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Extremity complaints are common in children; they are estimated to account for up to 10% of nonwell child visits to pediatricians’ offices.1 Conversely, rheumatologic conditions, are rare, affecting fewer than 200,000 children in the United States. Thus, clinicians caring for children need an efficient and effective means of distinguishing arthritis, lupus, and other autoimmune conditions from injuries, infections, tumors, and noninflammatory causes of extremity complaints. This chapter will discuss the key components of a focused history and physical examination useful for rapidly narrowing down the possible explanations of a child’s musculoskeletal ailment. The next chapter discusses laboratory and imaging studies that may be used to confirm the caregiver’s clinical suspicions.

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The reported incidence and prevalence of musculoskeletal diseases in children worldwide vary significantly. For example, among more than 30 epidemiological studies of juvenile arthritis, new cases are reported to arise at a rate of 0.008 to 0.226 per 1,000 children, yielding a reported prevalence of 0.07 to 4.01 per 1,000 children.2,3 Although there are likely geographic, genetic, and environmental factors that result in true variations in the likelihood of developing rheumatologic conditions, several additional factors also contribute to reported differences. First among these is the fact that most pediatric rheumatologic conditions are diagnosed on the basis of clinical criteria rather than definitive laboratory or imaging findings. New signs may develop over time, leading to reclassification of conditions. Thus, children treated for ankylosing spondylitis may later develop colitis, thereupon qualifying for a diagnosis of Crohn disease. Arthritis that resolves after one year may be called monocyclic juvenile arthritis by some caregivers, transient or postinfectious arthritis by others. Despite these uncertainties, outcomes in virtually all autoimmune conditions are optimized by expeditious diagnosis and early initiation of effective therapy. Recognition of signs and symptoms suggestive of rheumatologic conditions is thus essential for everyone who provides healthcare to children.

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The presenting symptoms of musculoskeletal conditions are more dependent upon the location of the abnormality than upon the specific diagnosis. Thus, fractures, tumors, and osteomyelitis all present with pain that may awaken the patient from sleep because of the constant stimulation of sensory nerves by lesions within bone. Conversely, for unknown reasons, children with arthritis seldom complain of pain; more than 90% of children with joint or extremity pain do not have arthritis, and more than 90% of those with arthritis do not complain of pain.4 Inflammatory arthritis may cause children to limp or lose milestones because joint effusions cause distension of the joint capsule and discomfort with motion. Pain, however, is generally absent. Thus, differences in the location, timing, and characteristics of a child’s symptoms enable a pediatrician to rapidly narrow the potential causes of musculoskeletal complaints. Confirmation of the suspected diagnosis may then be obtained from physical exam findings, often without need for further investigations.

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When a child presents with a musculoskeletal complaint, it is helpful to categorize the symptoms according to the nature of onset ...

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