MSK disorders Flashcards
What is genu varum?
Bow legs.
The normal toddler has a broad-based gait.
A pathological cause is rickets.
What is pes planus?
Flat feet, common in toddlers.
Marked flat feet is common in hypermobility.
What are the presenting symptoms of DDH if it is not detected on neonatal screening?
Limp or abnormal gait
Asymmetry of skin folds around the hip.
Limited abduction of the hip
Shortening of the affected leg
What is scoliosis?
Lateral curvature in the frontal plane of the spine
What are the causes of scoliosis?
Idiopathic
Congenital
Secondary (neuromuscular imbalance e.g. cerebral palsy, muscular dystrophy
What are the clinical features of scoliosis?
Irregular skin creases and difference in shoulder height.
How do you treat scoliosis?
Mild - self-resolving
Bracing should be considered
If severe, surgery
What are the clinical features of growing pains?
Age 3-12 years.
Pains symmetrical in lower limbs and not limited to joints.
Pain never present at the start of the day after waking.
Physical activités not limited; no limp
Physical exam normal and otherwise well
What is genu valgum?
Knock knees - the feet are wide apart when standing with the knees held together. It is seen in many young children and usually resolves spontaneously
What are the three features of in-toeing?
Metatarsus varus (front part of the foot points inwards)
Medial tibial torsion (inward twisting of the tibia)
Persistent anteversion of the femoral neck (inward twisting of the thigh bone)
What is the differential to consider in bow legs?
Rickets
Osteogenesis imperfecta
What is the differential to consider in knock knees?
Juvenile idiopathic arthritis
What is the differential to consider in flat feet?
Hypermobility
What are the differentials to consider in in-toeing?
Tibial torsion, femoral anteversion
What are the differentials to consider in out-toeing?
Hypermobility
Ehlers-Danls
Marfans
What are the differentials to consider in toe walking?
Spastic diplegia (CP)
Muscular dystrophy
Juvenile idiopathic arthritis
What is talipes equinovarus?
Clubfoot.
The entire foot is inverted and supinated, the forefoot adducted and the heel is rotated inwards and in plantar flexion. The affected foot is shorter and the calf muscles thinner than normal
Is talipes equinovarus often bilateral and can you fix it?
The foot is fixed, it cannot be corrected completely.
It is often bilateral
What are the risk factors for talipes equinovarus?
Being male Familial link Oligohydramnios Neuromuscular disorder such as spina bifida DDH
How do you treat talipes equinovarus?
Treatment is started promptly with plaster casting and bracing (Ponsetti method) which may be required for many months.
What is the role of US in DDH?
Allows detailed assessment
Quantifies the degree of dysplasia
Whether there is subluxation or dislocation
What are the pathological clinical features of hypermobility?
MSK pain mainly confined to the lower limbs, often worse after exercise
How do you treat hypermobility?
Advice about footwear
Exercises
Occasionally orthotics
What disorders are associated with hypermobility?
Down syndrome
Ehlers-Danlos syndrome
What is osteomyelitis?
Infection of the metaphysis of long bones. The skin is swollen directly over the affected site
What are the most common sites for osteomyelitis?
Distal femur and proximal tibia
How does osteomyelitis spread?
Usually due to haematogenous spread of the pathogen, but may arise by direct spread from an infected wound.
What pathogens often cause osteomyelitis?
Staph aureus predominantly
Also strep and h.influenzae if not immunised
How does osteomyelitis often present?
Markedly painful, immobile limb (pseudoparesis) in a child with an acute febrile illness.
Directly over the infected site there is swelling and exquisite tenderness, and it may be erythematous and warm.
Moving the limb causes severe pain
Could present with back pain in a vertebral infection or with a limp or groin pain in infection of the pelvis
What would investigations show in osteomyelitis?
Cultures: positive
Bloods: raised WCC and acute phase reactants
X-rays: initially normal, takes 7-10 days to show
MRI: identification of infection in the bone
Radionuclide bone scan: may be helpful if infection site is unclear
How would you treat osteomyelitis?
Prompt treatment with parenteral antibiotics required for several weeks to prevent bone necrosis, chronic infection, limb deformity and amyloidosis.
Surgery may be needed in atypical or immunodeficient children.
The affected limb is initially rested in a splint and subsequently mobilised.
What are the red flag clinical features of back pain?
Young age
High fever - infection
Night waking, persistent pain - osteoid osteomalacia or tumours
Painful scoliosis - infection or malignancy
Focal neurological signs - nerve root/ spinal cord compression
Associated weight loss, systemic malaise - malignancy
What are the different causes of back pain in children?
Mechanical causes Tumours: benign or malignant Vertebral osteomyelitis or disci tis Spinal cord or nerve root entrapment Scheuermann disease Spondylolysis Complex regional pain syndrome
What are the main causes of acute painful limp in 1-3 year olds?
Infection - septic arthritis, osteomyelitis of hip or spine
Transient synovitis
Trauma (NAI)
Malignant disease - leukaemia, neuroblastoma
What are the main causes of chronic or intermittent limp in 1-3 year olds?
DDH, talipes
Neuromuscular (CP)
JIA
What are the main causes of acute painful limp in 3-10 year olds?
Transient synovitis Septic arthritis/osteomyelitis Trauma and overuse injuries Perthes disease JIA Malignant disease (leukaemia) Complex regional pain syndrome
What are the main causes of chronic or intermittent limp in 3-10 year olds?
Neuromuscular disorders (Duchenne muscular dystrophy) JIA
What are the main causes of acute painful limp in 11-16 year olds?
Mechanical Slipped capital femoral epiphysis Avascular necrosis of the femoral head Reactive arthritis JIA Septic arthritis/osteomyelitis Bone tumours and malignancy Complex regional pain syndrome
What are the main causes of chronic or intermittent limp in 11-16 year olds?
Slipped capital femoral epiphysis
JIA
What is transient synovitis?
Inflammation of the inner lining (the synovium) of the capsule of the hip
At what age does transient synovitis present and after what?
2-12 year olds either accompanied of following a viral infection
How does transient synovitis present?
Sudden onset of pain in the hip or a limp. There is no pain at rest, but there is decreased range of movement, particularly internal rotation. The pain may be referred to the knee. The child is afebrile or has a mild fever and does not appear ill
How do you manage transient synovitis?
Bed rest, it usually improves within a few days
What is perthes disease?
Avascular necrosis of the capital femoral epiphysis of the femoral head due to interruption of the blood supply, followed by revascularisation and reostification over 18-36 months
What age and gender most likely to get perthes disease?
Mainly affects boys of 5-10 years of age,
How does perthes disease usually present?
Insidiously, with the onset of a limp, or hip or knee pain.It is bilateral in 10-20%
What investigation should be ordered if you suspect perthes disease and what would you find?
X-ray of both hips, early signs of perthes include increased density of the femoral head, which subsequently becomes fragmented and irregular
What is the treatment for perthes disease?
Early diagnosis - bed rest and traction
Severe/late diagnosis - the femoral head needs to be covered by the acetabulum to act as a mould for the re-ossifying epiphysis and is achieved by maintaining the hip in abduction with plaster or calipers
What is the consequence of a slipped capital femoral epiphysis?
It results in the displacement of the epiphysis of the femoral head postern-inferiorly requiring prompt treatment in order to prevent avascular necrosis
What age is a slipped capital femoral epiphysis most common and in what type of child?
10-15 years during the adolescent growth spurt, particularly in obese boys and is bilateral in 20%.
How does slipped capital femoral epiphysis present?
Limp or hip pain, which may be referred to the knee. The onset may be acute following minor trauma or insidious.
What would you find on examination of a slipped capital femoral epiphysis?
Restricted adduction and internal rotation of the hip
How do you treat slipped capital femoral epiphysis?
Management is surgical, usually with pin fixation in situ
What are the causes of polyarthritis?
Infection
IBD
Vasculitis (HSP, Kawasakis)
Haematological disorders (Haemophilia, sickle cell)
Malignant disorders (leukaemia, neuroblastoma)
Connective tissue disorders (JIA, SLE, polyarteritis nodosa)
Cystic fibrosis
What is reactive arthritis?
Transient joint swelling often in the ankles or knees, usually following an extra-articular infection.
Which organisms usually cause reactive arthritis at different ages?
The enteric bacteria often in children
Viral (STIs) in adolescents
What would the investigations show in reactive arthritis and how is it managed?
Low grade fever. X-rays and bloods usually normal.
Only NSAIDs are required and complete recovery can be anticipated
What age is septic arthritis most common?
<2 years
Is septic arthritis monoarthritis or polyarthritis?
Usually mono, a hip being particular concern in children
How does septic arthritis usually present?
Erythematous, warm, acutely tender joint, with a reduced range of movement, in an acutely unwell, febrile child. Often hold the limb still and cry if it is moved. Initial presentation may be with a limp or pain referred to the knee.
What would the investigations show in septic arthritis?
Increased WCC and acute-phase reactants.
Cultures must be taken.
US to identify an effusion.
X-rays to exclude trauma and other bony lesions.
X-rays initially normal apart from widening of the joint space and soft tissue swelling.
ASPIRATION OF THE JOINT SPACE UNDER US GUIDANCE FOR ORGANISMS AND CULTURE IS THE DEFINITIVE INVESTIGATION.
How would you treat septic arthritis?
A prolonged course of antibiotics is required, initially IV.
May need surgical drainage.
The joint is initially immobilised in a functional position, but subsequently must be mobilised to prevent permanent deformity.
What is JIA?
Persistent joint swelling (of >6 weeks) presenting before 16 years old in the absence of infection of any other defined cause.
How do you classify JIA?
Clinically and based on the number of joints affected in the first 6 months, as polyarthritis (>4) and oligoarthritis (<4) or systemic (with fever and rash). Subtyping is further classified according to the prescence of rheumatoid factor and HLA B27 tissue type.
What are the clinical features of JIA?
Gelling (stiffness after periods of rest), morning joint stiffness and pain. In the young child it may present with intermittent limp or deterioration in behaviour, mood or avoidance of previously enjoyed activities, rather than complaining of pain
What would you find on examination of JIA?
Swelling of the joint due to fluid within it, inflammation and it chronic JIA, proliferation (thickening) of the synovium and swelling of the periarticular soft tissues
What are the long-term examination findings of JIA?
Bone expansion from overgrowth, which in the knee may cause leg lengthening or valves deformity in the hands, discrepancy in digit length, and in the wrist, advancement of bone age.
What are the complications of JIA?
Chronic anterior uveitis Flexion contractors of the joints Growth failure Constitutional problems Osteoporosis Amyloidosis
How would you treat JIA?
NSAIDs Joint injections Methotrexate Systemic corticosteroids Cytokine modulators (anti-TNF)
What are the differential diagnoses for nocturnal wakening with leg pain?
Growing pains
Osteoid osteoma
Leukaemia, lymphoma, neuroblastoma
What are the differential diagnoses for febrile, toxic-looking infant, irritability with nappy changing?
Septic arthritis
Osteomyelitis
What are the differential diagnoses for sudden limp in an otherwise well young child?
Transient synovitis of the hip
Perthes disease
What are the differential diagnoses for fever, erythematous rash, red eyes, irritability in infant or young child?
Kawasaki’s disease
What are the differential diagnoses for irritability, fever, reluctance to move in an infant or young child?
Discitis
Vertebral osteomyelitis
What are the differential diagnoses for joint pain, stiffness and restriction with loss of joint function?
JIA
What are the differential diagnoses for hip pain in an obese adolescent boy?
Slipped capital fermoral epiphysis
What are the differential diagnoses for lethargy, unwilling to do physical activity, irritability, rash?
Juvenile dermatomyositis
What are the differential diagnoses for constitutional symptoms, lethargy, arthralgia in an adolescent female?
SLE
