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Paediatrics > MSK disorders > Flashcards

MSK disorders Flashcards

1
Q

What are the paediatric MSK disorders?

A 
Benign
-
Malignant (severe, progressive, painful, asymmetric)
-Malignancy
-Non accidentale injury
-Infection
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2
Q

How is the paediatric MSK assessed?

A

pGALS
Gait, Arm, Legs, Spine screen
pREMS
detailed regional examination of MSK

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3
Q

What are the variations of normal posture?

A 
#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
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4
Q

What are the causes of abnormal posture?

MSK, Neuro

A 
#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
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5
Q

What are the features of talipes equinovarus?

A

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

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6
Q

What are the causes of CTEV?

A 
1:1000 live births, M>F 2:1
Familial or idiopathic
Secondary to oligohydramnios
Malformation syndrome
Spina bifida
Associated with DDH
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7
Q

How is CTEV treated?

A

Promptly with plaster casting (Ponsetti method)

Surgery last line

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8
Q

What are the causes of torticollis?

A 
#Congenital
-Sternomastoid tumor (mobile non tender nodule)
resolves in 2-6 months
#Acquired
-Spasm
-ENT infection
-Spinal tumor
-C-spine defects
-Posterior fossa tumor
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9
Q

What is scoliosis?

A

A lateral curvature in the frontal plant of the spine

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10
Q

What are the causes of scoliosis?

A 
#Idiopathic (most common, mostly late onset, mostly pubertal girls)
#Congenital
-Hemivertebra
-Spina bifida syndromes (VACTERL)
#Secondary
-CP
-Muscular dystrophy
-NF
-Marfan
-LLD from JIA
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11
Q

What is Developmental dysplasia of the hip?

A 
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
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12
Q

How is DDH screened in newborns?

A

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

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13
Q

What are the genetic MSK conditions?

A 
#Achondroplasia
-AD
-50% new mutations
#Cleidocranial dysostosis
-AD
#Marfan syndrome
-AD
#OI type I
-AD
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14
Q

What are the features of Marfan syndrome?

A 
Tall stature
Arachnodactyly
Hyperextensible joints
High arched palate
Lens subluxation
Myopia
Lower segment>upper segment
Arm span> height
Scoliosis
AR, MVP, MR, Aortic aneurysms
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15
Q

What is osteogenesis imperfecta?

A 
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.
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16
Q

What are the causes of arthritis in children?

A 
Reactive arthritis
Septic arthritis
JIA
Henoch-Schonlein purpura
Systemic lupus erythematosus
Juvenile dermatomyositis
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17
Q

What are the causes of painful limbs?

A 
Growing pains
Hypermobility
Complex regional pain syndromes
Osteomyelitis
Malignancy
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18
Q

How to diagnose growing pains?

A 
3-12 years
Pain is symmetrical and not limited to isolated areas
Pain not present on waking
No limp or disability
Otherwise healthy
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19
Q

What are the causes of hyper mobility?

A

Normal
Marfan
Down
Ehlers-Danlos

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20
Q

What are the red flags in a child with back pain?

A 
Young age
High fever
Waking up in the night with persistent pain
Painful scoliosis
Focal neurology (incontinence)
Loss of weight, anorexia
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21
Q

What are the causes of back pain in a child?

A 
#Mechanical
#Tumors (osteoid osteoma)
#Osteomyelitis/discitis of vertebra
#Nerve root compression
#Spondylolysis/spondylolisthesis
#CRPS
22
Q

What are the causes of acute onset limb pain in children?

A 
#Accidental injury
#Non aciidental injury
#Osteomyelitis
#Malignancies
-ALL
-Neuroblastoma with mets/arthritis
-Osteogenic sarcoma
-Ewing tumor
#Benign tumor
-Osteoid osteoma
23
Q

What is osteomyelitis?

A

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

24
Q

What are the causative organisms in osteomyelitis?

A 
S aureus
Strep
H influenzae
Salmonella (in Sickle cell anemia)
TB
25
Q

What are the complications of osteomyelitis?

A 
Chronic osteomyelitis with sinus discharge
Bone necrosis
Limb deformity
Amyloidosis
Joint destruction
Septic arthritis
Subperiosteal abscess
Sepsis
26
Q

How is osteomyelitis managed?

A

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

27
Q

What are the causes of a painful knee?

A

Referred from hip
Local knee
-Osteochondritis of patellar tendon insertion
-Chondromalacia of patellar articular cartilage
-Avascular necrosis of femoral condyles
-Patella subluxation and dislocation

28
Q

What are the causes of acute painful limp?

A 
#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
29
Q

What are the causes of chronic intermittent limp?

A 
#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
30
Q

What are the clinical features of transient synovitis of the hip?

A

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

31
Q

What are the clinical features of septic arthritis?

A

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

32
Q

What is the most common cause of acute hip pain in children?

A

Transient synovitis

33
Q

What is Perthes’ disease?

A

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

34
Q

How is Perthes’ disease managed?

A

Early (hyper dense femoral head)
-bed rest and traction
Late (fragmented irregular femoral head)
-maintain hip in abduction

35
Q

What is slipped capital femoral epiphysis (SCFE)?

A

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

36
Q

What are the causes of polyarthritis?

A

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

37
Q

What are the viruses causing polyarthritis?

A 
Rubella
Mumps
Adenovirus
Coxsackie B
Herpes
Hepatitis
Parvovirus
38
Q

What is the most common form of arthritis in children?

A

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

39
Q

What are the features of septic arthritis?

A 
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
40
Q

What are the features of SLE in children?

A

Young pubertal girls
Malaise, arthralgia, malar rash
Kidney, CNS, lung involvement

41
Q

What are the features of juvenile dermatomyositis?

A

JDMS is rare
Malaise, proximal myopathy
Facial malar rash over nasal bridge
Heliotrope rash of eyelids

42
Q

What are the features of HSP?

A 
Most common vasculitis of children
Purpuric rash over lower legs and buttocks
Ankle or knee arthritis
Abdominal pain
Hematuria
Proteinuria
43
Q

How is septic arthritis investigated and managed?

A 
FBC, CRP, BCx, Aspiration and USS
Bone scan and MRI
IV Abx, joint drainage
Immobilize then mobilise
Analgesia
44
Q

What is Juvenile Idiopathic Arthritis?

A

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

45
Q

What are the subtypes of JIA?

A

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

46
Q

What are the clinical features of JIA?

A

Gelling (stiffness after rest)
Morning stiffness
Pain
Intermittent limp
Behavioural change and avoidance behaviour
Joint swelling (fluid, inflammation, proliferation)
Bone overgrowth (deformities)

47
Q

What are the complications of JIA?

A 
Chronic anterior uveitis and blindness
Flexion contractures in joints
Growth failure
Anemia of chronic disease
Delayed puberty
Osteoporosis
Amyloidosis and proteinuria with CKD
48
Q

How is osteoporosis managed?

A

Calcium and vit D supplements
Regular weight bearing exercises
Minimise corticosteroid therapy
Bisphosphonates

49
Q

How is JIA managed?

A 
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
50
Q

What is the prognosis of JIA?

A 
1:3 will have active disease as adults
Joint replacement surgery
Vision loss
Fractures from osteoporosis
Psychosocial effects
51
Q

What are the features of Systemic JIA?

A 
Fever, salmon pink macular rash
LN and HSM
Serositis
Oligo or poly arthritis
Poor prognosis
1:1 male female
52
Q

What are the features of polyarthritis JIA?

A 
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 -

Paediatrics (12 decks)

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