Musculoskeletal Flashcards
What is the treatment for hip congenital hip dysplasia and what is the risk?
Pavlik harness - keeps hip flexed and abducted
Risk = avascular necrosis to head of femur
What is Perthes Disease?
Avascular necrosis of the femoral head –> revascularisation over 18-36m
More common boys 4-8y
What is Osgood-Schlatter?
Avascular necrosis of the tibial tuberosity
What is slipped upper epiphysis?
Displacement of the epiphysis of femoral head postero-inferiorly
More in obese teenage boys
Features of transient synovitis
2-12y
Often associated with recent / intercurrent viral illness
Sudden onset hip / knee (referred) pain
Otherwise well
Genetics and presentation of osteogenesis imperfecta
- Dominant / recessive
- Mutation COL1A1 or 2 –> abnormalities in production in alpha chain of Type 1 collagen –> bone fragility and low bone mass
- Presentation: bowing frequent fractures, hypermobility
Causes of Rickets
Vitamin D Deficiency (1,25-dihydrocholecalciferol deficiency)
Phosphate deficiency (low calcium)
Presentation of Rickets
Bowed limbs
Metaphyseal swelling
Bone pain / miserable
Gross motor delay, delayed growth
Hypotonia, weakness
Bossed forehead
Delayed dentition
X-ray: cupping, splaying, fraying. General osteopenia
Rickets Biochemistry
- Low Vit D
- High PTH
- High Alk Phos
- Calcium / Phosphate normal or low
What is osteopetrosis and how does it present?
Failure of bone resorption –> brittle
Faltering growth
Recurrent infection
Hypocalcaemia
Anaemia, thrombocytopenia
Common organisms for septic arthritis
- Staph. aureus
- Group A strep
- Gram negative bacilli
Common infections preceding reactive arthritis
Salmonella
Shigella
Campylobacter
STIs
Strep
Mycoplasma
Lyme’s
Extra-articular features of JIA
Anterior uveitis
Leg length discrepency
Rheumatoid nodues in RF +ve
Low grade fever - polyarthritis
Define oligoarticular JIA
4 or fewer joints in the 1st 6 months of disease. Commonly larger joints eg knees, ankles, elbows. Usually presents 2-4y.
Difference between extended oligoarthritis and polyarthritis
Extended oligoarthritis = Asymmetrical large and small
Polyarthritis = Symmetrical large and small (often fingers)
Features of systemic arthritis (Still’s disease)
Oligo / poly
Acute illness
Malaise, anorexia, weight loss
Daily fever >2w
Salmon pink rash (worse with fevers)
Hepatosplenomegaly
Serositis
Raised inflammatory markers, low Hb
More in young girls
Treatment of systemic onset JIA
IV Methylprednisolone
Features of psoriatic arthritis
Asymmetric large and small
Dactylysis
Nail pitting
Psoriasis
+/- ant. uveitis
FHx
Features of enthositis related arthritis
HLA B27 +ve
Lower limb large joints
Milder spine
Tendon / ligament inflammation
What is macrophage activation syndrome and how does it present?
10% children with systemic JIA
Life threatening
Excessive activation and expansion of T cells and macrophages
- Presents: Continuous fever, low leukocytes / platelets –> multiple organ failure
Presentation of juvenile onset SLE
Usually teens. Need 4 of:
Rash - malar, discoid
Photosensitivity
Mouth ulcers
Arthritis
Serositis - pleural, pericarditis
Renal disease - proteinuria, casts
Neuro-psych disorders - psychosis, seizures
Low Hb / Plt / WCC
Positive for: Anti-DNA, anti-Smith, antiphospholipid Ab, ANA
Antibodies that may be present in SLE
Anti-Ro
Anti-La
Anti-dsDNA (most specific!)
Anti-Sm
Anti-RNP
ANA
Treatment for SLE
Supportive, avoid sun
Analgesia
ACEi for HTN / proteinuria
Steroids
DMARDs - hydroxychloraquin, cylophosphamide (AI suppression)
Why might children with SLE require life-long prophylactic ABx?
Can get vasculitis –> splenic infarction –> immunodeficiency
Presentation of jeuvenile dermatomyositis
Teens - AI
Erythematous rash + 2 of:
-Symmetrical weakness of prox muscles
- Periorbital swelling / discolouration
- Grotton’s papules - scaly rash of PIP/ MIPs
- Increased muscle enzyme: CK, AST, LDH
- EMG changes
- Biopsy - necrosis + inflammation
- MRI changes - diffuse white
Also may get lung disease, oligoarthritis
Presentation of Duchenne Muscular Dystrophy
More commonly boys. Progressive muscle degeneration.
Around 5y
Waddling gait
Gower’s sign (weak limb girdle)
Enlarged calves
Language delay
Slower, climbs stairs 1 by 1
Raised CK
Beyond ant. horn, no fasiculations
Inheritance pattern of Duchenne Muscular dystrophy
X-linked recessive deletion of dystrophin gene (Xp21)
Inheritance of myotonic dystrophy
Autosomal Dominant
Expanding CTG trinucleotide repeats on Ch 19 –> anticipation
Presentation of myotonic dystrophy
Congenital - severe. Hypotonia, feeding difficulty, resp. distress
Later onset - hypotonia, myopathic face, GDD.
Later complications - DM, cataracts, cardiac involvement
Common sites for osteomyelitis and most common organism
Distal femur
Proximal tibia
Organism: Staph. Aureus
Presentation of HSP (small vessel vasculitis)
- Abdominal pain
- Arthritis
- Non-thrombotic palpable purpura occur over buttocks and legs.
May follow URTI.
+/- intussusception
= IgA immune complex deposition in smaller vessels
Diagnostic criteria of Kawasaki (medium vasculitis)
Fever >38 for 5 days or more, + 4 of:
- Erythema / cacking lips and oral mucosa
- Bilateral non-purulent conjunctivitis
- Rash (diffuse, maculopapular, erythematous
- Erythema and oedema of hands / feet –> desquamation and peeling
- Cervical LN >1.5cm
Major complication of Kawasaki
MI and coronary artery aneurysm
Treatment for Kawasaki
IV Ig
High dose aspirin
Antiplatelet
Some may need steroid / immunosuppression
Describe Erb’s palsy
- Injury C5 and C6 roots.
- Motor: shoulder abduction and forearm flexion “waiter’s tip” deficit
- Sensory deficits – reduced sensation over posterior lateral aspect of arm, thumb, index finger (digital branches of medial nerve).
Describe presentation C7/8 injury
‘Ulnar claw’ – difficultly extending at elbow and wrist. Sensory – posterior and medial aspects of the arm.
Which antibody is most associated with Polyarticular JIA?
Rheumatoid factor
Which antibody is most associated with Oligoarticular JIA?
ANA
Antibody associated with Sjogren’s syndrome
Anti-Ro
What is present in the urine in Rhabdomyolisis?
Myoglobin
Which fracture is most associated with NAI?
Metaphyseal fracture
Caused by shearing forces
“corner” or bucket handle” fractures
