Red Flag Conditions

National Institute for Clinical and Healthcare Excellence (NICE) Guidance is available to aid clinical assessment and management of red flag conditions which can present with musculoskeletal features.

NICE guidance for the following:

Non-accidental injury 

Fever in children under 5 years and concern about infection 

Suspected cancer - there is also a visual graphic to emphasise the guidelines for children

Guidance to aid the diagnosis of acute rheumatic fever is also available. (Guidelines for Acute Rheumatic Fever)

Features that suggest life threatening conditions:

Infection / Septic arthritis / osteomyelitis: Complete non-weight bearing. Pseudo-paralysis of limb. Any attempt to passively move the limb is resisted and causes extreme distress. Limb held in a position which accommodates increased joint volume due to effusion (e.g., hip held in external rotation). Severe and non-remitting pain. Night pain and waking.  Fever and unwell child.  Immunocompromised - due to primary disease or medications. Sever and non-remitting pain. Back pain in the unwell child. If cultures are negative, consider acute rheumatic fever in endemic areas (e.g., school-aged children from Maori, Pacific Islands, India or Asia).

Malignancy:  Night pain. Severe and non-remitting pain. Bone pain. Pallor. Bruising. Lymphadenopathy. Hepatosplenomegaly. Anaemia, thrombocytopenia. Systemic symptoms (lethargy, weight loss, night sweats, fever). Complete non-weight bearing. Back pain in the unwell child.

Non-accidental injury:  Delay in seeking medical attention. History inconsistent with pattern of injury. Explanation of injury incongruent with developmental stage of child. Repeated presentations. Un-witnessed injury. Patterns of injury suggestive of non-accidental injury (e.g., bruising over soft tissue areas, multiple bruises, bruises at different stages of resolution, bruises that carry the imprint of an instrument or implement). Distinctive burns (e.g., round cigarette burn, forced immersion burns). Complete non-weight bearing with occult fracture. Type of fracture (e.g., metaphyseal fracture, posterior rib fractures, skull fracture, any type of fracture in a non-ambulant child). Multiple injuries. Unkempt appearance and poor hygiene.

Tuberculosis (TB): Needs to be suspected in endemic areas, in children with families from endemic areas or when a child is unwell with a swollen joint, and especially if they are immunosuppressed due to disease or treatment; note that children with TB may also have co-existent Human Immunodeficiency Virus (HIV) infection. Inflammatory markers may be elevated and there can be anaemia of chronic disease. Atypical infection including Mycobacterial infection must be suspected in the immunosuppressed (disease or treatment) and may not present with a red hot joint but with a more indolent or systemic course. 

Acute Rheumatic Fever: Joint pain, swelling and warmth primarily affecting large joints, particularly knees, ankles, wrists and elbows. Usually initially one joint is affected and then migratory (moves to affect other joints) and additive (becomes many joints affected). Joint pain is prominent, occurs at rest and is increased by movement.  Associated manifestations may include fever, arthralgia (if not arthritis), Carditis (signs ranging from tachycardia at rest, ECG showing prolonged PR interval, new cardiac murmur suggesting mitral and/or aortic insufficiency leading to acute heart failure), Erythema marginatum (non-pruritic, macular, serpiginous rash with erythematous border especially on trunk and upper, inner aspects of limbs), Sydenham chorea (usually symmetric, persistent, involuntary and purposeless movements of extremities) or Subcutaneous nodules (extensor surfaces, but rare). Evidence of streptococcal infection (streptococcal serology or throat swab positive for group A streptococcus).