Ensuring that all paediatricians and rheumatologists recognise significant rheumatic diseases

doi:10.1016/j.berh.2009.07.002

Best Practice & Research Clinical Rheumatology

Volume 23, Issue 5, October 2009, Pages 625-642

https://doi.org/10.1016/j.berh.2009.07.002 Get rights and content

In many health-care systems around the world, many generalists (defined here as a clinician who is not an expert in paediatric musculoskeletal [pMSK] medicine) will be the doctor to whom children with MSK problems are most likely to present. The generalist is likely to have a clinical background in family medicine and paediatrics, but may be a specialist in adult orthopaedics, adult rheumatology or emergency care. Therefore, it is critical that the generalist is able to quickly recognise a child with significant rheumatic disease in order to initiate the proper treatment or referral to a specialist. However, most generalists are ill equipped to be able to do so, because of current deficiencies in education and training. The aims of this article are as follows:

•
Demonstrate the need to improve the generalist's performance of clinical assessment in musculoskeletal medicine
•
Suggest solutions within medical education and manpower planning in health care
•
Focus on important areas of pMSK medicine to be learned by the generalist to help identify children with significant rheumatic disease

Section snippets

The need to improve the generalist's performance of paediatric musculoskeletal (pMSK) clinical assessment

MSK conditions are common in children and adolescents, affecting up to 30% of individuals [1], [2]. There is a broad spectrum of causes (Table 1), the majority of which are self-limiting, often trauma related, and will not need referral to specialist care. However, these causes also include potentially life-threatening conditions, or may also be a feature of many chronic diseases, which often do need referral. The role of the generalist in the early recognition of new patients and the

Potential solutions within medical education and manpower planning

We believe that clinical skills in pMSK medicine must be integral to core paediatric clinical teaching at undergraduate level and all doctors, whatever their ultimate career path, should be trained in core pMSK clinical skills. A co-ordinated evidence-based strategy is necessary to define the content and structure of core pMSK teaching, provide support to train the necessary personnel as teachers and evaluate the experience from both student and teacher perspectives. At the postgraduate level,

Clinical assessment approaches for the generalist

This section describes core pMSK clinical skills and knowledge that generalists should acquire to effectively triage new patients presenting with MSK features and which need to be addressed in their learning.

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The child with joint pain in primary care
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Citation Excerpt :
Investigation of the factors contributing to delays between onset of symptoms and presentation to secondary care of children with musculoskeletal symptoms with underlying malignancy, infection or inflammatory causes Development of further training to improve skills in MSK examination of children by primary care, emergency physicians and paediatricians [17] Prospective studies to evaluate which combination of laboratory tests identifies children with malignancy presenting with joint pains with the greatest sensitivity and specificity
Joint pains are a common reason for children to present to primary care. The differential diagnosis is large including some diseases that do not primarily affect the musculoskeletal system. Although the cause for many patients will be benign and self-resolving, in rare cases the diagnosis is associated with long-term morbidity and mortality if not detected early and appropriately treated. These include primary and secondary malignancies, septic arthritis, osteomyelitis, inflammatory arthritis, slipped upper femoral epiphysis (SUFE) and non-accidental injury. We highlight the importance of a thorough history and directed yet comprehensive examination. A diagnostic algorithm is provided to direct primary care physicians' clinical assessment and investigation with the evidence base where available. In many cases, tests are not required, but if there is suspicion of malignancy, infection or inflammatory conditions, laboratory tests including full blood count, blood film, erythrocyte sedimentation rate, C-reactive protein and lactate dehydrogenase help to support or exclude the diagnosis. Autoimmune tests, such as antinuclear antibodies and rheumatoid factor, have no diagnostic role in juvenile idiopathic arthritis; therefore, we advise against any form of ‘rheumatological/autoimmune disease screen’ in primary care. Imaging does have a place in the diagnosis of joint pains in children, with plain radiographs being most appropriate for suspected fractures and SUFE, whilst ultrasound is better for the detection of inflammatory or infective effusions. The appropriate referral of children to paediatric rheumatologists, oncologists, orthopaedic surgeons and the emergency department are discussed.
Slide Injury Leading to Bacteremia and Sepsis in a Pediatric Patient
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Orthopedic screening using pGALS assessment tools in children's between 5 and 12 years
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Assessment of Resident Knowledge in Pediatric Rheumatology
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¹: Tel: +1 201 996 5306; Fax: +1 201 996 9815.

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4Ensuring that all paediatricians and rheumatologists recognise significant rheumatic diseases

Section snippets

The need to improve the generalist's performance of paediatric musculoskeletal (pMSK) clinical assessment

Potential solutions within medical education and manpower planning

Clinical assessment approaches for the generalist

Pain

Europ J Paediatr Neurol

J Pediatr

Best Pract Res Clin Rheumatol

Curr Paediatr

Pediatr Clin North Am

J Pediatr

Chronic illness and disability

BMJ

Role of pediatric and internist rheumatologists in treating children with rheumatic diseases

Pediatrics

Access to pediatric rheumatology care in the United States

Arthritis Rheum

Identifying children with chronic arthritis based on chief complaints: absence of predictive value for musculoskeletal pain as an indicator of rheumatic disease in children

Pediatrics

Delay in access to appropriate care for children presenting with musculoskeletal symptoms and ultimately diagnosed with juvenile idiopathic arthritis

Arthritis Rheum

Delay in diagnosing juvenile arthritis

Med J Aust

Diagnosis delays in childhood cancer: a review

Cancer

Access to pediatric rheumatology subspecialty care in British Columbia, Canada

J Rheumatol

More ‘cries from the joints’: assessment of the musculoskeletal system is poorly documented in routine paediatric clerking

Rheumatology

Ambulatory care skills: do residents feel prepared?

Med Educ Online

Determinants of physician confidence in the primary care management of musculoskeletal disorders

J Rheumatol

Pediatric residents' performance of ankle and knee examinations after an educational intervention

Pediatrics

Rheumatology education and management skills in general practice: a national study of trainees

Ann Rheum Dis

Undergraduate rheumatology teaching in the UK: a survey of current practice and changes since 1990

Rheumatology

Current teaching of paediatric musculoskeletal medicine within UK medical schools–a need for change

Rheumatology (Oxford)

The current state of musculoskeletal clinical skills teaching for preclerkship medical students

J Rheumatol

4
Ensuring that all paediatricians and rheumatologists recognise significant rheumatic diseases