Joint pain and limps - conditions Flashcards
What types of trauma can cause limp
Toddlers fracture
NAI
What types of infection can cause limp
osteomyelitis
Septic arthritis
What types of malignancy may cause limps
Neuroblastoma
Acute lymphoblastic leukaemia
Bone tumours
What surgical causes may cause a limp
Inguinal hernia
Appendicitis
testicular torsion
What structural causes may cause a limp
Osgood-Schlatter disease
perthes disease
Slipped upper femoral epiphysis
DDH
What metabolic causes may cause a limp
rickets
What neurologica causes may cause a limp
cerebral palsy
What haematoligcal reasons may cause a limp
Sickle cell anaemia
haemophilia
What conditions should you consider in children age 0-3 with joint pain
- haematological malignancies
- Fracture
- DDH
What conditions should you consider in children age 4-10 with joint pain
- Transient synovitis
- Perthe’s disease
What conditions should you consider in children age 11-16 with joint pain
Slipped upper femoral epiphyses
Bone tumour
Symptoms of transient synovitis of the hip
- 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
What is the management of transient synovitis of the hip
- Ibuprofen/naproxen/paracetamol
- Activity restriction
- Follow up in a few days – improvement
- SAFETY NET RE SEPSIS
What are the risk factors for transient synovitis of the hip
- 2-12 yrs. (4-8)
- Male
- Recent URTI/gastroenteritis
What is Perthes Disease
- 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
What are the signs and symptoms of Perthes disease
• 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
What investigations should you request if suspecting perthes disease
• Bilateral hip X rays
- AP and frog lateral views
- Femoral head collapse – joint space narrowing
- Subchondral #
• FBC, CRP, ESR
• ? MRIWhat are the risk factors for Perthes diease
- Male
- 4-8 years
- Socioeconomic deprivation
- Hypercoagulable states
What is the management of Perthes Disease
- Supportive care with pain relief
- Mobilisation and monitoring
- PT
- > 5 surgery may be required as bone remodelling isn’t as affective at this age
Signs and symptoms of Slipped Upper femoral epiphysis
- 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)
Risk factors for Slipped Upper femoral epiphysis
- Obesity: weight >90th centile
- Adolescent males – puberty
- Endocrine disorders: Hypothyroid, Panhypopituitarism, GH deficiency
- African American, Hispanic
- Prior radiation
What is the management of Slipped Upper femoral epiphysis
- Urgent surgical repair: screw fixation
* Prophylactic fixation of contralateral hip
What Investigations should be undertaken if suspecting Slipped upper femoral epiphysis
- 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
What are the complications of slipped upper femoral epiphysis
- Long term OA – 90%
- Avascular necrosis of femoral head 10-15%
- Chondrolysis: acute cartilage necrosis
- Deformity
- Limb length discrepancy
What are the signs and symptoms of Juvenile idiopathic arthritis
- 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
What are the risk factors for Juvenile idiopathic arthritis
- Female
- HLA polymorphism
- FH autoimmunity
- <6 years old
What investigations should you consider if suspecting Idiopathic arthritis
- FBC: normal, decreased Hb or increased platelets
- ESR/CRP: can be raised
- RF
- Anti-CCP
- ANA
- Chlamydia in teenage?
- USS joint
- Ferritin
Complications of Juvenile idiopathic Arthritis
• Low mood
• Eye inflammation: 10-20% uveitis
• Stiff joints
• Medications can have an impact on
- Growth
- PubertyWhat is the acute management of Juvenile idiopathic arthritis
Physio
Pain relief - NSAIDs
what is the chronic management of juvenile idiopathic arthritis
Disease modifying drugs - methotrexate/sulfasalezine
Folic acid
pain relief
What are the risk factors for Developmental Dysplasia of the hip?
- First born
- Female
- Breech
- FH
- Oligohydramnios
- Macrosomia
- Swaddling - cultural
Dysplasia definition
Shallow or underdeveloped acetabulum (usually ant or anterolateral)
Subluxation definition
displacement of the joint with some contact remaining between the articular surfaces
What is a teratologic hip
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
What does the barlow test do
Dislocates a dislocatable hip by adducting and depressiong a flexed femur – ‘click of exit’
What does the ortolani test do
Reduces a dislocated hip be elevation and abduction of a flexed femur – ‘click of entry’
What is the Galaezzi test
Hip flexed at 90 degrees, feet on table, femur appears shortened on dislocated side
what would you find on examination between 3-12 months in developmental dysplasia of the hip
- Limitations of hip abduction: laxity resolves and stiffness begins to occur (most sensitive) Will be decreased symmetrical in bilateral disloations.
- Limb length discrepancies
What is the klisic test
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
What would you find on examination >12 months in a child with developmental dysplasia of the hip?
- 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
When would you do an Xray if suspected developmental dysplasia of the hip
o Primary imaging >4-6 months as femoral head begins to ossify
o Positive physical exam
o Leg length discrepancy
- AP view of pelvis
When would you do an US scan if suspecting developmental dysplasia of the hip
- 4 weeks – 6 months
- Positive physical exam
- RF
- Monitoring of reduction using Pavlik harness
- Not cost effective for routine screening
What are the non operative management options for developmental dysplasia of the hip
- abduction splinting/bracing (Pavlik harness)
-
indications/contraindications for abduction splinting/bracing (Pavlik harness)
- 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
What are the indications for closed reduction and spica casting
o 6-18 months old
o failure of Pavlik treatment
What are the operative management options for developmental dysplasia of the hip
Open reduction and spica casting
Open reduction and femoral osteotomy
Open reduction and pelvic osteotomy
What are the indications for Open reduction and spica casting
o > 18 months old
o failure of closed reduction
What are the indications for Open reduction and femoral osteotomy in developmental dysplasia of the hip
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
What are the indications for Open reduction and pelvic osteotomy
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
What are the risk factors for septic arthritis
- Underling joint disease
- Joint prosthesis
- IVDU
- DM/cutaneous ulcers
- Intra-articular steroid injections
- Low socioeconomic status
- Hx or RA or OA
What are the signs and symptoms of septic arthritis
- Hot, swollen, tender, restricted joint
- Short Hx of Sx
- Fever
What investigations would you order if you suspected septic arthritis
- Synovial fluid, gram stain and culture and WCC
- Blood culture
- FBC
- CRP/ESR
- USS: effusion for aspiration
- X-ray: degeneration changes?
What is the management of septic arthritis
- IB Abx + joint aspiration for 2 w
- Oral Abx 4 weeks further
- RISK OF OSTEOMYELTIIS AND JOINT DESTRUCTION
