Paeds: The Limping Child (1) Flashcards
The general classification of MSK disorders in children (3)
- Inflammatory / tissue threatening
- Mechanical
- Idiopathic – often medically unexplainable/non tissue threatening (including non organic/functional)
What to ask about in the Hx taking of MSK problems
Specific symptoms:
- Limp
- Stiffness
- Joint swelling
- Pain
- Loss of function/stiffness
Extra-articular symptoms:
fever, weight loss, weakness, rash, sleep, bruising etc…
Review of systems
Examination of a child presenting with MSK problems (+mnemonic)
- Height/weight
- Temp/pulse/BP
- MSK including gait
- Full examination of systems inc rashes
Aetiology of MSK problems (inflammatory, mechanical, idiopathic) based on the presence of:
- pain
- stiffness
- swelling
- sleep disturbance
- instability
- physical signs
Examples of inflammatory MSK childhood disorders
Examples of mechanical MSK childhood disorders
Examples of idiopathic MSK conditions in children
Organisms responsible for septic arthritis
Source: local or haematogenous
- Staph Aureus: 60%
- Streps
- Gonococcus
- Gm-ve bacilli
Risk factors for septic arthritis
- Joint disease (e.g. RA)
- Chronic renal failure
- Immunosuppression (e.g. DM)
- Prosthetic joints
What criteria are used for diagnosis of septic arthritis?
Name and describe them
The Kocher criteria for the diagnosis of septic arthritis:
- fever >38.5
- non-weight bearing
- raised ESR
- raised WCC
Symptoms of septic arthritis
- acutely inflamed tender
- swollen joint
- ↓ROM
- systemically unwell: fever
Possible investigations in septic arthritis
- Joint aspiration for MCS
- ↑↑ WCC (e.g. >50,000/mm3) : mostly PMN
- ↑ESR/CRP
- ↑WCC
- Blood cultures
- X-ray
Management of septic arthritis
- synovial fluid should be obtained before starting treatment
- intravenous antibiotics which cover Gram-positive cocci are indicated e.g. recommends flucloxacillin or clindamycin (if penicillin allergic), IV Vanc + cefotaxime
- antibiotic treatment is normally be given for several weeks (BNF states 6-12 weeks)
- needle aspiration should be used to decompress the joint
- arthroscopic lavage (joint wash out under GA) may be required
- splint joint
- physiotherapy after infection resolves
Possible complications of septic arthritis
- Osteomyelitis
- Arthritis
- Ankylosis: fusion
Alder Hay protocol for choosing antibiotics in septic arthritis for children aged birth-one month + what organisms are likely to be responsible
Likely organisms:
- Gp B strep
- Staph aureus
- Kingella kingae
Antibiotics:
IV cefotaxime + flucloxacillin (clindamycin if allergic)
Alder Hay protocol for choosing antibiotics in septic arthritis for children aged one month- 5 years + what organisms are likely to be responsible for the infection
Organisms likely to cause infection:
- Staph aureus
- Gp A strep
- Kingella kingae
Antibiotic: IV cefuroxime
Alder Hay protocol for choosing antibiotics in septic arthritis for children aged 5 years and above + what organisms are likely to be responsible for the infection
Organisms:
- Staph aureus
- Gp A strep
- Strep pneumoniae
Antibiotic: IV Flucloxacillin
Organisms that may cause acute osteomyelitis
Source: local or haematogenous
Organisms:
- Staph Aureus
- Strep
- E. coli
- Pseudomonas
- Salmonella (in Sickle Cell Disease)
Risk factors for acute osteomyelitis
- Vascular disease
- Trauma
- Sickle Cell Disease
- Immunosuppression (e.g. DM)
Children
- rich blood supply to growth plate
- usually affects metaphysis
Signs and symptoms of osteomyelitis
- Pain
- tenderness
- erythema
- warmth
- ↓ROM
- Effusion in neighbouring joints
- Signs of systemic infection
Possible investigations of acute osteomyelitis
- ↑ESR/CRP, ↑WCC
- +ve blood cultures in 60%
- X-ray
- MRI is sensitive and specific
X-ray changes in osteomyelitis
- changes take 10-14 days
- Haziness
- ↓ bone density
- Sub-periosteal reaction
- Sequestrum and involucrum
sequestrum → a piece of devitalised bone that has been separated from its surrounding bone during the process of necrosis
involucrum → if sequestrum becomes encased in a thick sheath of periosteal new bone
Management of osteomyelitis
- IV antibiotics: Vanc + cefotaxime until MCS known
- Drain abscess and remove sequestra
- Analgesia
The classic triad of reactive arthritis
Classic triad:
- urethritis
- conjunctivitis
- arthritis
Causes of reactive arthritis
Reactive arthritis
- develops following an infection where the organism cannot be recovered from the joint
Management of reactive arthritis
- symptomatic: analgesia, NSAIDS, intra-articular steroids
- sulfasalazine and methotrexate are sometimes used for persistent disease
- symptoms rarely last more than 12 months
Features of reactive arthritis
- typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months
- arthritis is typically an asymmetrical oligoarthritis of lower limbs
- dactylitis
- symptoms of urethritis
- eye: conjunctivitis (seen in 10-30%), anterior uveitis
- skin: circinate balanitis (painless vesicles on the coronal margin of the prepuce), keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
‘Can’t see, pee or climb a tree’
Hx in reactive arthritis in kids
- May be history of recent infection
- Single or multiple joints
- No systemic features
- Resolves by 6 weeks
- Important to consider alternative diagnoses
What’s conncetion of Henoch-Schonlein Purpura and MSK problems?
HSP = commonest paediatric vasculitis (small vessel)
Symptoms:
- Palpable Purpura
- Arthralgia / Arthritis
- Abdominal pain
- Nephritis
- Headaches
What’s Henoch-Schonlein-Purpura?
Henoch-Schonlein purpura (HSP) is
- IgA mediated small vessel vasculitis
- degree of overlap with IgA nephropathy (Berger’s disease)
- HSP is usually seen in children following an infection
