MSK disorders Flashcards
What are the paediatric MSK disorders?
Benign - Malignant (severe, progressive, painful, asymmetric) -Malignancy -Non accidentale injury -Infection
How is the paediatric MSK assessed?
pGALS
Gait, Arm, Legs, Spine screen
pREMS
detailed regional examination of MSK
What are the variations of normal posture?
#Genu varum (bow legs) 1-3 years -can be rickets -Osteogenesis imperfecta Blount disease #Genu valgum (knock knees) 2-7 years -JIA #Pes Plans (flat feet) 1-2 years -tarsal fusion #In-toeing 1-2 years -Metatarsus varus -Tibial torsion -Femoral anteversion #Out-toeing 6-12 months -Femoral retroversion -Marfan -Ehler Danlos #Toe walking 1-3 years -spastic diplegia -tight Achilles tendon -JIA -Duchenne muscular dystrophy
What are the causes of abnormal posture?
MSK, Neuro
#Talipes equinovarus (clubfoot) -could be positional talipes (normal and passive correctable) #Vartical talus #Talipes calcaneovalgus -dorsiflexed everted foot -associated with DDH #Pes planus (Flat feet) #Tarsal coalition #Pes cavus -associated with Friedrich ataxia #Developmental dysplasia of the hip #Scoliosis #Troticollis
What are the features of talipes equinovarus?
Foot inverted and supinated
Forefoot adducted
Heel internally rotated and plantation flexed
Shorter foot
Thinner calf muscles
Often bilateral
Fixed in position, can’t fully recorrect passively
What are the causes of CTEV?
1:1000 live births, M>F 2:1 Familial or idiopathic Secondary to oligohydramnios Malformation syndrome Spina bifida Associated with DDH
How is CTEV treated?
Promptly with plaster casting (Ponsetti method)
Surgery last line
What are the causes of torticollis?
#Congenital -Sternomastoid tumor (mobile non tender nodule) resolves in 2-6 months #Acquired -Spasm -ENT infection -Spinal tumor -C-spine defects -Posterior fossa tumor
What is scoliosis?
A lateral curvature in the frontal plant of the spine
What are the causes of scoliosis?
#Idiopathic (most common, mostly late onset, mostly pubertal girls) #Congenital -Hemivertebra -Spina bifida syndromes (VACTERL) #Secondary -CP -Muscular dystrophy -NF -Marfan -LLD from JIA
What is Developmental dysplasia of the hip?
Spectrum of disorders From dysplasia to subluxation to frank dislocation of the hip If missed, will lead to hip dysplasia 1:1000 live births Mostly resolves spontaneously
How is DDH screened in newborns?
Barlow test to check if posteriorly dislocating
Ortolani test to relocate by abducting
Repeat tests at 2 months
Presents later as a limp or abnormal gait
What are the genetic MSK conditions?
#Achondroplasia -AD -50% new mutations #Cleidocranial dysostosis -AD #Marfan syndrome -AD #OI type I -AD
What are the features of Marfan syndrome?
Tall stature Arachnodactyly Hyperextensible joints High arched palate Lens subluxation Myopia Lower segment>upper segment Arm span> height Scoliosis AR, MVP, MR, Aortic aneurysms
What is osteogenesis imperfecta?
Group of disorders of collagen metabolism Causing bone fragility, bowing, pathological fractures Type I most common (AD) -Childhood fractures -Blue sclera -Deafness Rx Bisphosphonates Type II is lethal.
What are the causes of arthritis in children?
Reactive arthritis Septic arthritis JIA Henoch-Schonlein purpura Systemic lupus erythematosus Juvenile dermatomyositis
What are the causes of painful limbs?
Growing pains Hypermobility Complex regional pain syndromes Osteomyelitis Malignancy
How to diagnose growing pains?
3-12 years Pain is symmetrical and not limited to isolated areas Pain not present on waking No limp or disability Otherwise healthy
What are the causes of hyper mobility?
Normal
Marfan
Down
Ehlers-Danlos
What are the red flags in a child with back pain?
Young age High fever Waking up in the night with persistent pain Painful scoliosis Focal neurology (incontinence) Loss of weight, anorexia
What are the causes of back pain in a child?
#Mechanical #Tumors (osteoid osteoma) #Osteomyelitis/discitis of vertebra #Nerve root compression #Spondylolysis/spondylolisthesis #CRPS
What are the causes of acute onset limb pain in children?
#Accidental injury #Non aciidental injury #Osteomyelitis #Malignancies -ALL -Neuroblastoma with mets/arthritis -Osteogenic sarcoma -Ewing tumor #Benign tumor -Osteoid osteoma
What is osteomyelitis?
Infection of the metaphysic of long bones
Commonly the distal femur and proximal tibia
But any bone can be affected
Usually from hematogenous spread
Can be from direct spread or inoculation
What are the causative organisms in osteomyelitis?
S aureus Strep H influenzae Salmonella (in Sickle cell anemia) TB
What are the complications of osteomyelitis?
Chronic osteomyelitis with sinus discharge Bone necrosis Limb deformity Amyloidosis Joint destruction Septic arthritis Subperiosteal abscess Sepsis
How is osteomyelitis managed?
Blood cultures and FBC with CRP and Xray/USS
IV Abx until CRP drops and clinical recovery
Continue PO Abx for several weeks
Aspirate if very grave
Surgical drainage if no response
Splint the limb and mobilise later
What are the causes of a painful knee?
Referred from hip
Local knee
-Osteochondritis of patellar tendon insertion
-Chondromalacia of patellar articular cartilage
-Avascular necrosis of femoral condyles
-Patella subluxation and dislocation
What are the causes of acute painful limp?
#1-3 years -Septic arthritis/osteomyelitis -Transient synovitis -Trauma -ALL/Neuroblastoma #3-10 years -Transient synovitis -Septic arthritis/osteomyelitis -Trauma/overuse -Acute Perthes disease -JIA -ALL -CRPS #11-16 years -Mechanical -Acute slipped capital femoral epiphysis -AVN of femoral head -Reactive arthritis -JIA -Septic arthritis/osteomyelitis -AVN of femoral condyles -Bone tutors/malignancy CRPS
What are the causes of chronic intermittent limp?
#1-3 years DDH CTEV CP JIA #3-10 years Chronic Perthes disease DMD JIA Tarsal coalition #11-16 years Chronic slipped capital femoral epiphysis JIA Tarsal coalition
What are the clinical features of transient synovitis of the hip?
Onset - acute limp, non weight bearing, follows viral infection
Fever - mild/absent
Appearance - Clinically well, 2-12 year olds
Hip movement - Painful on moving, limited internal rotation, no pain at rest
WBC - normal
CRP/ESR - normal, slightly high
USS - effusion
Xray - normal
Management - rest, analgesia
Follow up - resolves within a week
3% may get Perthes’ disease
What are the clinical features of septic arthritis?
Onset - acute limp, non weight bearing
Fever - high
Appearance - Clinically ill looking
Hip movement - held in flexion, pain at rest, worsens on moving
WBC - high
CRP/ESR - high
USS - effusion
Xray - widened joint space
Management - aspiration, antibiotics, rest, analgesia, blood cultures
Follow up - joint destruction if untreated
What is the most common cause of acute hip pain in children?
Transient synovitis
What is Perthes’ disease?
Avascular necrosis of the capital femoral epiphysis of the femoral head due to interruption of blood supply
Followed by revascularisation and reossification over 18-36 months
M>F 5:1
20% bilateral
Insidious limp, hip or knee pain
Xray both hips, can do MRI, bone scan
Prognosis good if <6 years and <50% epiphysis affected
Complications - femoral head deformity, degenerative arthritis
How is Perthes’ disease managed?
Early (hyper dense femoral head)
-bed rest and traction
Late (fragmented irregular femoral head)
-maintain hip in abduction
What is slipped capital femoral epiphysis (SCFE)?
Displacement of the epiphysis of the femoral head postero-inferiorly which can lead to avascular necrosis
Restricted abduction and internal rotation
10-15 years of age
Mostly in obese boys
20% bilateral
Associated with hypothyroidism, hypogonadism
Mx = pin fixation in situ
What are the causes of polyarthritis?
Infection - bacterial, TB, viral, atypical, reactive, RF
IBD - CD, UC
Vasculitis - HSP, Kawasaki disease
Haematological - Hemophilia, SCD
Malignancy - ALL, neuroblastoma
CTD - JIA, SLE, dermatomyositis, MCTD, PAN
Genetic - cystic fibrosis
What are the viruses causing polyarthritis?
Rubella Mumps Adenovirus Coxsackie B Herpes Hepatitis Parvovirus
What is the most common form of arthritis in children?
Reactive arthritis (GI infection, strep infection, RF)
Transient joint swelling < 6 weeks
Ankles or knees, low grade fever
NSAIDs only
Salmonella, Shigella, Capylobacter, Yersinia
Chlamydia, Gonococcus, Mycoplasma, Borrelia
What are the features of septic arthritis?
Most common in <2 years old Acutely unwell child with a joint with acute inflammation Can cause bone destruction Staph aureus (single joint), Hib (multiple joints) Pseudoparesis with hip in flexion, abduction and external rotation
What are the features of SLE in children?
Young pubertal girls
Malaise, arthralgia, malar rash
Kidney, CNS, lung involvement
What are the features of juvenile dermatomyositis?
JDMS is rare
Malaise, proximal myopathy
Facial malar rash over nasal bridge
Heliotrope rash of eyelids
What are the features of HSP?
Most common vasculitis of children Purpuric rash over lower legs and buttocks Ankle or knee arthritis Abdominal pain Hematuria Proteinuria
How is septic arthritis investigated and managed?
FBC, CRP, BCx, Aspiration and USS Bone scan and MRI IV Abx, joint drainage Immobilize then mobilise Analgesia
What is Juvenile Idiopathic Arthritis?
Most common chronic inflammatory joint disease in children
Persistent joint swelling > 6 weeks
Before 16 years of age
In the absence of infection or other causes
95% of cases are different from Rheumatoid arthritis
Affects 1:1000
7 subtypes based of number of affected joints in the first 6 months of the disease
What are the subtypes of JIA?
Polyarthritis (>4 joints) - poor prognosis
Oligoarthritis (4 or less joints) - most common, best prognosis
Systemic (with fever and salmon pink rash) - poor prognosis
Psoriatic
Enthesitis
Undifferentiated
What are the clinical features of JIA?
Gelling (stiffness after rest)
Morning stiffness
Pain
Intermittent limp
Behavioural change and avoidance behaviour
Joint swelling (fluid, inflammation, proliferation)
Bone overgrowth (deformities)
What are the complications of JIA?
Chronic anterior uveitis and blindness Flexion contractures in joints Growth failure Anemia of chronic disease Delayed puberty Osteoporosis Amyloidosis and proteinuria with CKD
How is osteoporosis managed?
Calcium and vit D supplements
Regular weight bearing exercises
Minimise corticosteroid therapy
Bisphosphonates
How is JIA managed?
Goals are to induce remission and prevent deformity and disability Refer to Paed Rheumatology Education and support for child and family Physiotherapy to protect joint function Eye referral Avoid contact sports in active flares NSAIDs during flares IA steroid injections Weekly SC MTX with FBC, LFT monitoring IV Methylprednisolone pulses Biologics in severe cases Joint Xrays ANA and RF and HLAB27
What is the prognosis of JIA?
1:3 will have active disease as adults Joint replacement surgery Vision loss Fractures from osteoporosis Psychosocial effects
What are the features of Systemic JIA?
Fever, salmon pink macular rash LN and HSM Serositis Oligo or poly arthritis Poor prognosis 1:1 male female
What are the features of polyarthritis JIA?
Either RF + or - Females 5 times more likely Symmetrical large and small joints and fingers Rheumatoid nodules in RF + C spine and TMJ joints in RF -
