MSK Flashcards
How does talipes equinovarus (clubfoot) occur?
intrauterine compression
can be secondary to oligohydramnios during pregnancy (e.g. spina bifida)
How would you treat Talipes Equinovarus?
Ponsetti method (plaster casting and bracing)
If very severe (corrective surgery)
What are examples of abnormal feet posture?
talipes equinovarus vertical talus talipes calcaneovalgus flat feet tarsal coalition pes cavus
What are the methods used to identify developmental dysplasia of the hip? When is it done?
Barlow manoeuvre
Ortholani manoeuvre
during the neonate exam
What is the Barlow manoeuvre?
checks if an unstable hip can be dislocated posteriorly out of the acetabulum
adduction on hip and posterior force on knee
What is the Ortholani manoeuvre?
to see if the dislocated hip can be relocated into the acetabulum
abduction on hip and anterior force on femur
How does developmental dysplasia of the hip present?
limp or abnormal gait
asymmetrical skinfolds of hip
limited abduction of hip
shortening of affected leg
If DDH is suspected, what investigation should be carried out? What is being looked for ?
USS
subluxation (partial dislocation) or dislocation
How would you treat DDH? what risk is associated with this treatment?
splint or harness
must be done properly or risk necrosis of femoral head
if fails surgery
What are some risk factors for DDH?
female
breech position
c-section
1st child
prematurity
oligohydramnios
family history
club feet
spina bifida
What is scoliosis? What are the consequences of scoliosis?
lateral curvature in the frontal plane of the spine
most changes - mild, pain-free and primarily cosmetic
if severe - cardiorespiratory failure from distortion of chest
What are the causes of scoliosis?
idiopathic - most common (early onset or late onset) mainly teenage girls
congenital (spina bifida)
secondary (neuromuscular imbalance, neurofibromatosis, Marfan)
What would you see on examination of scoliosis?
Inspection of child while they stand straight
- irregular skin creases
- differences in shoulder height
examine back when bent forwrd - if scoliosis disaapears on forward bending is is POSTURAL
How would you treat scoliosis?
mild - resolve spontaneously
severe - X-Ray - bracing, surgery (bilateral rod stabilisation) indicated if severe
What is torticollis? what is the most common cause in infants?
wry neck - sternomastoid tumour which presents in first few weeks
How do growing pains present?
3-12 years old
episodes of generalised pain in the lower limbs
pains symmetrical in lower limbs which aren’t limited to joints
pains never present at start of the day
doesn’t limited
How does hypermobility present?
musculoskeletal pain mainly confined to lower limbs, which is worse after exercise
joint swelling usually absent or transient
Hyper mobility effects which joints?
hyperextension of thumbs and fingers
elbows and knees hyperextended beyond 10 degrees
palms placed flat on floor with knees straight
Hypermobility is a features of what conditions?
Down’s, Marfan’s and Ehlers-Danlos
What is complex regional pain syndromes? Who does it normally affect?
Most dramatic MSK pain
usually adolescent females
What are some general features of complex regional pain syndromes?
most dramatic MSK pain, usually in adolescent females
triggered by minor trauma
hyperaesthesia
allodynia
What are differences between the localised and diffuse forms of complex regional pain syndromes?
Localised form - usually unilaterally foot and ankle (affeted part cool, swollen and mottled)
Diffused form - severe widespread pain and disturbed sleep patterns, feeling exhausted during the day, extreme tenderness over soft tissues
What is osteomyelitis? What is normally affected?
infection of metaphysis of long bones - most commonly distal femur and proximal tibia
What organisms most commonly cause osteomyelitis?
Staph Aureus
Streptococcus
Haemophilus Influenzae
How does osteomyelitis present?
painful, immobile limb with an acute febrile illness
swelling and exquisite tenderness
sterile effusion of an adjacent joint
*presentation may be more insidious in infants
What investigations would you carry out for osteomyelitis?
blood cultures usually positive
WBC and acute phase reactants are raised
MRI - allows differentiation of bone from soft tissue infection
How would you treat osteomyelitis?
parenteral abx - flucloxacillin
aspiration or surgical decompression of subperiosteal space may be needed
surgical drainage if no response to abx
If there is knee pain why would you assess the hip?
Hip pain is often referred pain to the knee
What is osgood-schlatter? Who does it normally affect?
osteochondritis of the patellar tendon
affecting adolescent males who are physically active
How does Osgood-Schlatter present?
Knee pain after exercise
Localised tenderness
sometimes swelling over tibial tuberosity
often hamstring tightness
bilater in 25-50%
How would you treat Osgood-Schlatter?
reduced activity and physio for quad muscle strengthening
hamstring stretches
Back pain in very young is a symptom of concern. What are some red flags which would indicate worrying pathology ?
high fever - infection
night waking, persistent pain - osteoid osteoma or tumours
painful scoliosis - infection or malignancy
focal neurological signs - nerve root irritation, loss of bowel.bladder control
weight loss, systemic malaise - malignancy
What are some causes of a limp?
transient synovitis
Perthe’s
Slipped Capital Femoral Epiphysis
DDH
What age group is normally affected by transient synovitis? When is normally contracted?
most common cause of acute hip pain in (2-12 y/o)
follows or is accompanied by a viral infection
How does transient synovitis?
sudden onset of pain in hip/limp
no pain @ rest
decrease ROM, particularly internal rotation
child is afebrile
What investigations would you carry out to differentiate transient synovitis vs septic arthritis?
Joint aspiration
blood cultures
In some cases what does transient synovitis precede?
Perthe’s Disease
How would you treat transient synovitis?
bed rest
skin traction (rare)
What are some ways you would differentiate septic arthritis from transient synovitis?
In septic Arthritis
moderate/high fever
child looks ill
hips held felxed
pain at rest
raised ESR
doesn’t resolve by itself
What is Perthe’s disease? Who does it normally affect?
avascular necrosis of capital femoral epiphysis of femoral head
mainly affects boys, 5:1 (5-10 y/o)
How does Perthe’s present?
onset of limp
hip/knee pain
bilaterally in 10-20%
What would you be seen on X-ray of patient with Perthe’s?
X-ray both hips - increased density of femoral head which becomes fragmented and irregular
if X-ray is normal, either repeat or bone scan and MRi if symptoms persist
How would you treat Perthe’s disease?
If early - bed rest and traction
if Late/severe - plaster/calipers or femoral/pelvic osteotomy
What is SCFE? What can it lead to?
slipped capital femoral epiphysis
displacement of epiphysis of femoral head postero-inferiorly
can lead to avascular necrosis
What groups of patients normally affected by SCFE?
10-15 y/o, during growth spurt, particularly if obese
associaed with metabolic endocrine abnormalities (hypothyroid and hypogonadism)
How does SCFE present?
limp/hip pain which may be referred to nee
onset acute, following minor trauma
on examination - restricted abduction and internal rotation
Treatment for SFCE?
surgery
How would you define arthritis?
pain, swelling, heat, redness and restricted movement in a joint
What are some causes of arthritis?
infection (bacterial, viral, rheumatic fever)
inflamm. bowel disease
vasculitis (henoch-schonlein purpura, Kawasaki)
haematological (haemophilia, sickle-cell)
malignant - leukaemia, neuroblastoma
connective tissue disorder - JIA, SLE, PAN
What is reactive arthritis?
transient joint swelling that lasts less than 6 weeks often of ankles and knees
usually follows extra - articular infection
What is the most common form of arthritis in childhood?
reactive arthritis
What organisms usually causes infection that precedes reactive arthritis?
salmonella, shigella, campylobacter and yersinia
STIs in adolescents
What would you see on investigations of reactive arthritis?
low grade fever
acute phase reactants are normal/mildly elevated
X-rays normal
How would you treat reactive arthritis?
NSAIDs
In what age group is septic arthritis most commonly seen?
<2 y/o
How is septic arthritis normally contracted?
Usually haematogenous
puncture/infected skin lesions
may spread from adjacent osteomyelitis
Most common organism for septic arthritis?
Staph Aureus
How does Septic Arthritis present?
erythematous, warm, acutely tender joint, decrease in ROM, acutely unwell febrile child
How would you investigate septic arthritis?
increased WCC
increased acute-phase reactants
blood cultures
USS of joints
X-ray to exclude trauma - will show normal then widening of joint space and soft tissue swelling
Aspiration of joint space - culture
How would you treat septic arthritis?
IV course of abx (penicillin, flucloxacillin)
washing out of joint or surgical drainage
What is JIA?
Juvenile Idiopathic Arthritis
persistent joint swelling >6 weeks, which presents before 16 y/o
How is JIA is classified?
> 4 joints = polyarthritis
4 joints = oligoarthritis
if with fever and rash = systemic
further subtype = rheumatoid factor and HLA B27
What would you find on history of JIA?
gelling
morning joint stiffness and pain
intermittent limp
poor behaviour and mood
avoidance of enjoyed activities
What would you find of examination of JIA?
swelling, inflammation and proliferation
pyrexia salmon-pink rash lymphadenopathy arthritis uveitis anorexia and weight loss
long term - bone expansion from overgrowth
- in knee leg lengthening or valgus deformitiy
- in hands - discrepancy in digit length,
- in wrists - advancement of bone age
If patient has suspected JIA but has systemic features, what must be considered?
Sepsis and Malignancy
What complications can arise from JIA?
Chronic anterior uveitis - can lead to visual impairment
flexion contractures of joints
growth failure
osteoporosis
How would you treat JIA?
physical therapy
opthalmology, dentistry and ortho
NSAIDs
joint injections
MTX
systemic corticosteroids
cytokine modulators
How many JIA sufferes will have the disease in adulthood? What is the consequence of this?
1/3
joint replacement
visual impairment
osteo fractures
psychosocial morbidity
What is JIA when it has systemic symptoms?
Still’s disease
What is osteoporosis in children?
1 or more vertebral crush fractures
OR
size-adjusted bone density 2.0 SDS + 2 or more long bone fractures by 10/3 or more long bone fractures by 19
Causes of osteoporosis in children?
Osteogenesis imperfecta
Galactosemia
Idiopathic
Steroid-induced
Malabsorption
Immobilisation
What is osteogenesis imperfecta?
BRITTLE AND FRAGILE
Bone fragility, fractures and deformity
AD inheritance
defects in Type 1 collagen
How does osteogenesis imperfecta present?
bone pain
impaired growth
deafness
blue sclera
‘wormian’ bones
How would you classify Osteogensis Imperfecta?
Sillence classification
I - mild
II - lethal
III - progressively deforming, severe
IV - moderate
How would you treat OI?
bisphos - pamidronate
What is rickets? How does Rickets present?
FAILURE TO MINERALISE NEW BONE
metaphyseal swellings
bowing deform
slowing of linear growth
motor delay
hypotonia
fractures
resp distress
Causes of rickets?
vit D deficiency - maternal vit d insufficient, lack of sunlight, lack of vit d in diet
