Orthopaedics and Rheumatology Flashcards
What is genu varum/bow legs?
Knees wide apart
Pathological cause is rickets
Blount disease - severe progressive and unilateral bow legs
What is genu valgum?
Knock knees
Seen in many young children, resolves spontaneously
What is metatarsus varus?
Adduction deformity Occurs in infants Highly correctable Heel held in normal position No treatment required unless persists/symptomatic
What is medial tibial torsion?
Tibia laterally rotated less than normal in relation to femur
Occurs in toddlers
May be due to bowing
Self corrects within 5 years
What is persistent ante version of the femoral neck?
At the hip, femoral neck twisted more than normal
Presents in childhood
Usually self corrects by 8
Children sit between fit, hips fully internally rotated
What are causes of toe walking?
Between ages 1-3 Mild cerebral palsy Tightness in achilles or inflammatory arthritis Spastic diplegia In boys - exclude Duchennes
What is talipes equinovarus?
Clubfoot Entire food inverted and supinated, heel rotated in Affected foot shorter Calf muscles thinner Position of foot is fixed Often bilateral
What are the causes of talipes equinovarus?
Can be familial
Usually idiopathic
May be secondary to oligohydramnios
Or feature of malformation syndrome or neuromuscular disorder e.g. spina bifida
What is the treatment for club foot?
Ponsetti method
Plaster cating and bracing
What is vertical talus?
Where the foot is stiff and rocker bottom in shape
What is talipes calcaneovalgus?
Foot dorsiflexed and everted
Usually results from intrauterine moulding and self corrects
Association with DDH
What is pes cavus associated with?
High arched foot
In older children - neuromuscular disorders e.g. Friedreich ataxia and type 1 hereditary motor sensory neuropathy
What is DDH?
Developmental dysplasia of the hip
Spectrum from dysplasia to subluxation to dislocation
What tests of the NIPE check from DDH?
Barlow’s - hip can be dislocated posteriorly out of acetabulum
Ortolani’s - relocated back into acetabulum on abduction
What is the presentation of DDH?
Usually spotted on NIPE Thereafter - limp or abnormal gait Asymmetry of skin folds around hip Limited abduction of hip Shortening of affected leg
What is the management of DDH?
USS shows detail, degree of dysplasia
Infant may be placed in splint or harness to keep hip flexed and abducted
What are the causes of scoliosis?
Idiopathic - early onset <5 or late onset girls 10-14 during pubertal growth spurt
Congenital - structural defect e.g. hemivertebra, spina bifida
Secondary - related to other disorders e.g. cerebral palsy, muscular dystrophy, Marfan’s
What is torticollis?
Wry neck - twisting of neck causes it to be held on one side
Most common cause is sternomastoid tumour
Present with mobile non vendor nodule
Condition resolves in 2-6 months
Or later in childhood due to muscle spasm, secondary to ENT infection or spinal tumour
What is the presentation of growing pains?
Wakes child from sleep
Settles with massaging
Age range 3-12 years
Symmetrical in lower limbs
Not limited to joints
Never present at start of day after waking
Physical activities not limited - no limp
Physical examination normal and otherwise well
What are the types of paediatric fractures?
Buckle Transverse Oblique Spiral Segmental Salter-Harris - at growth plate Comminuted Greenstick
What is the Salter-Harris classification?
SALTR Straight across Above BeLow Through Crush
What pain medication is not used in children?
Codeine and tramadol as there is unpredictability in their metabolism
Aspirin contraindicated under 16 due to risk of Reye’s syndrome except in certain circumstances e.g. Kawasaki
What else might a child present with alongside hip pain?
Limp Refusal to use affected leg Refusal to weight bear Inability to walk Pain Swollen or tender joint
What are common causes of joint pain 0-4 years?
Septic arthritis
DDH
Transient sinovitis
What are common causes of joint pain 5-10 years?
Septic arthritis
Transient sinovitis
Perthes disease
What are common causes of joint pain 10-16 years?
Septic arthritis
Slipped upper femoral epiphysis SUFE
Juvenile idiopathic arthritis
What are the red flags for hip pain?
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
What is the criteria for an urgent referral in a limping child?
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
What are investigations for hip/joint pain?
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
What is the presentation of septic arthritis?
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
What are common bacteria causing septic arthritis?
Staph aureus most common
Neisseria gonorrhoea in sexually active teens
Group A strep/strep pyogenes
H influenza
E Coli
What are the differentials of septic arthritis?
Transient sinovitis
Perthes
Slipped upper femoral epiphysis
Juvenile idiopathic arthritis
What is the management of septic arthritis?
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
What is transient synovitis?
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
What is the presentation of transient synovitis?
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
What is the management of transient synovitis?
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
What is the presentation of septic arthritis in the hip in infants?
Leg held flexed, abducted, externally rotated
No spontaneous movement
Marked tenderness over head of the femur
Swollen thigh
What is reactive arthritis?
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
What are common causes of reactive arthritis?
Enteric bacteria - salmonella, shigella, campylobacter
Viral infections, STIs e.g. chlamydia, gonococcus
Mycoplasma
Borrelia - Lyme disease
What is osteomyelitis?
Infection of bone and bone marrow
Mostly occurs in metaphysic of long bones
What is the most common bacterial cause of osteomyelitis?
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
What are the risk factors for osteomyelitis?
More common in boys and under 10 Open bone fracture Orthopaedic surgery Immunocompromised Sickle cell anaemia HIV TB
What is the presentation of osteomyelitis?
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
What are the investigations for osteomyelitis?
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
What is seen on x-ray in chronic osteomyelitis?
Periosteal reaction along lateral shaft of tibia
Multiple hypotenuse areas within the metaphysical regions
What is the management of osteomyelitis?
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
What is Perthes disease?
Disruption of blood flow to the femoral head causing avascular necrosis
Who is Perthes most common in?
Children aged 4-12
Mostly between ages 5-8
More common in boys
What is the main complication of Perthes?
Revascularisation or neovascularisation and healing, leads to remodelling and a soft and deformed head can lead to early hip osteoarthritis
What is the presentation of Perthes?
Slow onset
Pain in hip or groin
Restricted hip movements
Referred pain to knee
No history of trauma (or think SUFE)
What are the investigations for perthes?
Xray, but could be normal
Bloods normal
Technetium bone scan
MRI scan
What is the management of perthes?
Maintain healthy position and alignment to reduce damage or deformity Bed rest Traction Crutches Analgesia Physio Regular xrays Surgery
What is SUFE?
Slipped upper femoral epiphysis
Head of femur displaced and slips along the growth plate
Who is SUFE more common in?
8-15 years
Presents slightly earlier in females, more common in boys
More common in obese kids
What is the presentation of SUFE?
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
What is the diagnosis and management for SUFE?
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
What is rickets?
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
What are the symptoms associated with rickets?
May be asymptomatic Lethargy Bone pain Swollen wrists Bone deformity Poor growth Dental problems Muscle weakness Pathological or abnormal fractures
What bone deformities can occur in rickets?
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
What are some of the risk factors for rickets?
Darker skin
Low exposure to sunlight
Live in cold climates
Spend majority of time inside
What are the investigations for rickets?
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
What is the management of rickets?
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
What is Osgood-Schlatters?
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
What is chondromalacia patellae?
Softening of the articular cartilage of the patella
Often associated with hyper mobility and flat feet
Treatment is rest and physio for quadriceps strengthening
What is osteochondritis dissecans?
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
What are some of the causes of back pain?
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
What are the red flags of back pain?
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
What are causes of an acute painful limp in a child?
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
What are some causes of a chronic and intermittent limp?
DDH
Neuromuscular e.g. cerebral palsy
JIA, perthes, Duchenne, tarsal coalition
What is osteogenesis imperfecta?
Genetic condition, results in brittle bones, due to collagen
What is the presentation of osteogenesis imperfecta?
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
What is the management of osteogenesis imperfecta?
Bisphophonates to increase bone density
Vit D supplementation to prevent deficiency
Physio and occupational therapy
MDT support
What is JIA?
Juvenile idiopathic arthritis
Autoimmune inflammation
> 6 weeks in patient under the age of 16
Systemic, polyarticular, oligoarticular, enthesitis related, juvenile psoriatic
What are the key features of systemic JIA?
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
What are the differentials for a fever lasting more than 5 days?
Aside from non infectious causes - Kawasaki disease, Still’s disease, rheumatic fever, leukaemia
What is a key complication of systemic JIA?
Macrophage activation syndrome - severe activation of immune system
DIC, anaemia, thrombocytopenia, bleeding, non blanching rash.
There is a low ESR
What is polyarticular JIA?
Idiopathic inflammatory arthritis in 5 joints or more
Systemic symptoms are mild
May have mild fever, anaemia, reduced growth
Can be seropositive or negative
What is oligoarticular JIA?
In 4 joints or less
Usually only affects a single joint
Classically associated with anterior uveitis
Antinuclear antibodies positive
What is enthesitis related arthritis?
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
What is seen in juvenile psoriatic arthritis?
Can be symmetrical or asymmetrical Plaques of psoriasis Pitting of nails Onycholysis Dactylitis - inflammation of full finger Enthesitis
What is the management of JIA?
NSAIDs and analgesia relieves symptoms
Steroids
DMARDs e.g. methotrexate, sulfasalazine
Biological therapy - TNF inhibitors e.g. infliximab
What is Ehlers-Danlos?
Umbrella term of genetic conditions that causes defects in collage - hyper mobility in joints and connective tissue
What are the types of Ehlers-Danlos?
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
What is the presentation of hyper mobile EDS?
Joint pain, hypermobility Joint dislocations Soft stretchy skin Poor healing of wounds, bleeding Headaches GORD, abdo pain, IBS Dysmenorrhoea, menorrhagia PROM Incontinence
What is the Beighton score?
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
What is the management of EDS?
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
What is POTS?
Postural orthostatic tachycardia syndrome
Can occur with hypermobile EDS
Inappropriate tachycardia on sitting or standing, results in presyncope, syncope, headaches, disorientation, nausea and tremor
What is Henoch-Schonlein purpura?
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
What is the presentation of Henoch-Schonlein?
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
What is key in diagnosis of HSP and differentials?
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
What is the PRES criteria?
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
What is the management of HSP?
Supportive; simple analgesia, rest, hydration
Could use steroids, considered in severe GI pain or renal involvement
Close monitoring of urine dipstick and blood pressure
What is a key complication of Kawasaki disease?
Coronary artery aneurysm
What are the features of Kawasaki disease?
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
What is Kawasaki disease?
Mucocutaneous lymph node syndrome, systemic medium sized vessel vasculitis
What are the stages of Kawasaki disease?
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
What is the management of Kawasaki disease?
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
What causes acute rheumatic fever?
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
What is the presentation of rheumatic fever?
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
What are the investigations for rheumatic fever?
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
What is the management of rheumatic fever?
Tonsillitis with phenoxymethylpenicillin penicillin V for 10 days
NSAIDs for joint pain
Aspirin and steroids - carditis
Prophylactic abx
Treat complications
What are the complications of rheumatic fever?
Recurrence
Valvular disease e.g. mitral stenosis
Chronic heart failure
