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Diseases » Arthralgia » Treatments

Treatments for Arthralgia



Contents

Treatments for Arthralgia

The list of treatments mentioned in various sources for Arthralgia includes the following list. Always seek professional medical advice about any treatment or change in treatment plans.

Arthralgia: Research Doctors & Specialists

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Book Excerpts: Treatment of Arthralgia

Treatments of Arthralgia: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the treatments of Arthralgia.

Ankle Pain/Swelling: Treatment
(In a Page: Signs and Symptoms)

  • PRICE
    –Protection from additional strain/injury
    –Relative rest (stretching is okay) ±crutches
    –Ice for initial 24–48 hours after trauma
    –Compression (elastic wrap or ankle support)
    –Elevation of foot (higher than the pelvis)
  • Casting is often indicated for fractures and significant ankle sprains
  • Short-term bracing may reduce risk of reinjury
  • Surgery may be indicated (e.g., bimalleolar fracture, trimalleolar fracture)
  • Physical therapy referral to improve strength, range of motion, and proprioception
  • NSAIDs or other analgesic

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Elbow Pain/Swelling: Treatment
(In a Page: Signs and Symptoms)

  • General principles of fracture management include immobilization, analgesia, NSAIDs, and elevation
  • Immediate anatomic reduction is required in cases of neurovascular compromise
  • Nondisplaced fractures should be immobilized with the elbow flexed at 90°
  • Displaced or intra-articular fractures usually require open reduction with internal fixation
  • Joint aspiration may relieve pain if effusion is present
  • Epicondylitis is treated with rest, NSAIDs, and physical therapy
  • Elbow dislocation requires reduction followed by splint immobilization
  • Splinting may be beneficial
  • Reduction of a subluxed radial head (nursemaid's elbow) is performed by placing the thumb over the radial head while supinating, then flexing, the forearm

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Jaw Pain/Swelling: Treatment
(In a Page: Signs and Symptoms)

  • Dental or periodontal pathology, oral lesions, salivary pathology, and oral neoplasms require specialized treatment by dental specialist or oral surgeon
  • TMJ: Initial treatment includes pain management, bite block (night guard), cold/warm compresses, intra-articular steroid/lidocaine injections, and avoidance of jaw clenching and gum chewing
  • Temporal arteritis: Temporal artery biopsy and high- dose steroids
  • Headache: Pain relievers, stress reduction, migraine-specific therapy (e.g., triptans), and manipulation
  • Neuralgia and neuropathies may be treated with NSAIDs, anticonvulsants (e.g., valproic acid, gabapentin), medical pain management and/or directed therapy (e.g., nerve block)
  • Treat underlying systemic etiologies and behavioral disease as necessary
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» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Knee Pain/Swelling: Treatment
(In a Page: Signs and Symptoms)

  • Conservative therapy is usually sufficient
  • OA: Lifestyle modification (e.g., weight loss, exercise); anti-inflammatory medications (e.g., NSAIDs, COX-2 inhibitors); joint injections may benefit some people (e.g. corticosteroids, hyaluronic acid); surgery may be necessary for those who fail conservative treatment
  • Ligamentous injuries: ACL injuries may require definitive treatment via reconstructive surgery; PCL injuries are usually not repaired
  • Meniscal tears may require repair or excision; however, most meniscus injuries are asymptomatic or mild and require no treatment
  • Patellofemoral syndrome often responds to physical therapy and exercise
  • Joint infection (e.g., septic arthritis) is a surgical emergency; irrigation, debridement, and antibiotic administration should be considered

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Low Back Pain/Swelling: Treatment
(In a Page: Signs and Symptoms)

  • In absence of red flag symptoms, return to activity as soon as possible; rest has not been shown to improve recovery
  • Acetaminophen, NSAIDs, opioids, and/or muscle relaxants for pain; epidural corticosteroid injections may be indicated for resistant pain
  • Patient education (weight loss, exercise, proper back biomechanics and ergonomics)
  • Physical therapy, including pain relief modalities (ice, heat, ultrasound), stretching, strengthening, aerobic conditioning, and relaxation therapy
  • Surgery may be indicated for refractory disease, large neurologic deficits, unbearable pain, or significant limitations
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» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Shoulder Pain/Swelling: Treatment
(In a Page: Signs and Symptoms)

  • Slings may be used for comfort but early range of motion (24–48 hours) is necessary to prevent adhesive capsulitis
  • Conservative therapy is beneficial for most cases of shoulder pain: Rest, ice, NSAIDs, and opioid narcotics
  • Subacromial cortisone injection if other anti-inflammatory methods fail; however, multiple injections are discouraged because of possible tissue atrophy
    • Physical therapy is generally the mainstay of treatment
      –Conditioning and strengthening
      –Progressive range of motion exercises for adhesive capsulitis
  • Full thickness rotator cuff tears may require surgical repair
  • Adhesive capsulitis may require surgical lysis of adhesions
  • Prevent future injuries by promoting strength and flexibility

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Toe Pain/Swelling: Treatment
(In a Page: Signs and Symptoms)

  • Gout: NSAIDs, corticosteroids, colchicines for acute attacks; colchicine, urate-lowering agents (e.g., allopurinol, probenecid) for chronic management
  • Ingrown toenails: Warm soaks, removal of toenail if persistent
  • Pseudogout: NSAIDs, corticosteroids, colchicines for acute attacks; NSAIDs, colchicine, urate for chronic management
  • Trauma: Most closed toe fractures can be treated with stiff-soled shoes (to unload the metatarsal heads); “buddy-tape” immobilization may help relieve pain; rest, ice, NSAIDs, elevation
  • Reiter's syndrome: Prednisone, indomethacin, sulfasalazine, methotrexate; local injection of steroid
  • Septic arthritis: Treatment is based on clinical scenario and initial Gram stain; ceftriaxone for gram-negative infections, cefazolin for gram positives, add gentamicin for pseudomonal infections
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» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Wrist & Hand Pain/Swelling: Treatment
(In a Page: Signs and Symptoms)

  • Corticosteroid injection for carpal tunnel improves symptoms in more than half of patients; surgical intervention to release the transverse ligament and decompress the nerve entrapment may be indicated
  • NSAIDs reduce inflammation and use of cock-up splints applied during activities and while sleeping reduces strain from repetitive use and reduces symptoms
  • Corticosteroid injection along tendon sheaths and wearing a thumb spica splint treat tenosynovitis
  • Ganglion cysts are treated by draining the thick fluid and injecting with steroid; surgical removal is occasionally necessary
  • Casting of suspected fractures and repeat X-ray in 7–9 days prevents complications of occult fracture
  • Antihistamines and steroids treat swelling from stings
  • Treat rheumatologic and medical causes
  • Biofeedback and relaxation may be beneficial in selected cases

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Arthritis – Multiple Joints: Treatment
(In A Page: Pediatric Signs and Symptoms)

  • Even though unlikely, if septic arthritis (such as with Neisseria gonorrhoeae) is a possibility, antibiotic treatment should be started immediately
  • Appropriate treatment of malignancy
  • NSAIDs for JRA and spondyloarthropathies as an initial therapy; disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine and methotrexate, and biologics (e.g., TNF blockers) are added depending on clinical response
  • Specific treatments of other mixed connective tissue diseases depending on their severity
  • Corrective and/or supportive medical/surgical interventions
  • Supportive therapy such as PT and OT to increase range of motion and strength; insoles to correct leg length discrepancy
  • Psychosocial support especially with chronic diseases

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Arthritis – Single Joint: Treatment
(In A Page: Pediatric Signs and Symptoms)

  • If septic arthritis is a possibility, broad-spectrum antibiotic treatment should be started immediately
  • Fractures and most internal derangements require orthopedics involvement
  • Appropriate referral and treatment for malignancy
  • JRA and SpA are usually treated with NSAIDs initially, DMARDs (e.g., sulfasalazine and methotrexate) and biologics (e.g., TNF blockers) are added depending on the degree of inflammation and the response of individual patient
  • Supportive therapy such as PT and OT to increase range of motion and strength; insoles to correct leg length discrepancy
  • Psychosocial support, especially with chronic arthritis

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Scrotal Swelling: Treatment
(In A Page: Pediatric Signs and Symptoms)

    • Hydrocele
      –Usually resolves spontaneously by 1 year of age
      –Surgery is indicated at 6–12 months if stable, sooner if hydrocele is tense or progressively enlarging
    • Hernia
      –Inguinal hernias must be repaired surgically to avoid incarceration
      –Contralateral side is frequently explored surgically and closed if necessary
  • Varicocele: Can be associated with infertility and may need to be surgically repaired
  • Edema: Treatment of the cause of generalized edema
  • Tumor and leukemia: Management by pediatric oncologist
  • Men and teenage boys should be taught testicular self-examination to assist with early detection of testicular cancer

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Source: In A Page: Pediatric Signs and Symptoms, 2007

Scrotal swelling: Emergency interventions
(Handbook of Signs & Symptoms (Third Edition))

If severe pain accompanies scrotal swelling, ask the patient when the swelling began. Using a Doppler stethoscope, evaluate blood flow to the testicle. If it’s decreased or absent, suspect testicular torsion and prepare the patient for surgery. Withhold food and fluids, insert an I.V. line, and apply an ice pack to the scrotum to reduce pain and swelling. An attempt may be made to untwist the cord manually, but even if this is successful, the patient may still require surgery for stabilization.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Rheumatoid arthritis: Treatment
(Professional Guide to Diseases (Eighth Edition))

Salicylates, particularly aspirin, are the mainstay of RA therapy because they decrease inflammation and relieve joint pain. Other useful medications include nonsteroidal anti-inflammatory drugs (such as indomethacin, fenoprofen, and ibuprofen), antimalarials (hydroxychloroquine), gold salts, penicillamine, and corticosteroids (prednisone). Immunosuppressants, such as cyclophosphamide, methotrexate, and azathioprine, are also therapeutic and are being used more commonly in early disease. (See Drug therapy for arthritis.)

Supportive measures include 8 to 10 hours of sleep every night, frequent rest periods between daily activities, and splinting to rest inflamed joints. A physical therapy program including range-of-motion exercises and carefully individualized therapeutic exercises forestalls joint function loss; application of heat relaxes muscles and relieves pain. Moist heat usually works best for patients with chronic disease. Ice packs are effective during acute episodes.

Advanced disease may require synovectomy, joint reconstruction, or total joint arthroplasty.

Useful surgical procedures in RA include metatarsal head and distal ulnar resectional arthroplasty, insertion of a Silastic prosthesis between the metacarpophalangeal and proximal interphalangeal joints, and arthrodesis (joint fusion). Arthrodesis sacrifices joint mobility for stability and pain relief. Synovectomy (removal of destructive, proliferating synovium, usually in the wrists, knees, and fingers) may halt or delay the course of this disease. Osteotomy (the cutting of bone or excision of a wedge of bone) can realign joint surfaces and redistribute stresses. Tendons may rupture spontaneously, requiring surgical repair. Tendon transfers may prevent deformities or relieve contractures. (See When arthritis requires surgery.)

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Neurogenic arthropathy: Treatment
(Professional Guide to Diseases (Eighth Edition))

Effective management relieves pain with analgesics and immobilization using crutches, splints, braces, and restriction of weight bearing to the affected joint.

In severe disease, surgery may include arthrodesis or, in severe diabetic neuropathy, amputation. However, surgery risks further damage through nonunion and infection.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Juvenile rheumatoid arthritis: Treatment
(Professional Guide to Diseases (Eighth Edition))

Successful management of JRA usually involves administration of anti-inflammatory drugs, physical therapy, carefully planned nutrition and exercise, and regular eye examinations. Both child and parents must be involved in therapy.

Aspirin is the initial drug of choice, with dosage based on the child’s weight. However, other nonsteroidal anti-inflammatory drugs (NSAIDs) may also be used. If these prove ineffective, gold salts, hydroxychloroquine, and penicillamine may be tried. Because of adverse effects, steroids are generally reserved for treatment of systemic complications, such as pericarditis or iritis, that are resistant to NSAIDs. Corticosteroids and mydriatic drugs are commonly used for iridocyclitis. Low-dose cytotoxic drug therapy is currently being investigated. (See Drug therapy for arthritis, pages 367 and 368.)

Physical therapy promotes regular exercise to maintain joint mobility and muscle strength, thereby preventing contractures, deformity, and disability. Good posture, gait training, and joint protection are also beneficial. Splints help reduce pain, prevent contractures, and maintain correct joint alignment.

Surgery is usually limited to soft-tissue releases to improve joint mobility. Joint replacement is delayed until the child has matured physically and can handle vigorous rehabilitation. (See When arthritis requires surgery, page 369.)

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Psoriatic arthritis: Treatment
(Professional Guide to Diseases (Eighth Edition))

In mild psoriatic arthritis, treatment is supportive and consists of immobilization through bed rest or splints, isometric exercises, paraffin baths, heat therapy, and aspirin and other nonsteroidal anti-inflammatory drugs. Some patients respond well to low-dose systemic corticosteroids; topical steroids may help control skin lesions. Gold salts and, most commonly, methotrexate therapy are effective in treating both the articular and cutaneous effects of psoriatic arthritis. Antimalarials are contraindicated because they can provoke exfoliative dermatitis.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Septic arthritis: Treatment
(Professional Guide to Diseases (Eighth Edition))

Antibiotic therapy should begin as soon as a Gram stain has been done; it may be modified when drug sensitivity of the infecting organism is known. Bioassays or bactericidal assays of synovial fluid and bioassays of blood may confirm clearing of the infection.

Rest, immobilization, elevation, and warm compresses help with pain relief. Analgesics are given for pain, if needed. The affected joint can be immobilized with a splint or put into traction until the patient can tolerate movement.

In severe cases, needle aspiration (arthrocentesis) or surgery may be done under sterile conditions to remove grossly purulent or infected joint fluid. Late reconstructive surgery is warranted only for severe joint damage and only after all signs of active infection have disappeared, which usually takes several months. Recommended procedures include arthroplasty and joint fusion. Prosthetic replacement remains controversial because it may exacerbate the infection, but it has helped patients with damaged femoral heads or acetabula.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Scrotal swelling: Emergency interventions
(Professional Guide to Signs & Symptoms (Fifth Edition))

If severe pain accompanies scrotal swelling, ask when the swelling began. Using a Doppler stethoscope, evaluate blood flow to the testicle. If it’s decreased or absent, suspect testicular torsion and prepare the patient for surgery. Withhold food and fluids, insert an I.V. line, and apply an ice pack to the scrotum to reduce pain and swelling. An attempt may be made to untwist the cord manually, but even if this is successful, the patient may still require surgery for stabilization.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Rheumatoid arthritis: Treatment
(Handbook of Diseases)

Salicylates, particularly aspirin, are the mainstay of RA therapy, because they decrease inflammation and relieve joint pain. Other useful medications include nonsteroidal anti-inflammatories (such as indomethacin, fenoprofen, and ibuprofen), antimalarials (hydroxychloroquine), sulfasalazine, gold salts, and corticosteroids (prednisone). (See Drug therapy for arthritis.)

Immunosuppressants — such as methotrexate, cyclosporine, and azathioprine — are also therapeutic. They’re being used more commonly early in the disease process. Cox-2 inhibitors, such as rofecoxib and celecoxib, significantly reduce the risk of GI bleeding. Cyclophosphamide, which suppresses the immune system and is associated with toxic adverse effects, may be used in patients who have been unsuccessful with other therapies.

UNDER STUDY:  A number of new drugs are becoming popular for RA therapy:  

❑  Etanercept, an injectable, and infliximab, given I.V. every 2 months, inhibit the inflammatory protein tumor necrosis factor.

❑  Leflunomide blocks the growth of new cells.

❑  Anakinra, an injectable, blocks another inflammatory protein, interleukin-1.

Supportive measures include 8 to 10 hours of sleep every night, frequent rest periods between daily activities, and splinting to rest inflamed joints. A physical therapy program, including range-of-motion exercises and carefully individualized therapeutic exercises, forestalls loss of joint function.

Application of heat relaxes muscles and relieves pain. Moist heat usually works best for patients with chronic disease. Ice packs are effective during acute episodes.

Treatment in advanced disease

Advanced disease may require synovectomy, joint reconstruction, or total joint arthroplasty. (See When arthritis requires surgery, page 743.)

Useful surgical procedures in RA include metatarsal head and distal ulnar resectional arthroplasty, insertion of a Silastic prosthesis between MCP and PIP joints, and arthrodesis (joint fusion). Arthrodesis sacrifices joint mobility for stability and relief of pain.

Synovectomy (removal of destructive, proliferating synovium, usually in the wrists, knees, and fingers) may halt or delay the course of the disease. Osteotomy (the cutting of bone or excision of a wedge of bone) can realign joint surfaces and redistribute stresses.

Tendons may rupture spontaneously, requiring surgical repair. Tendon transfers may prevent deformities or relieve contractures. Apheresis may slow down RA or stop it from wor-sening.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Neurogenic arthropathy: Treatment
(Handbook of Diseases)

Effective management relieves associated pain with an analgesic and immobilization, using crutches, splints, braces, and restriction of weight bearing.

In patients with severe disease, surgery may include arthrodesis or, in those with severe diabetic neuropathy, amputation. However, surgery risks further damage through nonunion and infection.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Juvenile rheumatoid arthritis: Treatment
(Handbook of Diseases)

Successful management of JRA usually involves administration of an anti-inflammatory, physical therapy, carefully planned nutrition and exercise, and regular eye examinations. The child and his parents must be involved in therapy.

A nonsteroidal anti-inflammatory drug (NSAID) — such as aspirin, ibuprofen, or naproxen — is used to reduce pain and swelling. If this proves ineffective, a disease-modifying antirheumatic drug (DMARD), such as methotrexate, is a useful second-line agent. In addition, gold salts, hydroxychloroquine, auranofin, aurothioglucose, etanercept, or sulfasalazine may be considered. Responses to individual drugs may differ among the various subtypes of JRA. Because of adverse effects, systemic steroids are generally reserved for treatment of systemic complications that are resistant to NSAIDs and DMARDS, such as pericarditis and iritis. However, an intra-articular steroid can be effective in managing pauciarticular and polyarticular JRA.

CLINICAL TIP: Joint rest (by splinting) used for up to 3 days after joint injections with a corticosteroid may improve anti-inflamma-tory response.

Corticosteroids and mydriatics are commonly used for iridocyclitis. Low-dose cytotoxic drug therapy is currently being investigated.

Physical therapy promotes regular exercise to maintain joint mobility and muscle strength, thereby preventing contractures, deformity, and disability. Good posture, gait training, and joint protection are also beneficial. Splints help reduce pain, prevent contractures, and maintain correct joint alignment.

Generally, the prognosis for JRA is good, although disabilities can occur. Surgery is usually limited to soft-tissue releases to improve joint mobility. Joint replacement is delayed until the child has matured physically and can handle vigorous rehabilitation.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Psoriatic arthritis: Treatment
(Handbook of Diseases)

In mild psoriatic arthritis, treatment is supportive and consists of immobilization through joint rest or splints, isometric exercises, paraffin baths, heat therapy, and aspirin and other non-steroidal anti-inflammatory drugs. Some patients respond well to low-dose systemic corticosteroids; topical steroids may help control skin lesions. More severe arthritis requires treatment with more powerful drugs called disease-modifying antirheumatic drugs.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Septic arthritis: Treatment
(Handbook of Diseases)

The goals of treatment are to provide oxygen and to treat respiratory distress, if present; to monitor and reverse shock through volume expansion; to treat underlying infections with antibiotic therapy; and to support poorly functioning organs.

Treatment begins with the administration of I.V. fluids and the insertion of a pulmonary artery catheter to check pulmonary circulation and PAWP. Administration of whole blood or plasma may be necessary to help raise the PAWP to a satisfactory level of 14 to 18 mm Hg. A urinary catheter allows accurate measurement of hourly urine output.

The patient may require endotracheal intubation and placement on a ventilator to overcome hypoxia. Adjustments are necessary to promote adequate cellular oxygenation and support hyperdynamic needs.

Antibiotic therapy

Treatment also requires immediate administration of I.V. antibiotics to control the infection. Depending on the organism, an antibiotic combination may be necessary.

Appropriate anti-infectives for causes of septic shock depend on the suspected organism. Other measures to combat infections include surgery to drain and excise abscesses and debridement.

Other drug therapy

If shock persists after fluid infusion, treatment with a vasopressor, such as dopamine, maintains adequate blood perfusion to vital organs. Other treatment includes correction of acidosis and, possibly, I.V. corticosteroids.

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Source: Handbook of Diseases, 2003

Scrotal swelling: Nursing considerations
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Keep the patient on bed rest and administer an antibiotic. Provide adequate fluids, fiber, and stool softeners. Place a rolled towel between the patient’s legs and under the scrotum to help reduce severe swelling. Or, if the patient has mild or moderate swelling, advise him to wear a loose-fitting athletic supporter lined with a soft cotton dressing. For several days, administer an analgesic to relieve his pain. Encourage sitz baths, and apply heat or ice packs to decrease inflammation.

Prepare the patient for needle aspiration of fluid-filled cysts and other diagnostic tests, such as lung tomography and computed tomography scan of the abdomen, to rule out malignant tumors.

Patient teaching

Encourage the patient to perform regular testicular self-examinations. Explain the importance of wearing a scrotal support for comfort and to decrease edema.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Scrotal swelling: Emergency Actions
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If severe pain accompanies scrotal swelling, ask when the swelling began. Using a Doppler stethoscope, evaluate blood flow to the testicle. If it’s decreased or absent, suspect testicular torsion and prepare the patient for surgery. Withhold food and fluids, insert an I.V. line, and apply an ice pack to the scrotum to reduce pain and swelling. An attempt may be made to untwist the cord manually, but even if this is successful, the patient may still require surgery for stabilization.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Scrotal swelling: Nursing considerations
(Nursing: Interpreting Signs and Symptoms)

▪ Place the patient on bed rest.

▪ Administer an antibiotic, if ordered.

▪ Provide adequate fluids, fiber, and stool softeners.

▪ Place a rolled towel between the patient's legs and under the scrotum for elevation to help reduce severe swelling.

▪ Apply ice packs to the scrotum.

▪ Administer an analgesic to relieve pain.

▪ Prepare the patient for needle aspiration of fluid-filled cysts and other diagnostic tests, such as lung tomography and a computed tomography scan of the abdomen, to rule out malignant tumors.

Patient teaching

▪ Explain the disorder and treatment plan.

▪ For mild or moderate swelling, advise the patient to wear a loose-fitting athletic supporter lined with a soft cotton dressing.

▪ Tell the patient to use a sitz bath and apply heat or ice packs to decrease inflammation.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Back, Joint, and Extremity Pain - Case 5-1: 2-Year-Old Boy: VI. Treatment
(Pediatric Complaints and Diagnostic Dilemmas)

Standard management of epidural abscesses includes antibiotic therapy and surgical drainage. Sporadic cases reported in the literature have been treated with antibiotics alone. Candidates for antibiotic therapy without surgical drainage may include patients without neurologic deficits and those with numerous abscesses that would be technically difficult to drain. In those children who are treated with antibiotics without surgical drainage, diagnostic surgical aspiration to identify the infecting organism should be strongly considered. This decision usually is made in consultation with infectious disease and neurosurgical specialists. The empiric antibiotic regimen should include agents with activity against S. aureus, such as oxacillin or vancomycin. Vancomycin should be the initial antibiotic if (a) methicillin-resistant Staphylococcus aureus (MRSA) accounts for more than 10% to 15% of local S. aureus isolates, (b) a household member works in a nursing home or other facility with high rates of MRSA colonization, and (c) the patient lives with someone known to be colonized with MRSA. Cefotaxime and metronidazole should be added if gram-negative or anaerobic organisms are suspected. Ultimate antibiotic selection depends on the results of blood and abscess culture. The duration of antibiotic treatment usually is determined by improvements in clinical findings (e.g., improved pain and function), laboratory results (e.g., normalization of ESR and CRP levels), and radiologic imaging studies (e.g., resolved epidural fluid collection on MRI). Most children require approximately 6 weeks of parenteral antibiotic therapy.
Mortality rates for adults with spinal epidural abscesses range from 5% to 25%. Mortality rates in children are substantially lower. There were no deaths among the 34 children reviewed in one series. Approximately 75% to 85% of children treated for spinal epidural abscess have normal neurologic function at the completion of therapy. Risk factors for persistent deficits include multiple medical problems, previous spinal surgery, and severe neurologic deficit at presentation.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Back, Joint, and Extremity Pain - Case 5-2: 2-Year-Old Boy: VI. Treatment
(Pediatric Complaints and Diagnostic Dilemmas)

Although specific treatment strategies vary from center to center, all modern approaches treat the complications of ALL at presentation, treat the leukemia, and manage treatment-related complications. Acute management involves blood product transfusions and treatment of infection, hyperviscosity, compressive symptoms, and metabolic abnormalities. The term tumor lysis syndrome describes the constellation of metabolic abnormalities resulting from spontaneous or treatment-induced tumor necrosis. Acute tumor cell destruction releases intracellular contents into circulation, leading to hypocalcemia, hyperphosphatemia, hyperkalemia, and hyperuricemia. Management of tumor lysis syndrome includes vigorous hydration, urine alkalinization, uric acid reduction, and diuretic therapy.
Specific therapy for ALL is instituted in three distinct phases. Remission induction therapy lasts approximately 4 weeks, during which most children have a complete remission (defined as the absence of clinical signs and symptoms of disease), recovery of normal blood cell counts, and recovery of normocellular bone marrow. Agents currently used for remission induction include dexamethasone or prednisone, vincristine, and l-asparaginase. Other agents may be used if the patient is considered to be at high risk or has CNS involvement. Consolidation therapy aims to kill additional leukemic cells with further systemic therapy and to prevent CNS relapse with intrathecal chemotherapy. Maintenance therapy aims to continue remission achieved by the first two phases; it is required because shorter treatment protocols are associated with a high rate of relapse. Methotrexate and 6-mercaptopurine are often used for consolidation and maintenance therapy.
Children with high WBC counts (greater than 50,000/mm3) and those who are younger (less than 2 years of age) or older (greater than 10 years of age) at diagnosis have the worst prognosis. However, between 95% and 98% of children diagnosed with ALL achieve complete remission after induction therapy. Relapse occurs in 20% to 30%, either during subsequent treatment or within the first 2 years after its completion. Relapse can affect virtually any site of the body, although bone marrow relapse is most common. Since the introduction of effective CNS-directed therapy, the frequency of CNS relapse has decreased to approximately 5%. Isolated testicular relapse occurs in 1% of boys. Bone marrow relapse is often treated with intense chemotherapy combined with bone marrow transplantation. The event-free survival rate after relapse ranges from 30% to 60%.
Late sequelae of ALL therapy include second neoplasms, neuropsychologic effects, endocrine dysfunction, and other organ-specific complications. Second neoplasms occur in 2.5% of patients; CNS tumors are the most common second neoplasm. Children who are younger than 5 years of age at ALL diagnosis and those who receive cranial irradiation are at highest risk. Short stature occurs due to cranial irradiation –induced growth hormone deficiency. Some late complications are related to specific chemotherapeutic agents, such as cardiomyopathy from anthracycline or bladder fibrosis from cyclophosphamide therapy. Chemotherapy may also have long-term effects on the child 's immune system. Recovery of the immune system usually occurs within 1 to 2 years after the completion of chemotherapy. However, some children have low antibody titers of clinically significant viruses to which they have been previously immunized.

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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Back, Joint, and Extremity Pain - Case 5-3: 14-Year-Old Boy: VI. Treatment
(Pediatric Complaints and Diagnostic Dilemmas)

The goals of treatment are to prevent further slippage and to restore function. The patient should not be allowed to bear weight on the affected extremity once the diagnosis has been confirmed. An untreated stable slip may progress to a more severe unstable slip, leading to increased morbidity. The most common surgical treatment involves percutaneous fixation of the displaced femoral head with one or more metallic pins or screws.
Prophylactic treatment of the asymptomatic contralateral hip is controversial. Given the high incidence of eventual bilateral involvement (20% to 50% of cases), some surgeons have advocated treatment of the contralateral hip at the time of initial surgery. Other orthopedic surgeons recommend fixation of an asymptomatic contralateral hip only in those patients who are at highest risk of developing SCFE of the contralateral hip, such as those with known endocrine or metabolic disorders.
Outcome after repair is generally good but depends on the degree of abnormality before repair. Subsequent avascular necrosis of the femoral head complicates 15% of cases. Avascular necrosis is most often a consequence of vascular injury associated with initial femoral head displacement rather than a consequence of the repair. Patients with a moderate or severe degree of femoral head displacement at presentation are also more likely to develop associated osteoarthritis. Chondrolysis or destruction of cartilage may occur after pin placement but has also occurred in patients without any surgical therapy. Leg length discrepancy may result from incomplete reduction, avascular necrosis, or chondrolysis. Early recognition and treatment of SCFE prevents many of these complications.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Back, Joint, and Extremity Pain - Case 5-4: 16-Year-Old Girl: VI. Treatment
(Pediatric Complaints and Diagnostic Dilemmas)

Therapeutic strategies include a combination of medical and surgical interventions. Medical therapy includes 5-aminosalicylates, corticosteroids, immunomodulators, and antibiotics. Oral sulfasalazine consists of 5-aminosalicylic acid (5-ASA) bound to sulfapyridine. The sulfa moiety functions as a carrier, facilitating delivery of the agent to the colon, where it is cleaved by resident bacteria into therapeutically active 5-ASA. The 5-ASA decreases colon inflammation by inhibiting leukotriene synthesis via the lipoxygenase pathway of arachidonic acid metabolism. It also decreases neutrophil-mediated tissue damage by interfering with myeloperoxidase activity and scavenging reactive oxygen species. Newer oral 5-ASA analogues (e.g., mesalamine) function by either pH-dependent or timed-release mechanisms that allow the drug to be distributed throughout the small bowel.
Corticosteroids continue to be the mainstay of treatment. They exert antiinflammatory effects by decreasing cytokine release, capillary permeability, and neutrophil and monocyte function. Newer corticosteroids have a strong affinity for intestinal steroid receptors, leading to high topical antiinflammatory potency. Because they are rapidly transformed into inactivated metabolites by the liver after absorption, they cause fewer systemic side effects. For example, budesonide binds to intestinal receptors 15 times more efficiently than prednisolone but undergoes rapid hepatic metabolism, so systemic bioavailability is only 10%, compared with 80% for prednisolone. Delayed-release (time- and pH-dependent) formulations of budesonide permit more effective delivery of the drug to the terminal ileum and proximal colon.
Immunomodulators are being used to target the inflammatory response more selectively. For example, tumor necrosis factor- α (TNF-α), a cytokine, activates components of the immune system involved in Crohn's disease. Infliximab, a chimeric (mouse-human) anti-TNF-α immunoglobulin G antibody, binds to TNF-α and neutralizes its activity. Infliximab infusions administered at 4- to 12-week intervals induce remissions in patients with moderate to severe Crohn 's disease and facilitate healing of fistulas. Infliximab also permits significant reduction in steroid use in children.
The antibiotic metronidazole may reduce Crohn's disease activity. It has also been used to treat perianal fistulas and abscesses. Indications for bowel resection include intractable disease, severe fistula formation, uncontrolled hemorrhage, and bowel perforation. More than 50% of children with Crohn 's disease require intestinal surgery within 10 to 15 years after diagnosis. The disease is not usually limited to one portion of the gastrointestinal tract, so surgery is not curative. Recurrent disease after bowel resection is common.
The course of Crohn's disease is characterized by periods of symptom exacerbation and remission. Only 1% of children with well-documented Crohn 's disease will have no relapses after diagnosis and initial therapy. Many children with Crohn 's disease also suffer from medication- and central venous catheter–related complications. In the long term, impaired height velocity is common. Approximately 8% of patients with severe Crohn 's disease develop colorectal cancer. Death from Crohn's disease in childhood is rare; however, the risk of death is 1.5 times higher in affected adults compared with age-matched controls.

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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Back, Joint, and Extremity Pain - Case 5-5: 13-Year-Old Boy: VI. Treatment
(Pediatric Complaints and Diagnostic Dilemmas)

Severe bone pain should be considered a medical emergency that prompts timely and aggressive management until the pain decreases to a tolerable level. Major barriers to effective management of pain are inadequate assessment of pain and biases against opioid use. Most of the time, these biases are based on clinician uncertainty regarding opioid tolerance and physical dependence, and confusion with addiction.
As previously mentioned, bone infarction resembles osteomyelitis. Fever in cases of bone infarction is due to necrosis and inflammation associated with marrow ischemia. Blood cultures must be obtained if empiric antibiotics are initiated. Appropriate antibiotics should cover Salmonella spp. and S. aureus, the most common causes of osteomyelitis in children with SCD.
Patients with signs of moderate to severe dehydration should receive 10 to 20 mL/kg of intravenous normal saline, followed by intravenous fluid at or slightly above (1.0 to 1.5 times) the daily fluid requirement. It is important to assess the severity of pain at presentation and at frequent intervals, using age-appropriate pain-measuring scales. Pain should be reevaluated every 15 minutes until pain starts to decrease, then every 30 to 60 minutes as needed. Severe acute pain requires intravenous medication such as morphine sulfate, hydrocodone, or fentanyl, with or without NSAIDs such as ketorolac and ibuprofen. Patient-controlled analgesia (PCA) devices restore patient control over pain and may be used for patients in severe pain. PCA pumps provide analgesic medication continuously at a low baseline rate and allow patients to self-administer an additional dose of opioid whenever they feel a need for more pain relief. Continuous epidural analgesia has been used in patients with pain below the 4th thoracic dermatome for whom intravenous PCA opioids and nonopioid analgesics have failed; however, not much information is available about its use in patients with SCD.
Patient and parental preferences for pain medication should be considered, because individual variations in drug metabolism determine the dose-response to analgesia. The use of parental meperidine should be avoided because of CNS toxicity related to its metabolite normeperidine. Patients receiving opioids for longer than 1 or 2 weeks should be weaned slowly over several days to prevent withdrawal symptoms.
Side effects of opioids, including respiratory depression and sedation, should be monitored closely. Antiemetics such as Compazine (prochlorperazine) or metachlorpropamide effectively treat symptoms of opioid-related nausea. Stool softeners to prevent constipation should be taken daily if patients continue to take opioids for longer than a few days.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Back, Joint, and Extremity Pain - Case 5-6: 9-Year-Old Boy: VI. Treatment
(Pediatric Complaints and Diagnostic Dilemmas)

There are three distinct aspects to the treatment of ARF: eradication of the GABHS, secondary prophylaxis, and treatment of the ARF manifestations.
At the time of ARF diagnosis, patients require treatment for acute streptococcal pharyngitis regardless of the results of a throat culture or rapid antigen test. The treatment is not thought to alter the course of the active ARF illness, but it removes the inciting agent. After completion of this therapeutic regimen, secondary prophylaxis is begun.
Recurrence of ARF from a subsequent GABHS infection is a well-recognized phenomenon, and the degree of cardiac involvement increases with each episode of ARF. Both asymptomatic and symptomatic GABHS throat infections can cause recurrences of ARF, so prevention of these infections is vital. For this reason, continuous antibiotic prophylaxis is necessary for all patients with ARF. The American Heart Association has provided guidelines regarding choice of antibiotic, route and schedule of administration, and duration of prophylaxis. The risk for recurrence is greatest within the first 5 years after the initial attack, but in some cases lifelong prophylaxis is indicated.
After ARF, patients with valvular heart disease, require protection against infective endocarditis in addition to their ongoing secondary prophylaxis. A short course of additional antibiotics is required to protect the valves during certain procedures, such as dental procedures, cystoscopy, and intestinal surgery.
Antiinflammatory medications such as aspirin are effective treatment for the carditis and arthritis symptoms of ARF. Corticosteroids are reserved for the treatment of more severe carditis, where their use may more promptly suppress the inflammation, which may be critical in patients with life-threatening cardiac symptoms. Aspirin is highly effective for symptomatic treatment of the arthritis of ARF, and failure to respond to this therapy should bring the diagnosis of ARF into question. Congestive heart failure is managed with diuretics and inotropic support as indicated by the severity of the symptoms.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003


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