Paediatric MSK

Question 1

features of perthe’s disease

Answer 1

hip pain : develops slow progessively over few weeks

limp

stiffness and reduced range of hip movement

poss referred pain to knee

no hx of trauma.

Question 2

What is Perthes Disease?

how does it happen?

where does it affect the most.

does it heal eventually?

Answer 2

degenerative condition

disruption of blood flow to femoral head causing avascular necrosis of bone.

affecs epiphysis of femur - bne distal to growth plate (physis)

hip joints of kids affects - 4-8 yrs old.
more boys

over time revascularisation and neovascularisation and healing of femoral head. -

Question 3

diagnosis of perthes disease

Answer 3

plain x ray:
early changes - widening of joint space

later changes ;decreased femoral head size/flattening

technetium bone scan or magnetic resonance imagine if normal xray and sx persist.

MRI
blood test - normal

Question 4

complications of perthes disease

Answer 4

osteoarthritis

soft and deformed femoral head. , leads to early hip osteoarthritis = artificial total hip replacement in around 5% of pts.

premature fusion of growth plates

Question 5

pain triggered by minor trauma child what should i think (older child)

Answer 5

slipped upper femoral epiphysis.

Question 6

how would you manage perthe disease?

aim of management

conservative
other

Answer 6

aim is to maintain healthy position and alignment in the joint and reduce risk of damage or deformity to femoral head.

bed rest
traction
crutches
analgesia

physio - retain range of movement in muscle/joints without putting excess stress on the bone

regular x rays

surgery - severe to improve alignment and function of femoral head and hip

Question 7

What is transient Synovitis?

Answer 7

irritable hip.

acute hip pain following recent viral infection.

commonest cause of hip pain in kids.

3-8 yrs.

Question 8

features of transient synovitis

Answer 8

limp/refusal to weight bear

groin or hip pain

low-grade fever is present in minority : high fever should raise septic arthritis suspicion

Question 9

you would assume transient synovitis and not sepsis in?

how to mx

Answer 9

child 3-9 yrs
well
afebrile
mobile but limping
sx less than 72 hours

self - limiting , rest and analgesia

Question 10

What is osteogenesis imperfecta?

Answer 10

brittle bone disease

group of disorders of collagen metabolism = bone fragility and fractures.

mc: milder form OI type 1

Question 11

genetics of osteogenesis imperfecta

Answer 11

autosomal dominant

abnormality in type 1 collagen due to decreased synthesis of pro alpha 1 or pro alpha 2 collagen polypeptides

Question 12

features of osteogenesis imperfecta

Answer 12

presents in childhood

fractures following minor trauma

blue sclera

deafesssecondary to otosclerosis
hypermobility
triangular face
short
deafness - early childhood
bone defomity - bowed legs and scoliosis
joint and bone pain
dental imperfections common

Question 13

how would you investigate osteogenesis imperfecta?

Answer 13

adjusted calcium, phosphate, parathyroid hormone and alp results usually normal

Question 14

how would you manage osteogenesis imperfecta?

people in mdt that give tx

Answer 14

cant be cured

give bisphosphonates to increase bone density. vit d supplements to prevent deficiency.

physio and OT
paeds
ortho surgeon
specialist nurse
social worker

Question 15

What is osgood-schlatter disease?

Answer 15

tibial apophysitis

type of osteochondrosis characterised by inflammation at the tibial tuberosity.

its a traction apophysitis - caused by repeated avulsion of the apophysis into which the patellar tendon is inserted

mx : supportive: reduce physical activit, ice, nsaids. sx settle: stretching and physio

Question 16

what is the pt left with is osgood-schlatters post resolving?

complication

Answer 16

hard boney lump on knee

rare comp: full avulsion fracture: tibial tuberosity seperated from rest of tibia.

requires surgery

Question 17

how does osgood-schlatter disease present

Answer 17

visible or palpable hard and tender lump at tibial tuberosity.

pain in anterior aspect of knee

pain worse on physical activity, kneeling and on extension of knee.

Question 18

What is rickets, and what are predisposing factors?

Answer 18

Inadequately mineralised bones, causing soft and easily deformed bones. (osteomalaica, but in kids)

Usually due to vit D deficiency

Dietary deficiency of calcium (e.g. developing countries)
Prolonged breastfeeding
Unsupplemented cows milk formula
Lack of sunlight

Question 19

How does Rickets Present

Answer 19

Abnormalities
- Genu varum (bow legs) - younger kids
- Genu valgum (knock knees) - older kids
Also:
- Aching bones/joints
- Rickety rosary (swelling of costochondral junction)
- Kyphoscoliosis
- Crainotabes (soft skull delayed closure of sutures)
- Harrison’s sulcus

Question 20

Investigations in rickets

Answer 20

Serum 25-hydroxyvitamin D - low
X ray - osteopenia (radiolucent bones)

Calcium and phosphate maybe low
ALP and PTH maybe high

Question 21

Management of rickets

Answer 21

Oral vit D - Ergocalciferol + calcium supplementation

*Bow legs normally self resolve by 4

Question 22

What is septic arthritis?

Answer 22

Infection within a joint. Most common in under 4s. Emergency, can destroy joint and cause sepsis.

Common complication of joint replacement

Question 23

How does septic arthritis present?

Answer 23

Single, hot, swollen, red joint
Non weight bearing
Stiffness and reduced motion
Systemic symptoms (fever, lethargy, malaise)

Question 24

What bacteria commonly cause septic arthritis?

Answer 24

Staph aureus
N gonorrhoea (sexually active)
Group A strep (pyogenes - under 5)
H influenzae
E coli

Question 25

Ix of septic arthritis, and how long should abx be done for?

Answer 25

Joint aspiration
- Yellow/cloudy, high WCC, culture positive, neutrophils
- Send for gram staining, culture, antibiotic sensitivity and crystal microscopy
- Take before antibiotics

Blood culture.

3-6 weeks,

Question 26

What scoring criteria is used to diagnose septic arthritis?

Answer 26

Fever>38.5 (high grade)
Non weight bearing
Raised ESR
Raised WCC

Question 27

What is osteomyelitis and what are its types?

Answer 27

Infection of bone/marrow

Haematogenous
- Results from bacteraemia, monomicrobial
- Most common form in children
- Vertebral osteomyelitis is most common in adults

Non haematogenous
- Contiguous spread from adjacent infection; tissues, bone, direct injury/trauma to bone
- Most common form in adults, often polymicrobial

Question 28

Rf for 2 types of osteomyelitis

Answer 28

Haem
- Sickle cell, IV drug use, immunosuppression, IE

Non haem
- Diabetic foot, DM, PAD, penetrating injury, cellulitis

Question 29

What microorganisms most commonly cause osteomyelitis?

Answer 29

Staph aureus most common
P aeurginosa (gram negative rod)
Salmonella (important in sickle cell)
N gonorrhoea
M Tuberculosis

Question 30

What is the imaging modality of choice in osteomyelitis. what might you see on initial imaging investigation?

Answer 30

MRI, X ray can be normal, but possible signs are:
- Involucrum/sequestrum (fallen leaf sign)
- Periosteal thickening
- Lytic lesions
- Cortical bone less

Question 31

Mx of osteomyelitis

Answer 31

6 weeks flucloxacillin
Clindamycin if allergic

Surgical debridement may be needed
(abscess, failure to respond, vertebral osteomyelitis)

Question 32

What is slipped upper/capital femoral epiphysis

Answer 32

Rare hip condition seen usually in obese boys, where head of femur is displaced along growth plate, postero-inferiorly. ~12 years.

Question 33

Presentation of slipped upper femoral epiphysis

Answer 33

Hip pain, can be longstanding, usually following minor trauma (disproportionate to pain)
- High, groin, thigh, knee pain
- Leg preferred in external rotation, restricted internal rotation due to pain.
- Painful limp
- Can be bilateral or unilateral

Question 34

Ix and Mx of slipped upper femoral epiphysis

Answer 34

X ray normally diagnostic (antero-posterior and lateral, frog leg views)

Managed surgically with internal fixation, with a single cannulated screw in the centre of the epiphysis

Question 35

Complications of slipped upper femoral epiphysis

Answer 35

Osteoarthritis
Avascular necrosis of femoral head
Chondrolysis
Leg length discrepancy

Question 36

What is discoid meniscus?

Answer 36

A congenital abnormality where the meniscus (usually C shaped) ends up disc shaped, commonly affects lateral meniscus. 6-10 years

Makes the meniscus broader, thicker and more circular causing pain, swelling, clicking, decreased range of motion and locking/giving way of the knee

Question 37

Types of discoid meniscus

Answer 37

Complete: Meniscus fully covers tibial plateau
Incomplete: partially covers
Wrisberg: Lacks posterior tibial attachments, much more instability, clicking and locking

Question 38

Ix and complications of discoid meniscus

Answer 38

MRI is Gold standard imaging
Untreated:
- Early onset osteoarthritis
- Post meniscectomy: pain, instability, join degeneration etc

Question 39

What is juvenile idiopathic arthritis?

Answer 39

Inflammatory arthritis lasting >6 weeks in someone younger than 16.

If there are systemic symptoms its called Still’s disease

Question 40

Presentation of stills disease

Answer 40

Subtle salmon pink rash
High swinging fevers
Enlarged lymph nodes
Weight loss
Joint inflammation/pain
Muscle pain
Pleuritis/pericarditis

Question 41

Ix in juvenile idiopathic arthritis

Answer 41

ANA may be raised (associated with anterior uveitis)
RF negative
Raised: CRP, ESR, platelets and ferritin

Question 42

What are important types of Juvenile idiopathic arthritis

Answer 42

Oligoarticular - 1 joint, girls under 6, anterior uveitis (refer to ophthalmology) ANA positive
Polyarticular - >5 joints, symmetrical, may have fever, anaemia, reduced growth
Enthesitis related - Involves inflammation where tendon inserts into muscle. HLAB27, psoriasis, anterior uveitis.
Psoriatic - Skin psoriasis and associated hand changes (pitting, onycholysis, dactylitis, enthesitis)

Question 43

How is juvenile idiopathic arthritis?

Answer 43

Paediatric rheumatology
- NSAID
- Steroids
- DMARD (methotrexate etc)
- Biologics (Anti-TNF etc)

Question 44

What is scoliosis, with types, presentation and examination

Answer 44

Lateral (coronal plane) spinal curvature >10 degrees, often has vertebral rotation.
Affects females most and can be congenital, neuromuscular, syndromic (marfans, ehlers danlos)
Affects females more
Uneven shoulders, hips, ribcage asymmetry, back pain
Adams forward bend test, rib hump on side of bend.
Cobb angle>10 = scoliosis. >50 progress into adulthood.

Question 45

What is torticollis?

Answer 45

A condition where the head is tilted one way but rotated to the opposite side.

Can be congenital or acquired

Presents with head tilt to one side and rotation to other. Palpable mass or tightness in sternocleidomastoid (fibrosis)

USS to assess SCM

Physio, botulinum toxin, surgery etc for management

Good prognosis if physio, resolved by 1 yr

Question 46

What is developmental dysplasia of the hip, what can it lead to and when is it normally picked up?

Answer 46

Congenital hip abnormality causes instability and potential for subluxation (partial) or full dislocation.

Can lead to weakness, recurrent dislocation, abnormal gait, or early degenerative changes.

Usually picked up during newborn examination or when child presents with hip asymmetry.

Question 47

Rf for developmental dysplasia of the hip

Answer 47

First degree family history
Breech from 36 weeks
Breech at birth if 28 weeks
Multiple pregnancy
Female
Firstborn

Question 48

How is developmental dysplasia of the hip screened for?

Answer 48

During NIPE Exam 6-8 weeks.
Features suggesting DDH:
- Different leg lengths
- Restricted hip abduction on one side
- Significant bilateral restriction in abduction
- Different in knee level when hips flexed
- Clunking of hips during special tests

If breech, do USS at 6 weeks ALWAYS

Question 49

Developmental dysplasia of the hip - screening special tests

Answer 49

Ortolani test - baby on back with knees and hips flexed. Palms on baby’s knees with thumbs on inner thigh and four fingers on outer thigh. Gently abduct and apply pressure behind legs to see if legs dislocate anteriorly

Barlow test - Baby on back with hips adducted and flexed to 90 and knees bent to 90. Gentle downward pressure applied to knee to see if femoral head will dislocate posteriorly.

(clicking is a common finding -> hip will be normal on USS. Clunking more likely to indicate DDH, requires USS)

Question 50

Mx of developmental dysplasia of the hip

Answer 50

Most will stabilise by 3-6 weeks

If <6 months of age, Pavlik harness is fitted and kept on permanently, holding the femoral head in the correct position and allowing acetabulum (hip socket) to take correct shape.

Pavlik harness keeps hips flexed and abducted.

Usually removed after 6-8 weeks.