Arthritis – Single Joint
Arthritis – Single Joint: Excerpt from In A Page: Pediatric Signs and Symptoms
Arthritis in a single joint, or monoarthritis, is a difficult diagnostic challenge, because any disorder affecting joints may initially present as monoarthritis. After establishing that the arthritis is truly monoarticular, the most important considerations are septic joint and trauma. Joint pain may arise not only from joint itself but from adjacent bone, ligaments, tendons, bursae, or soft tissues. Presence of effusion usually indicates intra-articular pathology, although osteomyelitis, fractures, or tumors may cause effusion as well.
Differential Diagnosis
- Septic arthritis
–Rapid diagnosis critical: Untreated septic arthritis causes irreversible joint and bone destruction
–Usually presents hyperacutely with very tender, swollen, warm, red joint with severely restricted range of motion
–Usual pathogens: Haemophilus influenzae type b, Staphylococcus aureus, group B strep in neonates, and Neisseria gonorrhoeae in adolescents; fungal and mycobacterial arthritis are seen rarely, may have chronic course
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Lyme arthritis
–Second most common manifestation of Lyme disease (after erythema migrans)
–Monoarthritis of a knee occurs in about two-thirds of children with Lyme disease
-
Reactive arthritis
–Probably the most common etiology of childhood rheumatic diseases
–Transient sterile arthritis following a bacterial GI infection
–Usually full resolution, but a few children have a chronic course
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Trauma, overuse, fracture
–Often acute onset with significant pain
-
Malignancy such as leukemia, neuroblastoma and osteogenic sarcoma
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Pauciarticular juvenile rheumatoid arthritis (JRA)
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Spondyloarthropathies (SpA)
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Congenital hip dysplasia
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Slipped capital femoral epiphysis (SCFE)
–Most common adolescent hip disorder
–Separation of the femoral growth plate
–More common in obese males
-
Spontaneous osteonecrosis of the joint
–Mostly in hip (Legg-Calvé-Perthes disease), shoulder, and knee
–More common in males
-
Internal structural abnormality
–Discoid meniscus, osteochondritis dissecans, synovial chondromatosis
-
Hemarthrosis due to trauma, bleeding disorder such as hemophilia, or benign tumors such as hemangiomas and pigmented villonodular synovitis
-
Periodic fever syndromes such as familial Mediterranean fever
Workup and Diagnosis
- History
–Acute or chronic
–Mechanical (pain worsens with activities, improves
with rest, and usually involves weight-bearing joints)
–Inflammatory (waxing and waning, symptoms
unrelated to use, morning stiffness)
–History of trauma
–Night-time symptoms
–Attempted treatments
–Systemic symptoms: Fever, rash, pain, fatigue
–Past medical history: Birth history, existing medical
conditions, surgeries, broken bones, growth and development, medications
–Unusual exposures such as tick bites
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Physical exam
–Vital signs, including growth parameters
–Musculoskeletal exam for swelling, tenderness, warmth, redness, range of motion, asymmetry
–Muscle strength and neurologic exam (tone, sensory and reflexes)
–Lympadenopathy, organomegaly, rash, systemic symptoms
-
Radiologic evaluation may include X-ray, US, MRI, and bone scan to evaluate for fracture, infection, tenosynovitis, or internal derangements
-
Lab investigation may include CBC, ESR, CRP, examination of synovial fluid, viral titers (parvovirus), Lyme titers, RF, and ANA
Treatment
-
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
Book Source Details
- Book Title: In A Page: Pediatric Signs and Symptoms
- Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
- Year of Publication: 2007
- Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: In A Page: Pediatric Signs and Symptoms
Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 1-4051-0427-9
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» Next page: Monoarticular (Oligoarticular) Arthritis (A Pocket Manual of Differential Diagnosis)
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