Acute and Non-acute Lower Extremity Pain in the Pediatric Population

Part III

Allison D. Duey-Holtz, MSN, RN, CPNP; Sara L. Collins, MSN, RN, CPNP; Leah B. Hunt, PA-C, MMSc; Polly F. Cromwell, MSN, RN, CPNP

Disclosures

J Pediatr Health Care. 2012;26(5):380-392. 

In This Article

Immune Mediated

Juvenile Idiopathic Arthritis

Definition. Juvenile idiopathic arthritis is any form of arthritis or arthritis condition that develops in a person younger than 18 years (Arthritis Foundation, 2009).

Etiology.

  • Juvenile idiopathic arthritis is considered an autoimmune condition

    • Polyarticular

    • Pauciarticular

    • Systemic onset

History of Present Illness.

  • Morning stiffness or stiffness after naps that tends to resolve in the ensuing hours

  • Unilateral or bilateral joint swelling

  • May present with a history of trauma

  • More common in female patients

  • Persistent pain despite use of over-the-counter treatments

  • Review family history for other diseases including psoriasis, ankylosing spondylolysis, sacro-ileitis, inflammatory bowel disease, or uveitis

Physical Examination.

  • Polyarticular: Usually presents symmetrically, affecting five or more joints; most commonly affected joints are the knees, wrists, and ankles, although the hips, shoulders, neck, and jaw also can be affected

    • Most commonly associated with uveitis

  • Pauciarticular/oligoarthritis: Affects four or fewer joints; affects female patients 3:1; a positive antinuclear antibody test in this group suggests high risk for developing uveitis

  • Systemic: High spiking fevers, papular rash, general lymphadenopathy, ill appearing, serositis, splenomegaly and hepatomegaly, joint involvement develops slowly but may include up to five "smaller" joints such as fingers and the cervical spine

Diagnostic Tests.

  • Diagnosis of exclusion; must rule out non-inflammatory musculoskeletal conditions that cause joint pain such as Legg-Calve-Perthes, Osgood Schlatter, and SCFE

  • AP and lateral radiographs of bilateral lower extremities should be obtained; the radiographs should be normal initially in patients with JIA

  • No single laboratory test can diagnosis JIA because it is a diagnosis of exclusion; obtain a CBC, ESR, and CRP to exclude infectious or neoplastic etiology; an elevated ESR and CRP can be associated with JIA, but normal laboratory findings do not exclude the diagnosis; rheumatology may order ASO, anti-deoxyribonuclease B, and Lyme serology in Lyme-endemic areas

    • Additional inflammatory laboratory tests: the antinuclear antibody test will only confirm uveitis; only 3% to 5% of children with JIA have a positive rheumatoid factor

Treatment.

  • Exclude other etiologies first, especially if the patient has a positive family history of the aforementioned conditions

  • Refer the patient to pediatric rheumatology

  • Subspecialist care may include scheduled anti-inflammatory drugs such as naproxen, 10–20 mg/kg/day in a divided dose twice a day; diclofenac, 2–3 mg/kg/day in a divided dose three or four times a day; or ibuprofen, 30–40 mg/kg/day in a divided dose two or three times a day (Arthritis Foundation, 2009; Junnilla & Cartwright, 2006; Stanley & Ward-Smith, 2011)

Toxic Synovitis/Transient Synovitis of the Hip

Definition. Toxic synovitis/transient synovitis of the hip is the most common source of hip pain in the young child. It consists of acute hip pain with a limp in childhood without any associated musculoskeletal or constitutional symptoms.

History of Present Illness.

  • Limp may be present

  • The patient is afebrile

Physical Examination.

  • Mild/moderate hip pain with motion; the patient should not have refusal to range joint

  • May have a limp

Diagnostic Tests.

  • Normal or mildly elevated CBC, ESR, and CRP levels

  • A hip ultrasound may show effusion

Treatment.

  • NSAIDs

  • Follow-up in 2 to 3 days or sooner with increased symptoms

  • Ambulation as tolerated and restrict sports activities

  • Refer to the emergency department or an orthopedic surgeon with increasing pain and/or fever (Herring, 2008; Morrissy & Weinstein, 2006; Staheli, 2007; Staheli & Song, 2007)

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