Weinstein Lovell and Winters Pediatric Orthopaedics 7e

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CHAPTER 11  |  Juvenile Idiopathic Arthritis

A

B FIGURE 11-9.  The cervical spine in a child with polyarticular JIA. A. At 6 years of age, there are no radiographic abnormali- ties. B. At 21 years of age there is ankylosis of C2–C5.

ERA. It is especially important in boys above the age of 6, where there is a family history of HLA-B27–associated illness, or SI joint or spinal inflammatory pain. Synovial Fluid Analysis.  Arthrocentesis with synovial fluid analysis and culture should be performed in all children

with an acute arthritis accompanied by fever or in children for whom the diagnosis is unclear. In JIA, synovial fluid is type II, or inflammatory. The appearance is typically yellow and cloudy with decreased viscosity. Leukocyte counts are generally between 15 and 20,000 cells/mm 3 ; however, they may range as high as 100,000 cells/mm 3 (130–132). There is typically a neutrophil predominance (130). Synovial Biopsy.  A synovial biopsy should be performed if the diagnosis remains unclear after laboratories, imaging, and synovial fluid analysis. Biopsy is particularly helpful if a diag- nosis of tuberculosis, PVNS, or sarcoidosis is being considered. TREATMENT RECOMMENDATIONS Medications.  The fundamental purpose of pharmaco- logic therapy is to achieve pain control, decrease inflammation, prevent joint destruction, and to maintain remission. The medications used are individualized for each patient, depend- ing on their subtype of arthritis, degree of inflammation, and previous pharmacologic response. Nonsteroidal Anti-Inflammatory Drugs.  NSAIDs are the initial therapeutic intervention in many children with JIA. NSAIDs provide both analgesia and anti-inflammatory effects. NSAIDs affect the biosynthesis of prostaglandins by direct inhibi- tion of cyclo-oxygenase (COX) (133). There are two ­isoforms

FIGURE 11-10.  CT scan of SI joints in a child with JAS showing erosions and sclerosis of the SI joints. (Courtesy of D. Ruben Burgos- Vargas.)