Paediatrics MSK and Congenital heart Flashcards
What are some causes of hip pain in children?
Transient synovitis
Development dysplasia of the hip
Legg- Perthes disease
Slipped upper femoral epiphysis
JIA
Septic athritis
What are the different types of Talipes that can come about, and what is the treatment?
Talipes:
- Equinovarus
- Calcaneovulgas
Treatment:
- Ponseti methods
- Surgery
*oligohydramnios is associated with this
What is a key clinical finding of someone with osteogenesis imperfecta?
Blue sclera
*most are autosomal dominant
What type of murmur is heard with VSD?
pansytolic murmur
- usually grade 3-6
What murmur is usually heard in ASD?
Ejection systolic Murmur over the pulmonary area
- fixed splitting of S2 sound
What is meant by fixed splitting?
A2 and P2 usually split during inspiration due to increased volume in the right side. There is usually no splitting during expiration.
In fixed splitting there is a constant split
List some clinical signs of ASD:
Soft mid systolic murmur
- heard in pulmonary area
Fixed splitting of S2 sound
Signs of congestive heart failure
Harrison’s grooves
What pulses are checked in a paediatric examination?
Brachial and femoral
*not radial
What congenital condition is highly associated with coarctation of the aorta?
Turner’s syndrome
What are the typical clinical findings of a child with co-arctation of the aorta?
Differential blood pressure in arm to leg
Absent/ weak/ delayed femoral pulses.
Radio-femoral delay
Ventricular heave
Breathless
Floppy baby
Murmur
- if present it will be a ejection systolic due to aortic stenosis
or
- systolic murmur heard best between the shoulder blades
X-ray
- rib notching
What investgiations do you want to do into suspected acyanotic heart disease/
Echocardiogram ECG X-ray Oxygen saturation 4 limb BP
What are some of the signs a child may have a cyanotic heart disease?
Blue hue/ blue appearance to them
- cyanosis
Poor feeding
Murmurs
Finger clubbing
- 6 months on
Hypoxic spells
- “TET spells”
Polycaethemia
What is the most common cause of cyanotic heart disease and what are its features?
Tetralogy of fallot
- Large SVD
- Overriding aorta
- Pulmonary stenosis causing RV obstruction
- RV hypertrophy
What are some of the major risk factors for tetralogy of fallot?
Rubella Maternal age >40 Family history DiGeorge syndrome and Edwards Maternal diabetes Alcohol abuse during pregnancy
What findings may be seen on a child with tetralogy of fallot?
Cyanosis signs
Ejection systolic murmur
- due to pulmonary stenosis
Loud single S2
- only the aortic might close as the stenosis may be severe enough to affect the pulmonary valve
Palpable thrill over the right ventricle
What sign is seen on x-ray of a child with tetralogy of fallot?
Boot shaped heart
In tetralogy of fallot a child may experience a Tet/ Hypoxic spell. What causes these and what maneuver can be done to elevate the hypoxia?
Brought on by:
- crying
- fever
Putting child in squatting position (knees to chest) and giving small amount of morphine to slow breathing
if this doesn’t work:
- 100% oxygen
- Beta blockers
What is the most common type of congenital heart defect?
Ventricular septal defect
What are some clinical findings of a patent ductus arteriosus?
Continual machinery murmur heard midway below the left clavicle
Wide pulse pressure - as blood flows back through the duct during diastole
Bounding femoral pulse
**potentially cyanotic lower limbs if pulmonary hypertension occurs, which causes deoxygenated blood to flow out and into the aorta as it starts to descend.
What is the treatment for patent ductus arteriosus?
Stable:
- Ibuprofen/ NSAIDs - to close the duct
Unstable:
- surgically ligation - scar over the lateral aspect of the chest
What murmur is most likley to be heard in tetralogy of fallot and why?
Hard systolic ejection murmur in the pulmonary area
- due to high pressure needed to overcome the pulmonary circulation
What classification system is used to assess fractures? of the growth plate
Salter Harris Classification system I - straight across II - above III - below IIII - through IV - Crush
What fractures occur in children but no adults?
Buckle fractures
Plastic fractures
Greenstick fractures
What are the features of an innocent murmur?
Asymptomatic No thrill or heave Soft systolic Varies with position Localised to one area
What congenital heart condition is associated with use of lithium during pregnancy? and what symptoms will you see?
Ebstein’s anomaly
Where the tricuspid leaflets are displaced.
- pansystolic murmur due to tricupsid regurgitation
- mid - diastolic murmur due to tricupsid stenosis
Which cardiogenic abnormalities are cyanotic?
- Tetralogy of fallot
- Transposition of the great vessels
- Pulmonary atresia
- Tricuspid atresia
What does PANDAS stand for and what disease can it commonly be associated with?
Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections
Rheuamatic fever
What are the managements for a patent ductus arteriosus and Where would you find a scar following a patent ductus ligation?
Ibuprofen
or
Indomethacin
Surgery scar:
- Around the ribs laterally
Or closed via catheter
In tetralogy of fallot if putting the baby into the squatting position to help with cyanotic episodes does not work, what additional things can be done in hospital?
Oxygen
- 100%
Morphine
- slow breathing rate
Fluid bolus
Beta blockers
What are the signs of a innocent murmur?
7 S’s
Systolic Soft - Max 1-2 grade Sensitive - change with position Small - do not radiate Sweet - not harsh Short - no crescendo decrescendo Single
Which murmur will be systolic and radiate to the back?
Pulmonary stenosis
When taking a history of congenital cardiovascular disease, what history of relatives with congenital cardiovascular disease is relevent?
1st degree
or
>1 non-1st degree relative
List the congenital conditions and the most associated cardiac pathology, in order:
Down Syndrome:
- VSD
- AVSD
Turner Syndrome:
- Coarctation of aorta
- Bifleaflet aortic valve
Edward’s syndrome
- ASD
- VSD
DiGeorge’s syndrome
- Transposition of the great vessels
- Tetralogy of Fallot
Noonan syndrome
- hypertrophic cardiomyopathy
- pulmonary stenosis
Which syndromes commonly have swollen hands and feets, and what is causing it?
Down’s syndrome
Noonan’s syndrome
Turner’s syndrome
*lymphatics not cardiac related
At which grade of murmur is a thrill palpable?
Grade 4
Why is blood pressure taking on the right side?
Incase of coarctation of the arota?
How does transposition of the great vessels present in a child?
No murmur
Large single S2 sound
Right sided ventricular heave
In an MSK assessment of a child, what are the main things you must be concerned about:
TIM:
Tumours
Trauma
Infection
Inflammation
Mechanical
Muscle disease
Metabolic disease
What is the sign called when a child uses their hands to push up off their limbs?
Gower’s sign
What is the number one sign seen in a neonate with septic arthritis of the hip?
Pseudo-paralysis.
Septic arthritis until proven otherwise.
What features help to distinguish between synovitis of the hip and septic arthritis?
Pyrexia
Inability to bear weight
A raised ESR
High WBC
Highlight come key features of kawasaki disease:
Persistent high fever Red palms Conjunctivitis Strawberry tongue Lymphadenopathy High platelet count
What are the features of a deformity which suggest it is a normal variant and does not require further follow up?
5 S’s
Symmetrical deformity no Symptoms no Systemic signs no Skeletal dysplasia no Stiffness
Examples:
- in- toeing
- out toeing
- knock knees
What are the causes of a patent ductus arteriosus and what is the murmur heard with it and name some management strategies:
Prematurity
Rubella
Continuous murmur subclavicular left clavicle
Management:
- NSAIDs
- Surgical ligation
What would you expect the FBC to be in tetralogy of fallot?
Polycythemia
What signs and symptoms would you expect to see in a child with DDH:
Neonate:
- Barlow and Ortolani tests
> 3 months:
- Poor abduction
- limb length discrepancies
> 1 year/ walking
- painless limb
- toe walking on affected side
- uneven skin folds
- Trendelenburg gait (weak abductors)
- scoliosis
- lordosis
What should one consider in children with suspected slipped upper femoral epiphysis who present out with normal age brackets.
additionally, what investigations should be carried out routinely?
What is the treatment?
Slipped upper femoral epiphyseal is associated with:
- hypothyroidism
- pan-hypopituitaism
- renal disease.
this is especially true when a child is outwith typical age brackets
Investigations:
- x-ray - AP and frog leg
- if inconclusive then MRI
Treatment: - Cannulated screws to fix the plate or - corrective osteotomy *note usually bilaterally this is done
Give some differentials for Slipped upper femoral epiphyseal:
Hip fracture
Transient synovitis
Perthes disease
Osteomyelitis
What is the position of a slipped upper femoral epiphyseal?
Inferior and posterior
When should surgery for VSD done by and what is the major complication that can occur with this defect?
Surgery should be done by 12 months
Complication:
- Eisenmenger’s syndrome
What is the medical management of a VSD?
Dietician
- extra calories
(high energy and reduced feeding causes faltering growth)
Diuretics + ACE inhibitors
What signs suggest growing pains instead of something sinister?
Never present at start of day Bilateral Worse after long day of activity No limp No systemic features Normal miltestones
What are the symptoms and clinical findings of Leg-Perthes?
Limping pain
Groin pain
- which radiates to ipsilateral knee
Findings:
- antalgic gait
- Trendelenburg sign (weak glutes)
- limited ROM - especially of internal rotation
- Muscle wasting
- LLD if severe
What are some x-ray findings you may see with Leg-Perthes and what are the treatment options?
X-ray:
- collapsing and flattening of the femoral head
- widening of joint
Treatment: <5 years old/ moderate disease: - non-weight baring - NSAIDs - Physiotherapy
> 5 years old/ severe:
- Surgical (Varus osteotomy/ hip replacement)
- casts to hold hip into shape
Highlight the differences between transient synovitis and septic arthritis:
Transient synovitis:
- More common
- able to weight bare
- no pyrexia or minimal
- normal inflammatory markers
- No pus or cultures grown in joint capsule
- NSAIDs help
Septic:
- Less common
- unable to weight bare
- Moderate to severe pain even at rest
- pyrexia
- inflammatory markers elevated
- Positive aspiration with pus
- IV antibiotics
When does tetralogy usually present?
2 months
When should surgery for tetralogy be done by?
6 months
What is the life saving surgery done for transposition of the great vessels and what is the definitive surgery?
Life saving surgery:
- Balloon atrial Septostomy (creates a AVD to allow blood mixing)
Definitive:
- Atrial switch procedure
When does symptoms of transposition of the great vessels occur?
usually occurs several hours after birth once the ductus arterioles has shut
Why is it so important to pick up left to right shuts (Acyanotic) defects?
Eisenmenger syndrome can occur within 10-15 yeas which is irreversible and causes death
In terms of co-arctation what simple test using the sats probe can be done to help guide the diagnosis?
Place two probes on. One on right arm and another on the legs The leg will read lower as it receives blood through ductus
What are the risk factors for bone tumours?
Retinoblastoma
Previous radiotherapy treatment
Tubosclerosis
Li - Fraumeni syndrome
- osteosarcoma
What is the investigations into bone tumours and what is definitive daignosis and what is the treatment?
X-ray
MRI imaging of the tumour for greater details
CT Chest/Abdo/Pelvis
*check lungs
Biopsy is needed
**note that all of this should be discussed at MDT before making any decisions given that biopsies may make some cancers worse
Treatment:
- Aggressive resection with margins
- Chemotherapy
What are the features of a patent ductus arteriosus?
Continues machinary murmur
- heard best below left clavicle
Large pulse pressure
- drop as blood moves into pulmonary circulation
Bounding pulse
Heaving apex
*indomethacin can be used to fix it
How are ASDs fixed?
Transcather for secundum defects
Surgical repair for primum or secundum
What is the medical and surgical management for transposition of the great arteries?
Medical:
- Prostaglandin to maintain ductus arteriosus
Surgical:
Before definitive surgery: Intra-arterial Balloon Septostomy
- arterial switch
What investigations are needed to confirm SUFE and what is the corrective surgery for the SUFE?
Pelvic x-rays:
- AP
- Frog leg
Surgical fixation
- Cannulated screw through the epiphysis
When is the surgery for tetralogy carried out?
6 months
How is transposition of the great arteries managed before surgery and when is surgery done by?
Prostaglandin infusion to keep PDA patent
Arterial Balloon Septostomy
*3 weeks the arterial switch is performed.
What congenital heart defect is Fontan circulation associated with and how does it work?
Associated with Tricuspid atresia, pulmonary atresia and hypoplastic left heart syndrome
*these are all essentially univentricular circulations (relying solely on one ventricle to pump blood around the body)
The fontan circulation looks to plug the venous return directly into the lungs and by-pass the right side of the heart.
*means the left ventricle has to pump blood all round the body and into the lungs
What other operation can be done for transposition other than an arterial switch?
Baffle operation
Where do you find the septum ostium primum?
Near the ventricle
What is the long term complication of ASD?
Pulmonary hypertension
Heart failure
Stroke
Arrhythmias
