Paediatric MSK & Rheumatology Flashcards
Causes of a limp in children under 4yrs
Acute = NAI Soft tissue or fracture injury Malignancy/tumour Osteomyelitis or septic arthritis Discitis
Chronic = DDH
Cerebral palsy
JIA
Duchene muscular dystrophy.
Causes of a limp in a child between 4 and 10yrs
Fracture or soft tissue injury Malignancy/tumour Osteomyelitis or septic arthritis Transient synovitis Perthe's disease
Causes of a limp in a children between 10-18yrs
Fracture or soft tissue injury Tumour or malignancy Osteomyelitis or septic arthritis Perthe's disease Slipped upper femoral epiphysis Osgood-Schlatter disease Osteochondritis deissecans Chondromalacia patellae JIA
Difference between osteomyelitis and septic arthritis
Osteomyelitis - infection of bone
Septic arthritis - infection of synovium and joint space
Developmental dysplasia of the hip risk factors, manoeuvres, presentation in later life
Barlow or Ortolani manoeuvre at birth then repeated at 8weeks.
RF = female sex, breech position at birth, family history, high brith weight, oligohydramnios, first born.
Presents = abnormal gait, limp, asymmetrical skin folds at hip, poor hip abduction, shorter let on affected side. Rx = Pavlik harness, splint and surgery.
Transient synovitis
Acute and sudden limp and pain on exercise (NOT AT REST).
Post viral infection in boys.
Can precede Perthe’s disease
Self-limiting.
Perthe’s Disease pathology and features
Avascular necrosis of the femoral head.
More common in boys.
Limp/Antalgic gait. Hip pain which can refer to groin, thigh and knee.
Slipped Upper femoral epiphysis
Slipped capital femoral epiphysis. Proximal femoral epiphysis is displaced.
More common in males, in rapid growing/growth spurt, obese, has been associated with endocrine abnormalities.
Ix = frog-leg x-ray
Rx = surgical pinning to prevent necrosis.
Osgood-Schlatter disease
Anterior knee pain during adolescence
Inflammation of patellar ligament.
Osteochondritis dissecans
Separation of part of cartilage and bone.
Mostly in athletes and exacerbated by activity
Chondromalacia patellae
Softening of cartilage in knee. Commonly seen in athletes.
Malignancies which cause limps
Primary bone tumours e.g. osteosarcoma, soft tissue sarcoma, leukaemia, lymphoma.
Discitis
Infection or inflammation of the intervertebral disc space, uncommon in children. Limited back movement and local tenderness.
Muscular dystrophies and limps
Duchenne and Becker muscular dystrophies cause muscle weakness.
Duchenne presents within first 3 years.
Becker preened around 11yrs.
X-linked. Duchenne’s is worse.
Definition of Juvenile Idiopathic Arthritis
Collection of chronic (great than 6weeks) paediatric arthropathies. Diagnosis of exclusion/idiopathic.
Different types of Juvenile Idiopathic Arthritis
Systemic arthritis Oligoarticular Polyarticular rheumatoid factor + or - ve Psoriatic arthritis Enthesitis-related arthritis
Risk factors for JIA
Female
HLA polymorphism
Under 6yrs
Family history of autoimmune disease
Systemic arthritis JIA
Associated with BIG pyrexia and generally unwell
Lymphadenopathy, splenomegaly and hepatomegaly.
Erythematous rash
Serositis
Oligoarticular JIA
Most common! 2 types - persistent or extended. 4 or more joints, most commonly hands, knees elbow, wrist, ankle. Asymmetrical Associated with chronic anterior uveitis
Polyarticular JIA
5 or more joints involved.
Rheumatoid factor positive or negative. Positive is more common.
Psoriatic artheritis
Arthritis + psoriasis or arthritis + dactylics/nail pitting or nail changes.
RF = 1st degree relative with psoriasis.
Other symptoms apart form arthritis seen in enthesitis related arthritis JIA.
Enthesitis (inflammation at muscle to bone insertion) Symptoms of acute anterior uveitis (red eye, pain, blurred vision and photophobia)
Sacroiliac tenderness
HLAB27 +VE
Rheumatoid factor and ANA negative.
General presentation of JIA
Functional loss of range of movements persistent swlling MORNING stiffness Joint deformity Warm, pain, colour change due to increased blood flow, increased growth factors.
Signs of an inflamed joint (untreated JIA)
Periarticular osteoporosis Inflamed or fibrosis synovium Increased synovial fluid Loss of cartilage Erosion of bone
Investigations for JIA
FBC - anaemia, thrombocytosis, exclude malignancies.
ESR - elevated in systemic and polyarticular JIA.
ANA - +ve with oligoarticular and polyarticular JIA, -ve in systemic and enthesitis JIA
RF - positive in RF-positive polyarticular.
X-ray of joint
Infection screen.
Management of JIA
MDT
NSAID
Disease modifying anti-rheumatic drug e.g. Methotrexate or Sulfasalazine
Corticosteriods oral or intra-articular
Biologics and novel drugs e.g. cytokine IL-6 inhibitor Tocilizumab or TNF-α
Causes of osteoporosis in children
Congenital - osteoporosis imperfecta, inborn errors, haematological problems, idiopathic.
Acquired - drug-induced esp steroids, major endocrinopathies, malabsorption, immobilisation
Osteoporosis definition
Low bone mass and micro-architecture deterioration. Increased fragility and fracture risk.
Osteoporosis imperfecta genetics
Most are autosomal dominant inheritance. Mutations in collagen gene.
Different types of osteoporosis imperfecta
I - most common, blue sclerae.
II - lethal with fracture present before birth.
III - progressively severe
IV - mild with variable age onset.
Symptoms of osteoporosis imperfecta
Bone fragility and brittle Fractures Deformities such as bowed-leg. Bone pain Poor growth Impaired mobility
Management of osteoporosis imperfecta
MDT (surgeon, physio, nurse, surgeon)
Biphosphonate medications reduce fracture rate, increase growth height, reduce pain, increase mobility.
Uses of vitamin D
Increase calcium and phosphorus gut absorption
Increase calcium release from bone (resorption)
Role in immunity
Definition of rickets
Failure to mineralise growing bone or osteoid tissue at epiphyseal growth plates.
Causes of low vit D
Insufficient exposure to sunlight. Inadequate dietary intake Poor absorption (coeliac, CF or Crohn's) Obesity Poor Vit D activation due to CKD, enzyme deficiency, or enzyme inactivity due to anticonvulsant meds. Anti-epileptic drugs e.g. carbamazepine
Risk factors for vitamin D deficiency
Covered up skin (e.g. Muslim females) Dark skin (e.g. African) Exclusively breast-fed babies due to maternal vit D deficient will cause low vit D in breast milk. Veganism High BMI
Presentation of low Vit D/Rickets
Bowed legs Hypocalcaemia convulsions Motor delay Metaphyseal swelling Slow growth rate Hypotonia Fractures Frontal bossing of the skull Craniotabes Muscle weakness Bone pain Weak tooth enamel = more cavities.
Investigations for Rickets
X-ray - cupping, splaying or fraying or metaphases/champagne glass appearance. Vitamin D levels via (25[OH)D) Serum calcium and phosphorous High ALP Parathyroid hormone raised
Differentials for rickets
Soft tissue sarcoma or bone malignancy Fracture at bone osteomyelitis Parathyroid hormone disease Rheumatoid arthritis Muscular dystrophies
Management of Rickets
Vitamin D supplements and calcium mostly D3
Knee pain differentials
Osgood-Schlatter disease
Chondromalacia patella
Osteochondiritis dissecans
Patella dislocation
Causes of a more chronic onset limp in under 4yrs
DDH
Neuromuscular e.g. cerebral palsy
JIA
Duchenne’s muscular dystrophy
Causes of a more chronic onset limp in 4-10yrs
Perthe’s
JIA
Causes of a more chronic onset limp in over 10yrs
SUFE
JIA
3 features on an x-ray for Perthe’s
Fragmentation of proximal femoral epiphysis
Flattening of the proximal femoral epiphysis
Increased density of the femoral head
Criteria for septic arthritis
Kocher’s
Fever, can’t weight bear, high ESR and high WCC
Movement of hip with SUFE
Flexion of hip leads to external rotation.
Example of bisphosphonate
Alendronic acid
