Musculoskeletal disorders Flashcards
What is the management of clubfoot?
Also known as talipes equinovarus
Involves entire foot inversion and supinated
Positional talipes (caused by intrauterine pressure) is common and can be corrected with passive manipulation.
If foot is fixed, this may be associated with oligohydramnios or spina bifida. Treatment is with plaster casting and bracing (Ponseti method)
What are the clinical features of developmental dysplasia of the hip?
Discovered during Barlow/Ortolani test
Confirmed via ultrasound
Ultrasound may also be conducted if identified as high risk
What are the risk factors for developmental dysplasia of the hip?
Female sex: 6 times greater risk Breech presentation Positive family history Firstborn children Oligohydramnios Birth weight > 5 kg Congenital calcaneovalgus foot deformity
What is the management of developmental dysplasia of the hip?
Splint or Pavlik harness
Progress monitored by ultrasound
Surgery if conservative fails
What are the clinical features of torticollis?
Presents with a wry neck
Caused by tumour on sternocleidomastoid muscle
Can be felt in first week of life
Usually self-resolves after 6 months
What are the clinical features of osteomyelitis?
Infection of the metaphysis of the long bones
Normally caused by staph aureus
Typically affecting distal femur or proximal tibia
• Swelling and exquisite tenderness
• Painful, immobile limb
• Acute febrile illness
• Sterile effusion
Investigations: • Raised WCC and CRP • Blood cultures positive • X-Ray normal for first week. Then might see then may see new bone formation • Ultrasound shows periosteal elevation • MRI to identify infection in bone
What is the management of osteomyelitis?
Take blood cultures before starting antibiotics
High dose empirical IV antibiotics for 2-4 weeks
Once clinical recovery or fall in CRP demonstrated, switch to oral antibiotics
Immobilise affected leg and give analgesia
Surgical debridement if necrotic or biofilm
What are the clinical features of Osgood-Schlatter disease?
Typically presents in sporty/active adolescent males
Osteochondritis of the patellar tendon
* Knee pain after exercise * Swelling over tibial tuberosity * Localised tenderness
What is the management of Osgood-Schlatter disease?
Pain relief:
• NSAIDs
• Paracetamol
• Ice pack over tibial tuberosity 3x a day
Stop sporting activities or
Reduce frequency/duration/intensity
What are the clinical features of chondromalacia patellae?
Softening of the articular cartilage of the patella
Typically affects adolescent women
• Pain when patella apposes femoral condyle
• Such as going up stairs or standing from a sitting position
Management is with physiotherapy to strengthen quadriceps
What are the clinical features of osteochondritis dissecans?
Persistent knee pain in physically very active adolescents
Localised tenderness of femoral condyles
• Knee locking
• Knees giving way
Management is rest and quadricep exercises
What are the clinical features of transient synovitis?
Most common cause of hip pain in children
Typically follows or is accompanied by viral infection
• Sudden onset hip pain
• Not painful at rest
• Decreased range of motion
• Mild fever but may be afebrile
Management:
• If worry of septic arthritis, take joint aspirate and blood culture
• If not, bed rest, NSAIDs, paracetamol
• Will resolve after a few days
What are the clinical features of Perthes disease?
Avascular necrosis of the femoral epiphysis of the femoral head
Followed be revascularisation and reossification for 18-36 months
• Limp or hip/knee pain
• Insidious onset
Investigations:
X-Ray of both hips - Increased density in femoral head
What is the management of Perthes disease?
To keep the femoral head within the acetabulum: cast, braces
If less than 6 years: observation
Older: surgical management with moderate results
Operate on severe deformities
What are the clinical features of Slipped Upper Femoral Epiphysis? (SUFE)
Displacement of the epiphysis of the femoral head posteroinferiorly
Prompt treatment required to prevent necrosis
Most common in 10-15 y/o that are obese
Associated with metabolic abnormalities
* Limp or hip pain * Restricted abduction and internal rotation of hip
Investigation:
X-Ray
What is the management of Slipped Upper Femoral Epiphysis?
Internal fixation with screws
What are the clinical features of reactive arthritis?
MOST COMMON form of arthritis in childhood
• Transient joint swelling (< 6 weeks)
• Often affects the ankles and knees
• Usually follows evidence of extra-articular infection
• Enteric bacteria (Salmonella, Shigella, Campylobacter and Yersinia) = Children
• Sexually transmitted infections (Chlamydia, Gonococcus) = Adolescents
• More rare causes include Mycoplasma and Borrelia burgdorferi (Lyme disease)
• Rheumatic fever and post-streptococcal reactive arthritis are more common in low-income countries
• Patients may have a low-grade fever
What is the management of reactive arthritis?
Self-resolving
NSAIDs for pain
What are the clinical features of septic arthritis?
Typically occurs in <2 y/os Staph aureus infection Affects one joint, the hip typically • Erythematous, tender joint • Reduced range of motion • Febrile • Infant holds limb still • Cries when joint moved • Joint effusion
Investigations: • Joint aspiration under ultrasound is diagnostic • High WCC • High CRP/ESR • Ultrasound shows effusion • X-ray to rule out trauma
What is the management of septic arthritis?
IV antibiotics for first 2 weeks, then 4 weeks of oral antibiotics
Suspected Gram-positive
□ Vancomycin + joint aspiration
□ 2nd line = clindamycin or cephalosporin + joint aspiration
Suspected Gram-negative
□ 3rd generation cephalosporin (e.g. ceftriaxone) + joint aspiration
□ 2nd line = IV ciprofloxacin + joint aspiration
Affected joints should be aspirated to dryness regularly
What are the clinical features of juvenile idiopathic arthritis?
Persistent joint swelling (> 6 weeks duration) presenting before 16 years of age in the absence of infection or any other defined cause Polyarthritis = > 4 joints Oligoarthritis = < 4 joints Systemic = Fever and rash • Stiffness after rest • Morning stiffness • Joint pain
What is the management of juvenile idiopathic arthritis?
Patients should be managed by a specialist paediatric rheumatology multidisciplinary team
○ Physical/Occupational therapy is encouraged
○ Inactivity leads to deconditioning, disability and decreased bone mass
NSAIDs are useful for controlling pain and stiffness
Corticosteroids are useful adjunctive agents (whilst waiting for second-line agents to have an effect)
DMARDs (oral or SC methotrexate) used when the disease fails to respond to conventional treatments
○ 2nd line: Sulfasalazine
What are the clinical features of osteogenesis imperfecta?
Group of disorders of collagen metabolism causing bone fragility Causes bowing and frequent fractures ○ Type I § Autosomal dominant § Fractures during childhood § Blue sclerae § Some develop hearing loss § MANAGEMENT: Bisphosphonates
○ Type II § Severe, lethal form § Multiple fractures before birth § Many infants are stillborn
What are the features of growing pains?
Never present at the start of the day after the child has woken No limp No limitation of physical activity Systemically well Normal physical examination Motor milestones normal Symptoms are often intermittent Worse after a day of vigorous activity
