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Red Flags

Red Flags typically refer to features that may suggest serious life threatening disease such as malignancy (leukaemia), infection (septic arthritis or osteomyelitis) or non-accidental injury. We also include features that may suggest inflammatory joint or muscle disease.

More information about these red flags are available in the following NICE Guidelines 

Key red flags are 

Malaise or / systemic upset (fever, reduced appetite, weight loss, sweating, lethargy, pallor, lymphadenopathy, organomegaly) - consistent with malignancy, infection but also inflammatory disease (e.g some forms of juvenile arthritis, multisystem disease such as vasculitis).

Night pains - not responding to simple (paracetamol/ibuprofen) analgesia.

Myoglobinuria – “coca-cola coloured" urine (sign of muscle destruction)

Pain in bones - often described as deep and throbbing in nature, rather than joints.

Bony tenderness - consistent with Inflammatory conditions, malignancy.

Behavioural change (irritable, poor sleep) - consistent with Inflammatory conditions, malignancy, infection.

Swollen joint(s) (often subtle or difficult to appreciate).

Incongruence in history, presentation, examination findings always consider safeguarding and non-accidental injury.

Features suggestive of inflammatory joint or muscle disease include;

  • Loss of skills (handwriting) or regression of achieved motor milestones.
  • Pain at rest improving with activity.
  • Pain or stiffness after periods of reduced activity (e.g. in the morning, after a long car journey, or after sitting still at school, sometimes called 'gelling').
  • Muscle cramps with activity.
  • Muscle weakness (may manifest as fatigue).
  • Difficulty climbing stairs or difficulty rising from the floor – Gower’s manoeuvre (proximal muscle weakness).
  • Muscle wasting or atrophy (suggests chronicity), seen in muscular dystrophy and Spinal muscle atrophy (SMA).
  • Frequent falling (stumbling) may be a sign of muscle weakness.
  • Slow eating or drinking with difficulty swallowing or chewing.
  • Muscle tenderness: suggests inflammatory muscle disease.
  • Joint Contractures: can be due to joint or muscle disease.
  • Toe walking: can be a sign of neurological or muscle disease.
  • Myotonia – delayed relaxation of muscles after contraction (e.g on shaking hands), associated with myotonic dystrophy.
  • Pseudohypertrophy – classically involving calf muscles.
  • Cardiac disease and/or arrhythmias – associated with muscular dystrophies.
  • Family history (of muscle or cardiac diseases) – explore inheritance patterns (in muscular dystrophy and atrophy).
  • Growth faltering more likely consistent with chronic inflammatory conditions.

Non-accidental injury (NAI) is common, and potentially life-threatening and often presents with musculoskeletal problems, such as pain, swelling, limping, or non-weight bearing and all healthcare professionals who have contact with children should be alert to the possibility of abuse. Early intervention is crucial, and any concerns about neglect or abuse should be discussed with senior clinical staff or the designated child protection lead, to protect vulnerable children. You need to ensure that you are familiar with your local procedures and protocols for child protection.

Points to consider in detecting non-accidental injury:

  • Is the history variable or inconsistent with the injuries seen?
  • Was there a delay in seeking attention following an injury? 
  • In a limping child – could this be due to a fracture or soft tissue injury? Is there a history of trauma, and is it consistent with the injury? 
  • Are there multiple injuries? 
  • Are there multiple attendances to the Emergency department, primary care or other healthcare services? 
  • Are there signs of neglect, such as an unkempt, persistently dirty or smelly child - and especially in a child with learning difficulties or chronic illness?
  • Are the findings consistent with the developmental age of the child?

Certain patterns of injury are suggestive of non-accidental injury:

  • Bruising in a non-mobile child.
  • Bruising over soft tissues, multiple bruises, clusters of bruises, bruises in the shape of a hand or implement or instrument.
  • Burns in particular shapes eg cigarette burns, burns suggestive of forced immersion.
  • Certain types of fractures are more suggestive of abuse than others (although none are pathognomonic) eg classic metaphyseal lesions, usually caused by twisting/shearing forces.
  • Exclude bruising or soft tissue swelling due to medical causes – eg vasculitis, coagulation disorders. 
  • Exclude metabolic bone disease with recurrent fractures (e.g osteogenesis imperfecta or osteoporosis secondary to chronic corticosteroids).
  • Remember a child with an organic diagnosis and especially chronic illness or disability may still be at risk of abuse or neglect.

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