Musculoskeletal disorders

Question 1

What is the management of clubfoot?

Answer 1

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)

Question 2

What are the clinical features of developmental dysplasia of the hip?

Answer 2

Discovered during Barlow/Ortolani test
Confirmed via ultrasound
Ultrasound may also be conducted if identified as high risk

Question 3

What are the risk factors for developmental dysplasia of the hip?

Answer 3

Female sex: 6 times greater risk
Breech presentation
Positive family history
Firstborn children
Oligohydramnios
Birth weight > 5 kg
Congenital calcaneovalgus foot deformity

Question 4

What is the management of developmental dysplasia of the hip?

Answer 4

Splint or Pavlik harness
Progress monitored by ultrasound
Surgery if conservative fails

Question 5

What are the clinical features of torticollis?

Answer 5

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

Question 6

What are the clinical features of osteomyelitis?

Answer 6

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

Question 7

What is the management of osteomyelitis?

Answer 7

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

Question 8

What are the clinical features of Osgood-Schlatter disease?

Answer 8

Typically presents in sporty/active adolescent males
Osteochondritis of the patellar tendon

* Knee pain after exercise
* Swelling over tibial tuberosity 
* Localised tenderness

Question 9

What is the management of Osgood-Schlatter disease?

Answer 9

Pain relief:
• NSAIDs
• Paracetamol
• Ice pack over tibial tuberosity 3x a day

Stop sporting activities or
Reduce frequency/duration/intensity

Question 10

What are the clinical features of chondromalacia patellae?

Answer 10

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

Question 11

What are the clinical features of osteochondritis dissecans?

Answer 11

Persistent knee pain in physically very active adolescents
Localised tenderness of femoral condyles
• Knee locking
• Knees giving way

Management is rest and quadricep exercises

Question 12

What are the clinical features of transient synovitis?

Answer 12

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

Question 13

What are the clinical features of Perthes disease?

Answer 13

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

Question 14

What is the management of Perthes disease?

Answer 14

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

Question 15

What are the clinical features of Slipped Upper Femoral Epiphysis? (SUFE)

Answer 15

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

Question 16

What is the management of Slipped Upper Femoral Epiphysis?

Answer 16

Internal fixation with screws

Question 17

What are the clinical features of reactive arthritis?

Answer 17

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

Question 18

What is the management of reactive arthritis?

Answer 18

Self-resolving

NSAIDs for pain

Question 19

What are the clinical features of septic arthritis?

Answer 19

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

Question 20

What is the management of septic arthritis?

Answer 20

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

Question 21

What are the clinical features of juvenile idiopathic arthritis?

Answer 21

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

Question 22

What is the management of juvenile idiopathic arthritis?

Answer 22

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

Question 23

What are the clinical features of osteogenesis imperfecta?

Answer 23

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

Question 24

What are the features of growing pains?

Answer 24

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