Paeds - MSK

Question 1

what is osteogenesis imperfecta?

Answer 1

brittle bone disease
inherited AD
it is a group of disorder where defective collagen metabolism causes bone fragility, bowing and frequent fractures

Question 2

what are the two types of osteogenesis imperfecta?

Answer 2

type 1 - collagen normal quality insufficient quantities (most common)
type 2 - collagen is not of sufficient quality or quantity - severe - many are still born

Question 3

how do you treat osteogenesis imperfecta

Answer 3

bisphosphonates - reduces fracture rates

calcium supplements

Question 4

what are the features of osteogenesis imperfecta?

Answer 4

presents in childhood 
fractures following minor trauma 
blue sclera 
deafness secondary to otosclerosis 
dental imperfections are common.

Question 5

what id the pathology of rickets?

Answer 5

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

Question 6

what are the risk factors/causes of rickets?

Answer 6

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

Question 7

what are the clinical features of rickets?

Answer 7

bone pain
growth retardation
delayed achievements of motor milestones
body deformities
muscle weakness
bow legs
numbness or parenthesis - seen with hypocalcaemia

Question 8

what investigations would you perform for rickets? what would they show?

Answer 8

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

Question 9

how do you treat rickets?

Answer 9

calcium and vitamin D (ergocalciferol) supplementation

Question 10

what is transient synovitis?

Answer 10

a self limiting disorder of the hip that commonly affects young children between 2 and 12 years
usually associated with a viral infection

Question 11

what is the most important differential diagnosis for transient synovitis?

Answer 11

septic arthritis

Question 12

what are the features of transient synovitis?

Answer 12

limited movement 
pain 
limp
positive leg roll 
fever

Question 13

what investigations would you perform for suspected transient synovitis?

Answer 13

FBC
ESR and CRP - to rule out septic arthritis
X-ray

Question 14

how is transient synovitis managed?

Answer 14

symptomatic relief

Question 15

what is septic arthritis?

Answer 15

infection of 1 or more joints caused by pathogenic inoculation of microbes or via haematogenous spread

Question 16

what are the common causes of septic arthritis?

Answer 16

the most common cause is staphylococcus aureus

can be from osteomyelitis spreading into joints

Question 17

what are the clinical features of septic arthritis?

Answer 17

hot
swollen
restricted joint
fever

Question 18

what is the most common place for septic arthritis in children?

Answer 18

the hip

can also be in knee

Question 19

what investigations would you perform for septic arthritis?

Answer 19

synovial fluid gram stain and culture 
synovial fluid white cell count 
blood culture 
WCC
ESR and CRP

Question 20

what criteria can be used to differentiate between transient synovitis and septic arthritis?

Answer 20

Kocher criteria 
fever >38.5
non weight bearing 
raised ESR 
raised WCC

Question 21

how do you manage septic arthritis?

Answer 21

synovial fluid should be obtained before starting treatment
Vancomycin or clindamycin for gram positive
ceftriaxone if gram negative

Question 22

what is osteomyelitis?

Answer 22

an inflammatory condition of the bone caused by an infecting organism, most common staphylococcus aureus

Question 23

what are the common causes of osteomyelitis in infants, children up to 4 years and older children?

Answer 23

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

Question 24

what is a common cause of septic arthritis in patients with sickle cell anaemia?

Answer 24

salmonella species

Question 25

what are the common features of osteomyelitis?

Answer 25

pain at the site of infection malaise and fatigue local inflammation, erythema or swelling low grade fever

Question 26

what investigations would you perform if you suspected osteomyelitis ?

Answer 26

WBC count - may be raised ESR and CRP- usually raised USS MRI

Question 27

how would you treat osteomyelitis

Answer 27

flucloxacillin for 6 weeks | clindamycin if penicillin allergic

Question 28

what is perthe's disease?

Answer 28

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.

Question 29

what are the symptoms of perthe's disease ?

Answer 29

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

Question 30

what investigations would you perform and what would they show in perthe's disease?

Answer 30

bilateral hip x-rays - will show femoral head collapse and fragmentation, subchondral fracture FBC, ESR, CRP- to exclude other conditions

Question 31

what are some complications of perthes disease?

Answer 31

osteoarthritis limb length inequality stiffness and loss of rotation

Question 32

what classification can be used to assess the severity of perthes disease?

Answer 32

Catterall classification - severity based on the epiphyseal involvement

Question 33

how do you manage perthe's disease?

Answer 33

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

Question 34

what is slipped capital femoral epiphysis?

Answer 34

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

Question 35

what are the risk factors for slipped capital femoral epiphysis?

Answer 35

puberty obestiy endocrine disorder male

Question 36

what are the clinical features of slipped capital femoral epiphysis?

Answer 36

hip, groin, medial thigh or knee pain | loss of internal rotation of the leg in flexion

Question 37

what investigations would you perform for slipped capital femoral epiphysis?

Answer 37

observational gait analysis - leg externally rotated | X-ray

Question 38

how would you treat slipped femoral epiphysis?

Answer 38

surgical rapir - internal fixation | prophylatic fixation of the contralateral hip

Question 39

what is osgood schlatter disease and how is it managed?

Answer 39

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

Question 40

what is DDH?

Answer 40

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.

Question 41

what are the risk factors for DDH?

Answer 41

``` 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

Question 42

what would you see on clinical examination of an infant with DDH? what would confirm the diagnosis

Answer 42

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

Question 43

how is DDH managed?

Answer 43

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

Question 44

what is JIA?

Answer 44

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

Question 45

what are the symptoms of JIA?

Answer 45

``` pyrexia salmon-pink rash lymphadenopathy arthritis uveitis anorexia and weight loss ```

Question 46

what investigations would you perform for JIA? how is it managed?

Answer 46

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

Question 47

what are some causes of limping child?

Answer 47

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

Question 48

what is Kohlers disease?

Answer 48

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.

Question 49

how does Kohler's disease present?

Answer 49

a unilateral antalgic gait | local tenderness of the medial aspect of the poor

Question 50

what investigations would you perform for Kohler's disease?

Answer 50

Cray | MRI/CT

Question 51

how is Kohler's disease managed?

Answer 51

rest avoidance of weight baring exercise analgesia immobilisation in a short leg cast can speed recovery