Level 2 - MSK Flashcards

1
Q

What is developmental dysplasia of hip?

A
  • A spectrum of severity ranging from stable acetabular dysplasia to established hip dislocation
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2
Q

Epidemiology of DDH?

A
  • Affects 1-3% of newborns
  • Females 6:1 males
  • Left hip most commonly affected
  • Bilateral in 1/3
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3
Q

Risk factors for DDH?

A

o Sibling with DDH

o Vaginal deliveries, breech delivery

o Oligohydramnios

o Multiple pregnancy, prematurity

o Cerebral palsy

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4
Q

Describe disease progression in DDH?

A

o Capsular laxity + shallow acetabulum

o Instability/subluxation/dislocation

o Muscle contracture

o Progressive acetabular dysplasia with a fibro-fatty substance filling the acetabulum (pulvinar); femoral head becomes hypoplastic

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5
Q

What would parents notice in DDH? What is Galeazzi’s sign?

A
  • Notice delayed walking, painless limp, limited abduction, increased falls
  • Galeazzi sign – hips and knees flexed 90o, unilateral femoral shortening may signify hip dislocation
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6
Q

What screening tool is performed to prevent missing DDH? When should furthe testing be performed?

A

o NIPE baby check at <48 hours and 6-8 weeks

o If high risk, baby should have USS at 2-4 weeks

o Barlow’s manoeuvre

 Screen for a dislocatable hip

 Gentle backward pressure to the head of each femur in turn

 A subluxable hip is suspected on palpable displacement

o Ortolani’s test

 Screens for dislocated hip

 Abduction and lateral rotation

 Move a posteriorly dislocated femoral head forwards into the acetabulum

 Palpable movement suggests that the hip is dislocated or subluxed, but reducible

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7
Q

What imaging should be done in DDH and when?

A

o Dynamic USS (<4.5 months)

o Pelvic X-rays (>4.5 months) Shallow acetabulum with incd acetabular index and hypoplastic femoral head

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8
Q

Prognosis of DDH?

A
  • Most unstable hips stabilise spontaneously by 2-6 weeks, any hip that remains dislocatable or pathologically unstable requires prompt treatment
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9
Q

What is the management of DDH in <6 months?

A

o Long-term splinting in flexion-abduction (Pavlik harness)

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10
Q

What is the management of DDH in 6-18 months?

A

o Exam-under-anaesthetic and open/closed reduction followed by immobilisation in spica hip (casting)

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11
Q

What is the management of DDH in >18 months?

A

o Open reduction with corrective femoral/pelvic osteotomies to maintain stability

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12
Q

Complications in DDH?

A
  • Re-dislocation, stiffness, blood loss, avascular necrosis
  • Premature degenerative joint disease
  • Lower back pain
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13
Q

What is transient synovitis?

A
  • Hip pain, swelling of joint often following a viral infection (recent URTI, gastric illness)
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14
Q

How common is transient synovitis?

A
  • Most common cause of acute hip pain in 4-10 year olds
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15
Q

Risk factors for transient synovitis?

A
  • Boys twice as likely
  • HLABR7 in Reiter’s syndrome
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16
Q

Symptoms of transient synovitis?

A
  • Sudden onset pain in hip or limp
  • No pain at rest, decreased ROM particularly internal rotation
  • Referred pain to the knee
  • Afebrile commonly, looks well
  • Usually develops 2-4 weeks after a genitourinary or gastrointestinal infection
17
Q

DDx of transient synovitis?

A
  • Septic Arthritis, Perthe’s disease, Slipped upper femoral epiphysis
18
Q

Investigations in transient synovitis? What must be excluded and how?

A
  • Diagnosis of exclusion
  • Blood - FBC, (elevated WCC, CRP, ESR, normocytic normochromic anaemia)
  • Need to exclude septic arthritis

o Joint aspiration and blood cultures

o X-ray normal

o USS fluid in joint

19
Q

Management of transient synovitis? Complications?

A
  • Bed rest, analgesia (NSAIDs)
  • Usually resolves in a few days
  • 3% develop Perthe’s disease
20
Q

Causative organisms in reactive arthritis?

A

o C. trachomatis and Chlamydia pneumoniae are the most frequent causative pathogens

o Enteric bacteria (Salmonella, Shigella, Campylobacter, Yersinia)

o Borrelia burgdorferi (Lyme’s disease)

21
Q

What is Reiter’s syndrome?

A

o Large joint oligoarthritis, urogenital tract infection and uveitis

22
Q

What is juvenile idiopathic arthritis?

A
  • Joint inflammation presenting in children under the age of 16 years and persisting for at least six weeks in absence of any infection or other defined cause
23
Q

Epidemiology of juvenile idiopathic arthritis?

A
  • Commonest chronic inflammatory joint disease in children
  • 1 in 1000 children in the UK
24
Q

Subtypes of JIA?

A

o 7 distinct subtypes based on number of joints affected in first 6 months (polyarthritis >4, oligoarthritis <4 or systemic (fever and rash)

o Psoriatic and enthesitis & presence of RF and HLA B27 tissue are further subtypes

25
Q

Symptoms of JIA?

A
  • Gelling (stiffness after periods of rest)
  • Morning joint stiffness and pain
  • Intermittent limp or deterioration of behaviour when doing activities
  • Swelling of joint, thickening of synovium
  • Bone overgrowth, digit length discrepancy
26
Q

What other symptoms are seen in JIA and in what classifications?

A
  • Rheumatoid nodules, psoriasis, nail pitting (polyarthritis RF positive)
  • Systemic - fever, malaise, salmon rash, lymphadenopathy and hepatosplenomegaly (systemic arthritis)
  • Inflammation at tendon/ligament insertion (enthesitis arthritis)
27
Q

DDx of JIA?

A
  • Septic arthritis
  • Osteomyelitis
  • Reactive Arthritis
  • SLE, sarcoid
28
Q

Investigations of JIA?

A
  • Clinical diagnosis
  • Bloods

o FBC (normocytic anaemia), elevated CRP/ESR

o ANA, RF, HLA B27 useful for classification

  • Imagine

o X-ray often normal in early JIA

o USS

  • Aspirate if suspect septic arthritis
29
Q

Where should the management of JIA be done? What other healthcare professional is important?

A
  • Managed in specialist rheumatology MDT
  • Physiotherapy to maintain function, encourage physical activity as much as possible
30
Q

Medical therapy in JIA?

A

o NSAIDs

o Intra-articular corticosteroid injections (1st line in oligoarticular JIA)

o Methotrexate (1st line if multiple joints affected or same joint injected >3 times) (sulfasalazine/etanercept can be used instead)

o Systemic steroids

o Tocilizumab when steroids and methotrexate fail for polyarticular arthritis

31
Q

Surgical management of JIA?

A

o Joint replacement may be required

32
Q

Complications of JIA?

A
  • Chronic anterior uveitis
  • Flexion contracture of joints
  • Growth Failures
  • Anaemia of chronic disease