Musculoskeletal Flashcards
What bones is osteomyelitis commonest in in children?
Long bones: distal femur + proximal tibia
What pathogens may be causative of osteomyelitis?
How does it spread?
What non-infective cause may present similarly to osteomyelitis?
Usually S.Aureus Others: Streptococcus HiB TB (esp immunodefc)
Sickle cell disease
How does osteomyelitis present? (5)
Fever
Painful immobile limb (pseudoparesis)
Swelling / extreme tenderness esp on movement
Erythematous + warm
Poss sterile effusion of adjacent joint
What Ix are done if suspect osteomyelitis? (2+4)
Blood cultures (usually +ve) Raised WCC + CRP/ESR
X-Ray (7-10d show subperiosteal new bone formation)
USS (periosteal elevation)
MRI (diff from soft tissue infection)
Radionuclide bone scan (if infection site unclear)
How is osteomyelitis managed? (4)
IV Abx immediately (until clinical recovery/ CRP norm)
Aspiration / surg decompression (if atypical/ immunodefc)
Surgical drainage if Abx fail
Limb splinted /then mobilised
What are some complications of acute osteomyelitis if not treated soon enough? (6)
Bone necrosis Chronic osteomyelitis Spread → septic arthritis (when adj to epiphyseal plate) Discharging sinus Limb deformity Amyloidosis
How does subacute osteomyelitis present differently to acute?
Mild localised pain / tenderness (warmth, red, swelling) Exac by activity Night pain (relieved by aspirin) Minimal loss of func Poss adjacent joint effusion
What are some symps of chronic osteomyelitis? (6)
Bone pain Persistent fatigue Excessive sweating/chills Local swelling Pus draining from sinus Skin changes
How does chronic osteomyelitis occur?
What organisms involved?
How treated?
Untreated acute/ pre-existing syphillis
Multiple organisms involved
Req amputation (due to poor vacs of remaining bone + untreated spreads to other bones → sepsis)
Why is early identification of congenital dislocated hip (DDH) important?
Early ID responds to conservative treatment
Late ID requires complex treatment/surgery
How is DDH (developmental dysplasia of hip) screened for?
What is the incidence?
What Ix can Dx DDH?
Screened at newborn baby checks (Barlow + Ortolani manoeuvres) + repeated 8wks later as routine surveillance
Screening detects 6-10 in 1000
Barlow = hip dislocated posteriorly out of acetabulum Ortolani = relocated back into acetabulum on abduction
USS - showship quality + dysplasia quantity
How does DDH present later in life (if not already picked up on screening)? (4)
Limp/abnormal gait \+ Abnormal skin folds /Abducted limb /Shortening of affected leg
What are the RFs for DDH? (4)
Female (risk x6)
+ve FH (20% of affected)
Breech (30% of affected)
Neuromuscular disorder
How is DDH managed (conservatively)?
Splint/harness for several months (keeps hips flexed / adducted)
Monitor progress with USS/X-Ray
What is septic arthritis?
What is a complication ?
Serious infection of joint space
can → bone destruction
What child age group does septic arthritis typically occur in? + what joint?
Common in <2y/o boys
Mainly hip affected (only 1 joint)
How may septic arthritis occur?
What organisms involved?
Blood spread
Puncture wound/ infected skin lesions (e.g. chicken pox)
From adjacent osteomyelitis in epiphyseal plate
Similar organisms to osteomyelitis (S.Aureus**, strep, TB) + E.Coli
How may septic arthritis present? (5)
Acutely unwell, febrile child
Swollen thigh
Marked tenderness over head of femur
Leg held: flexed / abducted / externally rotated (reduces intracapsular pressure)
No spontaneous movement (pseudo paralysis)
How is a Dx of septic arthritis made? What Ix? (7)
Dx difficult as joint covered by subcut fat
Joint aspiration using USS + culture → definitive Dx (ideally perform first unless would signify delay Abx admin)
Blood cultures
Raised WCC
CRP/ESR
USS deep joints
X-Ray (exclude trauma)
MRI (demo adjacent osteomyelitis)
How is septic arthritis managed? (3)
IV Abx (then oral) Wash out / surgical drainage if not rapid resolution/deep seated infection (e.g. hip) Joint immobilised in functional position → then mobilised to prevent permanent deformity
What are the common fractures seen in NAI? (4)
Posterior ribs
Long bones e.g. humerus (esp if child not yet mobile)
Multiple fractures
Complex skull fractures
In a child presenting with a fracture, what 2 conditions (which increase fracture risk) must be ruled out?
Osteogenesis imperfecta
Copper defc
What are the main principles of management in a bone fracture? (5)
Control haemorrhage
Prevent limb ischaemia
Treat pain
Remove potential sources of contamination
→ then reduce fracture + immobilise
What is Juvenile Idiopathic Arthritis defined as?
What is its prevalence
How are the subtypes classified
Which is the commonest subtype
JIA = persistent (>6wk) joint swelling in <16yrs in absence of infection or other defined cause
1 in 1000 children
Classified by no. affected joints in 1st 6m: Polyarthritis (>4), Oligoarthritis (<4), Systemic (w. fever/rash)
Persistent oligoarthritis (50%)
What features in the Hx may you see in Juvenile Idiopathic Arthritis (3)
What are some long-term effects?
Initially joint swelling only minimal
Gelling (stiffness after periods of rest)
Morning joint stiffness + pain
Long term: bone expansion (from overgrowth) → deformities
What is the typical age onset of oligoarthritis (persistent/extended)
Female:Male?
What lab test/result
List some extra-articular features (2)
1-6yrs
Female 5: 1 Male
ANA +/-
Chronic anterior uveitis
Asymmetrical (leg length) growth
What articular pattern is seen in polyarthritis (of JIA)?
What are some extra-articular features
Symmetrical large + small joints + fingers (+RF-ve poss cervical spine + temperomandibular)
RF-ve: Low-grade fever, Chronic anterior uveitis
RF+ve: Rheumatoid nodules sim to adult RA
What is the age onset on systemic arthritis?
What lab results would be abnormal? (4)
1-10y/o Anaemia Raised neutrophils Raised platelets Raised CRP/ESR
What is the articular pattern in systemic arthritis?
What are the extra-articular features?
Oligo or poly
May have initial arthralgia/myalgia
Initial acute illness / malaise / high fever Salmon pink macular rash Lymphadenopathy Hepatosplenomegaly Serositis
What is the articular pattern for enthesitis-related arthritis?
What are the extra-articular features(2)
Lower limb
Initially large joint → mild lumbar/sacral involvement
Enthesitis (inflame at tendon/lig insertion into bones (often Achilles)
Occasionally acute uveitis
What are the different types of Juvenile Idiopathic Arthritis? (8) in the order of most common
Oligoarthritis persistent (50%) Polyarthritis RF-ve (15%) Systemic arthritis (10%) Oligoarthritis extended Psoriatic arthritis Enthesitis-related arthritis Polyarthritis RF+ve Undifferentiated arthritis
What are some associated conditions with Juvenile Idiopathic Arthritis? (6)
Chronic anterior uveitis Flexion contractors of joints Growth failure (general/localised) Constitutional problems (e.g. delayed puberty, anaemia) Osteoporosis Amyloidosis
What are some causes for osteoporosis in children? (4)
What can be done to reduce the risk of developing? (4)
Diet
Reduced weight bearing
Delayed menarche
Systemic corticosteroids
Dietary VitD + Calcium
Wt bearing exercises
Minimise oral corticosteroids
Bisphosphonates
What are the treatment options for JIA? (5)
NSAIDs + analgesia (symp relief) Joint injections (1st line for oligo) Methotrexate (for poly) Systemic corticosteroids (severe systemic arthritis) (avoid to minimise growth suppression / osteoporosis) Cytokine modulators (e.g. anti-TNFa)
What is Perthe’s disease?
Age onset / gender
= Avascular necrosis of femoral head epiphyses due to vascular interruption → revascularisation + reossification over 18-36m
5-10yrs
Male 5:1 Female
How does Perthe’s disease present?
DDx?
Ix? (3)
Gradual onset of limp / hip or knee pain (usually unilateral but bilateral in 10-20%)
DDx: transient synovitis
→ Bilateral hip X-Rays if suspect
Bone scan + MRI may aid Dx
What are the features of Reactive Arthritis? (commonest childhood arthritis) (4)
Transient joint swelling (ankles/knees) (<6wks)
Low grade fever
Inflamm of joints/skin/mucous membs/ urinary/GI tract
Eyes often involved
What are the causes of Reactive Arthritis? (3)
Divided into:
Post-Strep (Rheumatic fever)
Classical post-GI/UTI
Post-infective (inc others e.g. STI)
What is rickets?
What are the causes? (6)
= Failed mineralisation of growing bone / osteoid tissue (type of osteomalacia)
Vit D defc*
Extreme prematurity (diet defc phos/Ca)
Malabsorption (e.g. CF, Coeliac, panc insuff)
Drugs (esp anticonvulsants)
Impaired metabolic conversion / activation of VitD (chronic liver disease, hereditary type 1 Vit-D resistant rickets)
Target organ resistance to activated VitD (hereditary Vit-D dependant rickets type 2)
List the features of rickets (5)
Poor growth Delayed fontanelle closure (big forehead) Delayed baby teeth Odd ribs (Harrison sulci) Varus deformity of elbows + knees
How is Rickets Dx?
How is it managed?
Wrist X-Ray → shows wider epiphyseal plate
Blood tests → Low Ca/VitD/Phos, High parathyroid
Nutritional / Correction of RFs / daily VitD3
What is the cause of SUFE (slipped upper femoral epiphysis) in 10-15yrs + in <10yrs
What is it due to?
10-15yrs - obese (commonest)
<10yrs - endocrine abn (e.g. hypothy/hypogonadism) (bilateral)
Due to femoral head epiphysis displacing poster-inferiorly
How does SUFE present? (3)
Acute (post minor trauma) or insidious
Limp / hip pain (+ poss referred knee pain)
Restricted abduction + internal rotation of hip
How is SUFE managed?
Dx X-Ray (frog view)
Needs prompt to prevent avascular necrosis
Analgesia
Surgical fixation
What are some causes of scoliosis? (6)
Idiopathic (commonest) Congenital (e.g. VACTERL) Secondary to: Neuromuscular imbalance (CP/DMD) Bone disorders (NF1) Connective tissue (Marfan) Leg length discrepancy (JIA one knee)
What is Torticollis?
= Flexion, extension or twisting of neck muscle → allowing to move beyond normal position
What is the commonest cause of acute hip pain in children? + what age group
Transient synovitis
Occurs 2-12yrs
How does transient synovitis present? (5)
During/post-virus
Sudden onset limp / hip pain (poss referred knee pain)
Pain only on movement
Limited range of movement (esp internal rotation)
Afebrile
Normal Ix if suspect transient synovitis (5)
WCC (raised) CRP/ESP (slightly raised) USS (fluid in joint) XRay (normal Joint aspiration + culture (if suspect early septic arthritis of hip)
How is transient synovitis managed?
Best rest + analgesia
Usually resolves in <1wk
What are the DDx for acute painful limp in:
1-3yrs (4)
3-16yrs (6)
1-3yrs: Infection (septic arthritis, osteomyelitis) Inflamm - transient synovitis Trauma Malignancy (leukaemia, neuroblastoma)
3-16yrs: Infection (septic arthritis / osteo) Inflamm - transient synovitis JIA Trauma Malignancy (leukaemia) Perthe's Older: SUFE, Reactive arthritis
What are the DDx for chronic intermittent limp in:
1-3yrs (3)
3-10yrs (3)
10-16yrs (2)
1-3yrs:
DDH / talipes
Neuromuscular (e.g. CP)
JIA
3-10yrs:
Perthe’s (chronic)
Neuromuscular (DMD)
JIA
10-16yrs:
SUFE (chronic)
JIA
What should be considered as DDx in a children with nocturnal wakening w. leg pain? (3)
Growing pains
Osteoid osteoma
Malignancy (anaemia, bruising, infections)
What should be considered in a child with ‘clunking’ hip movement on screening / limp in older infant?
What other features would be seen to match this Dx?
DDH
Asymm upper leg skin folds
Limitied hip abduction
What are the DDx of a febrile / toxic looking infant, showing irritability with nappy changing? (2)
Septic arthritis
Osteomyelitis
What are the DDx of a sudden limp in otherwise well child? (2)
Transient synovitis of hip
Perthe’s
What musculoskeletal disorder would be considered in a child showing fever, erythematous rash, red eyes + irritability (young child / infant)
Kawasaki disease
What would be considered in a child showing joint pain, stiffness + restriction (+ poss loss of function)?
JIA
What would be considered in an adolescent obese boy showing hip pain?
SUFE
What would be considered in an adolescent girl with constitutional delay, lethargy + arthralgia?
SLE
