Paed:MSK Flashcards
What is the definition of Juvenile Idiopathic Arthritis?
Persistent joint swelling (>6weeks) presenting before the age of 16 and in the absence of infection or any other defined cause.
What are the seven different subtypes?
Persistent oligoarthritis - 1-4joints involved.
Extended oligoarthritis - <4joints involved >6months
Polyarthritis RF-ve
Polyartrtiis RF+ve
Systemic arthritis
Psoriatic arthritis
Enthesistis related
Features of JIA?
Gelling (stiffness after rest) Morning stiffness Pain Swelling Loss or ROM Warmth Systemic arthritis: Malaise, fever, salmon-pink rash, lymohadenopathy
Complications of JIA?
Uveitis Flexion cotnractures of joints Growth failure Anaemia of chronic disase Osteoporosis
Differentials of JIA?
Spetic arthritis
Reactive arthritis
Non-accidental injury
malignanccy
Management of JIA?
NSAIDS + analgesics Joint injections Methotrexate Systemic corticosteroids Cytokine modulators + other immunotherapies
Diagnosing psoriatic arthritis?
Psoriasis and Arthritis
or
Arthritis w/ 2 of: FH of psoriasis, Nail changes, Dactylitis
What is reactive arthritis?
Transient joint swelling <6weeks often of ankles or knees, usually following extra-articular infection. Most common form of arthritis in childhood.
What causes reactive arthritis?
Enteric bacteria often (Salmonella, shigella, campylobacter)
Also: Viruses and STIs (chlamydia, mycoplasma, borellia burgoferi)
Presentation of reactive arthrtitis
Joint swelling with low grade fever.
acute phase reactants normal or slightly elevated
x rays normal
Management of reactive arthritis?
NSAIDs
What is septic arthritis?
Serious infection of joint space, can lead to bone destruction.
Presentation of septic arthritis?
Erythematous, warm, acutely tender joint. acute in onset Decreased ROM Acutely unwell, febrile child pseudoparesis joint effusion
Causative organisms of septic arthritis?
Neonate: Group B strep
>2yrs: S. Aureus
adolescents: Neisseria Gonorrhoea
How does septic arthritis happen?
Haematogenous spread
Puncture wound
Infecred skin lesions (chicken pox)
Adjacent bone extension
Investigations of septic arthritis?
raised WCC and acute phase reactants Blood cultures US if deep joints if effusion X ray to exclude trauma Bone scan MRI Aspiration of joint space - culture
Risk factors for septic arthritis?
Prematurity
C section
Pt treated on NICU
Invasive procedures
What is Kocher criteria for?
Differentiation of septic arthritis from transient synovitis in the child with a painful hip.
What are the Kocher criteria?
WCC>12,000 Inability to weight bear Fever >38.5 ESR>40 1= 3% chance of SA 2=40% chance of SA 3=93% chance of SA 4= 99% chance of SA
Management of SepticArthritis?
IV Abx
Surgical drainage
Immobilisation then mobilisation
Complications of septic arthritis:
Femoral head destruction Deformity Joint contracture Limb-length discrepancy Gait abnormalities
What is osteomyelitis?
Infection of the metaphysis of long bones. Most commonly femur and proximal tibia
What methods of cause of osteomyelitis?
Haematogenous spread from a pathogen
Direct spread from an infected wound
Causative pathogens of osteomyelitis?
Staph. Aureus, strep, h.influenzae
Presentation of osteomyelitis?
Painful, immobilised limb acute febrile illness swelling and tenderness warm and erythematous movement causes pain sterile effusion of adjacent joint
Investigations for osteomyelitis?
Positive blood cultures Raised WCC, CRP, ESR Xrays: normal but soft tissue swelling us: Periosteal elevation MRI: Subperiosteal pus + purulent debris in bone Radionuclide bone scan
Treatment of osteomyelitis?
IV abx
aspiration or surgical decompression of the subperiosteal space
splint
What is Perthes disease?
Idiopathic avascular necrosis of the proximal femoral epiphysis in children.
clinical features of perthes disease?
gradual onset
painless limp
intermittent hip, knee, groin or thigh pain
Examination findings on Perthes disease?
Hip stiffness - loss of IR and abduction
gait disturbance - antalgic, trendelenburg gait
limb length discrepancy
Treatment of perthes disease?
Sx relief: NSAIDs, traction, crutch
Restore ROM: physio, muscle lengthening
Containment of hip: osteotomy
Operative
Pathophysiology of perthes disease?
- OSteonecrosis occurs secondary to disruption of blood supply to femoral head. Followed by revascularisation with subsequent resorption, and later collapse.
May be ass w/ abnormal clotting factors
Repeated subclincial trauma and mechanical overload lead to bone collapse and repair
What is SUFE?
Slipped upper (capital) femoral epiphysis. Leads to slippage of the metaphysis relative to the epiphysis.
What conditions are associated with SUFE?
Endocrine disorders: Hypothyroidism(^TSH), renal dystrophy, GH deficiency, panhypopituitarism
Presentation of SUFE?
Groin and thigh pain
Limp
Knee pain
Examination findings SUFE?
Decreased hip ROM - ER happens during passive flexion
Loss of hip IR, abduction, +flexion
Treatment of SUFE?
Percutaneous pinning in situ
Fixation of contralateral hip
Surgical hip dislocation and capital realignment
What is transient synovitis
Inflammation if the synovium causing hip pain
Risk factors for transient synovitis?
Viral infection
Bacterial infection (eg post strep toxic synovitis)
Trauma
Allergic reaction
Clinical features of transient synovitis?
Recent URTI Mild/absent fever acute/gradual onset of groin/thigh pain refusal to weight bear improves during day
Examination findings of Transient Synovitis?
Mild/moderate restriction of hip IR
painless arc of motion
Treatment of Transient Synovitis?
NSAIDs
Define osteoporosis?
A disease characterised by low bone mass and microarchitectural deterioration of bone tissue, leading to advanced bone fragility and a consequent increase in fracture risk.
Diagnosing osteoporosis in children?
1 or more vertebral crush fractures OR Size adjusted bone density <2SD's either: - 2 or more long bone # by 10 - 3 or more long bone # by 19
Congenital causes of Osteoporosis?
OSteogenesis imperfecta
Inborn errors eg. galctosaemia
Haematological problems
Idiopathic
Acquired causes of osteoporosis?
Drug induced (esp steroids!) Major endocrinopathies Malabsorption Immobilisation Inflammation
Wha is osteogenesis imperfecta?
AD
Mostly caused by defects in Type 1 collagen genes.
Bone is brittle and fragile.
Clinical features of Osteogenesis Imperfecta
Bone fragility, fractures, deformity Bone pain Impaired mobility poor growth deafness, hernias, valvular prolapse
Types of Osteogenesis Imperfecta?
1: Mild
2: Lethal
3: progressively deforming, severe
4: Moderate
Treatment of osteogenesis imperfecta?
Bisphosphonates
Surgery
Physiotherapy
Education
What is rickets?
Failure in mineralisation of the growing bone or osteoid tissue.
What is osteomalacia?
Failure of mature bone to mineralise.
Causes of Rickets?
Nutritional (1) rickets: Dark skin, poor sunlight exposure, low calcium/vit D diet
Intestinal malabsorrption; Small bowel enteropathy(coeliacs), pancreatic insuffiency (CF), chlolestatic liver disease
Defective production of vit D: Fanconi syndrome, chronic renal disease, familial hypophosphataemia rickets
Increased metabolism of vit D: anticonvulsants induce enzymes - pheonobarbitals
Defective production: Chronic liver disease
Clinical features of rickets
Earliest sign: Craniotabes (thinning of skull/softenign) Frontal bossing of skull Misery FtT/Short stature Delayed closure of anterior fontanelle Rickets rosary harrison sulcus bowing of knees seizures (late) Resp distress
diagnosis of rickets
Dietary hx if vitamins and calcium intake Bloods: - Decreased serum calcium - Decreased phosphate - Increased plasma alkaline phosphatase - Decreased 25-hydroxy vit D - increased PTH Wrist X-ray: - Cupping and fraying of metaphyses -widened epiphyseal plate
Management of rickets?
Dietary advice
Correction of predisposing risk factors
Daily vit D
calcium
What is Kohlers disease?
Infarction of the navicular bone presenting as medial mid foot pain and a limp in younger children, esp with load bearing sports.
Treatment of Kohlers?
Rest. nowt else
What is osgood schlatters disease?
Failure of the tibial tubercle apophysis due to repetitive traction and stress from extensor mechanism.
Presentation of osgood schlatters?
Painful swelling over a prominent tibial tubercle
Usually unilateral
ass w/ running and jumping
