Initial Evaluation of Children with

Arthritis

Cahya Dewi Satria

Child Health Department

Medical Faculty, Public Health & Nursing
Universitas Gadjah Mada/ Dr Sardjito Hospital
 Background
• Musculoskeletal pain in children are common, affecting
about 10-20 % of school children.1,2
• Various local and systemic, acute and chronic, benign and
malignant conditions are associated with musculoskeletal pain.3
• Arthritis in childhood is common. The pattern, presentation
and duration of arthritis help differentiate between the various
possible diagnoses.4
• Pain, joint line tenderness and limitation of range of motion on
both active and passive movement characterize articular
disorders.5

1. Malleson P, Beauchamp R. Diagnosing musculoskeletal pain in children CMAJ. 2001;2:183-8.

2. A Gedalia. ==Join pain in children: an algorithmic approach. IMAJ. 2012;4:837-42.
3. Islam M, Taliukder M, Rahman S. An Approach to Child with Arthritis. Bangladesh J child health. 2014;38:109-
16.
4. Prabhu AS, Balan S. Approach to a child with monoarthritis. Indian J Pediatr. 2010;77(9):997-1004.
 Table 1. Common Causes of Articular Involvement in Children

1. Khubchandani RP, D’Souza S. Initial evaluation of a child with arthritis—An algorithmic approach. The Indian Journal of
Pediatrics. 2002;69(10):875-80.
 Table 2. Juvenile Idiopathic Arthritis (JIA)- Durban Classification1

1. Petty R, Cassidy J, Laxer R, Lindsley C. Textbook of Pediatric Rheumatology 2011:211-88.

 Table 3. Chronology 1

1. Khubchandani RP, D’Souza S. Initial evaluation of a child with arthritis—An algorithmic approach. The Indian
Journal of Pediatrics. 2002;69(10):875-80.
 Table 4. Extra-articular signs to be looked in a child with arthritis1

1. Islam M, Taliukder M, Rahman S. An Approach to Child with Arthritis. Bangladesh J child health. 2014;38:109-16.
 DEFINITION
• Arthritis is manifested as a swollen joint or a joint
having at least 2 of the following conditions: limited range
of motion, pain on movement, or warmth overlying the
joint.
• Children with arthritis more commonly present with
complaints of joint swelling and/or gait disturbance.1

1. Petty R, Cassidy J, Laxer R, Lindsley C. Textbook of Pediatric Rheumatology 2011:211-88

 Diagnosis
• The most important aspects of the diagnosis are
comprehensive history taking and a detailed clinical
examination.1
• Clinical informations in patient including :
– demography,
– disease chronology,
– inflammatory nature,
– progression,
– distribution of joint involvement and
– extra-articular manifestations
 help narrow the diagnostic possibilities.

1. Singh S, Mehra S. Approach to polyarthritis. Indian J Pediatr. 2010;77(9):1005-10.

 • Important aspects to be emphasized from the
history taking are as follows:
age of onset of the disease,
gender,
onset of disease and duration and
characteristics of the pain and/or stiffness.1

1. Islam M, Taliukder M, Rahman S. An Approach to Child with Arthritis. Bangladesh J

child health. 2014;38:109-16.
 Red flags signs
Red flags signs are followings:
fever,
malaise,
systemic upset (reduced appetite, weight loss,
sweating),
bone or joint pain with fever ,
refractory or unremitting pain,
persistent night-waking,
incongruence between history and presentation.1
1. Foster HE, Kay LJ, Friswell M, Coady D, Myers A. Musculoskeletal screening examination (pGALS) for school-age children based on the
adult GALS screen. Arthritis Rheum. 2006;55(5):709-16.
 Physical examination
• The focused examination of the affected joint should include inspection of the
skin for warmth, redness, swelling, and soft tissue involvement, using the
contralateral side for comparison. Passive and active range of motion should be
observed.1
• A recently developed and validated tool is the pediatric Gait, Arms,
Legs, Spine screening (pGALS), which is a simple musculoskeletal
screening examination that can be performed in a few minutes (Figure 1).11
• The pediatric Gait, Arms, Legs, Spine screening (pGALS) has been
demonstrated excellent sensitivity to detect abnormality, quick to perform with
highly acceptable to school age children and their parents.3

1. Goff I, Bateman B, Myers A, Foster H. Acceptability and Practicality of Musculoskeletal Examination in Acute
General Pediatric Assessment. jpeds. 2010;156:657-62.
2. Foster H, JAnidal S. pGALS – paediatric Gait Arms Legs and Spine: a simple examination of the
musculoskeletal system. Pediatric Rheumatology. 2013;11:2-7.
3. Foster HE, Kay LJ, Friswell M, Coady D, Myers A. Musculoskeletal screening examination (pGALS) for school-
age children based on the adult GALS screen. Arthritis Rheum. 2006;55(5):709-16.
 Fig.1. The The pediatric Gait, Arms, Legs, Spine screening (pGALS) assessment 1,2

1. Foster H, JAnidal S. pGALS – paediatric Gait Arms Legs and Spine: a simple examination of the musculoskeletal system. Pediatric
Rheumatology. 2013;11:2-7.
2. Foster HE, Kay LJ, Friswell M, Coady D, Myers A. Musculoskeletal screening examination (pGALS) for school- age children based on the
adult GALS screen. Arthritis Rheum. 2006;55(5):709-16.
 Appearance Movement
Gait V V
Arm V V
Leg V V
Spine V V

With Prof Helen Foster (Advanced Ped Rheum Course,Mumbai, 2016)

 Laboratory

• Laboratory tests in rheumatology are important tools that

help to support the diagnosis of autoimmune diseases,
evaluate the disease activity, monitor the side effects of
therapy, and also assist the physician to exclude
rheumatologic mimics.1
• In rheumatic diseases markers of inflammation like CRP and
erythrocyte sedimentation rate (ESR) are usually raised.
• In addition, various autoantibodies like anti- nuclear
antibody, rheumatoid factor, anti-neutrophil cytoplasmic
antibody help in diagnosis of systemic autoimmune
rheumatic diseases. 2

1. Agarwal M, Sawhney S. Laboratory tests in pediatric rheumatology. Indian J Pediatr. 2010;77(9):1011-6.

2. Aggarwal A. Clinical application of test used in rheumatology. Indian J Pediatr. 2002;10:889-92.
 Case
Male, 12 years old

History taking:
• Pain and swollen at genu sinistra and
dextra since 6 weeks ago. Symptom is
persist until now with the same location.
•Limitation of movement is also persist.
• There is morning stiffness.
•There are NO: fever, abdominal pain, rash
 Physical exam:
•General appearance: look pain
with limitation of movement
•Vital Signs: normal
•Extremity: arthritis at both of genu,
limitation movement
pGALS examination:
1. Do you have any pain ? Yes
2.Do you have any difficulty to getting dress ? No
3. Do you have difficulty to go up and go down at stairs?
Yes
Appearance: Movement:
Gait √ x
Arm √ √
Leg x x
Spine √ √
 CONCLUSION
• Arthritis in a child could be a benign self-limiting
illness, but sometimes might be a serious chronic
illness resulting in significant morbidity and /or
mortality.
• In spite of broad differential diagnosis, an organized
approach including careful history taking and physical
examination is very much essential for correct
diagnosis.
• pGALS is a useful way to increase awareness of joint
disease
• Laboratory tests are important tools that help to
support the diagnosis.
MATURNUWUN