MSK conditions - limps

Question 1

What is a toddler’s fracture

Answer 1

Spiral fracture of distal tibia
Usually from a simple ground level fall
Usually preschool

Question 2

Presentation of toddler’s fracture

Answer 2

Local tenderness on tibia

child may limp/not weight bear

Question 3

Treatment for toddlers fracture

Answer 3

Cast for 5-6 weeks

Question 4

Child presents with a limp and local tenderness on tibia.
They fell over at ground level and are preschool age.
Likely diagnosis?

Answer 4

Toddler’s fracture

Question 5

What is transient synovitis?

Presentation

Answer 5

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

Question 6

Treatment for irritable hip?

Answer 6

Rest
? physio
?NSAIDs

Question 7

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?

Answer 7

Irritable hip/transient synovitis

Question 8

What is septic arthritis and how does it usually come on? Most likely causative organism?
Age group most affected?

Answer 8

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

Question 9

How does septic arthritis present?

Answer 9

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

Question 10

Investigations for clinically suspected septic arthritis

Answer 10

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

Question 11

What are Kocher’s criteria?

Answer 11

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

Question 12

Treatment of septic arthritis

Answer 12

IV antibiotics
?wash out joint/surgical drainage
?immobilise joint in short term - to be mobilised later

Question 13

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?

Answer 13

Septic arthritis
4/4 Kocher’s criteria
(Fever >38.5, Can’t weight bear, ESR >40 in first hour, White cells > 12)

Question 14

Treatment of septic arthritis

Answer 14

IV antibiotics
Wash out joint/surgical drainage
Temporarily immobilise the joint (mobilise later)

Question 15

What is Perthe’s disease?

If left alone what will happen, over what time frame?

Answer 15

Avascular necrosis of capital femoral epiphysis because of an interruption of blood supply
It revascularises and reossifies itself after 18-36 months

Question 16

Who is most likely to get Perthe’s disease? Risk factors

Answer 16

Boys (80%)
short
low birth weight
passive smoking
low socioeconomic status

Question 17

Presentation of Perthe’s disease

Answer 17

Unilateral (85%) hip/knee pain
limp
reduced ROM
no Hx of trauma

Roll test - guarding and spasm

Question 18

X ray changes seen in Perthe’s disease

Answer 18

Sclerosis, fragmentation and flattening of proximal femoral epiphysis

Question 19

Treatment for Perthe’s disease

Answer 19

Rest, physiotherapy

Surgery maybe if really bad

Question 20

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?

Answer 20

Perthe’s disease

Question 21

Slipped capital femoral epiphysis - what happens and typically when?

Answer 21

Epiphysis of femoral head displaced postero-inferiorly

Usually at the onset of pubery

Question 22

Slipped capital femoral epiphysis - who is at highest risk?

Answer 22

Boys (12-15)
at onset of puberty 
with a FHx of SCFE
either tall and thin or short and fat
association with hyothyroidism/hypogonadism

Question 23

Slipped capital femoral epiphysis presentation

Answer 23

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

Question 24

Suspected slipped capital femoral epiphysis

investigation and treatment

Answer 24

X ray

surgery - pin fixation in situ

Question 25

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?

Answer 25

Slipped capital femoral epiphysis

Question 26

What is meant by developmental dysplasia of the hip (DDH)?

Answer 26

An umbrella term - can mean
dysplasia
subluxation
dislocation

Question 27

What two tests are done to screen for developmental dysplasia of the hip (DDH)?

Answer 27

Barlow manoeuvre - see if hip can be dislocated posteriorly

Ortolani manoeuvre - can hip be relocated, is the hip dislocated

Question 28

If developmental dysplasia is suspected what should be done?

Answer 28

ultrasound scan of joint
orthopaedics referral

60% correct themselves with no treatment

Question 29

Neoplasm causing limp - features

Answer 29

pain
1/3 palpable mass
70-92% tenderness
5000 benign: 1 malignant

Question 30

What is juvenile idiopathic arthritis?

Answer 30

6 weeks+ of joint swelling in child under 16 without any other cause (infective etc)

Question 31

how can juvenile idiopathic arthritis be classified?

Answer 31

by the number of joints affected
if its psoriatic
presence of rheumatoid factor/HLA B27 etc

Question 32

features of juvenile idiopathic arthritis

Answer 32

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

Question 33

juvenile idiopathic arthritis - treatments

Answer 33

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

Question 34

juvenile idiopathic arthritis - what will be seen in a blood test

Answer 34

Increased ESR