MSK Disorders Flashcards
What is a single painful swollen joint until proven otherwise?
Septic arthritis
Inttial management of someone with a single painful swollen joint
send to paeds A&E urgently for further assessment and management
Most common organism in septic arthritis
Most common organism is staphylococcus aureus
Investigations for septic arthritis
Bedside – basic obs, examination (look for local trauma)
Bloods – FBC, U+E, blood cultures,
Imaging/other – joint aspiration (in theatre, purulent), XR or MRI considered
Most important investigations in septic arthritis
Blood cultures + joint aspiration
Management of septic arthritis
Broad spectrum ABX according to Trust policy then switch to pathogen targeted after consulting micro for advice –> Usually IV course followed by several weeks of oral medication
Analgesia for pain
Refer to orthopaedics if complications arise
What is the most common chronic joint disease of childhood?
Juvenile idiopathic arthritis
How to diagnosis JIA?
Diagnosis of exclusion
Inflammation of one or more joints lasting at least 6 weeks in a child under 16 years of age where all other differentials have been ruled out.
Clinical features of JIA
Joint pain and swelling
Stiffness with rest (particularly in the mornings)
Fatigue
Rash
Fever
What is the specific fever pattern in JIA?
Spiking fever in quotidian pattern
What is the pathognomonic rash seen in JIA?
Salmon pink rash
Investigations for JIA
Bedside
Urine Dipstick (to check for evidence of glomerulonephritis that may suggest underlying vasculitic condition)
Bloods
Autoimmune Screen (ANCA, ANA, anti-dsDNA, anti-CCP)
What marker may be raised in JIA?
ANA
Management of JIA
Requires specialist paediatric rheumatology input
Regular physiotherapy input
Analgesia (usually NSAIDs)
Steroids may be used as adjuncts
DMARDs (e.g. methotrexate)
Biologic Agents (e.g. TNF-alpha inhibitors)
Most children respond well to treatment
What is the most common cause of acute hip pain in children? What is it often associated with?
Transient synovitis
Often associated with a preceding viral infection
Clinical features of transient synovitis
Acute-onset hip pain
Limp
Symptoms of viral infection (usually URTI)
Investigations for transient synovitis
Primarily a clinical diagnosis
Ultrasound may demonstrate a joint effusion
Joint aspiration if there is any concern about septic arthritis
What diagnosis MUST you exclude before diagnosing transient synovitis?
Septic arthritis
Management of transient synovitis
Rest
Analgesia (paracetamol and/or NSAIDs)
Often resolves within days
NOTE: NICE says if child is well, afebrile, sx <72h, then can be considered for community management
What does reactive arthritis present with? How do you remember this?
Triad of arthritis, urethritis, and conjunctivitis
“can’t see, can’t pee, can’t climb a tree”
What is reactive arthritis? What does it occur after?
Inflammatory arthritis that occurs 1-4w post genitourinary or GI ix
What diagnosis must be excluded before diagnosing septic arthritis?
septic arthriits
Management of reactive arthritis
Supportive + pain managment
What is ehler danlos syndrome?
Autosomal dominant condition that affects Type 3 collagen
Genetic inheritance of ehler danlos syndrome
AD
What is affected in ehler danlos syndrome? What does this lead to?
Autosomal dominant condition that affects Type 3 collagen
Tissue is more elastic resulting in joint hypermobility and elasticity of skin
When to suspect ehler danlos syndrome?
If recurrent joint dislocation occurs
What conditions are associated with ehler danlos syndrome?
Associated conditions: aortic regurgitation, mitral valve prolapse, aortic dissection, easy bruising, subarachnoid haemorrahge
What is SUFE? Who is it more common in?
Displacement of the femoral head epiphysis posteriorly and inferiorly.
More common in male and obese children.
Clinical features of SUFE
Gradual-onset hip pain
It may also manifest with knee pain (referred from the hip)
Limp
What to consider if child presents with knee pain?
Pain is referred from the hip
How does SUFE present on investigation?
Loss of internal rotation when leg is flexed
Investigations for SUFE
AP and lateral frog-leg views bilaterally
Management of SUFE
Internal fixation with cannulated screw
What sign may be seen on XRay with SUFE?
Threthowan’s sign
What is Perthe’s disease? Who is it more common in?
Disorder of the hip characterised by avascular necrosis of the femoral head
More common in boys
Presentation of Perthe’s disease
Gradual-onset hip pain
Some patients may present with knee pain (referred from the hip)
Limp
redcued ROM
Investigations for Perthre’s disease
XR bilaterally shows widened joint space, and later a small/flat femoral head
Management of perthe’s disease if <5 years
Simple analgesia + mobilisation and monitoring
Management of Perthe’s disease if >5 years
simple analgesia + may consider surgical containment, or the salvage procedure (remodelling of the acetabulum)
Salvage procedure
Remodelling of the acetabalum
Used in children >5 with perthe’s disease
What is DDH? What does it lead to an increased risk of?
An abnormality of the hip joint in which the acetabulum is shallow and does not fully cover the head of the femur. Leads to an increased risk of joint dislocation.
RFs for DDH
female (6x), breech, FHx, oligohydramnios, LBW, multiple pregnancy
When is DDH usually picked up?
In neonatal screening, or in NIPE. See a Positive Ortolani test
+ Positive Barlow test
Which tests are positive in DDH? What’s the difference between them?
Barlow + Ortolani
Barlow –> attempts to use posterior force + adduction to dislocate
Ortolani –> attempts to use anterior force + abduction to relocate
What may patients with DDH present with if missed on neonatal screening?
abnormal gait, leg length discrepancy, ASYMETRICAL SKIN FOLDS
Investigations for DDH
All infants screened at newborn exam + 6week check with Barlow and Ortolani’s → ortho referral with US in 2-4w
Some infants require routine US scanning if B+O negative in 4-6w:
1st degree FHx of early hip problems
Breech 36w+ gestation regardless of px at birth or MOD
Multiple pregnancy
Which infants still require routine US scanning for DDH even if Barlow and Ortolani tests are normal? When is this carried out?
1st degree FHx of early hip problems
Breech 36w+ gestation regardless of px at birth or MOD
Multiple pregnancy
Carried out in 4-6 weeks
What imaging is done in DDH?
Ultrasound of hips (if 6 weeks-6 months)
Hip X-ray (>6 months)
Management of DDH
depends on the age
Most unstable hips will spontaneously stabilise by 3-6 weeks of age
Pavlik harness (dynamic flexion-abduction orthosis) in children younger than 4-5 months
Older children may require surgery
What is chondromalacia patellae?
Knee condition characterised by inflammation of the cartilage on the under-side of the patella.
Clinical features of chondromalacia patellae
Common in teenage girls
Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
Management of chondromalacia patellae
Simple analgesia (Paracetamol and/or NSAIDs)
Physiotherapy
What is os-good schlatter disease? WHo does it typically affect?
Common condition involving the knee joint caused by inflammation of the patellar ligament at its insertion into the tibial tuberosity.
Typically affects physically active adolescents.
How does osgood-schlatter disease present?
Knee pain
Worse after exercise
Swelling and tenderness over tibial tuberosity
Management of osgood schlatter disease
Analgesia
Paracetamol and/or NSAIDs
Application of ice packs over tibial tuberosity
Consider reducing or stopping all sporting activity whilst the pain abates
Consider recommending a change in the type of activity (I.e. avoiding activities that involve running and jumping)
What is osteochondritis dissecans? Who does it affect?
Joint condition characterised by avascular necrosis of subchondral bone. Fragments of bone and cartilage can then break loose and cause joint pain and dysfunction.
Most commonly affects the knee joint and is more common in children and adolescents.
Clinical features of osteochondritis dissecans
Joint pain and swelling
Patients may describe a sensation of locking within the knee joint and may complain that the knee feels like it ‘gives way’
Joint crepitus
Management of osteochondritis dissecans
Most cases resolve with rest and simple analgesia
Surgery may be performed in some cases where the symptoms fail to resolve with rest
anterior knee pain on walking up and down stairs and rising from prolonged sitting
chondromalacia patellae
Pain, tenderness and swelling over the tibial tubercle
Osgood-schlatter disease
Intermittent swelling and locking of knee joint
Osteochondritis dissecans
Clinical features of patellar subluxation
Medial knee pain due to lateral subluxation of the patellaKnee may give way
Clinical features of patellar tendonitis
More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination
What is talipes equinovarus? AKA?
Congenital defect characterised by inversion and supination of the foot usually resulting from intrauterine compression.
Also known as clubfoot.
talipes equinovarus
clubfoot
Clinical features of talipes equinovarus
Inverted and supinated foot
May be bilateral
Management of talipes equinovarus
Passive manipulation
Using plaster casting and bracing (Ponseti method)
May require physiotherapy input
Surgery in cases that fail to improve with manipulation
Ponseti method
Passive manipulation using plaster casting and bracing for clubfoot
What is the most common bone cancer in children? Where does it most often affect?
Osteosarcoma
Most common in the knee (60%)
What is seen in Xray in osteosarcoma?
XR – sunburst appearance, elevated periosteum (Codman’s triangle)
What is the most common bone cancer in adolsecents? Where does it present?
Ewing’s sarcoma
HIGHLY MALIGNANT, in long bones and pelvis
What is seen on Xray in Ewing’s sarcoma?
onion skinng periostium
What is osteomyelitis? Most common organism?
Bone infection, staph aureus
Presentation of osteomyelitis
warmth over bone, local pain/swelling, febrile
Investigations of osteomyelitis
blood culture, bone biopsy, MRI
Management of osteomyelitis
IV abx according to trust policy
What is Achrondoplasia? What is affected ?
Autosomal dominantdisorder associated with short stature.
Caused by a mutation (70% sporadic) in the fibroblast growth factor receptor 3 (FGFR-3) gene = abnormal cartilage
Genetic inheritance of achrondoplasi
AD
Mutation that is seen in achrondoplasia
Caused by a mutation (70% sporadic) in the fibroblast growth factor receptor 3 (FGFR-3) gene = abnormal cartilage
Presentaiton of achrondoplasia
short limbs (rhizomelia) with shortened fingers (brachydactyly)
large head with frontal bossing and narrow foramen magnum
midface hypoplasia with a flattened nasal bridge
‘trident’ hands
lumbar lordosis
THINK: Tyrian Lannister (Peter Dinkage)
Trident hands, lumbar lordosis, frontal bossing
Achrondoplasia
What is Rickets due to? What is it called in adults?
It is usually due to vitamin D deficiency. In adults, the equivalent condition is termed osteomalacia
RFs for rickets
Ca deficiency (malnutrition), unsupplemented cow’s milk formula, lack of sunlight
Presentation of rickets
genu varum (bow legs) in toddlers, genu valgum (knock knees) in older children, aching bones/joints,
genu varum
bow legs, seen in toddlers
genu valgum
knock kness, seen in older children
