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Phase 3a > Paeds - MSK > Flashcards

Paeds - MSK Flashcards

1
Q

Osteogenesis imperfecta

A

Genetic condition that results in fracture prone BRITTLE BONES.

Caused by mutations affecting collagen.

8 diff types varying in severity depending on mutations.

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2
Q

Osteogenesis imperfecta Sx

A

Recurrent/inappropriate fractures

  • HYPERMOBILE
  • BLU/GREY SCLERA
  • Triangular face
  • Short stature
  • DEAFNESS (early adulthood)
  • Dental problems (with forming teeth)
  • Bone deform
  • JOINT/BONE PAIN
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3
Q

Osteogenesis imperfecta Dx

A

Clinical
- assisted with x-rays
- sometimes Genetic testing

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4
Q

Osteogenesis imperfecta Mx

A

Incurable

  • Medical
    • BISPHOSPHONATES
    • VIT D SUPP
  • PHYSIO + OCCUPATIONAL THERAPY

+ other MDT (pediatrics, orthopedic surgery, specialist nursing + social/financial support)

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5
Q

Rickets

A

Softening + deforming of bones caused by defective bone mineralisation, particularly at growth plates -> growth retardation

Only occurs if epiphyses have not fused

Typically caused by vit D def

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6
Q

Common sites of rickets

A

Sites of rapid bone growth

  • Distal forearm
  • Knee
  • Costochondral joints
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7
Q

Characteristic factors of rickets

A
  • Growth retardation
  • Bony Deformaties (spine, bowed legs, dental abnormalities, WIDENING of bones at wrist/knees)
  • BONE PAIN
  • Muscle weakness
  • Delayed achievement of motor milestones

(sometimes hypocalcemic features e.g. paresthesia, seizures, tetany, spasm)

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8
Q

RFx for rickets

A
  • AGE: 6-24 MONTHS
  • BREASTFEEDING without any vit D supplementaton
  • FHx
  • Inadequate sunlight (sometimes potentially due to dark skin needing more sunlight)
  • Calcium/Phosphate deficiency (esp while breastfeeding)
  • MEDS:
    • Antacids (can cause phosphate precipitation in stomach)
    • Loop diuretics
    • Corticosteroids
    • Phenytoin (anticonvulsant - target organ calcitriol def)

Malabsorptive disorders; CKD (kidneys activate vit D) - more common in older so less likely to cause rickets

Can get 2ndry hyperparathyroid if hypocalcaemic -> worse

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9
Q

Rickets Dx

A
  • X-RAY of LONG BONE (WIDE EPIPHYSEAL PLATE, loss of defintion, Looser’s zone/pseudofracture)
  • SERUM:
    • calcium (norm = 2.3-2.7)
    • inorganic phosphate
    • 25-hydroxyvit D (norm in genetic forms)
    • parathyroid hormone (high if hypocalcaemic, norm if hypophosphataemia)
    • Urea + creatinine (for kidney disease)
  • alk phos (can be high)
  • Urinary calcium + phosphate
    • can caulculate percent Tubular Reabsorption of Phosphate -> LOW = diagnostic in absence of vit D def

+ others to rule out DDx (FBC, CRP/ESR, LFTs, KFTs, Malabsorption screen, AI tests)

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10
Q

Rickets Mx

A

Best = Prevention

  • Take vit D supps/use formula while feeding (400 IU/day for kids)
  • Erdocalciferol treatment if deficient (6000 IU - 8-12 wks)
  • Calcium supps

Admit if symptomatic hypocalcaemia

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11
Q

Transient synovitis

A

Temporary inflam in synovial membrane - in HIP

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12
Q

Transient synovitis presentation

A

Typically presents few weeks after viral upper resp tract infection

  • Limp
  • Refusal to weight bear
  • Groin/hip PAIN
  • Mild temp
    - if fever -> SEPTIC Tx
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13
Q

Transient synovitis RFx

A
  • 2-12 y/o
  • MALE
  • Recent viral infection
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14
Q

Transient synovitis Ix

A
  • FBC
  • ESR/CRP
  • XRAY

All should be mostly normal - mainly to exclude DDx

Shows raised fluid if USS done

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15
Q

Transient synovitis Tx

A
  • symtomatic: activity restriction + PAIN RELIEF (typically NSAIDs)
  • safty net for septic Sx
  • follow up 48hrs + 1wk later
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16
Q

Transient synovitis prognosis

A

typically improves after 24-48 hrs and fully gone after 1-2wks

Can recur (20%)

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17
Q

Legg-Clave-Perthes (Perthes) disease

A

IDIOPATHIC disruption of blood flow to FEMORAL HEAD -> AVASCULAR NECROSIS

Affects EPIPHYSIS

Typicaly between 5-8 y/o tho can occur from 4-12 years - more commonly in boys

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18
Q

Perthes disease pathophys

A

It’s ideopathic - could be due to repeated mechanical stress

REVASCULERISATION/
NEOVASCULARISATION occurs over time -> healing + remodelling BUT leaves kid with SOFT/DEFORMED femoral head -> early onset osteoarth of hip (requiring total hip replacement)

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19
Q

Perthes disease Px

A

Slow onset

  • LIMP (esp Trendelenburg)
  • hip/groin PAIN
    • can refer to knee
  • Restricted movement
  • can get muscle wasting

NO Hx OF TRAUMA -> DDx = slipped upper femoral epiphysis - more common in older

Associated w/ short stature, hyperactivity + delayed bone age

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20
Q

Perthes disease RFx

A
  • MALE
  • AGE: 4-8
  • Low socioeconomic
  • Hyper-coagulable states (usually genetic e.g. Factor V Leiden)
  • joint effusion/transient synovitis

More common in northern latitudes + south asia + inner city populations

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21
Q

Perthes disease Dx

A
  • 1st = BILATERAL HIP XRAY
    • femoral head collapse + fragmentation; subchondral frax
  • BLOODS (inflam markers to exlude DDx)
    • norm or slightly raised
  • Technetium bone scan (scintigraphy)
    • cold spot in hip in early stage
  • MRI (if xrays norm but clinically sx)
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22
Q

Perthes disease Tx

A

Acute = reduced activity + pain relief (NSAIDs/paracetamol) +/- traction; crutches

Ongoing:
- Physio + monitoring
- Non-surgical containment if lateral extrusion (e.g. brace)
- Surgical containment if: epiphyseal involvement >50% or at stage 1/2 at 7-12 y/o
- Any worse = salvage procedure
- >12 with arthritis = replacement arthroplasty after skeletal maturity

Assess with regular xrays

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23
Q

Causes of Hip Pain

A

0 – 4 years:

  • Septic arthritis
  • Developmental dysplasia of the hip (DDH)
  • Transient sinovitis

5 – 10 years:

  • Septic arthritis
  • Transient sinovitis
  • Perthes disease

10 – 16 years:

  • Septic arthritis
  • Slipped upper femoral epiphysis (SUFE)
  • Juvenile idiopathic arthritis

DON’T FORGET NEURO/SPINE PROBLEMS

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24
Q

Red flags for hip pain

A
  • Child under 3 years
  • Fever
  • Weight loss/Anorexia
  • Night sweats
  • Fatigue
  • Persistent pain/Waking at night with pain
  • Morning stiffness
  • Swollen or red joint
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25
Q

When is urgent referral require for a limping child

A
  • if they are UNDER 3
  • > 9 with pain/restricted ROM
  • Not able to weight bear
  • Evidence of neurovascular compromise
  • Severe pain or agitation
  • Red flags for serious pathology
  • Suspicion of abuse
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26
Q

Slipped Upper Femoral Epiphysis (SUFE)

A

Head of fenur slips along growth plate - fracture through growth plate

More common in boys aged 8-15 - esp OBESE kids
- girls tend to present a bit younger

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27
Q

SUFE Px

A

Obese teen male having a GROWTH SPURT - could be triggered by minor trauma but DISPROPORTIONATE PAIN

  • PAIN (hip, groin, thigh, knee)
    • BILATERAL in hips 60% of time
    • Typically KNEE PAIN
  • RESTRICTED hip MOVEMENT
  • ANTALGIC/TRENDELENBURG GAIT

Pt keeps hip EXTERNALLY ROTATED - restricted int rotation

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28
Q

SUFE RFx

A
  • PUBERTY
  • OBESITY
  • endocrine disorders
  • Male sex
  • African-american or Hispanic ancestry
  • Prior radiotherapy
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29
Q

SUFE Dx

A
  • X-RAYS
    • Bilateral antero-posterior
    • FROG-LEG LATERAL
    • Klein lines (drawn along superior cortex of NOF) - doesn’t intersect epiphysis (ABNORMAL)

Consider:

  • Metabolic panel
  • Serum TFTs
  • Serum GH
  • Other bloods (to exclude inflam)
  • Technitium bone scan
  • CT or MRI
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30
Q

SCFE Tx

A

Unstable:
- Urgent Surgical repair +/- prophylactically fix other hip too

Stable SCFE:

  • 1st: IN SITU SCREW FIXATION
  • 2nd: Open reduction + internal fixation with surgical hip dislocation
  • 3rd: Bone graft epiphysiodesis
    +/- porphylactic fixation

Late deformity:
- Corrective surgery

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31
Q

Developmental dysplasia of the Hip (DDH)

A

Structural abnormality of hips caused by abnormal development of FETAL bones during preg.

Causes instability -> risk of subluxation/dislocation.

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32
Q

DDH RFx

A
  • FIRST DEGREE FHx
  • BREECH PRESENTATION (from 36wks or at birth from 28wks)
  • Multiple preg
  • more common in females
  • postural deform
  • Having 1st baby
  • Packaging disorder
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33
Q

DDH Px:

A

Oft picked up during NEWBORN EXAMINATIONS:

  • Diff leg lengths/Difference in the knee level when the hips are flexed
    • Galliazi test
  • RESTRICTED hip abduction on one side; Trendelenburg gait
  • Significant BILATERAL RESTRICTED ABDUCTION
  • CLUNKING of the hips on special tests (basically testing dislocation)
    • Ortolani test
    • Barlow test

Otherwise:
- LIMP, Pain, Leg length deform
- Unilateral toe-walking
- Abnormal positioning of leg
- Delayed crawling/walking

34
Q

DDH Dx

A

1st: USS - everyone with RFx/exam findings

X-rays in older babies

  • Abnormal relationship between femoral head + acetabulam
35
Q

DDH Tx

A

PAVLIK HARNESS if LESS THAN 6 MONTHS
- fitted harness which holds femoral head in right place to allow development of normal acetabulum shape - kept on permanently
- usually removed after 6-8wks (once more stable)
- May use more ridgid abduction brace 2nd line

Surg required if older/harness fails
-> HIP SPICA CAST (immobolises for a while)

Hip reconstruction or salvage osteotomies if >6 y/o

36
Q

Juvenile Idiopathic Artritis (JIA)

A

Group of chronic pediatric inflam arthritides
- characterised by ONSET BEFORE 16 YEARS + Objective arthritis (infalm Sx) in at least one joint for AT LEAST 6 WEEKS

37
Q

JIA RFx

A
  • FEMALE
  • HLA polymorphism
  • FHx of AI CONDITIONS

Potential relation to Antibiotic exposure in childhood

OFt associated with/2ndry to other chronic conditions - IBD. coeliacs

38
Q

JIA Sx

A
  • Joint PAIN, SWELLING
  • FEVER
  • >6 WEEKS duration
    - otherwise just transient synovitis
  • Morning stiffness
  • Limp
  • Limited movement (e.g. can’t fully straighten)
  • RASH; ENTHESITIS, uveitis, rheumatoid nodules
39
Q

JIA Dx

A
  • BLOODS:
    • FBC,
    • ESR/CRP
    • ANA (positive in oligoarticular JIA)
    • RF (2 positive test required)
  • anti-CCP (possitive in RF-positive polyarticular JIA)
  • USS (synovitis - good for idenifying joints which need corticosteroid injection)

Chlamydia serology (rule out Reactive)
Ferritin (if systemic onset JIA is suspected)
MRI to rule out (synovial fluid/thickening)

40
Q

JIA Tx

A

1st line for inflam in general = steroids
(methyl/prednisolone; IV; Joint injections)

  • 1st: DMARD for polyarticular with 5 or more involved (at any point)
    • METHOTREXATE (not well tolerated)
      - IM
      - Nausea
  • 1st: Intrasrticular corticosteroid injections for OLIGOARTICLUAR (4 or less involved ever)
  • 1st: NSAIDs for everything else

Escalate to biologics (TNF-a inhib):

  • Adalimumab
  • Etanercept

If they have systemic onset JIA with macrophage activation syndrome (life threatening complication) - need to start with biologics (IL-1 or IL-6 typically)

41
Q

Criteria for Macrophage activation syndrome (MAS aka HLH)

A
  • FEBRILE
  • Known/suspected systemic onset JIA
  • ferritin >684 micrograms/L (>684 ng/mL) and any two of:
    • platelet count ≤181 x 10⁹/L,
    • aspartate aminotransferase >48 U/L,
    • triglycerides >1.76 mmol/L (>156 mg/dL),
    • fibrinogen ≤3.6 g/L (≤360 mg/dL)

CRP and ESR can go down due to prolonged inflam

42
Q

Osgood-Schlatter disease (OSD)

A

Knee pain caused by inflam at TIBIAL TUBEROSITY at INSERTION OF PATELLA LIGAMENT. An overuse syndrome.

Usually UNILATERAL but can be bilateral.

More common in males. TYpically ages 10-15.

43
Q

Osgood-Schlatter disease pathophys

A

Tibial tuberosity/patella tendon insertion is AT THE EPIPHYSEAL PLATE. Mechanical stress combined with growth ain epiphyseal plate = INFLAM of TIBIAL EPIPHYSEAL PLATE

Multiple small avulsion fractures occur (patella ligament pulls away tiny pieces of bone from tibial epiphyseal plate) FORMING TIBIAL TUBEROSITY.
- Initially tender from infalm but hard + non-tender.

44
Q

OSD RFx

A
  • Teen males
  • ATHLETIC PARTICIPATION
  • Hx of OSD in other knee

High position of patella; more proximal tendon insertion; Increased external tibial torsion

45
Q

OSD Sx

A
  • LOCALISED PAIN/Tenderness; swelling, warmth
  • Activity limitation
  • Prominence of tibial tubercule
  • Pain at tubercule with resisted knee extension
46
Q

OSD Dx

A
  • PLAIN X-RAYS

USS/MRI

47
Q

OSD Mx

A

Acute -> symtomatic relief

  • reduce physical activity
  • ICE
  • NSAIDs

After:
- stretching + physio

48
Q

potential compilcation of OSD

A

Full avulsion fracture - tibial tuberosity seperated from rest of tibia
- surgical intervention

49
Q

Investigations for limping child

A
  • Bloods: FBC, ESR/CRP, cultures if infection suspected
  • Xrays (look at joint above + below) - 2 views
  • USS - better for soft tissue + infection

MRI requires sedation for young kids

50
Q

Red flags for limping child

A

Unable to weight bear
Fever
Systemic illness
Severe pain
Limp or pain - worsening
Pain- waking the child at night
Redness, swelling and stiffness
Weight loss, anorexia

51
Q

Most common cause of limp in kids

A

Transient synovitis

52
Q

Septic arthritis spread

A

Direct, Haematogenous, Extension from adjacent bone/soft tissue

53
Q

Classic positioning of leg in septic arth of hip

A

bent and externally rotated

54
Q

Score for septic arth

A

Kocher Criteria (4/4 = 99% chance of septic arthritis)

55
Q

septic arth vs osteomyelitis aetiology

A

septic arth = most common <2 y/o

osteomyelitis most common <10 y/o

56
Q

osteomyelitis pathophys

A

Suspected to be due to slow, rich blood flow to metaphysis with less immune cells available in area

57
Q

septic arthritis vs osteomyelitis Px

A

septic arthritis is more likely to have systemic symptoms + swollen joint

58
Q

Which imaging is best for infection

A

USS (including in bone infection)

59
Q

What to do for febrile child

A

Just give Abx if suspected sepsis

60
Q

Common traumas causing limp

A
  • Fracture
    • small kids tend to keep walking due to thick periosteum
    • look for bruising, seelling, tendernedd
    • Toddler’s fracture
  • Foreign bodies
  • Non-accidental injury
61
Q

Red flags for non-accidental injury

A

Any brusing <4-6 months
Injury location
Any fracture in non-ambulatory child

62
Q

What to do if worried about non-accidental injury

A

All usual stuff but just admit if very concerned

63
Q

Red flags for bone cancer

A

Nigh tpain
Pain doesn’t go after treatment
Lump in soft tissues/bone

Can also get systemic Sx

64
Q

Bone tumour on x-ray

A

Bony destruction/hole
Soft tissue swelling
New bone formation

65
Q

good resourse is good for neuro exam

A

asia chart

66
Q

most likely location of septic arthritis

A

hip

67
Q

Define chronic illness

A

Long term illness that impact an individuals functioning (lasting more than 6 months/1 year)

68
Q

Complications of JIA

A
  • Wheelchair bound
  • Jaw stiffness
  • Enthesitis
  • Ank spond -> spinal stiffness
  • Uveitis -> loss of vision
69
Q

Types of JIA

A
  • Oligoarticular: 1-4 joints
  • Increases to >4 joints within a month = oligoarticular extended
    - Particularly prone to uveitis

Oligoarticular = ANA +VE

  • Polyarticular: >5 joints; usually small joints
    - Rheumatoid factor +ve
    - RF -ve

Esp in teen girls - more likely to get rheumatoid later on

  • Psoriatic arthritis (large joints/fingers esp)
    - if child or 1st degree relative has psoriasis
  • Enthesitis related arthritis (places where tendons attach)
    - closely related to Ank spond + HLA B27
  • System onset JIA (oft starts with pyrexia of unknown origin but the fevers follow a pattern)
    - salmon pink rash; worse during fever
70
Q

Juvenile SLE common features

A
  • Skin, kidneys + joints = most common sites of presentation
  • thrombocytopenia common
  • High ds-DNA
  • or High ANA
71
Q

Juvenile Dermatomyositis

A
  • Inflamed nailbeds
  • Gottron’s capsules on extensor surfaces
  • Heliotrope rash on cheeks
  • Muscle weakness
    • Oft have swallowing problems which can lead to aspiration

Ab +ve tends to have worse prognosis + need biologics

72
Q

Biopsychosocial impact of JIA + the Tx

A

Biologics can delay growth/puberty

Psychological:

  • Sick role, regression, mental health, body image

Social:

  • Reduced independance
  • Lack of peer relationship
  • Poor school attendance
73
Q

Scoliosis

A

Abnormal lateral curvature of the spine

  • most commonly initially presents in kids 10-15 y/o
74
Q

Scoliosis Px

A
  • visibly curved spine
  • leaning to 1 side
  • uneven shoulders
  • 1 shoulder or hip sticking out
  • the ribs sticking out on 1 side
  • clothes not fitting well
75
Q

Causes of scoliosis

A

8 in 10 cases idiopathic
- some genetic predisposition (can run in families)

  • congenital scoliosis
  • NEUROMUSCULAR scoliosis (cerebral palsey, muscular dystrophy)
    (- Degenerative scoliosis in older adults)
76
Q

Tx for scoliosis

A
  • May improve over time in infants
    • plaster cast / plastic brace to prevent deterioration
  • Back brace (older kids while still growing)
  • Surgery:
    • Younger kids:
      - minor procedure - rods inserted into back
      - remotely activates magnets in rods to lengthen
  • Surgical straightening aka SPINAL FUSION is an option once growth has stopped (major operation)
  • may need:
    • Analgesia, intrathecal analgesia + surgery as adults
77
Q

Risks of spinal surgery for scoliosis

A
  • Bleeding
  • Infection
  • Rods moving or grafts not attaching
  • Rarely - nerve damage (-> leg paralysis + incontinence)
78
Q

Torticollis

A

Painful, dystonia of neck -> abnormal head / neck position

79
Q

Causes of torticollis

A

Mainly idiopathic
- pain usually self-resoles after a few days

  • Muscular fibrosis
  • Congenital spinal abnormalities
  • Brain injuries / tumours
  • Trauma
  • Drugs - esp antipsychotics + some antiemetics
  • Infection e.g. esp in post-pharynx OR tetanus
80
Q

Torticollis Sx

A

Visible shape:

  • Laterocollis
  • Rotational torticollis
  • Anterocolis
  • Retrocollis

Other:

  • Pain
  • Occasional mass formation
  • Thickened / tight sternocleidomastoid muscle
  • Tenderness on c-spine
  • Head tremor
  • Unequal shoulder heights
  • Decreased neck movements
81
Q

Torticollis Dx:

A

Find underlying cause

  • US muscle tissue
  • opthalmologic evaluation to ensure it is not caused by vision problems
82
Q

Torticollis Tx

A
  • Physio
  • Sometimes use TOT collar
  • Microcurrent therapy (experimental)
  • Surgicla release of seternocleidomastoid heads
  • Analgesia
  • Muscle relaxents e.g. diazepam
  • Botulinum toxin
  • US diathermy

Phase 3a (26 decks)

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