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Paediatrics and Child Health > Locomotor System and Rheumatology > Flashcards

Locomotor System and Rheumatology Flashcards

1
Q

What would be a normal structural variation in an infants legs and feet?

A

Babies = flat-footed
Toddlers = bow-legged (genu varum)
Primary school child = knock-kneed (genu valgum)

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2
Q

When does a child’s foot begin to have a plantat arch?

A

3 years

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3
Q

When are bow legs most common?

A

0 - 2cm

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4
Q

What can marked genu varum indicate?

A

Rickets

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5
Q

When is genu valgum most apparent?

A

3 - 4 years

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6
Q

When should the legs become completely straight?

A

By 12 years

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7
Q

When would you refer a child with knock knee for XR/specialist opinion?

A

Separation > 10 cm between medial tibial malleoli

Unilateral genu valgum

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8
Q

When should intoeing resolve?

A

8 years

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9
Q

What are the main causes of scoliosis?

A

Idiopathic (95%)
Vertebral anomalies e.g. hemivertebrae
Muscle weaknes e.g. CP

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10
Q

Who gets postural scoliosis?

How/when is it resolved?

A

Babies

It goes whilst they are suspended/lean forward and should have completely gone by the age of 2

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11
Q

How can one determine structural scoliosis on examination?

A

Bending forward to touch toes causes asymmetry - presents as a hump on flexion (predominantly over the scapula)

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12
Q

How can you tell if talipes is postural?

A

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

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13
Q

How is (i) structural talipes and (ii) talipes calcaneovalgus managed?

A

i. Cannot be corrected manually, requires early splintage/surgery
ii. Calcaneovalgus can be corrected with simple exercises

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14
Q

Give five causes of leg pain and limping in children

A 
Growing pains
Osteomyelitis
Legg-Perthes disease
Slipped capital femoral epiphysis
Transient synovitis
Septic arthritis
Trauma
Neoplastic disease
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15
Q

Where are growing pains usually felt?

A

Bilateral

Shins and thighs

Muscles not bone

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16
Q

Who gets transient synovitis?

A

2 - 8 year old boys, often preceded by URTI

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17
Q

How does transient synovitis present?

A

Sudden onset of limp

No systemic symptoms

Preceded by URTI

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18
Q

When would you perform an MRI/bone scan in a child with leg pain?

A

Osteomyelitis

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19
Q

Where is pain in the hip referred to?

A

Knee

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20
Q

When is septic arthritis more common?

A

In children < 2 years old, but can occur at any age

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21
Q

What is the most common cause of septic arthritis?

A

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

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22
Q

How does the affected joint present?

How does it present in neonates?

A

Erythematous, warm, swollen, single joint

Reduced ROM

Bony tenderness

In neonates, the limb is immobile (pseudoparalysis)

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23
Q

What are the red flags for joint pain?

A

Fever

Refuses to use joint

ESR and CRP elevated

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24
Q

What is the definitive investigation for diagnosis of septic arthritis?

A

Joint space aspiration and culture (under US guidance)

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25
Q

What can septic arthritis often be confused for?

A

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)

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26
Q

Which joint(s) does SA most commonly affect?

A

Hip, knees and ankles

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27
Q

Which conditions can predispose to SA?

A

Immunodeficiency

Sickle cell disease

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28
Q

How does septic arthritis appear on XR?

A

Initially normal, apart from widening of the joint space and soft tissue swelling

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29
Q

What is the treatment for SA?

A

IV flucloxacillin (Vancomycin for MRSA)

Washing out/surgical drainage of joint

Temporary joint immobilisation/splinting

Physiotherapy

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30
Q

What is developmental dysplasia of the hip (DDH)?

A

The acetabulum is shallow and does not cover the femoral head, causing the hip joint to be dislocatable/dislocated

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31
Q

What are the risk factors for DDH?

A 
4 F's:
Frank breech position
Family history
Female
First born

Oligohydramnios

Neuromuscular/joint problems:
Spina bifida
CP
Talipes

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32
Q

What manoeuvres are used to test for DDH?

A

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

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33
Q

How is it investigation different in DDH in children who are (i) > 3 months or (ii) have risk factors?

A

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

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34
Q

When is Barlow’s and Ortolani’s done?

A

New born examination

Also at 6 - 8 weeks

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35
Q

How is DDH managed?

A

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

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36
Q

What are the complications of DDH?

A

Future hip replacements

Early onset osteoarthrits

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37
Q

What is osteogenesis imperfecta? What are its complications?

A

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

38
Q

What is osteomyelitis?

A

Pyogenic infection of bone - usually the metaphysis of long bones

39
Q

What scan can be done to detect osteomyelitis from its onset?

A

Radioisotope bone scan/MRI

XR is normal at first

40
Q

What is irritable hip?

A

Transient synovitis

41
Q

What is the duration of transient synovitis?

How is it managed?

A

2 week course

Rest and analgesia

42
Q

What is reactive arthritis?

A

Acute inflammatory arthritis occurring with or following intercurrent infection, but without evidence of a causative organism in the joint

43
Q

When does reactive arthritis usually occur?

A

7 - 10 days after gastroenteritis

Can be any age

44
Q

Which infections are associated with RA?

A

2- 4 weeks after gastrointestinal/genitourinary infection

Shigella
Salmonella
Yersinia
Campylobacter
STIs: Chlamydia and Gonorrhoea
45
Q

What triad of symptoms often occurs with reactive arthritis?

What is the name for this triad?

A

Reiter’s disease:
Conjunctivitis
Arthritis
Urethritis

46
Q

Reiter’s disease is associated with which allele?

A

HLA-B27

47
Q

What is the clinical presentation of reactive arthritis?

A

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
48
Q

Which markers are raised/positive in reactive arthritis?

A 
HLA-B27
ESR
CRP
Serum antibodies
WCC
49
Q

How is RA treated?

A

Intra-articular corticosteroids
Aspirate effusion
NSAIDS
Antibiotics (esp. in chlamydia)

50
Q

Which causes of arthritis can result in permanent joint damage?

A

Juvenile idiopathic arthritis
Acute septic arthritis
Haemarthrosis (joint bleeding in coagulation disorders)

51
Q

Which causes of arthritis usually resolve completely?

A

Reactice arthritis
HSP
Generalised allergic reactions
Rheumatic fever

52
Q

How is juvenile idiopathic arthritis (JIA) defined?

A

Chronic arthritis before the age of 16,
lasting at least 3 months,
after exclusion of other primary diseases

53
Q

How is JIA classified?

Which is the most common type?

A 
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
54
Q

What are the key features of pauciarticular JIA?

A

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

55
Q

What are the key features of polyarticular JIA?

A

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

56
Q

What is the relevance of rheumatoid factor in JIA?

A

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

57
Q

What is systemic onset arthritis?

A

Equivalent to Still’s disease in adults

58
Q

How would you diagnose systemic onset arthritis?

How does it present?

A

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

59
Q

What are the pharmacological management options for JIA?

A

NSAIDS

Local/systemic corticosteroids

DMARDS e.g. methotrexate

Immunosuppressants e.g. cyclosporin, azathioprine

Biological drugs e.g. infliximab, adalimumab, etanercept

60
Q

What are the non-pharmacological management options for JIA?

A

Physiotherapy

Hydrotherapy

Splints

Occupational therapy

61
Q

In JIA, which treatment is first line for multiple joint involvement?

A

Methotrexate

62
Q

What is iridocyclitis?

A

Anterior uveitis/irits

Inflammation of iris and ciliary body

63
Q

What are the complications of JIA?

A

Joint deformities

Uveitis (in pauci- ANA +ve)

Osteoporosis

Growth and sports restriction

64
Q

What score is used to test degree of hypermobility?

A

Beighton score

65
Q

When is joint hypermobility often worst?

A

During adolescent growth spurts

66
Q

When does rheumatic fever usually occur?

A

Sensitivity reaction to group A beta-heamolyitc streptococcal infection, usually after acute tonsillitis

67
Q

What is Perthe’s disease?

A

Self-limiting hip disorder, characterised by avascular necrosis of the femoral head

68
Q

What does Perthe’s disease usually follow?

A

It usually follows an episode of transient synovitis

69
Q

Who is Perthe’s usually seen in?

A

Boys aged 4 - 8

Caucasian

Delayed skeletal maturity

70
Q

Why does necrosis occur in Perthe’s disease?

I.e. What is its pathogenesis?

A

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

71
Q

Which type of fracture commonly occurs in Perthe’s?

A

Sub-chondral collapse fracture

72
Q

How does Perthe’s present?

A

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

73
Q

How does an XR of Perthe’s appear?

A

Decrease in size of nuclear femoral head

Patchy density

Widening of joint space

74
Q

How should Perthe’s be managed?

A

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

75
Q

What is the expected recovery time for Perthe’s?

A

Up to 3 years

76
Q

Which condition usually affects overweight teenagers?

A

Slipped capital upper femoral epiphysis (SCUFE)

77
Q

Why do kids get SCUFE?

A

Instability of the proximal femoral growth plate

78
Q

How does SCUFE present?

A

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

79
Q

What are the main risk factors for SCUFE?

A 
Obesity 
Local trauma
Hypothyroidism
Growth hormone deficiency
Vitamin D deficiency
Pelvic radiation
Bone dysplasia
80
Q

How is SCUFE categorised?

A

Stable (90%) or unstable (10%), depending whether the patient can walk or not

or, be presentation:

Acute
Acute-on-chronic
Chronic

81
Q

How does SCUFE appear on XR?

A

‘Frog leg’

Widening of epiphyseal line or displacement of the femoral head

82
Q

What are the complications of SCUFE?

A

Chondrolysis

Avascular necrosis of epiphysis

83
Q

How should you manage SCUFE?

A

Patient should not be allowed to walk
Analgesia and immediate referral to orthopaedics
Surgery - closure of epiphysis, usually using screws

84
Q

What is the commonest cause of limp in young children?

A

Transient synovitis

85
Q

Who does transient synovitis usually affect

A

Boys aged 2 - 8

86
Q

What is Osgood-Schlatter disease?

A

Multiple small avulsion fractures from contraction of quadriceps at its insertion into proximal tibial apophysis?

87
Q

What is located at the proximal tibial apophysis?

A

Ossification centre

88
Q

Who does Osgood-Schlatter disease commonly occur in?

A

Active adolescents, more commonly boys

89
Q

How does Osgood-Schlatter disease present?

A

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

90
Q

How is Osgood-Schlatter disease treated?

A

Analgesia

RICE: Rest, ice, compress, elevate

91
Q

What is the disease duration of Osgood-Schlatter disease?

A

Usually 2 - 3 weeks but can go on for up to 1 year

Paediatrics and Child Health (11 decks)

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