ILA 1: infection, inflamm, immunity

Question 1

PC: limp. 4 main diseases and typical age groups

Answer 1

1. Development dysplasia of the hip (DDH) 0-5yrs
2. Perthes (disease of hip) 5-10yrs
3. Slipped capital femoral epiphysis (SCFE) 10-15yrs
4. Septic arthritis (under 2yrs)

Question 2

DDH RFs?

Answer 2

breach, FHx, forceps, twin, oligohydramnios, female, clubfoot, c-section

Question 3

DDH symptoms

Answer 3

• Waddle
• Limp
• Shortening of affect leg
• Asymmetry of skinfolds around hip
• Cant abduct hip

Question 4

DDH ix

Answer 4

Screening at 72 hrs and 8wks old: Baby check - Ortolanis (abduct; dislocated?) test and Barlow (adduct; dislocatable?) manoeuvre

Question 5

DDH mx

Answer 5

Pavlik harness (fabric splint) to keep hip flexed and abducted

Question 6

Perthe’s PP and prognosis factors

Answer 6

Idiopathic avascular necrosis of capital femoral epiphysis (head) followed by revascularisation and reossification over 18-36 months
>6y bad prognosis (due to reossification), <6y better prognosis

Question 7

Perthe’s age range and sex preference

Answer 7

• 5-10yrs

- Boys 5:1 girls

Question 8

Perthe’s symptoms and DD

Answer 8

S&S: insidious hip/ knee pain or limp
Unilateral
O/E:
- Roll test - reduced internal rotation + pain + guarding
- Reduced hip movements (all directions)

DD:
JAI - swelling (perthes no swelling)
Sickle cell anaemia - bilateral
Irritable hip - often diagnosed in case of early stage Perthes’

Question 9

Perthe’s ix

Answer 9

x-ray both hips (inc. frog views) - top of femur looks white, crescent sign (increased femoral head density, fragmentation)

Question 10

Perthe’s RFs

Answer 10

LBW, short stature, low SE class, passive smoking

Question 11

Perthe’s mx

Answer 11

• If hip in good position and no muscle spasm - monitor in out-patients w/ x-rays
• Pain and reduced movement - hospital for rest and skin traction (bandages and weights) +/- hydrotherapy
• Surgery: femoral head needs to be covered by acetabulum to acts as a mould for the re-ossifying epiphysis. This is achieved by maintaining the hip in abduction with plaster or callipers or by performing pelvic/femoral osteotomy

Question 12

SCFE/SUFE RFs

Answer 12

hypothyroid, growth hormone deficiency, hypogonadism, obese teenage boys

Question 13

SCFE complication

Answer 13

risk of AVN if not treated promptly

Question 14

SCFE symptoms and exam findings

Answer 14

Limp or hip pain (may be referred to knee)

Ex: restricted abduction and internal rotation of hip

Question 15

SCFE ix

Answer 15

Ix: hip x-ray + frog lateral view

Question 16

SCFE mx

Answer 16

fix with screw to hold it, don’t move it í hopefully bone will re-model
If endocrine disturbance - fix other side too

Question 17

Septic arthritis cause

Answer 17

• Staph A (haem inf prior to Hib immunisation - multi sites affected)

Question 18

SA symptoms

Answer 18

• S&S Hallmarks : CRP, ESR, limping, fever, can’t wait bare (4/5 = 99% chance septic arthritis)
• Acute red hot swollen, holding it still. Limp/ referred pain to knee
• Pt. hold knee flexed - can fit more fluid in - likely to have big effusion (hip position = fabour)
• Septic arthritis least likely to occur in knee (joint capsule and metaphysis separate)

Question 19

SA ix

Answer 19

• ↑WCC ↑ESR/CRP, blood cultures
• USS
• X-ray ?trauma (normal at start of septic arthritis - just increased joint space/ soft tissue swelling)
• MRI ?osteomyelitis
• aspiration under USS = gold standard

Question 20

SA mx

Answer 20

• Tx: surgical wash out + 6w IV cefuroxime (>3months)
  o (IV cefotaxime if <3months - risk of meningitis)
  o Aspirate when washing out, don’t aspirate first
• Initial immobilisation of joint in functional positive, then mobilisation to prevent deformity

Question 21

Most common cause of acute hip pain in kids?

Answer 21

Transient synovitis

Question 22

Transient synovitis DD?

Answer 22

Beware SEPITC ARTHRITIS (similar early presentation) - if suspected do joint aspirate + blood culture mandatory

Question 23

Transient synovitis symptoms

Answer 23

• Follows/ accompanied by viral infection
• Presentation: sudden onset hip pain or limp.
• No pain at rest, decrease range of movement - particularly internal rotation
• Pain referred to knee
• Afebrile, mild fever, not ill - unlike septic arthritis

Question 24

Transient synovitis mx and complication

Answer 24

Tx: bed rest (rarely skin traction)

In some cases transient synovitis may develop into Perthe’s