Orthopaedics and Rheumatology Flashcards

Question

What are common causes of joint pain 5-10 years?

Answer 1

Septic arthritis Transient sinovitis Perthes disease

Answer 2

Septic arthritis Slipped upper femoral epiphysis SUFE Juvenile idiopathic arthritis

Answer 3

``` 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 ```

Answer 4

``` Child under 3 Older than 9 with restricted or painful hip Unable to weight bear Evidence of neuromuscular compromise Severe pain or agitation Red flags of serious pathology Suspicion of abuse ```

Answer 5

``` Bloods, including inflammatory markers ESR + CRP for JIA and septic arthritis X-Rays for fractures, SUFE US for effusion in joint Joint aspiration - septic MRI - osteomyelitis ```

Answer 6

Infection inside a joint Most common under 4 Important complication of joint replacement Often a knee or hip Hot, red, swollen, painful Refusing to weight bear Stiffness, reduced range of motion Systemic symptoms e.g. fever, lethargy, sepsis

Answer 7

Staph aureus most common Neisseria gonorrhoea in sexually active teens Group A strep/strep pyogenes H influenza E Coli

Answer 8

Transient sinovitis Perthes Slipped upper femoral epiphysis Juvenile idiopathic arthritis

Answer 9

Aspiration before antibiotics Gram stain, crystal microscopy, culture, sensitivities Empirical abx - flucloxacillin or clindamycin if penicillin allergy If gonococcal - cefotaxime or ceftriaxone 4-6 weeks May require surgical drainage and washout

Answer 10

Irritable hip Temporary irritation and inflammation in the synovial membrane of the joint Most common cause of hip pain in children 3-10 Often associated with recent viral URTI

Answer 11

Do not have a fever - if so consider septic arthritis! ``` Occurs within few weeks of viral illness Acute or gradual onset Limp Refusal to weight bear Groin or hip pain Mild low grade temperature Should otherwise be well ```

Answer 12

Symptomatic - simple analgesia to ease discomfort Managed in primary care aged 3-9 if limp is present for less than 48 hours and otherwise well Safety net to attend A&E immediately if worsen or develop a fever Typically symptoms improve after 24-48 hrs, resolve within 1-2 weeks without any lasting problems

Answer 13

Leg held flexed, abducted, externally rotated No spontaneous movement Marked tenderness over head of the femur Swollen thigh

Answer 14

Most common form of arthritis in children Triggered by infection elsewhere in the body Transient joint swelling <6 weeks - often ankles or knees Usually follows extra-articular infection Low grade fever No treatment or only NSAIDs required Can't see - conjunctivits Can't pee - urethritis Can't climb a tree - arthritis

Answer 15

Enteric bacteria - salmonella, shigella, campylobacter Viral infections, STIs e.g. chlamydia, gonococcus Mycoplasma Borrelia - Lyme disease

Answer 16

Infection of bone and bone marrow | Mostly occurs in metaphysic of long bones

Answer 17

Staphylococcus aureus May have been introduced directly into bone e.g. fracture, or entered through another route e.g. skin or gums Can also be due to Streptococcus or Haemophilus influenza In sickle cell - there is an increased risk of staphylococcal and salmonella

Answer 18

``` More common in boys and under 10 Open bone fracture Orthopaedic surgery Immunocompromised Sickle cell anaemia HIV TB ```

Answer 19

``` Can present acutely in an acutely unwell child, or chronically with subtle features Refusing to use limb Will not weight bear Pain Swelling Tenderness ``` May be afebrile or have low grade fever Children with acute osteomyelitis may have high fever, particularly if spread to joint causing septic arthritis

Answer 20

``` X-rays, btu could be normal MRI Bone scan Bloods - raised CRP, ESR and WCC Blood culture Bone marrow aspiration or bone biopsy with histology ```

Answer 21

Periosteal reaction along lateral shaft of tibia | Multiple hypotenuse areas within the metaphysical regions

Answer 22

Flucloxacillin, 6 weeks for acute infection Consider adding fusidic acid or rifampicin for initial 2 weeks Or clindamycin, or vancomycin Aspiration or surgical decompression of subperiosteal space may be needed Surgical drainage Rested in splint and then mobilised

Answer 23

Disruption of blood flow to the femoral head causing avascular necrosis

Answer 24

Children aged 4-12 Mostly between ages 5-8 More common in boys

Answer 25

Revascularisation or neovascularisation and healing, leads to remodelling and a soft and deformed head can lead to early hip osteoarthritis

Answer 26

Slow onset Pain in hip or groin Restricted hip movements Referred pain to knee No history of trauma (or think SUFE)

Answer 27

Xray, but could be normal Bloods normal Technetium bone scan MRI scan

Answer 28

``` Maintain healthy position and alignment to reduce damage or deformity Bed rest Traction Crutches Analgesia Physio Regular xrays Surgery ```

Answer 29

Slipped upper femoral epiphysis | Head of femur displaced and slips along the growth plate

Answer 30

8-15 years Presents slightly earlier in females, more common in boys More common in obese kids

Answer 31

May have growth spurt May have hx of minor trauma Hip, groin, thigh, knee pain Restricted range of hip movement Painful limp Restricted movement in the hip Will prefer to keep hip in external rotation Limited movement of hip, restricted internal rotation

Answer 32

xray Bloods normal, use of inflammatory markers to exclude other diagnoses Technetium bone scan CT scan, MRI scan Surgery required to return femoral head to correct position

Answer 33

Defective bone mineralisation Osteomalacia in adults Due to deficiency in Vit D or calcium Or can be hereditary hypophosphataemic rickets - rare, low phosphate, x-linked

Answer 34

``` May be asymptomatic Lethargy Bone pain Swollen wrists Bone deformity Poor growth Dental problems Muscle weakness Pathological or abnormal fractures ```

Answer 35

Bowing of legs Knock knees Rachitic rosary - ends of ribs expand at costochondral junctions causing lumps along the chest Craniotabes - soft skull, delayed closure of sutures, frontal bossing Delayed teeth, underdevelopment of the enamel

Answer 36

Darker skin Low exposure to sunlight Live in cold climates Spend majority of time inside

Answer 37

Serum 25 hydroxyvitamin D <25 nmol/l = Vit D deficient Xrays show osteopenia - more radiolucent bones Serum calcium low Serum phosphate low Serum alkaline phosphatase high Parathyroid hormone high FBC and ferritin for iron deficiency anaemia Inflammatory markers U&Es, LFTs Malabsorption screen e.g. anti-TTG for coeliac Autoimmune and rheumatoid tests

Answer 38

Breastfeeding women and all children should take Vitamin D supplement Formula feed fortified Ergocalciferol for children with Vit D deficiency, for 6 mnths-12 years dose is 6000 IU per day for 8-12 weeks

Answer 39

Inflammation of the patellar ligament at its insertion at the tibial tuberosity Typically affects adolescent males Presents with knee pain after exercise, localised tenderness Most resolve with reduced activity and physio to strengthen muscles

Answer 40

Softening of the articular cartilage of the patella Often associated with hyper mobility and flat feet Treatment is rest and physio for quadriceps strengthening

Answer 41

Persistent knee pain in physically active adolescent Localised tenderness over femoral condyles Pain due to separation of bone and cartilage from medial femoral condyle, following avascular necrosis Rest, exercises, surgery

Answer 42

Mechanical pain - muscle spasm or soft tissue injury, poor posture, heavy loading Tumours - benign or malignant Spine is common site for osteoid osteoma Vertebral osteomyelitis or discitis - localised tenderness, resistance to walk or weight bear, IV antibiotics Spinal cord or nerve root entrapment Scheuermann disease - osteochronditis of the vertebral body Spondylolysis or spondylolisthesis - stress fracture Complex regional pain syndrome

Answer 43

Young age - pathology more likely High fever - infection Night waking, persistent pain - osteoid osteoma or tumours Painful scoliosis - malignancy or infection Focal neurological signs including nerve root irritation, loss of bowel or bladder control, compression Associated weight loss, systemic malaise

Answer 44

1-3 years - infection, osteomyelitis, septic arthritis, transient synovitis, trauma, malignancy 3-10 years - trauma, infection, perthes, JIA, malignancy, CRPS 11-16 years - mechanical, SUFE, JIA, arthritis, infection, malignancy

Answer 45

DDH Neuromuscular e.g. cerebral palsy JIA, perthes, Duchenne, tarsal coalition

Answer 46

Genetic condition, results in brittle bones, due to collagen

Answer 47

``` Hypermobility Blue sclera Triangular face Short stature Deafness from early childhood Dental problems particularly with formation of teeth Bone deformities e.g. bowed legs, scoliosis Joint and bone pain ```

Answer 48

Bisphophonates to increase bone density Vit D supplementation to prevent deficiency Physio and occupational therapy MDT support

Answer 49

Juvenile idiopathic arthritis Autoimmune inflammation >6 weeks in patient under the age of 16 Systemic, polyarticular, oligoarticular, enthesitis related, juvenile psoriatic

Answer 50

``` Systemic - Still's disease: Subtle salmon pink rash High swinging fevers Enlarged lymph nodes Weight loss Joint inflammation and pain Splenomegaly Muscle pain Pleuritis, pericarditis ``` Antinuclear antibodies and rheumatoid factors negative Raised inflammatory markers

Answer 51

Aside from non infectious causes - Kawasaki disease, Still's disease, rheumatic fever, leukaemia

Answer 52

Macrophage activation syndrome - severe activation of immune system DIC, anaemia, thrombocytopenia, bleeding, non blanching rash. There is a low ESR

Answer 53

Idiopathic inflammatory arthritis in 5 joints or more Systemic symptoms are mild May have mild fever, anaemia, reduced growth Can be seropositive or negative

Answer 54

In 4 joints or less Usually only affects a single joint Classically associated with anterior uveitis Antinuclear antibodies positive

Answer 55

More common in male children over 6 years Where muscle inserts into bone Type of seronegative spondyloarthropathy Have HLA B27 gene - look for psoriasis, IBD, anterior uveitis Tenderness in IPJs, wrist, over greater trochanter, quadriceps, base of achilles, metatarsal

Answer 56

``` Can be symmetrical or asymmetrical Plaques of psoriasis Pitting of nails Onycholysis Dactylitis - inflammation of full finger Enthesitis ```

Answer 57

NSAIDs and analgesia relieves symptoms Steroids DMARDs e.g. methotrexate, sulfasalazine Biological therapy - TNF inhibitors e.g. infliximab

Answer 58

Umbrella term of genetic conditions that causes defects in collage - hyper mobility in joints and connective tissue

Answer 59

Hypermobile - hyper mobility and soft and stretchy skin Classic - also have abnormal wound healing, autosomal dom Vascular - thin translucent skin, vessels prone to rupture Kyphoscoliotic - hypotonia, then kyphoscoliosis, tall and slim

Answer 60

``` Joint pain, hypermobility Joint dislocations Soft stretchy skin Poor healing of wounds, bleeding Headaches GORD, abdo pain, IBS Dysmenorrhoea, menorrhagia PROM Incontinence ```

Answer 61

One point for each side of the body - max of 9 points Palms flat on floor with straight legs - 1 point Elbows hyperextended Knees hyperextended Thumb can bend to touch forearm Little finger hyperextends past 90 degrees

Answer 62

Diagnosis with Beighton Exclude Marfan's by examining high arch palate, arachnodactyly, arm span Follow ups, physio, OT Maintain good posture Moderating exercise Psychology for chronic condition

Answer 63

Postural orthostatic tachycardia syndrome Can occur with hypermobile EDS Inappropriate tachycardia on sitting or standing, results in presyncope, syncope, headaches, disorientation, nausea and tremor

Answer 64

IgA vasculitis, presents with purpuric rash affecting lower limbs and buttocks Due to IgA deposits in blood vessels Affects skin, kidneys, GI tract Often triggered by URTI or gastroenteritis

Answer 65

Most common in children under age of 10 Purpura, joint pain, abdominal pain, renal involvement Abdo pain indicative of GI involvement; can lead to gastrointestinal haemorrhage, intussusception, bowel infarction HSP can cause nephritis, leading to microscopic or macroscopic haematuria and proteinuria - nephrotic syndrome

Answer 66

Exclude meningococcal septicaemia and leukaemia Other differentials include ITP and haemolytic uraemic syndrome causing non blanching rash ``` FBC and blood film Renal profile Serum albumin - nephrotic syndrome CRP for sepsis Blood cultures - exclude sepsis Urine dipstick for proteinuria Protein:creatinine ratio to quantify proteinuria BP for hypertension ```

Answer 67

For diagnosis of HSP Patient must have Palpable purpura (not petechiae) plus: Diffuse abdominal pain Arthritis or arthralgia IgA deposits on histology Proteinuria or haematuria

Answer 68

Supportive; simple analgesia, rest, hydration Could use steroids, considered in severe GI pain or renal involvement Close monitoring of urine dipstick and blood pressure

Answer 69

Coronary artery aneurysm

Answer 70

Persistent high fever more than 5 days Child unhappy and unwell Widespread erythematous maculopapular rash Desquamation on palms and soles Strawberry tongue - red tongue with large papillae Cracked lips Cervical lymphadenopathy Bilateral conjunctivitis

Answer 71

Mucocutaneous lymph node syndrome, systemic medium sized vessel vasculitis

Answer 72

Acute phase - most unwell with fever, rash, lymphadenopathy lasting 1-2 weeks. Subacute phase - acute symptoms settle, desquamation and arthralgia, risk of coronary artery aneurysms. 2-4 weeks Convalescent stage - remaining symptoms settle, blood tests return to normal, 2-4 weeks

Answer 73

High dose aspirin to reduce risk of thrombosis IV immunoglobulins to reduce risk of coronary artery aneurysms Follow up with ECHO to motor for coronary artery aneurysms

Answer 74

Autoimmune Antibodies to streptococcus bacteria Affects joints, heart, skin, nervous system Group A beta haemolytic strep, strep progenies causing tonsillitis, antibodies then cause type 2 hypersensitivity reaction Process usually delayed 2-4 weeks after infection

Answer 75

2-4 weeks after streptococcal infection, usually tonsillitis Fever, joint pain, rash, SOB Chorea, nodules Joint involvement - migratory arthritis (different joints affected at different times) ``` Heart involvement Carditis, pericarditis, myocarditis, endocarditis: tachycardia or bradycardia murmurs - valvular heart disease Pericardial rub, heart failure ``` Skin involvement Subcutaneous nodules Erythema marginatum rash - pink rings of varying size on torso and proximal limbs Nervous system involvement Chorea - uncontrolled rapid movements of the limbs

Answer 76

Throat swab - bacterial culture ASO anti streptococcal antibodies titres ECHO, ECG, CXR to assess heart involvement Jones criteria: 2 major or one major and two minor: ``` Major: J - joint arthritis O - organ inflammation N - nodules E - erythematous rash S - sydenham chorea ``` ``` Minor: F - fever E - ECG - prolonged PR A - arthralgia without arthritis R - raised CRP, ESR ```

Answer 77

Tonsillitis with phenoxymethylpenicillin penicillin V for 10 days NSAIDs for joint pain Aspirin and steroids - carditis Prophylactic abx Treat complications

Answer 78

Recurrence Valvular disease e.g. mitral stenosis Chronic heart failure