PAEDIATRIC MSK Flashcards
three risk factors for developmental dysplasia of the hip (DDH)
female, firstborn, breech
How can developmental dysplasia of the hip be screened for?
Barlows and Ortolani’s test
If a Barlows and Ortolani’s test is positive, what test should be done and when?
A hip ultrasound at 4-6 weeks
What is slipped upper femoral epiphysis (SUFE)
An adolescent hip disorder where there is weakness of the proximal femoral growth plate leading to displacement of the capital femoral epiphysis.
Risk factors for SUFE
Male (80%)
Adolescent (10-15)
Obesity
Endocrine disorders (hypothyroidism, hypogonadism)
Race (particularly Afro-Caribbean and Hispanic
How does SUFE present?
Hip pain and limp
Reduced range of movement- loss of internal rotation and in flexion
Pain may refer to knee
Trendelenburg gait test is positive
What physical test can be used for SUFE
Trendelenburg gait test
How is SUFE diagnosed
X rays - anterolateral and frog-leg
Shows shortened displaced epiphysis and widened growth plate
Differentials for SUFE
Osteoarthritis, hip fracture, perthes disease, septic arthritis
How is SUFE treated
Immediate surgical fixation to prevent further slipping
Complications of SUFE
Avascular necrosis, osteoarthritis
What is osteogenesis imperfecta?
A group of genetic disorders of collagen metabolism that lead to bone fragility and fractures
What is the inheritance of osteogenesis imperfecta?
Autosomal dominant
PAthophysiology of osteogenesis imperfecta
Abnormality in type 1 collagen production leading to decreased synthesis
What is the most common type of osteogenesis imperfecta
Type 1
Presentation of osteogenesis imperfecta (type 1)
Fractures from minor trauma
Blue sclera
Deafness (due to otosclerosis)
Dental imperfections
Bone deformities- leg bowing, barrel chest
How is osteogenesis imperfecta diagnosed
Bloods will be normal -calcium, PTH, ALP etc
Genetic testing
DEXA scan and bone biopsy
How is osteogenesis imperfecta treated?
Surgical treatment of deformities- e.g intramedullalry rods
Bisphosphonates
Dental procedures.
What is rickets
Failure of mineralisation of growing bone or osteoid tissue - usually dye to vitamin D deficiency
Causes of rickets
Nutritional - dark skin, decreased sunlight (northern latitudes), diet low in calcium, phosphorus and vitamin D
(E.g exclusive breastfeeding)
Intestinal - coeliac, pancreatic insufficiency (e.g CF)
Defective production of 24-hydroxyvitamin D (e,g chronic liver disease)
Defective production of 1,25-dihydroxyvitamin D (e.g kidney disease)
Presentation of rickets
- sensation of a ping pong ball being firmly pressed over the occipital or parietal bones
- frontal bossing of the skull
- rickety rosary (swelling of the costochondral junction)
- leg bowing or knock knees
- Harrison’s sulcus
- pigeon chest
- dental deformities
- muscle weakness
What can rarely present in rickets due to hypocalcaemia
Numbness, tetany, seizures
How is rickets diagnosed
Bloods: serum calcium, phosphorus, ALP (will be elevated), vitamin D, parathyroid hormone
X ray of wrist
What can be seen on X ray of the wrist in rickets
Cupping and fraying of the metaphysis and a widened epiphyseal plate
How is rickets managed?
Vitamin D supplementation
May need other treatments depending on cause (e.g coeliacs)
What is transient synovitis?
Also known as irritable hip- it is the most common cause of hip pain in children
Who does transient synovitis commonly effect?
Children aged 3-8
More common in boys
When might transient synovitis present?
After a viral infection
How does transient synovitis present?
Sudden onset hip pain- may be referred to the knee
No pain at rest
Decreased range of movement
Low grade fever - if high think septic arthritis
How is transient synovitis treated?
Bed rest
Usually self limiting
NSAIDs for symptomatic relief
What is Perthes disease?
Avascular necrosis of the capital femoral epiphysis of the femoral head due to an interruption in blood supply.
Who does Perthes disease effect?
Children usually under the age of 10
Much more common in boys
Rare in black people
Presentation of Perthes disease
Gradual onset limp/ hip pain (may be referred to the knee)
Limited range of movement
Short stature
Muscle wasting
How would Perthes disease and transient synovitis differ on presentation
Perthes disease should be suspected if pain is for more than 4 weeks (TS usually resolves after 2 weeks)
How is Perthes disease diagnosed?
Bilateral hip X ray
Technetium bone scan if X ray is normal.
Pathophysiology of Perthes disease
Ischaemia of the femoral head stops the epiphysis growing
Dead fragments of the bone are resorbed and replaced with tissue which is then revascularised and ossified
How is Perthes disease treated
If less than 50% of femoral head is involved then supportive measurements- bed rest
If more than 50% then immobilisation (keep the femoral head in the acetabulum by casts/ braces)
Surgical containment may be needed.
What is osteomyelitis
Infection of the metaphysis of long bones/
RF for osteomyelitis
Previous osteomyelitis
Penetrating injury
Diabetes
Recent surgery
Local infection
Immunocompromised
Most common bacteria involved in osteomyelitis
Staphylococcus aureus
What are the two types of osteomyelitis?
Haematogenous osteomyelitis (results from bacteraemia)
Non-haematogenous osteomyelitis (results for contiguous spread of infection from adjacent soft tissues or from direct injury
Risk factors for haematogenous osteomyletitis
sickle cell
IV drug use
immunosuppression
Infective endocarditits
Risk factors for non-haematogenous spread of osteomyelitis
diabetic foot ulcers, pressure sores, diabetes, peripheral artery disease
How does osteomyelitis present?
an acutely febrile child
painful immobile joint- movement will cause severe pain
What is Pott’s disease
vertebral osteomyelitis that results from haematogenous spread of TB
Damage to two adjacent bodies leads to vertebral collapse and abscess formation
Gold standard test for osteomyelitis
MRI scan
Diagnosis of osteomyelitis
Blood cultures,
X-rays (initially normal)
USS- periosteal elevation
MRI
May consider bone biospy
How is osteomyelitis treated?
6 weeks IV flucloxacillin
May need aspiration or sugical decompression
What is osgood schlatters
a common cause of knee pain in adolescents that is caused by overuse of the patella tendon at its insertion point on the tibial tuberosity
Who is affected by osgood schlatters
adolescents aged 10-15 years.
More common in males
Typically athletes- basketball, football, gymnastics e.g
How does osgood schlatters present ?
anterior knee pain
Pain exacerbated on movement
Swelling and tenderness of the tibial tuberosity
How is osgood schlatters diagnosed
mainly clinical diagnosis
May use imaging studies- Xray, USS, MRI
Management of osgood schlatters
supportive- pain management, encouragement of strengthening exercises
What is juvenille idiopathic arthritis
joint inflammation in children under 16 which persists for at least 6 weeks when other causes have been excluded
Epidemiology of JIA
most common rheumatic disorder in children
more common in females
Under 16 years
6 different presentations of JIA
- oligoarthritis
- Polyarthritis with negative RF
- Polyarthritis with positive RF
- Systemic arthritis
- Psoriatic arthritis
- enthesitis related arthritis
Presentation of JIA
- Joint swelling
- Joint stiffness
- Pain: may present as limp
- Rash - Salmon pink
- Fevers
- Malaise
- Uveitis
Explain oligoarticular arthritis JIA
affects just 1-4 joints in the first 6 months
Can go on to be extended (>4 joints after 6 months) or persistent (<4 joints after 6 months)
Usually knee and ankle affected
Explain polyarthritis JIA with negative RF
affects 5 or more joints in first 6 months
Explain polyarthritis JIA with positive RF
5 or more joints in the first 6 months
usually symmetrical involvement (particularly hands and feet)
may have systemic features- fever, enlarged spleen, lymphadenopathy
Explain systemic arthritis JIA
Arthritis with at least 2 weeks of daily fever (usually spikes in afternoon) and one of the following:
- salmon pink rash
- lymhpadenopathy
- hepatomegaly or splenomegaly
-serositis
what is macrophage activation syndrome
a life threatening condition that occurs in 10% of patients with systemic JIA.
Presents as high fever, hepatosplenomegaly, haemorrhagic manigestations and a sepsis -like condition
How is JIA diagnosed
Diagnosis of exclusion - may x ray, joint aspirate
Treatment of JIA
DMARDS- methotrexate
NSAIDs for symptom control
Joint injections
Biologics may be needed
What may causea fluctuant swelling behind the knee
Bakers cyst
What part of the bone is effected in osteomyelitis
metaphysis
What will calcium, PTH and phosphate be in osteogenesis imperfecta
normal
What bacteria may cause osteomyelitis in those with sickle cell
salmonella
What motion may be lossed in a slipped capital femoral epiphysis
internal rotation in flexion
what does barlow test aim to do
it attempts to dislocate a newborns femoral head
what is the first line investigation for developmental hip dysplasia in child over 4.5 months
hip x ray
what bedside test can be used to determine if leg length discrepancy is due to femoral or tibial shortening
Galaezzi’s testing
Describe ortolani’s test
attempts to relocate a dislocated femoral head (IDENTIFIES A DISLOCATED HIP)
- the hip is flexed to 90 degrees and abducted with the examiners fingers placed on the lateral part of the greater trochanter
describe Barlows tests
attempts to dislocate an articulated femoral head (IDENTIFIES A DISLOCATABLE HIP)- think able for barlow
- the hip is flexed to 90 degrees and adducted
- the examiner places hands on the knees and posterior pressure is placed through the hip
what features on examination may be used to look for developmental dysplasia of the hip
- ortolani and barlows tests
- limited hip abduction
- leg length discrepancy
- asymmetrical gluteal and thigh skinfolds
- limp in older children
how is developmental dysplasia of the hip diagnosed?
USS
if >4.5 months hip x-ray
who is screened for developmental dysplasia of the hip?
- infants who have a first degree relative with hip problems in early life
- those with a breech presentation at or after 36 weeks gestation (irrespective of their birth presentation)
- those who a part of a multiple pregnancy
At what times are all infants screened for developmental dysplasia of the hip?
at the NIPE examination and a 6 week baby check
How is developmental dysplasia of the hip treated?
Most will stabilise on their own
Palvik harness with follow ups over 3 moths
If not working surgery (closed reduction under GA with spica casting)
complications of developmental dysplasia of the hip
avascular necrosis
residual acetabular dysplasia
palvik harness disease
degenerative joint disease
what is torticollis
A neck deformity that involves shortening of the sternocleidomastoid muscle leading to limited neck rotation and lateral flexion
This leads to a head tilt to the affected side and rotation to the contralateral side
aetiology of torticollis
complicated deliveries are thought to be related
Under what age should a child with a limp have urgent paediatric assessment
under 3 years
what is the management of a slipped upper femoral epiphysis
insitu fixation with a cannulated screw
