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1
Q

Causes of limp in infants (1-3)

A 
Acute: 
Infection - Septic arthritis, osteomyelitis 
Transient synovitis 
Trauma 
Malignancy - leukaemia, neuroblastoma

Chronic:
DDH
Neuromuscular - cerebral palsy
Juvenile idiopathic arthritis

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2
Q

Causes of limp in school aged children (3-10)

A 
Acute: 
Transient synovitis 
Septic arthritis/osteomyelitis 
Trauma and overuse injuries
Juvenile idiopathic arthritis
Perthes disease 
Malignancy 
Complex regional pain syndrome

Chronic:
Perthes disease
Neuromuscular - duchenne muscular dystrophy
JIA

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3
Q

Causes of limp in adolescents (11-16)

A 
Acute: 
Mechanical - trauma, overuse, sports 
Slipped capital femoral epiphysis
AVascular necrosis of femoral head
Osteochondritis dissecans of knee
JIA
Reactive arthritis
Septic arthritis/osteomyelitis 
Malignancy
Complex regional pain syndrome

Chronic:
Slipped capital femoral epiphysis
JIA
Tarsal coalition

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4
Q

Investigations for limp/swollen joint

A 
FBC - raised wcc
CRP
ESR - sensitive for bone involvement/septic arthritis 
Blood culture 
X Ray - 2 views, both joints 
USS - effusion
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5
Q

Clinical features of transient synovitis

A 
2-12 year old 
Preceding upper respiratory infection
Acute painful limp, non-weight bearing 
Hip pain - Not rest, pain on movement 
Restriction of movement - limited internal rotation 
Afebrile
Appears well
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6
Q

Define Perthes disease

A

Self-limiting disease of femoral head, comprising of avascular necrosis, revascularisation, reossification due to interruption of blood supply

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7
Q

Clinical features of perthes disease

A 
School aged (<10) 
Boys (5:1 ratio) 
Insidious onset 
Chronic limp - painless 
Limited range of motion at hip joint 
asymmetric leg length 
Increased folds at hip joint 
Bilateral in 10%
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8
Q

Management of transient synovitis

A

Bed rest

May be preceding perthes disease

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9
Q

Investigations for perthes disease

A 
FBC 
ESR
CRP
Bilateral hip X Rays 
Bone scintigraphy
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10
Q

Define slipped capital femoral epiphysis

A

Displacement of epiphysis of femoral head due to weakness in proximal femoral head

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11
Q

Clinical features of slipped capital femoral epiphysis

A 
Adolescents
Acute painful limp / Chronic limp
Hip pain 
Referred knee pain 
Restricted range of motion if hip joint
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12
Q

Causes of slipped capital femoral epiphysis

A

Weak epiphyseal plate:
Pubertal hormones
Hypothyroidism, endocrine
Obesity

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13
Q

Define transient synovitis

A

Self limiting inflammatory disorder of hip that occurs commonly in young children (2-12)

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14
Q

Causes of swollen joint

A

Infective - septic arthritis, reactive arthritis, rheumatic fever
IBD
Vasculitis - henoch shonlein purpura, Kawasaki
Haematological - haemophilia, sickle cell
Malignancy - leukaemia, neurovlasfom
Connective tissue - JIA, SLE, polyarteritis nodosa

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15
Q

What is reactive arthritis

A

Inflammatory arthritis that occurs after exposure to enterococcal or genitourinary infections

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16
Q

Causes of reactive arthritis

A

Enterococcal bacteria: Salmonella, Shigella, Campylobacter, Yersinia
STIs: chlamydia, gonococcus

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17
Q

Clinical features of reactive arthritis

A

Transient joint swelling (<6wks)
Preceding infection
Arthritis - asymmetrical oligoarthritis of lower joints
Triad - arthritis, urethritis, conjunctivitis

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18
Q

Causes of septic arthritis

A

Haematogenous spread
Direct - puncture injury, chicken pox, osteomyelitis

Streptococcal, staphylococcal - most common
Haemophilus influenzae

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19
Q

Clinical features of septic arthritis

A

Acute onset swollen joint
Acute painful limp, non weight bearing
Acute pain - pseudoparalysis/holds limv still
Reduced range of movement
Febrile
Appears unwell
Erythematous, swollen, tender, restricted joint

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20
Q

Kocher criteria for septic arthritis

A

Non weight bearing
Temp >38.5
ESR raised
WBC raised

3 = 90% diagnostic

21
Q

Management of septic arthritis

A

IV antibiotics 2 weeks

Joint washout

22
Q

Prognosis of septic arthritis

A

Delayed treatment can cause irreversible Joint destruction and subsequent disability

23
Q

Define juvenile idiopathic arthritis

A

Persistent joint swelling (>6 weeks) presenting before 16 years old in absence of infection or any other cause

24
Q

Clinical features of JIA

A 
Joint swelling
Limp 
Joint pain 
Gelling - stiffness after rest
Morning stiffness
25
Clinical features of oligoarthritis JIA
Persistent: 1-4 joints affected for 6 months Extended: >4 joints affected > 6 months Chronic anterior uveitis in 20% ANA +/-
26
Clinical features of polyarthritis RF -ve
>4 joints affected | Chronic anterior uveitis
27
Clinical features of polyarthritis RF +ve
>4 joints affected RF +ve Rheumatoid nodules
28
Clinical features of systemic arthritis
Arthritis in at least 1 joint Preceded by 2 week fever Associated with: macular rash, lymphadenopathy, hepatosplenomegaly, serositis Anaemia, raised WCC + platelets + CRP/ESR
29
Clinical features of Psoriatic arthritis
Arthritis + psoriasis | Arthritis + 2 of: nail pitting, dactylitis, onycholysis, family hx of psoriasis
30
Clinical features of enthesitis-related arthritis
Arthritis - lower limb, lumbar spine, sacroiliac joint Enthesitis Male >6year old acute anterior uveitis, Reiter’s Syndrome HLAB27+
31
Complications of JIA
Chronic anterior uveitis - cataracts, glaucoma, visual impairment Flexion contractures - held in comfortable position Growth failure - generalised, localised overgrowth (leg length discrepancy, valgus deformity), localised undergrowth (micrognathia-jaw) Osteoporosis Delayed puberty Anaemia of chronic disease
32
Management of JIA
``` Paediatric rheumatology referral Physiotherapy NSAIDs, analgesia Corticosteroid joint injections Methotrexate Systemic corticosteroid - induction agent, avoid long term Biologics - refractory to methotrexate ```
33
Define developmental dysplasia of hip
spectrum of disorders of the femoral head and acetabulum, ranging from hip dysplasia, subluxation to dislocation
34
Clinical features of ddh
``` Detected on screening Limp Abnormal gait Asymmetrical skin folds at hip Leg length discrepancy Limited hip abduction ```
35
When is DDH screened for
Neonatal screening | 8 week baby check
36
What are the screening tests for DDH
Barlow maneovre: to see of hip is dislocatable; move femoral head down and adduct Ortolani maneovre: to revert femoral head into acetabulum; abduct head and up, hear ‘clunk’
37
Investigations for DDH
Uss hip | X Ray
38
Cause of osteomyelitis
Haematogenous spread Direct spread - skin infection Staph aureus, streptococcus, H influenzae, salmonella, TB
39
Pathophysiology of osteomyelitis in children
Infection of metaphysis of long bones - distal femur, proximal tibia In infants before maturation of growth plate - spread to cause joint destruction and arrested Growth Children with mature growth plate - spread limited Septic arthritis - if joint capsule inserted below growth plate, hips Subperiosteal abscess
40
Clinical features of osteomyelitis
Acute painful immobile limb With Acute febrile illness Swelling, erythema, warmth, tenderness at infected site Severe pain on movement
41
Investigations for osteomyelitis
FBC - wcc CRP, ESR Blood cultures X Ray - takes 7 days for bone rarefaction (osteopenia) and subperiosteal new bone formation to appear
42
Management of osteomyelitis
Antibiotics IV 2 weeks + immobilisation with splint Surgical drainage - if unresponsive to antibiotics
43
Define Rickets
Failure in mineralisation of growing bone
44
Physiology of vitamin D metabolism
Intake: diet, synthesis in skin by UVB (cholecalciferol) Hydroxylated by liver to calcidiol Hydroxhlated in kidney to calcitriol - active form Causes bone calcification + intestinal absorption
45
Pathophysiology of rickets
Low serum calcium Triggers PTH secretion Increased calcitriol synthesis + renal calcium reabsorption + bone resorption Normalised serum calcium but bone demineralisation
46
Causes of rickets
Nutritional: Decreased sunlight exposure Maternal vitamin D deficiency Exclusive breastfeeding into late infancy - deficient in Ca, phosph, vit D Prolonged parenteral nutrition in infancy - deficient in phosphorus Intestinal malabsorption - coeliac, CF Defective production of calcidiol - chronic liver disease Increased metabolism of calcidiol - antiepileptics Defective production of calcitriol - CKD
47
Clinical features of rickets
Craniotabes - softening of skull, parietal/occipital bones Rachitic rosary - palpable costochonral junctions Widened wrists, ankles - expansion of metaphysis Harrison’s sulcus - horizontal depression on lower chest wall at site of attachment of diaphragm Bowing of legs (weight bearing) Poor growth/short stature Delayed closure of anterior fontanelle
48
Diagnosis of rickets
Feeding history ``` Serum calcium Serum phosphate LFTs - ALP high Serum 25-hydroxyviramin D (low) Serum PTH (high) U+E ``` X Ray wrist - metaphyseal fraying, widened epiphyseal plate
49
Management of rickets
Diet: oily fish, egg yolks, milk, dairy, breakfast cereals Vitamin D3/cholecalciferol Supplementation Calcium supplementation Monitoring: ALP, calcidiol, calcium, phosphorus, X Ray

Paediatrics (15 decks)

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