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PAEDIATRIC MSK Flashcards

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1
Q

three risk factors for developmental dysplasia of the hip (DDH)

A

female, firstborn, breech

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2
Q

How can developmental dysplasia of the hip be screened for?

A

Barlows and Ortolani’s test

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3
Q

If a Barlows and Ortolani’s test is positive, what test should be done and when?

A

A hip ultrasound at 4-6 weeks

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4
Q
A
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5
Q

What is slipped upper femoral epiphysis (SUFE)

A

An adolescent hip disorder where there is weakness of the proximal femoral growth plate leading to displacement of the capital femoral epiphysis.

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6
Q

Risk factors for SUFE

A

Male (80%)
Adolescent (10-15)
Obesity
Endocrine disorders (hypothyroidism, hypogonadism)
Race (particularly Afro-Caribbean and Hispanic

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7
Q

How does SUFE present?

A

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

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8
Q

What physical test can be used for SUFE

A

Trendelenburg gait test

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9
Q

How is SUFE diagnosed

A

X rays - anterolateral and frog-leg
Shows shortened displaced epiphysis and widened growth plate

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10
Q

Differentials for SUFE

A

Osteoarthritis, hip fracture, perthes disease, septic arthritis

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11
Q

How is SUFE treated

A

Immediate surgical fixation to prevent further slipping

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12
Q

Complications of SUFE

A

Avascular necrosis, osteoarthritis

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13
Q

What is osteogenesis imperfecta?

A

A group of genetic disorders of collagen metabolism that lead to bone fragility and fractures

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14
Q

What is the inheritance of osteogenesis imperfecta?

A

Autosomal dominant

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15
Q

PAthophysiology of osteogenesis imperfecta

A

Abnormality in type 1 collagen production leading to decreased synthesis

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16
Q

What is the most common type of osteogenesis imperfecta

A

Type 1

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17
Q

Presentation of osteogenesis imperfecta (type 1)

A

Fractures from minor trauma
Blue sclera
Deafness (due to otosclerosis)
Dental imperfections
Bone deformities- leg bowing, barrel chest

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18
Q

How is osteogenesis imperfecta diagnosed

A

Bloods will be normal -calcium, PTH, ALP etc
Genetic testing
DEXA scan and bone biopsy

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19
Q

How is osteogenesis imperfecta treated?

A

Surgical treatment of deformities- e.g intramedullalry rods
Bisphosphonates
Dental procedures.

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20
Q

What is rickets

A

Failure of mineralisation of growing bone or osteoid tissue - usually dye to vitamin D deficiency

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21
Q

Causes of rickets

A

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)

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22
Q

Presentation of rickets

A
  • 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
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23
Q

What can rarely present in rickets due to hypocalcaemia

A

Numbness, tetany, seizures

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24
Q

How is rickets diagnosed

A

Bloods: serum calcium, phosphorus, ALP (will be elevated), vitamin D, parathyroid hormone

X ray of wrist

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25
What can be seen on X ray of the wrist in rickets
Cupping and fraying of the metaphysis and a widened epiphyseal plate
26
How is rickets managed?
Vitamin D supplementation May need other treatments depending on cause (e.g coeliacs)
27
What is transient synovitis?
Also known as irritable hip- it is the most common cause of hip pain in children
28
Who does transient synovitis commonly effect?
Children aged 3-8 More common in boys
29
When might transient synovitis present?
After a viral infection
30
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
31
How is transient synovitis treated?
Bed rest Usually self limiting NSAIDs for symptomatic relief
32
What is Perthes disease?
Avascular necrosis of the capital femoral epiphysis of the femoral head due to an interruption in blood supply.
33
Who does Perthes disease effect?
Children usually under the age of 10 Much more common in boys Rare in black people
34
Presentation of Perthes disease
Gradual onset limp/ hip pain (may be referred to the knee) Limited range of movement Short stature Muscle wasting
35
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)
36
How is Perthes disease diagnosed?
Bilateral hip X ray Technetium bone scan if X ray is normal.
37
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
38
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.
39
What is osteomyelitis
Infection of the metaphysis of long bones/
40
RF for osteomyelitis
Previous osteomyelitis Penetrating injury Diabetes Recent surgery Local infection Immunocompromised
41
Most common bacteria involved in osteomyelitis
Staphylococcus aureus
42
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
43
Risk factors for haematogenous osteomyletitis
sickle cell IV drug use immunosuppression Infective endocarditits
44
Risk factors for non-haematogenous spread of osteomyelitis
diabetic foot ulcers, pressure sores, diabetes, peripheral artery disease
45
How does osteomyelitis present?
an acutely febrile child painful immobile joint- movement will cause severe pain
46
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
47
Gold standard test for osteomyelitis
MRI scan
48
Diagnosis of osteomyelitis
Blood cultures, X-rays (initially normal) USS- periosteal elevation MRI May consider bone biospy
49
How is osteomyelitis treated?
6 weeks IV flucloxacillin May need aspiration or sugical decompression
50
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
51
Who is affected by osgood schlatters
adolescents aged 10-15 years. More common in males Typically athletes- basketball, football, gymnastics e.g
52
How does osgood schlatters present ?
anterior knee pain Pain exacerbated on movement Swelling and tenderness of the tibial tuberosity
53
How is osgood schlatters diagnosed
mainly clinical diagnosis May use imaging studies- Xray, USS, MRI
54
Management of osgood schlatters
supportive- pain management, encouragement of strengthening exercises
55
What is juvenille idiopathic arthritis
joint inflammation in children under 16 which persists for at least 6 weeks when other causes have been excluded
56
Epidemiology of JIA
most common rheumatic disorder in children more common in females Under 16 years
57
6 different presentations of JIA
1. oligoarthritis 2. Polyarthritis with negative RF 3. Polyarthritis with positive RF 4. Systemic arthritis 5. Psoriatic arthritis 6. enthesitis related arthritis
58
Presentation of JIA
- Joint swelling - Joint stiffness - Pain: may present as limp - Rash - Salmon pink - Fevers - Malaise - Uveitis
59
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
60
Explain polyarthritis JIA with negative RF
affects 5 or more joints in first 6 months
61
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
62
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
63
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
64
How is JIA diagnosed
Diagnosis of exclusion - may x ray, joint aspirate
65
Treatment of JIA
DMARDS- methotrexate NSAIDs for symptom control Joint injections Biologics may be needed
66
What may causea fluctuant swelling behind the knee
Bakers cyst
67
What part of the bone is effected in osteomyelitis
metaphysis
68
68
What will calcium, PTH and phosphate be in osteogenesis imperfecta
normal
69
What bacteria may cause osteomyelitis in those with sickle cell
salmonella
70
What motion may be lossed in a slipped capital femoral epiphysis
internal rotation in flexion
71
what does barlow test aim to do
it attempts to dislocate a newborns femoral head
72
what is the first line investigation for developmental hip dysplasia in child over 4.5 months
hip x ray
73
what bedside test can be used to determine if leg length discrepancy is due to femoral or tibial shortening
Galaezzi's testing
74
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
75
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
76
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
77
how is developmental dysplasia of the hip diagnosed?
USS if >4.5 months hip x-ray
78
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
79
At what times are all infants screened for developmental dysplasia of the hip?
at the NIPE examination and a 6 week baby check
80
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)
81
complications of developmental dysplasia of the hip
avascular necrosis residual acetabular dysplasia palvik harness disease degenerative joint disease
82
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
83
aetiology of torticollis
complicated deliveries are thought to be related
84
Under what age should a child with a limp have urgent paediatric assessment
under 3 years
85
what is the management of a slipped upper femoral epiphysis
insitu fixation with a cannulated screw
86

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