MSK Flashcards
Define Slipped upper femoral epiphysis - SUFE
The head of the proximal femur epiphysis is displaced (“slips”) along the growth plate
SUFE imaging Ix
Bilateral X-ray:Anteropost and ‘frog leg’ lateral position
Septic arthritis gold standard Ix
Aspiration of the joint: Gram staining, cell count, glucose level, crystal analysis cultures
Osteomyelitis Risk Factors
- Trauma from injury
- bones growing more blood supply easier for bacteria to travel into the bone
- Open bone fracture
- Orthopaedic surgery
- Immunocompromised
- Sickle cell anaemia
- HIV
- Tuberculosis
Osteomyelitis Sx
- Fever
- Tiredness
- Erythema
- Oedema
- Fussiness / irritability
- Lethargy
Vit D deficiency Loading dose in Age 1–5 months
3000 IU daily for 8–12 weeks.
Current guidance on vitamin d supplements in children under 5
- 0-1 year Vit. D RDI:
8.5-10mcg - 1-4 years RDI Vit D RDI: 10 mcg
When is vit D supplement not indicated for children
- > 500ml of infant formula a day
Fortified with vit D
Vit D deficieny risk factors
- Low / no exposure to the sun
- Dark skin tone
- Exclusively breastfed babies
- GI / malabsorption disorders: Coeliac, lactose intolerance, Cystic fibrosis
- Insufficient maternal vit D
- Premature baby
Define Osgood-Schlatter Disease
An inflammation at the tibial tuberosity where the patella ligament inserts
Oliogoarticular JIA
- affecting 1-4 joints in the first 6/12
- commonly affects the knee and ankle
- assoc with other inflammation (uveitis)
late stages of arthiriris
joint spaces narrowed and spaces fuse together
RED FLAGS in children
Fever: Septic arthritis,
WL
Osgood-Schlatter Disease presentation
- Ant. knee pain
- Pain is exacerbated by physical activity; running, jumping, and on extension of the knee
- Visible or palpable hard and tender lump at the tibial tuberosity
- Usually unilateral
OSD pathophysiology
There are multiple small avulsion fractures, where the patella ligament pulls away tiny pieces of the bone. This leads to growth of the tibial tuberosity, causing a visible lump below the knee. Initially this bump is tender due to the inflammation, but has the bone heals and the inflammation settles it becomes hard and non-tender.
OSD Risk factors
- Male > Female
Growth spurt age: - Boys 12-15 years
- Grils 8-12 years
- Active in sports which include running, jumping, and repetitive bending of the knee are at greater risk of developing the condition.
OSD complications
- Full avulsion fracture
- Ossicles (bony fragments) formation in the knee - may impinge on the patellar tendon, causing pain and limiting activity
OSD Sx
- Gradual onset of pain
- Swelling below the knee
- Pain relived on resting
- Pain exacerbate by activities
OSD Dx
- Tenderness over the tibial tuberosity that is provoked by knee extension against resistance
- Firm or bony enlargement of the tibial tuberosity
OSD Mx
- Rest
- Ice
- Analgesia / NSAIDs
- Physios
- Avoid aggrevating activities
- Refer Paeds ortho for persistent Sx
SUFE X-ray findings
- Widening of epiphyseal line or displacement of the femoral head
- Klein’s line does not intersect the femoral head
SUFE Acute presentation
- < 3/52 of Sx onset
- Painful limp
- External rotation of the hip joint
- length discrepency
- unable to weight bear
SUFE examination findings
- External rotation of the hip
- Leg length discrepency
- Limited ROM on internal rotation and abduction of the hip
SUFE Risk Factors
- Obesity
- Endocrine disorders
- Puberty: Girls 11-12 years
Boys 12-13 years
SUFE Mx
- Refer to paeds ortho stat
- Avoid excessive movements / weight bear on the affected hip
- Analgesia
- Surgically: In situ single-screw fixation of the epiphysis
SUFE complications
Avascaular necrosis AKA Osteonecrosis
Septic arthritis diagnostic criteria in aspiration
WBC > 50,000
Septic arthritis diagnostic criteria for prosthetic in aspiration
WBC > 1100
Septic arthritis presentations
- Acute presentation
- Hot, swollen, painful, restricted joint
- Fever (60% of cases)
- Erythema
- Swelling
Septic Arthritis examination findings
- Erythema
- Effusion
- Hot to touch
- Pain on palpation
- Fever
- Systemically unwell
Septic arthritis aspiration fluid characteristics
- Purulent
- Cloudy
Septic arthritis common causative organism
- Staph aureus
Septic arthritis Mx
- Empirical Abx until sensitivities
- Abx for 6/52 from diagnosis
- Surgical drainage and washout of the joint to clear the infection in severe cases
Osteomyelitis epidemiology
- < 5 years
- long bones: arms / legs
Paeds Osteomyelitis common site
metaphysis of the long bones
Paeds Osteomyelitis common causative organism
Staph aureus
Acute Paeds osteomyelitis
Infection in the bone - over 2/52
Paeds osteomyelitis Ix
- Bloods: FBC, ESR, CRP
- Blood culture: Before commencing Abx
- X-rays
- MRI
- Bone scan
Paeds osteomyelitis Mx
- Admit
- Blood culture
- Think Sepsis: IV Abx after blood culture / within 1h of presenting for high risk sepsis patient
Paeds osteomyelitis complications
- Sepsis
- Osteonecrosis AKA AVN
- Bone abscess
- Septic arthritis
- Chronic osteomyelitis
Paeds Septic arthritis complications
Joint damage: Septic arthritis can cause permanent damage to joints, including joint degeneration, stiffness, and dysfunction.
Osteomyelitis: An infection of the bone itself
Osteonecrosis: Bone tissue dies due to lack of blood flow
Sepsis: A widespread inflammation in the body
Death: In severe cases, septic arthritis can lead to death
Limb length discrepancy: A difference in the length of one leg compared to the other
Vit D deficiency serum level in children
Serum 25-hydroxyvitamin D (25[OH]D) levels < 25 nmol/L
Vit D sufficient serum level in children
Serum 25-hydroxyvitamin D (25[OH]D) levels > 50 nmol/L
Vit D deficiency in children complications
- Rickets
- Osteomalacia and muscle weakness
- Hypocalcaemia: seizures
- Dilated cardiomyopathy
Vit D deficiency Loading dose in Age 6-11 months
6000 IU daily for 8–12 weeks.
Vit D deficiency Loading dose in Age 12–18 years
- 10,000 IU daily for 8–12 weeks.
- A single or divided oral dose totalling 300,000 IU can be considered if there is concern about compliance with treatment.
Vit D deficiancy daily maintenance dose in children post loading dose regime
400–600 IU daily for 1/12
Define Juvenile Idiopathic Arthritis (JIA)
A collective term used to describe arthritis that affects children and young individuals under the age of 16
Systemic JIA Sx
- Muscle / joint pain
- High swinging fever 37-39
- WL
- Salmon-pink rash
Systemic JIA presentations
- Lymphadenopathy
- Serositis: inflammation to the serous membranes (pericarditis, pleuritis, peeritonistis)
- Hepato / SPlenomeagly
- Salmon-pink rash
- High Temp
Systemic JIA ANA, RF findings
-ve
Systemic JIA inflammatory marker findings
Raised for CRP, ESR, PLTs, Ferritin
Systemic JIA complication
Macrophage activation syndrome (MAS)
disseminated intravascular coagulation
Define Oligoarticular JIA AKA Pauciarticular JIA
Arthritis involving < 4 joints
Oligoarticular JIA Risk factors
- Female > Male
- Age < 6years
Oligoarticular JIA extrarticular complication
Ant. uveitis
Oligoarticular JIA Sx
- Pain in joints
- Swelling in joints
- Morning stiffness
NO Systemic Sx
Oligoarticular JIA auto-antibodies findings
- RF -ve
- ANA +ve
Oligoarticular JIA Mx
- Refer to paed Rheum
- Intra-articular steroid injection
Oligoarticular JIA commonly affects which joints
Large joints: knee and ankle
Define Polyarticular JIA
Idiopathic inflammatory arthritis in > 5 joints
Polyarticular JIA presentations
- can be Symmetrical inflammation
- affects smaller joints e.g. hands
- Minimal systemic Sx
Polyarticular JIA subtypes
- Seronegative: RF -ve
- Seropositive: RF +ve
Polyarticular JIA seronegative prevalence
toddler - preschool age
Female > Male
Polyarticular JIA seropositive prevalence
older children and adolescents
Define Juvenile Psoriatic Arthritis
seronegative (RF -ve) inflammatory arthritis associated with psoriasis
Juvenile Psoriatic Arthritis presentations
- Plaques of psoriasison the skin
- Pitting of the nails (nail pitting)
- Onycholysis, separation of the nail from the nail bed
- Dactylitis inflammation of the full finger
- Enthesitis, inflammation of the entheses, which are the points of insertion of tendons into bone
Systemic JIA Mx
- Refer to paeds rheum
- Physical activities
- Physio
- Oral steroid
JIA bloods Ix
- FBC, CRP, ESR, ANA, RF
JIA imaging Ix
- X-rays: to exclude trauma, osteomyelitis or malignancy
- Ultrasound: can show joint fluid, synovial hypertrophy and erosions if present
- MRI: delineates any bony changes, joint damage and extent of synovitis
JIA X-ray findings
- Bone erosion
- Narrowing of joint space
- Fusion of bones
Chronic JIA complications
- Growth failure or abnormality
- Osteoporosis
- Delayed puberty
