLP,ConnollySA,DrubachLA,etal.Acutehematogenousosteomyelitisofchildren:assessmentof
skeletalscintigraphybaseddiagnosisintheeraofMRI.JNuclMed200243:1310.
18.PeltolaH,PkknenM.Acuteosteomyelitisinchildren.NEnglJMed2014370:352.
19.JonesOY,SpencerCH,BowyerSL,etal.Amulticentercasecontrolstudyonpredictivefactors
distinguishingchildhoodleukemiafromjuvenilerheumatoidarthritis.Pediatrics2006117:e840.
20.AgodiA,BarchittaM,TrigiliaC,etal.Neutrophilcountsdistinguishbetweenmalignancyandarthritisin
childrenwithmusculoskeletalpain:acasecontrolstudy.BMCPediatr201313:15.
21.WallendalM,StorkL,HollisterJR.Thediscriminatingvalueofserumlactatedehydrogenaselevelsin
childrenwithmalignantneoplasmspresentingasjointpain.ArchPediatrAdolescMed1996150:70.
22.MallesonPN,SailerM,MackinnonMJ.Usefulnessofantinuclearantibodytestingtoscreenforrheumatic
diseases.ArchDisChild199777:299.
23.EichenfieldAH,AthreyaBH,DoughtyRA,CebulRD.Utilityofrheumatoidfactorinthediagnosisofjuvenile
rheumatoidarthritis.Pediatrics198678:480.
24.McGheeJL,KickingbirdLM,JarvisJN.Clinicalutilityofantinuclearantibodytestsinchildren.BMCPediatr
20044:13.
25.GrimbacherB,WarnatzK,YongPF,etal.Thecrossroadsofautoimmunityandimmunodeficiency:Lessons
frompolygenictraitsandmonogenicdefects.JAllergyClinImmunol2016137:3.
26.LoMS,ZurakowskiD,SonMB,SundelRP.Hypergammaglobulinemiainthepediatricpopulationasa
markerforunderlyingautoimmunedisease:aretrospectivecohortstudy.PediatrRheumatolOnlineJ2013
11:42.
27.McGheeJL,BurksFN,SheckelsJL,JarvisJN.Identifyingchildrenwithchronicarthritisbasedonchief
complaints:absenceofpredictivevalueformusculoskeletalpainasanindicatorofrheumaticdiseasein
children.Pediatrics2002110:354.
Topic6405Version15.0
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GRAPHICS
Differentialdiagnosisofjointpainorswellinginchildren
Singlejointinvolvement
Septicarthritisorosteomyelitis
Juvenileidiopathicarthritis
Lymediseaseinendemicareas
Reactivearthritis
Hemarthrosisduetotraumaorbleedingdiathesis
Malignancysuchasacutelymphoblastic
Multiplejointinvolvement
Acuterheumaticconditions
Systemiclupuserythematous
Juveniledermatomyositis
Sarcoidosis
Sjgren'ssyndrome
Mixedconnectivetissuedisease
HenochSchnleinpurpura
Juvenileidiopathicarthritis
Reactivearthritis
Lymedisease
Malignancy
Immunodeficiencyassociatedarthritis
Inflammatorybowelassociatedarthritis
Other
Chronicrecurrentmultifocalosteomyelitis
Chronicinfantileneurologicalcutaneousandarthritissyndrome(CINCA),alsoknownasneonatalonsetmultisysteminflammatory
disease(NOMID)
Prominentsystemicfeaturesandjointpain
Acuterheumaticconditions
Systemiclupuserythematous
Mixedconnectivetissuedisease
Kawasakidisease
HenochSchnleinpurpura
Systemicjuvenileidiopathicarthritis
Macrophageactivationsyndrome
Systemicvasculitis
Malignancysuchasneuroblastoma
Reactivearthritissuchasacuterheumaticfever
Bacterialinfection(tuberculosis,gonococcalinfection,Lymedisease,andBrucellainfection)
Viralinfection(EpsteinBarrandHepatitisBvirus)
Parasiticinfection(Malaria)
Inflammatorybowelassociatedarthritis
Autoinflammatorydisorders
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Periodicfeversyndromes
Chronicinfantileneurologicalcutaneousandarthritissyndrome(CINCA),alsoknownasneonatalonsetmultisysteminflammatory
disease(NOMID)
Cryopyrinassociatedperiodicsyndromes(CAPS)
Painwithoutjointswelling
Hipdisease
LeggCalvePerthesdisease
Slippedupperfemoralepiphysis(slippedcapitalfemoralepiphysis)
Benignhypermobilitysyndrome
Inheritedmetabolicdisorders
Gaucherdisease
Sheiedisease
Osteochondroses
OsgoodSchlatterdisease
Scheuermanndisease
Idiopathicpainsyndromes
Growingpains
Complexregionalpainsyndrome
Fibromyalgia
Thistableincludesthemostcommondisorderstoconsiderinthechildwithjointpainorswelling.
CourtesyofYukikoKimura,MDandTauntonRSouthwood,MD,FRACP,FRCPA,FRCP,FRCPCH.
Graphic57734Version9.0
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Seriousdiagnosesandassociatedfindingsinchildrenwithjointpainand/or
swelling
Emergency
diagnoses
Typicalclinicalfeatures
Investigations
Septicarthritisor
osteomyelitis
Hectic,spikingfeverillappearancerash
rapidonsetmonoarthritispseudoparalysis
pinpointbonytenderness
Bloodcultures,arthrocentesisformicroscopy
andculture,bloodcount,imagingofaffected
bone/joint(plainradiograph,CTscan)
Kawasakidisease
Hecticfever,irritableinfant,sentinelcervical
lymphnode,conjunctivitis,oralmucositis,
peripheralarthralgia/edema,rash,carditis,
peelingfingertips
Echocardiography,excludesepsis,blood
countandacutephaseproteins
Neoplasia
Irritability,pallor,unexplainedbruising,bone
pain(especiallynocturnal)
Bloodcount,bonemarrowexamination,
abdominalultrasound,imagingofaffected
area
Nonaccidentalinjury
Disparitiesbetweenhistorygivenandfeatures
onexamination,irritability,pallor,unexplained
bruisingandotherinjuries,bonepain
Bloodcount,bleedingandclottingstudies,
skeletalsurvey,refertochildprotection
proceduresforyourhospital
CT:computedtomography.
CourtesyofTauntonRSouthwood,MD,FRACP,FRCPA,FRCP,FRCPCHandYukikoKimura,MD.
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Keyelementsofthehistorywhenevaluatingachildwithjointpainorswelling
Category
Numberofjointsinvolvedandtheirlocation
Details
Singlejoint
Multiplejoints
Characteristics
Severityandqualityofpain
Frequencyofpain
Durationoftheepisode
Presenceofswelling,erythema,otherdiscoloration
Diurnalvariation
Interferencewithnormalactivities
Inabilitytobearweight
Progressionovertime
Precipitatingfactors
Trauma
Antecedentillness
Periodsofinactivity
Increasedphysicalactivity
Presenceandpatternofassociatedsymptoms
Fever
Rash
Weightloss
Abdominalpain
Diarrhea
Eyesymptoms
Other
Patternofsymptoms
Acuteversuschronic
Morningstiffness
Migratorypain
Recurrentepisodesofjointpainandswelling
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Reviewofsystemsinthedifferentialdiagnosisofchildhoodjointpainandswelling
Affected
system
Dermatologic
Ophthalmologic
Oral
Respiratory
Diagnosis
SLE
Malarrashandhairloss
Dermatomyositis
Gottron'spapules
SystemicJIA
Evanescentpinkmacularrash
HSP
Lowerextremitypurpuriclesions
OligoarthritisorpsoriaticJIA
Asymptomaticchronicanterioruveitis
Enthesitisrelatedarthritis
Acutesymptomaticuveitis(pain,
redness)
Kawasakidisease
Conjunctivalinjectionwithout
discharge
Sjgren'ssyndrome
Dryeyeswithkeratitis
SLE
Painlessoralulcersonpalate
Behetdisease
Largeextremelypainfuloralulcers
CForimmunodeficiency
Recurrentpneumonia
Granulomatosiswithpolyangiitis(Wegener's)
Destructiveuppertractlesions
SLEorsystemicJIA
Pleuritis
SLEorscleroderma
Interstitiallungdisease
Eosinophilicgranulomatosiswithpolyangiitis(Churg
Strauss)
Eosinophilicpneumonia
SciHub
Cardiovascular
Manifestation
ARForendocarditis
Newheartmurmur
https://www.uptodate.com/contents/evaluationofthechildwithjointpainandorswelling?source=see_
SLE,systemicJIA,orARF
Pericarditis
URL,DOI,
SLEorscleroderma
Raynaudphenomenon
Gastrointestinal
Genitourinary
Hematologic
Neurologic
Takayasuarteritis
Absentpulses
IBD,SLE,orvasculitis
Weightlossorpoorgrowth
IBD
Diarrheaandabdominalpain
Reactivearthritis
Precedinginfectiousgastroenteritis
HSP
Intermittentcolickyabdominalpain
Gonococcalarthritis
Pustularurethritisorcervicitis
Reactivearthritis
Nongonococcalurethritis
BehcetdiseaseorIBD
Largepainfulgenitalulcerations
SLEorhemoglobinopathy(eg,SCD)
Hemolyticanemia
SLE
Pancytopenia
Bleedingdisorders
Hemarthrosis
SLE
Seizuresandpsychosis
SLEorfibromyalgia
Difficultyconcentrating
SLE,vasculitis,orhypercoagulability
Stroke
Vasculitis
Asymmetricpolyneuropathy
Dermatomyositisandpolymyositis
Proximalmuscleweakness
SLE:systemiclupuserythematousJIA:juvenileidiopathicarthritisHSP:HenochSchnleinpurpura(IgAvasculitis)CF:
cysticfibrosisARF:acuterheumaticfeverIBD:inflammatoryboweldiseaseSCD:sicklecelldisease.
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SciHub
URL,DOI,
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ThepGALSmusculoskeletalscreen
SciHub
URL,DOI,
pGALS:pediatricGaitArmsLegsSpine.
Reproducedwithpermissionfrom:FosterHE,JandialS.pGALSAScreeningExaminationofthe
MusculoskeletalSysteminSchoolAgedChildren.ReportsontheRheumaticDiseases(Series5),HandsOn
15.ArthritisResearchCampaign2008June.Copyright2008ArthritisResearchCampaign.
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ThepGALSmusculoskeletalscreen(continued)
SciHub
URL,DOI,
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SciHub
URL,DOI,
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SciHub
URL,DOI,
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Jointexaminationofachild
Lowerlimbs:Patientlyingdown
1.Inspection.
a.Symmetry.
b.Size(limblength,musclewasting,jointenlargement).
c.Skin(scars,color,warmth,vascularpattern).
d.Posturaldeformity(flexion,valgus).
2.Palpation.
a.Solesoffeet,insertionsoftendonintobone(enthesitis).
b.Jointmargins(metatarsalsqueeze,anteriorankle,medialknee).
c.Palpatejointenlargement(isitbony,softtissue,orfluid?).
3.Activemovement:Curltoes,dorsiflexankles,bendkneesandhips,watchforsubtlecompensatorymovements.
4.Passivemovement:Jointrangeofmovement(notebothincreasedrange[hypermobility]andreducedrange
[restriction]).Forefootandhindfootinversion/eversion,relaxedpassiveextensionofknees,internalrotationofhips
(kneesandhipsflexedto90%).Watchforsubtleguardingandcompensatorymovements.
Upperlimbs:Patientsittingup
1.Inspectionsimilartoevaluationforlowerlimbs:Symmetry,size,scars,wasting,enlargement,nails.
2.Palpation:Jointmargins(metacarpalsqueeze,dorsalwrist,anteriorglenohumeral),palpatebonyenlargements,
warmth.
3.Activemovement:Fingerextension,fist,tuck,wristextension(prayerposition),armsstraightupthenbehindhead
thenbehindlowerback,neckextensionandrotation(chintoshoulder),bewarecompensatorymovements(especially
elbowliftonwristflexion,lateralflexionofspineonshoulderabduction).
4.Passivemovement:Jointrangeofmovement,wristflexionandextension(watchforsubtleguardingand
compensatorymovements).
SciHub
Axialskeleton:Patientstandingup
URL,DOI,
1.Inspectsymmetryfrombehind:Especiallyposteriorankles,pelvicposition,spine.
2.Spinalmovements:Scoliosis,lumbarmobility(lumbarcurveonforwardflexion,lumbarpainonhyperextension),
cervicalspineextensionandlateralrotation.
3.Gait:Normal,tiptoes,heels.
4.Musclepower:Gowerstest,Trendelenberggait.
5.Temporomandibularjoint.
6.Sacroiliacjoints:Directpalpation.
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Clinicalfeaturesassociatedwithbacterialpathogensthatcausearthritisin
children
Clinicalfeatures
Grampositivebacteria
Staphylococcusaureus
AllagesmaycausepolyarticularinfectionMRSAmaybeassociatedwithvenous
thromboembolismandpulmonarydiseasepossibleassociatedskinorsofttissue
infection
Coagulasenegative
staphylococci
Mostcommoncauseofbacterialarthritisassociatedwithprostheticjoints
GroupAStreptococcus
(S.pyogenes)
Mayoccurasacomplicationofconcurrentvaricellazostervirusinfection
Streptococcus
pneumoniae
(pneumococcus)
Childrenyoungerthantwoyearsofagechildrenolderthantwoyearsofagewith
underlyingmedicalcondition(eg,sicklecelldisease,immunodeficiency,etc)
GroupBStreptococcus
(Streptococcus
agalactiae)
Infantsyoungerthanthreemonthsofage
Nocardiaasteroides
Chronicmonoarticulararthritiswithagranulomatousreaction
Gramnegativebacteria
Kingellakingae
Childrenyoungerthan36months,indolentonset
Haemophilusinfluenzae
typeb(Hib)
IncompletelyimmunizedchildreninareaswithlowHibimmunizationrates
Neisseriagonorrhoeae
Newbornsusuallyaffectsjointsbelowthehipmaycausepolyarticularinfection
SciHub
Sexuallyactiveadolescentsusuallyoccursaspartofdisseminatedinfectionwithfever
andrashingirlsmayprecedeonsetofmenses
Neisseriameningitidis
Maycausepolyarticularinfectionassociatedrash
URL,DOI,
Salmonellaspecies
Childrenwithsicklecelldiseaseorrelatedhemoglobinopathies
NonSalmonellagram
negativebacilli
Newbornsinstrumentationofthegastrointestinalorurinarytractimmunocompromised
host
Pseudomonas
aeruginosa
Puncturewoundsinjectabledruguse
Streptococcus
moniliformis(ratbite
fever)
Ratbitemacularrashattimeofpresentation
Borreliaburgdorferi
(Lymedisease)
Tickbitehistoryoferythemamigransrashtraveltoorlivinginanendemicarea
intermittentinflammatoryarthritis
Brucella
Traveltoorlivinginanendemicareaingestionofunpasteurizeddairyproductschronic
monoarticulararthritiswithagranulomatousreaction
Mycobacteria
(tuberculosisand
atypicalspecies)
Chronicmonoarticulararthritiswithagranulomatousreaction
MRSA:methicillinresistantS.aureus.
Datafrom:KrogstadP.Septicarthitis.In:TextbookofPediatricInfectiousDiseases,6thed,FeiginRD,CherryJD,Demmler
HarrisonGJ,KaplanSL(Eds),Saunders,Philadelphia2009.p.742.
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30/9/2016
ContributorDisclosures
YukikoKimura,MD Consultant/AdvisoryBoards:Novartis[SystemicJIA(Canakinumab)]SOBI[SystemicJIA
(Anakinra)]. TauntonRSouthwood,MD,FRACP,FRCPA,FRCP,FRCPCH Grant/Research/ClinicalTrial
Support:Pfizer[Diseaseanddruginformationforpatientswithjuvenilearthritisandtheirfamilies(Etanercept).
Consultant/AdvisoryBoards:SOBI[NOMID//CINCA(Anakinra)]. RobertSundel,MD Nothingto
disclose ElizabethTePas,MD,MS Nothingtodisclose
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconformto
UpToDatestandardsofevidence.
Conflictofinterestpolicy
Close
SciHub
URL,DOI,
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