Musculoskeletal Flashcards
Screening for developmental dysplasia of the hip (DDH)
Barlow maneuvre at birth as routine examination of newborn:
Check if hip can be dislocated posteriorly out of the acetabulum
Or can be relocated back into the acetabulum (Ortolani Manoeuvre)
Repeat these at 8 weeks
Early detection usually responds to conservative treatment
Some centres perform US screening on all newborn infants (because acetabulum may only be mildly shallow - undetectable). However it is expensive, and has high false-positive rate. Can tell the degree of dysplasia and whether there is subluxation or dislocation
incidence of hip abnormality at birth
6-10 in 1000
Late presentation of hip abnormality
After 8 weeks Limp or abnormal gait Asymmetry Skinfolds around the hip Limited abduction of hip Shortening of affected leg
RF for developmental displasia of hip
Breech presentation
FHx
Female sex
Management of DDH
In US abnormal:
Splint or harness to keep the hip flexed and abducted for several months.
Progress monitored by US or XRAY
Risk of femoral head necrosis, so needs to be done by expert
If the conservative method fails, then surgery may be needed.
There is satisfactory response rate.
What is osteomyelitis
Infection of the metaphysis of long bones
Most commonly femur and proximal tibia
Skin is swollen directly over affected site
Causative factors of osteomyelitis
Staph aureus (most)
Streptococcus and HiB if not immunised
In sickle cell anaemia, there is a higher risk of staphylococcal and salmonella osteomyelitis
TB in an immunodeficient child
Clinical features of osteomyelitis
Markedly painful, immobile limb (pseudoparesis)
Acute febrile illness
Swelling and tenderness directly over the infected site.
Erythema and warmth?
Movement causes severe pain
Infants - more insidious. Swelling or reduced limb movement initially.
Back pain? vertebral infection
Limp or groin pain if pelvis
Occasionally, disseminated disease with multiple foci
Investigations for osteomyelitis
Blood cultures
WCC and CRP
X-rays initially normal. Soft-tissue swelling?
takes 7-10 days for bone rarefaction to become visible
Ultrasound may show periosteal elevation at presentation.
MRI allows identification of infection in bone (subperiosteal pus and purulent debris)
Management of osteomyelitis
Prompt treatment with parenteral antibiotics for several weeks (prevents bone necrosis, chronic infection with discharging sinus, limb deformity)
IV antibiotics until clinical recovery and normal CRP
Followed by oral abx for several weeks
If atypical presentation or immunodeficient or no quick response: aspiration/surgical decompression
Rest the affected limb in a splint and subsequently mobilise
What is subacute osteomyelitis? Symptoms?
Difficult to diagnose because characteristic Signs and symptoms absent
Insidious onset, mild symptoms and no systemic reaction
Mild to moderate localised pain - usually exacerbated by unusual physical activity
Night pain relieved by aspirin
Minimal loss of function
Symptoms usually last 1-6 months before diagnosis
Examination findings of subacute osteomyelitis
Localised tenderness
Occasionally warmth, redness, soft tissue swelling
Pain may occur with movement of the adjacent joint and some joint effusion may be present.
Surrounding muscle may show wasting
What is chronic osteomyelitis
Result of untreated acute osteomyelitis or a complication of pre-existing infection from syphillis
Multi-organism infections are common with chronic osteomyelitis
Permanent damage
Symptoms of chronic osteomyelitis
Bone pain Persistent fatigue Pus draining from a sinus Local swelling SKin changes Excessive sweating Chills
Risks of untreated/undertreated osteomyelitis
Can spread to other bones:
infection
sepsis
death
With chronic disease - there is destruction of bone, which is permanent and may result in the need for amputation due to poor vasculatisaton of the remaining bone
