Musculoskeletal/Rheumatology Flashcards
Remind yourself of the different types of fracture- focusing on those common in children
Others include:
- Linear
- Avulsion
- Segmental
Why are children more prone to green stick & buckle fractures?
- Have more cancellous bone compared to adults who have more cortical bone hence children’s bone are more flexible but not as strong
- Greenstick: flexibility
- Buckle: less strength against compression
Children have a high capacity for bone remodelling; what are advantages of this when it comes to fractures?
Bone remodelling is the process where bone tissue is taken from areas of low tension and deposited in areas of high tension. This allows bone to change to the optimum shape for function. Bones in children have a high capacity for remodelling, which means that even if they are set at an incorrect angle, they will remodel over time to return to the correct shape.
Describe the Salter-Harris classification for growth plate fractures
Mnemonic “SALTR”
- Type 1: straight
- Type 2: above
- Type 3: below
- Type 4: through
- Type 5: crush
Principles of management of fractures in children is same as in adults; remind yourself of 3 principles of fracture repair
-
Fix
- Open reduction
- Closed reduction
-
Hold
- External casts
- K wires
- IM nails
- Screws
- Plates & screws
- Rehabilitate
Describe the WHO pain ladder for children
Which pain medications are not used in children and why?
WHO pain ladder:
- Step 1: paracetamol or ibuprofen (or both)
- Step 2: morphine (if child needs morphine you need to consider whether they need admission)
- Codeine and tramadol not used due to unpredictability in metabolism; this means their effects vary too much to make them a safe and effective option.
- Aspirin contraindicated in children under 16yrs due to risk of Reye’s syndrome (except certain circumstances e.g. Kawasaki disease)
State some potential causes of hip pain in the following age groups:
- 0-4yrs
- 5-10yrs
- 10-16yrs
**NOTE: there is some overlap
0-4yrs
- Septic arthritis
- Developmental dysplasia of hip (DDH)
- Transient synovitis
5-10yrs
- Septic arthritis
- Transient synovitis
- Perthes disease
10-16yrs
- Septic arthritis
- Slipped upper femoral epiphysis
- Juvenile idiopathic arthritis
State some red flags for hip pain in children
- Child under 3 years
- Fever
- Waking at night with pain
- Weight loss
- Anorexia
- Night sweats
- Fatigue
- Persistent pain
- Stiffness in the morning
- Swollen or red joint
When do NICE recommend urgent referral for assessment of a limping child?
- Child under 3 years
- Child older than 9 with a restricted or painful hip
- Not able to weight bear
- Evidence of neurovascular compromise
- Severe pain or agitation
- Red flags for serious pathology
- Suspicion of abuse
State some investigations you may do for a child with hip pain; for each state why
- Joint aspiration: septic arthritis
- FBC: raised WCC in septic arthritis
- CRP & ESR: inflammatory markers in septic arthritis, JIA
- Ultrasound: look for joint effusion
- X-rays: fractures, SUFE
- MRI: osteomyelitis
Septic arthritis can occur at any age; however, in what aged children is it most common?
0-4yrs
What is the most common causative organism in children with septic arthritis?
What are some other common causative organisms?
Most common= Staphylococcus aureus
Other bacteria:
- Neisseria gonorrhoea (sexually active teens)
- Group A streptococcus (Streptococcus pyogenes)
- Haemophilus influenza
- Escherichia coli
*Remember, S.aureus most common cause in adults too, followed by S.pneumoniae
Describe presentation of septic arthritis
Septic arthritis usually only affects a single joint. This is often a knee or hip. It presents with a rapid onset of:
- Hot, red, swollen and painful joint
- Refusing to weight bear
- Stiffness and reduced range of motion
- Systemic symptoms such as fever, lethargy and sepsis
Septic arthritis can be subtle in young children, so always consider it as a differential when a child is presenting with joint problems.
State some differential diagnoses for septic arthritis in children
- Transient synovitis
- Perthes disease
- Slipped upper femoral epiphysis
- Juvenile idiopathic arthritis
What investigations would you do for child with suspected septic arthritis?
- FBC: raised WCC
- U&Es: baseline
- LFTs: baseline
- CRP: raised
- Joint aspiration (for gram staining, crystal microscopy, culture & abx sensitivities)
- Blood culture: ?sepsis
What criteria can be used to help diagnose septic arthritis?
Kocher criteria
Discuss the management of septic arthritis
If suspect septic arthritis require admission to hospital & ortho involvement:
- Empirical IV abx e.g. IV flucloxacillin (switch to more specific once sensitivities known); abx usually for 3-6 weeks
- May require surgical drainage & washout
Transient synovitis (also known as irritable hip) is one of most common causes of hip pain in children aged 3-10yrs; discuss:
- What it is
- What is it usually associated with?
- Temporary inflammation & irritation in synovial membrane of joint
- Recent viral URTI
*NOTE: don’t typically have fever. If they have fever & joint pain need urgent investigations & management for septic arthritis
Discuss typical presentation of transient synovitis
Symptoms of transient synovitis often occur within a few weeks of a viral illness. They present with acute or more gradual onset of:
- Limp
- Refusal to weight bear
- Groin or hip pain
- Mild low grade temperature
Children with transient synovitis should be otherwise well. They should have normal paediatric observations and no signs of systemic illness. When other signs are present, consider alternative diagnoses.
Discuss the management of transient synovitis
- Exclude other differential diagnoses
- Symptomatic management with simple analgesia
- Can be managed in primary care if limp present for <48hrs and other diagnoses excluded; must give clear safety net advice and follow up between 48hrs-1 week later
Discuss prognosis of transient synovitis, include:
- How long it lasts for
- Any lasting problems/effects
- Recurrence
- Often significant improvement in 24-48hrs; symptoms fully resolve in 1-2 weeks
- No lasting problems
- Reoccur in 20%
For Legg-Calve-Perthes disease discuss:
- Common age of presentation
- Which gender most common in
- Cause
- Pathophysiology
- Mostly between 5-8yrs (but can occur in children aged 4-12yrs)
- More common in boys
- Idiopathic
- There is disruption of blood flow to femoral head leading to avascular necrosis of epiphysis. Over time there is revascularisation or neovascularisation and healing of femoral head alongside remodelling of bone as it heals
Describe typical presentation of Perthes disease
5-8yr old boy presenting with slow onset of:
- Pain in the hip or groin
- Limp
- Restricted hip movements
- There may be referred pain to the knee
- No history of trauma (NOTE: if history of minor trauma in older child think of SUFE)
What investigations may you do in suspected Perthes disease?
- Initial investigation= x-ray
- Others:
- FBC, CRP/ESR: exclude other causes
- Technetium bone scan
- MRI scan
Discuss the management of Perthes disease
Severity, and hence management, varies between pts. Aim to to maintain healthy position and alignment of joint to reduce risk of complications:
- Initial management in younger & less severe disease is conservative:
- Bed rest
- Traction
- Crutches
- Analgesia
- Physiotherapy to retain ROM
- Regular x-rays to assess healing
- Surgery may required in severe cases, older children or if bones are not healing
What it the main complication of Perthes disease?
- Soft, deformed femoral head leading to early hip OA
- Can also get premature fusion of growth plates
5% pts need total hip replacement
For slipped upper femoral epiphysis (SUFE)/ slipped capital femoral epiphysis (SCFE) discuss:
- What age common in (think about differences between genders)
- Which gender more common in
- Other risk factors
- What it is
*
- More common in boys and presents aged 8-15yrs
- Less common in girls and presents earlier at 11yrs
- More common in obese children
- Head of femur is displaced along the growth plate
Describe typical presentation of SUFE/SCFE
Typically adolescent, obese male who is going through growth spurt:
- History of minor trauma
- Hip, groin, thigh or knee pain
- Restricted ROM in hip
- Painful limp
- Restricted movement in hip
- On examination, prefer to keep hip in external rotation (and will have restricted internal hip rotation)
What investigations would you do if you suspect SUFE/SCFE?
- Initial investigation= x-ray hip (AP & lateral- typically frog leg view)
- Others (to exclude alternative pathology):
- FBC
- CRP/ESR
- Technetium bone scan
- MRI
- CT scan
Discuss the management of SUFE/SCFE
- Surgery: internal fixation typically using single cannulated screw in centre of epiphysis
For osteomyelitis, remind yourself:
- What it is
- Most common causative organism
- Risk factors
- Infection of bone & bone marrow
- Staphylococcus aureus
- More common in boys & children <10yrs (often have risk factor)
- Risk factors:
- Open bone fracture
- Orthopaedic surgery
- Immunocompromised
- Sickle cell anaemia
- HIV
- Tuberculosis
Describe typical presentation of osteomyelitis
Can present acutely with unwell child or more chronically with subtle features:
- Refusing to use the limb or weight bear
- Pain
- Swelling
- Tenderness
- High fever (if acute & spread to joint), low grade fever or afebrile
What investigations would you do if you suspect osteomyelitis, include:
- Initial investigation
- Best/gold standard investigation
- Others
- Initial investigation= x-ray (but can be normal)
- Best/gold standard= MRI
- Others:
- FBC, CRP/ESR
- Blood culture (important to find causative organism)
- Bone marrow aspirate
- Bone biopsy
Discuss the management of osteomyelitis
- Abx for 6 weeks (first line for acute osteomyelitis is flucloxacillin or clindamycin if penicillin allergic. Usually couple of weeks of IV then switch to oral. Diff abx if sickle cell)
- May require surgery for drainage and debridement
For osteosarcoma, discuss:
- Age typically presents in
- Most common bone affected
- 10-20yrs
- Most common bone affected= femur (other sites= tibia, humerus)
Describe typical presentation of osteosarcoma
- Persistent bone pain- worse at night time and may disturb or wake from sleep
- Bone swelling
- Palpable mass
- Restricted joint movements
What investigations would you do if you suspect osteosarcoma?
*include NICE guidelines about referral
-
Very urgent direct access x-ray within 48hrs if child presents with unexplained bone pain or swelling
- If x-ray suggests osteosarcoma need very urgent specialist assessment within 48hrs
- ALP blood test: raised
- CT scan
- MRI
- Bone scan
- PET scan
- Bone biopsy
Discuss the management of osteosarcoma
- MDT management
- Surgical resection of lesion (often with limb amputation)
- Adjuvant chemotherapy
*MDT involves: oncologists, surgeons, nurses, physio, OTs, psychology, dietician, prosthetics & orthotics, social services
State 2 main potential complications of osteosarcoma
- Pathological fractures
- Metastasis
What is talipes?
There are many types but state two common types
- Fixed abnormal ankle position present at birth (also known as clubfoot). Can occur in isolation or with syndromes.
- Types:
- Talipes equinovarus: ankle in plantar flexion & supination
- Talipes calcaneovalgus: ankle in dorsiflexion & pronation
What is positional talipes?
- Common condition in which resting position of ankle is in plantar flexion & supination but it is not fixed in this position and is no structural bone deformity in ankle although muscles around ankle are tight.
- Refer to physiotherapy for exercises; resolves with time.
Discuss the management of talipes
“Ponseti method”
- Start immediately after birth
- Foot manipulated towards normal position and then cast is applied
- This is repeated over and over until foot in correct position
- Achilles tenotomy performed at some point to release tension in Achilles tendon
- Once finished with cast treatment, brace is used to hold feet in correct position when not walking until child is ~4yrs “boots & bars”
If Ponseti method doesn’t work then may require surgery.
Describe Barlow & Ortalani tests
Barlow’s test
- Adduct the hip whilst applying light pressure on the knee with your thumb, directing the force posteriorly.
- If the hip unstable, femoral head will slip over the posterior rim of the acetabulum & produce palpable sensation of subluxation or dislocation (+ve test)
Ortolani’s Test
- Ortolani manoeuvre is then used to confirm the positive finding (i.e. that the hip actually dislocated)
- Flex the hips and knees to 90°
- With your index fingers placing anterior pressure on the greater trochanters abduct the infant’s legs using your thumbs.
- A positive sign is a distinctive ‘clunk’ which can be heard and felt as the femoral head relocates anteriorly into the acetabulum.
Discuss the management of DDH
- Pavlik harness (if diagnosis made before 6 months of age): kept on permanently and adjusted as baby grows. Keeps hips flexed & abducted to hold femoral head in acetabulum to allow it develop a normal shape. Child reviewed regularly & harness normally removed after 6-8 weeks.
- Surgery if harness fails or diagnosis made after 6 months of age. Wear a hip spica cast to immobilise hips after surgery.
Describe typical features of achondroplasia
- Disproportionate short stature (reduced limb lenght but normal trunk length; more proximal long bones are affected most)
- Short digits
- Trident hands (a hand in which the fingers are of nearly equal length and deflected at the first interphalangeal joint, so as to give a forklike shape)
- Genu varum (bow legs)
- Flattened mid-face
- Flattened nasal bridge
- Frontal bossing
- Disproportionate skull
- Foramen magnum stenosis
What is Osgood-Schlatter disease?
Discuss pathophysiology
- Knee pain due to inflammation at tibial tuberosity where patella tendon attaches to the tibia “tibial apophysitis”
- Pathophysiology:
- Patella tendon inserts into tibial tuberosity
- Tibial tuberosity is at epiphyseal plte
- Repetitive stress (e.g. from running, jumping etc..) on patella tendon can cause inflammation at tibial tuberosity and therefore of the tibial epiphyseal plate
- Multiple small avulsion fractures occur (if full avulsion fracture involving entire tibial tuberosity occurs needs surgery)
- Leads to growth of tibial tuberosity causing visible bump below knee
- Bump initially tender due to inflammation but as bone heals and inflammation settles becomes non-tender and hard
Describe presentation of Osgood Schlatter disease; include age & gender of presentation
Usually an adolescent (10-15yrs) male with unilateral symptoms (but can be bilateral):
- Pain in anterior knee
- Visible or palpable hard, tender lump at tibial tuberosity
- Pain exacerbated by physical activity, kneeling or extension of knee
Describe typical presentation of osteogenesis imperfecta
- Recurrent and inappropriate fractures
- Hypermobility
- Blue / grey sclera
- Triangular face
- Short stature
- Deafness from early adulthood
- Dental problems, particularly with formation of teeth
- Bone deformities, such as bowed legs and scoliosis
- Joint and bone pain
What is Kawasaki disease also known as?
What is Kawasaki disease?
Age group it affects
Is there a clear cause or trigger?
Who is it more common in?(2)
- Mucocutaneous lymph node syndrome
- Systemic, medium-sized vessel vasculitis
- Typically <5yrs
- No clear cause or trigger
- More common in boys & Asian children (particularly Japanese & Korean)
Describe symptoms & signs of Kawasaki disease
- Persistent high fever (>above 39 degrees for >5 days)
- Unhappy & unwell child
- Widespread erythematous maculopapular rash
- Erythematous palms and/or soles
- Desquamation on palms & soles
- Strawberry tongue (red tongue with large papillae)
- Cracked lips
- Cervical lymphadenopathy
- Bilateral conjunctivitis
There are 3 phases to Kawasaki disease: acute, subacute and convalescent stage. Describe each including how long each stage lasts
Acute Phase
- Most unwell
- Fever, rash, lymphadenopathy
- 1-2 weeks
Subacute Phase
- Acute symptoms settle
- Get desquamation & arthralgia
- Risk of coronary artery aneurysm
- 2-4 weeks
Convalescent stage
- Remaining symptoms settle
- Investigation results normalise
- Coronary artery aneurysms regress
- 2-4 weeks
Discuss the management of Henloch Schonlein Purpura
Supportive management:
- Simple analgesia
- Rest
- Hydration
Debate about whether to use steroids as evidence suggests they shorten duration of illness but do not affect long term outcomes or reoccurrence rate. May be considered if severe GI pain or renal involvement.
Close monitoring with repeated urine dipsticks & blood pressures.
For enthesitis-related JIA, discuss:
- What it can be thought of as
- Associated signs to look out for
- Who is most commonly affected
- Can be thought of as paediatric version of seronegative spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis, reactive arthritis, IBD-related arthritis). Hence majority of pts have HLA B27 gene. Have inflammatory arthritis of joints aswell as enthesitis.
- Look for:
- Psoriasis symptoms/signs
- IBD symptoms
- Recent infections
- Boys >6yrs
Discuss the management of rheumatic fever
Refer immediately for specialist management:
- NSAIDS: joint pain
- Aspirin & steroids: carditis
- Prophylactic abx (oral or IM penicillin V):to prevent further streptococcal infections & recurrence of rheumatic fever- continue into adulthood
- Monitoring & managing other complications
Describe presentation of hypermobile EDS
- Joint hypermobility
- Joint pain after activity
- Frequent joint dislocations
- Soft, stretchy skin
- Easy bruising
- Poor healing
- Bleeding
- Headaches
- TMJ dysfunction
- Myopia
- Autonomic dysfunction (dizziness & syncope)
- GORD
- Abdo pain
- IBS
- Menorrhagia
- Dysmenorrhoea
- Premature rupture of membranes in pregnancy
- Urinary incontinence
- Pelvic organ prolapase
Describe presentation of classical EDS
- Very stretchy skin that is smooth & velvety
- Severe joint hypermobility
- Abnormal wound healing
- Lumps over pressure points
- Prone to:
- Hernias
- Prolpase
- Mitral regurgitation
- Aortic root dilation
Describe presentation of vascular EDS
- Thin translucent skin (almost see through)
- Skin, organs & arteries are fragile & prone to rupture
- Unusual facial features (such as a thin nose and lips, large eyes and small earlobes)
- Varicose veins
What syndrome can occur with hypermobile EDS?
Postural orthostatic tachycardia syndrome (POTS)
- Autonomic dysregulation
- Causes inappropriate tachycardia during changes of posture e.g. sitting up standing up
- Result sin pre-syncopal symptoms, syncope, headaches, disorientation, nausea, tremor
