1. The Child With Joint Pain Diagnostic Clues
Abraham Gedalia, M.D.
Professor of Pediatrics
Head, Division of Rheumatology
Departments of Pediatrics, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans
New Orleans, LA
Objectives: At the conclusion of this activity, the participants should be able to: 1. Discuss the approach to the child with joint pain or arthritis
2. Recognize the diagnostic clues of the different arthropathies
3. Develop strategy for the diagnosis

2. The Child With Joint Pain
IMPORTANT FACTS
Musculoskeletal pain during childhood is common
According to population surveys, 16% of school-aged
children reported to have limb pain٭
Joint Pain has multiple etiologies
Early diagnosis and treatment is critical to prevent
complications
٭ Cassidy Textbook of Pediatric Rheumatology 2005;37:704

3. The Child With Joint Pain
IMPORTANT QUESTIONS
How many joints are involved, is it one joint or many ?
Any associated fever ?
Any joint swelling ?
What is the duration of symptoms ?
Any associated morning stiffness, rash, mouth ulcers ?
Any associated muscle weakness ?
Any associated chest pain, abdominal pain, diarrhea ?
Any weight loss, skin bruises, and/or night pain ?
Any associated migraines and or sleep disturbances ?
Any associated eye problem ?
Any associated Trauma ? 3

4. The Child With Joint Pain
IMPORTANT QUESTIONS
How many joints are involved, is it one joint or many ?
Any associated fever ?
Any joint swelling ?
What is the duration of symptoms ?
Any associated morning stiffness, rash, mouth ulcers ?
Any associated muscle weakness ?
Any associated chest pain, abdominal pain, diarrhea ?
Any weight loss, skin bruises, and/or night pain ?
Any associated migraines and or sleep disturbances ?
Any associated eye problem ?
Any associated Trauma ?

5. Multiple Joint Involvement Single Joint Involvement
The Child With Pain
Multiple Joint Involvement
Single Joint Involvement
With Fever
Septic arthritis/Osteomyelitis
Sympathetic arthritis
Foreign body with infection
Traumatic arthritis
Soft Tissue infection
Rheumatic Diseases
Reactive arthritis
Toxic synovitis
Diskitis
Sarcoidosis
Hemoglobinopathy
Malignancies
Without Fever
Trauma
Mechanical derangement
Rheumatic Diseases
Toxic synovitis
Avascular necrosis
Subacuteosteomyelitis
Diskitis
Hemoglobinopathy
Reflex sympathetic
dystrophy
Malignancies
Psychogenic pain
With Fever
Bacterial infections
Sepsis
Viral infections
Lyme disease
Reactive arthritis
Rheumatic diseases
Post immunization
Immune deficiencies
Serum sickness
Inflammatory bowel
disease
Sarcoidosis
Familial Mediterranean fever
Malignancies
Without Fever
Rheumatic diseases
Joint hypermobility
Growing pains
Post immunization
Immune deficiencies
Guilain-Barre
Lyme Disease
Fibromyalgia syndrome
Chronic fatigue syndrome
Psychogenic pain
Malignancies

9. JRA: Definition a. Chronic pediatric arthropathies
b. Onset before 16 years of age
c. Presence of objective arthritis (in one
or more joints) for at least 6 weeks
Arthritis: Defined by swelling or effusion of joints, increased
warmth and/or painful limited movement with or
without tenderness

19. The Head of
the femur is
Slipping

26. Reflex sympathetic dystrophy
(RSD)
Bone scan
with technetium 99m
perfusion study

35. The Child With Joint Pain IMPORTANT DIAGNOSTIC CLUES
11 y/o Female with 4 week H/O joint pain & swelling
(elbows & R wrist). ESR: 93 mm/h; CRP: 5.8 mg/dl
Uric acid: 7.4 mg/dl; LDH: 1522 U/L
A bone scan with
abnormal increase
of tracer activity in
both fibulas and
left tibia
Bone marrow biopsy
shows near total
replacement of the
marrow with
leukemic cells 35

38. Diagnosis of benign joint hypermobility is confirmed if three of the five signs are present

39. 39 39

42. Suspected Rheumatic Conditions: DIAGNOSTIC TESTS
Body fluids
CBC, ESR, CRP, CMP
Rheumatoid factor
ANA / ANA Profile
Quantitative Immunoglobulins
HLA Typing
Muscle enzymes
ACE
Von Wllibrand factor antigen
ANCA
Genetic Mutations
Urine (UA, Prot / Creat)
Synovial Fluids
Ophthalmology (Slit lamp)
Other tests
CXR, CT, MRI, MRA, Bone
scan, Angiogram
EKG, ECHO
Tissue Biopsy
Bone marrow aspiration 42