Management of Swollen Joints in Children
Introduction

Children commonly present to A&E, General Practice and General Paediatrics with swollen joints.  Important differentials include malignancy, serious injury, infection and Juvenile Idiopathic Arthritis. 
  • Whilst many swollen joints will be due to trauma (inflammation in ligaments around the joints i.e. twists and sprains) which will heal over time with rest and anti-inflammatory medications, the more serious conditions need to be excluded.
  • It is estimated that 1:1000 children have Juvenile Idiopathic Arthritis (JIA) in the UK, with 1:10,000 being diagnosed each year (1). The natural history of JIA is that of a relapsing then remitting pattern.  Persistent active disease can result in joint destruction and potential reduction in function of that joint (2).
  • Associated Uveitis is often asymptomatic and there is an urgent outpatient need for ophthalmological review if you suspect JIA in a patient as these children can suffer permanent visual impairment or even blindness if it is not detected and treated.
  • Septic arthritis can lead to joint destruction, permanent loss of function and can even become limb or life threatening if left untreated (3). Treatment consists primarily of antibiotic therapy as directed in the Wessex First Line Empirical Antibiotic Therapy For Specific Childhood Infections 2014 (4) or the local departmental microbiology guide. Usually 2 weeks of this will be intravenous, or until clinical improvement seen, and the course completed using oral therapy (5).  Therapy can be targeted directly to cultured growth from blood cultures or joint aspiration.  The joint may need a wash out under general anaesthetic to reduce the risk of ongoing joint damage. 
 
Kocher Criteria for the diagnosis of Septic Arthritis (6):
A point is given for each of the four following criteria:
  • Non-weight-bearing on affected side
  • Erythrocyte sedimentation rate >40
  • Fever > 38.5 °C
  • White blood cell count >12,000
 
Score
Likelihood of septic arthritis
1 - 3%
2 - 40%
3- 93%
4. - 99%

Scope

This document is for use across the Wessex Region. It could be accessed by paediatric and A&E departments, and general practitioners via the PIER website.  
 
Purpose

The aim of this guideline is to clarify the actions needed to identify a cause for, and thus guide management for a child who presents with one or more hot swollen joints.  We aim to reduce missed diagnosis of septic arthritis, Osteomyelitis, malignancy and Juvenile Idiopathic Arthritis.
Guideline

History:
  • How many joints are affected
  • When was the joint heat/swelling/pain first noticed
  • Which joint/joints are involved and pattern of onset
  • How have things changed between then and now
  • Any associated trauma/injury
  • Any preceding illness
  • Systemic symptoms e.g. fever/rash/malaise/weight loss
  • Pain score (out of 10 or using Faces)
  • Medications/steps taken pre consultation e.g. analgesia/cold compress
  • Limitations e.g. limping/ joint restriction, effect on school
  • Family history of inflammatory joint problems
  • Family or personal history of autoimmune conditions including diabetes/thyroid/bowel disease
  • Related skin changes/skin conditions e.g. Psoriasis
  • Any recent foreign travel/TB contacts or tick bites
 
Examination:
Undertake overall joint assessment e.g. PGALS to document any other involved joint
  • Examine the child completely including their back, looking for rashes, organomegaly, lymphadenopathy, pallor and testes in boys
  • Expose the affected joint and its opposite counterpart
  • Observe swelling/size/joint position
  • Observe skin e.g. red/broken/insect bite
  • Feel for warmth and swelling
  • Observe patient controlled movements
  • Palpate joint and surrounding structures as pain allows
  • Check joint movements as pain allows
 
Differential Diagnosis:
  • Trauma – accidental or non-accidental
  • Infection inside the joint – Septic Arthritis or adjacent osteomyelitis
  • Infection of the overlying structures e.g. muscles/skin e.g. myositis or cellulitis
  • Inflammatory condition e.g. arthritis (especially if more than one joint affected), reactive synovitis, irritable hips
  • Blood inside the joint – Haemarthrosis
  • Malignancy e.g. bone tumour in bone adjacent to the joint, or leukaemia if multiple joints affected
 
Action if single joint involved:
 
As always assess ABCDE, provide analgesia and engage with play specialists where available.
 
Any history of trauma?
  • X-ray the joint to exclude fracture/bony injury or pathology. 
  • If no bony injury identified and soft tissue damage is minimal provide simple analgesia and support if necessary.
  • Orthopaedic opinion to exclude significant ligament damage requiring strapping/support or haemarthrosis or if bone injury seen
  • If non-ambulatory or mechanism not explaining the injury seek senior paediatric review and consider following the Non Accidental Injury protocol.
 
Any fever?
  • IV access – FBC and film, CRP, ESR, U&E, LFT, ASOT, Blood culture
  • Consider imaging the joint via X-ray, ultrasound or MRI (osteomyelitis)
  • Senior paediatric review and consider an urgent Orthopaedic review if septic arthritis suspected- ?Joint aspiration needed pre antibiotics starting
  • If septic Arthritis suspected antibiotics as per the Wessex Microbiology/local microbiological Guideline pending cultures
  • Liaise with local infectious diseases/microbiology team for discussion around length of treatment and targeting antibiotics.  Consider how to treat e.g. would a PICC line be suitable.
  • If reactive arthritis suspected following an illness and patient allowed home – for review in 3 days to a weeks’ time with anti-inflammatory medications regularly to ensure resolution/improvement ideally with the team who saw them e.g. A&E or General Paediatrics.
  • If swelling persists longer than 2 weeks or you feel this is more than one joint is affected inflammatory arthritis then is likely: please discuss with the consultant on call and if agreed then in hours with the peripheral rheumatology link consultant or paediatric rheumatology team helpline number 07760 158924.
 
 
No fever or trauma?
  • Consider X-ray of the joint or limbs affected for fracture (consider NAI) and bone tumour.
  • Consider U/S of the joint to look for synovitis
  • Bloods for FBC and film, ESR, ASOT, CRP, U&Es, LFTs, Lyme serology (Borellia Burgdorfeli IgG and IgM).
  • If bloods and imaging normal then seek senior paediatric medical review and consider discussing with the paediatric rheumatology services in hours (helpline number 07760 158924).
  • If non-ambulatory or mechanism not fully explaining the injury seek senior paediatric review and consider following the Non Accidental Injury protocol.
  • If reactive arthritis suspected following an illness and patient allowed home – for review  in a 3 days to a weeks’ time with anti-inflammatory medications regularly to ensure resolution/improvement ideally with the team who saw them e.g. A&E or General Paediatrics.
  • If swelling persists longer than 2 weeks or if more than one joint is affected inflammatory arthritis is likely: please discuss with the consultant on call and if agreed then in hours with the paediatric rheumatology team helpline number 07760 158924.  Arrange outpatient early ophthalmology review for Uveitis screening.
 
Discharge could be considered by the medical team
  1. No temperature
  2. Bloods normal
  3. X-rays normal (if unsure consider radiology or orthopaedic opinion)
  4. Well child with full range of movement in the affected joint
  5. Discussed with rheumatology team if arthritis suspected or likely (Helpline number 07760 158924) in hours or general paediatrics out of hours
Discharge home with advice to return if unwell, deteriorates and to take regular anti-inflammatories if no medical contraindication. Review in 2-3 days’ time to ensure resolution and plan further follow up/necessary referrals.
 
Orthopaedic review
  1. Temperature (if you have a coryzal child with minimal limb symptoms, consider discharge after senior medical review.)
  2. Raised CRP >20 , ESR >40 or WCC elevated neutrophilia
  3. Non weight bearing in a walking child (See Kocher Criteria for Septic Arthritis)
  4. Abnormality on x-ray/imaging

Action if multiple joints involved:
 
As always assess ABCDE, provide analgesia and engage with play specialists where available. Unless clearly a polytrauma assume this is likely an inflammatory arthritis.  Senior paediatric medical review followed by discussion with the paediatric rheumatology team (Helpline number 07760 158924) in hours.  Arrange outpatient early ophthalmology review for Uveitis screening.  If it seems most highly likely to be JIA then we may advise not to do any bloods until we see the patient to save them having multiple tests. If the diagnosis is not clear then a FBC/Film/ESR and CRP +/- ASOT may help exclude other pathology.
 
Safety net advice at point of discharge to include:
 
Seek further medical advice/return to the Emergency Department if your child develops any of the following symptoms:
 
  • Appears more unwell
  • Develops a high temperature
  • Pain increases in severity
  • Your child is unable to walk at all
  • More joints become swollen
  • The symptoms do not improve within 2 weeks
 
Use of NSAIDS in JIA
We recommend all children with swollen joint/s use the following BNF for Children doses of one of the NSAIDS:
  1. Ibuprofen – 30-40mg/kg/day in 3 divided doses equates to 10-13mg/kg three times a day (max 2.4g per day)
  2. Naproxen – 5-7.5mg/kg/dose, twice daily (max 1g per day)
Consider Omeprazole cover 10-20mg once daily for long term use or those with underlying gastric problems.
 
Other Resources available:
1) Local Limping Child Pathway
2) Local NAI Policy
3) Local microbiology Guidelines
References
  1. Juvenile Idiopathic Arthritis Website found at www.JIA.org.uk
  2. Consolaro, A., Negro, A., Chiara Gallo, M., Bracciolini, G., Ferrari, C., Schiappapietra, B., Pistorio, A., Bovis, F., Ruperto, N., Martini, A., Ravelli, A. “ Defining Criteria for Disease Activity States in Nonsystemic Juvenile Idiopathic Arthritis Based on a Three-Variable Juvenile Arthritis Disease Activity Score.” Arthritis Care & Research, 2014. 66(11):1703–1709
  3. Septic Arthritis NHS page found at http://www.nhs.uk/conditions/septic-arthritis/Pages/Introduction.aspx
  4. Wessex First Line Empirical Antibiotic Therapy For Specific Childhood Infections 2014 available at http://www.what0-18.nhs.uk/health-professionals/front-line-hospital-staff/empirical-antibiotics-guidelines/
  5. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults available at http://rheumatology.oxfordjournals.org/content/45/8/1039.full
  6. Kocher MS, Zurakowski D, Kasser JR (1999). "Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm.". Journal of Bone and Joint Surgery Am. 81 (12): 1662–70.
Document Version: 
1.1

Lead Authors: 
Dr Lisa Bray, Paediatric Consultant, St Richard's Hospital
Dr Alice Leahy, Paediatric Rheumatology Consultant, UHS
Approving Network:
Wessex Paediatric Rheumatology Network

Date of Approval: 
July 2023

Review Due:
July 2026