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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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