FIGURE 60.1 A diagnostic approach to joint pain a Most likely leukocyte count JIA, juvenile idiopathic arthritis Metaphyseal corner (“bucket-handle”) fractures resulting in joint pain are highly suggestive of inflicted injury These typically occur in children of age years or less and there may not be a clear history of trauma These fractures result from traction or torsion forces such as occur when the arms or legs are pulled or swung violently Radiographs may also aid in determining whether swelling is caused by a joint effusion or is simply soft tissue swelling outside the joint space, a distinction that is often difficult to make on physical examination alone In the setting of acute trauma and in the absence of fever, an effusion is indicative of a hemarthrosis and there is rarely a diagnostic or therapeutic indication for performing an arthrocentesis Clinicians must have a high index of suspicion for hemarthrosis in the child with hemophilia or other clotting disorder who presents with joint swelling, even without a clear history of trauma In the absence of an effusion, inquiries about the duration of symptoms should be made Children with conditions such as bursitis, tendonitis, and Osgood– Schlatter disease typically have chronic, low-grade pain and may inadvertently