Paediatric: Ortho/MSK Flashcards
What is another name for growth plates ? what are they ?
epiphysial plates
- hyaline cartilage that sits between epiphysis and metaphysis
are there more growth plates in children or adults?
only in children
- epiphyseal plates fuse during teenage years
are growth plates stronger or weaker than bone?
growth plates are stronger than bone
differences between child and adult bone ?
- Child bone is more flexible + less strong
- Child bone has a better blood supply so heal quicker
- presence of growth plates in child bone
which bone fractures are children more prone to ?
green stick fractures (one side breaks while other remains intact)
What is bone remodelling ? what determines it ?
process where bone tissues is taken from areas of low tension and depositied to areas of high tension
What can fractures of the growth plate cause ? what classification ?
can causes issues with growth in that bone
- Salter Harris classification (1-5)
Managment of child bone fracture ? (3)
- Mechanical alignment: closed or open (surgical) reduction
- Relative stability (external casts, screws)
- Pain management
describe the pain ladder in children ? what is avoided ?
- paracetamol or ibuprofen
- Then morphine
codeine + tramadol not used in kids
Hip pain presentation (5)
- Limp
- Refusal to use affected leg
- Inability to walk
- Pain
- Swollen or tender joint
joint pain + fever. Watch thinking ?
need to exclude septic arthritis
0-4 yo presenting with hip pain. differential ? (3)
- Septic arthritis
- DDH
- Transient synovitis
5-10 yo presenting with hip pain. differential ? (3)
- Septic arthritis
- Transient synovitis
- perthes disease
10-16 yo presenting with hip pain. differential ? (3)
- Septic arthritis
- Slipped upper femoral epiphysis
- Juvenile idiopathic arthritis
Red flags for child presenting with hip pain ?
- < 3yrs
- fever
- waking at night due to pain
- weight loss
- Night sweats
(could be leukaemia)
patient presenting with hip pain plus blood tests show inflam markers. differential ?
- JIA
- Septic arthritis
why would you do an USS of a joint in a child presenting with hip pain ?
if you suspect effusion (fluid) in the joint
What is septic arthritis ? most common in what age group ?
it is infection inside the joint - emergency
- Most common < 4yrs
septic arthirits pathophsyiology ? (how could bacteria get to joint ? (3)
- From a bacteraemia (recent UTI, chest infection)
- direct inoculation
- Spreading from adjacent osteomyelitis
septic arthritis presentation ?
Usually affects single joint (knee, hip)
- Hot, red, swollen + painful joint
- refusal to weight bear
- Stiffness + reduced ROM
- Systemic symptoms (fever, lethargy + sepsis)
What is the most common causative organism of septic arthritis ? in a sexually active teenager ?
- Staphylococcus aureus (most common)
- Sexually active teenager: Neisseria gonorrhoea
Septic arthritis management ? (3)
if suspected, require admission
- Joint aspiration (prior to Abx): send smpale for gram staining, crystal microscopy, culture + abx sensitivities
- Empirical IV Abx (for 3-6 weeks)
- May require surgical drainage + washout
septic arthritis complications (3)
- Mortality (10%)
- irreversible articular damage (=> sever osteoarthritis)
- Osteomyelitis
What is transient synovitis ? often associated with what ?
temporary (transient) irritation + inflammation of the synovial membrane of the joint (synovitis)
- Often associated with recent viral URTI
transient synovitis presentation ?
- Acute or gradual onset: limp, refusal to weight bear, groin or hip pain, mild low grade temp
- No signs of systemic illness
transient synovitis management ?
Symptomatic, symptoms will resolve within 1-2 weeks
- Safety net: fever (+septic arthritis)
What is perthes disease ? leads to what
disruption of blood flow to the femoral head => avascular necrosis => affects epiphysis of femur
perthes disease aetiology ?
idiopathic (no clear cause)
perthes disease disease course ?
overtime there is re/neo vascularisation + bone remodelling
perthes disease complications ?
soft + deformed femoral head => osteoarthritis
perthes disease presentaiton ? typical patient ?
boy 5-8
- slow onset hip or groin pain
- Limp
- Restricted hip movements
- no Hz of trauma
if there is Hx of trauma in a patient presenitng with slow osnet hip or groin pain, what would you consider ?
SUFE
perthes disease investigations ?
- Xray (can be normal) (first line)
- Blood tests (typically normal)
- Technetium bone scan
- MRI scan
Perthes disease management ?
conservative (aim to reduce deformity of femoral head)
- bed rest, traction, crutches, analgesia, physio
- Regular xrays
- consider surgery (to improve alignment)
What is SUFE ?
Slipped upper femoral epiphysis
- it is where the head of the femur is displaced (slips) along the growth plate
SUFE presentation ? typical patient (age, Hx)?
obese male 8-15 yrs undergoing growth spurt + Hx of minor trauma
- Vague hip/groin/thigh/knee pain
- Restricted ROM
- Painful hip
SUFE diagnosis ?
Xray
- blood tests (normal)
SUFE management ?
surgery required to correct femoral position
What is osteomyelitis ? typically where ?
infection in the bone + bone marrow
- typically in metaphysis of long bones
what is the usually causative organism in osteomyelitis ?
staphylococcus aureus
how can osteomyelitis spread ? (3)
- Direct inoculation
- Haematogenous
- Direct psread
- From nearby infection (septic arthritis)
osteomyelitis RF ? typical Hx ?
- Boys <10 yrs with open bone fracutre/surgery
osteomyelitis presentation ?
can be acute or chronic (acutely unwell child or chronically with more subtle features)
- refusal to weight bear or use limb
- pain, swelling, tenderness
- low grade fever (high grade => spread to septic arthritis)
osteomyelitis investigations ?
MRI or bone scan
- blood: raised inflam markers + WCC
- Bone marrow aspirate + culture (gold standard)
osteomyelitis management ?
- Abx
- may need surgery for drainage + debridement
What is developmental dysplasia of the hips (DDH) ? causes what ?
shower there are structural abnormalities of the hips due to abnormal dev of fetal bones during pregnancy => instability of hip => dislocation
DDH RF ? (3)
- first degree FHx
- Breech presentaiton
- Multiple pregnancy
when is DDH usually picked up ?
NIPE
what manoeuvres check for DDH ? describe
- Ortolani: a dislocated hip
- Barlow: a dislocatable hip
how is DDH diagnosed ?
US
how is DDH managed ? (2)
- palvik harness
- consider surgery
What is osteogenesis imperfecta ? causes what
genetic condition that results in brittle bones => prone to fracture
- affects production of collagen
how might osteogenesis perfecta present ? what signs ? (3)
recurrent + inappropriate fractures
- hyper mobility
- blue grey sclera (remember this one)
- short stature
how is osteogenesis perfecta managed ?
clinical diagnoses
- underlying genetic condition cannot be cured
- Meds: bisphophonates, vit D
what is rickets ? leads to what ?
(what’s this condition known as in adults)
condition affecting children where there is defective bone mineralisation => soft + deformed bones
(same as osteomalacia in adults)
what could cause rickets ?
- deficient in vit d or calcium
where do you get vit d from ? calcium ?
- Vit D: produced by body in response to sunlight or dietary: egg, oily fish, cereals)
- Calcium: dairy
do darker skinned ppl need more or less sungliht to make the same vit D
need more sunlight to make same Vit D
from what is Vit D make in the body ? in response to what ? where is it metabolised ? why is this important ?
vit D is hormone made form cholesterol in skin in response to UV radiation
- Kidneys metabolic vit D to active form
how would CKD affect Vit D levels
cause Vt D defieiceny as kidneys are responsible for metabolising it to active state
in what absorption is Vit D important in ? what does inadequate vit D then cause ?
cit is essentila in calcium + phsophate absorption form intestines + kidneys
- inadequate Cit D => low calcium + low phosphate => defective bone mineralisation
what kind of parathryoidsim condition does low vit D or calcium cause ? primary or secondary ?
secondary hyperparathyroidism
How would rickets present ?
may be asymptomattic
- lethargy, bone pain, swollen writs, poor growth, pathological fractures
- howling of legs knock knees
What Ix for rickets ? diagnostics ?
- serum 25-hydroxy vitamin D
- X-ray (diagnostic)
rickets management ?
- prevention is best (vit d supplementation)
- rickets: vit D + calcium supplementation
What is Osgood schlatters ? what age group ?
inflammation of tibial tuberosity where patella ligament inserts knee pain
- age 10-15 yrs (male)
describe the locution of the pain in Osgood schlatters ?
usually unilateral anterior knee pain
Osgood schlatters pathophys ?
stress from running/jumping at same time as growth in epiphyseal plate => inflam on tibial epiphyseal plate => growth + visible lumps just below knee
Osgood schlatters presentation ?
gradual onset of Sx
- visible or palpable tender lump below knee
- Pain exacerbated by activity
Osgood schlatters Mx ?
- reduce physical activity
- ice
- NSAIDs
symptoms usually resolve over time
What is juvenile idiopathic arthritis (JIA) ? diagnostic cretira ?
autoimmune inflammation in the joints
- diagnosed when there is arthritis with no other cause lasting > 6 weeks, <16 yrs
what is the triad of symptoms in JIA ?
- joint pain
- joint swelling
- joint stiffness
what are the different types of JIA ?
- systemic JIA
- palyarticular JIA
- oligoarticular JIA
- Enthesitic-related arthritis
- Juvenile psoriatic arthritis
Px present with salmon pink rash, fevers + joint pain. what diagnosis ?
systemic JIA
JIA management ? (3)
MDT approach
- NSAIDs
- Steroids
- DMARDs (methotrexate)
