PAEDS MSK/DERMATOLOGY TO DO Flashcards
1
Q
DDH
What is the management of DDH?
A
- If <6m = Pavlik harness to hold femoral head in position (flexed + abducted) to allow the hip socket (acetabulum) to develop normal shape (remove after 6-8w)
- Surgical reduction if harness fails or Dx >6m = hip spica cast to immobilise hip for prolonged period after surgery (risk of avascular necrosis + re-dislocation)
2
Q
OSTEOMYELITIS
What causes osteomyelitis?
A
S. Aureus #1 or H. influenzae (directly via bone or haematogenous spreading)
3
Q
OSTEOMYELITIS
What are some investigations for osteomyelitis?
A
- FBC (Raised WCC), raised ESR/CRP, blood cultures, bone marrow aspiration MC&S
- XR can be normal
- MRI is best imaging to establish Dx
4
Q
OSTEOMYELITIS
What is the management of osteomyelitis?
A
- IV empirical Abx (flucloxacillin or clindamycin if allergy) until sensitivities back
- Amoxicillin, cefotaxime or ceftriaxone if <4y + suspect H. influenzae
- ?Surgical drainage or debridement of infected bone
5
Q
PERTHE’S DISEASE
What are some risk factors for Perthe’s disease?
A
- Social deprivation
- LBW
- Passive smoking
6
Q
PERTHE’S DISEASE
What are the investigations for Perthe’s disease?
A
- Blood tests all normal
- XR of both hips (with frog views) is initial investigation + assesses healing
– Flattening of femoral head - Technetium bone scan or MRI may be needed to confirm Dx if normal XR
7
Q
PERTHE’S DISEASE
What are the complications of Perthe’s disease?
A
- Premature fusion of the growth plates
- Soft + deformed femoral head can lead to early hip OA
8
Q
PERTHE’S DISEASE
What is the general management of Perthe’s disease?
A
- Keep femoral head within acetabulum (cast, braces)
- Physio to retain ROM in muscles + joints without excess stress on the bone
9
Q
JIA
What is the criteria for a clinical diagnosis of JIA?
A
- Onset before 16y with no underlying cause
- Joint swelling/stiffness
- > 6w in duration to exclude other causes (i.e. reactive)
10
Q
JIA
What is the clinical presentation of JIA?
A
- Joint pain, swelling + stiffness (particularly morning) = hallmarks
- Limping/functional disability
- Decreased ROM
- Warmth + colour change
11
Q
JIA
What are the 4 types of JIA?
A
- Systemic JIA (Still’s disease)
- Polyarticular JIA
- Oligoarticular JIA
- Enthesitis-related arthritis
12
Q
JIA
How does systemic JIA (Still’s disease) present?
A
- Subtle salmon-pink rash
- High swinging fevers
- Lymphadenopathy, weight loss, muscle pain, splenomegaly
- Pleuritis, pericarditis + uveitis
13
Q
JIA
What are the investigations for systemic JIA?
A
- Antinuclear antibodies (ANA) + rheumatoid factor = NEGATIVE
- Raised inflammatory markers = CRP/ESR, platelets + serum ferritin
14
Q
JIA
What is the main complication of systemic JIA?
A
- Macrophage activation syndrome = severe activation of immune system with massive inflammatory response
15
Q
JIA
What is polyarticular JIA?
A
- ≥5 joints affected, equivalent of RA in adults
16
Q
JIA
What is oligoarticular JIA?
A
≤4 joints affected, often just monoarthritis
17
Q
JIA
What is oligoarticular JIA classically associated with?
A
Anterior uveitis = ophthalmologist referral
18
Q
JIA
What is enthesitis-relataed arthritis?
A
- Paeds version of seronegative spondyloarthropathies (ankylosing spondylitis, psoriatic/reactive arthritis, IBD-related arthritis)
19
Q
JIA
How might enthesitis-related arthritis present?
A
- Sx of psoriasis (psoriatic plaques, nail pitting, dactylitis) or IBD
20
Q
JIA
What is reactive arthritis?
A
- Arthritis that develops following an infection where the organism cannot be recovered from the joint
21
Q
JIA
How does reactive arthritis present?
A
- Reiter’s = can’t see (conjunctivitis), can’t pee (urethritis) and can’t climb a tree (arthritis)
22
Q
JIA
What are the XR features of JIA?
A
Same as RA (LESS) –
- Loss of joint space
- Erosions (causing joint deformity)
- Soft tissue swelling
- Soft bones (osteopenia)
23
Q
JIA
What are some complications from JIA?
A
- Chronic anterior uveitis > severe visual impairment
- Flexion contractures of joints
- Growth failure + constitutional problems like delayed puberty
- Osteoporosis
24
Q
JIA
What is the medical management of JIA?
A
- NSAIDs for Sx relief during flares
- Intra-articular steroids for oligoarthritis
- Avoid systemic steroids if possible (osteoporosis, growth suppression)
– IV methylprednisolone can be used if severe arthritis - DMARDs like methotrexate, rarely sulfasalazine for polyarthritis
- Biologics if poor control like tocilizumab, adalimumab, etanercept
25
SUFE/SCFE
What is slipped upper/capital femoral epiphysis? (SUFE/SCFE)?
- Displacement of femoral head epiphysis postero-inferiorly along the growth plate (through zone of hypertrophy)
26
SUFE/SCFE
What are the investigations for SUFE/SCFE?
- XR initial Ix of choice (AP + frog-leg views)
- Bloods (incl. inflammatory markers) normal
- ?Technetium bone scan + MRI scan
27
GROWING PAINS
What are growing pains?
Diagnosis by exclusion –
- Pain never present at start of day after waking but can awaken from sleep
- Physical activities are not limited, no limp, settles with massage
- Bilateral pain in lower limbs (shins/ankles) + not limited to joints
- Can be worse after a day of vigorous activity + intermittent
28
OSTEOPOROSIS
What is osteoporosis in paediatrics defined by?
- ≥1 vertebral crush #
- ≥2 long bone fractures by age 10 (≥3 by age 19)
- Bone mineral density less than 2.5 standard deviations below the mean
29
OSTEOPOROSIS
What are the causes of osteoporosis?
- Inherited = osteogenesis imperfecta, haematological issues
- Acquired:
– Drug induced (Steroids)
– Endocrinopathies (hypoparathyroidism)
– Malabsorption
– Immobilisation (disabilities)
– Inflammatory disorders
30
OSTEOGENESIS IMPERFECTA
What are some associations with osteogenesis imperfecta?
- Conductive hearing loss (otosclerosis)
- Blue/grey tinted sclera due to scleral thinness
- Valvular prolapse, aortic dissection > aortic incompetence
- Hernias
- 'Wormian bones' = skull feels like bubble wrap (wiggly black lines on skull XR)
31
OSTEOGENESIS IMPERFECTA
What are the investigations for osteogenesis imperfecta?
- Clinical Dx with XR to diagnose fractures + bone deformities
- DEXA scan to look at bone mineral density (osteoporosis)
- 7 types under the sillence classification
32
OSTEOGENESIS IMPERFECTA
In the Sillence classification, what is...
i) type 1?
ii) type 2?
iii) types 3–4?
i) Mildest form, common with blue sclera
ii) Lethal form, chest too small to allow breathing, lots of rib # + lungs do not function
iii) Normal sclera
33
RICKETS
What is rickets?
What is it caused by?
- Defective bone mineralisation > "soft" + deformed bones (paeds osteomalacia)
- Vitamin D deficiency (recommended paeds intake 400IU = 10mg)
34
RICKETS
What are some risk factors for rickets?
- Darker skin (need more sunlight)
- Lack of exposure to sun
- Poor diet or malabsorption
- CKD as kidneys metabolise vitamin D to active form
35
RICKETS
What are the symptoms of rickets?
- Bone pain, swelling + deformities
- Muscle weakness + poor growth (gross motor delay)
- Pathological or abnormal #
- May have hypocalcaemic convulsions or carpopedal spasm
36
RICKETS
What are some bone deformities seen in rickets?
- Bowing of legs, knock knees
- Harrison sulcus = indentation of softened lower ribcage at site of attachment of diaphragm
- Rachitic rosary = ends of ribs expand at costochondral junctions causing lumps along chest
- Craniotabes = soft skull with delayed closure of sutures + frontal bossing
- Expansion of metaphyses (esp. wrist)
37
RICKETS
What are some investigations for rickets?
- Serum biochemistry
- FBC + ferritin (Fe anaemia), inflammatory markers
- Kidney, liver + TFTs, malabsorption screen (anti-TTG)
- Autoimmune + rheumatoid tests
- XR required to diagnose
38
RICKETS
What would serum biochemistry show in rickets?
- Low = calcium + phosphate
- High = ALP + PTH
- 25-hydroxyvitamin D levels deficient (<25nmol/L)
39
RICKETS
What might an XR show in rickets?
- Osteopenia (radiolucent bones)
- Cupping
- Fraying of metaphyses
- Widened epiphyseal plate
40
RICKETS
What is the management of rickets?
Prevention #1 –
- Breastfeeding women should take vitamin D supplement
- Dietary advice to increase calcium + vitamin D
- Children vitamin D deficient > ergocalciferol
Vitamin D + calcium supplementation for children with rickets + specialist input
41
COMMON BIRTHMARKS
What is a salmon patch?
- 'Stork mark'
- Most common vascular birthmark
- Flat red or pink patches on baby's eyelids, neck or forehead at birth
- Fade completely in few months
42
COMMON BIRTHMARKS
What is a cavernous haemangioma?
- 'Strawberry mark'
- Raised marks on skin often red, F>M
- Not present at birth, appear in first month, increase in size then shrink + disappear
- Normally self-limiting, beware over eye + airway
43
COMMON BIRTHMARKS
What is a capillary haemangioma?
- 'Port wine stain' = permanent, often unilateral
- Present at birth + grows with infant, treated with laser therapy
- Seen in Sturge-Weber syndrome (neuro Sx)
44
ECZEMA
What is the clinical presentation of eczema?
- Infants = dry, red, itchy + sore patches of skin over face + trunk
- Young children = extensor surfaces
- Older children = mostly on flexor surfaces (creases), face + neck creases
45
ECZEMA
How should a flare of eczema be managed?
- Thicker emollients (hydromol or epaderm)
- Topical steroids (start with hydrocortisone > betnovate > dermovate)
- Wet wraps = cover affected areas in thick emollient with wrap to keep moisture overnight
- Severe = PO ciclosporin, corticosteroids
46
ECZEMA
What are some side effects of using topical steroids?
- Thinning of skin
- Telangiectasia
- Bruising
47
PSORIASIS
What is the pathophysiology of psoriasis?
- Chronic autoimmune condition where abnormal T-cell activation > hyperproliferation of keratinocytes + so psoriatic skin lesions
48
PSORIASIS
What are the different types of psoriasis?
- Plaque
- Guttate 'rain-drop'
- Erythrodermic + pustular
49
PSORIASIS
How does plaque psoriasis present?
- Well-demarcated, raised, silvery scaling lesions on extensor surfaces (elbows + knees)
- Scalp involvement, most often at hair margin
50
PSORIASIS
How does guttate psoriasis present?
- Explosive eruption of very small circular plaques on trunk, often 2w after strep throat
- Common in paeds, resolves in 3-4m
51
PSORIASIS
How does erythrodermic + pustular present?
- Most severe + life-threatening
- Widespread inflammation of skin > extensive erythematous areas or pustules under areas of erythema
- Systemic = pyrexia, malaise
- Admit
52
PSORIASIS
What is the clinical presentation of psoarisis?
- Koebner phenomenon = new plaques of psoriasis at sites of skin trauma
- Residual pigmentation of skin after lesions resolve
- Auspitz sign = small points of bleeding when plaques scraped off
- Nail changes (pitting + onycholysis)
53
PSORIASIS
What are some associations of psoriasis?
- 10–20% develop psoriatic arthritis
- Increased risk of CVD, metabolic syndrome, VTE
54
PSORIASIS
What is the management of psoriasis?
- 1st line = topical steroids, topical vitamin d analogues (calcipotriol)
- 2nd line = UV phototherapy
- 3rd line = immunosuppression with methotrexate or biologics
55
NAPPY RASH
What are the 2 main types of nappy rash?
- Irritant dermatitis = friction between skin/nappy + contact with urine + faeces
- Candida dermatitis = due to breakdown in skin + the warm, moist environment
56
NAPPY RASH
How do you differentiate between irritant dermatitis and candida dermatitis?
- Irritant = sore, red, inflamed skin but spares the skin creases
- Candida = involves skin creases, satellite lesions (small similar lesions near edges of principle lesion) + may have oral thrush
57
NAPPY RASH
What is the management of nappy rash?
- Highly absorbent nappies
- Maximise time not wearing + ensure dry before replacing nappy
- Change nappy + clean skin ASAP
- Water or gentle alcohol-free products to clean
- Topical imidazole if candida
58
STEVEN-JOHNSON
What is Steven-Johnson syndrome?
What versions are there?
- Disproportional immune response causes epidermal necrosis > blistering + shedding of top layer of skin
- SJS = <10% body surface, toxic epidermal necrolysis affects >10%
59
STEVEN-JOHNSON
What are some potential causes of Steven-Johnson syndrome?
- Meds = AEDs, Abx, allopurinol, NSAIDs
- Infections = herpes simplex, mycoplasma pneumonia, CMV, HIV
60
STEVEN-JOHNSON
What is the clinical presentation of Steven-Johnson syndrome?
- Non-specific Sx of fever, cough, sore throat + itchy skin
- Develop purple/red rash that spreads across skin, starts to blister
- Few days later skin sheds leaving raw tissue underneath = PAINFUL
61
STEVEN-JOHNSON
What is the management of Steven-Johnson syndrome?
- Admission as medical emergency, cease causative meds
- Nutritional care, Abx, analgesia, ophthalmology input
- Steroids, immunoglobulins + immunosuppressants by specialists
62
SCOLIOSIS
what are the causes?
- idiopathic = most common
- congenital = usually from congenital structural defect of the spine e.g. spina bifida
- secondary = neuromuscular imbalance (cerebral palsy, muscular dystrophy), disorders of bone or connective tissues
63
SCOLIOSIS
what is the clinical presentation?
- visible curve in spine
- shoulders, waist or hips look uneven
- one shoulder blade appears bigger
- ribs stick out further on one side
- low back pain
- back stiffness
- pain + numbness in legs
- fatigue (due to muscle strain)
64
SCOLIOSIS
what conditions can cause scoliosis?
cerebral palsy
muscular dystrophy
birth defects
infections
tumours
marfan syndrome
down syndrome
65
TORTICOLLIS
what are the causes of congenital torticollis?
- congenital muscular torticollis (CMT) = usually noticed in 1st month after birth. It causes shortening + fibrosis of sternocleidomastoid (can have palpable mass)
- malformed cervical spine
- spina bifida
66
TORTICOLLIS
what are the causes of acquired torticollis?
- MSK = muscle spasm
- infection = URTI, otitis media, dental infection, pharyngeal infection
- atlantoaxial rotatory fixation
- inflammation = juvenile idiopathic arthritis
- neoplasm = CNS tumours
67
TORTICOLLIS
what is the management?
treat the cause
- muscle spasm = self resolve
- infection = antibiotics
- Congenital = physiotherapy
68
OSGOOD SCHLATTERS
what are the risk factors?
- male gender
- age - 12-15 in boys, 8-12 in girls
- sudden skeletal growth
- repetitive activities such as jumping and sprinting
69
SEPTIC ARTHRITIS
What are common causes in...
i) infants?
ii) <4y?
iii) >4y?
i) GBS, S. aureus, coliforms
ii) S. aureus, pneumococcus, haemophilus
iii) S. aureus, gonococcus (adolescents)
70
SEPTIC ARTHRITIS
what is the criteria for diagnosing septic arthritis?
Kocher's modified criteria /5, ≥3 is likely
–Temp>38.5
– Raised CRP/ESR/WCC
– Non-weight bearing
71
OSTEOMYELITIS
What are some risk factors?
- Open #,
- orthopaedic surgery,
- sickle cell anaemia (Salmonella predominates),
- immunocompromised (HIV),
72
JIA
What are the features of polyarticular JIA?
Symmetrical, affects small joints (of hand + feet) as well as large joints (hips + knees)
73
JIA
How does polyarticular JIA present?
Mild systemic Sx = mild fever, anaemia + reduced growth
74
JIA
What is the immunology of polyarticular JIA?
If rheumatoid factor +ve = seropositive (tend to be older children)
75
JIA
what is the immunology of oligoarticular JIA?
ANA +ve but RF -ve
76
JIA
What is it associated with?
- HLA-B27 gene
- Prone to anterior uveitis = ophthalmology referral
77
JIA
What causes reactive arthritis?
Post STI (chlamydia) in older children or Salmonella, Campylobacter
78
OSTEOGENESIS IMPERFECTA
What is the pathophysiology?
Defects in type 1 collagen protein which is essential for the structure + function of bone, as well as skin, tendons + other connective tissues
79
RICKETS
What are some sources of vitamin D?
Sunlight, fortified cereals, eggs, oily fish
80
PSORIASIS
What are the causes?
- HLA-B13,
- environmental triggers (alcohol, stress, group A strep)
81
JIA
How does macrophage activation syndrome present?
- Acutely unwell with DIC,
- febrile,
- anaemia,
- thrombocytopenia,
- bleeding,
- non-blanching rash,
- low ESR
82
JIA
What is the management of macrophage activation syndrome?
Life-threatening = supportive + steroids
