Pre-exam 1.Inspect 2.Palpate 3.Gait+Back 4.ROM 5.GPE 6.Dev Description Differentials Invest MDT Prognosis Tips paeds.online

🦴 Juvenile Idiopathic Arthritis (JIA) CPSP Short Case

📚 Visit the comprehensive paediatric resource: www.paeds.online — clinical guides, cases & more
click to open

Pre‑exam protocol · Locomotor

Wash hands (sterilizing solution) Warm hands Introduce & rapport Position: standing / sitting / lying Exposure (shirt off, trousers rolled) Approach from right side
“کسی جوڑ میں درد تو نہیں” “بچہ چل سکتا ہے؟” “منہ کھولو, انگلی رکھو” “ذرا اٹھ کر دیکھائو”
STEP 1 Inspection
  • Dysmorphism, posture, scars, splints, wheelchair
  • Joints: symmetry, swelling, deformity, redness, muscle wasting
  • Skin: rash, bruises, BCG scar, steroid toxicity (acne, moon face, hirsutism, striae)
  • Nails: pitting, onycholysis, psoriatic changes
STEP 2 Palpation
  • Temperature (compare bilaterally, dorsum of hand)
  • Tenderness (look at child’s face, examine affected joint last)
  • Fluctuation / effusion (patellar tap, bulge sign)
  • Synovial thickening (boggy feel)
STEP 3 Gait & Back
  • Ask: “Bachaa Chal saktaa hai?” → observe antalgic / waddling gait
  • Back: spinal tenderness, deformity, scoliosis, kyphosis
  • ROM spine: flexion (touch toes), extension (arch back), lateral bending, rotation
  • Squat (proximal weakness), stand on one leg (Trendelenburg)
STEP 4 Range of Motion

Upper limb

  • Fingers: make fist, prayer sign, reverse prayer, radial/ulnar deviation
  • Elbow: flexion, extension, supination, pronation
  • Shoulder: abduction, adduction, rotation, circumduction, scratch back

Lower limb & spine

  • Hip: flexion, extension, abduction, adduction, rotation
  • Knee: flexion, extension, internal/external rotation
  • Ankle/foot: dorsi/plantar flexion, inversion, eversion
  • TMJ: open mouth (3 fingers), neck movements

Always stabilise pelvis / shoulder girdle; do passive movements only in affected joints.

STEP 5 Relevant GPE
  • Hands & nails: pitting, digital ulcers, Gottron’s, swan neck/boutonniere
  • Pulse, BP, murmur, pericardial rub
  • Face: malar rash, butterfly rash, micrognathia
  • Eye: slit lamp (uveitis), red eye, photophobia, synechiae, cataract
  • Oral: ulcers (SLE), nasal ulcers
  • Thyroid, lymph nodes, hepatosplenomegaly, genitalia (Tanner)
STEP 6 Functional & Dev Assessment
  • Comb hair, dress/undress (functional ability)
  • School performance, mobility, activities of daily living
  • Measurements: true leg length (ASIS to medial malleolus), apparent (umbilicus to malleolus)
  • Anthropometry: height, weight, BMI (growth delay, steroid effects)
Description template
“Thank you sir. I would like to complete my examination by doing [missed steps: vitals / anthropometry / slit lamp]. This is a [age]-year-old child, conscious, cooperative, with IV cannula in place. No distress or dysmorphism. Gait is [normal / antalgic]. Back examination unremarkable. He has [number] swollen joints including [right knee, elbow] with/without signs of active inflammation (redness, warmth, tenderness). Range of motion is reduced during [extension/flexion] at [joint]. No fixed flexion deformity or contracture. Afebrile (to touch). BCG scar present. No steroid toxicity, pallor, nail pitting, psoriasis, malar/discoid rash, oral/nasal ulcers, purpura, visceromegaly, lymphadenopathy or pericardial rub. He can dress/undress himself and is able/not able to walk. True leg length: [R] cm, [L] cm. Apparent leg length: [R] cm, [L] cm.”
Differentials (Mnemonic: Joints ache In TrAM)

Infections

  • Septic arthritis
  • Osteomyelitis
  • Reactive arthritis
  • Tuberculous arthritis
  • Acute rheumatic fever

Trauma

  • Local trauma
  • Avascular necrosis (Legg-Calve-Perthes)
  • Slipped capital femoral epiphysis

Autoimmune

  • JIA
  • SLE
  • JDM / MCTD / Scleroderma
  • IBD / Autoimmune hepatitis

Malignancy & Haematology

  • Haemophilia
  • Sickle cell disease
  • Leukaemia / lymphoma
Investigations
DIAGNOSISClinical diagnosis (arthritis ≥6 weeks, age <16y, exclude other causes)
SUPPORTIVECBC, ESR, CRP, Ferritin, ANA, RF, HLA-B27, Immunoglobulins, serum amyloid A
EXCLUDE OTHERSBlood cultures, TB workup, bone marrow biopsy, Lyme serology, viral studies
RULE OUT COMPLICATIONSJoint X-rays, ECG, 2D Echo, slit lamp (uveitis), synovial fluid analysis, DEXA

High risk for uveitis: oligoarticular, ANA+, age ≤6y, disease duration ≤4y → slit lamp 3-monthly.

MDT Management
Pharmacological
NSAIDs, Methotrexate, Sulfasalazine, Corticosteroids (oral/IV/intra-articular), anti-TNF (etanercept, infliximab), JAK inhibitors (tofacitinib)
PT & OT
Physical therapy (stretching, strengthening), occupational therapy (splinting, heat, ultrasound), aquatic therapy
Ophthalmology
Periodic slit-lamp (uveitis screening), management of uveitis (steroids, mydriatics), cataract/glaucoma monitoring
Orthopaedics
Tendon release, joint replacement (delayed until skeletal maturity), scoliosis management, heel cord lengthening
Psychology
Chronic pain management, counselling, school support, family education, support groups (AJAO)
Nutrition & Growth
Monitor growth, calcium/Vit D (steroid osteoporosis), avoid excessive weight, dietitian input
Prognosis & Counseling
Oligoarticular (without uveitis)Best prognosis
Polyarticular RF+ / sJIAPoorer prognosis; 50% active disease into adulthood
Systemic JIAMost difficult to control; monocyclic (11%) do well, persistent (55%)
Uveitis riskYoung girls, oligoarticular, ANA+ → highest risk; may lead to blindness
MAS (Macrophage activation syndrome)Life-threatening complication in sJIA

Support: American Juvenile Arthritis Organization (404-872-7100) · www.arthritis.org

Tips & Tricks

Time taking exam – practice repeatedly; you can offer missed steps at the end.

Never inflict pain – examine tender joints last, look at child’s face.

Always look at the child’s face during palpation (tenderness).

Expose properly – check for purpura, bruises, rashes (SLE, JDM, psoriasis).

External rotation = anterior surface turns laterally; internal rotation = turns medially.

Passive movements only in affected joints; avoid if painful.

Don't forget CVS – pericarditis, myocarditis in SLE/JIA.

Nelson Textbook of Pediatrics · CPSP short case · Juvenile Idiopathic Arthritis (JIA)