Nonoperative Management
Therapy
Physio
- prevent contractures
- prevent wasting
Splints
- dampen infection
- aid ADL's and schoolwork
Medications
NSAID
- mainstay of treatment
- paediatric suspensions available
- avoid Salicylates because of Reye's disease
IV Immunoglobin
- Still's
Methotrexate
- increased use
- much higher doses in kids
- attempt to prevent progression
- aggressive treatment in polyarticular disease with poor prognosis
Gold & Penicillamine
- seropositive
Sulphasalazine
- spondyloarthropathy
Systemic Steroids
Issue
- doesn't affect progression of disease
- se limited by SE: stunting / osteoporosis
Indications
- unresponsive Still's / Polyarthritis
Alternate day treatment
- minimal stunting
- avoid suppression hypothalamic - pituitary axis
HCLA
Indications
- flares of pauciarticular disease
- knee / flexor sheaths
Advantage
- non specific temporary palliative treatment
- allows good pain relief
- early mobilisation
- therefore preventing contractures / muscle atrophy
- preserving function
Infliximab
Monoclonal anti TNF antibody
- effective in 60%
- 5% develop allergic reactions
- 10% develop new autoantibodies
Operative Management
Joints
Shoulder
- may require soft tissue releases + synovectomy
Elbow
- may need synovectomy + radial head resection
Wrist
- very frequently involved
- short ulna
- ulnocarpal deviation (c.f. radial deviation in adult RA)
- require synovectomy / fusions
MCPJ
- radial deviation (c.f. ulna deviation in adult RA)
- synovectomy / realignments / replacement
Finger
- much less likely to be involved than adult form
- Boutonniere
- Swan neck quite rare
Thumb
- may develop flail thumb secondary to erosion
Hip
- Otto pelvis
- bilateral protrusio
- atlantoaxial subluxation
Synovectomy
Most common in wrist / hand / elbow
- limits pain and improves function in short term
- does not affect long term outcome or ROM (> 3 years)
Complications
Growth defects
- growth retardation with steroids
Epiphyseal disturbances
- external tibial torsion
- dysplasia of distal ulna (commonly short)
- dens hypoplasia
- scoliosis
Iridocyclitis
- pauciarticular disease
- can lead to blindness
Amyloidosis
- long standing Still's
- may be fatal
Prognosis
Polyarticular
- juvenile or systemic usually only last about 6/52
- 75% long remission with little residual disability
Poor prognosis
- systemic with multiple joint involvement
- RF +ve
- onset < 1 year old
- long active period disease > 5 years
Death uncommon
- infection early
- amyloidosis late