Paeds: The Limping Child (3)

Question 1

What’s Enthesitis related arthritis?

Answer 1

Question 2

What’s Psoriatic Arthritis?

• features/criteria

Answer 2

Psoriatic Arthritis

• Arthritis and psoriasis

or

• Arthritis and at least 2 of:
• dactylitis
• nail abnormalities, e.g. pitting
• family history of psoriasis

Question 3

Ix in suspected psoriatic arthritis

Answer 3

Non-diagnostic → exclude definable causes of arthritis, e.g. septic

• Anaemia of chronic disease
• sJIA - Leucocytosis / thrombocytosis
• ESR
• ANA →risk for uveitis, especially in oligo sub-type
• Radiology
• plain films / MRI with contrast /US / nuclear scans

Question 4

Aims of management of psoriatic arthritis

Answer 4

• Disease remission
• Symptomatic improvement
• Stiffness
• Pain
• Joint range of movement
• Prevent joint damage
• Normal growth and development
• Education and normal adolescence
• Prevent eye damage from uveitis

Question 5

Management of psoriatic arthritis

Answer 5

• MDT: paediatric rheumatologist, nurse specialist, OT/physio, ophthalmologist etc.
• Anti inflammatory drugs:
• NSAIDs
• Glucocorticoids - intra-articular
• Disease modifying drugs
• Methotrexate
• Biologics
• Anti TNF, e.g. etanercept / adalimumab

Question 6

Poor and good indicators for prognosis in psoriatic arthritis

Answer 6

Poor indicators

• Polyarticular onset and course
• Rheumatoid factor positive girls
• Systemic disease with persistent features
• Delay in starting effective treatment

Good indicators

•Oligoarticular disease

Question 7

What’s Perthes’ disease?

(epidemiology, pathophysiology)

Answer 7

Perthes’ disease

• a degenerative condition affecting the hip joints of children
• typically between the ages of 4-8 years

Pathophysiology: to avascular necrosis of the femoral head, specifically the femoral epiphysis → impaired blood supply to the femoral head → bone infarction

Perthes’ disease is 5 times more common in boys. Around 10% of cases are bilateral

Question 8

Features of Perthes’ disease

Answer 8

• hip pain: develops progressively over a few weeks (in 10-20% cases it’s bilateral)
• limp
• stiffness and reduced range of hip movement

Question 9

X-ray changes in Perthes’ disease

Answer 9

• normal initially
• early changes → widening of joint space
• later changes → decreased femoral head size/, ↑ density of femoral head, fragmented and irregular, flattening and sclerosis

Bone scan is useful

Question 10

Diagnosis of Perthes’ disease

Answer 10

• plain x-ray
• technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist

Question 11

Complications of Perthes’ disease

Answer 11

• osteoarthritis
• premature fusion of the growth plates

Question 12

Staging of Perthes’ disease

Answer 12

Question 13

Management of Perthes’ disease

Answer 13

• To keep the femoral head within the acetabulum: cast, braces
• If less than 6 years: observation
• Older: surgical management with moderate results
• Operate on severe deformities

Another source:

• If detected early and < half femoral head affected
• Bed rest and traction
• More severe
• Maintain hip in abduction with plaster
• Femoral or pelvic osteotomy

Question 14

Prognosis with Perthes’ disease

Answer 14

• Most cases will resolve with conservative management
• Early diagnosis improves outcomes

Question 15

The other name for Slipped upper femoral epiphysis

Answer 15

aka Slipped CAPITAL femoral epiphysis

Question 16

Epidemiology of slipped upper femoral epiphysis

Answer 16

• typically age group is 10-15 years
• more common in obese children and boys
• Two main groups
• Fat and sexually underdeveloped
• Tall and thin

Question 17

Presentation of the slipped upper femoral epiphysis

Answer 17

May present acutely following trauma or more commonly with chronic, persistent symptoms

• Shortened, externally rotated leg
• All movements painful
• hip, groin, medial thigh or knee pain
• loss of internal rotation of the leg in flexio
• bilateral slip in 20% of cases

Question 18

What happens in Slipped upper femoral epiphysis? (pathophysiology)

Answer 18

Displacement of the femoral head epiphysis postero-inferiorly

Question 19

Investigations in Slipped upper femoral epiphysis

Answer 19

• AP and lateral (typically frog-leg) views are diagnostic
• CT/MRI if there is diagnostic difficulty

Question 20

Management of Slipped Upper Femoral Epiphysis

Answer 20

internal fixation: typically a single cannulated screw placed in the center of the epiphysis

Question 21

Transient Synovitis

• another name
• presentation
• investigations
• management

Answer 21

Transient Synovitis aka Irritable Hip

• commonest cause of acute hip pain in children

Presentation

• 2-12yrs
• Sudden onset hip pain / limp
• Often following or with viral infection
• Not systemically unwell (fever should raise a suspicion of septic arthritis)

Investigations

• Polymorphonucleral lymphocyte (PMN) and ESR/CRP are normal
• -ve blood cultures
• May need joint aspiration and culture

Management

• Rest and analgesia
• Settles over 2-3d

Question 22

What should raise a suspicion of non-accidental injury?

Answer 22

• Inappropriate history
• Physical signs don’t match the story
• Other concerning features
• Concerns raised by others
• Physical and emotional abuse

Question 23

Chondromalacia patellae

• pathophysiology
• epidemiology
• presentation
• management

Answer 23

• *Pathophysiology:** Softening of the cartilage of the patella
• *Epidemiology:** Common in teenage girls

Presentation: Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting

Management: self limiting but may require physio for quads strengthening

Question 24

Pathophysiology of Osgood-Schlatter disease

Answer 24

Osgood-Schlatter disease (tibial apophysitis)

Pathophysiology:

• 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

Tibial tuberosity apophysitis + patellar tendonitis

Question 25

Presentation of Osgood-Schlatter disease

Answer 25

• Children 10-14yrs,
• commonly boys
• Associated with physical activity

Symptoms:

• pain below knee, especially with quads contraction
• pain and swelling at tibial tuberosity
• increased by exercise
• Tenderness +/- swelling of tibial tuberosity
• Pain on resisted extension of knee

Question 26

Investigations and diagnosis of Osgood Schlatter disease

Answer 26

• usually clinical diagnosis
• X-ray: tuberosity enlargement ± fragmentation

Question 27

Management of Osgood- Schlatter disease

Answer 27

• supportive - analgesics if needed
• rest
• consider plaster of paris (POP)
• physiotherapy
• physical activity may be carried out within the limits of symptoms appearing - may need braces, tapes etc

Prognosis: excellent - symptoms usually disappear within 2 years

Question 28

Can flat feet cause lower limb pain?

Answer 28

• Common cause of lower limb pain
• If symptomatic - correct with good footwear and insoles

Question 29

The naming of ‘growing pains’

Answer 29

This is a misnomer as the pains are often not related to growth - the current term used in rheumatology is ‘benign idiopathic nocturnal limb pains of childhood’

Question 30

Features of growing pains

Answer 30

• 25 - 40% of children!
• 3 - 5 years and 8 - 12 years

Typical history

• Wake during night with pain
• Eased with massage
• May be worse after active day
• No daytime symptoms
• No abnormal physical signs (no limp, no limitation of activity)
• never present at the start of the day after the child has woken
• systemically well
• normal physical examination
• motor milestones normal
• symptoms are often intermittent and worse after a day of vigorous activity