Paediatric MSK & Rheumatology Flashcards by Flick Burton

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.

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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

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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

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Difference between osteomyelitis and septic arthritis

Osteomyelitis - infection of bone

Septic arthritis - infection of synovium and joint space

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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.

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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.

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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.

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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.

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Osgood-Schlatter disease

Anterior knee pain during adolescence

Inflammation of patellar ligament.

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Osteochondritis dissecans

Separation of part of cartilage and bone.

Mostly in athletes and exacerbated by activity

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Chondromalacia patellae

Softening of cartilage in knee. Commonly seen in athletes.

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Malignancies which cause limps

Primary bone tumours e.g. osteosarcoma, soft tissue sarcoma, leukaemia, lymphoma.

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Discitis

Infection or inflammation of the intervertebral disc space, uncommon in children. Limited back movement and local tenderness.

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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.

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Definition of Juvenile Idiopathic Arthritis

Collection of chronic (great than 6weeks) paediatric arthropathies. Diagnosis of exclusion/idiopathic.

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Different types of Juvenile Idiopathic Arthritis

Systemic arthritis 
Oligoarticular
Polyarticular rheumatoid factor + or - ve
Psoriatic arthritis 
Enthesitis-related arthritis

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Risk factors for JIA

Female
HLA polymorphism
Under 6yrs
Family history of autoimmune disease

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Systemic arthritis JIA

Associated with BIG pyrexia and generally unwell
Lymphadenopathy, splenomegaly and hepatomegaly.
Erythematous rash
Serositis

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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

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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