MSK Problems Flashcards
MSK S+S
Limp
Joint pain and swelling
Remember that hip pain may be referred to the knee
Morning stiffness
Gelling - stiffness following period of inactivity
Weakness and instability
Associated systemic symptoms
Fever
Reduced feeding or growth
Rash
Poor sleep
DDx:
General
Must exclude trauma and infection
Consider general causes of MSK pain such as growing pains and hyper mobility.
DDx:
< 5 yrs old - acute and chronic
Irritable hip, neuroblastoma, leukemia
Developmental dysplasia of the hip, talipes, cerebral palsy, juvenile idiopathic arthritis (JIA)
DDx:
5-10 yrs old - acute and chronic
Irritable hip, pethes disease, osteosarcoma, leukaemia
JIA, Perthes, Duchenne, Cerebral palsy
DDx:
> 10 yrs old - acute and chronic
Slipped upper formal epiphysis (SUFE), reactive arthritis, osteosarcoma, leukaemia
JIA, SUFE, Osgood-Schlatter’s disease (inflammation of the tibial tuberosity)
Inherited skeletal problems:
How do they present?
Achondroplasia - what does it result in?
S+S?:
- Limbs
- Fingers
- Hands
- Head
- Nose
- Spine
Growth problems
Bone deformities
Motor delay
Dwarfism
Short limbs causing short stature
Short fingers and broad hands
Large head and frontal bossing with flattened nasal bridge
Lumbar lordosis
Inherited skeletal problems:
Osteogenesis Imperfecta - another name?
What is it?
Presentation?
Brittle bone disease
Collagen defect
Freq fractures
Hearing loss
Developmental dysplasia of the hip:
What is it?
2 causes?
Who is it more common in?
Uni/bilateral?
Hip instability and dislocation
Lose joint capsule or intrauterine problem such as being breeched/oligohydraminios
Girls
Usually unilateral
Developmental dysplasia of the hip:
S+S:
- Length
- Gluteal folds
- Abduction
- Gait
- Spine
Leg length discrepancy
Asymmetrical gluteal folds
Reduced abduction
When older, waddling gait and hyperlordosis
Developmental dysplasia of the hip:
Investigations:
2 tests
Imaging and when
Management if < 6 months and > 6 months
Newborns screening with Ortolani’s test and Barlow’s test
USS < 6 months
Hip XR > 6 months
Pavlik harness - highly effective if started early
Surgery
Paediatric fractures:
Incomplete fractures - what is it?
Increased flexibility of children’s long bones mean that longitudinal stress (e.g. from FOOSH) may result in bending/buckling of the bone without complete fracture.
Paediatric fractures:
What is a …?
Buckle (aka torus) fracture
Greenstick fracture
How are they managed?
No fracture line but buckle/bulge cortex which may be seen
Fracture line on inner cortex which does not extend to the opposite cortex
Cast/splint
Paediatric fractures:
Salter-Harris fractures
How is a mild fracture managed?
How is a severe fracture managed?
Fractures that involve the cartilaginous growth plate classified from 1-5
Closed reduction and cast/splint
Open reduction and internal fixation - risk of growth impairment and arthritis otherwise
Paediatric fractures:
Toddler’s fracture
what is it
when
where
X-ray - what do you see, when is it apparent that the fracture has occurred?
Management
Undisplaced spiral fracture of the tibial shaft in ambulatory toddler - 9-36 months
Normal with injury only apparent from new periosteal bone formation 7-10 days later
Cast/splint
Irritable Hip
AKA TSOH - what does that stand for?
Presentation: Site and onset of pain? Where may pain be referred to? What is reduced? What might it have been triggered from? What should be considered if multiple joints are affected?
Transient synovitis of the hip
Sudden onset of hip pain (on movement) and/or limp
Pain my be referred to knee
Reduced internal rotation
May be triggered by viral infection so there may be history of fever
JIA
Irritable hip
Investigations:
What may USS show?
What about XR?
How is TSOH diagnosed?
Management - conservative?
When does it resolve?
May show fluid
Normal
Diagnosis of exclusion so if imaging and bloods are negative (ruling out septic arthritis), TSOH, more likely.
Rest and ibuprofen until able to mobilise
1-2 wks
Perthes Disease:
What is it?
Who does it usually affect?
Age of onset?
Avascular necrosis of the femoral head
Boys
5-10 yrs old
Perthes Disease:
S+S: Sites and onset of pain and limp Where may it radiate to? Exacerbating factors How may it initially appear?
Gradual onset of hip and knee pain and limp
Groin and buttocks
Activity
Transient synovitis
Perthes Disease:
Investigations:
What might you see on hip XR? - 4
What can be used for early disease if XR is normal?
Widening joint space
Sclerosis
Fragmentation
Flattening of femoral head later on
MRI or bone scan
Perthes Disease:
Management
Simple analgesia and rest
Plaster or surgery to secure femoral head in acetabulum
Slipped Upper Femoral Epiphysis (SUFE)
What is it?
Who does it usually affect?
Age of onset?
Risk factors - 2
Displacement of the rounded head of the femur
Boys
10-16 yrs
Obesity
Hypogonadism - causes delayed bone maturation
Slipped Upper Femoral Epiphysis (SUFE):
S+S:
Where is the pain?
What is reduced?
Onset?
Investigations - what would you see on XR?
Management
Pain in groin, thigh and/or knee and limp
Internal rotation
Gradual
Displacement of femoral head
Surgical fixation to prevent further slippage and avascular necrosis of the femoral head
Juvenile Idiopathic Arthritis:
What is it also known as?
How is it defined?
Subtypes:
Juvenile RA (JIA)
Persistent >6 wks joint swelling in children < 16 yrs old
Oligoarticular JIA
Polyarticular JIA
Systemic-onset JIA
Psoriatic JIA
Juvenile Idiopathic Arthritis:
Signs and Symptoms
Pain Reduced function Leg length discrepancy Flexion contracture Systemic symptoms - malaise, fever
Juvenile Idiopathic Arthritis:
Investigations
What is done?
Inflammatory markers
X-rays
Autoantibodies
Juvenile Idiopathic Arthritis:
Stepwise Treatment - Step 1, 2, 3, 4
1 - Regular NSAID’s - ibuprofen, naproxen
2 - Steroids - intra-articular injections
3 - DMARDS - methotrexate
4 - Biologics - etanercept
