musculoskeletal problems in children
DESCRIPTION
Musculoskeletal problems in children. Kathy Bailey Consultant Paediatric Rheumatologist Coventry and Warwickshire. Why is it important?. Common History and examination essential Missed diagnosis permanent disability Simple problems require confident diagnosis - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/1.jpg)
Kathy BaileyConsultant Paediatric Rheumatologist
Coventry and Warwickshire
![Page 2: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/2.jpg)
Common
History and examination essential
Missed diagnosis permanent disability
Simple problems require confident
diagnosis
Will become part of curriculum!
![Page 3: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/3.jpg)
![Page 4: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/4.jpg)
Limp stiffness swelling pain restriction of movement
change in activities
not using limb colour change in limb
fever rash unwell
![Page 5: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/5.jpg)
HISTORY!!!◦ Inflammatory◦ mechanical◦ non-organic/psychosomatic
![Page 6: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/6.jpg)
HISTORY!!!◦ Inflammatory◦ mechanical◦ non-organic/psychosomatic
◦ Acute or chronic
![Page 7: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/7.jpg)
HISTORY!!!◦ Inflammatory◦ mechanical◦ non-organic/psychosomatic
◦ Acute or chronic
EXAMINATION◦ objective signs
![Page 8: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/8.jpg)
HISTORY!!!◦ Inflammatory◦ mechanical◦ non-organic/psychosomatic
◦ Acute or chronic
EXAMINATION◦ objective signs
TESTS◦ ???
![Page 9: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/9.jpg)
Age of child Duration Symptoms Impact on activities Joints affected Family History Antecedents
◦ infection/trauma/◦ illness
![Page 10: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/10.jpg)
Age of child Duration Symptoms Impact on activities Joints affected Family History Antecedents
◦ infection/trauma/◦ illness
Associated features:◦ Constitutional◦ Fever◦ Rash◦ Muscle weakness◦ Eyes◦ Weight loss◦ GI◦ bruising◦ LN/mucusitis ....etc
![Page 11: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/11.jpg)
Height and weight Temp/pulse/BP General observations Rash Systems examination
Urinalysis
![Page 12: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/12.jpg)
www.arc.org.uk/arthinfo/emedia.asp
![Page 13: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/13.jpg)
LOOKgait
swelling
deformity
rash/colour changes
![Page 14: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/14.jpg)
FEELheat
swelling
tenderness
![Page 15: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/15.jpg)
MOVErestriction
+/- pain
muscle strength
![Page 16: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/16.jpg)
Inflammatory Mechanical Psychosomatic
Pain +/- + +++
Stiffness ++ +/- +
Swelling +++ +/- +/-
Sleep disturbance
+/- - ++
Instability +/- ++ +/-
Physical signs
++ + +/-
(or ++++)
![Page 17: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/17.jpg)
InflammatoryInflammatory MechanicalMechanical IdiopathicIdiopathic
InfectionInfection
ReactiveReactive
Post StrepPost Strep
JIAJIA
Connective Connective tissue diseasestissue diseases
- SLE- SLE
- JDMS- JDMS
- Scleroderma- Scleroderma
- Vasculitis- Vasculitis
HypermobilityHypermobility
OsteochondrosesOsteochondroses
- osgood-schlatter- osgood-schlatter
- Scheuermann’s- Scheuermann’s
- Perthes- Perthes
Chondromalacia Chondromalacia patellapatella
Osteochondritis Osteochondritis dissecansdissecans
Slipped upper Slipped upper femoral epiphysisfemoral epiphysis
Pain Pain amplification amplification syndromessyndromes
- Localised- Localised
- Generalised- Generalised
Growing painsGrowing pains
![Page 18: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/18.jpg)
Acute
![Page 19: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/19.jpg)
Fever Localised tenderness
hot Painful to move Raised inflammatory markers
![Page 20: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/20.jpg)
Fever Localised tenderness
hot Painful to move Raised inflammatory markers
JOINT ASPIRATION
![Page 21: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/21.jpg)
Site %
Knee 39 Hip 25 Ankle 14 Elbow 12
Organisms
Staph Aureus
Tuberculosis
Salmonella in sickle cell disease
![Page 22: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/22.jpg)
![Page 23: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/23.jpg)
![Page 24: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/24.jpg)
•May be history of recent infection
•Single or multiple joints
•No systemic features
•Resolves by 6 weeks
•Important to consider alternative diagnoses
![Page 25: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/25.jpg)
Reactive Vasculitis (small vessel)
Palpable Purpura Arthralgia/
Arthritis Abdominal pain Nephritis Headaches
![Page 26: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/26.jpg)
1% of patients referred to paediatric rheumatology have underlying malignancy
![Page 27: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/27.jpg)
Acute Lymphoblastic Leukaemia◦ Bone pain and arthralgia in 20-40%◦ Suspect from history, exam, or blood count◦ Bone Marrow aspirate
![Page 28: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/28.jpg)
Acute Lymphoblastic Leukaemia
Neuroblastoma◦ Commonest solid tumour under infants◦ Bone pain from secondary spread◦ Urinary excretion of catecholamine metabolites
(VMA)
![Page 29: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/29.jpg)
Acute Lymphoblastic Leukaemia
Neuroblastoma
Primary Bone tumour◦ Osteoid osteoma – benign◦ osteosarcoma
![Page 30: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/30.jpg)
Features to raise concern:◦ Bone pain (night time)◦ Weight loss◦ Night sweats or fevers
◦ Abnormal bloods
◦ Xray changes
![Page 31: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/31.jpg)
![Page 32: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/32.jpg)
5 of following1. Fever >5 days; unresponsive to Abx2. Non purulent conjunctivitis3. lymphadenopathy >1.5cm4. Rash - polymorphous5. mucosal changes6. extremities
early - swelling/palmar erythema late – peeling
OR 4 plus coronary artery aneurysms
![Page 33: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/33.jpg)
![Page 34: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/34.jpg)
![Page 35: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/35.jpg)
![Page 36: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/36.jpg)
Prevent late sequel of coronary artery aneurysms
◦ Intravenous IVIG
◦ Aspirin – initially high, anti inflammatory then low dose, anti platelet
![Page 37: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/37.jpg)
Chronic
![Page 38: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/38.jpg)
JIA Juvenile Idiopathic Arthritis
JRA Juvenile Rheumatoid Arthritis
JCA Juvenile Chronic Arthritis
![Page 39: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/39.jpg)
JIA Juvenile Idiopathic Arthritis
JRA Juvenile Rheumatoid Arthritis
JCA Juvenile Chronic Arthritis
![Page 40: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/40.jpg)
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
![Page 41: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/41.jpg)
Disease of childhood onset ◦ under 16 years
Persistence of arthritis ◦ 1 or more joints ◦ 6 or more weeks◦ Exclusion of other diagnoses
![Page 42: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/42.jpg)
Defined by clinical features in first 6 months
![Page 43: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/43.jpg)
Defined by clinical features in first 6 months◦ Oligoarthritis 1-4 joints
Persistent Extended
![Page 44: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/44.jpg)
Girls >boys Younger age Best prognosis
![Page 45: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/45.jpg)
Girls >boys Younger age Best prognosis
Associated with uveitis
![Page 46: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/46.jpg)
Defined by clinical features in first 6 months◦ Oligoarthritis 1-4 joints◦ Polyarthritis 5 or more joints
RF positive RF negative
![Page 47: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/47.jpg)
Defined by clinical features in first 6 months◦ Oligoarthritis 1-4 joints◦ Polyarthritis 5 or more joints◦ Psoriatic Arthritis
Arthritis AND psoriasisOR Arthritis plus 2 of:
Nail pitting Dactylitis First degree relative with confirmed psoriasis
![Page 48: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/48.jpg)
Defined by clinical features in first 6 months◦ Oligoarthritis 1-4 joints◦ Polyarthritis 5 or more joints◦ Psoriatic Arthritis◦ Enthesitis Related Arthritis
Arthritis AND enthesitisOR Sacroiliac pain and HLA B27
![Page 49: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/49.jpg)
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
![Page 50: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/50.jpg)
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
![Page 51: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/51.jpg)
![Page 52: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/52.jpg)
![Page 53: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/53.jpg)
Poor indicators Polyarticular onset and course Rheumatoid factor positive girls Systemic disease with persistent features Delay in starting effective treatment
Good indicators Oligoarticular disease
![Page 54: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/54.jpg)
Goals◦ Disease remission◦ Symptomatic improvement
Stiffness Pain Joint range of movement
◦ Prevent joint damage◦ Normal growth and development◦ Education and normal adolesence◦ Prevent eye damage from Uveitis
![Page 55: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/55.jpg)
Multidisciplinary team
◦ Paediatric rheumatologist
◦ Nurse specialist
◦ Occupational Therapist
◦ Physiotherapist
◦ Social worker
◦ Ophthalmologist
◦ Podiatrist
![Page 56: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/56.jpg)
Anti inflammatory drugs◦ NSAIDs◦ Glucocorticoids
“Disease modifying drugs”◦ Methotrexate
◦ Etanercept◦ New biologic agents for recalcitrant disease
![Page 57: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/57.jpg)
![Page 58: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/58.jpg)
Avascular necrosis of the femoral head usually 2-10 (peak 4-6) yrs. 3-5 boys:girls Bilateral 30 %
![Page 59: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/59.jpg)
Imaging:
Asymmetry in femoral heads
Consider MRI or Nuclear medicine if clinical suspicion is high
![Page 60: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/60.jpg)
![Page 61: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/61.jpg)
10-13 years old Overweight boys 25% bilateral within 18/12
Slip of femoral head through growth plate (posteriorly and inferiorly)
![Page 62: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/62.jpg)
Imaging:
AP and (frog) lateral films needed CT/ MRI in cases of difficulty
![Page 63: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/63.jpg)
Klein line should intersect femoral head
![Page 64: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/64.jpg)
![Page 65: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/65.jpg)
![Page 66: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/66.jpg)
![Page 67: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/67.jpg)
Inappropriate history
Physical signs don’t match story
Other concerning features
Concerns raised by others
![Page 68: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/68.jpg)
Chondromalacia patella Adolescent girls Painful knees - kneeling
- going up stairs
![Page 69: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/69.jpg)
Osgood-Schlatter disease Adolescent boys Pain and swelling at tibial tuberosity Increased by exercise
![Page 70: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/70.jpg)
Osgood-Schlatter disease Adolescent boys Pain and swelling at tibial tuberosity Increased by exercise
Tenderness +/- swelling of tibial tuberosity Pain on resisted extension of knee
![Page 71: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/71.jpg)
Clinical diagnosis
DO NOT XRAY
![Page 72: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/72.jpg)
Very common
May be generalised or localised
Frequently responsible for musculoskeletal pain
![Page 73: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/73.jpg)
Common cause of lower limb pain
If symptomatic – correct with good footware and insoles
![Page 74: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/74.jpg)
![Page 75: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/75.jpg)
25-40% of children! 3-5 years and 8-12 years Typical history
![Page 76: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/76.jpg)
Wake during night with pain Eased with massage May be worse after active day No daytime symptoms
No abnormal physical signs
![Page 77: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/77.jpg)
No identifiable inflammatory or mechanical condition
Chronic pain Impact on daily activities
Average age 9 – 12 years Girls > boys Disease of the developed world
![Page 78: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/78.jpg)
Localised idiopathic pain eg RSD
CFS/ME
Fibromyalgia
Diffuse idiopathic pain
![Page 79: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/79.jpg)
![Page 80: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/80.jpg)
History History History Examination Examination Examination
Investigations: targeted
![Page 81: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/81.jpg)
Blood Count◦ ? Appropriate to clinical features
Inflammatory markers◦ Usually mirror clinical features◦ Not always raised in inflammatory conditions
Blood and synovial fluid cultures ANA/Rh Factor
◦ Not helpful in making a diagnosis Imaging
◦ Need to use best modality and ask the right question
![Page 82: Musculoskeletal problems in children](https://reader036.vdocuments.net/reader036/viewer/2022062321/568135fe550346895d9d711d/html5/thumbnails/82.jpg)
Musculoskeletal complaints are common in childhood
Serious pathology leads to long term disability if not appropriately managed
Diagnosis is dependant on good history and examination