Paeds MSK Flashcards
What is developmental dysplasia of the hip?
Ranges from hip dysplasia to complete dislocation
What are the risk factors for developmental dysplasia of the hip?
Females First born child Oligohydramnios Previous history of it in another child Big birth weight (>5kg) Breech presentation Congenital calcaneovalgus foot deformity
How would you detect developmental dysplasia of the hip in a newborn?
(on newborn exam or 8 week check up)
Barlow manoeuvre - to dislocate
Ortolani manoeuvre - to relocate
How would a child with developmental dysplasia of the hip present?
Limp / abnormal gait
Asymmetry of hip skin folds
Limited abduction or shortening of affected limb
+ on US of high risk groups
How would you confirm a diagnosis of developmental dysplasia of the hip?
US
How would you manage a child with developmental dysplasia of the hip?
Pavlik harness to keep hip flexed and abducted
If this doesn’t work or >6 months –> corrective surgery
CASE
A child with a fever, acutely painful limb
Won’t move it at all
O/E limb is swollen and tender, with an effusion in the joint below
Diagnosis?
Osteomyelitis
Trauma - fracture
Septic arthritis?
Bone tumour
Transient synovitis
How does osteomyelitis usually present?
+ in which bones
Distal femur and proximal tibia
Painful, immobile limb Fever Doesn't move the limb at all - movement causes pain Joint effusion Tender and swollen on examination
How would you investigate a child with suspected osteomyelitis?
Bloods:
- Raised WCC
- Raised ESR and CRP
- Positive blood cultures
CXR - nothing initially, then changes after about a week - new bone formation (subperiosteal) and localised bone thinning
MRI - differentiates bone from soft tissue swelling, shows subperiosteal pus and purulent debris in the bone
How would you manage a child with osteomyelitis?
Antibiotics - flucloxacillin basically for a long time - IV
then oral
If no response or / frank pus on aspiration / collection of pus / abscess - surgical drainage and debridement
+ rest limb in a splint and then mobilise
What are pathogens that commonly cause osteomyelitis?
Staph aureus
Streptococcus
Haemophilus influenzae
What are the risk factors for developing osteomyelitis?
Diabetes Sickle cell anaemia IV drug users Immunosuppression - due to HIV / medication Alcohol excess
CASE
A child with hip pain (sudden onset)
O/E decreased range of movement, mild fever
Diagnosis?
Transient synovitis (irritable hip)
Rule out septic arthritis
What are the symptoms of transient synovitis?
Acute hip pain
After viral illness
Decreased range of movement - lose internal rotation first
Mild fever
How would you investigate a child with sudden onset hip pain?
Bloods - ESR / CRP / WCC / cultures (for septic arthritis)
X ray - for fractures, trauma / slipped capital femoral epiphysis
US guided joint aspiration for septic arthritis
How would you manage a child with transient synovitis?
NSAIDS
bed rest - improves in a few days
CASE
Overweight 10 year old boy, with gradual onset hip / knee pain
What to look for on the history + exam
Differentials?
Hypothyroidism / hypogonadism for SCFE
Decreased range of movement - generally in Perthes, restricted abduction and internal rotation in flexion in SCFE
Slipped capital femoral epiphysis
Perthe’s disease
How would you investigate a child with gradual onset hip pain?
X ray - shows a slipper capital femoral epiphysis or in Perthes:
- Early joint space widening
- Later increased femoral head density
+ fragmented / irregular femoral head
How would you treat a slipped capital femoral epiphysis?
Surgical pin fixation
Gradual weight bearing
Therapy to increase range of movement
What are the complications of a slipped capital femoral epiphysis?
Avascular necrosis of the femoral head - Perthes disease
Chondrolysis - degeneration of the articular cartilage
What is Perthes disease?
Avascular necrosis of the capital femoral epiphysis
What are the symptoms associated with Perthes disease?
Gradual worsening hip / knee / pain, limp, stiffness
Decreased range of movement
What are the X ray changes associated with Perthes disease?
Fragmentation of the femoral head
Early = joint space widening
Later = increased femoral head density
How would you treat a patient with Perthes disease?
Rest
Physio
Plaster cast / surgery
What are the complications of Perthes disease?
Osteoarthritis
Premature fusion of growth plates
What are the differentials for a swollen joint in a child?
If septic signs / pain - septic arthritis
If after a different infection - reactive arthritis
If stiffness (especially in the morning) - JIA
If associated with long bone symptoms / signs - osteomyelitis
How do you differentiate between reactive arthritis and JIA?
Reactive = <6 weeks joint swelling JIA = >6 weeks joint swelling
Which joints are most commonly affected in reactive arthritis?
Ankles
Knees
Which infections is reactive arthritis associated with?
Enteric - shigella, salmonella, campylobacter
In adolescents - Chlamydia, gonorrhoea, mycoplasma
How would you investigate a child with suspected reactive arthritis?
CRP (may be raised)
X ray - would be normal
How would you treat a child with reactive arthritis?
NSAIDs
Intra-articular steroids
If persistent - sulfasalazine, methotrexate
What is a slipped capital femoral epiphysis?
Postero-inferior displacement of the femoral head epiphysis
What is septic arthritis?
Infection of the joint space
Which organism usually causes septic arthritis?
+ what is the route of entry
Staph aureus
by blood - SEPTIC
or through a puncture wound
How would a child with septic arthritis present?
Red, warm, tender joint
Unwell, febrile child
Decreased range of movement of joint
Joint effusion at peripheral joints
How would you investigate a child with suspected septic arthritis?
Bloods:
- FBC - raised WCC
- Raised CRP
USS
X ray - normal or widened joint space and swelling
US guided joint aspiration
How would you treat a child with septic arthritis?
Flucloxacillin (or if penicillin allergic, Clindamycin, if MRSA - vancomycin)
If gonococcus - cephalosporin
If persists - drainage / washout of joint
Outline the types of JIA
Oligoarthritis (persistent <4 joints, extended >4 joints) Polyarthritis (RF positive or negative) Systemic arthritis Psoriatic arthritis Enthesitis-related arthritis
How would you manage a patient with JIA? (overall)
Education and support Physical therapy Monitor complications Social stuff - school, social worker Medical
What are the complications of JIA?
Uveitis
Osteoporosis
What medical treatments would you use in a patient with JIA?
NSAIDs Intra-articular steriods - triamcinolone Methotrexate Anti-TNF - Etanercept If really bad - systemic corticosteroids
