Musculoskeletal Flashcards
Genu Varum (Bow Legs) Causes
Normal variant
Rickets
Osteogenesis
Blount Disease- severe progressive and unilateral
Genu Valgum (Knock-knees)
Internalleolar distance >8cm
Usually resolves spontaneously
Pes Planus (Flat feet) in Toddlers
Flatness of medial longitudinal arch
Presence of fat pad which disappears with age
Arch demonstrated standing on tip-toe or passive extension of big toe
Feature of hypermobility
Causes In-toeing
Metatarsus Varus
Medial tibial torsion
Persistent anteversion of femoral neck
Features Metatarsus Varus
Occurs in infants
Passively correctable
Heel held in normal position
Treatment if persists beyond 5 years
Features Medial tibial torsion
Occurs in toddlers
Associated with bowing o tibiae
Self-corrects by 5y
Tibia is laterally rotated less than normal in relation ot the femur
Features Femoral Neck anteversion
Presents in childhood
Corrects by age 8
Associated with hypermobility
W sitting (sit between feet with hips internally rotated)
Femoral neck is twisted more forward than normal
Osteotomy for persistent anteversion
MSK variations and normal ages
Bow Legs 1-3y Knock-knees 2-7y Flat feet 1-2y In-Toeing 1-2y Toe Walking 1-3y
Toe Walking
Common in young children
Walks normally on request
dDx: cerebral palsy, Duchenne, tightness of Achilles or inflammatory arthritis of the foot
Positional Talipes Features
Due to intrauterine compression
Mild deformity
Correctable to neutral position
Passive exercises in marked deformity
Talipes Equinovarus CAVE
Cavus Midfoot
Adductus Forefoot
Varus Hindfoot
Equinous Hiindfoot
Mx Talipes equinovarus
Plaster casting (Ponsetti method) Corrective surgery
Vertical Talus Features
Foot stiff
Rockerbottom shape
Confirmation by Xray
Surgery required
Talipes Calcaneovalgus
Foot dorsiflexed and everted
Due to intrauterine moulding
Usually self corrects
Associated with DDH
Tarsal Coalition
Lack of segmentation between one or more bones of foot
Coalitions become symptomatic as they ossify
Foot is progressively rigid with limited foot motion
More symptomatic during preadolescence
Radiograph normal until ossified
Corrective surgery
Pes Cavus
High arched foot
Associated with neuromuscular disorders in older children
Treatment required if symptomatic
Late Presentation DDH
Hip dysplasia- requires complex Mx including surgery Limp or abnormal gait Asymmetry of skinfolds around hip Limited abduction of the hip Shortening of affected leg
Ix DDH
Neonatal screening: Barlows (dislocates) Ortolani (relocates)
Repeated at 8 w
US in high risk infants
Mx DDH
Most spontaneously stabilise by 3-6w
Pavlick Harness- hip flexed and abducted (babies <4-5m)
Cx splinting: necrosis of femoral head
Surgery if fails
Risk factors DDH
female sex: 6 times greater risk breech presentation positive family history firstborn children oligohydramnios birth weight > 5 kg congenital calcaneovalgus foot deformity
Definition of scoliosis
Lateral curvature of front plane of the spine
Structural scoliosis: rotation of vertebral bodies
Causes of scoliosis
Idiopathic (early <5y or late 10-14y onset)
Congenital
Secondary
Mx Scoliosis
Mild resolves spontaneously
Severity and progression determined by Xray
Bracing
Surgery if co-existing pathology
Torticollis (Wry neck) Causes
Most commonly sternomastoid tumour Muscular spasm ENT infection Spinal tumour Cervical spine arthritis Malformation Posterior fossa tumour
Features Sternomastoid tumour
Occur in first few weeks of life Mobile, non tender nodule Felt within body of sternocleidomastiod Restriction of head turning and tilting of head Resolves by 2-6m
Features Growing Pains
Generalised pains in lower limbs Typically 3-12y Pain in night, waking from sleep Resolves with massage/comforting Symmetrical in lower limbs No limitation of physical activity
Features hypermobility
MSK pain confined to lower limbs Pain worse on exercise Symmetrical hyperextension -thumbs and fingers to forearm -elbows and knees >10' -flat feet with normal arch on tiptoe -hyperextensibility of knee Recurrent mechanical joint and muscle pain Associated with: Down's syndrome, Ehler-Danlos, Marfans
Complex Region Pain Syndrome Features
Most dramatic musculoskeletal pain
Usually adolescent females
Typically with distraction movement is normal
Localised forms typically foot and ankle
Triggered by minor trauma
Hyperasthesia, allodynia, cool, sweollen, mottled, flexed
Diffuse forms are widespread pain with disturbed sleep
Extreme exhaustion
Acute Onset Limb Pain dDx
NAI Trauma Osteomyelitis Bone Tumours Septic Arthritis
Osteomyelitis Pathology
Infection of metaphysis
Most common sites distal femur and proximal tibia
Haematogenous spread/direct spread from wound
Usually staph aureus
In sickle cells likely staph or salmonella
Non-immunised possibly strep or H.influenzae
Osteomyeltitis Presentation
Markedly painful immobile limb Acute febrile illness Swelling and tenderness over site Movement causes severe pain Sterile effusion of adjacent joint More insidious presentation in infants Pelvic infection- limp or groin pain Vertebral infection- back pain Multiple foci in disseminated infection
Ix Osteomyelitis
Positive blood cultures
WCC and acute phase reactants raised
Initially normal Xray w soft tissue swelling
Xray at 7d subperiosteal new bone formation and localised bone rarefaction
US periosteal elevation
MRI subperiosteal pus and purulent debris in bone
Redionucleotide bone scan can localise site
Xray chronic changes- periosteal reaction along lateral shaft
Mx Osteomyelitis
Parenteral Antibiotics for several weeks
IV until clinical recovery and acute phase reactants return to normal
Oral therapy for several weeks
Aspiration or surgical decompression of subperiosteal space (atypical or immunodeficiency)
Surgical draining if no response to Abx
Resting in splint
Cx Osteomyelitis
Bone necrosis
Chronic infection with discharging sinus
Limb Deformity
Amyloidosis
Malignancy presenting as bone pain
ALL (primarily at night)
Neuroblastoma (systemic arthritis or met bone pain)
Osteogenic sarcoma
Ewing tumour
Presentation malignant bone tumours
Pain or swelling
Pathological fracture
Osteoid Osteoma Typical Hx
Pain more severe at night Improves with NSAIDs Affects boys Involves femur, tibia or spine Localised soft tissue swelling/joint effusion
Xray Osteoid osteoma
Usually diagnostic
Sharply demarcated radiolucent nidus of osteoid tissue
Surrounding sclerotic bone
dDx Painful Knee
Osgood Schlatter Chondromalacia Patellae Osteochondritis Dissecans Subluxation and dislocation of patella Trauma
Osgood-Schlatter Features
Sporty teens esp. football
Pain and tenderness over tibial tuberosity
Hamstring tightness
Chondromalacia Patellae Features
Softening oif patella cartilage
common in teenage girls
Characteristically pain walking up stairs and rising from sitting
Associated with hypermobility and flat feet
Osteochondritis Dissecans Features
Pain after exercise
Intermittent swelling and locking
Suluxation of the Patella
Medial knee pain due to lateral subluxation
Instability or giving way
Associated with hypermobility
Dislocation may occur (laterally with severe pain)
Red Flags for Back Pain
Young age
High fever- infection
Night pain/waking- osteoid osteoma
Painful scoliosis- infection/malignancy
Focal neurology- nerve root/cord compression
Weight loss, systemic malaise- malignancy
Causes of back pain
Mechanical- spasm or soft tissue pain
Tumours- spin in osteoid osteoma
Vertebral osteomyeltitis/discitis- localised tenderness
Spinal cord/root entrapment- tumour/prolapsed disc
Scheuermann disease- osteochondosis of vertebral body (fixed thoracic kyphosis)
Spondylolysis- stress fracture of pars interarticularis
Complex region pain syndrome
Causes of a limp- toddlers
Toddlers:
- infection
- transient synovitis
- trauma
- malignant .e.g. leukaemia, neuroblastoma
Causes of a limp- child
Child:
- transient synovitis
- Septic arthritis/osteomyeltitis
- Trauma/overuse injury
- Perthes
- Juvenile idiopathic arthritis
- Malignancy .e.g. leukaemia
- Complex region pain syndrome
Causes of a limp- teens
Teens:
- Mechanical .e.g. overuse, trauma
- SUFE
- Avascular necrosis of femoral head
- Reactive arthritis
- Juvenile idiopathic arthritis
- Septic arthritis
- Osteochondritis dissecans
- Bone tumour and malignancy
- Complex regional pain syndrome
Features Transient synovitis
Children aged 2-12y
Follows viral infection
Sudden onset pain in hip or a limp
No pain at rest
Decreased range of movement , esp. internal rotation
Afebrile or mild fever, but generally well
Features Perthes
Mainly affects boys
5-10y
Insidious presentation
Onset of limp or hip/knee pain
Ix Perthes
Xray both hips lateral and frog leg
Increased density in femoral head
Repeat if normal Xray but persisting symptoms
Bone/MRI scan
Mx Perthes
Rest
Physiotherapy to optimise hip movement
Traction, plaster casts and surgery
Prognosis Perthes
<6y good prognosis
Older children poor prognosis
Cx: deformity of femoral head, metaphyseal damage, degenerative arthritis
Pathology SUFE
Displacement of epiphysis of femoral head posterior-inferiorly. Progresses to avascular necrosis
Features SUFE
10-15y during puberty/adolescent growth spurt
Typically obese boys
Association with metabolic endocrine abnormality
Limp or hip pain referred to knee
Restricted abduction and internal rotation of the hip
Mx SUFE
Internal fixation: typically a single cannulated screw placed in the center of the epiphysis
dDx Polyarthritis
Infection .e.g. sepsis, TB, virus Reactive; strep infection Inflammatory bowel disease: UC, Chron's Vasculitis: HSP, Kawasaki Haematological: Haemophilia, sickle cell Malignancy: neuroblastoma, leukaemia Connective tissue disorder: JIA, SLE, dermatomyositis, PAN, MCTD Cystic fibrosis
Features reactive arthritis
Transient joint swelling Usually <6w Often knee/ankle Follows extrarticular infection esp. enteric bacteria and STIs, rheumtic fever, Lyme Low grade fever Normal acute phase reactants
Features septic arthritis
Children <2y Single joint affected Particularly hip Staph (HiB in non-immunised) Erythematous, warm, tender joint Reduced range of movement Acutely unwell child Limb held still Peripheral joint effusion
Posturing Hip Septic Arthritis
Leg held flexed, abducted, externally rotated
Pseudoparalysis
Marked tenderness over head of femur
Movement resisted
Ix Septic Arthritis
WCC and acute phase reactants raised Blood cultures US deep joints identifies effusion Xray excludes trauma and bony lesions - initially normal with some joint widening Aspiration under US for culture
Mx Septic arthritis
Immediate IV antibiotics
Wash out of joint or surgical drainage
Immobilisation
Juvenille Idiopathic Arthritis Features
Joint swelling >6w Gelling (stiffness following rest) Morning joint stiffness Pain Intermittent limp Activity avoidance Prliferation of synovium
IX JIA
Usually normal
ANA positive but not specific
Long-term effects JIA
Bone expansion from overgrowth
- Leg lengthening
- Valgus deformity
- digit length discrepancy
- advancement of wrist bone age
Cx JIA
Chronic anterior uveitis Flexion contractures of joints Growth failure Constitutional .e.g. anaemia, delayed puberty Osteoporosis Amyloidosis
Types JIA
Oligoarthritis (persistent): 1-4 joints
Oligoarthritis (extended): >4 joints after 6m
Polyarthritis (RF +ve): symmetrical large and small joints
Polyarthritis (RF-ve)
Systemic Arthritis: acute illness and inflamamtory marker
Psoriatric arthritis: psoriasis and dactylitis
Enthesitis-related arthritis: Lower large joints HLAB27+
Undifferentuated: >2 subtype feature
Mx JIA
Induction of remission
NSAIDs and analgesia
Joint injection under US, with sedation
Methotraxate: weekly dose and regular bloods
Systemic corticosteroids: pulsed IV prednisolone
-life saving in macrophage activation syndrome
Cytokine modulation .e.g. anti-TNF, IL-1, CTLA-4, IL-6
Features Achondroplasia
AD inheritance Short stature Marked limb shortening Large head and frontal bossing Depression of nasal bridge Short and broad hands Lumbar lordosis
Thanatophoric dysplasia Features
Results in still birth Large head Short limbs Small chest Xray- characteristically curved femurs Sporadic inheritance
Cleidocranial dysostosis Features
AD inheritance Absence of clavicles Delay in closure of anterior fontanelle Delayed ossificatrion of skull Child can touch shoulders at the front of the chest Short stature
Arthrogryposis Features
Stiffness and contractures of the joints
Associated with oligohydramnios, chromosomal abnormalities, and widespread abnormalities
Usually sporadic
Marked flexion contractures of the knees, elbows, and wrists
Dislocation of the hips
Talipes Equinovarus and socliosis common
Thin skin with reduced subcut tissue
Marked muscle atrophy around affected joints
Impaired walking in severe forms
Mx Arthrogryposis
Phsyiotherapy Correction of deformities -splints -plaster casting -surgery
Osteogensis imperfecta Features
Bone fragility: bowing and fractures Fractures in childhood Blue sclerae Development of hearing loss Type 2: fatal, multiple fractures before birth
Mx Osteogenesis Imperfecta
Bisphosphonates to reduce fractures
Splinting of fractures to reduce deformity
Osteopetrosis Features
RARE Dense but brittle bones Faltering growth Recurrent infection Hypocalcaemia Anaemia Thrombocytopenia Poor prognosis
Mx Osteopetrosis
Bone marrow transplantation can be curative
Marfan’s syndrome Features
Tall stature Long thin digits (arachnodactyly) Hyperextensive joints High arched palate Dislocation of lenses of eyes (usually upwards) Severe myopia Altered body proportion (lower>>upper) -lower segment (pubis to soles) -upper segment (crown to pubis) Arm span greater than height Chest deformity Scoliosis
Cx Marfans Syndrome
Cardiovascular: -degeneration of media of vessel walls Dilated incompetent aortic root -valvular incompetence -mitral valve prolapse and regurgitation -aneurysm of aorta (risk dissection/rupture) Monitor by echo
