MSK conditions - limps Flashcards
What is a toddler’s fracture
Spiral fracture of distal tibia
Usually from a simple ground level fall
Usually preschool
Presentation of toddler’s fracture
Local tenderness on tibia
child may limp/not weight bear
Treatment for toddlers fracture
Cast for 5-6 weeks
Child presents with a limp and local tenderness on tibia.
They fell over at ground level and are preschool age.
Likely diagnosis?
Toddler’s fracture
What is transient synovitis?
Presentation
Also know as irritable hip Acute onset often after viral infection (Usually unilateral) Hip pain (+/- limp) No pain on rest usually 2-12 years old
Treatment for irritable hip?
Rest
? physio
?NSAIDs
Child presents with a limp and pain in right hip.
They are 7 years old and had a cold last week. Pain came on acutely, but is not present on rest.
They have no fever, can walk on it and bloods are normal (WCC, CRP)
Likely diagnosis?
Irritable hip/transient synovitis
What is septic arthritis and how does it usually come on? Most likely causative organism?
Age group most affected?
Infection of joint space, after blood spread or puncture would/infected skin lesions
Staph aureus most common cause (H influenza used to be a cause before vaccination)
Under 2’s most commonly affected
How does septic arthritis present?
Erythematous, warm, acutely tender joint
Reduced ROM
Fever
Child often holds limb still, flexed, abducted and externally rotated - cry if moved
effusion may be present if the joint is peripheral
Investigations for clinically suspected septic arthritis
Blood cultures
Bloods - white cells, CRP
X-ray - late changes (2-3/52) +ve after 4/52 in 90%
Aspiration of joint for organisms (USS guided) is diagnostic
What are Kocher’s criteria?
Distinguish between irritable hip and septic arthritis
Fever >38.5
Can’t weight bear
ESR >40 in first hour
White cells > 12
3/4 - 92% chance of septic arthritis - more = more likely
Treatment of septic arthritis
IV antibiotics
?wash out joint/surgical drainage
?immobilise joint in short term - to be mobilised later
Child presents with limp and fever
Reduced range of movement and struggles to weight bear. Leg is held flexed, abducted and externally rotated. Child cries if leg is moved. Joint feels warm to touch, is red and tender.
Child’s temperature is 39’c, ESR - 60, WCC - 15
Most likely diagnosis?
What is their score on Kocher’s criteria?
Septic arthritis
4/4 Kocher’s criteria
(Fever >38.5, Can’t weight bear, ESR >40 in first hour, White cells > 12)
Treatment of septic arthritis
IV antibiotics
Wash out joint/surgical drainage
Temporarily immobilise the joint (mobilise later)
What is Perthe’s disease?
If left alone what will happen, over what time frame?
Avascular necrosis of capital femoral epiphysis because of an interruption of blood supply
It revascularises and reossifies itself after 18-36 months
Who is most likely to get Perthe’s disease? Risk factors
Boys (80%) short low birth weight passive smoking low socioeconomic status
Presentation of Perthe’s disease
Unilateral (85%) hip/knee pain
limp
reduced ROM
no Hx of trauma
Roll test - guarding and spasm
X ray changes seen in Perthe’s disease
Sclerosis, fragmentation and flattening of proximal femoral epiphysis
Treatment for Perthe’s disease
Rest, physiotherapy
Surgery maybe if really bad
6 year old boy presents with limp and pain in one hip and knee
he is short and overweight for his age. He was born with a low birth weight, his parents smoke and are unemployed. There is no history of any trauma.
O/E - reduced ROM, guarding on the roll test
X-ray shows sclerosis, fragmentation and flattening of proximal femoral epiphysis
likely diagnosis?
Perthe’s disease
Slipped capital femoral epiphysis - what happens and typically when?
Epiphysis of femoral head displaced postero-inferiorly
Usually at the onset of pubery
Slipped capital femoral epiphysis - who is at highest risk?
Boys (12-15) at onset of puberty with a FHx of SCFE either tall and thin or short and fat association with hyothyroidism/hypogonadism
Slipped capital femoral epiphysis presentation
Pain in hip, thigh, knee which starts as a vague groin pain
weight bearing is painful so limps
reduced abduction and internal rotation at the hip
Suspected slipped capital femoral epiphysis
investigation and treatment
X ray
surgery - pin fixation in situ
13 year old boy presents with limp and painful hip and knee. He is short and fat and has hypothyroidism. Just started puberty
Pain started as a vague groin pain, progressed to pain and caused limp.
Abduction and internal rotation are reduced
likely diagnosis?
Slipped capital femoral epiphysis
What is meant by developmental dysplasia of the hip (DDH)?
An umbrella term - can mean
dysplasia
subluxation
dislocation
What two tests are done to screen for developmental dysplasia of the hip (DDH)?
Barlow manoeuvre - see if hip can be dislocated posteriorly
Ortolani manoeuvre - can hip be relocated, is the hip dislocated
If developmental dysplasia is suspected what should be done?
ultrasound scan of joint
orthopaedics referral
60% correct themselves with no treatment
Neoplasm causing limp - features
pain
1/3 palpable mass
70-92% tenderness
5000 benign: 1 malignant
What is juvenile idiopathic arthritis?
6 weeks+ of joint swelling in child under 16 without any other cause (infective etc)
how can juvenile idiopathic arthritis be classified?
by the number of joints affected
if its psoriatic
presence of rheumatoid factor/HLA B27 etc
features of juvenile idiopathic arthritis
Gelling (joints get stiff after inactivity (car ride))
morning stiffness of joint
pain (or they stop doing things they used to like doing)
fever and salmon rash
chronic anterior uveitis
flexion contractures of joints
growth failure/delayed puberty
juvenile idiopathic arthritis - treatments
NSAIDs - for pain joint injections (with USS guide) methotrexate (nausea common) systemic corticosteroids - avoided where possible though due to effect on growth etc biologics - anti-TNFa etc
juvenile idiopathic arthritis - what will be seen in a blood test
Increased ESR
