Paediatric MSK Flashcards
features of perthe’s disease
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.
What is Perthes Disease?
how does it happen?
where does it affect the most.
does it heal eventually?
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. -
diagnosis of perthes disease
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
complications of perthes disease
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
pain triggered by minor trauma child what should i think (older child)
slipped upper femoral epiphysis.
how would you manage perthe disease?
aim of management
conservative
other
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
What is transient Synovitis?
irritable hip.
acute hip pain following recent viral infection.
commonest cause of hip pain in kids.
3-8 yrs.
features of transient synovitis
limp/refusal to weight bear
groin or hip pain
low-grade fever is present in minority : high fever should raise septic arthritis suspicion
you would assume transient synovitis and not sepsis in?
how to mx
child 3-9 yrs
well
afebrile
mobile but limping
sx less than 72 hours
self - limiting , rest and analgesia
What is osteogenesis imperfecta?
brittle bone disease
group of disorders of collagen metabolism = bone fragility and fractures.
mc: milder form OI type 1
genetics of osteogenesis imperfecta
autosomal dominant
abnormality in type 1 collagen due to decreased synthesis of pro alpha 1 or pro alpha 2 collagen polypeptides
features of osteogenesis imperfecta
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
how would you investigate osteogenesis imperfecta?
adjusted calcium, phosphate, parathyroid hormone and alp results usually normal
how would you manage osteogenesis imperfecta?
people in mdt that give tx
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
What is osgood-schlatter disease?
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
what is the pt left with is osgood-schlatters post resolving?
complication
hard boney lump on knee
rare comp: full avulsion fracture: tibial tuberosity seperated from rest of tibia.
requires surgery
how does osgood-schlatter disease present
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.
What is rickets, and what are predisposing factors?
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
How does Rickets Present
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
Investigations in rickets
Serum 25-hydroxyvitamin D - low
X ray - osteopenia (radiolucent bones)
Calcium and phosphate maybe low
ALP and PTH maybe high
Management of rickets
Oral vit D - Ergocalciferol + calcium supplementation
*Bow legs normally self resolve by 4
What is septic arthritis?
Infection within a joint. Most common in under 4s. Emergency, can destroy joint and cause sepsis.
Common complication of joint replacement
How does septic arthritis present?
Single, hot, swollen, red joint
Non weight bearing
Stiffness and reduced motion
Systemic symptoms (fever, lethargy, malaise)
What bacteria commonly cause septic arthritis?
Staph aureus
N gonorrhoea (sexually active)
Group A strep (pyogenes - under 5)
H influenzae
E coli
Ix of septic arthritis, and how long should abx be done for?
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,
What scoring criteria is used to diagnose septic arthritis?
Fever>38.5 (high grade)
Non weight bearing
Raised ESR
Raised WCC
What is osteomyelitis and what are its types?
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
Rf for 2 types of osteomyelitis
Haem
- Sickle cell, IV drug use, immunosuppression, IE
Non haem
- Diabetic foot, DM, PAD, penetrating injury, cellulitis
What microorganisms most commonly cause osteomyelitis?
Staph aureus most common
P aeurginosa (gram negative rod)
Salmonella (important in sickle cell)
N gonorrhoea
M Tuberculosis
What is the imaging modality of choice in osteomyelitis. what might you see on initial imaging investigation?
MRI, X ray can be normal, but possible signs are:
- Involucrum/sequestrum (fallen leaf sign)
- Periosteal thickening
- Lytic lesions
- Cortical bone less
Mx of osteomyelitis
6 weeks flucloxacillin
Clindamycin if allergic
Surgical debridement may be needed
(abscess, failure to respond, vertebral osteomyelitis)
What is slipped upper/capital femoral epiphysis
Rare hip condition seen usually in obese boys, where head of femur is displaced along growth plate, postero-inferiorly. ~12 years.
Presentation of slipped upper femoral epiphysis
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
Ix and Mx of slipped upper femoral epiphysis
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
Complications of slipped upper femoral epiphysis
Osteoarthritis
Avascular necrosis of femoral head
Chondrolysis
Leg length discrepancy
What is discoid meniscus?
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
Types of discoid meniscus
Complete: Meniscus fully covers tibial plateau
Incomplete: partially covers
Wrisberg: Lacks posterior tibial attachments, much more instability, clicking and locking
Ix and complications of discoid meniscus
MRI is Gold standard imaging
Untreated:
- Early onset osteoarthritis
- Post meniscectomy: pain, instability, join degeneration etc
What is juvenile idiopathic arthritis?
Inflammatory arthritis lasting >6 weeks in someone younger than 16.
If there are systemic symptoms its called Still’s disease
Presentation of stills disease
Subtle salmon pink rash
High swinging fevers
Enlarged lymph nodes
Weight loss
Joint inflammation/pain
Muscle pain
Pleuritis/pericarditis
Ix in juvenile idiopathic arthritis
ANA may be raised (associated with anterior uveitis)
RF negative
Raised: CRP, ESR, platelets and ferritin
What are important types of Juvenile idiopathic arthritis
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)
How is juvenile idiopathic arthritis?
Paediatric rheumatology
- NSAID
- Steroids
- DMARD (methotrexate etc)
- Biologics (Anti-TNF etc)
What is scoliosis, with types, presentation and examination
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.
What is torticollis?
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
What is developmental dysplasia of the hip, what can it lead to and when is it normally picked up?
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.
Rf for developmental dysplasia of the hip
First degree family history
Breech from 36 weeks
Breech at birth if 28 weeks
Multiple pregnancy
Female
Firstborn
How is developmental dysplasia of the hip screened for?
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
Developmental dysplasia of the hip - screening special tests
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)
Mx of developmental dysplasia of the hip
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.
