Pediatric emergency medicine trisk 2995 2995
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (46.53 KB, 1 trang )
may enter the bursa and produce a popliteal cyst (Baker cyst). Patients with popliteal
cysts have a palpable and visible enlargement in the popliteal area, best seen while the
patient is standing with knees extended.
Rupture of a popliteal cyst with drainage of fluid into the calf muscles may present
as an emergency. Affected patients complain of sudden pain in the calf associated with
swelling in the leg. On physical examination they have induration, erythema, warmth,
and tenderness of the calf, as well as ankle edema. An effusion in the knee joint and
evidence of synovial thickening are often present. Homan sign may be positive, but
other signs of venous thrombosis, including palpable venous cords, dilation of
collateral veins, or arterial spasm, are usually absent.
Differentiation of a ruptured popliteal cyst from thrombophlebitis may be difficult,
though the latter are very rare in otherwise healthy children, and the former relatively
common in children with arthritis. Elevated D -dimers and other evidence of a
consumptive coagulopathy characterize venous thrombosis, while most children with
JIA do not have such abnormalities (with the exception of patients with sJIA
experiencing MAS). Ultimately, ultrasound or MRI may be needed to establish the
diagnosis. Intra-articular administration of steroids (triamcinolone hexacetonide, 1
mg/kg) is the recommended initial treatment for a ruptured Baker cyst. If there is an
inadequate response or if the syndrome is chronic, surgical excision of the cyst may be
necessary.
Cervical Spine Involvement. This complication usually is seen in children with
established severe polyarticular JIA. Although cervical spine involvement is known to
occur in 30% to 50% of patients with JIA, subluxation of the atlantoaxial (AA) joint or
the lower cervical spine is less common in children than adults. Clinical evidence of
pressure on the spinal cord is seen in 23% to 65% of adults with radiologic evidence of
AA subluxation. Similar data are not available for children.
Neck stiffness that is worst in the morning is the most common symptom of cervical
spine involvement in JIA. Occasionally, torticollis may be the presenting manifestation
of cervical arthritis. Severe pain in the neck and referred pain over the occipital and
retro-orbital areas also may occur. The pain has a dull, aching quality and is often
aggravated by neck movement. On physical examination, torticollis and/or loss of
lordosis of the cervical spine, as well as limitation of range or movement of the neck,
are the typical findings.
Paresthesia of the fingers is the most common symptom of spinal cord compression.
Weakness of the arms and legs and inability to control the bladder or bowels are other
complaints that should suggest spinal cord compression. During the initial stages,
exaggerated deep tendon reflexes and an extensor plantar reflex are noted. Chronic
myelopathy results in muscle atrophy and loss of deep tendon reflexes. Lateral
radiographs of the neck in flexion and in extension are required for complete evaluation
of the cervical spine. The patient should be asked to actively and slowly flex and
