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Year 4 Paediatrics > Locomotor System > Flashcards

Locomotor System Flashcards

1
Q

When taking a paediatric MSK history, what questions are important to ask?

A
  1. OPERATES+ (SOCRATES)
  2. Potential triggers - specifically trauma, infection, immunisations?
  3. Associated features - fever, rash, lethargy, weight loss?
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2
Q

When is it appropriate to examine joints in children?

A
  1. Child with muscle, joint of limb pain
  2. Unwell child with pyrexia
  3. Limping child
  4. Delay of milestones
  5. Clumsy child in the absence of neurological signs
  6. Associated conditions e.g. IBD, cystic fibrosis, arthritis
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3
Q

What are the red flags associated with MSK conditions/rheumatology?

A
  1. Fever, reduced appetite, weight loss, night sweats
  2. Bruising, lymphadenopathy, hepatosplenomegaly
  3. Night pain or waking/unremitting pain
  4. Inconsistent history, unwitnessed incidents, repeat presentations to healthcare, unkempt appearance
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4
Q

Using a surgical sieve, can you provide differentials for this case:
3 year old girl brought to A&E with 1 week history of URTI, a fever and limp for one day, now refusing to walk and eating ok. Temperature is 37.4, comfortable at rest, painful restriction of left hip and other leg joints are fine.

A

Vascular: Bleeding?
Iatrogenic: Septic arthritis/osteomyelitis/TB
Trauma (don’t forget non-accidental)
Autoimmune: inflammatory bowel disease, lupus, juvenile dermatomyositis, HSP
Metabolic: mucopolysaccariodes
Iatrogenic
Neoplasia: leukaemia/osteoma
Congenital: congenital diaphragmatic hernia (missed late walking/limp)
Degenerative: Perthes, osteochondritis

…most likely:

  1. Transient synovitis
  2. Septic arthritis - if unwell, high pyrexia, rigid joint
  3. Perthes disease - usually boys 4-9 years
  4. Acute lymphoblastic leukaemia (rare but important)
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5
Q

What investigations would be carried out for the 3 year old girl with fever and a limp/painful left hip? (5)

A
  1. FBC, CRP, blood culture
  2. X-ray
  3. Ultrasound
  4. Joint aspiration (under GA and before antibiotics) if there is a possibility of septic arthritis
  5. MRI
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6
Q

When are ‘growing pains’ more likely to occur in terms of age and time of onset?

A

Ages 3-5 years and 8-12 years. They are intermittent cramps pains in calves, thighs or shin in the evening or at night

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7
Q

What is the management for benign nocturnal pains of childhood?

A
  1. Reassurance
  2. Massage and simple analgesia e.g. paracetamol - especially before bed on days which have been very active
  3. Daily muscle stretching
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8
Q

What features may suggest pains described are not simple growing pains?

A
  1. Pain during the day
  2. Joint swelling seen
  3. Child unwell with other symptoms
  4. Abnormal examination
  5. Abdominal investigation findings
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9
Q

What are the differential diagnoses for growing pains?

A
  1. Cancer (acute lymphoblastic leukaemia) or benign bone tumours
  2. Juvenile idiopathic arthritis
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10
Q

What are the differential for this case:
4 year old boy with a limp and right knee swelling - causing reduced play and stiff in the mornings.
He is otherwise fit and well, good appetite, no fever and no pain at night.
O/E all joints fine except right knee

A 
A: acute septic arthritis
R: reactive to infection
T: trauma
H: haemophilia/leukaemia
I: immunological HSP
T: TB
I: IBD
S: sarcoidosis

Juvenile idiopathic arthritis

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11
Q

What are the features of JIA? (3)

A 
Onset before 16th birthday
No other cause
At least 6 weeks of: 
- joint swelling
- limited joint range and tenderness/pain
- morning stiffness
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12
Q

What are the signs/symptoms of JIA? (6)

A
  1. Joint swelling
  2. Pain
  3. Warmth
  4. Redness
  5. Morning stiffness
  6. Anorexia/lethargy
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13
Q

What may be seen on X-ray in JIA? (3)

A
  1. Excess fluid in cavity
  2. Thinning of cartilage
  3. Damage to bone (erosion of bone)
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14
Q

What are the subtypes of JIA?

A
  1. Oligoarthritis (persistent, extended)
  2. Polyarthritis (rheumatoid factor negative/positive)
  3. Systemic onset
  4. Enthesitis-related arthritis
  5. Psoriatic arthritis
  6. Undifferentiated
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15
Q

What are children with JIA at a high risk of?

A

Uveitis - this can lead to loss of vision

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16
Q

What are the differentials for suspected JIA in terms of infection? (2)

A
  1. Bacterial: septic arthritis, osteomyelitis

2. Viral: rubella, parvovirus B19, TB

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17
Q

What are the post-infective differentials for JIA? (3)

A
  1. Reactive arthritis
  2. Post-streptococcal reactive arthritis
  3. Rheumatic fever
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18
Q

What are the orthopaedic differentials for JIA? (4)

A
  1. Perthes
  2. Slipped upper fermoral epiphysis
  3. Hip dysplasia
  4. Chondomalacia patellae
19
Q

Which two inherited conditions cause hyper-mobility and can be potential differentials for JIA?

A
  1. Ehlers-danlos

2. Marfans

20
Q

How does JIA typically present? (7)

A

It is a diagnosis of exclusion - so the whole host of differentials need to be excluded first.
History may include:
1. Limp, stiffness, loss of function, pain, malaise
2. Gradual onset
3. Worse after rest or inactivity
4. Described as “little old person in the mornings”
5. History of associated rash, fever, weight loss
6. Sore throat, URTI, antecedent infections
7. Family history of arthritis, psoriasis, colitis, rheumatic fever

21
Q

Which hip is affected more commonly in DDH?

A

Left

22
Q

When is developmental dysplasia of the hip more common?

A
  1. Breech presentation
  2. Female
  3. Swaddling
  4. Premature
  5. Twins - multiple births
23
Q

If DDH is undetected at birth, how might it present?

A

Limping in toddles/when first learning to walk

24
Q

What is Ortolani’s test?

A

Putting a dislocated hip back in the socket - it starts out of the joint and can be put back in

25
Q

What is Barlow’s test?

A

Seeing if a hip can easily be dislocated - it will be in the joint when starting the test

26
Q

When is USS recommended for DDH?

A

6-8 weeks

27
Q

What is the first line treatment for a baby under 6 months old with DDH?

A

Bracing

28
Q

If a baby presents with DDH older than 6 months old or if bracing fails (approximately 5%), what is the first line treatment?

A

Surgery

29
Q

What are the risks of DDH surgery? (3)

A
  1. Re-dislocation
  2. Stiffness
  3. Avascular necrosis (5-15%)
30
Q

What are the long term complications of DDH? (2)

A
  1. Osteoarthritis (leading to early hip replacements)

2. Lower back pain

31
Q

What are the main features of transient synovitis? (5)

A
  1. Acute onset hip pain +/- refusal to weight bear
  2. Generally no pain at rest
  3. Often preceded by a viral URTI
  4. Treat with rest and analgesia
  5. Usually resolves spontaneously in 2 weeks
32
Q

What are the main features of Perthes disease, and how does it present?

A
  1. Loss of blood supply (avascular necrosis) to the femoral epiphysis
  2. Leads to abnormal growth of the epiphysis and eventual remodelling of the bone
  3. More common in boys, aged 4-8 years old
  4. Associated with low birth weight and a positive family history
  5. Present with knee/hip pain and effusion
  6. 12% of cases are bilateral
33
Q

What do early X-rays show in Perthes disease?

A

Joint space widening

34
Q

When is conservative management recommended in Perthes disease?

A

When children are <8 years old or the bone age is <6 years

35
Q

If a child with Perthes requires surgery, what does this involve?

A

Proximal varus osteotomy

36
Q

In transient synovitis, in a young child, what is the first line recommended treatment?

A

USS

37
Q

In suspected Perthes disease, what is the first line treatment?

A

X-ray

38
Q

13 year old boy with severe hip pain, worse on running and jumping, and hypothyroidism, what is the most likely diagnosis?

A

Slipped upper femoral epiphysis

39
Q

What are the 4 types of slipped upper femoral epiphysis and why does it occur?

A

It is due to an instability of the proximal femoral growth plate

  1. Pre-slip: wide epiphyseal line, no slippage
  2. Acute: sudden slip, usually spontaneous
  3. Acute-on-chronic: acute pain on chronic slip
  4. Chronic: steadily progressive slip
40
Q

Which age group and gender does SUFE affect most?

A

Boys aged 10-17 years

41
Q

What are the risk factors for SUFE? (4)

A
  1. Obesity/overweight
  2. Pelvic radiotherapy
  3. Hypothyroidism
  4. Trauma
42
Q

Which hip is most commonly affected in SUFE?

A

Left hip

43
Q

What is the management for SUFE? (3)

A
  1. Immediate bed test and analgesia
  2. Immediate oath opinion
  3. Urgent surgical closure of the epiphysis (within 24 hours - as more it slips, the less blood supply, higher chance of avascular necrosis) (treated with percutaneous screws)

Year 4 Paediatrics (18 decks)

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