Joints Flashcards
What is juvenile idiopathic arthritis
Arthritis occuring in someone who is less than 16 years old and lasts for more than 6 weeks
Which joints does juvenile idiopathic arthritis tend to occur in
Medium sized- ankles, knees and elbows
How does pauciarticular juvenile idiopathic arthritis present
Joint pain and swelling of medium sized joints
Limp
What are the different types of juvenile idiopathic arthritis
Pauciarticular- 4 joints or less
Polyarticular- more than 5
Systemic- with systemic symptoms like fever
What antibody can be positive in JIA
ANA
Risk factor is SLE fhx
Pathophysiology of congenital hip dysplasia
When the femoral head does not sit within the acetabulum, as such they grow out of proportion to one another. If femoral head not in the acetabulum get hypertorphy of the ligaments. Caused by an excess of force on hip from various origins
Risk factors for congenital hip dysplasia
Anything which causes too much force on hip
- breech position
- first born child
- female
- oligohydramnios
Symptoms of congenital hip dysplasia in newborns
Different length legs in children
Asymmetrical skin folds over the hip
Symptoms of congenital hip dysplasia in older children
Painless limping
Waddling gait
Painful osteoarthritis
How to visualise congenital hip dysplasia
Under 4.5 months- ultrasound
Over 4.5 months- X-ray
How is CHD screened for
Barlow and ortolani test
How does barlow and ortolani test diagnose CHD
Barlow test initially- adduct hip whilst keeping knee straight
Ortolani test- flexing babies hip and adducting it will put femoral head back in place
How to treat CHD
Under 6 months- pavlik harness for 1-2 months which holds femoral head in place
Over- surgery
What should be done in all children under 2 with an acute limp
Refer urgently
What is slipped upper femoral epiphysis
When the head of the femur (ball) slips off the neck of the femur at the growth plate
It slips postero-inferiorly
Risk factors for slipped upper femoral epiphysis
Obese
Males
Aged 10-15
Hypothyroidism
Hypogonadism
How can slipped upper femoral epihysis present
Can be acutely following trauma or more commonly with chronic symptoms
These include gradual onset pain (can be anywhere) and limp
How is slipped upper femoral epiphysis diagnosed
AP and lateral (frog legs) X-ray on BOTH legs
SUFE can be bilateral in 20% of cases
What movement is lost in SUFE
internal rotation when flexed as such on examination the leg is often shortened and extenrally rotated
What is the management for superior upper femoral epiphysis
Internal fixation- single cannulated screw placed in the centre of epiphysis
What is transient synovitis
Acute synovitis which in children typically occurs a few weeks after an infection- be careful when diagnosing as should exclude all other causes first
Factors which indicate can keep transient synovitis care at the GP
Afebrile
Can bear weight
No swelling
Redness
Between 3-9 (rare in under 3s)
Not obese
What is perthes disease
Avascular necrosis of the femoral head
Can be bilateral
Presentation of perthes disease
Limp
Reduced movement as stiff
Progressive hip pain
X-ray finding of perthes disease
Loss of joint space initially then loss of femoral head
How to image perthes disease and if symptoms persist but no changes
X-ray
If persist MRI or technetium
Management of perthes disease
If under 6 and not severe collapse of the head- observation, physio and serial x-rays
If over 6 surgical management
What is osgood schlatters disease demogrpahic
Sporty teens
Presentation of osgood schlatters
Pain after excerise in sporty teens
Anterior tibia
Management of osgood schlatters
Pain relief- paracetamol or NSAIDS
Lifestyle advice- reduce activity, wear knee brace, ice packs on tuberosities
Complication of juvenile idiopathic arthritis
Anterior uveitis
Damage to joint
Osteoporosis
Growth failure
Management of juvenile idiopathic arthritis
NSAIDS or paracetamol
Can use intra-articular or oral corticosteroids
IF Fail to respond to these
1st line- oral methotrexate
2nd line- sulfasalazine
Cn use inflammatory cytokine block agents too
What is systemic JIA also known as
STILLS disease
S- spiking fever (mainly in evening)
T- there could be arthralgia
I- increase in size of liver and spleen
L- lose weight,anaemia
L- looks like cancer
S- salmon pink rash that comes and goes with fever
What are types of osteogenesis imperfecta
T1- mildest and most common
T2- lethal
T3- severely progressive and deforming
T4- moderately progressive
Features of osteogenesis imperfecta
Multiple fractures
Blue sclera
Discoloured teeth
Aortic root dilatation
Aortic regurg
Mitral valve prolapse
What is osteogenesis imperfecta
Group of collagen metabolism disordersleading to increased bone fragility and thinning of the sclera
Complications of pavlik splinting
Avascular necrosis
Temporary femoral nerve palsy
What causes anterior knee pain on exercise or climibing stairs with a grating sound or crepitus on examination
Chondromalacia patellae
Management of chondromalacia patellae
Physio
What are the 3 types of spina bifida and what are they
Spina bifida occurs when there is a failure of the vertebral arch to fuse
Spina bifida occulta- just failure to fuse
Meningocele- herniation of the meninges through the arch causing a sac
Myelomingocele- herniation of meninges containing neural tissue
What presents with dimple, tuft of hair or lipoma over spine
Spina bifidia
Difference in presentation of the spina bifidas
Occulta- can be incidental or through tethered chord syndrome
Meningocele- no abnormal neurology but sac can burst causing meningitis or hydrocepahlus
Myelomeningocele- severe abnormal neurology like bladder/bowel dysfunction, club foot or paresis
What is tethered chord syndrome
When inelastic tissue of caudal spine fuses to local area
Can present with pain on exercise, gait issues and neurological dysfunction
Inheritance of muscular dystrophies
X-linked
How does duchenne muscular dystrophy present
1-3 years of age
Delayed walking and waddling gait
Difficulty to walk stairs
Bulky calfs (pseudohypertrophy as muscle replaced by fibrotic tissue)
Prognosis and complications of duchenne muscular dystrophy
Cant walk at 12
Get cardiomyopathy and resp muscular issues
Die by 20-30
Presentation of reactive arthritis
GI infection, throat or UTI
3 weeks later triad of
- conjunctivitis
- arthritis
- urethritis normally first symptoms
How does reactive arthritis arthritis present
Oligoathritis of large joints
Ethesitis like plantar fasciitis
Rarer symptoms of reactive arthritis
Keratoderm blenhoragicum- hard nodules on feet
Balanitis- swelling of glans of penis
What type of condition is reactive arthritis
Seronegative spondyloarthropathy- associated with HLA-B27 and RF negative
Risk factors for perthes disease
Hyperactivity
Short stature
What organism is associated with septic arthritis in SCD
Salmonella
X-ray findings of septic arthritis
Joint widening
Ill defined articular margins
Most common site of septic arthritis
Hip
If patient deteriorates rapidly in osteomyeltis despite IV abx what do
Surgical debridement
Most common site of osteomyelitis
Upper tibia or lower femur
What is trendelenburg test in DDH
Positive- as hip tilts to one side
What is a greenstick fracture
When bone breaks and bends
- common in at wrist when children fall forwards
What is a greenstick fracture
When bone breaks and bends
- common in at wrist when children fall forwards
- no complications
Management of greenstick fractures
Manipulation plaster immobilisation
What is chondromalacia patella
Wearing away of cartilage in the patella
What do if suspect transient synovitis but feverish
Admit
Management of stills disease
1st line- NSAIDS, steroids
2nd line DMARDS like steroids
3rd line- toclizimumab
How do gRowing pains present
Pain worse in joints at night
Up until when is bowed legs normal
3 years
What is pes planus
Flat feet
Up until when is pes planus normal
4-8 years
How does osteosarcoma present
Swelling around a joint
Painless most often
Reduced mobility
What is osteochondritis dissecans pathophysiology
Get reduced blood flow to patella- leads to fragmentation of bone and cartilage
Presentation of osteochondritis dissecans
Pain after exercise
Locking and catching of knee
Gives way easily
How is reactive arthritis managed
Pain relief
Long term complications of perthes disease
Short leg
Osteoarthritis
What rfx require USS for breech detection
Breech delivey
FHx
Investigations for osteomyelitis
Blood cultures
X-ray but wont show anything til 7 days when will see bone destruction, osteopenia
Management of osteomyelitis and septic arthritis abx wise
IV flucloxacillin (clindamycin if pen allergic)
Vancomycin if MRSA
Osteomyelitis presentation
Leg swelling
Immobile
Tender and erythematous
Onset insidious
Septic arthritis presentation
Acute limb pain
Swelling
Not mobilising limb
Red
Management of septic arthritis
IV fluclox
Joint washout
What is gowers sign and what seen in
When getting up walk hands up legs and body
Duchenne muscular dystrophy
What investigations done for duchenne muscular dystrophy
CK initially
If elevated gold standard now is genetic testing
What infections can precede reactive arthritis
UTI
GI
Throat
What is trethowans sign seen in and what is it
SUFE
Where the line of klein passess above the femoral head and does not line up with one on other side
What is irritable hip
Transient synovitis
How are growing pains managed
Heat packs
Pain relief if needed
What causes joint pain and hyperextension of joints
Hypermobile joints
Recurrent broken bones including bones broken in utero
Osteogenesis imperfecta
Management if positive barlow and ortolani
USS at 6 weeks to assess
Differences between becker and duchenne muscle dystrophy
Becker presents at around 10 but duchenne between 1 and 6
Becker far less severe
Becker rarer
How does spinal muscle atrophy present
Difficulty to maintain head
Breathing difficulties
Weak cough and cry
Proximal muscle weakness
Hypotonia
Inheritance of spinal muscular atrophy
Autosomal recessive
Abdo mass with limp
Neuoblastoma
Metastasies to bones quickly and evidence of metastatic disease most common presentation
What do first; joint aspirate or IV abx
Joint aspirate
How is positional talipes differentiated from talipes equinovirus
In positional talipes the foot van be easily moved from position and isnt fixed
How does dislocated knee present
Severe knee pain and swelling
Feeling it pop
Wanting to flex the knee
Blood findings of osteogenesis imperfecta
All normal
Presentation of meningocele
Protrusion of meninges through vertebrae with no abnormal neurology but are at risk of meningitis and hydrocephalus
What is differnece between anencephaly and encephalocele
Anencephaly- failure of fusion of cranial neural tube which presents with with stillbirth
Enancephalocele- herniation of brain and meninges through midline skull defect
What test is used to determine if leg shortening is tibial or femoral
Galleazis
Gold standard for duchenne
Genetic testing
Where do Ewings sarcomas appear vs osteosarcoma
Ewings- middle of long bones
Osteosarcoma- around knee
How do Ewings sarcomas present
Like an infection with a fever
