Orthopaedics, genetics, ENT, skin, eyes Flashcards
Red flags in limping child?
Night time wakening, night sweats, fatigue, anorexia, weight loss -> malignancy.
Redness or swelling of fever -> infection.
Unexplained rash, early morning pain/stifness -> inflammatory bone disease
Unexplained bruising -> NAI, haematological disease.
Severe pain or agitation following traumatic injury -> ?compartment syndrome.
Examination of limping child?
Carry out Paediatric Gait, Arms, Legs and spine assessment.
Gait pattern Deformity or swelling Erythema or warmth Brusing Limb length discrepancy Signs of hypermobility Systemic features - tachycardia, fever, pallor, lymphadenopathy, eye problem, rash.
Investigations for limping child?
FBC, CRP, ESR, blood culture
Imaging - plain XR, USS, CT, MRI
What is developmental dysplasia of hip and risk factors?
Spectrum of hip instability, ranging from dislocated hip to hips with various degrees of acetabular dysplasia (shallow acetabulum).
Risk factors: Female Breech presentation Positive FH Firstborn children Oligohydramnios Birth weight >5kg Congenital calcaeneovalgus foot deformity.
Features of developmental dysplasia of the hip?
More common in left hip, 20% bilateral. Delayed walking Painless limp Waddling gait Asymmetrical skin creases in 30% of cases.
Screening of developmental dysplasia of the hip?
Screened at birth and 6 week check.
Barlow - backward pressure applied to each femoral head to see if it dislocates
Ortolani - forward pressure applied to attempt to relocate dislocated hip.
What do you find on examination of developmental dysplasia of hip?
Shortened femur (allis sign), and limited abduction.
How to diagnose developmental dysplasia of hip and how to manage?
USS to confirm.
Most stabilise spontaneously by 3-6 weeks of age.
Pavlik harness in children younger than 4-5 months.
Older children may require surgery - open reduction and derogation femoral osteotomy for children with delayed diagnoses. May require total hip replacement in early childhood.
Where in the bone does osteomyelitis commonly start?
Metaphysis due to relative stasis of blood.
Most common causes of osteomyelitis?
Neonates - E. coli, Group B strep.
Staph aureus most common in all age groups.
Sickle cell - Salmonella
Features of Rickets?
Vitamin D deficiency. Leg bowing Craniotabes Enlarged metaphyses Enlarged costochondral junction Misery Hypotonia Developmental delay Growth faolire Late eruption of teeth
Causes of rickets?
Due to inadequate sun exposure: Infants with pigmented skin Full coverage with religious garments Urban living conditions Winter
Inherited abnormalities of vitamin D metabolism Mineral deficiency Chronic renal disease Renal osteodystrophy Rickets of prematurity
Diagnosis and management of rickets?
Wrist X-ray - cupping/fraying of metaphysis and widened metaphyseal plate
Reduced calcium
Reduced phosphate
Increased PTH and ALP.
Features and examination of transient synovitis?
Common, self-limiting, occurs between 2-10 years, following viral infection.
Sudden onset of pain Limp Refusal to bear weight on affected side No pain at rest Most common cause of hip pain in children
Limited passive abduction and rotation in otherwise well and afebrile child.
Diagnosis and management of transient synovitis?
Diagnosis of exclusion Acute phase reactants - WBC, CRP, ESR Blood cultures - negative in transient synovitis Joint aspiration if still in doubt X-ray not usually required.
Supportive, resolves in 2 weeks.
Safety net
Analgesia (NSAIDs)
Review in 48 hours to check symptoms are resolving
Review in 7 days from onset to check symptoms have resolved
Undertake Ix (bloods, XR) if uncertain of diagnosis or any red flags.
Features of Juvenile Idiopathic Arthritis?
Arthritis occurring in someone <16 years, lasts for more than 6 weeks.
Systemic JIA:
- children <5 years
- symmetrical arthritis of knees, wrist, ankles and tarsals
- systemic features - fever, spikes, rash, lymphadenopathy, myalgia
- Worst prognosis in younger age.
Polyarticular JIA:
- 5 or more joints
- RF positive.
Oligoarticular JIA: - young girls <6 years Asymmetric arthritis of knees, ankles, elbows. - ANA positive vs negative - Associated with anterior uveitis.
Psoriatic JIA
Enthesitis-related JIA
Features - Joint pain and swelling - usually of medium joints (elbow, knee, ankle) Limp ANA positive Salmon-pink rash Arthritis Anorexia and weight loss.
Diagnosis of JIA
FBC - anaemia Acute phase reactants raised RF negative usually ANA positive usually X-rays - soft tissue swelling in early stages, bony erosions and loss of joint space later.
Management of JIA?
Physiotherapy
Analgesia
DMARDS - corticosteroids, methotrexate, biological agents.
Features of Perthe’s disease?
Age 4-8
Avascular necrosis of femoral head, specifically femoral epiphysis.
M>F 10% bilateral.
Hip pain - develops progressively over a few weeks
Limp
Stiffness and reduced range of hip movement
X-ray - early changes include widening of joint space, later changes include decreased femoral head size/flattening.
Diagnosis, management and complications of Perthe’s disease?
Plain X-ray
Technetium bone scan or MRI if normal X-ray and symptoms persist.
Cast and braces to keep femoral head within acetabulum.
Observe in age <6
Older - surgical management with moderate results
Operate on severe deformities.
Complications - osteoarthritis, premature fusion of growth plates.
Staging of Perthe’s disease?
Catterall staging
1 - clinical and histological features only
2 - sclerosis with or without cystic changes and preservation of articular surface
3 - loss of structural integrity of femoral head
4 - loss of acetabular integrity
Features of reactive arthritis?
Arthritis that develops following infection where organism can’t be recovered from joint.
Post-STI - chlamydia trachomatis
Post-dysenteric illness - shigella, salmonella, campylobacter
Reiter’s syndrome - urethritis, conjunctivitis, arthritis.
Management of reactive arthritis?
Analgesia - NSAIDs, intra-articular steroids.
Sulfasalazine and methotrexate sometimes used for persistent disease
Symptoms rarely last >12 months.
Features and causes of scoliosis?
Sidewards curvature of spine occurring most often during growth spurts just before puberty.
Causes - Cerebral palsy, muscular dystrophy, mostly unknown causes.
Features - uneven shoulders, one shoulder blade appears more prominent than the other, uneven waist, one hip higher than the other.
What is torticollis?
Wry neck
Painfully twisted and tilted neck
Top of head generally tilts to one side while chin tilts to other side
Congenital or acquired
Also due to damage of muscles or blood supply to neck.
Features of Osgood Schlatters Disease?
Stress from exercise at same time as growth of epiphyseal plate leads to inflammation of tibial epiphyseal plate.
Ultimately leads to growth of tibial tubercle (causing visible bump).
10-15 years. M>F.
Unilateral usually.
Visible/palpable hard tender bump.
Pain at knee (over bump)
Pain worse following exercise.
Management and prognosis of osgood Schlatters disease?
Reduction in physical activities that put stress on knees.
Rest
NSAIDs
ICE
Stretching and physiotherapy once symptoms settle
Pain usually intermittent and triggered by activity
Pain settles once growth ceases and plates fuse
Bump usually remains as hard boney lump
Rare complication is avulsion features where tibial tuberosity is separated by patella tendon from the rest of the knee, and usually requires surgical intervention.
Features of Down’s syndrome?
Face - round/flat face, protruding tongue, up slanting palpebral fissures, small low-set ears, brushfirld spots in iris, epicanthic folds. Flat occiput Single palmar crease Sandal gap between big and first toe Hypotonia Congenital heart defects - endocardial cushion defect, VSD, secundum ASD, ToF, isolated PDA. Duodenal atresia Hirschsprung's disease.
