MSK Disorders Flashcards
What is transient synovitis and who does it tend to affect? What is a red flag which should make you reconsider this Dx?
Irritable hip, usually affects those 3-10 years old (most common cause of hip pain in children)
-> If aged <3 with an acute limp then URGENT hospital assessment is required
How would a child with transient synovitis present and how would you manage them?
Present with:
- Acute hip pain associated with a viral infection
- Low grade fever
Ix and Mx:
- Clinical diagnosis
- Rule out other Dx if queried (pGALS, ESR/CRP, FBC)
- Self limiting
What criteria can be used to distinguish transient synovitis from septic arthritis?
Kocher Criteria:
- > more likely to be septic arthritis if:
- Temperature >38.5 [1]
- Unable to weight bear on limb [1]
- ESR >40 [1]
- WCC >12 [1]
Score of 0 = unlikely SA, 1 = 3% SA risk, 2 = 40%, 3 = 93% and 4 = 100% risk of SA
What is septic arthritis and who does it commonly affect?
Infectious arthritis of the synovial joint (75% cases = hip)
- most common in children <2y
- often presents late
What causes septic arthritis? What are some RFs?
Usually due to haematogenous spread (e.g. puncture around or infected skin lesions)
RFs:
- Arthritis (RhA, Osteoarthritis, Crystal arthritis)
- Joint prosthesis
- Chronic disease, immunosuppression
Organism = usually Staph Aureus [but Salmonella is also associated in those with sickle cell disease]
How may a child with septic arthritis present?
Sx:
- Single joint affected, usually hip
- Painful/tender, red, warm, reduced ROM (infants will hold limb still - pseudoparalysis and cry)
- Acutely unwell, febrile child
How would you investigate and manage a child with suspected septic arthritis?
Ix:
- Septic screen
- Bloods = FBC, CRP/ESR, cultures
- Joint aspiration and MC&S
- Imaging - XR (1st line but not evident until >2-3w of symptoms), MRI (2nd line shows soft tissue and effusions)
Mx:
= Antibiotics -> IV (2w) then Oral (4w)
> 1st line = Flucloxacillin
> 2nd line = Clindamycin (in pen-allergy), Vancomycin (if MRSA caused), 3rd gen cephalosporin e.g. Cefotaxime (if Gram-negative)
+ Joint wash out and aspirated to dryness as required (through closed needle aspiration or athroscopically)
- Surgical drainage may be required
What is JIA or Still’s disease?
JIA = juvenile idiopathic arthritis where there is persistent joint swelling (6w+) presenting in this aged <16, in the absence of infection/other defined cause
- > 95% have disease distinct from adult RhA
- > 1/1000 children affected
How is JIA classified? How may a child present with JIA and Still’s disease?
7 clinical subtypes which is based on number of joints affected in first 6 months and presence of HLA B27 and RhF
- Polyarthritis = >4 joints
- Oligoarthritis = less than or =4
- Systemic with fever and rash = Still’s*
Sx:
> Gelling (stiffness following rest periods)
> Morning stiffness and joint pain
> Intermittent limp
> Limited movement
*late signs:
» inflammation +/- bone expansion i.e. knock knees)
» SALMON coloured macular rash (systemic JIA)
» intermittent fever
» Visual impairment - chronic anterior uveitis
» Swan neck deformity and hand problems
How would you investigate a child with suspected JIA?
Ix:
- Clinical Dx
- Bloods (FBC, CRP/ESR, ANA, RhF, anti-CCP)
- Imaging (classification and prognosis) -> USS +/- MRI
How would you manage a child with JIA?
Mx:
- > MDT rheumatology approach
- OT and PT involvement as inactivity leads to disability and decreased bone mass
- > Analgesia (NSAIDs)
- > I Intra-articular, oral or IV corticosteroids are useful adjunctive agents (whilst waiting for second-line agents to have an effect) – avoided if possible due to risk of growth suppression and osteoporosis!!
- > DMARDs e.g. oral/SC methotrexate or 2nd line is sulfasalazine
- > Biologics e.g. anti-TNF
Prognosis:
- Most children can expect good disease control and QoL
- Poor control leads to significant morbidity from joint damage (fractures from osteoporosis) and visual impairment (anterior uveitis)
- Ensure growth is occurring, no anaemia etc
What is reactive arthritis and some common causative organisms?
Reactive arthritis is an inflammatory arthritis occurring after exposure to particular genitourinary or GI infections.
Preceding common causes:
- > Enteric bacteria (salmonella, shigella, campylobacter, Yersinia)
- > Viral infections
- > STIs (in adolescents)
How would a patient present with reactive arthritis?
Sx:
- > Transient joint swelling (<6w), often the ankles or knees
- > Follows evidence of extra-articular infection
- > Low-grade fever
- > May also have urethritis, conjunctivitis
How would you investigate and manage a child with reactive arthritis?
Ix:
- > Dx of exclusion
- > Normal XR
- > Bloods show normal/mildly elevated CRP
Mx:
- > NSAIDs/Analgesia
- > Self-limiting
What is SUFE and who does it tend to affect?
SUFE = slipped upper femoral epiphysis
- > Displacement of the epiphysis/femoral head posterio-inferiorly
- > requires prompt treatment to prevent avascular necrosis
- > Affects those aged 10-15y i.e. during growth spurts
- > 20% cases are bilateral
- > RF = OBESITY, male, metabolic/endocrine disease
