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Paediatrics > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

1
Q

Risk factors for DDH

A
  • female (6x)
  • breech presentation
  • +ve FHx
  • firstborn children
  • oligohydramnios
  • birth weight >5kg
  • congenital calcaneovalgus foot deformity
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2
Q

Which hip usually for DDH

A

slightly more common in left hip

20% cases bilateral

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3
Q

Which infants require routine DDH screening?

A

USS

  • 1o FHx of hip problems in early life
  • breech presentation at or after 36 weeks GA, irrespective of presentation at birth or mode of delivery
  • multiple pregnancy

all infants screened at both newborn check and also 6 week baby check using Barlow and Ortolani tests

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4
Q

How do we examine for DDH?

A
  • Barlow test: attempts to dislocate an articulated femoral head
  • Ortolani test: attempts to relocate a dislocated femoral head

other important factors include:

  • symmetry of leg length
  • level of knees when hips and knees are bilaterally flexed
  • restricted abduction of the hip in flexion
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5
Q

How do we image DDH?

A
  • ultrasound is generally used to confirm the diagnosis if clinically suspected
  • however, if the infant is > 4.5 months then x-ray is the first line investigation
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6
Q

How do manage DDH?

A
  • Most unstable hips will spontaneously stabilise by 3-6 weeks of age (repeat US or XR to monitor progress)
  • Pavlik harness or splint (dynamic flexion-abduction orthosis) in children younger than 4-5 months (follow up with XR at 6 months of age)
  • older children may require surgery (e.g. reduction with spica casting)
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6
Q

How do manage DDH?

A
  • Most unstable hips will spontaneously stabilise by 3-6 weeks of age (repeat US or XR to monitor progress)
  • Pavlik harness or splint (dynamic flexion-abduction orthosis) in children younger than 4-5 months (follow up with XR at 6 months of age)
  • older children may require surgery (e.g. reduction with spica casting)
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7
Q

What do you call the harness used in DDH?

A

Pavlik harness (dynamic flexion-abduction orthosis) in children younger than 4-5 months

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8
Q

Obese boy with groin/thigh/knee pain

Ix XR = displacement of the femoral head epiphysis postero-inferiorly

A

slipped capital femoral epiphysis aka ‘slipped upper femoral epiphysis’

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9
Q

Slipped capital femoral physics epidemiology and features

A

Basics

  • typically age group is 10-15 years
  • More common in obese children and boys
  • Displacement of the femoral head epiphysis postero-inferiorly
  • May present acutely following trauma or more commonly with chronic, persistent symptoms

Features

  • hip, groin, medial thigh or knee pain
  • loss of internal rotation of the leg in flexion
  • bilateral slip in 20% of cases
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10
Q

Slipped capital femoral epiphysis ix and mx

VIVA: What are the XR findings?

A

Investigation

  • AP pelvis and FROG lateral views obtained
  • Trethowan’s sign = line of Klein does not intersect superior femoral epiphyses/asymmetry between line of Klein’s on either side

Management

  • Don’t let the patient walk, analgesia, immediate orthopaedic referral
  • internal fixation: typically a single cannulated screw placed in the center of the epiphysis
    *
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11
Q

A 6-year-old boy is brought to surgery by his mother. For the past 2 months he has been complaining of pain in his shins and ankles at night-time. His symptoms are bilateral he is otherwise well. There is no family history of note. Clinical examination is unremarkable. What is the most likely diagnosis?

A

Growing pains aka ‘benign idiopathic nocturnal limb pains of childhood’

Growing pains are equally common in boys and girls and occur in the age range of 3-12 years.

Features of growing pains

  • never present at the start of the day after the child has woken
  • no limp
  • no limitation of physical activity
  • systemically well
  • normal physical examination
  • motor milestones normal
  • symptoms are often intermittent and worse after a day of vigorous activity
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12
Q

Features of septic arthritis

A

Symptoms

  • joint pain
  • limp
  • fever
  • systemically unwell: lethargy

Signs

  • swollen, red joint
  • typically, only minimal movement of the affected joint is possible
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13
Q

Septic arthritis ix

A
  • joint aspiration: for culture. Will show a raised WBC
  • raised inflammatory markers
  • blood cultures
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14
Q

How do we diagnose septic arthritis?

A

Kocher’s criteria:

  • Non-weight bearing - 1 point
  • Fever >38.5ºC - 1 point
  • WCC >12 * 109/L - 1 point
  • ESR >40mm/hr - 1 point

0 = very low risk

1 point = 3% probability of septic arthritis

2 points = 40%

3 points = 93%

4 points = 99%

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15
Q

Septic arthritis mx

A
16
Q

Transient synovitis aka ‘irritable hip’ features

A

acute hip pain following a recent viral infection. It is the commonest cause of hip pain in children. The typical age group is 3-8 years.

lasts 2 weeks

Features

  • limp/refusal to weight bear
  • groin or hip pain
  • a low-grade fever is present in a minority of patients
    • high fever should raise the suspicion of other causes such as septic arthritis
17
Q

Transient synovitis mx

A

If concerned about septic arthritis: perform joint aspiration and blood cultures

Bed rest

Pain relief can be achieved with paracetamol or NSAIDs

Usually resolves after a few days

18
Q

What is Perthes disease? epidemiology

A

Perthes’ disease is a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head, specifically the femoral epiphysis. Impaired blood supply to the femoral head causes bone infarction.

5x more common in boys

10% bilateral

lasts months

19
Q

Features of Perthes’ Disease

A
  • Hip pain: developed progressively over a few weeks
  • limp
  • stiffness and reduced range in hip movement
  • short, disruptive behaviour (hyperactivity)
  • XR = early changes including widening of joint space, alter changes include decreased femoral head size/flattening
20
Q

How do we diagnose Perthes’

A
  • plain XR of hip
  • Technetium bone scan or MRI is normal XR and sx persist
21
Q

Complications of Perthes disease

A
  • osteoarthritis
  • premature fusion of the growth plates (short bones)
22
Q

How do we stage Perthes’ disease

A
23
Q

How do we manage Perthes’ Disease?

A

Non-surgical tx = benign, self-limiting

supportive care for acute pain = simple analgesia, ice packs, protective pad over tibial tubercle

keep femoral head within acetabulum = cast, braces

activity continuation

physical therapy = stretch quadriceps and hamstring muscles, strength quadriceps, encourage hip abduction

education = about exacerbations and management

surgical tx reserved for patients who fail to respond to conservative measures (only if >6 years)

24
Q

What do we do with a child with limp/hip pain has a fever

A

referred for same-days assessment, even if a diagnosis of transient synovitis is suspected

25
Q

Achondroplasia

A

AD, short stature, mutation in FGFR-3 gene

RFs = advancing paternal age

Abnormal cartilage gives rise to:

  • short limbs (rhizomelia) with shortened fingers (brachydactyly)
  • large head with frontal bossing and narrow foramen magnum
  • midface hypoplasia with a flattened nasal bridge
  • ‘trident’ hands
  • lumbar lordosis

Mx:

  • no specific therapy
  • some may benefit from limb lengthening procedures = application of lizard frames and targeted bone fractures
26
Q

Juvenile Idiopathic Arthritis (JIA)

A
26
Q

Juvenile Idiopathic Arthritis (JIA)

A

Paediatrics (18 decks)

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