Locomotor System and Rheumatology Flashcards
What would be a normal structural variation in an infants legs and feet?
Babies = flat-footed
Toddlers = bow-legged (genu varum)
Primary school child = knock-kneed (genu valgum)
When does a child’s foot begin to have a plantat arch?
3 years
When are bow legs most common?
0 - 2cm
What can marked genu varum indicate?
Rickets
When is genu valgum most apparent?
3 - 4 years
When should the legs become completely straight?
By 12 years
When would you refer a child with knock knee for XR/specialist opinion?
Separation > 10 cm between medial tibial malleoli
Unilateral genu valgum
When should intoeing resolve?
8 years
What are the main causes of scoliosis?
Idiopathic (95%)
Vertebral anomalies e.g. hemivertebrae
Muscle weaknes e.g. CP
Who gets postural scoliosis?
How/when is it resolved?
Babies
It goes whilst they are suspended/lean forward and should have completely gone by the age of 2
How can one determine structural scoliosis on examination?
Bending forward to touch toes causes asymmetry - presents as a hump on flexion (predominantly over the scapula)
How can you tell if talipes is postural?
If the foot, with talipes equinovarus, can be fully dorsiflexed and everted so that the little toe touches the outside of the leg without undue force
How is (i) structural talipes and (ii) talipes calcaneovalgus managed?
i. Cannot be corrected manually, requires early splintage/surgery
ii. Calcaneovalgus can be corrected with simple exercises
Give five causes of leg pain and limping in children
Growing pains Osteomyelitis Legg-Perthes disease Slipped capital femoral epiphysis Transient synovitis Septic arthritis Trauma Neoplastic disease
Where are growing pains usually felt?
Bilateral
Shins and thighs
Muscles not bone
Who gets transient synovitis?
2 - 8 year old boys, often preceded by URTI
How does transient synovitis present?
Sudden onset of limp
No systemic symptoms
Preceded by URTI
When would you perform an MRI/bone scan in a child with leg pain?
Osteomyelitis
Where is pain in the hip referred to?
Knee
When is septic arthritis more common?
In children < 2 years old, but can occur at any age
What is the most common cause of septic arthritis?
Haematogenous spread of S.aureus
Can often be following a puncture wound or infected skin lesion
Hib used to be the most common before introduction of the vaccine
How does the affected joint present?
How does it present in neonates?
Erythematous, warm, swollen, single joint
Reduced ROM
Bony tenderness
In neonates, the limb is immobile (pseudoparalysis)
What are the red flags for joint pain?
Fever
Refuses to use joint
ESR and CRP elevated
What is the definitive investigation for diagnosis of septic arthritis?
Joint space aspiration and culture (under US guidance)
What can septic arthritis often be confused for?
Osteomyelitis
In young children, septic arthritis may result from spread of adjacent osteomyelitis into joints where the capsule inserts below the epiphyseal growth plate (shown by MRI)
Which joint(s) does SA most commonly affect?
Hip, knees and ankles
Which conditions can predispose to SA?
Immunodeficiency
Sickle cell disease
How does septic arthritis appear on XR?
Initially normal, apart from widening of the joint space and soft tissue swelling
What is the treatment for SA?
IV flucloxacillin (Vancomycin for MRSA)
Washing out/surgical drainage of joint
Temporary joint immobilisation/splinting
Physiotherapy
What is developmental dysplasia of the hip (DDH)?
The acetabulum is shallow and does not cover the femoral head, causing the hip joint to be dislocatable/dislocated
What are the risk factors for DDH?
4 F's: Frank breech position Family history Female First born
Oligohydramnios
Neuromuscular/joint problems:
Spina bifida
CP
Talipes
What manoeuvres are used to test for DDH?
Barlow’s: adduct hip and apply posterior pressure, a clunk is felt if the hip subluxates out of acetabulum
Ortolani’s: abduct and put pressure on greater trochanter, clunk is felt in DDH if hip is relocated into acetabulum
How is it investigation different in DDH in children who are (i) > 3 months or (ii) have risk factors?
i. Galeazzi sign: with hip and knee flexed, one leg appears shorter than the other as hip is dislocated into a fixed psotion
ii. USS before 12 weeks
When is Barlow’s and Ortolani’s done?
New born examination
Also at 6 - 8 weeks
How is DDH managed?
Immobilise hip joint with ‘Pavlik harness’ splint for three months - allows development of acetabular rim
Most unstable hips resolve by 2 - 6 weeks
Surgery in those where splinting has failed, or in children > 6 months old
What are the complications of DDH?
Future hip replacements
Early onset osteoarthrits
What is osteogenesis imperfecta? What are its complications?
Rare genetic mutation in genes for collagen
Children get brittle bones and lax ligaments
Severe: multiple fractures in utero
Less severe: Fractures, blue sclera, deafness
What is osteomyelitis?
Pyogenic infection of bone - usually the metaphysis of long bones
What scan can be done to detect osteomyelitis from its onset?
Radioisotope bone scan/MRI
XR is normal at first
What is irritable hip?
Transient synovitis
What is the duration of transient synovitis?
How is it managed?
2 week course
Rest and analgesia
What is reactive arthritis?
Acute inflammatory arthritis occurring with or following intercurrent infection, but without evidence of a causative organism in the joint
When does reactive arthritis usually occur?
7 - 10 days after gastroenteritis
Can be any age
Which infections are associated with RA?
2- 4 weeks after gastrointestinal/genitourinary infection
Shigella Salmonella Yersinia Campylobacter STIs: Chlamydia and Gonorrhoea
What triad of symptoms often occurs with reactive arthritis?
What is the name for this triad?
Reiter’s disease:
Conjunctivitis
Arthritis
Urethritis
Reiter’s disease is associated with which allele?
HLA-B27
What is the clinical presentation of reactive arthritis?
Sudden pain and unilateral joint swelling
Limp
Hip and leg are flexed, externally rotated and abducted
Malaise and fatigue
Slight fever
Lower back pain Heel pain - Achille's inflammation Reiter's triad Circinate balanitis Dystrophic nail changes Apthous ulcers
Which markers are raised/positive in reactive arthritis?
HLA-B27 ESR CRP Serum antibodies WCC
How is RA treated?
Intra-articular corticosteroids
Aspirate effusion
NSAIDS
Antibiotics (esp. in chlamydia)
Which causes of arthritis can result in permanent joint damage?
Juvenile idiopathic arthritis
Acute septic arthritis
Haemarthrosis (joint bleeding in coagulation disorders)
Which causes of arthritis usually resolve completely?
Reactice arthritis
HSP
Generalised allergic reactions
Rheumatic fever
How is juvenile idiopathic arthritis (JIA) defined?
Chronic arthritis before the age of 16,
lasting at least 3 months,
after exclusion of other primary diseases
How is JIA classified?
Which is the most common type?
Pauciarticular (4 or less joints) - most common Polyarticular (more than 4 joints) Systemic onest (Still's disease) Psoriatic Spondylo-arthropathies (HLA-B27) Enthesitis/tendon-related
What are the key features of pauciarticular JIA?
ANA +ve - greater incidence of chronic uveitis
Usually < 6 and female
Affects large joints - knees, ankles, elbows
Swollen joint with limited ROM, but not much pain
Muscle wasting
Child usually feels well
What are the key features of polyarticular JIA?
Symmetrical involvement of large and small joints
Poor weight gain
Mild anaemia
Morning stiffness
Irritability
Often Rh factor and ANA negative, with no eye involvement
What is the relevance of rheumatoid factor in JIA?
Often negative
It is a marker for persistence of polyariticular arthritis in adulthood. These children can develop rheumatoid nodules.
Asymmetric polyarticular JIA tends to Rh -ve
What is systemic onset arthritis?
Equivalent to Still’s disease in adults
How would you diagnose systemic onset arthritis?
How does it present?
Arthritis with at least 2 weeks of daily high-spiking fever
Plus one of:
Salmon pink rash
Lymphadenopathy
Hepatosplenomegaly
Serositis e.g. pericarditis/pleuritis/peritonitis
It is usually symmetrical and affects several joints
What are the pharmacological management options for JIA?
NSAIDS
Local/systemic corticosteroids
DMARDS e.g. methotrexate
Immunosuppressants e.g. cyclosporin, azathioprine
Biological drugs e.g. infliximab, adalimumab, etanercept
What are the non-pharmacological management options for JIA?
Physiotherapy
Hydrotherapy
Splints
Occupational therapy
In JIA, which treatment is first line for multiple joint involvement?
Methotrexate
What is iridocyclitis?
Anterior uveitis/irits
Inflammation of iris and ciliary body
What are the complications of JIA?
Joint deformities
Uveitis (in pauci- ANA +ve)
Osteoporosis
Growth and sports restriction
What score is used to test degree of hypermobility?
Beighton score
When is joint hypermobility often worst?
During adolescent growth spurts
When does rheumatic fever usually occur?
Sensitivity reaction to group A beta-heamolyitc streptococcal infection, usually after acute tonsillitis
What is Perthe’s disease?
Self-limiting hip disorder, characterised by avascular necrosis of the femoral head
What does Perthe’s disease usually follow?
It usually follows an episode of transient synovitis
Who is Perthe’s usually seen in?
Boys aged 4 - 8
Caucasian
Delayed skeletal maturity
Why does necrosis occur in Perthe’s disease?
I.e. What is its pathogenesis?
Loss of blood supply to the nucleus of the proximal femoral epiphysis, resulting in abnormal growth
Regenerated bone eventually becomes remodelled, increasing the chance of fractures
Which type of fracture commonly occurs in Perthe’s?
Sub-chondral collapse fracture
How does Perthe’s present?
Pain in the hip or knee
Limping/antalgic gait - Trendelenburg gait is seen in the late phase
Effusion
Limited hip ROM
No history of trauma
How does an XR of Perthe’s appear?
Decrease in size of nuclear femoral head
Patchy density
Widening of joint space
How should Perthe’s be managed?
Bracing/traction: < 6 years
Children with a skeletal age < 6 usually do well without treatment
Proximal varis osteotomy: > 6 years or 50% femoral head necrosis
What is the expected recovery time for Perthe’s?
Up to 3 years
Which condition usually affects overweight teenagers?
Slipped capital upper femoral epiphysis (SCUFE)
Why do kids get SCUFE?
Instability of the proximal femoral growth plate
How does SCUFE present?
Pain during walking, exacerbated by running/jumping
More commonly right sided
Acute: severe pain, cannot stand. Limp with limited ROM
Acute-on-chronic: Pain, limp and altered gait occuring for several months then suddenly becoming very painful
Chronic: mild symptoms with altered gait. Shortening of leg and thigh muscle atrophy
What are the main risk factors for SCUFE?
Obesity Local trauma Hypothyroidism Growth hormone deficiency Vitamin D deficiency Pelvic radiation Bone dysplasia
How is SCUFE categorised?
Stable (90%) or unstable (10%), depending whether the patient can walk or not
or, be presentation:
Acute
Acute-on-chronic
Chronic
How does SCUFE appear on XR?
‘Frog leg’
Widening of epiphyseal line or displacement of the femoral head
What are the complications of SCUFE?
Chondrolysis
Avascular necrosis of epiphysis
How should you manage SCUFE?
Patient should not be allowed to walk
Analgesia and immediate referral to orthopaedics
Surgery - closure of epiphysis, usually using screws
What is the commonest cause of limp in young children?
Transient synovitis
Who does transient synovitis usually affect
Boys aged 2 - 8
What is Osgood-Schlatter disease?
Multiple small avulsion fractures from contraction of quadriceps at its insertion into proximal tibial apophysis?
What is located at the proximal tibial apophysis?
Ossification centre
Who does Osgood-Schlatter disease commonly occur in?
Active adolescents, more commonly boys
How does Osgood-Schlatter disease present?
Gradual onset of pain and swelling below the knee
Pain relieved by rest
Tenderness/swelling at tibial tuberosity
Pain provoked by knee extension against resistance or hyperflexing the knee
How is Osgood-Schlatter disease treated?
Analgesia
RICE: Rest, ice, compress, elevate
What is the disease duration of Osgood-Schlatter disease?
Usually 2 - 3 weeks but can go on for up to 1 year
