Locomotor, Nutrition, Developmental problems Flashcards
Kocher criteria for Septic arthritis
WCC>12000
ESR/CRP elevated
Non-Wx bearing
Temp>38
ALL 4= 99% Septic Arthritis
Epidemiology of septic arthritis
50% in first 2 years of life
2x more common in Boys
Underlying joint disease or prosthetic joints or bacteraemia increase risk
Presentation of septic arthritis
Likely < 3 years old 75% Lower limb (Knees>Hip>Ankle) Acute, hot swollen joint Pain on passive movement Pseudoparalysis Cannot weight bear Systemic symptoms
Diagnosis of septic arthritis
Joint aspiration under GA + USS guided
Then Gram stain and culture of synovial fluid
+/- FBC, ESR, CRP, Blood cultures
X-ray findings in septic arthritis
Initially normal +/- Widened joint spaces B/C effusion
Later will have space narrowing, erosive changes, subluxation, dislocation
Management of septic arthritis
Abx after aspiration
-IV up to 3/52 followed by oral for 4-6/52
Surgical involvement if recurrent or affecting hip
Splintage improves pain
Physio to avoid stiffness
Indications for a LP in septic arthritis
If H.Influ then do an LP as there is increased incidence of meningitis
What is developmental dysplasia of the hip
Abnormal formation of the hip joint where there is a shallow acetabulum that doesn’t cover the femoral head sufficiently
Risk Factors for DDH
FEMALE (6X more likely) Breech delivery FHx 1st born Oligohydramnios Other joint problems High birth Wx
Screening for DDH
1st day- Hips examined
6 weeks USS
How are Breech babies screened for DDH
All have USS
Same if 1st degree relative with DDH
Presentation of DDH
From birth or shortly after
Delay in walking
Waddling gait (like a pregnant lady)
Shortened affected leg
Barlow and Ortolani tests
Tests for DDH
Barlow- Press hips posteriorly when flexed to attempt to dislocate
Ortolani- Hips flexed and then abducted to try and relocate the dislocated hip
Management of DDH
Most spontaneously stabilise at 3-6 weeks therefore use double nappies until this point
No success + <6 months= Bracing with Pavlik harness for 3/12
Then consider surgery if above fails
Complications of DDH
OA, Lower back pain
Also a risk of re-dislocation and/or avascular necrosis
Commonest cause of hip pain in 3-10 years
Reactive arthritis/Irritable hip
Presentation of irritable hip/reactive arthritis
Slight limp and hip pain Hx viral infection No systemic symptoms Likely single joint No pain at rest but pain O/E
What features would likely indicate septic arthritis over reactive arthritis in a child with limp
Systemically unwell Fever Night pain and pain on rest Cannot Wx bear > 2 weeks Very elevated inflammatory markers
When would you discharge a child with reactive arthritis?
Non-dramatic physical signs
X-rays and bloods normal
Advise NSAIDS and rest
Reiter’s syndrome
Form of reactive arthritis
“Cant see, can’t wee, can’t climb a tree”
Uveitis, urethritis and arthritis
Classification of JIA
Objective arthritis in >/= 1 joint for at least 6 weeks \+/- Swelling, warmth, reduced movement < 16 years Nil other cause found Most common in girls under 4 years
Oligoarticular/Pauarticular JIA vs Polyarticular JIA vs Still’s disease
Oligo/Pau= Up to 4 joints affected. Most common. Poly= >4 joints affected Still's= Systemic onset JIA
Presentation of JIA
Joints- Painful, swollen, stiff on mornings, cartilage erosion
Walk on toes
Hepato/Splenomegaly
Still’s= + Fever, salmon-pink rash, Uveitis, Wx loss, Anorexia
Likely Blood result changes in Still’s disease
Leukocytes, ESR, CRP and platelets can be raised
HB can be low
Can be similar in non-systemic JIA
Rh and Anti-nuclear factor in JIA
Rh can be -ve or +ve
Anti-nuclear factor +ve in 70% Pauarticular JIA
Management of JIA
Mild exercise alongside rest each day
Physio and splints
NSAIDS and hot baths +/- Steroid injections
Long term: Methotrexate, Sulfasalazine, oral corticosteroids
Surgery to preserve joint function
Osteomyelitis presentation
Fever, Swelling, erythema and severe bony pain
Child will stop using the affected limb
Lucency and periosteal thickening can sometimes be seen on an X-ray
What does a child under 3 years with an acute limp need?
A secondary care assessment
Benign idiopathic nocturnal limb pain of childhood (Growing pains)
Preschool children (~3-5 years) or 8-12 years
Pain at night and no limp by the day
No interference with normal activities
Meeting motor milestones
Most common age range irritable hip is seen
2-8 years
When are Bow legs normal
< 3 years
Surgical referral for Blout’s disease if > 4 years
ALL and limp
ALL can cause pathological fractures and thereby lead to limp/pain/tenderness
Therefore always have malignancy as a differential
Osgood Schlatters
Knee pain in active children
Red flags indicating an organic cause of limp
Day and night pain There on weekends and vacations Interruption of normal activities- ask about play Unilateral Localised to a join Unremitting Refusal to walk Systemic manifestations Wx loss, bruising, night sweats, hepatosplenomegaly Pain on passive internal rotation
Reassuring features indicating a non-organic cause of limp
Painless passive internal rotation Pain only at night/school days No interference with normal activities Bilateral Pain located between joints Not systemic Pain without limp is also reassuring
What is Perthe’s disease
Osteochondritis of the femoral head
Can be caused by or develop into avascular necrosis
Risk factors for Perthe’s disease
MALE
Short
Trisomy 21
Think a child in Primary school
Presentation of Perthe’s disease
Short child 4-8 years who is hyperactive
Progressive hip pain over weeks
Reduced movement, discrepancy in leg length
Limp
Can be bilateral
What gait is classically seen in Perthe’s disease
Trendelenberg gait- Unaffected side rises above affected side
X-ray of perthe’s disease
Sub-chondral linear lucency
Widened joint space early on
Collapsed deformity later on
Management of Perthe’s disease
< 6 years= Observation
If older then try physio and strengthening then callipers (non-wx bearing device) if good imaging
surgery if above fails
What is Slipper upper femoral epiphysis
Femoral head epiphysis displaced postero-inferiorly
Risk factors for SUFE
Secondary school age (10-16 years) Obese Hypothyroidism Trauma Pelvic RT
Presentation of SUFE
Pain, Limp, Reduced movement
Externally rotated hip +/- shorter length
Can be bilateral and thereby look like a ‘normal hip on x-ray’
If Unilateral look for Klein’s line on X-ray- Inferolateral displacement “melting ice cream appearance”
Management of SUFE
Surgical fixation/closure to prevent AVN and chondrolysis
Normal calorie requirements
150mls/kg/day until around 6/12
How many mls per oz
30mls: 1 oz
Maintenance fluids
1st 10kg= 100mls/kg/day
2nd 10kg= 50mls/kg/day
subsequent kgs= 20mls/kg/day
Common causes of malabsorption
GORD Chronic infection CF Immunodeficiency Eating disorder
Definition of malnutrition
BMI<18.5
or
> 10% Wx loss over 3/12
Indicated by falling across two centile lines on serial Hx and Wx (or <3rd centile)
