MSK Presentations in Children Flashcards
What are the broad differential diagnoses for the limping child?
- Traumatic
- Infectious
- Neoplastic
- Inflammatory
- Congenital
- Neuromuscular
- Developmental causes
What are the characteristics which help to distinguish between benign and malignant MSK conditions in children?
What questions should be asked when a limping child presents?
- Duration and progression of limp
- Recent trauma and mechanism?
- Associated pain and its characteristics
- Accompanying weakness?
- Time of day when limp is worse?
- Can the child walk or bear weight?
- Has the limp interfered with normal activities?
- Presence of systemic symptoms like fever or weight loss?
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Beware the limitations of paediatric hx and the possibility of non-accidental injury.
- History of trauma?
What are the differential diagnoses of an antalgic gait in children:
- <4 years?
- 4-10 years?
- >10 years?
What are the differential diagnoses of a nonantalgic limp in children?
What can alter a normal gait?
- Pain
- Mechanical problem
- Neuromuscular problem
What are the types of limp?
- Antalgic gait
- Equinus gait
- Trendelenburg gait
- Circumduction gait
Describe antalgic gait and state the variants.
- Painful limp.
- Shortened stance phase on affected side.
- Variant of the classic antalgic gait is the cautious gait of a child with back pain. For example, a child with diskitis will lose the normal rhythmic flexion and extension of the lumbar spine.
- Another variant is the complete refusal to walk.
- This pattern is seen most often in toddlers and may indicate a condition causing pain that cannot be avoided by any of the possible gait alterations.
What are the common causes of antalgic gait?
- Trauma
- Overuse syndrome
- Inflammation - transient synovitis, JIA
- Infection - septic arthritis
- Perthes disease
- SUFE
What are the common causes of equinus gait?
- Idiopathic toe walking
- Calf muscle contracture
- Cerebral palsy
- Late presentation DDH
- Late presentation CTEV
- DMD
Desribe the clinical picture of late presentation DDH.
- Motor delay especially infant girl.
- Unilateral equinus foot posture in stance.
- Asymmetric thigh creases.
- Asymetric / limited hip abduction.
- Shortening.
- Parental concern.
What are the common causes of Trendelenburg gait in children?
- Hip dysplasia
- Cerebral palsy
- Later stages of Perthes disease
- Longstanding SUFE
What is circumduction gait?
What are its common causes?
- During swing phase, circumduction gait allows a functionally longer limb to progress forward.
- May be associted with ‘vaulting’ over the long limb during stance.
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Common causes:
- Structural or functional leg length inequalities.
- Painful foot conditions - reduce ankle movement.
What physical manifestations would cause you to have a higher index of suspicion of non-accidental injury?
What are the signs of scoliosis in children?
What would be top of the list of differentials in a child with a swollen knee?
Juvenile idiopathic arthritis
What is the most sensitive test for hip OA?
- Internal rotation of the hip (pulling foot outwards) with the hip flexed at 90°.
- 40° is normal
- 15° is limited
What is Macnicol’s sign?
Loss of adduction in flexion - a sensitive sign of hip inflammation.
What are the differentials for hip pain?
What is Kocher’s criteria?
Allows differentiation of septic arthritis from transient synovitis of the hip.
What are the appropriate investigations for hip pain?
- Temperature
- Urinalysis
- FBC / film / differential WCC
- CRP
- Plasma viscosity
- Erythrocyte Sedimentation Rate
- Blood cultures
- Imaging
- Joint aspiration
Compare the clinical aspects of plasma viscosity and ESR.
Describe the physiological mechanisms of CRP.
State the normal range and how this changes with pathology.
- CRP is a member of the class of acute-phase reactants, as its levels rise dramatically during inflammatory processes.
- This increment is due to a rise in the plasma concentration of IL-6, which is produced predominantly by macrophages.
- CRP binds to phosphocholine on microbes.
- It is thought to assist in complement binding to foreign and damaged cells and enhances phagocytosis by macrophages.
- Normal concentration in healthy human serum is usually lower than 10mg/L, slightly increasing with ageing.
- Higher levels are found in late prengancy, mild inflammation and viral infections (10-40mg/L).
- Active inflammation or bacterial infection - 40-200 mg/L.
- Severe bacterial infections and burns - >200mg/L.
What is the most common malignant primary bone tumour?
Describe it.
- Osteosarcoma is typically located around the knee and is a very aggressive lesion associated with a soft tissue mass, cortical destruction, a permeative pattern of bone change.
Describe Ewing’s sarcoma.
- Highly malignant tumour.
- Type of peripheral primitive neuroectodermal tumour (PNET).
- Ewing’s sarcoma is found in the lower extremity more than the upper extremity, but any long tubular bone may be affected.
- The most commmon sites are the metaphysis and diaphysis of the femur, followed by the tibia and humerus.
- Radiologically, Ewing’s sarcoma is often associated with a lamellated or ‘onion skin’ periosteal reaction.
- The clinical presentation includes pain and swelling of weeks or months.
- Erythema and warmth of the local area are sometimes seen.
- Osteomyelitis is ofen the initial diagnosis based on intermittent fevers, leukocytosis, anaemia and an increased ESR.
What is Osgood-Schlatter disease?
- Osgood–Schlatter disease (OSD) is inflammation of the patellar ligament at the tibial tuberosity (apophysitis).
- Characterised by a painful bump just below the knee that is worse with activity and better with rest.
- Episodes of pain typically last a few weeks to months.
- One or both knees may be affected and flares may recur.
- Lateral radiograph of the left knee showing fragmentation of the tibial tubercle with overlying soft tissue swelling, consistent with Osgood-Schlatter disease.
What would you do if you have a child who is limping but has no constitutional sysmptoms and no localised abnormalities by hx or examination?
- This is a frequent dilema.
- Consider using plain films to rule out a fracture, followed by observation and re-evaluation in a few days, depending on the severity of the limp and the family situation.
- Consider checking FBC / film / pv / CRP.
