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P84 Pediatrics
Rheumatology Toronto Notes 2019
Management
• goalsoftherapy:eliminateinflammation,preventjointdamage,promotenormalgrowthand development as well as normal function, minimize medication toxicity
• exercisetomaintainROMandmusclestrength
• multidisciplinaryapproach:OT/PT,socialwork,orthopedics,ophthalmology,rheumatology
• 1stlinedrugtherapy:NSAIDs,intra-articularcorticosteroids
• 2ndlinedrugtherapy:DMARDs(methotrexate,sulfasalazine,leflunamide),corticosteroids(acute
management of severe arthritis, systemic symptoms of JIA, topical eye drops for uveitis), biologic agents (IL1, IL6 inhibition for systemic arthritis, TNF antagonist for polyarticular JIA)
Limb Pain
Evaulation of Limb Pain
Table 41. Differential Diagnosis of Limb Pain
Cause
Trauma Infectious
Septic arthritis
Osteomyelitis
Inflammatory
Transient synovitis JIA Spondyloarthritis SLE Dermatomyositis HSP
Anatomic/Orthopedic
Legg-Calvé-Perthes disease Slipped capital femoral epiphysis Osgood-Schlatter disease
Neoplastic
Leukemia Neuroblastoma Bone tumour
Hematologic
Hemophilia (hemarthrosis) Sickle cell anemia
Pain Syndromes
Growing pains
Fibromyalgia
Complex regional pain syndrome
<3 yr
x
x x
x x
x x
x x
3-10 yr
x
x x
>10 yr
x
x x
x
x
x xx xx xx
x x x x
x x x x x x
x x x x
x x x x x
x x
Red Flags for Limb Pain
• Fever
• Pinpoint pain/tenderness
• Pain out of proportion to degree of
inflammation
• Night pain
• Weight loss
• Erythema
• mustruleoutinfection,malignancy,andacuteorthopedicconditions
Clinical Presentation
• demographics(age,gender)
• patternofonsetandprogressionofsymptoms(includingacuityandchronicity)
• morningstiffness,limp/weight-bearingstatus,nightpain
• jointinvolvement(type,distribution)±spine(axial)involvement
• extra-articularmanifestationsandsystemicsymptoms
• functionalstatus–activitiesofdailyliving
• familyhistory(arthritis,IBD,psoriasis,spondyloarthropathies,uveitis,bleedingdisorders,sicklecell
anemia)
• pastmedicalillness,intercurrentinfection,travel,sickcontacthistory,jointinjury
Physical Exam
• growthparameters
• screeningexamination(pediatricgait,arms,legs,spineexam)
• jointexam:inspection/palpation(swelling,erythema,warmth,tenderness,deformity),ROM • adjacentstructures(bone,tendon,muscle,skin)
• leglength
• neurologicexam
Investigations
• basic:CBCanddifferential,bloodsmear,ESR,CRP,x-ray
• asindicated:blood(ANA,RF,culture,viral/bacterialserology,CK,PTT,sicklecellscreen,
immunoglobulins, complement), urinalysis, synovial fluid (cell count, Gram stain, culture), TB skin test, imaging, bone marrow aspiration, slit lamp exam