Musculoskeletal Flashcards
What is the incidence and risk factors of congenital dislocated hip?
6-10 per 1000 live birth
Most resolve spontaneously
Female x6
FH
Breech birth
Neuromuscular disorder
How is congenital dislocated hip screened for?
Neonatal screening
Barlow manoeuvre - hip dislocates posteriorly
Ortolani manoeuvre - hip can be relocated back into acetabulum on abduction
Repeated at 8 weeks
USS if still suspected
What is osteomyelitis and what causes it?
Infection of metaphysis of long bones
Common sites - distal femur and proximal tibia
Usually haematological spread of pathogen but can spread from wound
Most caused by staph. aureus but streptococcus and Hib if not immunised
How does osteomyelitis present?
Markedly painful, immobile limb (BONE) in child with acute febrile illness
Site is swollen, tender and warm
Movement causes severe pain
What investigations are needed for osteomyelitis?
Blood culture - usually +ve
WBC and CRP raised
X-ray shows soft tissue swelling, need MRI
What is the treatment for osteomyelitis?
IV Abx for several weeks
Aspiration of site
What is sub-acute osteomyelitis?
Lack of signs and symptoms - mild pain - worse after exercise or at night
What is chronic osteomyelitis?
If acute osteomyelitis isn’t treated -> sepsis, amputation, death
Complications are bone necrosis, chronic infection, discharging sinus, limb deformity and amyloidosis
What is septic arthritis?
Serious infection of joint space which can lead to bone destruction
Results from haematological spread or puncture wound or infected skin lesions
Spread from adjacent osteomyelitis in young children
Usually one joint (hip) affected by staph. aureus (always rule out Hib and TB)
How does septic arthritis present?
Erythematous, warm JOINT with reduced movements in febrile child
What investigations are done for septic arthritis?
WCC and CRP are raised
Blood cultures
USS shows effusion
Aspirate joint space under USS for organisms and culture = DIAGNOSIS
How is septic arthritis treated?
IV Abx
Washing out of joint
What fracture suggest NAI?
Ribs
Long bones (esp humerus) if child isn’t mobile
Multiple fractures
Complex skull fractures
What are the most common fractures?
Distal forearm Hand, phalanges Carpal-metacarpal Clavicle Ankle
How are fractures managed?
Control haemorrhage
Treat pain
Prevent limb ischaemia
Remove sources of contamination
What is juvenile idiopathic arthritis?
Persistant joint swelling (>6 weeks)
Presenting before 16yo
Absence of infection or any defined cause
Gelling (stiffness after periods of rest)
Morning joint sitffness
Pain
Long term bone expansion from overgrowth -. deformities and advanced bone age
What are the types of JIA?
Number of joints affected in first 6 months:
Polyarthritis >4
Oligoarthritis
Systemic
What is oligoarthritis?
Most common
1-6yo
F>M
Knee, ankle, wrist most common - not symmetrical
Chronic ant UVEITIS - if ANA +ve then more likely
Excellent prognosis
What is polyarthritis?
F>M
Symmetrical large and small joints - esp jaw
RF +ve is more severe, occurs in older and has worse prognosis
RF -ve is less severe
What is systemic arthritis?
Adolescents
F=M
Oligo/polyarthritis
Acute illness -> malaise, daily high fever, salmon rash, lymphadenopathy, hepatosplenomegaly
Anaemia, raised neutrophils and platelets, v high CRP
Variable to poor prognosis
What is psoriatic arthritis?
7% 1-16yo F=M Assymmetrical large and small joints Psoriasis, nail pitting, chronic ant uveitis Moderate prognosis
What is enthesitis-related arthritis?
7%
6-16yo
F
What is undifferentiated arthritis?
1%
1-16yo
F=M
Overlapping articular and extra-articular patterns between sub-types
What conditions are associated with JIA?
Chronic anterior uveitis - severe visual impairment so need regular opthalmological screening
Flexion contractures of the joints - joint is held in most comfortable position
Growth failure - generalised or from corticosteroid treatment
Osteoporosis - reduce risk by dietary supplements of calcium and vit D, weight bearing exercise
What are treatments for JIA?
NSAIDs and analgesia - relieve symptoms
Joint injections - under USS guidance
First line treatment for oligoarticular HIA
Bridging treatment for polyarticular when starting methotrexate
Methotrexate - early use reduces joint damage, less effective in systemic disease
Systemic corticosteroids - avoid if poss, may be life saving in severe systemic
Cytokine modulators (anti-TNF, IL-1) - once methotrexate doesn’t work
What is Perthe’s disease and what is the epidemiology?
Avascular necrosis of capital femoral epiphysis due to interruption of blood suplly followed by revascularisation and reossification
Affects boys 5-10yo
How does Perthe’s disease present?
Limp, knee or hip pain
Bilateral in 20%
X-ray of hips - increased density in femoral head -> fragmented and irregular
What is prognosis of Perthe’s disease?
If identified early - bed rest and traction
More severe disease - femoral head must be covered by acetabulum to act as mould so hip is kept in abduction with plaster on calipers
What is reactive arthritis?
Most common form of arthritis in childhood
Transient joint swelling
How does reactive arthritis present?
Low grade fever with inflammation of joints, skin, mucous membranes, urinary and GI tract
CRP normal or mildly raised
HLA-B27 +ve
NSAIDs only treatment needed, unless chronic the steroids and methotrexate
What is rickets and what causes it?
Failure of mineralisation of growing bone or osteoid tissue
Seen in children with malabsorptive conditions, extreme prems from low phosphorus
Drugs - anticonvulsants (phenytoin)
Hepatic and renal disease - impaired metabolic conversion of vit D
How is vit D metabolised?
Sunlight reacts with 7-dehydrocholesterol on skin -> vitamin D3 (cholecalciferol)
Vit D3 enters liver and is metabolised to 25(OH)D3
Hydroxylated in kidney -> 1,25(OH)2D3 = most active form
How does rickets present?
Ping-pong sensation of skull (craniotabes) Palpable costochondral junctions Wide wrists and ankles Bowed legs Misery Hypotonia Seizures
What are risk factors for slipped upper femoral epiphysis?
Boys 10-15yo, particularly obese
Bilateral in 20%
Associated with hypothyroidism, hypogonadism
How is slipped upper femoral epiphysis treated?
Surgical pin fixation in situ
What is flat foot?
Pes planjus
Physiological in toddlers
May indicate congenital tarsal coalition
In older child, rigid flat foot is pathological - tendo-Achilles contracture
What is talipes?
Positional talipes - common from intrauterine compression - can be passively manipulated
Talipes equinovarus - entire foot inverted and supinated, forefoot adducted
Affected foot is shorter
Associated with DDH and spina bifida
What is osteogenesis imperfecta?
Group of disorders of collagen metabolism -> bone fragility, bowing and frequent fractures
What is type 1 OI?
Most common and due to autosomal dominant inheritance
Fractures during childhood
Blue sclera
?hearing loss
Dilated aortic root and thin heart valves
Treat with bisphosphonsates to reduce fracture rate
What is type 2 OI?
Severe, lethal form with multiple fractures pre-birth
Many are stillborn
What is type 3 OI?
Severely progressive
May be born with fractures and have short stature and impaired dentition
What is polydactly associated with?
>5 digits on hands or feet Trisomy 13 - Patau Trisomy 21 Tibial hemimelia Ellis-van Creveld syndrome
What is syndactyly associated with?
Fusion of 2 or more digits
Apert syndrome
Poland syndrome
What is scoliosis?
Lateral curvature of frontal plane of spine
Mainly mild, pain free and cosmetic but can cause cardiorespiratory failure
What are causes of scoliosis?
Idiopathic - onset before 5 or during puberty growth spurt
Congenital - VACTERL
What is skeletal dysplasia?
Heterogeneous group of >200 disorders of abnormalities of cartilage and bone growth
Involves growth plate
What is achondroplasia?
Autosomal dominant but 50% new mutations Short limbs Large head Frontal bossing Depression of nasal bridge Short and broad hands Lumbar lordosis
What is thanatophoric dysplasia?
Results in stillbirth
Large head
Extremely short limbs
Small chest
What is cleidocranial dyostosis?
Autosomal dominant
Absence of part or all of clavicle - can bring shoulders together
What is arthrogryposis?
Stiffness and contracture of joints with unknown cause
Dislocating hips
Talipes
Scoliosis
What is torticollis and what causes it?
Flexion, extension or twisting of muscle in neck allowing abnormal movement
Sternocleidomastoid tumour
Muscular spasm
ENT infection
What is transient synovitis?
Most common cause of acute hip pain in 2-12 yo
Follows or is accompanied by viral infection
No pain at rest but decreased movement
Does not appear ill
Normal WCC
Normal/slightly high ESR
What is the diagnostic criteria for Kawasaki disease?
Fever >38.5 for >5 days
Plus 4 of:
Bilateral non-purulent conjunctivitis Oral mucosal changes Cervical lymphadenopathy Hands and feet: red, swollen and peeling Polymorphous rash
What are the complications of Kawasaki?
Cardiac artery aneurysm
Myocarditis and MI
Pericarditis
Cardiac tamponade
How is Kawasaki managed?
IV immunoglobulin
Aspirin
