Paeds: The Limping Child (3) Flashcards
What’s Enthesitis related arthritis?
What’s Psoriatic Arthritis?
- features/criteria
Psoriatic Arthritis
- Arthritis and psoriasis
or
- Arthritis and at least 2 of:
- dactylitis
- nail abnormalities, e.g. pitting
- family history of psoriasis
Ix in suspected psoriatic arthritis
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
Aims of management of psoriatic arthritis
- 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
Management of psoriatic arthritis
- 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
Poor and good indicators for prognosis in psoriatic arthritis
Poor indicators
- Polyarticular onset and course
- Rheumatoid factor positive girls
- Systemic disease with persistent features
- Delay in starting effective treatment
Good indicators
•Oligoarticular disease
What’s Perthes’ disease?
(epidemiology, pathophysiology)
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
Features of Perthes’ disease
- hip pain: develops progressively over a few weeks (in 10-20% cases it’s bilateral)
- limp
- stiffness and reduced range of hip movement
X-ray changes in Perthes’ disease
- 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
Diagnosis of Perthes’ disease
- plain x-ray
- technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist
Complications of Perthes’ disease
- osteoarthritis
- premature fusion of the growth plates
Staging of Perthes’ disease
Management of Perthes’ disease
- 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
Prognosis with Perthes’ disease
- Most cases will resolve with conservative management
- Early diagnosis improves outcomes
The other name for Slipped upper femoral epiphysis
aka Slipped CAPITAL femoral epiphysis
Epidemiology of slipped upper femoral epiphysis
- typically age group is 10-15 years
- more common in obese children and boys
- Two main groups
- Fat and sexually underdeveloped
- Tall and thin
Presentation of the slipped upper femoral epiphysis
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
What happens in Slipped upper femoral epiphysis? (pathophysiology)
Displacement of the femoral head epiphysis postero-inferiorly
Investigations in Slipped upper femoral epiphysis
- AP and lateral (typically frog-leg) views are diagnostic
- CT/MRI if there is diagnostic difficulty
Management of Slipped Upper Femoral Epiphysis
internal fixation: typically a single cannulated screw placed in the center of the epiphysis
Transient Synovitis
- another name
- presentation
- investigations
- management
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
What should raise a suspicion of non-accidental injury?
- Inappropriate history
- Physical signs don’t match the story
- Other concerning features
- Concerns raised by others
- Physical and emotional abuse
Chondromalacia patellae
- pathophysiology
- epidemiology
- presentation
- management
- *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
Pathophysiology of Osgood-Schlatter disease
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
Presentation of Osgood-Schlatter disease
- 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
Investigations and diagnosis of Osgood Schlatter disease
- usually clinical diagnosis
- X-ray: tuberosity enlargement ± fragmentation
Management of Osgood- Schlatter disease
- 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
Can flat feet cause lower limb pain?
- Common cause of lower limb pain
- If symptomatic - correct with good footwear and insoles
The naming of ‘growing pains’
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’
Features of growing pains
- 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
