Zakiudin Munasir :

HERCULE POIROT IN :
BONE AND JOINT PAIN IN CHILDREN
Causes bone and joint pain in
children
43 medical conditions:
1. Trauma
2. Infection
3. Malignancy
4. Metabolic
5. Autoimmune
6. Growing pain
Synonym:
Juvenile Idiopathic
Arthritis (JIA)
One of the most
frequent chronic
illnesses in children
Short-term
disabilities
Long-term disabilitis
Juvenile
Rheumatoid
Arthritis (JRA)
A chronic arthritis that persists for a minimum of 6
consecutive weeks in one or more joints, commencing
before the age of 16 years and after active exclusion
other causes. (Cassidy et al.,1989:Ansell,1990)
Definition
High remittent fever with one or more of the following-
rash, hepatomegaly, splenomegaly, generalized
lymphadenopathy, serositis, usually pericarditis.
Arthritis may be absent at the onset, but myalgia or
arthralgia are ussualy present
Systemic disease
JUVENILE CHRONIC (RHEUMATOID) ARTHRITIS
5 or more joints develop in the
onset period usually
insidiously and symmetrically

Further divided by the
presence of IgM rheumatoid
factor
Polyarthritic onset:
Most common mode with 4 or
fewer joints involved
Particularly knees and ankles
Young children with positive
antinuclear antibodies who are at
risk from chronic iridocyclitis, and
older boys (aged 9 upwards) who
frequently carry the
histocompatible leucocyte antigen
(HLA) B27
Pauci-articular onset:
Include:
Juvenile psoriatic arthritis
Arthritis of inflammatory bowel
disease
Reiters syndrome
While some are as yet
unclassified.
Polyarthritic onset:
Classification:
By mode of onset during the first six
months
(Cassidy et al.,1989:Prieur et al., 1990)
Criteria for Classification of
Juvenile Rheumatoid Arthritis
1. Age at onset < 16 yr
2. Arthritis (swelling or effusion, or presence of two or more of the
following signs : limitation of range of motion, tenderness or pain
on motion, and increased heat) in one or more joints
3. Duration of disease 6 wk or longer
4. Onset type defined by type of disease in first 6 mo:
a. Polyarthritis : > 5 inflammed joints
b. Oligoarthritis (pauciarticular disease) : < 5 inflammed joints
c. Systemic-onset : arthritis with characteristic fever
5. Exclusion of other forms of juvenile arthritis
Modified from Cassidy JT, Levinson JE, Bass JC, et al :A study of classification criteria for a diagnosis of
juvenile rheumatoid arthritis, 1986
Treatment approach of
rheumatic diseases
American College of
Rheumatology Guideline

The goals of osteoarthritis (OA)
management are :
To control pain and other symptoms,
Minimize disability, and
Educate the patient about the disease
and its therapy
Multidiscipline
approach
Non-
pharmacologic
treatment
Pharmacologic
treatment
Surgery
THERAPEUTICS PRINCIPLES
Nonsteroidal antiinflammatory drugs
COX2 inhibitors
Steroids (systemic onset or uveitis)
Analgesics
Antiinflammatory
medications
Physical therapy
Ocupational therapy
Psychologic support
Exercise
Rehabilitation
techniques

Immunosuppressants
Biologic agents
Advance therapy
PHARMACOLOGIC THERAPY
Acetaminophen
Acetyl salicylic acid
Analgesics
Naproxen
Ibuprofen
Diclofenac
NSAID
The main therapy
for rheumatic
disease
Only for systemic or uveitis Corticosteroid
PHARMACOLOGIC THERAPY
Methotrexate, salazopyrin, hydroxychloroquine,
Other cytotoxics/immuno-suppressive drugs
(Azathioprine, cyclophosphamide, cyclosporine,
mycophenolate mofetil)
Disease modifying
antirheumatic
drugs
(DMARDs) :
Biphosphonate
Calcitonin
Antiosteo-
porotic
Etanercept, infliximab
Biologic agents
(biologic
DMARDs)
Table: Clinical Outcome-by Onset and Course Subtypes
Onset Type (N) Course Subtype
(n)
Profile Outcome
Polyarthritis
(78)
RF seropositive
(16)
Female
Older age
Hand-wrist
Involvement
Erosions
Nodules
Unremitting
Poor
ANA seropositive
(38)
Female
Young age
Good

Seronegative (24) Variable Good
ANA, anti nuclear antibodies; RF, rheumatoid factors
Cassidy JT, Levinson JE, et al: A sudy of classification criteria for a diagnosis of juvenile rheumatoid
arthritis. Arthritis Rheum 29: 274-278, 1986
Table: Clinical Outcome-by Onset Type and Course Subtypes (cont.)
Onset Type (N) Course Subtype (n) Profile Outcome
Oligoarthritis
(121)
ANA seropositive
(66)
Female
Young age
Chronic
uveitis
Excellent
(except eyes)
RF seropositive (8) Polyarthritis
Erosions
Unremitting
Poor
HLA-B27 positive
(120)
Male
Older age
Good
Seronegative (35) Variable Excellent
Systemic
disease (51)
Oligoarthritis (30) Variable Good
Polyarthritis (21) Erosions poor
43
43
Endoscopically Detected Bleeding Ulcer
Endoscopically Detected Bleeding Ulcer
When pain strikes, it's natural for child to
want to sit still
But it's important to maintain a regular
exercise program
Muscles must be kept strong and healthy
so they can help support and protect joints
Regular exercise also helps to maintain
range of motion.
GROWING
PAIN
Positive connotation :
Most parents accept it as a benign condition
Negative connotation :
This diagnosis has been too frequently applied to children who
actually have a serious rheumatic or malignant disease
Most occur in preschool- to school-aged
children
The pathophysiology is unknown
Growing pains
Growing Pains (Benign Nocturnal
Pains of Childhood)
Age at onset
4 to 12 years
Sex ratio
Probably equal, slightly more girls in
some series
Symptoms
Deep aching, cramping pain in thigh or
calf, usually in the evening or during the
night; never present in the morning;
bilateral; responds to massage and
analgesia
Signs
Physical examination results are normal
Investigations
Laboratory and radiographic studies (if
done) have normal results
Modified from Cassidy JT, Petty RE, Laxer RM, Lindsley, ed. Textbook of Pediatric Rheumatology, 2005
V
Children who have unusual
symptoms or abnormal
findings on examination
should not be diagnosed
as having growing pains

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