Rheumatology Flashcards
What are red flag symptoms of joint pain in a child?
- Fever
- Malaise/lethargy
- Morning joint stiffness or pain
- Night pain refractory to simple analgesia and symptomatic during the daytime
What are red flig sign’s of joint pain in children?
- Joint swelling
- Bony tenderness to palpation
- Muscle weakness
- Fall in height or weight growth curve
What are benign symptoms of joint pain?
- Worse with activity and better with rest
- Worse at the end of the day
- If night pain relieved with simple analgesia
What are signs indicate joint pain is benign?
- No joint swelling
- No bony tenderness
- Normal strength
- Normal height and weight growth
If a child presented with joint pain, what would your differential diagnosis be?
- JIA
- Septic arthritis/osteomyelitis
- Growing pains
- Joint trauma
- Irritable hip
- HSP
- Haemarthrosis
- Rheumatic fever
- Serum sickness
- Reactive arthritis
- Hip problems - DDH, perthes, SUFE
If a child had joint pain, what bloods could you do to help narrow the diagnosis?
- FBC - wbc and neutrophil count
- CRP/ESR
- Blood film
- Blood cultures
In children aged 1-3, what can cause an acute painful limp?
- Infection - septic arthritis, osteomyelitis or hip
- Transient synovitis
- Trauma
- Malignancy - leukaemia, neuroblastoma
In children aged 1-3, what can cause a more chronic or intermittent limp?
- DDH
- Talipes
- Neuromuscular problems - CP
- JIA
In children aged 3-10 years, what problems can cause an chronic or intermittent limps?
- Perthes
- Neuromuscular disorders - DMD
- JIA
In children aged 3-10 years, what problems can cause an acute painful limp?
- Transient synovitis
- Septic arthritis/osteomyelitis
- Trauma/Overuse
- Perthes disease
- JIA
- Malignancy - leukaemia
- CRPS
In children aged 11-16, what can cause a chronic or intermittent limp?
- SUFE
- JIA
- Tarsal Coalition
In children aged 11-16, what can cause acute painful limps?
- Trauma/overuse
- SUFE
- Avascular necrosis of femoral head
- Reactive arthritis
- JIA
- Septic arthritis/osteomyelitis
- Osteochondritis dessicans
- Malignancy
- CRPS
What are growing pains?
Episodes of generalised pain in the lower limbs which are common in preschool and school-aged children.
Pain often wakens child from sleep and massaging/comforting helps
What features need to be present for the diagnosis of growing pains to be met?
Rules of Growing Pains:
- Age range 3-12 years
- Pain symmetrical in both limbs and not limited to joints
- Pains never present at start of the day
- Physical activities not limited/no limp
- Normal pGALS
What part of the bone does osteomyelitis affect?
Metaphysis
What are the most common sites to be affected by osteomyelitis?
- Distal femur
- Proximal tibia
What are the modes of spread of osteomyelitis?
- Haematogenous
- Direct spread from infected wound
What are the most common organisms which cause osteomyelitis?
- Staph. Aureus
- Streptococcus
- H. influenzae
How does osteomyelitis present in children?
- Painful, immobile limb - may be first thing in infant
- Fever
- Swelling over site + tenderness
What is juvenile idiopathic arthritis?
Defined as persistent joint swelling >6 weeks duration presenting before 16 years of age in the absence of infection or any other defined cause
What are the different types of JIA?
- Oligoarticular - Pauciarticular JIA
- Oligoarticular - Extended JIA
- Polyarthritis - Rh positive/negative
- Systemic onset arthritis
- Psoriatic Arthritis
- Enthesitis related arthritis
- Undifferentiated
What is the articular pattern of oligoarticular persistent JIA?
1-4 joints
Knee, ankle and wrist most common
What is the articular pattern of oligoarticular entended JIA?
>/= 5 joints after first 6 months
Asymmetrical distribution of large and small joints
What is the articular pattern of RF negative Polyarthritic JIA?
- Symmetrical large and small joint arthritis
- Marked finger involvement
- Cervical joints and TMJ may be involved
What is the articular pattern of RF postivie Polyarthritic JIA?
- Symmetrical large and small joint arthritis
- Marked finger involvement
What is the articular pattern of systemic onset JIA?
INITIALLY NO ARTHRITIS
Oligo/polyarthritis
Aches and pains in joints and muscles
What are the features of psoriatic arthritis?
- Asymmetrical distribution large and small joints
- Dacytlitis
- Psoriasis
- Nail pitting
- Onycolysis
- Chronic anterior uveitis
What are the features of enthesitis related JIA?
- Lower limb - large joints initially
- Mild lumbar/SI involvement
- Enthesitis
What are the extra articular features of RF negative polyarticular JIA?
- Low-grade fever
- Chronic anterior uveitis
What are the extra articular features of RF positive Polyarthritic JIA?
Rheumatoid nodules (10 %)
Similar to adult rheumatoid arthritis
Which has a poorer prognosis; RF positive or RF negative polyarticular JIA?
RF positive JIA
What are the extra-articular features of systemic onset JIA?
- Acute illness
- Malaise
- High daily fever
- Salmon pink macular rash
- Lymphadenopathy
- Hepatosplenomegaly
- Serositis
What are extra-articular features of persistent and extended oligoarticular JIA?
Chronic anterior uveitis (20%)
What are complications of JIA?
- Chornic anterior uveitis -> blindness
- Flexion contractures of the joints
- Growth failure
- Osteoporosis
- Anaemia of chronic disease
- Delayed puberty
- Amyloidosis (very rare)
What is chronic anterior uveitis?
Inflammation of the uvea, the pigmented layer that lies between the inner retina and the outer fibrous layer composed of the sclera and cornea
Signs include:
- Burning/Redness
- Blurred vision
- Photophobia or sensitivity to light
- Irregular pupil
- Dilated ciliary vessels
Why do flexion contractures occur in the joints of those with JIA?
Joint is held in the most comfortable position , thereby minimising pressure within the joint
What limits the spread of metaphyseal infection in children which isn’t present in infants?
Growth plates
If you suspected JIA, how would you confirm your diagnosis?
Exclude differential diagnosis
-
Clinical Examination - Most important - examination of ALL joints
- Movement restriction is often most important sign
-
Consider:
- ANA
- HLA-B27
- Inflammatory markers (CRP, ESR, WBC, platelets)
- RF
- X-ray, MRI
Which sex is JIA more common in?
Female - 3:1
How would you manage a child with JIA?
- Regular opthalmalogical review
-
Drug treatment
- Short Term - NSAID, Intraarticular injections, Systemic steroids in polyarticular JIA
- Long Term - DMARD (Methotrexate, Biologics)
- Physiotherapy
- OT
- Psychotherapy
What is transient synovitis?
Irritable hip
Most common cause of acute hip pain in children
Often follows/accompanied by viral infection
How does transient synovitis present?
- Sudden onset hip pain with limp
- No pain at rest
- Decreased movement - particularly internal rotation
- Referred pain - knee
If a child presents with symptoms of transient synovitis, what must yoiu rule out before making the diagnosis?
Septic arthritis - joint aspiration and BCs
What is reactive arthritis?
Transient joint swelling (usually < 6 weeks) often of ankles or knees, which usually follows extra-articular infection
What are the common causes of reactive arthritis in children?
Enteric organisms - salmonella, campylobacter, shigella, yersinia
