Arthritis in A Teenager



Arthritis in A Teenager


B. J. Manaster, MD, PhD, FACR



DIFFERENTIAL DIAGNOSIS


Common



  • Juvenile Idiopathic Arthritis (JIA)


  • Ankylosing Spondylitis (AS)


  • Psoriatic Arthritis


  • Septic Joint


  • Pigmented Villonodular Synovitis (PVNS)


  • Femoral Acetabular Impingement (FAI)


  • Developmental Dysplasia of Hip


Less Common



  • Hemophilia: MSK Complications


  • Synovial Osteochondromatosis


  • Legg-Calvé-Perthes, Secondary Changes


  • Chronic Reactive Arthritis


  • Inflammatory Bowel Disease Arthritis


  • Osteoid Osteoma of Hip, 2° Changes


Rare but Important



  • Congenital Insensitivity/Indifference to Pain


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Surprising number of arthridities originate during childhood or teenage years


  • Early and accurate diagnosis is important to initiate treatment and avoid later debilitating joint disease


Helpful Clues for Common Diagnoses



  • Juvenile Idiopathic Arthritis (JIA)



    • May have 1 of several manifestations



      • 5% appear indistinguishable from adult rheumatoid arthritis (RA); most become seropositive


      • 40% are pauciarticular, affecting knee, elbow, and ankle most frequently; seronegative; 25% develop iridocyclitis


      • 20% have Still disease: Acute systemic disease with fever, anemia, hepatosplenomegaly; 25% of these have polyarticular destructive arthritis, affecting small and large joints alike


      • 25% have seronegative polyarticular disease, symmetric & widespread in adult distribution; no systemic complaints & seronegative


    • Specific features generally distinguishing JIA from other teenage arthridities



      • Enlarged metaphyses and epiphyses (“balloon joints”) due to overgrowth, secondary to hyperemia from inflammatory process


      • Cartilage narrowing & widened notches related to pannus formation & erosion


      • Often asymmetric


    • Other distinguishing features



      • Periostitis may be 1st manifestation in young child


      • Fusion frequently occurs in carpals


      • Interbody fusion in cervical spine limits growth of vertebral bodies, giving “waisted” appearance


  • Ankylosing Spondylitis (AS)



    • Earliest manifestations (clinical and radiographic) occur during teenage years


    • Spinal manifestations initiate radiographic disease process



      • Osteitis at anterior corners of vertebral bodies


      • SI joint widening and erosions; may be asymmetric initially


      • Teenagers normally have wide SI joints with indistinct cortices; do not overcall!


    • Appendicular disease most frequently is in large proximal joints, particularly hips; may be erosive or productive


  • Psoriatic Arthritis



    • 30-50% of psoriatic patients develop spondyloarthropathy



      • Bilateral asymmetric erosive disease; may eventually fuse


    • 20% of psoriatic patients develop arthropathy prior to skin and nail changes


    • Distinguishing features



      • May have “sausage” digit with periostitis


      • DIP disease predominates; hands > feet


      • Aggressive erosive disease (“pencil-in-cup”) and eventual fusion


  • Septic Joint



    • Monostotic; cartilage damage and osseous deformity eventually leads to secondary osteoarthritis


    • If longstanding & slow process in child (especially tuberculous or fungal septic joint), hyperemia leads to overgrowth of epiphyses & metaphyses: “Balloon” joint


  • Pigmented Villonodular Synovitis (PVNS)



    • Monoarticular; nodular mass or nodules lining synovium



    • Causes erosion if longstanding


    • Large effusion; iron deposition results in foci of low signal, which bloom on GRE


  • Femoral Acetabular Impingement (FAI)



    • Often bilateral abnormalities, though complaints usually begin unilaterally


    • Morphologic abnormalities of femoral head, neck, or acetabulum → impingement



      • Lateral femoral neck “bump,” limiting normal head/neck cutback: Cam type


      • Acetabular rim overgrowth or retroversion: Pincer type


      • Multiple etiologies: Trauma, DDH, SCFE


      • → labral tear and cartilage damage → early osteoarthritis


      • Onset of complaints 2nd or 3rd decade


  • Developmental Dysplasia of Hip



    • Multiple types of dysplasia



      • Shallow acetabulum


      • Femoral varus or valgus


      • Acetabular or femoral retroversion


    • Develop labral hypertrophy; with shear stress, labrum tears; eventual cartilage damage and early osteoarthritis


Helpful Clues for Less Common Diagnoses

Aug 10, 2016 | Posted by in PEDIATRICS | Comments Off on Arthritis in A Teenager

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