MSK Flashcards
What are the 3 main differentials for a limping child?
- Infection e.g. sepsis/osteomyelitis.
- Trauma e.g. NAI, fracture.
- Tumour.
What is the likely cause of a limp in a child aged 0-3?
- Non-accidental injury
- Osteomyelitis/septic arthritis.
- DDH.
What is the likely cause of a limp in a child aged 3-10?
- Trauma.
- Transient synovitis.
- Osteomyelitis.
- Perthe’s disease.
What is the likely cause of a limp in a child aged 10-15?
- Trauma.
- Osteomyelitis.
- SUFE.
- Perthe’s disease.
What must you remember to consider as a differential in a limping child?
Intra-abdominal pathology e.g. hernia, testicular torsion.
Why might you want to ask about socioeconomic class and smoking status in a child presenting with a limp?
Social deprivation and passive smoking are RF’s for Perthe’s disease.
What investigations might you want to do on a child presenting with a limp?
- General observations e.g. HR, BP, T, RR, O2 sats.
- FBC, BM, ESR and CRP.
- XR - AP and lateral views of the the joint and the joints above and below.
- USS - effusion in joints?
- CT/MRI.
Describe Kocher’s criteria.
fever >38.5 degrees C
non-weight bearing
raised ESR
raised WCC
3/4 features = septic joint.
Give 3 signs of septic arthritis.
- Systemically very unwell.
- Pain at rest.
- Raised WCC and CRP.
What is transient synovitis?
Acute onset joint inflammation following illness often respiratory.
How does transient synovitis differ from septic arthritis?
Transient synovitis: no pain at rest, XR normal, USS may show effusion, rest, physiotherapy and NSAIDs often help.
Give 3 risk factors for DDH.
- female sex: 6 times greater risk
- breech presentation
- positive family history
- firstborn children
- oligohydramnios
- birth weight > 5 kg
- congenital calcaneovalgus foot deformity
What tests can be done on clinical examination in the neonatal period to pick up DDH?
- Ortolani test.
- Barlow manoeuvre.
Can be confirmed with USS.
What are the 2 main risks associated with the surgical management of DDH.
- Avascular necrosis.
2. Re-dislocation.
What is Perthe’s disease?
A self-limiting idiopathic disease characterised by avascular necrosis of the femoral head.
Describe the management of Perthe’s disease.
To keep the femoral head within the acetabulum: cast, braces
- If less than 6 years: observation
- Older: surgical management with moderate results
- Operate on severe deformities
Give 3 risk factors for Perthe’s disease.
- ADHD.
- Deprivation.
- Passive smoking.
- LBW and short stature.
What is SCFE?
Slipped capital femoral epiphysis - a fracture through the growth plate leads to slippage of the femoral head through the zone of hypertrophy.
Who is likely to be affected by SCFE?
A pre-pubescent obese male.
How does SCFE present?
hip, groin, medial thigh or knee pain
loss of internal rotation of the leg in flexion
What is the treatment for SCFE?
Surgical pinning of the hip.
What is chondrosarcoma?
A malignant neoplasm of cartilage.
What is the criteria for making a clinical diagnosis of juvenile idiopathic arthritis?
Joint swelling/stiffness >6 weeks in children <16 and no other cause is identified.
Describe the non-medical mx for JIA.
Liaison with school for additional support.
Physiotherapy.
Describe the medical mx for JIA.
- Steroid joint injections.
- NSAIDS.
- Methotrexate.
- Systemic steroids.
Give 5 potential consequences that can occur if you fail to treat JIA.
- Permanent deformity.
- Disability.
- Pain.
- Bony overgrowth.
- Uveitis.
Define osteoporosis in children.
-The finding of one or more vertebral compression (crush) fractures is indicative of osteoporosis, in the absence of local disease or high-energy trauma.
- In the absence of vertebral compression (crush) fractures, the diagnosis of osteoporosis is indicated by the presence of both a clinically significant fracture history and BMD Z-score ≤ -2.0. A clinically significant fracture history is one or more of the following:
1) two or more long bone fractures by age 10 years;
2) three or more long bone fractures at any age up to age 19 years
Describe the aetiology of osteoporosis in children.
- Inherited/congenital e.g. osteogenesis imperfecta, inborn errors, idiopathic.
- Acquired e.g. drug induced, malabsorption, immobilisation
What investigation might you do to determine if a child has osteoporosis?
DEXA scan
What is osteogenesis imperfecta?
An AD inherited osteoporotic condition that leads to bone weakness in children. It is due to a defect in type 1 collagen genes.
Give 5 signs of osteogenesis imperfecta.
- Bone fragility.
- Fractures.
- Deformity.
- Pain.
- Impaired mobility.
- Poor growth.
- Blue sclera.
- Bruises.
- Deafness secondary to otosclerosis
- Dental imperfections are common
Describe the mx of osteogenesis imperfecta.
MDT approach - physicians, surgeons, physiotherapists, OT’s.
Bisphosphonates e.g. pamidronate
What is Rickets?
A disorder of bone mineralisation, it leads to bone weakness.
What is the main cause of Rickets?
Vitamin D deficiency.
Give 3 signs of Rickets.
knock-knee, bow leg, Rachitic rosary
What might you find when examining a child with Rickets?
- Metaphyseal swelling.
- Bone deformity e.g. bowed legs.
- Motor delay.
- Hypotonia.
- Fractures.
- Cupping and spraying seen on XR.
What investigations might you do to determine if a child has Rickets?
- Serum biochemistry e.g. ALP, PTH.
- Bone profile.
- Measure vitamin D levels.
- XR.
Describe the treatment for Rickets.
Treat the underlying problem.
If vitamin D deficiency, give Adcal D3.
What is the role of vitamin D?
It acts to increase Ca absorption at the gut and Ca reabsorption at the kidneys.
Give 3 sources of vitamin D.
- Sunlight!
- Cereals.
- Egg yolk.
- Oily fish.
- Spreads.
Briefly describe how Vitamin D is converted into 1,25-(OH)2-vitamin D.
Vitamin D3 (cholecalciferol) -> 25-OH-vitamin D (conversion in liver with 25 hydroxylase) -> 1,25-(OH)2-vitamin D (conversion in kidney with 1 hydroxylase)
Secretion of which hormone will increase in response to low calcium?
PTH.
Increased PTH = bone resorption, Ca reabsorption at kidneys and Ca absorption at gut.
Give 5 differentials for a painful joint.
Life-threatening differentials:
- Leukaemia.
- Septic arthritis.
- NAI.
Pain and swelling:
- Trauma.
- Infection.
- Reactive arthritis.
- JIA.
Pain and no swelling:
- Perthe’s disease.
What investigations might you do on a child who you suspect may have JIA?
- ANA may be positive, especially in oligoarticular JIA
- rheumatoid factor is usually negative
- ophthalmology review for anterior uveitis
Name 5 types of JIA.
- Oligoarticular.
- Polyarticular.
- Psoriatic.
- Enthesitis related.
- Systemic onset JIA.
Define oligoarticular JIA.
<4 joints involved, often asymmetrical. Normally ANA+ and associated with a high risk of developing uveitis.
Define polyarticular JIA.
> 4 joints involved, often symmetrical and more destructive.
What extra-articular features might you see in someone with JIA?
- Psoriasis.
- Dactylitis.
- Nail pitting.
Which type of JIA is most similar to ankolysing spondylitis?
Enthesitis related arthritis.
The point where the tendon joins a bone is inflamed.
Which antigen is closely associated with enthesitis related arthritis?
HLAB27.
What signs might you see in someone with systemic onset JIA?
- pyrexia
- salmon-pink rash
- lymphadenopathy
- arthritis
- uveitis
- anorexia and weight loss
What analgesia is appropriate for a paediatric fracture?
Paracetamol.
Oromorph.
Which age group does transient synovitis most commonly affect?
2-10y
What is the mx of transient synovitis?
- Rest
2. Analgesia
