Paeds- MSK Flashcards
differential diagnosis of pain with no swelling in MSK
- hypermobile joints syndrome
- orthopaedics syndrome- e.g. Perthes
- metabolic- hypothyroidism, lysosomal storage disease
- tumour- benign/ malignant
differential diagnosis of pain with swelling in MSK
- trauma
- infection- septic/oesteomyelitis
- rheumatic fever
- JIA
- vasculitis
- CF
- metabolic
- malignancy
- congenital
- sarcoidosis
define JIA
Juvenile Idiopathic Arthritis
joint inflammation presenting in children <16 and persisting for at least 6 weeks with other causes excluded
how can JIA be classified?
- Oligoarticular
- polyarticular RF -ve
- polyarticular RF +ve
- systemic onset JIA
- psoriatic
- enthesitis related arthritis (ERA)
classification of JIA- describe:
oligoarticular JIA
- most common
- affects 1-4 joints during 1st 6 months
- persistent and extended
- 70% ANA positive
- mostly affects ankles and knees
- swelling, stiffness, reduced ROM, little pain
classification of JIA- describe:
Polyarticular RF -ve
- 5+ joints during 1st 6 months
- more common in females
- peaks in toddlers and preadolescence
- affects large and small joints
- stiffness, little swelling
- destructive arthritis
classification of JIA- describe:
Polyarticular RF +ve
- 5+ joints during 1st 6 months with +ve RF seen on 2 occassions
- symmetrical involvement of small joints
- rheumatoid nodules
- swelling and stiffness
- systemic- fever, hepatosplenomegaly, serositis
classification of JIA- describe:
Systemic onset JIA
- arthritis with >2 weeks daily fever + 1 of:
- rash
- lymph node enlargement
- hepatosplenomegaly
- serositis
- MAS
classification of JIA- describe:
psoriatic JIA
arthritis and psoriasis
dactylitis, nail pitting, psoriasis
classification of JIA- describe:
enthesitis related arthritis
- arthritis and enthesitis
- HLAB27, onse over 6, reiter syndrome
give some complications of JIA
- chronic anterior uveitis
- flexion contracture
- growth failure
- constitutional problems
- osteoporosis
how is JIA diagnosed?
- clinical !
FBC:
- normocytic anaemia
- ESR/ CRP raises
- RF, HLAB27
- raised platelets
how is JIA managed and treated?
manage:
- refer to rheumatology
- physio
- hydrotherapy
treat:
- NSAIDS
- steroids- intra-articular
- DMARD’s- methotrexate and sulfasalazine
- biologics- tacilizumab, rituximab
what is juvenile SLE?
chronic, autoimmune disease affecting all organs
relapsing and remitting
describe the classification of SLE
SOAP BRAIN MD
Serositis
Oral ulcers
Arthritis
Photosensitivity
Blood (low- anaemia, leukopenia) Renal ANA Immunologic- (antibodies to DNA) Neurologic (psych, seizures)
Malar rash
Discoid rash
what are the most common sites for osteomyelitis?
distal femur
proximal tibia
aetiology of osteomyelitis
- staph aureus
- group A beta heamolytic strep
- haemophilus influenza
clinical signs in osteomyelitis
- severe
- immobile limb
- red/warm/ tender over area
- acute febrile illness
- lethargy
investigations in osteomyelitis
- XR- initially normal, then subperiosteal bone formation occurs after 7-10 days
- MRI
- blood cultures
- FBC- raised infection markers
treatment of osteomyelitis
IV cefuroxime for at least 6 weeks
- use co-amoxiclav or flucloxacillin if unsure
- surgical drainage if unresponsive
if a child presents limping, what should be your first major concern?
septic arthritis
what organisms can cause septic arthritis?
- staph aureus
- haemophilus influenza
how does septic arthritis present clinically?
- erythematous, warm, acute tender joint
- reduced ROM
- febrile child
investigations and findings in a patient with septic arthritis
- raised infection markers
- blood cultures
- USS of deep joints
- aspiration of joint space with USS- definitive !!
how is septic arthritis managed?
long course Abx
wash out/ surgical drainage may be required
what is developmental dysplasia of the hip?
spectrum of severity ranging from mild acetabular dysplasia with a stable hip through to more severe forms of dysplasia with neonatal hip instability
risk factors for developmental dysplasia of the hip
- female (6 times greater)
- breech presentation
- positive FH
- firstborn child
- oligohydramnios
how does developmental dysplasia of the hip present clinically?
- screening at 6-8 weeks
- signs of asymmetry
describe the signs of asymmetry seen in developmental dysplasia of the hip
- asymmetrical gluteal folds
- limb length discrepancy
- limitation and asymmetry of hip abduction
- benign hip clicks
what is the barlow test?
developmental dysplasia of the hip- attempts to dislocate an articulated femoral head posteriorly
what is the Ortolani test?
attempts to relocate a dislocated femoral head- assessed in developmental dysplasia of the hip
how is developmental dysplasia of the hip diagnosed ?
- dynamic USS
how is a patient with developmental dysplasia of the hip managed?
- pavlik harness if younger than 4-5 months
- older= surgery
what is transient synovitis of the hip?
- irritable hip
- chief cause of hip pain in children aged 4-10
how is transient synovitis of the hip diagnosed?
diagnosis of exclusion
how is transient synovitis of the hip differentiated from septic arthritis?
septic arthritis:
WCC> 12
ESR> 40
what findings would be seen clinically in a patient with transient synovitis of the hip?
pain on internal rotation of the hip
how is transient synovitis of the hip managed?
self limiting- rest and analgesia
what is Perthe’s disease?
temporarily disrupted blood flow to the femoral head causing avascular necrosis
bone remodelling occurs leading to abnormal ossification
describe the epidemiology of perthes disease
- 5-10
- males 4:1
symptoms of Perthes disease
- pain in hip/ groin
- referred pain in thigh/ knee
- pain worse on activity, relieved by rest
- painful muscle spasms
- limping
how is a diagnosis of Perthe’s disease made?
- limited abduction and internal rotation
- xray/ MRI= space widening
give a later finding on XR/MRI in a patient with Perthes disease
decreased femoral head size w/ patchy density
how is Perthe’s disease managed?
- surgery
- limit activity
- physio
describe the epidemiology of slipped upper femoral epiphysis (SUFE)
- 10-16
- male dominance
- obesity is a major risk factor
what is SUFE?
displacement of a growth plate with epiphysis slipping inferiorly and posteriorly
when and how does SUFE present?
- after a minor injury !
- limping and hip pain
- limited ROM
how is SUFE managed?
fixation
what is Achondroplasia?
reduced growth of cartilaginous bone
most common form of short-limb dwarfism
describe the gene mutation seen in achondroplasia
G380R in fibroblast growth receptor 3 (FGFR3)
autosomal dominant !
clinical presentation of achondroplasia
- large skull, normal length trunk and short arms and legs
- frontal bossing
- lumbar lordosis
what is osteogenesis imperfecta?
inherited condition causing fragility of bone
aetiology of osteogenesis imperfecta
- autosomal dominant (types 1 and 4)
- 90%- mutations in COL1A1 and COL1A2
which types of ostoegensis imperfecta are more severe?
2 and 3
autosomal recessive
clinical findings on X ray in osteogenesis imperfecta
low bone density
bowing of long bones
how is a patient with osteogensis imperfecta managed?
- physio and rehab
- surgery if required
- bisphosphonates- alendronate, zoledronate, pamidronate
what is Rickets?
vitamin D deficiency
how does Rickets present clinically?
- metaphyseal expansions
- bowing deformities
- fractures
- Harrison’s sulcus - indentation of softened lower ribcage where diaphragm attaches
Rackety rosary- palpable costochondral junctions
causes of vitamin D deficiency
- lack of exposure to sunlight
- dark skin
- lack of it in diet
- malabsorption- coeliac, pancreatic insufficiency, CF
- drugs- anticonvulsants (e.g. phenobarbital
- impaired metabolic conversion- hepatic/ renal disease
describe the biochemistry of a patient with Rickets
- low phosphorus
- serum calcium low
- raised alkaline phosphatase
- raised PTH
what is Osgood Schlatter disease?
self-limiting disorder of the knee found during adolescence
osteochondiritis of the patella tendon insertion at the knee
explain the pathophysiology behind Osgood Schlatter disease
Common in active adolescents, possibly caused by multiple small avulsion
fractures from contractions of the quadriceps muscles at their insertion
into the proximal tibial apophysis (ossification centre)
how does Osgood Schlatter disease present clinically?
- onset of pain and swelling below knee
- relieved by rest
- tenderness
how is Osgood Schlatter disease diagnosed?
X-ray:
- irregular apophysis
- seperation from tibial tuberosity
presentation of a patient with osteogenesis imperfecta
- BLUE/ GRAY SCLERA
- fracture Hx
- dental problems
- short stature
- hypermobility
