Diagnosis of musculoskeletal conditions in children and adolescents

Note: Most musculoskeletal symptoms in children and adolescents are associated with benign, transient, noninflammatory conditions.

Most musculoskeletal symptoms in children and adolescents are associated with benign, transient, noninflammatory conditions, and are often related to trauma. The challenge for general practitioners is to distinguish these conditions from musculoskeletal pain associated with serious pathology, such as fracture, infection, systemic inflammatory disease or malignancy.

Note: The challenge for general practitioners is to distinguish benign mechanical and trauma-related conditions from pain associated with a serious pathology, such as fracture, infection, systemic inflammatory disease or malignancy.

Clinical features suggestive of serious rheumatological pathology requiring urgent management (also known as ‘red flags’) are outlined in Serious musculoskeletal conditions to exclude and their alerting features (‘red flags’) in children and adolescents. These features are considered by the Rheumatology Expert Group to suggest potentially serious, organ- or life-threatening rheumatological disease. Refer patients urgently for assessment by an experienced clinician. Multiple presentations to an emergency department with the same symptoms should also raise suspicion for the presence of serious pathology.

Note: Seek urgent specialist advice if any of the ‘red flag’ features are present.

Table 1. Serious musculoskeletal conditions to exclude and their alerting features (‘red flags’) in children and adolescents
[NB1]
Serious conditions to exclude	Alerting features (‘red flags’)
musculoskeletal injury
trauma (eg fracture, dislocation) nonaccidental injury [NB2]	pain associated with other signs of injury (eg nonweightbearing, swelling, deformity, bruising)
musculoskeletal infection
septic arthritis osteomyelitis reactive arthritis acute rheumatic fever	pain and systemic upset (eg crying, loss of appetite) nonweightbearing fever, tachycardia, hypotension dehydration signs of inflammation (eg acute swelling, erythema, marked reduction in range of motion) monoarticular arthritis [NB3] recent Streptococcus pyogenes (group A streptococcus) pharyngitis or impetigo, and new cardiac murmur or signs of cardiac failure
malignancy in childhood
leukaemia neuroblastoma benign and malignant bone, cartilage and fibrous-tissue tumours	bone pain, pain with nocturnal waking, pain out of proportion to examination findings fever weight loss lymphadenopathy hepatosplenomegaly bruising, bleeding
systemic inflammatory disease
juvenile idiopathic arthritis (JIA) systemic lupus erythematosus (SLE) and other inflammatory connective tissue diseases juvenile dermatomyositis systemic vasculitides including IgA vasculitis and Kawasaki disease autoinflammatory periodic fever syndromes	arthralgia or arthritis constitutional symptoms rash eye symptoms (eg ocular pain, redness, photophobia, visual loss) recurrent fevers
amplified musculoskeletal pain syndromes (AMPS)
localised AMPS (complex regional pain syndrome [CRPS]) diffuse AMPS (paediatric fibromyalgia)	pain out of proportion to examination findings
nonrheumatological systemic disease
inflammatory bowel disease vitamin deficiencies genetic skeletal dysplasias haemoglobinopathies, haemophilia and haemarthroses cystic fibrosis coeliac disease	various depending on the condition: arthralgia or arthritis bowel symptoms (eg pain, diarrhoea, rectal bleeding) loss of weight, growth impairment, deformity anaemia, bleeding tendency, bruising, haemarthrosis productive cough
Note: NB1: This list is not exhaustive. NB2: If nonaccidental injury (child abuse) is suspected, immediately refer children for paediatric and forensic expert advice. Hospital paediatric services can often provide initial phone advice and directions for follow-up and care. In some jurisdictions, it is mandatory to report nonaccidental injuries in infants and children to state authorities. NB3: Monoarticular arthritis (monoarthritis or monoarthropathy) is acute inflammation involving a single joint. In children and adolescents, the most important diagnosis to exclude is septic arthritis, but it may also be an early single-joint presentation of an oligo-or polyarticular inflammatory process.

Common noninflammatory musculoskeletal conditions in children and adolescents include:

mechanical and trauma-related conditions
benign nocturnal limb pain
postactivity musculoskeletal pain
benign hypermobility
overuse-related trauma
degenerative changes in growing bone
amplified pain syndromes (AMPS), including localised AMPS (also known as complex regional pain syndrome CRPS) and diffuse AMPS (also known as paediatric fibromyalgia).

Benign hypermobility (or generalised joint hypermobility) is very common in healthy children and adolescents. It may be associated with diffuse AMPS but rarely requires any investigation or referral to a specialist. See the separate topic Benign hypermobility.

Nonaccidental injury¹ (child abuse) must be considered in children and adolescents with multiple musculoskeletal injuries or repeat presentations with injuries. If nonaccidental injury is suspected, immediately refer children for paediatric and forensic expert advice.

Note: If nonaccidental injury (child abuse) is suspected, immediately refer children for paediatric and forensic expert advice.

Systemic inflammatory conditions in children and adolescents are uncommon. If a general practitioner suspects a child or adolescent may have a systemic inflammatory condition, they should discuss the case early with a specialist.

Note: If a general practitioner suspects a child or adolescent may have an inflammatory condition, they should discuss the case early with a specialist.

Specific systemic inflammatory conditions are covered in detail elsewhere; refer to the relevant clinical topic. Important paediatric systemic inflammatory conditions include:

all types of juvenile idiopathic arthritis (JIA)
juvenile dermatomyositis
systemic lupus erythematosus (SLE)
systemic vasculitides including immunoglobulin A vasculitis and Kawasaki disease
autoinflammatory periodic fever syndromes
acute rheumatic fever.

¹ If nonaccidental injury (child abuse) is suspected, immediately refer patients for paediatric and forensic expert advice. Hospital paediatric services can often provide initial phone advice and directions for follow-up and care. In some jurisdictions, it is mandatory to report nonaccidental injuries in infants and children to state authorities.Return