Orthopaedics And Rheumatology Flashcards
Juvenile idiopathic arthritis
Autoimmune inflammation occurs in the joints
Arthritis without any other cause
Lasting >6 weeks
<16s
Key features of inflammatory arthritis
Joint pain
Swelling
Stiffness
Subtypes of juvenile idiopathic arthritis
Systemic JIA Polyarticular JIA Oligoarticular JIA Enthesitis related arthritis Juvenile psoriatic arthritis
Systemic juvenile idiopathic arthritis features
Still’s disease Systemic illness Subtle salmon-pink rash High swinging fevers Enlarged lymph nodes Weight loss Joint inflammation and pain Splenomegaly Muscle pain Pleuritic and pericarditis
Systemic JIA (Stills disease) investigations
ANA and RF negative
Raised inflammatory markers
Raised CRP, ESR, platelets, serum ferritin
Complications of systemic juvenile idiopathic arthritis
Macrophage activation syndrome: Acutely unwell child DIC Anaemia Thrombocytopenia Bleeding Non-blanching rash Life-threatening Low ESR key finding
Polyarticular juvenile idiopathic arthritis presentation
Idiopathic inflammatory arthritis in 5 joints or more
Symmetrical and can affect small joints of hands and feet
Can also affect hips and knees
Mild fever, anaemia, reduced growth
Mild systemic symptoms
Polyarticular JIA investigations
Rf negative, seronegative in younger
Seropositive patients are older
Oligoarticular JIA presentation
<4 joints
Usually only affects a single joint, mono arthritis
Tends to affect larger joints, often knee or ankle
Occurs more frequently in <6year old girls
Anterior uveitis, refer to ophthalmology, follow-up for uveitis
No systemic symptoms usually
Oligoarticular JIA investigations
Inflammatory markers normal or mildly elevated
ANA often positive
Rf often negative
Enthesitis- related arthritis presentation
Males >6 years
Inflammation of point where tendon inserts into bone
Check for psoriasis, IBD, anterior uveitis
Seronegative spondyloarthropathies
Ankylosing spondylitis Psoriatic arthritis Reactive arthritis Inflammatory bowel disease- related arthritis Inflammatory arthritis Enthesitis
Causes of enthesitis
Traumatic stress
Repetitive stress during sporting activities, caused by autoimmune inflammatory process
Investigations enthesitis-related arthritis
MRI
HLA B27
Key areas to palpate to elicit tenderness of entheses
Interphalangeal joints in hand
Wrist
Over greater trochanter on lateral aspect of hip
Quadriceps insertion at anterior superior iliac spine
Quadriceps and patella tendon insertion around patella
Base of Achilles, at calcaneus
Metatarsal heads on base of foot
Juvenile psoriatic arthritis presentation
Symmetrical poly arthritis affecting small joints
Asymmetrical arthritis affecting large joints in lower limb
Juvenile psoriatic arthritis signs on examination
Plaques of psoriasis on skin Nail pitting Onycholysis: separation of nail from nail bed Dactylitis; inflammation of full finger Enthesitis: inflammation of entheses
Management of JIA
Paediatric rheumatology
MDT
NSAIDs: ibuprofen
Steroids: oral, intramuscular, intra-articular in oligoarthritis
DMARD: methotrexate, sulfasalazine, leflunomide
Biologic therapy: TNFi, etanercept, infliximab, adalimumab
Ehler-Danlos syndrome
Genetic condition
Defects in collagen
Hyper mobility of joints
Abnormalities in connective tissue
Hyper mobile Ehlers-Danlos syndrome presentation
Hyper mobility in joints Joint pain after exercise or inactivity Joint dislocations, shoulders or hips Soft- stretchy skin Easy bruising Poor healing of wounds Bleeding Headaches Autonomic dysfunction causing dizziness and syncope Abdominal pain IBS Menorrhagia and dysmenorrhea Premature rupture of membranes in pregnancy Urinary incontinence Pelvic organ prolapse Temporomandibular joint dysfunction Myopia and other
Beighton score for hyper mobility
Palms flat on floor with straight legs Elbows hyperextend Knees hyperextend Thumb can bend to touch forearm Little finger hyper extends past 90 degrees
Management of Ehlers Danlos
Physiotherapy: strengthen and stability joints
Occupational therapy: maximise function
Maintaining good posture in joints
Moderating intensity of activity to minimise flares
Psychology
Postural orthostatic tachycardia syndrome
Autonomic dysfunction in hyper mobile Ehlers-Danlos syndrome
Inappropriate tachycardia on sitting or standing up
Distressing symptoms: pre-syncope, syncope, headaches, disorientation, nausea and tremor
Types of Ehlers-Danlos
Hyper mobile
Classical
Vascular
Kyphoscoliotic
Salter Harris classification
TY1: straight across growth plate TY2: above TY3: below TY4: through TY5: crush
Fracture management
Mechanical alignment via reduction
Provide relative stability
Pain ladder for children
Paracetamol or ibuprofen
Morphine
Causes of hip pain 0-4 years
Septic arthritis
DDH
Transient synovitis
5-10 years hip pain
Perthes
Septic arthritis
Transient synovitis
10-16 years joint pain
Septic arthritis
SUFE
Juvenile idiopathic arthritis
Red flags for hip pain
Child <3 years Fever Waking at night with pain Weight loss Anorexia Night sweats Fatigue Persistent pain Stiffness in morning Swollen or red joint
Criteria for urgent referral for assessment in 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
Investigations for hip pain
Blood tests including inflammatory markers (CRP and ESR) for JIA and septic arthritis
Xrays are used to diagnose fractures, SUFE and other boney pathology
Ultrasound can establish an effusion (fluid) in the joint
Joint aspiration is used to diagnose or exclude septic arthritis
MRI is used to diagnose osteomyelitis
Septic arthritis presentation
Most common in <4s Hot, red, swollen and painful joint Refusing to weight bear Stiffness and reduced range of motion Systemic symptoms: fever, lethargy, sepsis
Bacteria in septic arthritis
Staph aureus most common
Neisseria gonorrhoea (gonococcus) in sexually active teenagers
Group A streptococcus (Streptococcus pyogenes)
Haemophilus influenza
Escherichia coli (E. coli)
DD for septic arthritis
Transient sinovitis
Perthes disease
Slipped upper femoral epiphysis
Juvenile idiopathic arthritis
Septic arthritis management
Admission
Involve orthopaedics
Aspirate joint prior to giving antibiotics
Send sample for gram staining, Crystal microscopy, culture and antibiotic sensitivities
Joint fluid may be purulent
Empirical IV antibiotics 3-6weeks
Surgical drainage and joint washout
Transient synovitis presentation
Recent URTI 3-10 years Limp Refusal to weight bear Growing or hip pain Mild low grade temperature
Management of transient synovitis
Symptomatic management
Resolve in 1-2weeks
Perthes disease
Avascular necrosis of femoral head
Revascularisiation and healing, remodelling
Complication: hip osteoarthritis
Perthes presentation
Pain in hip or groin Limp Restricted hip movements Referred pain to knee No history of trauma
Perthes investigations
XRAY
Blood tests normal
Technetium bone scan
MRI
Perthes management
Bed rest, traction, crutches, analgesia
Physiotherapy
Regular X-rays
Surgery in severe case
Slipper upper femoral epiphysis presentation
8-15 years Obese children Minor trauma Hip, groin, thigh or knee pain Restricted range of hip movement Painful limp Restricted movement in the hip Restricted internal rotation
SUFE diagnosis
XRAY Blood tests normal Technetium bone scan CT MRI
Management of SUFE
Screw surgery
Development dysplasia of hip risk factors
First degree family history
Breech presentation from 36 weeks onwards
Breech presentation at birth if 28 weeks onwards
Multiple pregnancy
DDH screening
Neonatal examination
Birth
6-8 weeks
Features of DDH
Different leg lengths
Restricted hip abduction on one side
Significant bilateral restriction in abduction
Difference in the knee level when the hips are flexed
Clunking of the hips on special tests
Ortolans
Barlow
DDH diagnosis
Ultrasound
XRAY
DDH management
Pavlik harness 6-8 weeeks
Surgery
Hip spica cast post surgery
