MSK Flashcards
State three variations of normal posture
Genu Varum
Genu Valgum
Pes Planus
What is Genu Varum?
AKA Bow Legs
Common in under 2s
Pathological causes include Rickets and Blount Disease
What is Blount Disease?
Autosomal recessive osteochondrodysplasia
Often unilateral
What is Genu Valgum?
AKA knock knees
Physiological from ages 4-7
Refer if intermalleolar distance >8cm
What is Pes Planus?
AKA Flat Feet
Normal in toddlers as they have flat medial arch and fat pad
Demonstrated by tip toes
How is Pes Planus managed?
Footwear support and arch device
What does a fixed painful flat foot indicate?
Tendoachilles contracture
Juvenile Idiopathic Arthritis
Name two variations of Abnormal Gait
In Toeing
Toe Walking
Give three causes of In Toeing
Metatarsus Varum (Adduction Deformity)
Medial Tibial Torsion
Persistent anti version of femoral neck (‘W Sit’)
How does Toe Walking present?
Normally resolves by 3y
Common in ASD
If still present consider DMD in boys or Cerebral Palsy
State two ABNORMAL postures
Talipes (Club foot)
Pes Cavus
Talipes is a fixed abnormal ankle position presenting at birth. What are the three types?
Equinovarus (plantarflexed and supinated)
Calcaneovalgus (dorsiflexed and pronated)
Positional (resting is equinovarus, but not fixed, treated wrath physio)
Talipes is treated by Ponseti. What is this? (Give 5 points)
Started immediately after birth
Foot is manipulated and cast is applied
Repeated over and over until corrected
Achilles tenotomy at some point to release tension
After casts a boot is used for four years
What is Pes Cavus?
Abnormally high longitudinal arch
Associated with neuromuscular disorders such as Friedreich’s Ataxia and Sensory Neuropathy
How might a child with Hip Pain present?
Limp
Refusal to use affected leg
Inability to walk
Describe the aetiology of Hip Pain in different age groups: 0-4y
Septic Arthritis
DDH
Transient Synovitis
Describe the aetiology of Hip Pain in different age groups: 5-10y
Septic Arthritis
Transient Synovitis
Perthes
Describe the aetiology of Hip Pain in different age groups: 10-16y
Septic Arthritis
Slipped Upper Femoral Epiphyses
Juvenile Idiopathic Arthritis
Give three red flags for hip pain
<3y
Fever
Night Pain
How can you investigate Hip Pain?
Bloods XRay USS Joint Aspiration MRI (?Osteomyelitis)
Define Perthes Disease?
Disruption of blood supply to femoral head causing Avascular Necrosis of Femoral Epiphyses
Describe the pathophysiology of Perthe’s Disease
Mostly occurs in 5-8 year olds
Idiopathic
Overtime there is revascularisation and neovascularisation which can lead to Hip OA
How does Perthes Disease present?
Slow onset hip/groin pain that may refer to knee
Limp
Restricted hip movements
How would you investigate Perthes Disease?
XRay (Early - widening of joint space, Late - Flattening of Femoral Head)
Full range of bloods (Normal)
MRI
Technetium Bone Scan
How is Perthes Disease managed?
Bed rest, crutches, Physio
Regular XRays
Surgery if severe/older/non healing to improve joint alignment
What is SUFE?
Where the head of the femur slips along the growth plate
Most common in boys aged 8-15
More common in obese children
How does SUFE present?
May be triggered by minor trauma
Hip/Groin/Knee/ Thigh Pain
Painful Limp
Restricted Hip Movement
How does SUFE appear OE?
Hip is often externally rotated
How is SUFE investigated?
Frogs Leg XRay
Bloods (Generally normal)
What XRay views can be used for SUFE?
AP
Frogs Leg Lateral (May worsen slip)
Describe the XRay changes in SUFE
Pre Slip - Widening and irregularity of growth plate, demineralisation of metaphysis
Slip - Posteromedial
Chronic Slip - Physis becomes sclerotic and metaphysis widens
How is SUFE managed?
Corrective surgery
What is Developmental Dysplasia of Hip?
Structural abnormality in hips caused by abnormal development of foetal bones in pregnancy, leading to a tendency for subluxation/dislocation
How does DDH present?
May be picked up on newborn examinations
Hip Asymmetry/Reduced ROM/Limp
Can persist into adulthood (weakness, recurrent dislocation)
Give three risk factors for DDH
Family History
Breech Presentation
Multiple Pregnancies
How would you investigate DDH?
USS (<4m)
XRay (>4m) - Shallow Acetabulum and Head displacement
What are the USS findings in DDH?
Measures alpha-angle, which is a measurement of the bony roof of the acetabulum
Uses Graf’s Classification
You may see abormal skin folds or differing leg lengths in a newborn with DDH. What are the two screening tools for DDH in NIPE?
Barlow - Downward pressure at 90 degrees to see if dislocatable
Ortolani- Abduct and push forwards to see if dislocated
Isolated clicking is normal, clunking requires USS
How is DDH managed?
If less than 6 months, a Pavlik Harness is used (kept on permanently for 6-8 weeks)
Surgery if harness fails or child is diagnosed after 6 months
What is Scoliosis?
Lateral curvature in the frontal plane of the spine
Describe the pathophysiology of Scoliosis
Rotation of vertebral bodies causes prominence in back from rib asymmetry
If severe can cause cardioresp failure due to rib distortion
What causes Scoliosis?
Idiopathic (Girls aged 10-14)
Congenital (Spina Bifida, VACTERL)
Secondary (Cerebral Palsy, Marfans)
Why do you ask a patient with suspected Scoliosis to lean forward?
If it disappears - leg length discrepancy
How is Scoliosis managed?
Mild may resolve spontaneously
Severe may require bracing or corrective surgery
What is Osgood Schlatters Disease?
Inflammation at tibial tuberosity (where patella tendon inserts)
Describe the pathophysiology of Osgood Schlatters Disease
Stress from running jumping at same time as growth in epiphyses, growth plate results in inflammation of tibial epiphyseal plate
Multiple avulsion fractures where tendon pulls away bone leading to visible lump below knee
Typically males aged 10-15
How does Osgood Schlatters Disease present?
Gradual onset of symptoms
Visible/Palpable hard tender lump
Anterior knee pain
How is Osgood Schlatters Disease managed?
Rest, Ice, NSAIDs, Stretching, Physio
May be left with lump
What is Chondromalacia Patellae?
Softening of articulate cartilage of patella, normally affecting adolescent females
How does Chondromalacia Patellae present?
Pain when Patella is slightly opposed to femoral condyles (eg standing, or walking up stairs)
Often associated with hyper mobility and flat feet
How is Chondromalacia Patellae managed?
Physio for quad muscle tightening
What is Osteochondritis Dissecans?
Persistent knee pain in physically very active individual and localised tenderness over femoral condyles
Describe the pathophysiology of Osteochondritis Dissecans
Bone and cartilage separate from medial condyles due to Avascular Necrosis
Complete separation results in loose body formation and locking/giving away
How is Osteochondritis Dissecans managed?
Rest and Quadriceps exercises
Arthroscopic surgery
Septic Arthritis is a serious joint infection, most common in under 2s. Describe the pathophysiology
Usually haematogenous spread but can be from puncture wounds/infected skin lesions
Usually affects hip
Most common organism is S.Aureus
How does Septic Arthritis present?
Erythematous, warm, acutely tender joint
Reduced ROM
Acutely unwell/febrile child
Limp or referred pain
How would you investigate Septic Arthritis?
Bloods (inc CRP and FBC)
Hip USS (look for effusions, aspirate for organisms)
XRay (excludes fracture, may show soft tissue swelling)
Measured against Kocher criteria
How is Septic Arthritis managed?
Empirical IV Abx for 2-4 weeks
<3m or Sickle Cell - IV Ceftriaxone
>3m - IV Flucloxacillin
Can switch to oral when showing improvement
If severe may require surgical drainage and washout
Reactive arthritis is the most common form of arthritis in children. How does it present?
Transient joint swelling (<6 weeks) often of ankles or knees following extra articular infection
Low grade fever
Name four infections associated with Reactive Arthritis
STI
Lyme Disease
Rheumatic Fever
Campylobacter
How is Reactive Arthritis investigated?
Bloods (Acute Phase Reactants May be elevated)
XRays (normal)
How is Reactive Arthritis managed?
NSAIDs
What is Osteomyelitis?
Infection in the bone and marrow, normally in metaphysis
Describe the pathophysiology of Osteomyelitis
Most commonly caused by S.Aureus
May be due to direct inoculation or haematogenous spread, or spread from septic arthritis
Risk factors include open fractures, sickle cell, TB, HIV
State the clinical features of Acute and Chronic Osteomyelitis respectively
Acute (<2 weeks) - refusal to weight bear, pain, swelling
Chronic - slowly developing symptoms
How is Osteomyelitis investigated?
MRI
Bloods (raised WCC and Inflamm)
Blood Culture
Bone Biopsy
How is Osteomyelitis managed?
Extensive Abx
<3m or Sickle - IV Ceftriaxone
>3m - IV Flucloxacillin
May require drainage and debridement
What is Transient Synovitis?
Temporary irritation and inflammation in the synovial membrane of joint
Most common cause of hip pain ages 3-10y
Associated with recent viral URTI
How does Transient Synovitis present?
AFEBRILE
Limp
Refusal to weight bear
Groin pain
Within a few weeks of viral illness
How is Transient Synovitis managed?
Simple analgesia
If they develop a fever - A and E
Follow up at 48h and at one week
What is an Osteosarcoma?
Bone cancer commonly presenting in adolescents aged 10-20, usually affecting femur
How do Osteosarcomas present?
Persistent bone pain, particularly worse at night
Bone swelling/mass
Restricted movements
How is a suspected Osteosarcoma investigated?
Urgent XRay within 48 hours
Bloods (raised ALP)
CT/MRI Staging
What are the XRay findings of an Osteosarcoma?
Poorly defined lesions with fluffy appearance
Periosteal reaction that’s described as sun burst
How is an Osteosarcoma managed?
Surgical resection (?limb amputation) Adjuvant Chemo
Define Rickets
Defective bone mineralisation due to Vitamin D Deficiency (equivalent in adults is Osteomalacia)
Describe the pathophysiology of Rickets
Reduced calcium and phosphate lead to secondary hyperparathroidism and increased bone resorption
Rickets can be asymptomatic. How else can it present?
Lethargy Bone pain Bone deformity Poor growth Dental problems
State four bone deformities associated with Rickets
Bowing of knees
Knock knees
Delayed Teeth
Craniotabes (soft skull)
How is Rickets investigated?
Serum 25 Hydroxyvitamin D (<25nmol/l)
XRay (Osteopenia)
U and Es, LFTs, TFTs
How is Rickets managed?
Breast fed babies are at higher risk so mothers and babies should take Vitamin D supplements
Ergocalciferol - 6000IU per day for 8 to 12 weeks
Calcium supplements
What is Achondroplasia?
Most common cause of disproportionate short stature (skeletal dysplasia) caused by an Autosomal Dominant genetic defect of fibroblast growth factor
Abnormal function of epiphyseal plates restricts bone length
Give four clinical features of Achondroplasia
Short stature (4ft)
Femur and Humerus most affected
Short digits
Disproportionate skull
Why do patients with Achondroplasia have a disproportionate skull?
Skull bases fuse by endochondrial ossification which is affected, whereas vault grows my membranous ossification (unaffected)
Leads to frontal bossing and flattened nasal bridge
How is Achondroplasia managed?
No cure
Leg lengthening may add height but cause chronic pain
What complications are patients with Achondroplasia more at risk of?
Kyphoscoliosis
OSA
Cervical Cord Compression
Hydrocephalus
What is Osteogenesis Imperfecta?
A group of 8 different types of mutations affecting type 1 collagen, causing recurrent and inappropriate fractures
Some of the mutations are inherited in an autosomal dominant manner
How does Osteogenesis Imperfecta present? Name 5 features
Recurrent and inappropriate fractures Hyper mobility Blue Sclera Short Stature Early deafness
How is Osteogenesis Imperfecta diagnosed?
XRays
Genetic Testing
How is Osteogenesis Imperfecta managed?
Bisphosphonates and Vitamin D
Define Charcot Marie Tooth Disease
Symmetrical slowly progressive distal muscular wasting due to mutations in myelin. Various forms of inheritance
How does Charcot Marie Tooth Disease present?
May trip over a lot when young
Bilateral foot drop
Loss of ankle reflexes progressing to knees
Pes Cavus
How is Charcot Marie Tooth disease investigated?
Nerve conduction studies (motor and sensory neuropathy) Nerve biopsy (onion bulb, may be hypertrophic)
What is Guillaine Barre Syndrome?
Acute post infectious polyneuropathy
Typically presents 2-3 weeks after URTI/Campylobacter with ascending progressive symmetrical weakness over a few days to weeks
How does Guillaine Barre present?
Loss of tendon reflexes and autonomic involvement
Sensory symptoms in distal limbs
Bilateral facial weakness
70% Dysautonomia (tachy,Brady,hypo, hypertension etc)
How is Guillaine Barre diagnosed?
MRI spinal cord (exclude lesion)
2nd week - increased protein in CSF, reduced velocity in conduction studies
How is Guillaine Barre managed?
Supportive
Full recovery might take up to two years
Give a brief description of Endochrondrial Ossification
Development of bone from a cartilage precursor, using ossification centres.
How majority of long bones are formed
Physiologically stops at around 2y
Give a brief description of membranous ossification
Development of bone directly from mesenchyme
Uses osteoblasts which secrete osteoid, become embedded to form osteocytes, and then form mature bone (osteons)
Carries on into adulthood
How to bones grow?
Interstitial - Length
Appositional - Width
