MSK Flashcards
What is a congenital cause of Osteoporosis on Children
- Osteogenesis Perfecta: Brittle Bone disease
- Majority AD
- Inherited disease of Type 1 collagen
What are the signs of Osteogenesis Imperfecta (OI)
Joint laxity and fragility Bone Fractures and Deformity Low density, BRITTLE, fragile bones Poor Growth Bone Pain Impaired Mobility Deafness, hernias and Valvular Prolapse
What can OI be mistaken for
Child abuse
How do you class OI
Type 1: mildest and commonest - blue sclerosae and hearing loss
Type 2: lethal form - born with multiple factors and blue sclerae
Type 3: Severe form - Fractures at birth and progressive deformity - blue/white sclerae
Type 4: Moderate form: fragile bones and white sclerae
How do you Ix OI
X-ray: many fractures, osteoporotic bones, bowing deformity of long bones
Histology: immature disorganised bone
How do you treat OI
Prevent Injury: Physio, Rehab and Occy health
Osteotomy: to correct deformity
Bisphosphates
What is the most common cause of Septic Arthritis and what are its risk factors
Staph Aureus - children 2yrs
Strep B - neonates
Neisseria Gonorrhoeae - adolescents
- Prematurity
- C-section
- Invasive procedures
How does septic arthritis present
- Temp and vital signs to exclude haemodynamic instability
- Localized swelling
- Effusion, tenderness, warmth
- Position of comfort – flexion, abduction, and external rotation
- Severe pain with passive ROM
- Unwillingness to move joint
What are the 4 prognostic signs for septic arthritis
Kocher Criteria - Temp - >38.5 - WCC - > 12 - ESR - > 40 - Non weightbearing (3 or more high chance septic arthritis)
What Ix should you do for septic arthritis
Blood Culture +/- US guided Aspiration
Whats is the treatment for septic arthritis and what are complications
Urgent surgical drainage and lavage of joint
IV Antibiotics e.g flucloxacillin
operative rarely indicated for Gonorrhoea
Complications; Femoral Head destruction Deformity Joint Contracture Limb Length Discrepancy Gait Abnormalites
What is Transient Synovitis of the Hip
Inflammation of the Synovium causing hip pain
May be a mild/absent fever
What is the cause Transient Synovitis
Considered to precede a viral illness e.g URTI
OR
Bacterial Infection e.g post strep toxic synovitis
OR
trauma or allergy
How do you examine for Transient Synovitis and what would be found on Ix
Pain in extremities of movements
Normal bloods and radiology
What is the treatment for Transient Synovitis
Selflimiting usually resolved by 1-2 weeks
Rest and Analgesia
What is Perths Disease
Avascular necrosis (caused by lack of blood supply) of the femoral head/epiphysis - leading to bone remodelling distorting the epiphysis/femoral head
What is Perths most common in
3 - 11 yr old boys
Cause unknown
How does Perthes Disease present
- Pain in knee and hip causing limp
- Gait disturbance - antalgic, trendelenburg gait
- Late finding - limb length discrepancy
What will be found on examination of Perthes Disease
Movement of hip limited
Especially internal rotation and abduction
What investigations may be performed in Perthes
X- ray and MRI
- Joint space widening - due to decrease size of femoral head
- Collapse and Deformity of femoral head
What is the prognosis of Perthes
Risk of early onset OA and hip replacement in deformed hip
What is the treatment for Perthes disease
Lateral Pillar Classification:
Group A - Height of Lateral Pillar is 100%
Group B - Height of Lateral Pillar is >50%
Group C - Height of Lateral Pillar is <50%
Conservative treatment: limited weight bearing, physical therapy, bed rest and NSAIDS:
- Young children (< 6y of age) usually do well
- Lateral pillar A classification
- Femoral head mostly undamaged
- Consider casting and bracing before surgery if femoral head deformity develops or range of motion worsens
Surgery: femoral osteotomy
Older children (> 8y of age)
Lateral pillar B/C classification
Extensive damage to the femoral head
- Group C rarely do well whatever you do!
What is slipped upper femoral epiphysis
Displacment through growth plate with epiphysis slipping down and back
What are the risk factors for SUFE
Boys
10-16
Obesity
Endocrine Disorders: Hypothyroidism, renal osteodystrophy, GH deficiency
What are the signs of SUFE
Presents after minor injury:
Limp - antalgica with externally rotated foot
pain in groin, thigh and knee
90% weightbear and 10% cannot
What may be seen on examination and X-ray of SUFE
Examination:
- Loss of Hip IR, abduction and flexion
- obligatory ER during passive flexion
X-ray: Anteriorposterior and Frog leg lateral of both hips - widening of joint space, femoral head slipped posteriorly and inferiorly
What is the Rx of SUFE
Avoid weight bearing until surgery
- Urgent surgical internal fixation with pinning of femoral head
- Prophylactic pinning of contralateral hip
What are complications of SUFE
Avascular necrosis of femoral head
Early OA
What is Rickets
Normal bone density but abnormal mineral content during bone growth
What are the S/S of Rickets
- Soft bones - bowed legs, knocked knees
- Growth Retardation
- Motor Delay
- Malaise
- Hypotonia
- Fractures
What are the causes of rickets
Vitamin D deficiency:
- malabsorption,
- poor diet
- lack of sunlight,
- maternal Vit D deficiency - breastmilk
What Ix may be performed in rickets
plasma:
- Vit D deficiency: low 25-(OH)D3 and raised PTH
- Alkaline phosphate high
- low PO4 and
- Ca2+ variable - normal or low
X-ray - cupped ragged/frayed metaphyses, bowing of legs
How do you Rx rickets
Treat Underlying Problem:
- Give Calciferol (vit D) +/- Calcium (if hypocalcaemia)
What are the 3 ways osteomyelitis can occur
- Direct Innocculation of infection into bones (trauma/surgery)
- Continuous spread of infection e.g soft tissue and joints
- Haematogenous seeding - high blood floe in developing bones
Where does haematogenous seeding most commonly occur in children
Long bones
What are the risk factors for Osteomyeltis
Risk of trusts
Vascular supply e.g sickle cell
Pre-existing bone/joint problems
Immunodeficnency
What organism most commonly causes Osteomyelitis
Staph Aureus
What organism most commonly causes osteomyelitis in sickle cell and immunocomprimised
SS: Salmonella
IC: TB
What are the clinical features of Osteomyeltits
Fever
Pain gradual onset
Local findings: pain, tenderness, warmth and erythema
Cortex erosion of bone and exudation of pus
Sequata - infected dead bone
What may you find on Ix of Osteomyelitis
ESR/CRP raised WCC raised Blood culture Bone Biopsy - gold standard X-ray - early changes not visible!! MRI - most sensitive showing inflammation
What is the treatment of Osteomyelitis
Surgical Debridement
IV Vancomycin and Cefotaxime
What is Osofod - Schlotter Disease
Inflammation of the Patellar Ligament at Tibial tuberosity (apophysitis)
90% self limiting
Who is OSD common in
10-15 yrs
Sporty boys
What are the signs of OSD
Pain below the knee and worse on strenuous exercise
What may be found on Ix of OSD
X-ray: tibial tuberosity enlargement +/- fragmentation
MRI - tendonitis
What is the treatment for OSD
Limitation of activity, ice and NSAIDS
Knee padding and Physiotherapy
Tibial Tubercle excision once skeletally mature if all else fails
What is discoid Meniscous
Rare anatomical variant usually affecting lateral meniscus of knee
How does discoid Meniscous present
Asymptomatic until the meniscus tears causing pain, swelling and snapping
What will be found on Ix of Discoid Meiscuc
MRI - thickened meniscal body
What is the Rx of Discoid Meniscus
Stretching and strenghting knee muscles
Surgical excision partial or total depending on damage
What is developmental dysplasia of the hip (DDH)
Ranges from slight acetabular dysplasia to established hip dislocation
What is important about DDH
Early Diagnosis - appropriate realignment can result in good outcome
Late diagnosi more complex outcomes
When should all babies be assessed for DDH
Hip examination 1st few days and at 6 wks of life
What are the signs of DDH
Unequal leg length
Shortening
Widened Peritoneum and buttock flattening on affected side
Skin Crease Asymmetry
Delay in walking
Limited abduction of hip whilst in flexion
What are risk factors for DDH
Breech Birth Increased birth weight Oligohydamniosis Older mother Postmaturity Sibling with DDH
What Examinations and Investigations should be done for DDH
Neonatal Hip tests: Ortolani, Barlow and Galeazzi Manouveres
US - in high risk/abnormal exam babies
X-ray
What is the Rx for DDH
Hips still unstable by 6 wks
- Long term splinting in flexion-abduction in Pavlik Harness
- 6-18 mths - arthography and closed reduction and period of immobilisation - open reduction If closed techniques fail
- After 18mths - Open Reduction
What is JIA
Inflammation of the joints that isn’t caused by any other condition
What is Oligoarthritis
When 4 or fewer joints are affected in first 6 months child may go on to develop arthritis in other joints after 6 months - extended oligoarthritis
What is Polyarthritis
5 or more joints affected In first 6 months
Two types:
- positive RF
- negative RF
what is enthesitis related Arthritis
Affects joints of legs and spine causing inflammation where tendon attaches bone - stiffness in neck and back
What is Psoriatic Arthritis
Can affect any joint but usually the fingers and toes (swollen sausages) with psoriasis a scaly rash
What is systemic onset/stills disease JIA
Arthritis involving ≥ 1 joint AND intermittent fever that lasts for at least two weeks with fever spikes occurring on at least 3 consecutive days AND ≥ 1 extra-articular manifestation when fever spikes: -pink macular rash on trunk and limbs -Hepatomegaly/Splenomegaly -Lymphadenopathy -Serositits
What are the signs of JIA
Painful, swollen or stiff joints Joints warm to touch Increased tiredness Fever Limp but no injury
What investigations should be done for JIA
Bloods WCC raised ESR/CRP raised RF - in seropositive polyarthritis LFT - raised in systemic ANA raised - oligo, poly and psioratic
US and MRI
Joint Aspiration - rule out septic arthritis
What is the treatment of JIA
MDT approach: PT, OT, dieticians
1st line: NSAIDS low disease activity
2nd: DMARDS in active disease e.g Methotrexate
biological therapy e.g Tocilzumab if not responding to DMARDS
Systemic Corticosteroids used in short courses in severe disease e.g Prednisalone
What should you do if there is knee pain
Think hip!
What do growing pains cause
No Limp!!!!!
