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.
Talipes ‘club foot’ - state the following:
- Pathophysiology
- Management
Pathophysiology:
- Congenital fixed abnormal ankle position
- Can occur spontaneously or as part of other syndromes
- Often identified at newborn examinations
Management:
- Ponseti method
- May require surgery if Ponseti method is unsuccessful
State the 2 types of talipes or “club foot” and briefly describe them
Talipes equinovarus:
- Ankle plantar flexed and supinated
Talipes calcaneovalgus:
- Ankle dorsiflexed and pronated
Outline the Ponseti method for club foot management
Performed by a trained therapist
Often started soon after birth
Repeated until foot is in the correct position
- Manipulation of feet and cast applied to hold in position
- At some point, an Achilles tenotomy is performed to release tension in the achilles tendon
- Then a brace is used to hold feet in correct position when not walking, until about 4 years old “boots and bars”
Outline how positional talipes differs from congenital club foot and how management changes
In congenital club foot, there is a fixed ankle position which cannot be manipulated into position
However in positional club foot, it occurs when the child is at rest however is able to be manipulated into position and there is no bony abnormality
The Ponseti method is used for congenital club foot, however in positional club foot, a more conservative approach is required with a physiotherapist
Developmental dysplasia of the hip - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Congenital condition where there are abnormalities of fetal bone development of the hips
- Leads to a tendancy of the hip subluxation or dislocation
- If not treated, can lead to problems in adulthood with recurrent dislocations and degenerative changes
Presentation:
Generally picked up on newborn examinations
- Clunking sensation on Barlow and Ortolani test
Can be picked up later in life with hip asymmetry, different leg lengths or reduced ROM in hips
Investigations:
Screened for at newborn check
- Further tests with ultrasound
- X-rays may be used in older infants
Management:
< 6 months old = Pavlik harness, kept on for around 2 months (hips are flexed and abducted)
> 6 months old or failed harness = Surgery followed by spica cast
State 3 risk factors for developmental dysplasia of the hips
- Breech presentation / birth
- First degree family history DDH
- Multiple pregnancy
