Pediatric emergency medicine trisk 1163 1163

FIGURE 60.1 A diagnostic approach to joint pain. a Most likely leukocyte count. JIA, juvenile
idiopathic arthritis.

Metaphyseal corner (“bucket-handle”) fractures resulting in joint pain are
highly suggestive of inflicted injury. These typically occur in children of age 3
years or less and there may not be a clear history of trauma. These fractures result
from traction or torsion forces such as occur when the arms or legs are pulled or
swung violently.
Radiographs may also aid in determining whether swelling is caused by a joint
effusion or is simply soft tissue swelling outside the joint space, a distinction that
is often difficult to make on physical examination alone. In the setting of acute
trauma and in the absence of fever, an effusion is indicative of a hemarthrosis and
there is rarely a diagnostic or therapeutic indication for performing an
arthrocentesis. Clinicians must have a high index of suspicion for hemarthrosis in
the child with hemophilia or other clotting disorder who presents with joint
swelling, even without a clear history of trauma.
In the absence of an effusion, inquiries about the duration of symptoms should
be made. Children with conditions such as bursitis, tendonitis, and Osgood–
Schlatter disease typically have chronic, low-grade pain and may inadvertently