MSK Presentations in Children Flashcards

1
Q

What are the broad differential diagnoses for the limping child?

A
  • Traumatic
  • Infectious
  • Neoplastic
  • Inflammatory
  • Congenital
  • Neuromuscular
  • Developmental causes
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2
Q

What are the characteristics which help to distinguish between benign and malignant MSK conditions in children?

A
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3
Q

What questions should be asked when a limping child presents?

A
  • 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?
  • Beware the limitations of paediatric hx and the possibility of non-accidental injury.
    • History of trauma?
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4
Q

What are the differential diagnoses of an antalgic gait in children:

  • <4 years?
  • 4-10 years?
  • >10 years?
A
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5
Q

What are the differential diagnoses of a nonantalgic limp in children?

A
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6
Q

What can alter a normal gait?

A
  • Pain
  • Mechanical problem
  • Neuromuscular problem
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7
Q

What are the types of limp?

A
  • Antalgic gait
  • Equinus gait
  • Trendelenburg gait
  • Circumduction gait
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8
Q

Describe antalgic gait and state the variants.

A
  • 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.
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9
Q

What are the common causes of antalgic gait?

A
  • Trauma
  • Overuse syndrome
  • Inflammation - transient synovitis, JIA
  • Infection - septic arthritis
  • Perthes disease
  • SUFE
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10
Q

What are the common causes of equinus gait?

A
  • Idiopathic toe walking
  • Calf muscle contracture
  • Cerebral palsy
  • Late presentation DDH
  • Late presentation CTEV
  • DMD
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11
Q

Desribe the clinical picture of late presentation DDH.

A
  • Motor delay especially infant girl.
  • Unilateral equinus foot posture in stance.
  • Asymmetric thigh creases.
  • Asymetric / limited hip abduction.
  • Shortening.
  • Parental concern.
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12
Q

What are the common causes of Trendelenburg gait in children?

A
  • Hip dysplasia
  • Cerebral palsy
  • Later stages of Perthes disease
  • Longstanding SUFE
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13
Q

What is circumduction gait?

What are its common causes?

A
  • During swing phase, circumduction gait allows a functionally longer limb to progress forward.
  • May be associted with ‘vaulting’ over the long limb during stance.
  • Common causes:
    • Structural or functional leg length inequalities.
    • Painful foot conditions - reduce ankle movement.
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14
Q

What physical manifestations would cause you to have a higher index of suspicion of non-accidental injury?

A
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15
Q

What are the signs of scoliosis in children?

A
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16
Q

What would be top of the list of differentials in a child with a swollen knee?

A

Juvenile idiopathic arthritis

17
Q

What is the most sensitive test for hip OA?

A
  • Internal rotation of the hip (pulling foot outwards) with the hip flexed at 90°.
    • 40° is normal
    • 15° is limited
18
Q

What is Macnicol’s sign?

A

Loss of adduction in flexion - a sensitive sign of hip inflammation.

19
Q

What are the differentials for hip pain?

A
20
Q

What is Kocher’s criteria?

A

Allows differentiation of septic arthritis from transient synovitis of the hip.

21
Q

What are the appropriate investigations for hip pain?

A
  • Temperature
  • Urinalysis
  • FBC / film / differential WCC
  • CRP
  • Plasma viscosity
  • Erythrocyte Sedimentation Rate
  • Blood cultures
  • Imaging
  • Joint aspiration
22
Q

Compare the clinical aspects of plasma viscosity and ESR.

A
23
Q

Describe the physiological mechanisms of CRP.

State the normal range and how this changes with pathology.

A
  • 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.
24
Q

What is the most common malignant primary bone tumour?

Describe it.

A
  • 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.
25
Q

Describe Ewing’s sarcoma.

A
  • 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.
26
Q

What is Osgood-Schlatter disease?

A
  • 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.
27
Q

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?

A
  • 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.