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Foundations of Practise > Joint pain and limps - conditions > Flashcards

Joint pain and limps - conditions Flashcards

1
Q

What types of trauma can cause limp

A

Toddlers fracture

NAI

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2
Q

What types of infection can cause limp

A

osteomyelitis

Septic arthritis

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3
Q

What types of malignancy may cause limps

A

Neuroblastoma
Acute lymphoblastic leukaemia
Bone tumours

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4
Q

What surgical causes may cause a limp

A

Inguinal hernia
Appendicitis
testicular torsion

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5
Q

What structural causes may cause a limp

A

Osgood-Schlatter disease
perthes disease
Slipped upper femoral epiphysis
DDH

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6
Q

What metabolic causes may cause a limp

A

rickets

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7
Q

What neurologica causes may cause a limp

A

cerebral palsy

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8
Q

What haematoligcal reasons may cause a limp

A

Sickle cell anaemia

haemophilia

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9
Q

What conditions should you consider in children age 0-3 with joint pain

A
  • haematological malignancies
  • Fracture
  • DDH
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10
Q

What conditions should you consider in children age 4-10 with joint pain

A
  • Transient synovitis

- Perthe’s disease

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11
Q

What conditions should you consider in children age 11-16 with joint pain

A

Slipped upper femoral epiphyses

Bone tumour

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12
Q

Symptoms of transient synovitis of the hip

A
  • Limited abduction + internal rotation
  • Pain on touching
  • Pain on passive movement
  • Walk but limp
  • Involuntary guarding on log roll
  • Abducted and externally rotated hip
  • +/- fever
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13
Q

What is the management of transient synovitis of the hip

A
  • Ibuprofen/naproxen/paracetamol
  • Activity restriction
  • Follow up in a few days – improvement
  • SAFETY NET RE SEPSIS
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14
Q

What are the risk factors for transient synovitis of the hip

A
  • 2-12 yrs. (4-8)
  • Male
  • Recent URTI/gastroenteritis
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15
Q

What is Perthes Disease

A
  • Self-limiting disease of femoral head comprising of necrosis, collapse, repair and remodelling
  • Part or all of the top of the thigh bone: ball part of ball and socket joint loses its blood supply and can become misshapen
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16
Q

What are the signs and symptoms of Perthes disease

A

• Generally painless limp – gluteus Medius lurch
• Pain can occur with activity
• Pain can refer to the knee/thigh/buttock
• ROM: limitation due to impingement:
o - Internal rotation
o - Abduction in extension
• Muscle wasting – gluteal and quadriceps
• Short stature

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17
Q

What investigations should you request if suspecting perthes disease

A 
•	Bilateral hip X rays
       - AP and frog lateral views
       - Femoral head collapse – joint space narrowing
       - Subchondral #
•	FBC, CRP, ESR
•	? MRI
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18
Q

What are the risk factors for Perthes diease

A
  • Male
  • 4-8 years
  • Socioeconomic deprivation
  • Hypercoagulable states
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19
Q

What is the management of Perthes Disease

A
  • Supportive care with pain relief
  • Mobilisation and monitoring
  • PT
  • > 5 surgery may be required as bone remodelling isn’t as affective at this age
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20
Q

Signs and symptoms of Slipped Upper femoral epiphysis

A
  • Gait: affected leg externally rotated
  • Trendelenburg gait: lean trunk to affected side
  • Acute: sudden onset of pain + non-weight bearing
  • Gradual: Vague pain referring to the knee
  • ROM: decreased flexion of hip (passive and active)
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21
Q

Risk factors for Slipped Upper femoral epiphysis

A
  • Obesity: weight >90th centile
  • Adolescent males – puberty
  • Endocrine disorders: Hypothyroid, Panhypopituitarism, GH deficiency
  • African American, Hispanic
  • Prior radiation
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22
Q

What is the management of Slipped Upper femoral epiphysis

A
  • Urgent surgical repair: screw fixation

* Prophylactic fixation of contralateral hip

23
Q

What Investigations should be undertaken if suspecting Slipped upper femoral epiphysis

A
  • Bilateral AP x rays: Klein’s line doesn’t intersect femoral head
  • Bilateral Frog laterals: Bloomberg’s sign: Physis is blurred/widened
  • ? metabolic panel: TFTs, serum GH
24
Q

What are the complications of slipped upper femoral epiphysis

A
  • Long term OA – 90%
  • Avascular necrosis of femoral head 10-15%
  • Chondrolysis: acute cartilage necrosis
  • Deformity
  • Limb length discrepancy
25
Q

What are the signs and symptoms of Juvenile idiopathic arthritis

A
  • Joint pain – often knee
  • Joint swelling/effusion
  • Morning stiffness: not like first nappy change
  • Limp/decreased movement
  • Non-puritic salmon coloured rash on trunk and proximal extremeties
  • Enthesis: inflammation of tendon and ligament insertions on bone
26
Q

What are the risk factors for Juvenile idiopathic arthritis

A
  • Female
  • HLA polymorphism
  • FH autoimmunity
  • <6 years old
27
Q

What investigations should you consider if suspecting Idiopathic arthritis

A
  • FBC: normal, decreased Hb or increased platelets
  • ESR/CRP: can be raised
  • RF
  • Anti-CCP
  • ANA
  • Chlamydia in teenage?
  • USS joint
  • Ferritin
28
Q

Complications of Juvenile idiopathic Arthritis

A 
•	Low mood
•	Eye inflammation: 10-20% uveitis
•	Stiff joints
•	Medications can have an impact on 
         - Growth
         -  Puberty
29
Q

What is the acute management of Juvenile idiopathic arthritis

A

Physio

Pain relief - NSAIDs

30
Q

what is the chronic management of juvenile idiopathic arthritis

A

Disease modifying drugs - methotrexate/sulfasalezine
Folic acid
pain relief

31
Q

What are the risk factors for Developmental Dysplasia of the hip?

A
  • First born
  • Female
  • Breech
  • FH
  • Oligohydramnios
  • Macrosomia
  • Swaddling - cultural
32
Q

Dysplasia definition

A

Shallow or underdeveloped acetabulum (usually ant or anterolateral)

33
Q

Subluxation definition

A

displacement of the joint with some contact remaining between the articular surfaces

34
Q

What is a teratologic hip

A

o dislocated in utero and irreducible on neonatal exam
o presents with a pseudoacetabulum
o associated with neuromuscular conditions and genetic disorders
o commonly seen with arthrogryposis, myelomeningocele, Larsen’s syndrome, Ehlers-Danlos

35
Q

What does the barlow test do

A

Dislocates a dislocatable hip by adducting and depressiong a flexed femur – ‘click of exit’

36
Q

What does the ortolani test do

A

Reduces a dislocated hip be elevation and abduction of a flexed femur – ‘click of entry’

37
Q

What is the Galaezzi test

A

Hip flexed at 90 degrees, feet on table, femur appears shortened on dislocated side

38
Q

what would you find on examination between 3-12 months in developmental dysplasia of the hip

A
  • Limitations of hip abduction: laxity resolves and stiffness begins to occur (most sensitive) Will be decreased symmetrical in bilateral disloations.
  • Limb length discrepancies
39
Q

What is the klisic test

A

o used to detect bilateral dislocations
o line from the long finger placed over the greater trochanter and the index finger over the ASIS should point to the umbilicus
o if the hip is dislocated, the line will point halfway between the umbilicus and pubis

40
Q

What would you find on examination >12 months in a child with developmental dysplasia of the hip?

A
  • pelvic obliquity
  • lumbar lordosis: in response to hip contractures resulting from bilateral dislocations in a child of walking age
  • Trendelenburg gait : results from abductor insufficiency
  • toe-walking: attempt to compensate for the relative shortening of the affected side
41
Q

When would you do an Xray if suspected developmental dysplasia of the hip

A

o Primary imaging >4-6 months as femoral head begins to ossify
o Positive physical exam
o Leg length discrepancy
- AP view of pelvis

42
Q

When would you do an US scan if suspecting developmental dysplasia of the hip

A
  • 4 weeks – 6 months
  • Positive physical exam
  • RF
  • Monitoring of reduction using Pavlik harness
  • Not cost effective for routine screening
43
Q

What are the non operative management options for developmental dysplasia of the hip

A
  • abduction splinting/bracing (Pavlik harness)

-

44
Q

indications/contraindications for abduction splinting/bracing (Pavlik harness)

A
  • Indications
    o < 6 months old and reducible hip
  • Contraindications:
    o teratologic hip dislocations and patients with spina bifida or spasticity
     requires normal muscle function for successful outcomes
45
Q

What are the indications for closed reduction and spica casting

A

o 6-18 months old

o failure of Pavlik treatment

46
Q

What are the operative management options for developmental dysplasia of the hip

A

Open reduction and spica casting
Open reduction and femoral osteotomy
Open reduction and pelvic osteotomy

47
Q

What are the indications for Open reduction and spica casting

A

o > 18 months old

o failure of closed reduction

48
Q

What are the indications for Open reduction and femoral osteotomy in developmental dysplasia of the hip

A

o > 2 years old with residual hip dysplasia
o anatomic changes on femoral side (e.g., femoral anteversion, coxa valga)
o best in younger children (< 4 years old)
- after 4 years old, pelvic osteotomies are utilized

49
Q

What are the indications for Open reduction and pelvic osteotomy

A

o > 2 years old with residual hip dysplasia
o severe dysplasia accompanied by significant radiographic changes on the acetabular side (increased acetabular index)
o used more commonly in older children (> 4 yr)
o decreased potential for acetabular remodeling as child ages

50
Q

What are the risk factors for septic arthritis

A
  • Underling joint disease
  • Joint prosthesis
  • IVDU
  • DM/cutaneous ulcers
  • Intra-articular steroid injections
  • Low socioeconomic status
  • Hx or RA or OA
51
Q

What are the signs and symptoms of septic arthritis

A
  • Hot, swollen, tender, restricted joint
  • Short Hx of Sx
  • Fever
52
Q

What investigations would you order if you suspected septic arthritis

A
  • Synovial fluid, gram stain and culture and WCC
  • Blood culture
  • FBC
  • CRP/ESR
  • USS: effusion for aspiration
  • X-ray: degeneration changes?
53
Q

What is the management of septic arthritis

A
  • IB Abx + joint aspiration for 2 w
  • Oral Abx 4 weeks further
  • RISK OF OSTEOMYELTIIS AND JOINT DESTRUCTION

Foundations of Practise (20 decks)

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