The Child with Knee Pain: Differential Diagnosis and Physical Examination Tips

Transcription

1 The Child with Knee Pain: Differential Diagnosis and Physical Examination Tips Yukiko Kimura, MD Chief, Pediatric Rheumatology Professor of Pediatrics Suzanne C. Li, MD PhD Attending, Pediatric Rheumatology Associate Professor of Pediatrics Joseph M. Sanzari Children s Hospital Hackensack University Medical Center

2 Pedialink Pediatric Musculoskeletal Medicine

3 Major Causes of Musculoskeletal Pain in Children Mechanical Traumatic Inflammatory Infectious Neoplastic

4 History Age Location(s) Presence of systemic symptoms (fever, rash, weight loss, etc.) Recent infections Chronicity and severity of symptoms Ability to bear weight Recent SIGNIFICANT trauma Presence of joint swelling Mechanical vs inflammatory symptoms

5 Clues to Inflammatory Pain: Arthritis Pain and stiffness after INactivity Pain improves gradually with mild-moderate activity Can have pain with activity Joint swelling or warmth Tenderness of the joint Pain on passive range of motion and limitation of motion

6 Tumors and Malignancies: Red Flags Symptoms Pain at rest (not only with activity) Nocturnal pain Refusal to weight bear Physical findings Palpable and tender bony lesion Organomegaly (esp splenomegaly) and significant lymphadenopathy Laboratory testing Leukopenia, anemia, thrombocytopenia Relative thrombocytopenia (normal platelet count when ESR is elevated) Very high LDH

7 Observe Gait GAIT If possible, have the child walk up and down a long hallway Normal gaits change with development Toddler School age Adolescent

8 Gait: Walk on toes and heels Have child walk on her toes when walking toward you Walk on her heels as she walks away Look for feet and ankle abnormalities Flat feet Antalgic gaits may be worsened by walking on toes or heels if foot/ankle/heel involved Infection JIA Sever s disease Enthesitis-related arthritis

9 Examination of the Lower Patient should be supine Observe the legs Feel for warmth & effusion at the knee Active and passive range of motion Also assess in prone position Extremity

10 Range of motion: General pointers Upper extremities (patient should be upright) Lower extremities (patient should be supine) Active (have patient do) and passive ROM Passive ROM: Make sure you push the joint to the end points of motion Examine at least one joint above and below Compare both sides

11 First observe legs while standing

12 Pathological genu valgus and varum

13 Genu valgus & Flexion deformities due to arthritis

14 Asymmetrical flexion contracture (Oligoarticular JIA)

15 Multiple Contractures due to JIA

16 Genu Recurvatum due to hypermobility

17 More hypermobility: Pes Planus with Pronation

18 Next: observe when supine

19 Comparing both sides makes it easier to see differences Observe for: Joint swelling Muscle atrophy Leg length discrepancy

20 Dactylitis (Psoriatic arthritis) Notice nail changes

21 Observe from the side as well as above/below

22 Observe from behind (especially ankles)

23

24 Regional Examination The Knee

25 The Knee Examination Observe for knee swelling Localized (bursa) i.e., Baker cyst (out-pouching behind the knee) or generalized effusion Palpate for tenderness, warmth, effusion Palpate for tenderness Joint line Inferior pole of patella (Sinding-Larsen-Johansson disease) Tibial tuberosity (Osgood- Schlatter disease) Warmth may be subtle

26 Knee Examination (continued) Evaluate for fluid Ballotte patella (patellar tap) Examine for fluid wave ( bulge sign ) Evaluate for ROM and POM (Pain on Motion): Active and passive Put hand on knee while flexing (may feel a thrill or crepitus) With patient supine: Flex knee so heel touches buttock (135 ) Knee should slightly hyperextend (5-10 ) With femur fixed: 10 internal/external rotation

27 Mechanical Knee Pain: Causes Patellofemoral syndrome Teenaged girls with knee pain Hypermobility syndromes All ages Femoral anteversion and retroversion Pes planus with pronation

28 Patellofemoral Malalignment Syndrome Common in teenage girls Worsens with activity Stair climbing Sitting for a long time ( theater sign ) May include patella alta and patella subluxation Presents with patella apprehension sign and/or patella inhibition sign Abnormal increased Q angle

29 Patello-Femoral Syndrome +/-Crepitus with ROM Patella apprehension sign Pushing patella laterally causes apprehension Patella inhibition sign Inhibition of patella motion by pushing against the patella while patient contracts the quadriceps

30 Exaggerated Q angle

31 First Half Summary 1 Be aware of clues to the diagnosis (inflammatory vs mechanical) in the history Age is an important factor Some gait and stance abnormalities can be developmental Some diagnoses are more common in specific age groups Observing the gait, including toe and heel walk can provide clues

32 First Half Summary 2 The knee is one of the most commonly affected joints in injury, mechanical problems and inflammation The knee examination consists of: Observation (especially important to look at both) Palpation(warmth, swelling, tenderness: where?) Active and passive ROM (is there pain at extremes?) Special maneuvers to assess stability when injury is suspected