Musculoskeletal Flashcards
Osteogenesis Imperfecta
An autosomal dominant genetic condition that results in brittle bones that are susceptible to fractures. - A genetic mutation that affects the formation of collagen which is needed to maintain the structure and function of bone, skin, tendons and other connective tissues.
Presentation of Osteogenesis Imperfecta
Recurrent and inappropriate fractures - Blue/grey sclera
- Hypermobility
- Triangular face
- Deafness from early adulthood
- Dental problems
- Bone deformities
Ix for Osteogenesis Imperfecta
Mainly a clinical diagnosis - X-rays can be helpful for diagnosing fractures and deformities - Genetic testing is done rarely
Management of Osteogenesis Imperfecta
Bisphosphonates to increase bone density - Vit D supplementation - Physio and occupational therapy input to maximise strength and function - Management of fractures
Rickets
A condition where there is defective bone mineralization causing ‘soft’ and deformed bones
Causes of Rickets
Vitamin D deficiency - produced by the body in response to sunlight or through food such as eggs, oily fish - Calcium deficiency - found in dairy products and some green vegetables - Hereditary hypophosphatemic rickets - an X-linked dominant condition
Pathophysiology of Rickets
Vit D is a hormone created from cholesterol by the skin in response to UV radiation. - Those with malabsorption disorders such as IBD are more likely to have Vit D deficiency as well as those with CKD. - Vitamin D is essential in calcium and phosphate absorption from the intestines and kidneys as well as regulating bone turnover and promoting bone reabsorption. - Inadequate vit D leads to a lack of calcium and phosphate which are needed for bone formation therefore there is defective bone mineralisation. - Low calcium causes secondary hyperparathyroidism as the parathyroid gland tries to raise calcium levels by secreting PTH which stimulates increased reabsorption of calcium and causes further bone mineralisation problems.
Risk Factors of Rickets
Darker skin - Low exposure to sunlight - Colder climates -Spending majority of time indoors
Presentation of Rickets
Lethargy - Bone pain - Poor growth - Dental problems - Muscle weakness
Bone Deformities of Rickets
- Bowing of the legs - legs curve outwards 2. Knock knees - legs curve inwards 3. Rachitic rosary - the ends of the ribs expand at the costochondral junctions causing lumps along the chest 4. Craniotabes - soft skull with delayed closure of the sutures and frontal bossing 5. Delayed teeth
Ix for Rickets
- Serum 25-hydroxyvitamin D - <25 nmol/L establishes deficiency - X-rays - Serum calcium and phosphate may be low - Serum ALP and PTH may be high - Full blood tests to rule out other pathology including FBC, ESR, CRP, LFTs, TFTs, Malabsorption screen
Management of Rickets
Prevention is the best management - NICE recommend 400 IU supplements for children and young people - Children with deficiency can be treated with ergocalciferol (vit D) - For those with diagnosed rickets, vit D and calcium supplementation is needed.
Transient Synovitis
Irritable hip ;Temporary irritation and inflammation in the synovial membrane - often associated with a viral URTI
What is the most common cause of hip pain in children aged 3-10?
Transient Synovitis
Who is typically affected by Transient Synovitis
Ages 4-8 (uncommon in <3s (think Septic Arthritis))
Presentation of Transient Synovitis
Symptoms usually occur within a few weeks of a viral illness - Limp - Refusal to weight bear - Groin or hip pain - Mild low grade temperature - Otherwise well - no signs of systemic illness. 30% have a low grade fever (exlude septic arthritis)
Management of Transient Synovitis
Symptomatic management - Exclusion of other diagnoses particularly septic arthritis
Prognosis of Transient Synovitis
Generally good prognosis with recovery within 1-2 weeks without any long term effects
Septic Arthritis
Infection inside a joint
Septic Arthritis is most common in children under __ years
4
Who does Septic Arthritis affect?
Any age but common in <4 y/o
Causes of Septic Arthritis
- Staphylococcus aureus - Neisseria gonorrhoea in sexually active teenagers - Group A Strep - Strep Pyogenes - Haemophilus influenzae - E coli
Presentation of Septic Arthritis
- Only affects a single joint - knee or hip - Hot, red, swollen and painful joint - Refusal to weight bear - Stiffness and reduce range of motion - Fever, lethargy and sepsis
Management of Septic Arthritis
- Admission to hospital with involvement of the orthopaedic team - Joint aspiration prior to antibiotics -> gram staining, crystal microscopy, culture and antibiotic sensitivities - Empirical IV antibiotics followed by specific antibiotics once sensitivities are received - Surgical drainage and washout may be needed
Osteomyelitis
Infection of the bone and bone marrow - typically in the metaphysis of the long bones. Infection can be introduced directly into the bone e.g open fracture or travelled to the
bone from the blood after entering through another medium
What is the most common cause of Osteomyelitis ?
Staph aureus
What is chronic Osteomyelitis ?
Chronic osteomyelitis is a deep seated, slow growing infection with slowly developing symptoms
Risk Factors of Osteomyelitis
- Males under 10 - Open bone fractures - Orthopaedic surgery - Immunocompromised
- Sickle cell anaemia
- HIV
- TB
Presentation of Osteomyelitis
- Systemic symptoms such as fever - Refusing to use the limb or weight bear - Pain - Swelling - Tenderness
First Line Ix for Osteomyelitis
X -rays
Gold Standard Ix for Osteomyelitis
MRI
Other Ix for Osteomyelitis
Bloods including CRP, ESR and white cells - Blood cultures - Bone marrow aspiration
Management of Osteomyelitis
Extensive and prolonged antibiotic therapy - Surgery may be needed for drainage and debridement of the infected bone
Perthes Disease
Disruption of blood flow to the femoral head causing avascular necrosis of the bone - affecting the epiphysis of the femur. Over time, there is revascularization or neovascularization and healing of the femoral head with remodelling of the bone as it heals
Perthes Disease affects those between ages __ and __
4 to 12
Perthes Disease most commonly affects ___
5-8 year old boys (M:F = 5:1)
Causes for Perthes Disease
Mainly idiopathic
Presentation of Perthes Disease
- Slow onset of pain in the hip or groin - Limp - Restricted hip movements - Referred pain to the knee - No history of trauma
Ix for Perthes Disease
- X-ray which can be normal - Blood tests can typically normal, particularly inflammatory markers - Technetium bone scan - MRI scan
Initial Management of Perthes Disease
- Initial management is conservative to maintain healthy position and alignment in the joint and reduce the risk of damage or deformity to the femoral head including bed rest, traction, analgesia and crutches
Other Management options for Perthes Disease
- Physiotherapy is used to retain movement in the muscles and joints - Regular x-rays - Surgery may be used in severe cases, older children or those that are not healing
What is a discoid meniscus?
A discoid meniscus is a congenital abnormality of the knee joint where the meniscus is thicker and more disc-like than the typical crescent shape, leading to potential knee pain and mechanical symptoms.
Which of the following is a type of discoid meniscus?
A) Incomplete
B) Complete
C) Wrisberg-ligament variant
D) All of the above
D) All of the above
Explanation: The three types of discoid meniscus are:
Incomplete: The meniscus is slightly thicker and wider than normal, usually asymptomatic.
Complete: The meniscus covers the tibial plateau completely.
Wrisberg-ligament variant: The meniscus is not attached to the femur or tibia due to missing ligaments, leading to instability.
What are common symptoms of a discoid meniscus?
Knee pain, especially on the lateral side
Swelling
Locking or catching sensations
Limited range of motion
Quadriceps weakness
Which imaging modality is commonly used to diagnose a discoid meniscus?
A) X-ray
B) MRI
C) Ultrasound
D) CT scan
B) MRI
Explanation: MRI is effective in diagnosing discoid meniscus and evaluating associated meniscal tears.
What is the initial treatment for a symptomatic discoid meniscus?
A) Rest and physical therapy
B) Surgical resection
C) Corticosteroid injections
D) Arthroscopic meniscectomy
A) Rest and physical therapy
Explanation: Initial treatment includes immobilization, restricted activities, and quadriceps muscle strengthening. Surgical intervention is considered if symptoms persist.
True or False: Total meniscectomy is the preferred surgical treatment for discoid meniscus in children.
False
Explanation: Partial meniscectomy is preferred to preserve meniscal function and reduce the risk of degenerative changes.
True or False: With appropriate treatment, the prognosis for children with discoid meniscus is generally good.
True
Explanation: Early recognition and appropriate management can lead to favorable outcomes for children with discoid meniscus.
What are potential complications of an untreated discoid meniscus?
Meniscal tears
Knee instability
Early-onset osteoarthritis
Which of the following is a preventive measure for discoid meniscus?
A) Regular knee exercises
B) Early diagnosis and management
C) Avoiding high-impact sports
D) None of the above
B) Early diagnosis and management
Explanation: While discoid meniscus is a congenital condition and cannot be prevented, early diagnosis and appropriate management can prevent complications
Which organization provides information and support for knee joint abnormalities?
A) American Academy of Orthopaedic Surgeons (AAOS)
B) American Heart Association
C) National Institute of Mental Health
D) American Cancer Society
A) American Academy of Orthopaedic Surgeons (AAOS)
Explanation: The AAOS offers resources and support for individuals with musculoskeletal conditions, including knee joint abnormalities.
Slipped Femoral Epiphysis
Head of the femur is displaced along the growth plate
Slipped Femoral Epiphysis commonly affects ___
More common in males and typically between ages of 8-15 years old - More common in obese children
Presentation of Slipped Femoral Epiphysis
- Adolescent, obese male undergoing a growth spurt - History of minor trauma which may trigger the onset of symptoms - Hip, groin, thigh or knee pain - Restricted range of hip movement - Painful limp - Restricted movement in the hip - Wanting to keep the hip in external rotation with restricted internal rotation.
First Line Ix for Slipped Femoral Epiphysis
X -rays
Other Ix for Slipped Femoral Epiphysis
Blood tests are normal, but inflammatory markers may be used to exclude other causes of joint pain - CT/MRI scan
Management of Slipped Femoral Epiphysis
Surgery is needed to return the femoral head to correct position and fix it in place
Complications of Slipped Femoral Epiphysis
Osteoarthritis, Perthes Disease, Leg Length Discepancy
Osgood-Schlatter Disease is caused by __
Caused by inflammation at the tibial tuberosity where the patellar ligament inserts - a common cause of anterior knee pain in adolescents. Normally is unilateral but can be bilateral
Osgood-Schlatter Disease typically occurs in ___
Typically occurs in male patients aged 10-15 years
Pathophysiology of Osgood-Schlatter Disease
Patella tendon inserts into the tibial tuberosity which is at the epiphyseal plate - Stress from running, jumping and other movements at the same time as growth in the plate results in inflammation on the tibial epiphyseal plate. - There are small avulsion fractures where the patellar ligament pulls away tiny pieces
of the bone, leading to growth of the tibial tuberosity, causing a visible lump below the
knee
- Initially, the bump is tender due to inflammation but as the bone heals and
inflammation settles, it becomes hard and non-tender.
Presentation of Osgood-Schlatter Disease
Gradual onset of symptoms - Visible or palpable hard and tender lump at the tibial tuberosity - Pain in the anterior aspect of the knee - Pain is exacerbated by physical activity, kneeling and on extension of the knee
Management of Osgood-Schlatter Disease
Reduction in physical activity - Ice - NSAIDs for symptomatic relief - Stretching and physiotherapy can be used to strengthen the joint once symptoms settle. - Symptoms will generally resolve over time but the patient is usually left with a hard, boney lump on their knee
Developmental Dysplasia of the Hip
Structural abnormality in the hips caused by abnormal development of the foetal bones during pregnancy leading to instability in the hips and a tendency for dislocation
When is Developmental Dysplasia of the Hip diagnosed?
Usually picked up during the newborn examinations or later when the child presents with hip asymmetry, reduced range of movement in the hip or limp
Risk Factors for Developmental Dysplasia of the Hip
female (6:1), oligohydramnios, macrosomia
Indications for routine US in Developmental Dysplasia of the Hip
First degree family history - Breech presentation from 36 week onwards - Breech presentation at birth if 28 week onwards - Multiple pregnancy
Screening for Developmental Dysplasia of the Hip
NIPE examination usually picks this up - this may be suggested with 1. Different leg lengths 2. Restricted hip abduction on one side 3. Significant bilateral restriction in abduction 4. Difference in the knee level when the hips are flexed 5. Clunking of the hips on special tests - Ortolani and Barlow tests
Ix for Developmental Dysplasia of the Hip
If suspected, ultrasound will establish the diagnosis. - X-rays can also be helpful in older infants
What is Barlow Test ?
Attempts to dislocate femoral head
What is Ortolani Test ?
Attempts to relocate femoral head
Management of Developmental Dysplasia of the Hip
Pavlik harness if the baby presents at less than 6 months of age which is fitted and kept on permanently and adjusts for the growth of the baby. - The aim of this is to hold the femoral head in the correct position to allow the hip socket to develop a normal shape and helps to keep the baby’s hips flexed and abducted - reviewed after 6-8 weeks - Surgery may be needed when the harness fails or if the diagnosis is made after 6 months of age
Juvenile Idiopathic Arthritis
Autoimmune inflammation which occurs in the joints
When is Juvenile Idiopathic Arthritis diagnosed?
Diagnosed when there is arthritis without any other cause, lasting more than 6 weeks in a patient under the age of 16
Key features of Juvenile Idiopathic Arthritis
Key features are joint pain, swelling and stiffness
Presentation of Systemic Juvenile Idiopathic Arthritis
- Subtle salmon-pink rash - High swinging fever - Enlarged lymph nodes - Weight loss - Joint pain and inflammation - Splenomegaly - Muscle pain
Ix for Juvenile Idiopathic Arthritis
ANA and RF will be negative - Raised CRP, ESR, platelets and serum ferritin
What is Polyarticular Juvenile Idiopathic Arthritis
Idiopathic inflammatory arthritis in 5 joints or more which tends to be symmetrical and can affect small or large joints
Symptoms of Polyarticular JIA
Minimal systemic symptoms but can have mild fever, anaemia and reduced growth
Polyarticular JIA : RF?
- Most children will be RF negative but in older children and adolescents, they can be RF positive - similar pattern to RA.
What is Oligoarticular JIA?
Involves 4 joints or less, often only a single joint
Who is Oligoarticular JIA more common in?
More common in girls under the age of 6 and affects the larger joints
Classic feature of Oligoarticular JIA
Classic feature is anterior uveitis for which patients should be referred to ophthalmology
Symptoms of Oligoarticular JIA
No systemic symptoms, inflammatory markers may be normal or mildly elevated, ANA positive but RF is usually negative.
Enthesitis - Related Arthritis is more common in ___
More common in male children over 6 years
What is Enthesitis - Related Arthritis the paediatric version of ?
The paediatric version of the seronegative spondyloarthropathies such as ankylosing spondylitis
What is Enthesitis?
Enthesitis is inflammation at the point where the muscle inserts into a bone - can be caused by traumatic stress or an autoimmune process.
Majority of patients with Enthesitis - Related Arthritis will have which gene?
HLA-B27 gene
Signs/Symptoms of Enthesitis - Related Arthritis
They may have signs and symptoms of psoriasis and IBD
Complications of Enthesitis - Related Arthritis
Prone to anterior uveitis
Juvenile Psoriatic Arthritis
Seronegative inflammatory arthritis associated with psoriasis - Can be symmetrical polyarthritis affecting the small joints or an asymmetrical arthritis affecting the large joints in the lower limbs
Signs of Juvenile Psoriatic Arthritis
May have nail pitting, dactylitis, enthesitis, plaques of psoriasis on the skin
Management of JIA
- NSAIDs such as ibuprofen - Steroids either oral, IM or intra-articular in oligoarthritis - DMARDS such as methotrexate - Biologicals such as TNF inhibitors such as infliximab/adalimumab
What is scoliosis?
Scoliosis is a lateral (side-to-side) curvature of the spine, typically exceeding 10 degrees, leading to a C-shaped or S-shaped appearance.
Which of the following is the most common type of scoliosis in children?
A) Idiopathic scoliosis
B) Congenital scoliosis
C) Neuromuscular scoliosis
D) Degenerative scoliosis
A) Idiopathic scoliosis
Explanation: Idiopathic scoliosis is the most prevalent type in children, with no known specific cause.
What are common symptoms of scoliosis in children?
Uneven shoulders or hips
Prominent rib hump on one side
Leaning to one side
Back pain (less common in children)
Which physical examination test is commonly used to assess scoliosis?
A) Trendelenburg test
B) Forward bend test
C) Straight leg raise test
D) Patrick’s test
B) Forward bend test
Explanation: The forward bend test helps identify asymmetry in the back, indicating potential scoliosis.
Which imaging modality is considered the gold standard for evaluating scoliosis?
A) X-ray
B) MRI
C) CT scan
D) Ultrasound
A) X-ray
Explanation: X-rays are used to measure the degree of spinal curvature and assess skeletal maturity
What is the primary goal of bracing in scoliosis management?
A) To correct the spinal curvature
B) To prevent further progression of the curve
C) To alleviate back pain
D) To improve posture
B) To prevent further progression of the curve
Explanation: Bracing aims to halt the progression of the spinal curve, especially during periods of growth.
True or False: Surgery is recommended for all children with scoliosis.
False
Explanation: Surgical intervention is typically reserved for cases with severe curvature or when non-surgical treatments fail to prevent progression
True or False: Most children with mild scoliosis require lifelong treatment.
False
Explanation: Children with mild scoliosis often require monitoring but may not need ongoing treatment
What are potential complications of untreated scoliosis?
Chronic back pain
Respiratory issues due to reduced lung capacity
Cardiovascular problems
Neurological deficits
Which of the following is a recommended preventive measure for scoliosis?
A) Regular spinal exercises
B) Routine screening during growth periods
C) Avoiding heavy lifting
D) Maintaining a healthy weight
B) Routine screening during growth periods
Explanation: Early detection through screening can lead to timely interventions, preventing progression
What is torticollis?
Torticollis is a condition characterized by a persistent tilt of the head to one side, often accompanied by limited neck movement.
Which of the following is the most common type of torticollis in children?
A) Congenital muscular torticollis
B) Acquired torticollis
C) Spasmodic torticollis
D) Cervical dystonia
A) Congenital muscular torticollis
Explanation: Congenital muscular torticollis is the most prevalent form in children, often presenting at birth.
What are common symptoms of torticollis in children?
Head tilts to one side
Limited neck movement
Swollen neck muscles
Uneven shoulders
Which physical examination test is commonly used to assess torticollis?
A) Trendelenburg test
B) Forward bend test
C) Neck rotation test
D) Straight leg raise test
C) Neck rotation test
Explanation: The neck rotation test helps assess the range of motion and identify any restrictions in neck movement.
What is the first-line treatment for congenital muscular torticollis?
A) Physical therapy
B) Surgical intervention
C) Botulinum toxin injection
D) Oral analgesics
A) Physical therapy
Explanation: Early intervention with physical therapy focusing on stretching and strengthening exercises is the primary treatment.
True or False: Most children with congenital muscular torticollis recover completely with early treatment.
True
Explanation: With early and appropriate treatment, most children experience full recovery.
What are potential complications of untreated torticollis?
Facial asymmetry
Developmental delays
Persistent neck deformity
Which of the following is a recommended preventive measure for torticollis?
A) Regular neck exercises
B) Avoiding prolonged positioning on one side
C) Early screening for neck abnormalities
D) All of the above
D) All of the above
Explanation: Regular neck exercises, avoiding prolonged positioning on one side, and early screening can help prevent torticollis.
Which condition should be considered in the differential diagnosis of torticollis?
A) Cervical spine fracture
B) Meningitis
C) Both A and B
D) None of the above
C) Both A and B
Explanation: Cervical spine fractures and meningitis can present with similar symptoms and should be ruled out.
True or False: Support groups and educational resources are beneficial for families managing a child with torticollis.
True
Explanation: Support groups and educational resources provide valuable information and emotional support for families.
