Paediatric joint disease Flashcards
What are some examples of normal paediatric conditions usually referred?
- Flat feet: usually self-limiting
- Toe walkers: children often take first steps on their tip toes, but examination required to exclude tight Achilles tendon and cerebral palsy
- In-toeing gait: can be due to femoral torsion, tibial torsion, or metatarsus (inwardly pointing forefoot), all usually self-limiting
- Bow legs (genu varum): usually self-limiting, sometimes caused by Rickets
- Knock knees (genu valgum): usually self-limiting
- (in general, if symmetrical issue then usually normal, but if asymmetrical then pathology should be suspected)
Child sitting in the W position in excessive femoral anteversion…
What are the 3 paediatric hip disorders?
- Developmental dysplasia of the hip (DDH)
- Perthes disease
- Slipped upper femoral epiphysis (SUFE)
What is the pathology of DDH (developmental dysplasia of the hip)?
- DDH is due to failure of the normal development of the acetabulum and the femoral head and acetabulum do not articulate properly
- joint can dislocate easily
What is the aetiology of DDH? (what is DDH associated with)
DDH is associated with:
- breech presentation (baby born feet first rather than head first)
- family history
- other congenital deformities / twins
Normal hip anatomy VS DDH hip anatomy…
What are the clinical features of DDH?
(majority are picked up on routine baby checks)
Late presenting DDH can present with:
- loss of abduction
- leg length discrepancy
- child will have a limp
What are the 2 special tests for dysplastic hips?
- Barlow test (attempt to dislocate a reduced hip): with child’s hip flexed to 90 degrees, try to dislocate hip by gently adducting, a clunk is felt if +ve
- Otrolani test (attempt to reduce a dislocated hip): with hips at 90 degrees, gently abduct hip, +ve test if hip reduces with a clunk
Barlow test diagram…
What is the management for DDH?
- most are self-limiting
- conservative: abduction splint holds hips in abduction (Pavlik harness)
- surgical: reduction, osteotomies to pelvis/hip to restore normal anatomy
Pavlik harness (holds hips in abduction)…
What is Perthes disease?
- blood supply to the femoral head is interrupted, causing avascular necrosis and collapse of the femoral head
What are the clinical features of Perthes disease?
- child with knee or hip pain and a limp
- aged 4 to 8yrs
What investigations should be done for suspected Perthes?
- Plain x-ray: sclerosis and fragmentation of epiphysis
- (MRI also very sensitive for diagnosis and staging)
What does involvement of femoral head mean about prognosis of Perthes disease?
- if less than 50% of femoral head involved: good prognosis and usually self-limiting
- if more than 50% of femoral head involved: poor prognosis, high risk for OA in later life
What is the single biggest risk factor for a SUFE and what are the 2 main groups affected by SUFE?
- obesity
- (2 groups affected: athletic children, overweight boys with delayed puberty)
What are the clinical features of a SUFE?
- typically adolescents
- hip pain and limp (history can be acute or gradual), pain may be referred to knee
- examination: reduced hip flexion, +ve Trendelenburg gait
What investigation should be done for suspected SUFE?
- X-ray: AP, frog-lateral view
X-ray of SUFE (frog-lateral view)…
What is the treatment for a SUFE?
- Surgical: epiphysis should be pinned in situ to prevent further displacement
- note: treatment should be prompt to prevent avascular necrosis of the femoral head
What is congenital talipes equinovarus (clubfoot)?
- a deformity of the lower limb with calf-wasting and the classic inward-pointing foot (equinus deformity due to tight Achilles tendon and associated contraction of soft tissues on medial side of ankle)
Untreated talipes equinovarus showing inversion contracture…
Intraoperative view of talipes equinovarus surgery showing release of soft tissues…
Post-operative image from talipes equinovarus surgery showing corrected deformity and soft tissue coverage…
What is the management for talipes equinovarus?
- Conservative: manipulation and casting for 3 months
- Surgical: severe cases only, soft tissue release
- (prognosis: foot and limb will never be normal in terms of appearance but patient will live a normal life)
What is osteogenesis imperfecta and what is the pathology?
- aka. brittle bone disease
- OI is a type 1 collagen disorder predisposed to multiple fractures
Pathology: - 4 different types of OI
- OI is usually inherited as an autosomal dominant condition (types 1 and 4)
- types 2 and 3 are sporadic and recessive but rare (type 2 is lethal)
What are the clinical features of osteogenesis imperfecta?
- fragile bones and low-energy fractures
- (blue sclerae occur in types 1 and 2 OI)
- associated features: deafness, joint laxity, brownish teeth, face dysmorphia, valvular defects
Blue sclera (occurs in types 1 and 2 osteogenesis imperfecta)…
What is the treatment for osteogenesis imperfecta?
- Conservative: gentle handling, IV bisphosphonates to improve bone strength
- Surgical: intramedullary telescoping rods for prevention of deformity and further fracture (established deformity is treated with osteotomy)
What is cerebral palsy?
- a non-progressive upper motor neurone, neuromuscular disorder that results from injury to an immature brain
- (can be caused by perinatal infection such as meningitis)
What are the clinical features of cerebral palsy?
- muscle weakness and spasticity
- ataxic gait, cognitive impairment and emotional disturbance
What is the management for cerebral palsy?
- (diagnosis is a clinical one)
- Conservative: physio, OT, SALT
What are some clinical features of a non-accidental injury (NAI)?
- vague and inconsistent history
- children <2 yrs: fractures are rare
- delayed presentation
- may be other bruises (may be old bruises)
- child may be withdrawn, particularly when parents are present
- (note: OI can sometimes be mistaken for NAI)
What is the management for NAI?
- social workers should be involved
- fractures/bruises should be treated as normal
What are the 2 paediatric knee conditions?
- Osgood-Schlatter disease
- Osteochondritis dissecans
What is the pathology of Osgood-Schlatter disease?
- inflammation of the insertion point of the patella tendon at the tibial tuberosity
Osgood-Schlatter disease diagram…
What are the clinical features of Osgood-Schlatter disease?
- localised pain over the tibial tuberosity (tender/swollen)
- pain worse with activity, relieved by rest
What is the management for Osgood-Schlatter disease?
- Conservative: rest, analgesia, activity modification (activity will not make it worse)
What is Osteochondritis dissecans?
- a small area of avascular bone on an articular surface (usually in the knee, medial femoral condyle)
- caused due to repeated trauma in a susceptible patient
What are the clinical features of osteochondritis dissecans?
- adolescents and young adults
- intermittent ache, swelling, joint locking
What investigations should be done for suspected osteochondritis dissecans?
- X-ray: shows variably sized lesion on medial femoral condyle (fragmented in children), lesion may be attached or loose
- MRI: can also be used to help define lesion
What is the management for osteochondritis dissecans?
- Conservative: activity modification to allow to heal (usually self-limiting)
- Surgical: surgical stabilisation for loose lesions, or removal of loose body
What is juvenile idiopathic arthritis (JIA)?
- JIA is a persistent autoimmune inflammatory arthritis lasting > 6 weeks in patients younger than 16 yrs (it is a diagnosis of exclusion)
What are the clinical features of JIA?
- systemic: fevers, malaise, salmon pink rash
Joint disease: pain, stiffness, swelling ( > 6 weeks ), can cause stunted growth
What investigations should be done for suspected JIA?
- diagnosis is clinical and that of exclusion
- X-ray: can help
- Blood tests: can help (FBC, ESR/CRP, RhF, ANA)
What is the management for JIA?
- MDT approach
- pharmacological: NSAIDs, corticosteroids, biologics
What is transient synovitis (aka. irritable hip)?
- cause of limp in children from inflammation of the synovial lining of the hip joint
- symptoms: usually preceded by a viral infection (URTI common), acute onset limp, fever
- management: bloods, joint aspirate and culture to rule out septic arthritis
