Paediatric MSK

Question 1

What are your differentials for a child with an acute limp?

Answer 1

Need to exclude:
Septic arthritis
Osteomyelitis 
SUFE
Perthes
DDH
Fracture/trauma 
Malignancy 

Other:
Transient synovitis of hip
Functional limp
JIA/reactive arthritis

Question 2

a child presents with a limp. what are some key questions you need to ask?

Answer 2

Acute or chronic/insidious onset?
Able to weightbear/walk at all?
Any previous trauma?
Any recent illnesses? (particularly gastro etc)
Any other illnesses such as IBD etc?
Do they have a fever or any other infective symptoms?
Any deformity/swelling noticed?
Pain with certain movements?
Morning stiffness or history of ‘gelling’ after long car rides?
Birth history–> risk factors for DDH
Systemic constitutional symptoms of malignancy?
FMH of rheumatoid arthritis/SLE/autoimmunity

Question 3

what are some key investigations all children with suspected bone/joint infections get?

Answer 3

blood culture
FBE
blood film
plain x-rays
CRP

then +/- joint aspirate; bone scan/MRI according to clinical judgement

Question 4

what are the three clinical presentations of JIA?

Answer 4

oligoarticular JIA
polyarticular JIA
systemic JIA (still’s disease)

Question 5

what are some complications of untreated JIA?

Answer 5

overgrowth of limb and subsequent deformity

erosive disease

Question 6

what is the most common cause of intoeing in children?

Answer 6

internal femoral torsion

Question 7

what does talipes equinovarus mean?

Answer 7

clubfoot deformity- can either be postural or fixed

Question 8

what is osgood schlatter’s syndrome

Answer 8

this is when there is pain and swelling of the tibial tuberosity due to inflammation of the patellar ligament.

often clinically seen as a tender bump/lump on the tibial tuberosity in active 10-14 yr olds.

self resolving over many months with physiotherapy to strengthen quadriceps/hamstring muscles.

some may require surgical excision of lump

Question 9

what is a good way of seeing whether there is any hip involvement in a child who presents with joint pain?

Answer 9

as the child to ‘squat and walk like a duck’. if they are able to do so; then unlikely to involve the hip

Question 10

what must you exclude in a child you suspect might have systemic JIA?

Answer 10

septic arthritis
malignancy
osteomyelitis

Question 11

where often does SUFE pain present?

Answer 11

can present as thigh/knee pain, hence always assess the hip joint

Question 12

what is the treatment of SUFE?

Answer 12

surgical correction with screws

Question 13

a child presents with dactylitis. what condition must you think of?

Answer 13

psoriatic arthritis

Question 14

what is the technical name for ‘banana shaped feet’?

Answer 14

metatarsus adductus

Question 15

up to which age is bowed legs considered normal?

Answer 15

up to 2 yrs; it is common for toddlers to appear bowed legged

Question 16

what is a ddx for osgood schlatter disease?

Answer 16

enthesitis, particularly if both knees are affected

Question 17

a child complains of leg pain at night. what are your differentials?

Answer 17

growing pains (especially if bilateral)- most common

benign osteoma (if unilateral)- rare

Question 18

what are the common malignant causes of bone pain in children?

Answer 18

leukaemia
neuroblastoma
lymphoma

Question 19

what are the two most common primary bony malignancies in children?

Answer 19

osteosarcoma

ewings sarcoma

Question 20

what is the difference between osteomalacia and rickets?

Answer 20

no difference; both mean a disorder in bone mineralisation often due to vitamin D deficiency or calcium deficiency.

rickets is the condition in kids and osteomalacia is the condition in adults

Question 21

what are some causes of rickets in a child?

Answer 21

vitamin D deficiency due to little vitamin D exposure, malabsorption disorders, severe liver disease, prolonged anticonvulsant therapy

Question 22

a child comes in with a confirmed elbow fracture. how might you manage their pain in ED?

Answer 22

Pharmacological

• Simple analgesia= panadol up to 20mg/kg
• Intranasal fentanyl
• IV morphine if required
• ketamine if manipulating fracture

Non-pharmacological

• distraction techniques, play therapy
• immobilisation, bracing

Question 23

a young child falls on her outstretched hand. What type of fractures is she at risk of?

Answer 23

1. buckle fracture of the distal radius
2. greenstick fracture of the distal radius
3. complete fracture of the distal radius
4. supracondylar fracture of the elbow
5. scaphoid fracture
6. proximal humeral fracture
7. lateral condylar fracture

Question 24

what is a quick way of assessing neurological involvement in child with an upper limb fracture?

Answer 24

Ask them to:
Make a fist- median nerve
Make a star with their hands- testing ulnar nerve
Give you the thumbs up- radial nerve

Question 25

how do we classify supracondylar fractures and which is more common?

Answer 25

flexion - distal fragment displaced anteriorly

extension- more common; distal fragment displaced posteriorly

Question 26

what are the complications of a supracondylar fracture?

Answer 26

Deformity due to malunion

Neuropraxia

Vascular compromise- radial or brachial artery

–>compartment syndrome

Question 27

what is the peak age group for a supracondylar fracture in children?

Answer 27

5-8 yrs old

Question 28

a child presents with a fracture of the shaft of the humerus. what must you consider?

Answer 28

non-accidental injury

Question 29

a boy presents with a sore elbow after falling on an outstretched hand. on examination the elbow has reduced ROM, is tender and there is swelling, more markedly on the lateral side. what are you worried about and how could you confirm this?

Answer 29

ix= AP and lateral x-rays of elbow

looking for lateral condylar fracture

–> always requires an urgent orthopaedic review due to known poor outcomes