MSK Flashcards
Which acronym should be used to ensure you don’t miss anything during MSK consultation?
TIM
Tumour, trauma
Infection, inflammation
Mechanical, muscle disease, metabolic
What is bone matrix composed mostly of?
type 1 collagen
How can bone anatomy/structure be divided?
diaphysis
proximal and distal metaphysis, distal and proximal epiphysis, separated by growth plate/physis during childhood
What are the three types of joints?
fibrous- sutures of skull
cartilaginous- symphysis pubis
synovial- skeletal joints
Define enthesis
point of insertion of a tendon, ligament, fascia, joint capsule into bone
What is Gower’s sign?
use of hands to splint legs to rise from sitting. Sign of muscular weakness
In which condition is Gower’s sign common?
DMD
Around what age does normal adult pattern of gait become established?
around 7
List three signs of malignant leg pain?
nocturnal (benign is also nocturnal)
deep boring pain unresponsive to pain relief
altered function
unilateral
persists in day time
List three features of benign leg pain
nocturnal
wakes from sleep but return to sleep with analgesia
quickly resolves with massage, analgesia
functionally normal the next day
bilateral
relationship to exercise
Three differentials for malignant bone pain?
Bone tumour
Leukaemia
Neuroblastoma
Name two organisms implicated in septic arthritis
staph aureus
strep pneumoniae
haemophilus influenza
What may be the source/focus of septic arthritis in a child?
septicaemia, pharyngitis, meningitis, cellulitis
How can you distinguish between a transient synovitis/reactive arthritis and septic arthritis in a child?
if all of the following features present then likely septic arthritis:
pyrexia within the last week
inability to weight bear through that limb
raised ESR
WBC>12
Does a normal plain radiograph exclude osteomyelitis?
no as changes occur late
List three features of osteomyelitis presentation
pyrexia
local erythema and tenderness
acutely unwell
night pain
limp
recent infection
Which infection is associated with osteomyelitis?
varicella zoster, due to introduction of s aureus by scratching- haematogenous spread
TB also
What is the fastest diagnostic method for TB?
PCR
List three other differentials for infectious causes of joint swelling in children other than reactive arthritis
rheumatic fever
HLA B27 associated reactive syndrome (Reiter’s syndrome)= reactive arhtritis
transient synovitis of the hip
List three features of rheumatic fever
carditis, arthritis, rash
What is the cause of rheumatic fever
strep infection
List two features of Reiter’s syndrome
urethritis, arthritis, conjunctivitis
What is the cause of transient synovitis of the hip?
idiopathic
Which age group are affected by synovitis of the hip?
3-10
What are the two views of X-rays?
lateral and AP (coronal)
How is dislocation described in terms of anterior or posterior?
relative to most distal part of fracture e.g. distal segment humerus is shifted/separated posterior to the shaft of the humerus
Important aspects of examination when suspected fracture?
pulses, CRT, movement, sensation
Which is the most common fracture in children?
supracondylar
Two risks associated with supracondylar fractures?
damage to neurovascular bundle
cubitus varus
What is the length of time in cast for fractures in general in children?
4 weeks
Varus and valgus deformity in knee technical name?
genus varum
genus valgus
What is a buckle fracture?
one side of the bone bends (cortex), raising a little buckle, without fracturing the other side of the bone
What is the name of a buckle fracture with associated fracture?
greenstick (one side bent and the other is broken). This only occurs in children (<10 commonly)
What are the management option for clavicular fracture?
conservative and surgical
When would you opt for surgical repair in clavicular fracture?
compound, neurovascular damage, soft tissue threat
When should you consider diagnosis of juvenile idiopathic arthritis in a child and why?
child presenting with joint pain and stiffness, as delaying treatment could lead to irreversible damage to eyes
Name a malignant bone cancer
osteosarcoma
How to distinguish between septic arthritis and transient synovitis of the hip?
Pyrexia with infection
Child present with knee pain and limp and shortened leg. What should be in your differential?
Slipped capital femoral epiphysis
What is a complication of slipped capital femoral epiphysis?
avascular necrosis of the hip, therefore anyone presenting with knee pain- check the hip!
List three signs of neonatal hip instability
asymmetrical groin creases
leg length difference
restriction abduction
instability
What is congenital muscular torticollis?
swelling of sternocleinomastoid associated with birth trauma, difference in lateral side to side flexion
What is the treatment of congenital muscular torticollis?
early physiotherapy, majority are corrected
Name two bone cancers in paeds?
Ewing’s sarcoma
osteosarcoma
What is the most common site of Ewing’s sarcoma?
knee
Name the three main risk factors for DDH
first degree relative positive FH
breech after 35 weeks
Lower limb deformity
What is the treatment of DDH?
12 weeks in harness/splint that maintain hips flexed and abducted
What is congenital talipes equinovarus?
club foot
What are the four features of club foot?
CAVE
Cavus
adductus
varus of the heel
equinus
Options for treatment of club foot?
Casting
Achilles tenotomy
Orthotics
What are the 5S’s?
stiffness
symmetry
symptoms
skeletal dysplasia
systemic illness
What is physes?
growth plate
What is a monteggia fracture dislocation?
dislocation of radial head with plastic deformation of the ulna
What is the classification of growth plate injuries?
salter harris type I to V
Which eye condition is associated with juvenile idiopathic arthritis?
chronic anterior uveitis
What is a complication of chronic anterior uveitis?
leading cause of childhood blindness
Name three inflammatory disorders that affect children
juvenile idiopathic arthritis
SLE
vasculitis
dermatomyositis
What is Kawasaki disease?
form of vasculitis that mainly affects children under 5
Name two vasculitis conditions that are prevalent among children
HSP
kawasaki disease
List three features of kawasaki disease
high and persistent fever
rash
miserable- meningitis irritation
List one severe complication of kawasaki disease with late presentation
coronary artery aneurysm
List two childhood malignancies where they may be limping
Leukaemia
neuroblastoma
osteosarcoma
List three difference between fractures in adults and children
buckle and greenstick fractures
healing time
remodelling
different treatment
What is Perthe’s disease?
a childhood condition that occurs when blood supply to the ball part (femoral head) of the hip joint is temporarily interrupted and the bone begins to die.
List three red flags of back pain in a child
night pain
>4 weeks
neuro signs
limitation of movement due to pain
<4 years
11 year old boy who plays football three times per week has pain around his patellar ligament and patellar tuberosity. What is the likely diagnosis?
Osgood Schlatter’s syndrome= overuse syndrome
List the MSK components you assess for in a baby check
Erb’s palsy
Supernumerary digits
Food deformities
DDH
Congenital muscular torticollis
List two causes of rickets
Vitamin D deficiency
Calcium deficiency
Hypophosphatasia
Vitamin D dependent rickets
Which enzymes are raised in muscular dystrophy?
creatinine kinase, LDH, AST and ALT
Why must you be wary when requesting autoantibody tests in MSK investigations?
E.g. RF raised transiently during illness
ANA found in 5% normal healthy children and negative in most with juvenile arthritis
HLAB27 (found in 10% of healthy population)
A 15 year old girl fell off a low bench and dislocated both her shoulders, which required surgical reduction. She previously attended A&E having dislocated her right shoulder.
On examination, her skin is velvety with multiple bruises and scars.
What is the most likely diagnosis?
Ehlers-Danlos syndrome
What is Ehlers-Danlos syndrome?
=group of disorders that affect connective tissues. Hypermobility is a hallmark feature
A 13 year old boy is brought in having fallen of his bike. He is found to have a fracture through a well-defined lytic lesion of his proximal humerus. It has been asymptomatic. What is the most likely diagnosis?
simple bone cyst
A 4 year old girl has noticed to by her father to be limping over the past three weeks. Although she has been walking since one year old, she has recently reverted to descending the stairs on her bottom. On examination, her temperature is 36.8 ºC, with a tender, swollen right knee. She is very well in herself. What is the single most important investigation?
Slip lamp test
This is a typical history of the presentation of JIA. At this age this girl runs a 30% risk of uveitis which is associated with subtle gradual loss of vision so not noticed by a child of 4 years. JIA does not give the acute red and painful eye that would lead to prompt presentation.
ANA is associated with <50%of cases of JIA, but is not diagnostic, and management, including the commencement of eye screening is not changed by fining a positive ANA. It is a test often requested by GP/A+E staff- but is not useful in confirming the diagnosis.
The urgent aspiration suggests that you thought this was a septic arthritis or osteomyelitis. The history is too benign and too chronic for that.
A FBC and blood film is useful if you are considering leukaemia, which is an important differential to have considered. It is a good answer, and will be done working up a new monoarthritis case, but is not the best answer as recognising this history fits well with JIA is the best response.
MRI is useful when the diagnosis is not clear, and is also not wrong, but not the best answer. Clinically this fits very well with JIA and subjecting the child to an MRI at this age involves a GA, and will likely only confirm your clinical diagnosis.
