Rosen & Barkin's 5-Minute Emergency Medicine Consult (74 page)

Unclear diagnosis in ill-appearing child or if concern of secondary joint infection

• No evidence of septic joint, systemic infection, or organ failure from drug therapy
  
• Patient appears comfortable.
  
• Appropriate follow-up has been arranged.
  

• Orthopedics if septic joint suspected
  
• Rheumatologist if meds need adjustment
  

• Children need long-term consults with a rheumatologist.
  
• Children with JIA need frequent eye exams to rule out uveitis (which is often asymptomatic until permanent damage has occurred).
  

• Rule out acute joint infection (always consider Lyme disease in the appropriate geographic context).
  
• Consider systemic onset JIA in child with prolonged diurnal febrile illness that is unresponsive to antibiotics.
  
• Consider MAS in systemic onset JIA patients who appear septic.
  
• Review patient’s medications to identify potential side effects or immunosuppression.
  

• Beresford MW, Baildam EM. New advances in the management of juvenile idiopathic arthritis-1: Non-biological therapy.
  Arch Dis Child Educ Pract Ed
  . 2009;94:144–150.
  
• Beresford MW, Baildam EM. New advances in the management of juvenile idiopathic arthritis-2: The era of biologicals.
  Arch Dis Child Educ Pract Ed
  . 2009;94:151–156.
  
• Espinosa M, Gottlieb BS. Juvenile idiopathic arthritis.
  Pediatr Rev.
  2012;33:303–313.
  
• Gowdie PJ, Tse SM. Juvenile idiopathic arthritis.
  Pediatr Clin N Am.
  2012;59:301–327.
  
• Marzan KA, Shaham B. Early juvenile idiopathic arthritis.
  Rheum Dis Clin Am.
  2012;38:355–372.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Septic Joint
  
• Lyme Disease
  

CODES

• 714.30 Polyarticular juvenile rheumatoid arthritis, chronic or unspecified
  
• 714.31 Polyarticular juvenile rheumatoid arthritis, acute
  
• 714.32 Pauciarticular juvenile rheumatoid arthritis
  

BASICS

• Localized to 1 joint, not migratory
  
• 1 etiology does not exclude another
  
• Infectious (septic) arthritis:
  Rapidly destructive process causes significant disability
  
  • Contiguous extension (cellulitis, osteomyelitis), hematogenous spread, direct inoculation
    
  • Predisposing factors:
    
    • Local pathology (inflammatory arthritis, trauma, prosthetic joint)
      
    • Immunosuppression
      
    • IV drug use
      
• Crystalline:
  
  • Gout:
    Uric acid overproduction or underexcretion, deposited within and around joints.
    
  • Pseudogout:
    Calcium pyrophosphate
    
• Noninflammatory conditions
  
  • Osteoarthritis (DJD), trauma (fractures, hemarthrosis), autoimmune disorders
    
  • Progressive joint destruction; mechanical dysfunction
    
    • Bone reactive changes (spurring)
      
    • Subchondral bony erosions
      

• Infectious (septic)
  
  • Most common organisms nongonococcal
    
    • Gram-positives:
      Streptococcus, Staphylococcus
      (80%
      )
      
  • Some associations:
    
    • Staphylococcus aureus:
      (trauma, IV drug use)
      
    • Neisseria gonorrhea
      (STD)
      
    • Salmonella (sickle cell) but most common causes in sickle cell same (
      Staphylococcus, Streptococcus
      )
      
    • Less common: Fungal (chronic), spirochete (Lyme), viral (polyarticular), mycobacteria (TB)
      
• Crystalline:
  
  • Gout
    : Uric acid overproduction, underexcretion within, around joints
    
  • Tophi: Crystal deposits near recurrent flare sites. Progressive enlargement, may ulcerate “spit out” (discharge) crystals
    
  • Negatively birefringent crystals
    
  • Pseudogout:
    Calcium pyrophosphate
    
  • Positively birefringent crystal
    
  • Bariatric surgery: Postoperative gout flares common, frequent, significant. Prophylactic treatment effective, recommended
    
• Inflammatory
  
  • Diligent search for underlying cause, resultant conditions: arthridites (rheumatoid, psoriatic), inflammatory bowel disease, Reiter syndrome
    
• Noninflammatory conditions
  
  • Osteoarthritis or degenerative joint disease (DJD), overuse, overload (obesity)
    
  • Trauma (fractures, hemarthrosis)
    
  • Hemorrhagic disorders
    
  • Neuropathic disorders (Charcot joint)
    

• Infectious (septic) arthritis
  
  • Low incidence, high morbidity, sepsis (8%)
    
  • Most common:
    S. aureus
    , hip > knee, 50% coexisting osteomyelitis
    
  • Present like adults: Joint swollen, painful, worsened with weight bearing, movement; constitutionally ill (fever, lassitude)
    
  • Immediate aspiration, empiric treatment, admission mandatory
    
• Inflammatory
  
  • A diagnosis only after septic joint excluded; then considerations same as adults
    
• Noninflammatory:
  
• Orthopedic considerations to not overlook:
  
  • Salter–Harris epiphyseal plate fractures
    
  • Congenital hip dysplasia
    
  • Slipped capital femoral epiphysis (SCFE)
    
    • Overweight adolescents
      
  • Legg–Calve–Perthes:
    
    • Osteonecrosis femoral head
      
    • Age 4–9
      
  • Bleeding disorders, hemorrhage
    

DIAGNOSIS

Early accurate diagnosis allows directed therapy, earlier resumption of function, activities of daily living (ADL); longer-term morbidity lessened

• Isolated to 1 joint, not migratory
  
  • Acute pain, swelling, redness, warmth
    
  • Decreased range of motion, nonweight bearing (effusion, pain, osteomyelitis)
    
• Infectious (septic) arthritis:
  
  • Constitutionally ill, fever, chills
    
  • Larger joints swollen, painful range motion
    
    • Knee > hip = shoulder > ankle > wrist
      
  • N. gonorrhea
    : Urethral discharge painful, purulent (males)
    
  • Lyme disease:
    
    • Spirochete
      Borrelia burgdorferi
      
    • Deer tick (
      Ixodes dammini
      )
      
    • Circular expanding, centrally clearing, eruption (
      erythema chronicum migrans
      )
      
    • Knees, shoulders most common
      
• Crystalline:
  
  • Sudden, severe pain, swelling, erythema
    
  • Recurrent, self-limited flares
    
  • Gout:
    Great toe joint (“podagra”) > ankle > tarsal joints > knee
    
  • Tophi: Crystal granulomas overlying affected joints; ulcerate, drain crystals
    
  • Pseudogout
    : Knee > wrist > ankle = elbow
    
• Inflammatory:
  
  • Protean manifestations, findings related to systemic conditions
    
  • Individual, multiple, combination organ system involvement. Example: Reiter syndrome: Iritis, urethritis, arthritis
    
• Noninflammatory conditions
  
  • Osteoarthritis (DJD):
    
    • Stiffness AM (inactivity), after activity (synovial gelling), relieved with rest
      
  • Trauma: Acute or distant, gradual swelling episodes, pain pattern same as DJD
    
  • Neuropathic: Charcot joint (“bag of bones”), little or no pain—chronic neuropathy
    
  • Hemarthrosis, hemorrhagic disorders
    

• See “Description,” “Etiology,” “Pediatric Considerations,” and “Signs and Symptoms.”
  
• Complete, meticulous history: Joint issues or involvement (recent, remote), systemic conditions (direct, local, remote manifestations), immune status (HIV, medications, disease process), STD (history, exposure, treatment type and duration), IV drug use.
  

See “Description” and “Signs and Symptoms.”

• Meticulous history and physical exam
  
• Condition—related diagnostic studies
  
• Arthrocentesis for synovial fluid analysis is the definitive diagnostic procedure.