MSK Flashcards
Which JIA has a particularly poor prognosis?
RhF +ve polyarthritis
Which JIA is more common in boys than girls?
Ethesitis-related arthritis
DDx for limp in children
Traumatic/mechanical
- Scoliosis
- Fracture
- SUFE
- Sprain/contusion
- Leg length discrepancy
Inflammatory
- JIA
- Transient synovitis
- Osgood Schlatter’s
Vacular
- Perthe’s
Infectious
- Osteomyelitis
- Septic arthritis
- Reactive arthritis
Malignancy
- Osteoma
- Ewing’s sarcoma
Neuromuscular
- CP
- Musculr dystrophy
- Peripheral neuropathy
Metabolic
- Ricket’s
Traumatic/mechanical causes of limp
- Scoliosis
- Fracture
- SUFE
- Sprain/contusion
- Leg length discrepancy
Infectious causes of limp/joint pain
- Osteomyelitis
- Septic arthritis
- Reactive arthritis
Inflammatory causes of limp/joint pain
- JIA
- Transient Synovitis
- Osgood-Schlatter’s
- Reiter’s
- Lupus
- Ank spond
Vacular causes of limp/joint pain
Perthe’s (AVN)
Three “severities” of DDH
Dysplasia, subluxation, dislocation
When is DDH normally picked up?
NIPE - in Barlow/Ortolani manoeuvres
Which manoeuvres are used to assess DDH?
Barlow and Ortolani
Signs of DDH
Asymmetry of skin folds around buttocks and hips. Limited abduction. One leg may be shorter than the other
What is DDH
Developmental dysplasia of the hip - ball and socket joint is not formed completely
What happens in most cases of DDH
Resolves spontaneously by 3-6 weeks
Mx DDH
R/f for ORTHOPAEDIC OPINION
1) Observation - use USS if under 6 months, XR after
2) >6mos. Place in Pavlik harness/splint up to 6mos. Keeps hip flexed and abducted.
3) Surgery if conservative measures have failed - with spica casting
Which infants are at highest risk of DDH? How should they be monitored?
Breech
FHx
- Monitored with USS at 6/52
Which imaging modality is best in assessing DDH?
USS < 6months
XR > 6mos
Mx of fractures
Consider safeguarding
Pain management - PO ibuprofen/paracetamol. IV opioids
Immobilisation
Mx distal radius #
Manipulation
K-wire fixation if fracture off-ended
Mx of femoral shaft #
ADMIT
Orthopaedic management
0-6 mos: Pavlik’s harness, Gallow’s traction
2-18mos: Gallow’s traction
1-6yrs: straight leg skin traction, hip spica cast
6-12yrs: elastic intramedullary nail
11yrs+: elastic intramedullary nail, end caps, ridid intramedullary nails, submuscular plating
Signs/symptoms of SUFE
Acute onset hip/groin pain/referred knee pain
Restricted abduction and internal rotation
- Legs presents as slightly shorter and externally rotated
Commonest age of presentation SUFE
Adolescents (10-15 years)
Pathophysiology of SUFE
Posterior-inferior slippage after fracture through the growth plate
What is a SUFE?
Slipped upper femoral epiphysis - a fracture through the growth plate in the femoral head
Posterior-inferior slippage
Patients at higher risk of SUFE
Boys
Obesity
Metabolic abnormalities - hypoCa, hypothyroid, hypogonad
What views should be requested in SUFE XR?
AP
Frog lateral
Mx of SUFE
Surgical repair - screw fixation
Age of presentation Perthe’s
5-10 years
What is Perthes?
AVN of capital femoral epiphysis of femoral head due to interruption of the blood supply, followwd by revascularisation and ossification over 18-36 months
Signs/symptoms of Perthes
Insidious limp, hip pain
Referred knee pain
What percentage of Perthes is bilateral
10-20%
Ix requested in suspected Perthes
AP
Frog lateral
(+MRI/bone scan)
Findings on XR Perthes
Increased density in femoral head
Fragmented/irregular femoral head
Widening of joint space
Most important factor in Perthes prognosis?
Early diagnosis - if 1/2 femoral head affected, bed rest and traction
If >1/2 affected, plaster/calipers to keep femoral head close to acetabulum to use as mould for reossification
Mx for Perthes
Supportive care (analgesia, ice packs, etc.)
Continued activity
Physical therapy - stretching and strengthening of quads and hamstrings
Surgical treatment if fail to resond to conservative measures
Commonest chronic inflammatory joint disease in children/adolescents
JIA
What is JIA?
Juvenile idiopathic arthritis - persistent joint swelling for more than 6 weeks before 16 years old. Absence of an infecive cause.
How many subtypes of JIA? exist? Give examples
7 Poly (>4 joints) Oligo (<4 joints) Systemic (if ever presents with rash) RhF/B27 tissue subtypes
What percentage of JIA diagnoses are distinct from RhA in adulthood?
95%
Signs/symptoms of JIA?
“Gelling” - stiffness after rest/in morning
Swollen joints - swelling of the joint fluid, inflammation, thickening of synovium.
- High fever (paroxysmal)
- Malaise
- Salmon rash
- Raised APPs (ESR)
Difficulty eating - TMJ involvement
Intermittent limp
Behavioural/mood change
What are the features of uncontrolled JIA?
Overgwoth of inflammed synovium = limb/digit length discrepancy, valgus deformity
Chronic anterior uveitis
Flexion contractures of joints
Growth failure
Osteoporosis (non weight bearing, steroids)
Management of JIA?
Specialist paediatric rheum MDT
PTOT
Continued activities such as cycling and swimming
Medical: analgesia, NSAIDs, STEROIDS (IV, PO, intra-articular)
DMARDs - if failure to respond. Methotrexate and sulfasalazine
TNF-alpha inhibitors
Complications of reduced activity due to MSK conditions
Deconditioning
Disability
Decreased bone mass –> osteoporosis
Which DMARDs can be used in JIA failing to respond to conventional treatments?
Methotrexate
Sulfasalazine
Why are steroids avoided in JIA if possible?
Growth suppression
Osteoporosis
DDx joint swelling
JIA Transient synovitis Lupus Reiter's Septic arthritis Reactive arthritis
What is transient synovitis?
“Irritable hip” - inflammation of the synovium
Commonest cause of acute hip pain in children
Transient synovitis
Age of presentation transient synovitis
2-12 years
Major differences between transient synovitis and septic arthritis
SA: fever, hip held flexed, severe pain, High WCC, Raised APPs, widened joint space
Common features of transient synovitis
Often a preceding viral infection (but tend to be afebrile at the time of presentation)
Sudden onset hip pain/limp
No pain at rest
Reduced ROM, particularly internal rotation
Normal WCC/APP
Ix for transient synovitis
USS (fluid in joint)
XR (normal)
Joint aspiration - only if fears of septic arthritis
Mx of transient synovitis
Conservative
- Analgesia (paracetamol/NSAIDs)
- Bed rest
How long does it take for transient synovitis to self resolve?
2-3 days
Mx of ricket’s
Vitamin D (Ergocaliciferol (D2), Cholecalciferol (D3). Calcium
What is Osgood-Schlatter’s syndrome?
Osteochondritis of the patellar tendon insertion at the knee.
Commonest demographic presentation of OSS?
Adolescent, physically active males (particularly running/jumping)
Signs/symptoms OSS?
Knee pain after exerise. Localised tenderness.
Tibial tuberosity tenderness
Hamstring tightness
OFTEN BILATERAL
What percentage of OSS is bilateral?
25-50%
Mx OSS
- Pain relief: paracetamol, NSAIDs, ice packs, protective knee pads
- Stretching
- Reduce quad-heavy activity, e.g. running and jumping
- Increased quad-light activity e.g. swimming, cycline
Commonest organism in psoas abscess
S.aureus
Mx for psoas abscess
Drainage and abx
Which joints does reactive arthritis most commonly affect?
Knees and ankles
What is reactive arthritis?
Transient joint swelling and pain after preceding extrarticular infection (<6 weeks)
How long does reactive arthritis usually last?
<6 weeks
Which infections does reactive arthritis often follow?
Enteric: salmonella, shigella, campylobacter (children)
STIs
Mycoplasma
Lyme
Signs/symptoms of reactive arthritis
Joint pain/swelling after extra-articular infection
Low grade fever
Normal or mildly elevated APPs
XR findings reactive arthritis
Normal
Mx reactive arthritis
Self-resolving
Pain relief: NSAIDs, paracetamol
Steroids if severe
DMARDs if ongoing - methotrexate, sulfasalazine
Where is the infection in osteomyelitis?
Metaphysis (commonly of long bones). Often distal femur/proximal tibia
Why is joint destruction from osteomyelitis less common younger children than adolescents?
The growth place limits spread.
But can lead to growth arrest
Signs and symptoms of osteomyelitis
Limp
Limb/joint pain/swelling - painful and immobile
Fever
Sterile effusion of adjacent joint
Complications osteomyelitis
Spread to cause septic arthritis
Ix and results osteomyelitis
FBC (rasied WCC, APPs)
BC: positive
XR: initially normal but subperiostal new bone formation shows after 7-10 days + localised bone rarefaction
MRI: to distinguish between bone and soft tissue infection
Acute osteomyelitis mx
High dose empirical IV abx (2-4 weeks) - depending on culture from MC&S
Can swith to PO once clinical recovery
Immobilise affected limb
Analgesia
Surgical debridement/decompression if dead bone
When should blood cultures be taken in osteomyelitis/septic arthritis?
BEFORE STARTING ABX
Septic arthritis
Infection of joint space
Commonest causative organism septic arthritis (after neonatal period)
S. aureus
Signs/symptoms infective arthritis
Acute onset joint pain/swelling NON-weight bearing High grade fever Erythematous, warm Pseudoparesis (hip held in flexed position) - severe pain at rest
Septic arthritis Ix
FBC (Raised WCC, ESR, CRP)
BC: positive (MC&S)
XR: widened joint space
USS: joint fluid
JOINT ASPIRATION UNDER USS
Septic arthritis mx
Prolonged abx
- 2 weeks IV
- 4 weeks PO
(+ve: vanc; -ve: cef)
Joint aspiration/washing out/drainage
Appropriate abx in septic arthritis gram +ve
Vancomycin
Appropriate abx in septic arthritis gram -ve
Ceftriaxone
Osteoid osteoma
Benign tumour
Adolescent boys
Femur, tibia, spine
More painful at night
Osteoid osteoma common sites
Femur, tibia, spine
Inheritance pattern of achondroplasia
AD
Features of achondroplasia
Short stature (due to short limbs) Large head Frontal bossing Depressed nasal bridge Lumbar lordosis
What is the pathophysiology osteogenesis imperfecta?
Disorder of collagen metabolism leading to bone fragility
Features of T1 osteogenesis imperfecta
Childhood fractures
Blue sclera
Hearing loss
Mx osteogenesis imperfecta
Bisphosphonates
Features of hypermobility
Knees “giving way”
Flat foot w/ arch on tip toes
Younger female girls
Mechanical joint/muscle pain
Features of growing pains
Nocturnal idiopathic pain Symmetrical Not limited to joints NEVER present at start of day No limp Physical acitvity not limited Physical examination normal
Commonest cause torticollis
SCM tumour (mobile, non-tender nodule) Restriction in head turning/tilting
Pes cavus
High arch - indicative of neuromuscular disorders
Positional talipe
Club foot caused by intrauterine compression
Normal size foot, corrected by manipulation
Passive exercises from physio
Equinovarus talipe
Entire foot inverted and supinated
Shorter foot with thinner calf muscles
Often BILATERAL
Signs and symptoms of chrondromalacia patellae
Young adults (overuse in physical activity) Passive movements usually painless Repeated extension = grating/crepitus/small effusion
Pathophysiology chrondomalacia patellae
Degeneration of the articular ligament on the posterior surface of the patella
