Paediatric Rheumatology / Orthopaedics Flashcards
State some differentials for Henoch-Schonlein purpura
- Meningococcal septicaemia
- Leukaemia
- DIC / pancytopenia
- Haemolytic uraemic syndrome
- Immune thrombocytopenic purpura (ITP)
- Non-accidental injury
- Forceful coughing/vomiting
Henoch-Schonlein purpura - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- IgA vasculitis
- Purpuric rash affecting the lower limbs and buttocks
- Inflammation causes IgA deposits in blood vessles, leading to leaking of small blood vessels under the skin
Most common age:
- Children < 10 years
Presentation:
- Purpuric rash affecting the lower limbs and buttocks
- Joint pain
- Abdominal pain
- Renal involvement (IgA nephritis)
Investigations:
Need to exclude other serious pathologies = multiple investigations
- FBC and blood film
- CRP and blood cultures
- U&Es and renal profile
- Serum albumin
Management:
Mainly supportive = analgesia, rest and hydration
- Use of steroids is controversial
*can expect to improve within a few days, however may have recurrence
State at what age septic arthritis is most common in children
Under 4
State some differentials for septic arthritis in children
- Juvenile idiopathic arthritis
- Transient synovitis
- SUFE (slipped upper femoral epiphyses)
- Perthes disease
- Fracture
Kawasaki disease - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- Medium vessel vasculitis
- No clear cause or trigger
Most common age:
- Under 5’s (boys and asian children)
Presentation:
- Persistent high fever (> 5 days)
- Widespread erythematous maculopapular rash
- Desquamation on hands and feet
- Strawberry tongue
- Cracked lips
- Cervical lymphadenopathy
- Bilateral conjuntivitis
Investigations:
- Inflammatory markers (particularly ESR)
- Echo (coronary artery pathology)
- FBC (anaemia, leukocytosis, thrombocytosis)
- LFTs (elevated liver enzymes, hypoalbuminaemia)
- Urinalysis (elevated WCC)
Management:
- IV immunoglobulins (reduce risk coronary artery aneurysms)
- High dose aspirin (reduce risk thrombosis)
- Follow up echocardiograms for coronary artery pathology
State some cardinal features of Kawasaki disease
- High fever (not responding to typical antipyretics)
- Maculopapular rash
- ‘Strawberry tongue’ mucositis
- Desquamation of hands and feet
- Conjunctivitis (non-sticky, sparing limbus)
- Anterior cervical lymphadenopathy
- Arthritis
Detail the typical progression of Kawasaki disease
Over period of disease = approx. 5-10 weeks
Acute phase (1-2 weeks)
- Worst symptomatically with fever, rash and lymphadenopathy
Subacute phase (2-4 weeks):
- Symptoms improving slightly
- Desquamation and arthralgia
- Risk of coronary artery aneurysm forming
Convalescent phase (2-4 weeks):
- Remaining symptoms settle
- Blood tests return to normal
- Coronary artery aneurysm tends to regress
State 2 common triggers of Henoch-Schonlein purpura
- URTI
- Gastroenteritis
State the WHO pain ladder management for children
Only 2 steps
- Simple - Paracetamol or Ibuprofen
- Morphine
Codeine and Tramadol aren’t used due to unpredictability with metabolism
State some differentials for hip pain - try and group in age categories:
- 0-4 years
- 5-10 years
- 10-16 years
0-4 years:
- Septic arthritis
- Transient synovitis
- Developmental dysplasia of the hip
5-10 years:
- Septic arthritis
- Transient synovitis
- Perthes disease
10-16 years:
- Septic arthritis
- SUFE
- Juvenile idiopathic arthritis
State some red flags for hip pain
Joint related:
- Red hot swollen joint
- Persistent pain
- Stiffness in morning
Systemic:
- Under 3 years old
- Fever
- Waking at night from pain
- B symptoms e.g. night sweats, weight loss
- Fatigue
Transient synovitis ‘irritable hip’ - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Temporary irritation and inflammation of the synovial membrane
- Most common cause of hip pain in ages 3-10
Presentation:
Often recent history of viral URTI
- Hip pain
- Inability to weight bear
- Limp
- Mild low grade temperature
Onset can be acute or gradual
Investigations:
- Generally not needed unless unsure of diagnosis or septic arthritis cannot be ruled out (consider joint aspiration)
Management:
- Generally symptomatic management with analgesia
Safety netting advice to attend A&E if they develop a fever
Review 2 days after and at 1 week after to check symptoms are resolving
*Recurrence can occur in up to 20% of cases
Perthes disease - state the following:
- Pathophysiology
- Most common age and gender
- Presentation
- Investigations
- Management
Pathophysiology:
- Idiopathic temporarily disrupted blood flow to the femoral head, leading to avascular necrosis
Most common age:
- Children aged 5-10 years
- More common in boys
Presentation:
- Hip pain (think also of pain in knee - referred pain)
- Limp
- Restricted hip movements
*No history of trauma
Investigations:
- First line = X-ray (although this can sometimes be normal)
Additional tests
- Inflammatory blood tests (to rule out other differentials)
- Bone scan
- MRI scan
Management:
Conservative if young and not severe
- Crutches
- Bed rest
- Traction
- Analgesia
- Physiotherapy to retain ROM
If severe, may need surgical intervention
Regular x-rays can be used to monitor recovery
Slipped upper femoral epiphysis - state the following:
- Pathophysiology
- Most common age / gender / main risk factor
- Presentation
- Investigations
- Management
Pathophysiology:
- Occurs when the head of the femur is displaced, along the growth plate
Most common age:
- 8-15 years (average 12 years)
- More common in boys
- Obesity is the main risk factor
Presentation:
Typically obese boy, undergoing a growth spurt
May have a minor trauma that triggered symptoms
- Hip pain disproportional to severity of trauma
- Restricted ROM
- Painful limp
- Prefer to keep hip in external rotation (limited internal rotation)
Investigations:
- First line = X-ray
Additional tests
- Inflammatory blood tests (to rule out other differentials)
- Bone scan
- MRI scan
Management:
- Surgery is the only management, required to return femoral head to correct position and fix to keep it in place
Osteosarcoma - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- Type of bone cancer
- Femur is most common bone affected, also commonly the tibia and humerus
Most common age:
- Between 10-20 years
Presentation:
- Persistent bone pain (worse at night, often waking from sleep)
- Bone swellings / palpable mass
- Restricted joint movements
Investigations:
- Very urgent x-ray within 48 hours (shows periosteal reaction “sun burst” appearance)
- Blood tests (may show raised ALP)
- May require further tests for staging etc. e.g. MRI, bone biopsy, PET scan
Management:
- Surgical resection of lesion, often resulting in amputation
- Plus adjuvant chemotherapy
- Include MDT approach e.g. physiotherapist, psychologist etc.
