Paeds MSK Flashcards
What is osteogenesis imperfecta?
- autosomal dominant
- brittle bones susceptible to fracture
What is the pathophysiology of osteogenesis imperfecta?
- genetic mutation
- affects formation of collagen
- needed for structure and function of bone, skin, tendons, connective tissue
How does osteogenesis imperfecta present?
- recurrent and inappropriate fractures
- hypermobility
- blue/grey sclera
- triangular face
- dental problems
- bone deformities
How is osteogenesis imperfecta investigated?
- clinical diagnosis
- X-Rays for fractures
- normal bloods
How is osteogenesis imperfecta managed medically?
- bisphosphonates
- Vit D
How is osteogenesis imperfecta managed by the MDT?
- physio and OT
- ortho surgeons
- specialist nurses
What is rickets?
- defective bone mineralisation causes ‘soft’ and deformed bones
- called osteomalacia in adults
What is the aetiology of rickets?
- vit D deficiency (lack of sunlight or food)
- calcium deficiency (dairy + green veg)
- hereditary hypophosphataemic rickets
What are risk factors for rickets?
- darker skin
- low exposure to sunlight
- cold climates
- time indoors
How does rickets present?
- lethargy
- bone pain
- poor growth
- dental problems
- muscle weakness
What bone deformities does rickets present with?
- bowed legs
- knock knees
- rachitic rosary (costochondral junction swelling)
- craniotabes (soft skull)
- delayed teeth
How is rickets investigated?
- serum 250hydroxyvitamin D >25nmol/L
- raised ALP and PTH
- low calcium and phosphate
What is the management of rickets?
- Prevention (more likely if breastfed)
- oral Vit D 400IU supplements for breastfeeding women and all children
- ergocalciferol (vit D) if deficient
What is transient synovitis?
- irritable hip
- temporary irritation and inflammation in the synovial membrane
What is the epidemiology and aetiology of transient synovitis?
- MC cause of hip pain in children aged 3-10
- often associated with viral URTI: symptoms occur within a few weeks
What is the presentation of transient synovitis?
- refusal to weight bear
- limp
- groin or hip pain
- mild low grade temp
What is the management of transient synovitis?
- exclude septic arthritis
- symptomatic management
- recovery within 1-2 weeks without long term effects
When should children be admitted to hospital with transient synovitis?
- under 3: septic arthritis is more common
- fever
What is septic arthritis and what is the epidemiology?
- infection inside a joint
- MC in children <4 years
What bacteria cause septic arthritis?
- S. aureus is MC
- N. gonorrhoea (sexually active teens)
- Group A strep (S. pyogenes)
- H. influenzae
- E. coli
What is the presentation of septic arthritis?
- hot, red, swollen, painful joint
- refusal to weight bear
- affects single joint e.g. hip or knee
- stiffness and reduced ROM
- systemic symptoms: fever, lethargy, sepsis
What are the Kocher criteria?
- fever >38.5
- non-weight bearing
- raised ESR
- raised WCC
What is the management for septic arthritis?
- admit to hospital
- joint aspiration before Abx: gram staining, MC&S
- empirical IV Abx followed by specific Abx
- surgical drainage and washout
What is osteomyelitis?
- infection of the bone and bone marrow
- typically in metaphysis of long bones
How can infection be introduced to bone in osteomyelitis?
- open fracture or from blood
- chronic osteomyelitis is slow growing and deep seated
What are risk factors for osteomyelitis?
- males <10
- open bone fracture
- orthopaedic surgery
- immunocompromised
- sickle cell anaemia
- HIV/TB
How does osteomyelitis present?
- refusal to use limb or weight bear
- pain
- swelling
- tenderness
- systemic symptoms: fever
How is osteomyelitis investigated?
- first line: X-Ray
- GOLD: MRI
- bloods + cultures
- Bone marrow aspirate
How is osteomyelitis managed?
- extensive and prolonged Abx therapy
- surgery for draining and debridement
What is Perthes Disease?
- disruption of blood flow to femoral head causing
- avascular necrosis of bone
- revascularisation and bone remodelling as it heals
What is the aetiology and epidemiology of Perthes disease?
- idiopathic
- MC boys 5-8y but can affect all children from 4-12
What is the presentation of Perthes disease?
- slow onset of pain in hip or groin
- limp
- restricted hip movement
- referred knee pain
- no history of trauma
How is Perthes disease investigated?
- X-Ray (may be normal)
- bloods
- technetium bone scan
- MRI
How is Perthes disease managed?
- conservative to maintain position and alignment
- reduce risk of damage or deformity to femoral head
- bed rest, analgesia, crutches, traction
- physio, X-Ray, surgery
What is slipped femoral epiphysis?
- head of femur dislocated along growth plate
What is the epidemiology of slipped femoral epiphysis?
- mc in males
- aged 8-15
- obese children
How does slipped femoral epiphysis present?
- adolescent, obese male undergoing growth spurt
- painful limp
- wanting to keep hip in external rotation with restricted internal rotation on flexion
- hip, groin, knee or thigh pain
How is slipped femoral epiphysis investigated?
- 1st line: X-Ray
- bloods normal
- CT/MRI
How is slipped femoral epiphysis managed?
- surgery to return femoral head to correct position and fix in place
- internal fixation with cannulated screw
What is osgood-schlatter disease?
- inflammation at tibial tuberosity where patellar ligament inserts
- usually unilateral
What is the epidemiology of osgood-schlatter disease?
- males aged 10-15
- common cause of anterior knee pain in adolescents
What is the pathophysiology of osgood-schlatter disease?
- patella tendon inserts into tibial tuberosity
- stress from movement during growth causes inflammation
- ligament pulls away tiny pieces of bone > new bone formation and calcification in response to injury
- leads to tender bump > hard, non-tender as it heals
How does osgood-schlatter disease present?
- pain exacerbated by physical activity, kneeling and on extension
- gradual onset of symptoms
- palpable lump at tibial tuberosity
How is osgood-schlatter disease managed?
- NSAIDs
- reduce physical activity
- ice
- stretching
What is DDH?
- structural abnormality in hips caused by abnormal development of fetal bones
- leads to instability in hips and tendency for dislocation
How is DDH recognised?
- in newborn exam
- child presents with hip asymmetry
- reduced ROM in hip or limp
What are risk factors for DDH?
- 1º FHx
- breech presentation from 36 weeks onwards
- female
- first born
- oligohydramnios
How is DDH screened for after birth? (what is seen)
- NIPE
- different leg lengths
- restricted hip abduction on one side
- significant bilateral restriction in abduction
- difference in knee level when hips flexed
- clunking of hips on special testing
What are the special tests for DDH?
- Ortolani
- Barlow
What is the Barlow test?
- attempts to dislocate an articulated femoral head
What is the ortolani test?
attempts to relocate a dislocated femoral head
What are other signs of DDH?
- asymmetrical skin folds
- different leg lengths
- limited abduction of hip
How is DDH investigated?
- USS
- X-Ray
How is DDH managed?
- Pavlik harness if <6 mo
- keeps femoral head in correct position
- keeps hips flexed and abducted
- may need surgery if harness fails or diagnosis >6 mo
What is JIA?
- autoimmune inflammation in joints
- arthritis without any other cause
- lasts more than 6 weeks in patient under 16
What is the presentation of systemic JIA?
- idiopathic inflammatory condition
- subtle salmon pink rash
- enlarged lymph nodes
- high swinging fever
- joint pain and inflammation
- splenomegaly
- muscle pain
What are the results of investigations of systemic JIA?
- ANA and RF negative
- raised CRP, ESR, platelets
What is a key complication of systemic JIA?
- macrophage activation syndrome
- massive inflammatory response
- DIC, anaemia, bleeding, non-blanching rash
- low ESR
How does polyarticular JIA present?
- 5 joints or more
- symmetrical
- affects small/large joints
- minimal systemic symptoms: mild fever, anaemia, reduced growth
What results are found in investigation of polyarticular JIA?
- mostly negative for RF
- seropositive are older children and adolescents
What is oligoarticular JIA?
- involves 4 or less joints
- aka pauciarticular JIA
How does oligoarticular JIA present?
- 4 or less joints (usually monoarthritis)
- large joints e.g. knee or ankle
- anterior uveitis
What is seen on investigation of oligoarticular JIA?
- no systemic symptoms
- normal/mildly elevated inflammatory markers
- ANA positive
- RF negative
What is juvenile psoriatic arthritis?
- seronegative inflammatory arthritis
- symmetrical polyarthritis affecting small joints OR
- asymmetrical arthritis affecting large joints
How does juvenile psoriatic arthritis present?
- plaques of psoriasis
- pitting and onycholysis
- dactylitis
- enthesitis
What is the epidemiology of enthesitis-related arthritis?
- more common in male children over 6 years
- paeds version of seronegative spondyloarthropathies
- most have HLA-B27 gene
What is enthesitis?
- inflammation at point where muscle inserts into bone
- caused by trauma or autoimmune
How does enthesitis-related arthritis present?
- signs and symptoms of psoriasis and IBD
- prone to anterior uveitis
How is JIA managed?
- NSAIDs
- steroids - oral, IM or intra-articular
- DMARDs e.g. methotrexate
- biologics e.g. adalimumab
