Paeds - MSK Flashcards
what is osteogenesis imperfecta?
brittle bone disease
inherited AD
it is a group of disorder where defective collagen metabolism causes bone fragility, bowing and frequent fractures
what are the two types of osteogenesis imperfecta?
type 1 - collagen normal quality insufficient quantities (most common)
type 2 - collagen is not of sufficient quality or quantity - severe - many are still born
how do you treat osteogenesis imperfecta
bisphosphonates - reduces fracture rates
calcium supplements
what are the features of osteogenesis imperfecta?
presents in childhood fractures following minor trauma blue sclera deafness secondary to otosclerosis dental imperfections are common.
what id the pathology of rickets?
changes caused by deficient mineralisation at the growth plates of long bones.
(osteomalacia in adults is the impaired bone mineralisation of the bone matrix)
Rickets and osteomalacia usually occur together whilst the growth plates are open
what are the risk factors/causes of rickets?
Vitamin D deficiency (malabsorption, lack of sunlight, diet)
Renal failure
drug induced - anticonvulsants - phenytoin
liver disease
end organ resistance (very rare AR disorder)
phosphate deficiency
calcium deficiency
what are the clinical features of rickets?
bone pain
growth retardation
delayed achievements of motor milestones
body deformities
muscle weakness
bow legs
numbness or parenthesis - seen with hypocalcaemia
what investigations would you perform for rickets? what would they show?
X-ray a long bone - cupped, ragged metaphysal surfaces
serum calcium - may be decreased in hypocalaemic rickets
serum phosphate - low
serum alkaline phosphatase - raised
Parathyroid hormone levels
25-dihydroxyvitamin D levels will be low
how do you treat rickets?
calcium and vitamin D (ergocalciferol) supplementation
what is transient synovitis?
a self limiting disorder of the hip that commonly affects young children between 2 and 12 years
usually associated with a viral infection
what is the most important differential diagnosis for transient synovitis?
septic arthritis
what are the features of transient synovitis?
limited movement pain limp positive leg roll fever
what investigations would you perform for suspected transient synovitis?
FBC
ESR and CRP - to rule out septic arthritis
X-ray
how is transient synovitis managed?
symptomatic relief
what is septic arthritis?
infection of 1 or more joints caused by pathogenic inoculation of microbes or via haematogenous spread
what are the common causes of septic arthritis?
the most common cause is staphylococcus aureus
can be from osteomyelitis spreading into joints
what are the clinical features of septic arthritis?
hot
swollen
restricted joint
fever
what is the most common place for septic arthritis in children?
the hip
can also be in knee
what investigations would you perform for septic arthritis?
synovial fluid gram stain and culture synovial fluid white cell count blood culture WCC ESR and CRP
what criteria can be used to differentiate between transient synovitis and septic arthritis?
Kocher criteria fever >38.5 non weight bearing raised ESR raised WCC
how do you manage septic arthritis?
synovial fluid should be obtained before starting treatment
Vancomycin or clindamycin for gram positive
ceftriaxone if gram negative
what is osteomyelitis?
an inflammatory condition of the bone caused by an infecting organism, most common staphylococcus aureus
what are the common causes of osteomyelitis in infants, children up to 4 years and older children?
Infants:
- s aureus
- group B streptococci
- aerobic gram negative bacilli
Children up to 4:
- s aureus
- streptococcus pyogenes
- Haemophilus influenzae
- kingella kingae
older children
- s aureus
what is a common cause of septic arthritis in patients with sickle cell anaemia?
salmonella species
what are the common features of osteomyelitis?
pain at the site of infection
malaise and fatigue
local inflammation, erythema or swelling
low grade fever
what investigations would you perform if you suspected osteomyelitis ?
WBC count - may be raised
ESR and CRP- usually raised
USS
MRI
how would you treat osteomyelitis
flucloxacillin for 6 weeks
clindamycin if penicillin allergic
what is perthe’s disease?
a degenerative condition affecting the hip joints of children between the ages of 4-8 years
it is due to the blood supply to the head of the femur being disrupted - avascular necrosis of the femoral head which causes bone infarction
Typically self-resolves and normal functioning is regained
5 times more common in boys and 10% of cases are bilateral.
what are the symptoms of perthe’s disease ?
limp
limited range of movement at the hip joint
hip pain: develops progressively over a few weeks
they may have short stature - however, normal height is attained by their mid teens
what investigations would you perform and what would they show in perthe’s disease?
bilateral hip x-rays - will show femoral head collapse and fragmentation, subchondral fracture
FBC, ESR, CRP- to exclude other conditions
what are some complications of perthes disease?
osteoarthritis
limb length inequality
stiffness and loss of rotation
what classification can be used to assess the severity of perthes disease?
Catterall classification - severity based on the epiphyseal involvement
how do you manage perthe’s disease?
identify early
under 5 - mobilisation plus monitoring
5-7 years - less than 50% epiphyseal involovment - mobilisation and monitoring, if greater than 50% surgical containment
7-12 years - stage 1 or 2 - surgical containment, stage 3 or 4 - salvage procedure
over 12 - salvage procedure
what is slipped capital femoral epiphysis?
SCFE is the most common hip disorder in the adolescent age group
it occurs when weakness in the proximal femoral growth plate allows displacement of the capital femoral epiphysis
may present acutley following trauma or more commonly with chronic persistent symtoms
what are the risk factors for slipped capital femoral epiphysis?
puberty
obestiy
endocrine disorder
male
what are the clinical features of slipped capital femoral epiphysis?
hip, groin, medial thigh or knee pain
loss of internal rotation of the leg in flexion
what investigations would you perform for slipped capital femoral epiphysis?
observational gait analysis - leg externally rotated
X-ray
how would you treat slipped femoral epiphysis?
surgical rapir - internal fixation
prophylatic fixation of the contralateral hip
what is osgood schlatter disease and how is it managed?
Osgood-Schlatter disease (tibial apophysitis) is a type of osteochondrosis characterised by inflammation at the tibial tuberosity. It is a traction apophysitis thought to be caused by repeated avulsion of the apophysis into which the patellar tendon is inserted
Management is supportive
what is DDH?
Developmental dysplasia of the hip (DDH) is gradually replacing the old term ‘congenital dislocation of the hip’ (CDH). It affects around 1-3% of newborns.
what are the risk factors for DDH?
Risk factors female sex: 6 times greater risk breech presentation positive family history firstborn children oligohydramnios birth weight > 5 kg congenital calcaneovalgus foot deformity
- DDH is slightly more common in the left hip. Around 20% of cases are bilateral
what would you see on clinical examination of an infant with DDH?
what would confirm the diagnosis
Barlow test: attempts to dislocate an articulated femoral head
Ortolani test: attempts to relocate a dislocated femoral head
USS will confirm diagnosis if clinically suspected
how is DDH managed?
most unstable hips will spontaneously stabilise by 3-6 weeks of age
Pavlik harness (dynamic flexion-abduction orthosis) in children younger than 4-5 months
older children may require surgery
what is JIA?
Juvenile idiopathic arthritis (JIA), now preferred to the older term juvenile chronic arthritis, describes arthritis occurring in someone who is less than 16 years old that lasts for more than 6 weeks. Systemic onset JIA is a type of JIA which is also known as Still’s disease
what are the symptoms of JIA?
pyrexia salmon-pink rash lymphadenopathy arthritis uveitis anorexia and weight loss
what investigations would you perform for JIA?
how is it managed?
ANA may be positive, especially in oligoarticular JIA
rheumatoid factor is usually negative
NSAIDs, such as ibuprofen
Steroids, either oral, intramuscular or intra-artricular in oligoarthritis
Disease modifying anti-rheumatic drugs (DMARDs), such as methotrexate, sulfasalazine and leflunomide
Biologic therapy, such as the tumour necrosis factor inhibitors etanercept, infliximab and adalimumab
what are some causes of limping child?
Septic arthritis/osteomyelitis - unwell child with high fever
JIA - limp may be painless
Trauma
DDH - usually in neonates
Perthes - more common in 4-8 years - avascular necrosis of femoral head
Slipped upper femoral epiphysis - 10-15 years - displacement of the femoral head epiphysis posters-inferiorly
what is Kohlers disease?
s a rare bone disorder of the foot found in children between six and nine years of age. The disease typically affects boys, but it can also affect girls. … It is caused when the navicular bone temporarily loses its blood supply.
how does Kohler’s disease present?
a unilateral antalgic gait
local tenderness of the medial aspect of the poor
what investigations would you perform for Kohler’s disease?
Cray
MRI/CT
how is Kohler’s disease managed?
rest
avoidance of weight baring exercise
analgesia
immobilisation in a short leg cast can speed recovery
