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Approach to Back Pain in Children
Paediatric Emergency Medicine — Clinical Decision Algorithm

Red Flag Symptoms — Act Immediately

Neurological deficit (weakness, paraesthesia)
Bowel or bladder dysfunction
Saddle anaesthesia
Fever + back pain
Night pain (wakes from sleep)
Weight loss / night sweats
Age <5 years with back pain
Progressively worsening pain
Immunocompromised host
Recent spinal procedure or IV drug use
Step 1 — Initial Assessment
Child with Back Pain
Full history · Vitals · Neurological exam
Document: onset, character, radiation, aggravating/relieving, systemic symptoms, trauma, sport, travel, immunisation, country of origin
Any red flags present?
YES
Urgent workup
IV access · Bloods (CBC, CRP, ESR, cultures) · Urgent MRI spine · Surgical/ID consult
NO
Proceed to Step 2
Further risk stratification by age, mechanism, and examination
Step 2 — Risk Stratification by Presentation

Infectious / Inflammatory

  • Fever, elevated CRP/ESR
  • Refusal to walk (toddler)
  • Tenderness over vertebral body
  • Constitutional symptoms
  • Immigrant / TB-endemic origin
→ See Track A

Mechanical / Overuse

  • Adolescent athlete
  • Hyperextension sport
  • Pain with activity, relieved by rest
  • Positive stork test
  • No systemic features
→ See Track B

Neoplastic / Infiltrative

  • Night pain not relieved by rest
  • Weight loss, night sweats
  • Gibbus deformity
  • Bony tenderness + mass
  • Abnormal CBC
→ See Track C
Track A — Suspected Infectious Aetiology
CBC · CRP · ESR · Blood cultures · X-ray spine
Fever + elevated CRP/ESR?
YES
MRI spine with contrast
Admit · IV antibiotics (anti-staphylococcal ± MRSA cover) · Orthopaedic + ID consult
NO / LOW GRADE
Consider diskitis (toddler) or early osteomyelitis
MRI spine · Low threshold to admit · Repeat labs in 24–48h

Epidural Abscess — Do Not Miss

  • Fever + back pain + any neurological sign
  • Urinary retention, leg weakness, sensory level
  • MRI spine urgently — do not wait
  • Neurosurgical emergency
  • Triad: fever · back pain · neuro deficit (rarely all 3 together)

Pott's Disease (Spinal TB)

  • TB-endemic origin · BCG scar noted
  • Constitutional symptoms + gibbus deformity
  • IGRA preferred over TST in BCG-vaccinated
  • CXR: hilar adenopathy
  • Airborne precautions immediately
  • 12 months antitubercular therapy
Track B — Mechanical / Athletic Back Pain
High-risk sport? · Stork test · Hyperextension pain?
Positive stork test or hyperextension pain in athlete?
YES
X-ray lumbar spine (AP + lateral + oblique)
Look for pars defect "Scotty dog collar" · If equivocal → CT or MRI · Activity restriction · Sports medicine referral
NO
Likely muscular strain or overuse
NSAIDs · Physiotherapy referral · No imaging if afebrile + normal neuro · Return precautions

Spondylolysis

  • Pars interarticularis stress fracture
  • L5 most common (80–90%)
  • Oblique x-ray: "Scotty dog collar"
  • CT: most sensitive for bony defect
  • Treatment: rest, brace, physio 3–6 months

Spondylolisthesis — Grade Determines Urgency

  • Grade I–II (<50% slip): conservative management
  • Grade III–IV (>50%): urgent orthopaedic referral
  • Any neurological deficit → surgical consideration
  • Measure slip % on lateral x-ray
Track C — Suspected Neoplastic / Infiltrative

Investigations

  • CBC + differential · blood film
  • LDH · uric acid (leukaemia screen)
  • ESR · CRP · LFTs
  • X-ray spine (vertebral destruction, periosteal reaction)
  • MRI spine + whole spine — gold standard
  • Oncology consultation early

Key Diagnoses to Consider

  • Ewing sarcoma — destructive lesion, periosteal reaction, soft tissue mass
  • Osteoid osteoma — night pain, NSAIDs dramatically relieve; CT diagnostic
  • Leukaemia — metaphyseal lucent bands, pancytopenia
  • Lymphoma — vertebral involvement, mediastinal mass
  • Langerhans cell histiocytosis — vertebra plana (flattened vertebral body)
Do Not Miss — Back Pain as Referred Pain

Pulmonary

  • Lower lobe pneumonia
  • Empyema / parapneumonic effusion
  • Check SpO2 on every patient
  • Auscultate lung bases

Abdominal / Retroperitoneal

  • Pyelonephritis (CVA tenderness)
  • Pancreatitis (mid-back, elevated lipase)
  • Appendicitis (retrocaecal)
  • Psoas abscess

Vascular / Spinal Cord

  • Aortic aneurysm (rare in children)
  • Spinal cord tumour
  • Sickle cell vaso-occlusive crisis
  • Transverse myelitis
Imaging Decision Guide

X-Ray First

  • Athlete with hyperextension pain
  • Suspected fracture / trauma
  • Scoliosis screening
  • Initial screen for bony lesion
  • Always include oblique views if spondylolysis suspected

MRI Urgently

  • Any neurological deficit
  • Suspected epidural abscess
  • Suspected cord compression
  • Fever + back pain + elevated CRP
  • Suspected spinal TB with neuro signs

MRI Non-Urgently / CT

  • Diskitis / osteomyelitis without neuro deficit
  • Equivocal x-ray for spondylolysis (CT)
  • Suspected Pott's disease (MRI)
  • Osteoid osteoma characterisation (CT)
  • Night pain with normal x-ray
Approach to Chest Pain in Children
Paediatric Emergency Medicine — Clinical Decision Algorithm

High-Risk Features — Cardiac Until Proven Otherwise

Exertional chest pain or syncope
Palpitations with chest pain
Family history of sudden cardiac death <40 years
Known congenital heart disease
Pain radiating to arm, jaw, or back
Haemodynamic instability
Abnormal ECG
SpO2 <95% on room air
Kawasaki disease history
Marfan / connective tissue features
Step 1 — Initial Assessment (Every Patient)
Child with Chest Pain
Vitals · SpO2 · ECG within 10 min · Brief targeted history
Pain character · Onset · Exertional vs. rest · Positional · Associated symptoms · Medications · Family history
Haemodynamically unstable or SpO2 <95%?
YES
Resuscitation bay immediately
Oxygen · IV access · Continuous monitoring · Bedside echo · Cardiology stat
NO
Stable — proceed to ECG interpretation
ECG is mandatory in all children with chest pain
Step 2 — ECG Interpretation (Mandatory in All)
12-lead ECG — measure manually: QTc · PR · QRS · ST segments · Delta waves
Bazett formula: QTc = QT ÷ √RR interval. Normal <440ms (male) / <460ms (female). >500ms = very high risk.
ECG abnormal?
YES
Cardiac cause — see Track A
Admit · Continuous monitoring · Cardiology consult
NO — Normal ECG
Proceed to clinical characterisation
Normal ECG significantly lowers cardiac risk but does not exclude all causes
ECG Findings and Their Significance

Act Immediately

  • QTc >500ms — high risk Torsades de Pointes
  • ST elevation — myocarditis, pericarditis, ACS
  • Broad complex tachycardia — VT until proven otherwise
  • Complete heart block — 3rd degree AVB
  • Delta waves (WPW) — pre-excitation, risk of AF + VF
  • Brugada pattern — saddle ST in V1–V2

Investigate Further

  • QTc 460–500ms — borderline prolonged; check drugs, electrolytes
  • Diffuse saddle ST + PR depression — pericarditis pattern
  • 1st degree AVB — minor criterion for ARF; investigate further
  • T-wave inversions V1–V4 — RV strain, ARVC, Wellens
  • LVH criteria — HOCM, hypertensive heart disease

Generally Reassuring

  • Normal sinus rhythm
  • QTc <440ms
  • Normal axis and intervals
  • Benign early repolarisation pattern
  • Isolated sinus tachycardia (investigate cause)
Step 3 — Clinical Characterisation (Normal ECG)

Track A — Cardiac / Serious

  • Exertional onset or syncope
  • Palpitations with pain
  • Positional (worse lying flat)
  • Radiation to arm / jaw / back
  • Family history sudden death
  • Kawasaki / CHD history
→ Troponin · Echo · Cardiology

Track B — Pulmonary

  • Sudden onset with dyspnoea
  • Pleuritic (worse with breathing)
  • Decreased breath sounds
  • Known asthma — failed bronchodilator
  • Risk factors for PE
  • SpO2 borderline
→ CXR · POCUS · Consider CTPA

Track C — Musculoskeletal / Other

  • Reproducible chest wall tenderness
  • No exertional component
  • Worse with palpation / movement
  • Afebrile, normal vitals, normal ECG
  • Post-viral, adolescent, female
→ Likely benign — see Track C
Track A — Cardiac Causes

Myocarditis / Myopericarditis

  • Post-viral (Coxsackie B, parvovirus, influenza)
  • Positional pain, friction rub, fever
  • ECG: diffuse saddle ST, PR depression (Stage 1)
  • Always check troponin — any elevation = myopericarditis
  • Echo: effusion, wall motion, EF
  • If EF reduced: stop NSAIDs — admit ICU
  • If EF normal: NSAIDs + colchicine × 3 months
  • No sport for minimum 3–6 months

Arrhythmia — LQTS / WPW / VT

  • Exertional syncope + palpitations = cardiac emergency
  • LQTS: QTc >500ms · Stop all QT-prolonging drugs · IV Mg · Correct K+ (target >4.5) · Beta-blocker
  • WPW: delta waves · No adenosine if AF present · Cardiology urgently
  • CPVT: normal resting ECG · Exercise-induced VT · Beta-blocker / flecainide
  • Hold from all sport pending full workup
  • Screen first-degree family members

HOCM

  • Exertional chest pain / syncope / sudden death
  • Harsh systolic murmur — increases with Valsalva, decreases with squatting
  • ECG: LVH, deep septal Q waves in lateral leads
  • Echo: septal hypertrophy, LVOTO, SAM of mitral valve
  • Disqualify from competitive sport
  • Beta-blocker / verapamil / septal reduction

Anomalous Coronary / Kawasaki Sequelae

  • Exertional ischaemia in young athlete — consider anomalous coronary
  • History of Kawasaki disease → coronary aneurysm risk
  • ECG: ischaemic changes (ST depression, T-wave inversion)
  • Troponin elevated
  • CTA coronary arteries or stress echo
  • Cardiology and cardiac surgery referral
Track B — Pulmonary Causes

Pneumothorax

  • Sudden onset unilateral pain + dyspnoea
  • Decreased breath sounds · Hyperresonant · No wheeze
  • POCUS: absent lung sliding (barcode sign on M-mode)
  • CXR upright — measure lung collapse %
  • Small / stable: O2 + observation
  • Large (>20%) or symptomatic: aspiration or chest tube
  • Tension: needle decompression immediately — do NOT wait for CXR

Pulmonary Embolism

  • Rare in children — but do not miss in adolescents
  • Risk factors: OCP, immobilisation, thrombophilia, malignancy, central line
  • Pleuritic pain + tachycardia + hypoxia
  • ECG: sinus tachycardia, S1Q3T3 (uncommon in children)
  • D-dimer if low-moderate risk (high sensitivity, low specificity)
  • CTPA if high clinical suspicion
  • Anticoagulation: LMWH first-line in paeds
Track C — Musculoskeletal and Other Causes

Costochondritis

  • Most common cause of paediatric chest pain
  • Reproducible tenderness at costochondral junctions
  • No exertional component · Afebrile · Normal ECG
  • Treatment: NSAIDs + reassurance
  • Expected resolution 1–2 weeks
  • Do not over-investigate — increases anxiety

GERD / Oesophageal

  • Burning, epigastric component, post-prandial
  • Worse lying flat — may mimic pericarditis
  • Trial of antacid / PPI as both diagnostic and therapeutic
  • Oesophageal spasm: intermittent, severe, may radiate
  • Boerhaave syndrome (rare): vomiting + severe chest pain + mediastinal air

Anxiety / Functional

  • Diagnosis of exclusion — do not dismiss prematurely
  • Associated with hyperventilation, situational triggers
  • Recurrent brief episodes, often in school-aged girls
  • Normal ECG, normal exam
  • Acknowledge the pain — avoid reinforcing cardiac fear
  • Psychology referral if recurrent / functional impairment
Common QT-Prolonging Drugs in Paediatrics — Medication Reconciliation

High-Risk QT-Prolonging Drugs

  • Antibiotics: azithromycin, clarithromycin, fluoroquinolones
  • Antipsychotics: haloperidol, quetiapine, risperidone
  • Antidepressants: citalopram, escitalopram, TCAs
  • Antiemetics: ondansetron, metoclopramide, domperidone
  • Antifungals: fluconazole, voriconazole
  • Stimulants: high-dose amphetamines

Aggravating Factors — Compounding Risk

  • Hypokalaemia — target K+ >4.5 in LQTS
  • Hypomagnesaemia
  • Hypocalcaemia
  • Bradycardia
  • Female sex (longer baseline QTc)
  • Combining ≥2 QT-prolonging agents
  • Congenital LQTS + any QT-prolonging drug
Return to Sport — Minimum Timelines

Low Risk — Resume Sport

  • Costochondritis: as tolerated
  • Vasovagal syncope (confirmed): after workup
  • Isolated pericarditis (no myocarditis, normal echo): 3 months minimum

Restricted — Cardiology to Clear

  • Myopericarditis (mild troponin, preserved EF): 3–6 months
  • WPW post-ablation: cardiology clearance required
  • Borderline QTc (460–500ms): individualised
  • LQTS on beta-blocker: sport-specific guidance

Disqualified Pending Full Workup

  • Myocarditis (reduced EF): 6 months minimum, often longer
  • HOCM: usually disqualified from competitive sport
  • Anomalous coronary (unrepaired): no sport
  • QTc >500ms: no sport until evaluated
  • Exertional syncope without diagnosis: no sport
Investigation Decision Guide

All Patients — Mandatory

  • 12-lead ECG — within 10 minutes of arrival
  • SpO2 · HR · BP (bilateral if aortic concern)
  • Detailed medication reconciliation
  • Three-generation family history

Selective — Based on Presentation

  • Troponin: any post-viral or exertional chest pain
  • CXR: dyspnoea, pleuritic pain, suspected PTX or effusion
  • Echo: murmur, pericarditis, myocarditis, Kawasaki Hx
  • POCUS: suspected PTX or effusion — faster than CXR
  • D-dimer: suspected PE with low–moderate pretest probability

Specialist-Directed

  • Holter / event monitor: palpitations, intermittent symptoms
  • Exercise stress test: exertional symptoms, CPVT evaluation
  • CTA coronary: anomalous coronary, Kawasaki sequelae
  • Cardiac MRI: myocarditis characterisation, ARVC
  • Genetic testing: LQTS, HOCM, Brugada — family screening
Approach to Joint Pain in Children
Paediatric Emergency Medicine — Clinical Decision Algorithm

High-Risk Features — Do Not Miss

Fever + hot swollen joint = septic arthritis until proven otherwise
Complete refusal to bear weight
Kocher criteria ≥3
Bone pain + pallor + fatigue (leukaemia)
Bilateral joint involvement with fever + rash
Limp lasting >2 weeks without explanation
Neurological symptoms with joint pain
Joint pain + urinary symptoms (reactive arthritis, ARF)
New cardiac murmur + migratory arthritis (ARF)
Suspected non-accidental injury
Step 1 — Initial Assessment
Child with Joint Pain or Limp
Vitals · Full joint examination · Gait assessment
Document: age · affected joint(s) · onset and duration · fever · trauma · recent infection · rash · family history · sport · travel · tick exposure
Fever present or refuses to bear weight?
YES
High priority — see Track A
CBC · CRP · ESR · Blood cultures · Ultrasound · Apply Kocher criteria
NO
Afebrile — proceed to Step 2
Further stratification by age, mechanism, and duration
Step 2 — Clinical Characterisation (Afebrile)

Track A — Acute Hot Joint

  • Fever + swollen joint
  • Acute onset, refusing to weight bear
  • Elevated WBC / CRP
  • Any Kocher criteria met
→ Septic arthritis workup

Track B — Mechanical / Structural

  • Afebrile, insidious onset
  • Activity-related, athlete
  • Specific age-related diagnoses
  • Normal or mildly elevated CRP
→ Imaging-guided diagnosis

Track C — Inflammatory / Systemic

  • Morning stiffness >45 min
  • Multiple joints or migratory
  • Rash, systemic symptoms
  • Chronic / recurrent course
→ Inflammatory arthritis workup
Track A — The Hot Joint: Excluding Septic Arthritis
CBC · CRP · ESR · Blood cultures · Joint ultrasound
Apply Kocher criteria (hip) or equivalent clinical judgment (other joints)
Kocher Criteria Score
Fever >38.5°C · Non-weight bearing · ESR >40 · WBC >12,000 · (CRP >2 mg/dL = fifth criterion per Caird)

0–1 Criteria (~<3% probability)

  • Low risk for septic arthritis
  • Consider transient synovitis
  • Observe with NSAIDs
  • Mandatory 24–48h follow-up
  • Clear return precautions
  • If worsening → re-evaluate and consider aspiration

2 Criteria (~40% probability)

  • Intermediate risk — grey zone
  • Ultrasound-guided aspiration considered
  • Admit for observation vs. aspiration depends on clinical gestalt
  • Orthopaedics involved
  • Serial labs at 12–24h
  • Never discharge without follow-up plan

3–4 Criteria (>93% probability)

  • Treat as septic arthritis
  • Urgent orthopaedic consult
  • IV antibiotics (anti-staphylococcal ± MRSA)
  • Surgical washout in OR — do not delay
  • Blood cultures before antibiotics if <15 min delay
  • AVN risk if >4–6h delay (hip)

Septic Arthritis — Antibiotic Guide

  • Empiric (all ages): cefazolin 50mg/kg/dose IV TID
  • Add MRSA cover if: community MRSA prevalent, failed prior antibiotics, ill-appearing — use clindamycin or vancomycin
  • Neonate: add gram-negative cover (gentamicin or cefotaxime)
  • Adolescent sexually active: add ceftriaxone (gonococcal)
  • Lyme endemic area: doxycycline if Lyme arthritis confirmed
  • Duration: 3–4 weeks total (IV then oral step-down)

Joint Fluid Interpretation

  • Normal: WBC <200, clear, viscous
  • Non-inflammatory: WBC 200–2,000 — OA, trauma, AVN
  • Inflammatory: WBC 2,000–50,000 — JIA, reactive, Lyme, ARF
  • Septic: WBC >50,000 (PMN >90%) — septic arthritis
  • Lyme arthritis: WBC 10,000–100,000 — overlaps with septic range
  • Culture sensitivity: only 30–50% positive in confirmed septic arthritis — treat clinically
Track B — Age-Related Mechanical and Structural Diagnoses

Age 0–3 Years

  • Toddler's fracture — tibial spiral fracture; oblique x-ray; cast
  • Developmental dysplasia of hip — Galeazzi sign; Ortolani/Barlow; ultrasound
  • NAI — inconsistent history; posterior rib fractures; skeletal survey
  • Septic arthritis — any age; always consider with fever + joint

Age 4–10 Years

  • Transient synovitis — Kocher 0–1; post-viral; NSAIDs; 24–48h follow-up
  • Legg-Calvé-Perthes — painless limp; Trendelenburg; normal CRP; MRI
  • Septic arthritis — Kocher ≥3; urgent OR
  • Leukaemia — bone pain + pallor + pancytopenia; CBC mandatory

Age 10–17 Years

  • SCFE — obese male; Drehmann sign; Klein's line; non-weight bearing; urgent ortho
  • Osgood-Schlatter — tibial tuberosity pain; active adolescent; self-limiting
  • Sinding-Larsen-Johansson — inferior patellar pole; jumping athletes
  • Stress fracture — female athlete, RED-S risk; x-ray often normal; MRI
  • Gonococcal arthritis — sexually active; tenosynovitis; NAAT swabs

SCFE — Do Not Miss

  • Hip pathology causes knee and groin pain — always examine the hip in knee pain
  • Drehmann sign: hip externally rotates on flexion — pathognomonic
  • Klein's line on AP x-ray fails to intersect femoral head — Trethowan sign
  • Stable: weight bearing possible — urgent OR (24–48h)
  • Unstable: non-weight bearing — OR tonight; AVN risk up to 50%
  • Image both hips — bilateral in 20–40%

Legg-Calvé-Perthes — Do Not Miss

  • Peak age 4–8yr, male; painless limp for weeks to months
  • Trendelenburg gait — pelvis drops on unaffected side during stance
  • Limited internal rotation and abduction
  • Normal CRP/ESR/WBC — helps distinguish from septic arthritis
  • X-ray: femoral head sclerosis, flattening, fragmentation
  • MRI for staging and early diagnosis
  • Herring classification guides management
Track C — Inflammatory and Systemic Joint Disease
Inflammatory screen: CBC · CRP · ESR · ANA · RF · Anti-CCP · HLA-B27 · ASO titre · Blood cultures
Acute migratory large-joint arthritis or post-infectious pattern?
YES
Post-infectious arthritis workup
ASO · anti-DNase B · Lyme serology · GC/Chlamydia NAAT · stool culture · Echo (ARF)
NO — Chronic / Recurrent
JIA spectrum workup
ANA · RF · anti-CCP · HLA-B27 · Ophthalmology referral · Rheumatology
Post-Infectious Arthritis — Key Diagnoses

Acute Rheumatic Fever

  • Post-GAS pharyngitis (penicillin/amoxicillin only — azithromycin fails)
  • Migratory polyarthritis of large joints
  • Jones criteria: 2 major or 1 major + 2 minor
  • Major: carditis, polyarthritis, chorea, erythema marginatum, nodules
  • Echo mandatory — carditis = only criterion with long-term damage
  • Aspirin + penicillin + secondary prophylaxis

Reactive Arthritis

  • 2–4 weeks post-GI (Salmonella, Shigella, Campylobacter, Yersinia) or GU (Chlamydia) infection
  • Asymmetric oligoarthritis; lower limb predominant
  • Classic triad (Reiter): arthritis + urethritis + conjunctivitis
  • HLA-B27 positive in 60–80%
  • Culture-negative synovial fluid
  • Self-limiting 4–8 weeks; NSAIDs first-line

Lyme Arthritis

  • Endemic area (Ontario, BC, Maritimes) + tick exposure
  • Prior erythema migrans rash (may be absent)
  • Large joint monoarthritis — knee most common
  • Two-tier serology: ELISA then Western Blot
  • IgG positivity = late Lyme (>4 weeks)
  • Doxycycline 28 days (≥8yr); amoxicillin if younger
  • Screen for carditis (PR interval) and neuro involvement
JIA Spectrum — Subtypes and Key Distinguishing Features

Oligoarticular JIA

  • Most common subtype — ≤4 joints in first 6 months
  • Peak age 1–4yr; young girls; ANA positive
  • Highest risk of asymptomatic uveitis — slit-lamp mandatory even without eye symptoms
  • Knee most common; hip rarely affected
  • Morning stiffness >45 min; normal inflammatory markers possible

Polyarticular JIA

  • ≥5 joints; RF-negative (children) or RF-positive (resembles adult RA)
  • Symmetric small and large joint involvement
  • RF-positive subtype: most erosive; treat aggressively
  • Cervical spine involvement — flexion/extension views before procedures
  • Uveitis risk lower than oligoarticular

Systemic JIA (Still's Disease)

  • Quotidian fever + salmon rash + arthritis + serositis
  • Ferritin markedly elevated (>500; often >10,000 in MAS)
  • RF and ANA typically negative
  • MAS in 10–15%: rising ferritin + falling platelets + falling fibrinogen = ICU
  • IL-1 blockade (anakinra) highly effective

Enthesitis-Related Arthritis (ERA)

  • Adolescent males; HLA-B27 positive
  • Inflammatory back pain + enthesitis (heel, knee, pelvis)
  • Sacroiliitis on MRI — detects before x-ray changes
  • Acute anterior uveitis — painful, sudden, red eye (unlike asymptomatic JIA uveitis)
  • NSAIDs dramatically effective; TNF inhibitors for refractory axial disease

Psoriatic Arthritis

  • Dactylitis (sausage digit) — diffuse swelling of entire digit; pathognomonic for SpA
  • Nail pitting and onycholysis
  • Psoriatic skin lesions — check scalp, umbilicus, natal cleft, retroauricular
  • Family history of psoriasis
  • RF negative; CASPAR criteria for diagnosis
  • Uveitis risk — ophthalmology referral
Uveitis in Paediatric Arthritis — A Critical Safety Issue

Asymptomatic Uveitis (JIA-associated)

  • Occurs in oligoarticular and polyarticular JIA — especially ANA-positive young girls
  • No symptoms — no red eye, no pain, no vision change
  • Detected only on slit-lamp examination
  • Can cause band keratopathy, cataracts, glaucoma, and blindness if missed
  • Frequency of screening: every 3 months in high-risk (ANA+, oligoarticular, age <6yr)
  • Every child with JIA needs ophthalmology — regardless of eye symptoms

Acute Anterior Uveitis (HLA-B27-associated)

  • ERA, psoriatic arthritis, ankylosing spondylitis
  • Sudden onset — painful, photophobic, red eye, blurred vision
  • Slit-lamp: cells and flare in anterior chamber
  • Treatment: topical corticosteroids + cycloplegic drops immediately
  • Ophthalmology within 24 hours
  • Recurs in ~50% — patient education critical
Investigation and Imaging Decision Guide

Immediate / Urgent

  • Joint ultrasound: any suspected effusion — detects occult effusion, guides aspiration
  • X-ray (AP + lateral ± oblique): fracture, SCFE, Perthes, leukaemic lines, osteomyelitis
  • CBC + CRP + ESR + cultures: all febrile joint presentations
  • ECG + Echo: suspected ARF (carditis evaluation)
  • Joint aspiration: Kocher ≥2 or any clinically suspicious hot joint

Selective / Specialist-Directed

  • MRI joint: Perthes staging, stress fracture, osteomyelitis, JIA synovitis
  • MRI SI joints (STIR): sacroiliitis — ERA diagnosis
  • Two-tier Lyme serology: endemic area + large joint effusion
  • ASO + anti-DNase B: suspected ARF (confirm GAS exposure)
  • NAAT swabs (GC/Chlamydia): sexually active adolescent + arthritis
  • Skeletal survey: suspected NAI in child <5 years

Rheumatology Workup Panel

  • ANA — oligoarticular JIA; uveitis risk stratification
  • RF + Anti-CCP — RF-positive polyarticular JIA (worst prognosis)
  • HLA-B27 — ERA, ankylosing spondylitis, reactive arthritis
  • Ferritin — systemic JIA; MAS monitoring (>10,000 = alarm)
  • Complement (C3/C4) + dsDNA — lupus screen
  • LDH + uric acid — malignancy screen
Disposition Decision Guide

Admit / OR Tonight

  • Kocher ≥3 — septic arthritis presumed
  • Unstable SCFE
  • Any joint with neurological compromise
  • NAI — child must not be discharged
  • MAS / systemic JIA with ferritin >10,000
  • ARF with carditis
  • Gonococcal arthritis (IV antibiotics required)

Urgent Outpatient (Days)

  • Stable SCFE — non-weight bearing, ortho within 24–48h
  • Kocher 2 — observation with clear follow-up plan
  • Lyme arthritis — start antibiotics, rheum follow-up
  • Suspected JIA — rheumatology within 1–2 weeks
  • Suspected ERA — rheumatology within 2 weeks
  • Early Perthes — orthopaedics within 1–2 weeks

Safe to Discharge

  • Kocher 0–1 (transient synovitis) — NSAIDs, reliable follow-up in 24–48h
  • Toddler's fracture — cast, ortho in 1 week
  • Reactive arthritis (afebrile, improving) — NSAIDs, GP follow-up
  • Costochondritis / musculoskeletal
  • All discharged patients require explicit return precautions
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