Editor's note: The 2017 AAP National Conference & Exhibition will take place from Sept. 16-19 in Chicago.
When a patient complains of musculoskeletal pain, pediatric rheumatologist Linda Wagner-Weiner, MD, MS, FAAP, goes on a fact-finding mission.
That entails taking a good history, including family history, performing a thorough physical exam and perhaps ordering some lab work.
“I always think of rheumatologists as being like Sherlock Holmes trying to piece together the information and coming up with a direction, even if the patient does not fall into our area of diagnosis,” she said.
For example, if a child is waking up at night with pain, the differential diagnosis might include malignancy, infection and benign nocturnal pain of childhood (“growing pains”).
“It’s our job to figure out whether the musculoskeletal pain is associated with a specific disease or whether it might be injury or mechanical,” she said.
Dr. Wagner-Weiner and pediatric rheumatologist Melissa Tesher, MD, FAAP, will share some tricks of the trade during an interactive group forum titled “Hands-on Rheumatology: Musculoskeletal Evaluation.” The session will be held from 2:00-3:30 pm Sunday (I2133) and again from 2:00-3:30 p.m. Monday (I3112) in McCormick Place West, W181 A.
Dr. Tesher is assistant professor of pediatrics at University of Chicago, and Dr. Wagner-Weiner is associate professor of pediatrics at University of Chicago and attending physician at Comer Children’s Hospital. Both are members of the AAP Section on Rheumatology.
Some of the conditions they will be covering include juvenile idiopathic arthritis (JIA) and its subtypes, systemic lupus erythematosus, scleroderma subtypes, and mechanical problems that can lead to musculoskeletal symptoms such as hypermobility syndrome and amplification pain syndromes.
General pediatricians most likely will come across some of these diagnoses, Dr. Wagner-Weiner said. Whether they have a patient with JIA or lupus depends on how large their practice is and whether they care for certain ethnic groups.
The prevalence of JIA ranges from 10 to 400 cases per 100,000 population, and it is 2.5 to 3 times more common in females, Dr. Wagner-Weiner said. Lupus is less common at about 6 to 18 cases per 100,000 in Caucasians, with higher rates in Hispanics, blacks and Asians.
During the session, Dr. Wagner-Weiner and Dr. Tesher will show slides with musculoskeletal abnormalities and skin rashes that may be present in particular diseases, thus helping to guide the clinician in establishing an inclusive differential diagnosis. They also will ask for volunteers on whom they can demonstrate how to perform a detailed musculoskeletal examination.
One piece of advice Dr. Wagner-Weiner offers is to examine the whole musculoskeletal system even if a child hurts only in one location.
“I can’t tell you how many times I’ve had patients come to me and was told that they just have a bad knee, and I’ll find several other areas that are abnormal,” she said.
In addition, it’s important to get details about the onset of pain, duration, location, number of joints involved, time of day it occurs and if activity exacerbates pain.
“The goal of this session is to guide the pediatrician on how to perform an excellent musculoskeletal exam and from the knowledge gained from the exam be able to develop an appropriate differential diagnosis to help direct further evaluation and treatment,” Dr. Wagner-Weiner said.
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