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Painful swollen joints and limbs Flashcards

1
Q

What is typically meant by growing pains?

A

episodes of generalised pain in the lower limbs

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2
Q

What is another name for growing pains?

A

Nocturnal idiopathic pain

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3
Q

What is usual about the onset and resolution of an episode of growing pains?

A

Pain often wakes child from sleep, settles with massage or comforting

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4
Q

What are the 5 rules of growing pains?

A
  1. Age range 3-12 years
  2. Pains symmetrical in lower limbs and not limited to joints
  3. Pains never present at start of day after waking
  4. Physical activities not limited; no limp
  5. Physical examination normal (including pGALS) with the exception of joint hypermobility in some, and otherwise well
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5
Q

If generalised lower limb pain does not meet all 5 of the rules of growing pains what should be done?

A

Further assessment necessary

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6
Q

What are 4 features of pain caused by hypermobility?

A
  1. musculoskeletal pain mainly confined to lower limbs
  2. often worse after exercise
  3. joint swelling absent or transient
  4. either generalised or limited to peripheral joints e.g. hands and feed
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7
Q

Which age group of children is affected by hypermobility

A

older children or adolescents

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8
Q

What are 3 features of hypermobility?

A
  1. Symmetrical hyperextension of the thumbs and fingers that can be hyperextended onto the forearms
  2. Elbows and knees can be hyperextended beyond 10 degrees
  3. Palms can be placed flat on the floor with knees straight
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9
Q

What are 3 lower limb features of hypermobility?

A
  1. Hyperextensibility of knee joint
  2. Flat feet, with normal arches on tiptoe
  3. Feet are over-pronated secondary to ankle hypermobility
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10
Q

In which groups of children are mild degrees of hypermobility a normal finding?

A

younger female children (many children are asymptomatic and find being flexible an advantage in gymnastics and dancing)

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11
Q

What prolems might hypermobility cause?

A

recurrent mechanical joint and muscle pain, often activity related

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12
Q

What are 4 things required for the management of hypermobile children who expereicen recurrent mechanical joint and muscle pain?

A
  1. Referral for specialist assessment
  2. Advice about footwear
  3. Exercies
  4. Occasionally orthotics
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13
Q

What are 3 syndromes that hypermobility is a feature of?

A
  1. Down syndrome (chromosomal syndrome)
  2. Marfan (inherited collagen disorder)
  3. Ehlers-Danlos syndrome (inheriten collagen disorder)
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14
Q

What is the cause of the most dramatic type of musculoskeletal pain?

A

Complex regional pain syndromes (CRPS) - formerly known as idiopathic pain syndromes

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15
Q

In which group of children do complex regional pain syndromes usually present?

A

Adolescent females

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16
Q

What are the 2 forms of complex regional pain syndromes?

A
  1. Localised forms
  2. Diffuse forms
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17
Q

What is the typical type of localised complex regional pain syndrome?

A

Often presents with foot and ankle involvement, typically unilateral

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18
Q

What is the nature of the pain in localised complex regional pain syndrome?

A

Extreme and incapacitating, often triggered by minor trauma or without a clear precipitant. May present to clinic in a wheelchair

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19
Q

What may be the trigger of localised complex regional pain syndrome?

A

Minor trauma or without clear precipitant

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20
Q

What are 6 additional features of complex regional pain syndrome?

A
  1. Hyperaesthesia - increased sensitivity to stimuli
  2. Allodynia - pain from stimulus that does not normally produce pain
  3. Affected part (foot or hand) may be cool to touch
  4. Affected part may be swolen and mottled
  5. Held in flexion, minimal if any active movement
  6. Sometimes bizarre posturing
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21
Q

What is the typical range of movement in localised complex regional pain syndrome?

A

with distraction, typically the normal range of passive movements is possible

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22
Q

What are 4 key features of diffuse forms of complex regional pain syndromes?

A
  1. Severe widespread pain
  2. Disturbed sleep patterns
  3. Feeling exhausted during the day
  4. Extreme tenderness over soft tissues
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23
Q

How do joints affected in complex regional pain syndromes compare with those in fibromyalgia in adults?

A

tender points may be absent or fewer in number in children

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24
Q

What is the general health like of a chid or adolescent with complex regional pain syndromes?

A

otherwise well, physical exam otherwise normal

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25
Q

What does the management of complex regional pain syndrome involve?

A
  • Organic pathology needs to be excluded
  • MDT rehabilitation regimen required, predominantly physiotherapy based, either community or inpatient
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26
Q

What is the aetiology of complex regional pain syndromes?

A

unknown, but affected children often have significant associated stresses in their lives

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27
Q

What is the most common cause of acute-onset limb pain in children?

A

trauma - usually accidental from sports injuries or falls, occasionally non-accidental

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28
Q

What are 4 key causes of acute onset limb pain?

A
  1. Trauma - accidental or non-accidental
  2. Osteomyelitis
  3. Bone tumours
  4. Septic arthritis
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29
Q

What is osteomyelitis?

A

infection of the metaphysis of long bones

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30
Q

What are the 2 most common sites to be affected in osteomyelitis?

A
  1. Distal femur
  2. Proximal tibial

(may affect any bone)

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31
Q

What is the cause of osteomyelitis?

A

haematogenous spread of a pathogen, but may arise by direct spread from an infected wound

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32
Q

What is the physical appearance in osteomyelitis?

A

skin is swollen directly over the affected site, erythema

may be sterile effusion of adjacent joint

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33
Q

What might osteomyelitis progress to and how?

A

where joint capsule is inserted distal to the epiphyseal plate, as in the hip, osteomyelitis may spread to cause septic arthritis

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34
Q

What are 3 causative pathogens of osteomyelitis (in non-sickle cell patients)? Which is most common?

A
  1. Staphylococcus aureus - most common
  2. Streptococcus
  3. Haemophilus influenzae if not immunized
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35
Q

What are 2 pathogens that are at increased risk of causing osteomyelitis in sickle cell anaemia?

A
  1. Staphylococcus
  2. Salmonella
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36
Q

What needs to be considered as an alternative rare cause of osteomyelitis, particularly in the immunodeficient child?

A

tuberculosis

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37
Q

What are 6 features of the presentation of osteomyelitis?

A
  1. Painful, immobile limb (pseudoparesis)
  2. Acute febrile illness
  3. Swelling
  4. Exquisite tenderness over infected site
  5. Erythema and warmth over affected site
  6. Sterile effusion of adjacent joint
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38
Q

How does the presentation of osteomyelitis differ in infants?

A

more insidious; swelling or reduced limb movement is the initial sign

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39
Q

What are 3 sites/ types of presentation of osteomyelitis in children beyond infancy?

A
  1. Back pain - vertebral infection
  2. Limp
  3. Groin pain - infection of pelvis
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40
Q

What are 2 types of causative agents of osteomyelitis which may cause multiple foci?

A
  1. Disseminated staphylococcal
  2. Disseminated H. influenzae
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41
Q

What are 6 possible investigations for osteomyelitis?

A
  1. Blood cultures
  2. WCC, acute phase reactants
  3. X-rays - initially normal/soft tissue swelling
  4. Ultrasound
  5. Magnetic resonance imaging
  6. Radionuclide bone scan - if site unclear
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42
Q

What do X-rays initially show in osteomyelitis? When do they become abnormal and why?

A
  • initially normal other than showing soft tissue swelling
  • 7-10 days: subperiosteal new bone formation and localised bone rarefaction become visible
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43
Q

What might an ultrasound scan show at presentation of osteomyelitis?

A

periosteal elevation

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44
Q

What are 2 things that MRI may be helpful to show in osteomyelitis?

A
  1. Identification of infection in bone - subperiosteal pus and purulent debris in bone
  2. Differentiation of bone from soft tissue infection
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45
Q

When might a radionuclide bone scan be useful for osteomyelitis?

A

if site of infection unclear

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46
Q

What are 4 aspects of the management of osteomyelitis?

A
  1. prompt treatment with parenteral antibiotics - several weeks to prevent complications
    • IV until clinical recovery and acute-phase reactants have returned to normal
    • oral therapy for several weeks
  2. aspiration or surgical decompression of subperiosteal space performed if presentation atypical or in immunodeficient children
  3. surgical drainage if doesn’t respond rapidly to abx
  4. rest affected limb in splint initially and subsequently mobilise
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47
Q

What are 4 complications that a several week course or abx is given to prevent in osteomyelitis?

A
  1. Bone necrosis
  2. Chronic infection with discharging sinus
  3. Limb deformity
  4. Amyloidosis
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48
Q

What are 2 reasons why aspiration or surgical decompression of the subperiosteal space may be performed in osteomyelitis?

A
  1. Presentation is atypical
  2. Immunodeficient children
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49
Q

Why might surgical drainage be performed in osteomyelitis?

A

if doesn’t respond rapidly to antibiotic therapy

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50
Q

What are 4 types of malignant disease which may present with bone pain?

A
  1. Acute lymphoblastic leukaemia
  2. Neuroblastoma
  3. Osteogenic sarcoma
  4. Ewing tumour
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51
Q

How might acute lymphoblastic leukaemia present?

A

bone pain in children, sometimes primarily at night, and even frank arthritis

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52
Q

How might neuroblastoma present in children?

A

systemic arthritis or bone pain from metastases - may be difficult to localise

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53
Q

What are the 2 types of malignant bone tumours?

A
  1. Osteogenic sarcoma
  2. Ewing tumour
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54
Q

What are 3 ways that malignant bone tumours may present?

A
  1. Pain
  2. Swelling
  3. Pathological fracture
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55
Q

What should the investigation of bone tumours include?

A

Radiographs of joint, which should include long bone above and below (especially with knee pain, as distal femur and proximal tibia are most common sites)

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56
Q

What is a type of benign tumour that can be present in bones?

A

Osteoid osteoma

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57
Q

What age group of children and gender are affected by osteoid osteoma?

A

Adolescents - boys mostly

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58
Q

What are 3 regions where osteoid osteoma usually occurs?

A
  1. Femur
  2. Tibia
  3. Spine
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59
Q

What are 6 possible features of osteoid osteoma?

A
  1. Pain more severe at night
  2. Pain improves with NSAIDs
  3. Localised tenderness
  4. Soft tissue swelling
  5. Joint effusion - if near a joint
  6. Scoliosis if in spine
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60
Q

What is the diagnostic investigation for osteoid osteoma and what does it show?

A

X-ray: sharply demarcated radiolucent nidus (focus) of osteoid tissue surrounded by sclerotic bone

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61
Q

What are 3 investigations that may be used in suspected osteoid osteoma?

A
  1. x-ray
  2. CT
  3. MRI

latter 2 - may be required to confirm, may be indicated even if xray normal

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62
Q

What is the treatment of osteoid osteoma?

A

Surgical removal (pain management with NSAIDs)

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63
Q

What is the prognosis of osteoid osteoma following surgical removal?

A

good prognosis

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64
Q

What must always be assessed when a child presents with a painful knee?

A

examine hip - often referred pain to knee

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65
Q

What are 6 causes of a painful knee in children?

A
  1. Osgood-Schlatter disease
  2. Chondomalacia patellae
  3. Osteochondritis dissecans (segmental avascular necrosis of the subchrondral bone)
  4. Subluxation and disolocation of the patella
  5. Injuries - sport
  6. Arthritis - reactive, septic, juvenile idiopathic
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66
Q

What is Osgood-Schlatter disease?

A

osteochondritis of the patellar tendon insertion at the knee

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67
Q

What group is most commonly affected by Osgood-Schlatter disease?

A

adolescent males who are physically active (particularly football or basketball)

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68
Q

What are 4 clinical features of Osgood-Schlatter disease?

A
  1. Knee pain after exercise
  2. Localised tenderness
  3. Sometimes swelling over tibial tuberosity
  4. Hamstring tightness often present
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69
Q

In what proportion of cases of Osgood-Schlatter disease is it bilateral?

A

25-50%

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70
Q

What are 5 possible aspects of treatment for Osgood-Schlatter disease?

A
  1. Reduced activity
  2. Physiotherapy for quadriceps muscle strengthening
  3. Hamstring stretches
  4. Occasionally orthotics
  5. Knee immobiliser splint - may be helpful
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71
Q

What is chondromalacia patellae?

A

softening of articular cartilage of the patella

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72
Q

What group does chondromalacia patellae most commonly occur in?

A

adolescent females

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73
Q

When does pain occur in chondromalacia patellae?

A

When patella is tightly apposed to the femoral condyles e.g. standing up from sitting, or on walking up stairs

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74
Q

What is thought to be the cause of chondromalacia patellae and why?

A

Biomechanical component thought to be present in aetiology: often associted with hypermobility and flat feet

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75
Q

What 2 things is chrondromalacia patellae often associated with?

A
  1. Hypermobility
  2. Flat feet
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76
Q

What is the treatment for chondromalacia patellae?

A

physiotherapy for quadriceps muscle strengthening

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77
Q

What is the alternative name for osteochondritis dissecans?

A

Segmental avascular necrosis of the subchondral bone

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78
Q

What is osteochondritis dissecans?

A

separation of bone and cartilage from the medial femoral condyle following avascular necrosis

bone underneath the cartilage of joint is necrosed due to lack of blood flow and can then break loose, causing pain, possily hindering joint motion

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79
Q

What can osteochondritis dissecans lead to and what symptoms might this produce?

A

complete separation of articular fragments, may result in loose body formation and symptoms of knee locking or giving way

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80
Q

What is the presentation of osteochondritis dissecans?

A

Persistent knee pain in the physically very active adolescent with localised tenderness over the femoral condyles

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81
Q

What is the treatment for osteochondritis dissecans?

A

initially rest and quadriceps exercises

sometimes arthroscopic surgery required

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82
Q

What is subluxation and dislocation of the patella?

A

subluxation = partial dislocation of patella, aka patellar instability. slides laterally (outwards)

patellar dislication is due to substantial disruption of the medial patellofemoral ligament

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83
Q

What usually causes subluxation/ dislocation of the patella? 2 key causes

A
  1. Non-contact twisting injury to knee
  2. Direct contact to the inner (medial) aspect of the patella
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84
Q

What symptoms are caused by subluxation of the patella?

A

Feeling of instability or giving way of the knee

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85
Q

What is subluxation of the patella often associated with?

A

Generalised hypermobility

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86
Q

In which direction does dislocation of the patella usually occur?

A

Laterally

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87
Q

What are the symptoms of dislocation of the patella?

A

sudden, severe pain

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88
Q

What are 2 ways reduction is usually achieved in patellar dislocation?

A
  1. Spontaneously
  2. Gentle extension of the knee
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89
Q

What are 2 possible treatments for patellar dislocation?

A
  1. Quadriceps exercises
  2. Surgery to realign pull of the quadrieps on the patellar tendon
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90
Q

How does type of sport determine the injuries most often caused to the knee?

A

contact can result in acute injuries to kne, while non-contact sports with sustained activity tend to result in chronic injury and overuse syndromes

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91
Q

In what age group are sporting injuries to the knee common?

A

adolescents

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92
Q

What are 2 structures in the knee to which sporting injuries most frequently occur?

A

Menisci and ligaments

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93
Q

What type of investigation is most useful to determine the extent of damage in knee injuries from sport?

A

MRI

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94
Q

What is the usual management of sporting injuries to the knee?

A

usually conservative

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95
Q

What is likely to occur from injuries to the knee in infants and young children and why?

A

more likely to result in fractures as ligaments are relatively stronger than their bones

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96
Q

Why is back pain a symptom of concern in the very young and preadolescent ages?

A

in contrast to adults, cause can often be identified - the younger the child, the more likely there will be significant pathology

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97
Q

What are 6 red flag clinical features of back pain in children?

A
  1. Young age - pathology more likely
  2. High fever - infection
  3. Night waking, persistent pain - osteoid osteoma or tumours
  4. Painful scoliosis - infection or malignancy
  5. Focal neurological signs including nerve root irritation, loss of bowel/bladder control - nerve root/ spinal cord compression
  6. Associated weight loss, systemic malaise - malignancy
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98
Q

What are 7 causes of back pain in children?

A
  1. Mechanical causes
  2. Tumours: benign or malignant
  3. Vertebral osteomyelitis or discitis
  4. Spinal cord or nerve root entrapment
  5. Scheuermann disease
  6. Spondylolysis/ spondylolisthesis
  7. Complex regional pain syndrome
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99
Q

What are 2 things that may result in mechanical causes of back pain?

A
  1. Muscle spasm
  2. Soft tissue pain from injury
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100
Q

What are 3 causes of mechanical back pain in children?

A
  1. Sport-related
  2. Poor posture
  3. Abnormal loading e.g. carrying heavy school bags on one shoulder
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101
Q

What are 5 possible symptoms of vertebral osteomyelitis or discitis?

A
  1. Localised tenderness
  2. In infants, reluctance to walk or bear weight
  3. Pain on spine flexion
  4. Fever
  5. Systemic upset
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102
Q

What are 2 investigations that may be performed in vertebral osteomyelitis or discitis?

A
  1. X-ray - may show abnormalities
  2. MRI - often required
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103
Q

What is the treatment for vertebral osteomyelitis or discitis?

A

IV antibiotics

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104
Q

What are 2 possible causes of spinal cord or nerve root entrapment?

A

Tumour or prolapsed intervertebral disc

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105
Q

What is a prolapsed intervertebral disc often associated with?

A

trauma or heavy lifting

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106
Q

What is Scheuermann disease?

A

Osteochondrosis of the vertebral body; vertebrae grow unevenly with respect to the sagittal plane, meaning posterior angle often grater than the anterior, resulting in signature wedging shape of vertebrae, causing kyphosis

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107
Q

What is the typical presentation of Scheuermann disease?

A

fixed thoracic kyphosis with or without back pain

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108
Q

How is a diagnosis of Scheuermann disease usually made?

A

x-ray - may be coincidental finding and asymptomatic

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109
Q

What is spondylolysis?

A

stress fracture of the pars interarticularis of the vertebra

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110
Q

What increases the risk of spondylolysis?

A

certain sporting activities e.g. bowling in cricket or gymnastics

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111
Q

When can spondylolysis lead to spondylolisthesis and what is this?

A

If spondylolysis is bilateral; forward slip of the vertebral body, and potential cord or nerve root compression

112
Q

What is the presentation of spondylolysis/ spondylolisthesis?

A

pain on spine extension and localised tenderness

113
Q

What investigations are required in spondylolysis/ spondylolisthesis?

A

may be apparent on xray but often CT required

114
Q

How can the causes of limp be categorised?

A

Acute painful limp vs chronic or intermittent; by age

115
Q

What are 4 causes of acute painful limp in the age group of 1-3?

A
  1. Infection - septic arthritis, osteomyelitis of hip or spine
  2. Transient synovitis
  3. Trauma - accidental/ non-accidental
  4. Malignant disease - leukaemia, neuroblastoma
116
Q

What are 4 causes of a chronic and intermittent limp in children aged 1-3 years?

A
  1. Developmental dysplasia of the hip (DDH)
  2. Talipes
  3. Neuromuscular e.g. CP
  4. Juvenile idiopathic arthritis (JIA)
117
Q

What are 7 causes of an acute painful limp in children aged 3-10 years?

A
  1. Transient synovitis
  2. Septic arthritis/ osteomyelitis
  3. Trauma and overuse injuries
  4. Perthes disease (acute)
  5. Juvenile idiopathic arthritis (JIA)
  6. Malignant disease e.g. leukaemia
  7. Complex regional pain syndrome
118
Q

What are 4 causes of a chronic and intermittent limp in children aged 3-10 years?

A
  1. Perthes disease (chronic)
  2. Neuromuscular disorders e.g. Duchenne muscular dystrophy
  3. Juvenile idiopathic arthritis (JIA)
  4. Tarsal coalition
119
Q

What are 9 causes of an acute painful limp in children aged 11-16?

A
  1. Mechanical - trauma, overuse injuries, sport injuries
  2. Slipped capital femoral epiphysis (SCFE) (acute)
  3. Avascular necrosis of the femoral head
  4. Reactive arthritis
  5. Juvenile idiopathic arthritis (JIA)
  6. Septic arthritis/ osteomyelitis
  7. Osteochondritis dissecans of the knee
  8. Bone tumours and malignancy
  9. Complex regional pain syndrome
120
Q

What are 3 causes of a chronic and intermittent limp in children aged 11-16?

A
  1. Slipped capital femoral epiphysis (chronic)
  2. Juvenile idiopathic arthritis (JIA)
  3. Tarsal coalition
121
Q

What is an alternative name for transient synovitis?

A

irritable hip

122
Q

What is the most common cause of acute hip pain in children?

A

transient synovitis

123
Q

In what age of children does transient synovitis occur?

A

2-12 years

124
Q

What often occur with or before transient synovitis?

A

viral infection

125
Q

What is the presentation of transient synovitis?

A
  • sudden onset pain in hip or a limp
  • no pain at rest, but decreased range of movement, particularly reduced internal rotation
  • pain may be referred to knee
126
Q

Does the child have systemic symptoms with transient synovitis?

A

no - afebrile or mild fever only, does not appear ill

127
Q

What is difficult but important to distinguish transient synovitis from?

A

early septic arthritis of the hip joint

128
Q

What investigations are manadatory if there is any suspicion of septic arthritis?

A

joint aspiration and blood cultures

129
Q

What are 6 differences between transient synovitis and septic arthritis of the hip joint?

A
  1. mild/absent fever in TS, moderate/high in SA
  2. child often well in TS, looks ill in SA
  3. comfortable at rest in TS, severe pain at rest in SA
  4. Normal WCC in TS, normal or high in SA
  5. CRP/ESR normal/ slight raised in TS, very raised SA
  6. Normal radiograph TS, normal/widened joint space SA
130
Q

What is pain like at rest and on movement in septic arthritis?

A

hip held flexed, severe pain at rest, worse on any attempt to move

131
Q

What will an ultrasound scan show in TS and in SA?

A

both will show fluid in the joint

132
Q

What is the management of transient synovitis?

A
  1. rest, analgesia
  2. rarely, skin traction: pulling force to skin
133
Q

What is the management of septic arthritis?

A
  • joint aspiration, usually under ultrasound guidance
  • prolonged antibioitics, rest and analgesia
134
Q

What is the typical course of transient synovitis?

A

resolves <1 week, approx 3% develop Perthes disease

135
Q

What is the likely course of septic arthritis?

A

progressive and severe joint damage if not treated

136
Q

What do a small proportion of children with transient synovitis go on to develop?

A

Perthes disease

137
Q

How long does it usually take transient synovitis to resolve?

A

usually wihtin a few days, <1 week

138
Q

What is Perthes disease?

A

Avascular necrosis of the capital femoral epiphysis of the femoral head due to interruption of the blood supply, followed by revascularisation and reossification over 18-36 months

139
Q

What is the gender ratio of Perthes disease?

A

Male: Female 5:1

140
Q

What age group is most commonly affected by Perthes disease?

A

5-10 years of age

141
Q

What is the typical presentation of Perthes disease?

A

insidious; onset of limp, hip or knee pain

may be initially mistaken for transient synovitis

142
Q

What proportion of cases of Perthes disease is bilateral?

A

10-20%

143
Q

What are the investigations for Perthes disease?

A
  • if suspected, x-ray of both hips (including frog views) should be requested
  • bone scan and MRI can help
144
Q

What should be done if the x-ray is normal in suspected Perthes disease?

A

repeat may be required if clinical symptoms persist

145
Q

What will an x-ray show in Perthes disease?

A
  • Early signs include increased density in femoral head, which subsequently becomes fragmented and irregular
  • Image shows flattening with sclerosis and fragmentation of right femoral capital epiphysis (left hip normal)
146
Q

What are 5 options for treatment of Perthes disease?

A
  1. Rest
  2. Physiotherapy to optimise hip movement
  3. Traction
  4. Plaster casts
  5. Surgery
147
Q

What is the prognosis of Perthes disease and when is it best?

A

in most children good; particularly children <6 years of age with less than half the epiphysis involved

148
Q

What might result from Perthes disease in older children with more extensive involvement of the epiphysis?

A

Deformity of femoral head and metaphyseal damage more likely, with potential for subsequent degenerative arthritis in adult life

149
Q

What is slipped capital femoral epiphysis?

A

displacement of epiphysis of the femoral head postero-inferiorly

150
Q

Why does slipped capital femoral epiphysis require prompt treatment?

A

to prevent avascular necrosis

151
Q

At what age is slipped capital femoral epiphysis most common?

A

10-15 years, during adolescent growth spurt

152
Q

What gender and particularly what type of child is most prone to slipped capital femoral epiphysis?

A

obese boys

153
Q

In what proportion of slipped capital femoral epiphysis is it bilateral?

A

20%

154
Q

What can slipped capital femoral epiphysis be associated with?

A

metabolic endocrine abnormalities e.g. hypothyroidism and hypogonadism

155
Q

What is the presentation of slipped capital femoral epiphysis?

A
  • Limp or hip pain, may be referred to knee
  • May be acute onset, following minor trauma, or insidious
156
Q

What will examination show in slipped capital femoral epiphysis?

A

Restricted abduction and internal rotation of the hip

157
Q

How is a diagnosis of slipped capital femoral epiphysis made?

A

X-ray: frog (lateral) view should also be requested

158
Q

What is the management of slipped capital femoral epiphysis?

A

surgical, usually with pin fixation in situ

159
Q

What is developmental dysplasia of the hip (DDH)?

A

spectrum of disorders ranging from dysplasia to subluxation through to frank dislocation of the hip

160
Q

Why is early detection of DDH important?

A

usually DDH responds to conservative treatment, but late diangosis associated with hip dysplasia, which requires complex treatment often including surgery

161
Q

When is screening for DDH performed and what does it involve?

A
  • Neonatal screening - routine examination of newborn
  • Barlow manoeuvre: check if hip can be dislocated posteriorly out of acetabulum
  • Ortolani: if can be relocated back into acetabulum on abduction
162
Q

When is screening for DDH repeated?

A

routine surveillance at 8 weeks of age

163
Q

If presentation of DDH presents after screening, how does it usually present? 4 features

A
  1. limp or abnormal gait
  2. asymmetry of skinfolds around hip
  3. Limited abduction of hip
  4. Shortening of affected leg
164
Q

What is the usual prognosis if abnormality of the hip is detected on neonatal screening?

A

most resolve spontaneously, true DDH rare (sometimes some cases missed)

165
Q

What are 2 reasons why DDH may be missed during screening tests and what can be done to avoid this?

A
  1. Inexperience of examiner
  2. Not possible to clinically detect e.g. only mildly shallow acetabulum

some centres perform USS on all newborn infants

166
Q

What is a pro and 2 cons of ultrasound screening to detect DDH?

A
  • Pro: highly specific - if positive, likely to be accurate
  • Con: expensive
  • Con: high rate of false negatives i.e. low sensitivity
167
Q

When is USS screening to detect DDH most likely to be performed?

A

if infants at increased risk e.g. family history, breech presentation

168
Q

What are 4 aspects of the management of DDH?

A
  1. if suspected, specialist orthopaedic opinion should be obtained
  2. USS examination - detailed assessment
  3. Splint or harness to keep hip flexed and abducted (Pavlik harness) for several months
  4. Surgery if all else fails
169
Q

Why should an ultrasound examination be performed if clinical examination suggests DDH?

A

allows detailed assessment - quantifying degree of dysplasia and whether there is subluxation or dislocation

170
Q

How is progress of a splint or harness to treat DDH monitored?

A

repeat USS or x-ray

171
Q

Why is important that splinting is performed expertly in DDH?

A

necrosis of femoral head is a potential complication

172
Q

What are 5 features of acute arthritis?

A
  1. pain
  2. swelling
  3. heat
  4. redness
  5. restricted movement in joint
173
Q

What are 2 causes of monoarthritis that require urgent diagnosis and treatment?

A
  1. Septic arthritis
  2. Osteomyelitis
174
Q

What are 7 causes of polyarthritis?

A
  1. Infection: bacterial, viral, mycoplasma, Lyme disease, rickettsia, reactive, rheumatic fever
  2. IBD
  3. Vasculitis: HSP, Kawasaki
  4. Haematological: haemophilia, sickle cell disease
  5. Malignant: leukaemia, neuroblastoma
  6. Connective tissue disorders: JIA, SLE, JDM, MCTD, PAN
  7. Cystic fibrosis
175
Q

What are 7 infective causes of polyarthritis?

A
  1. Bacteria: sepsis/ septic arthritis, TB
  2. Viral: rubella, mumps, adenovirus, coxsackie B, herpes, hepatitis, parvovirus
  3. Mycoplasma
  4. Lyme disease
  5. Rickettsia
  6. Reactive: GI, streptococcal
  7. Rheumatic fever
176
Q

What are 2 vasculitic causes of polyarthritis?

A
  1. Henoch-Schonlein Purpura
  2. Kawasaki disease
177
Q

What are 2 haematological disorders that can cause polyarthritis?

A
  1. Haemophilia
  2. Sickle cell disease
178
Q

What are 5 connective tissue disorders that can cause polyarthritis?

A
  1. Juvenile idiopathic arthritis (JIA)
  2. Systemic lupus erythematosus (SLE)
  3. Dermatomyositis
  4. Mixed connective tissue disease (MCTD)
  5. Polyarteritis nodosa (PAN)
179
Q

What is the most common form of arthritis in childhood?

A

Reactive arthritis

180
Q

What is the typical clinical picture of reactive arthritis?

A

Transient joint swelling, usually <6 weeks

Often ankles or knees

Following (or rarely accompanying) extra-articular infection

181
Q

What are 6 causes of reactive arthritis?

A
  1. Enteric bacteria (salmonella, shigella, campylobacter, yersinia)
  2. Viral infections
  3. STIs (chlamydia, gonococcus)
  4. Mycoplasma
  5. Borrelia burgdorferi (Lyme disease)
  6. Rheumatic fever/ post-streptococcal
182
Q

What are 4 causes of gastroenteritis that can result in subsequent reactive arthritis?

A
  1. Salmonella
  2. Shigella
  3. Campylobacter
  4. Yersinia
183
Q

In what regions are rheumatic fever/ post-streptococcal reactive arthritides common?

A

low and middle-income countries (rare in high-income countries)

184
Q

How severe is fever in reactive arthritis?

A

low-grade

185
Q

What are 2 possible investigations for suspected reactive arthritis and what will they show?

A
  1. Acute-phase reactants (CRP, WCC) - normal or mildly raised
  2. X-rays: normal
186
Q

What is the treatment and prognosis of reactive arthritis?

A

No treatment or NSAIDs only’ complete recovery can be anticipated

187
Q

What 2 joints are most commonly affected in reactive arthritis?

A

Knees, ankles

188
Q

What is a serious outcomes of septic arthritis that means it must be treated promptly?

A

can lead to bone destruction

189
Q

In what age group is septic arthritis most common?

A

Children under 2 years

190
Q

What are 4 causes of septic arthritis?

A
  1. Haematogenous spread
  2. Puncture wound
  3. Infected skin lesions e.g. chickenpox
  4. Adjacent osteomyelitis if joints where capsule inserted below epiphyseal growth plate
191
Q

Which joint is a particular concern for a site of septic arthritis in infants and young children?

A

Hip

(most commonly in hip or knee)

192
Q

What is the most common cause of septic arthritis beyond the neonatal period?

A

Staphylococcus aureus

193
Q

In addition to Staph aureus what else used to be a common cause of septic arthritis and why is it no longer?

A

Haemophilus influenzae - prior to Hib immunisation

(often affected multiple sites)

194
Q

What are 2 underlying conditions to consider in a child with septic arthritis?

A
  1. Immunodeficiency
  2. Sickle cell disease
195
Q

What is the typical presentation of septic arthritis?

A
  • erythematous, warm, acutely tender joint with reduced range of movement
  • Acutely unwell, febrile chid
  • Pseudoparesis (weakness), pseudoparalysis (no movement) - hold limb still, cry if it is moved
  • Joint effusion may be detected in peripheral joints
196
Q

How can the joint effusion which may occur in osteomyelitis be differentiated from that of septic arthritis?

A

in osteomyelitis there is usually marked tenderness over the bone

197
Q

In what proportion of cases of osteomyelitis is there coexistent septic arthritis?

A

15%

198
Q

Why can the diagnosis of septic arthritis be difficult?

A

In toddlers, the joint is well-covered by subcutaneous fat

199
Q

What are 2 more subtle ways that septic arthritis can initially present?

A
  1. Referred knee pain from the hip
  2. Limp
200
Q

How is the leg likely to be held in a toddler with septic arthritis of the hip?

A
  1. leg held flexed,
  2. abducted,
  3. externally rotated
  4. no spontaneous movement (pseudoparalysis - no movement)
201
Q

Why is there a characteristic posture of the hip in septic arthritis in toddlers?

A

to reduce intracapsular pressure

202
Q

What are 7 investigations to perform in suspected septic arthritis and why?

A
  1. Aspiration of joint space under USS for organisms and culture = definitive
  2. Blood cultures
  3. Bloods: WCC, CRP raised
  4. USS of deep joints e.g. hip - identify effusion
  5. X-rays : exclude trauma, other bony lesions
  6. MRI
  7. Radioisotope bone scan: if site of infection unclear
203
Q

What is the definitive investigation to diagnose septic arthritis?

A

joint aspiration for microorganisms and culture under ultrasound guidance

204
Q

When should joint aspiration be performed in septic arthritis?

A

Immediately, unless would cause significant delay in giving antibiotics

205
Q

What is the management of septic arthritis? 3 things

A
  1. Prolonged course of antibiotics, initially IV
  2. Washing out of joint or surgical drainage if resolution does not occur rapidly or if joint deep-seated e.g. hip
  3. Joint initially immobilised in functional position, but subsequently mobilised to prevent permanent deformity
206
Q

What is the most common chronic inflammatory joint disease in children and adolescents in the UK?

A

Juvenile idiopathic arthritis

207
Q

What is the definition of juvenile idiopathic arthritis (JIA)?

A

Persistent joint swelling (of >6 weeks duration) presenting before 16 years of age in absence of infection or any other defined cause

208
Q

How distinct is JIA from rheumatoid arthritis in adults?

A

95% of children have disease that is clinically and immunogenetically distinct from RA in adults

209
Q

How many subtypes of JIA exist? What are they?

A

At least 8

  1. Oligoarthritis (persistent)
  2. Oligoarthritis (extended)
  3. Polyarthritis (RF negative)
  4. Polyarthritis (RF positive)
  5. Systemic arthritis
  6. Psoriatic arthritis
  7. Enthesitis-related arthritis
  8. Undifferentiated arthritis
210
Q

What is the age of onset and sex ratio of oligoarthritis (persistent)?

A

1-6 years

F:M 5:1

211
Q

What is the most common subtype of JIA?

A

Oligoarthritis (persistent) - 49% of all JIA

212
Q

What is the articular pattern of JIA oligoarthritis (persistent)?

A

1-4 joints (max) involved: knee, ankle or wrist most common

213
Q

What are 2 extra-articular features of JIA oligoarthritis (persistent)?

A
  1. Chronic anterior uveitis in 20%
  2. Leg length discrepency
214
Q

What laboratory abnormality may be present in JIA oligoarthritis (persistent)?

A

ANA may be positive or negative

215
Q

What is the typical age of onset and sex ratio of JIA oligoarthritis (extended)?

A
  • age 1-6 years
  • F:M 5:1
216
Q

What is the typical articular pattern of JIA oligoarthritis (extended)?

A

>4 joints involved after first 6 months

Asymmetrical distribution of large and small joints

217
Q

What are 2 extraarticular features of JIA oligoarthritis (extended)?

A
  • chronic anterior uveitis
  • asymmetrical growth
218
Q

What laboratory finding may be present in JIA oligoarthritis (extended)?

A

ANA

219
Q

What is the typical age of onset and sex ratio of JIA polyarthritis (RF negative)?

A

1-6 years

F:M 5:1

220
Q

What is the typical articular pattern of JIA polyarthritis (RF negative)?

A

symmetrical large and small joint arthritis

often marked finger involvement

cervical spine and temporomandibular joint may be involved

221
Q

What are 3 extra-articular features of JIA polyarthritis (RF negative)?

A
  1. Low grade fever
  2. Chronic anterior uveitis
  3. Late reduction of growth rate
222
Q

What is the typical age of onset and sex ratio of JIA polyarthritis (RF positive)?

A
  1. 10-16 years
  2. F:M 5:1
223
Q

What is the typical articular pattern of JIA polyarthritis (RF positive)?

A

symmetrical large and small joint arthritis, often marked finger involvement

224
Q

What is 1 extraarticular feature of JIA polyarthritis (RF positive)?

A

rheumatoid nodules

225
Q

What is a key laboratory finding of JIA polyarthritis (RF positive)?

A

RF+ve (long term)

226
Q

What is the typical age of onset and sex ratio of JIA systemic arthritis?

A
  • 1-10 years
  • 1:1
227
Q

What is the typical articular pattern of JIA systemic arthritis?

A

oligoarthritis or polyarthritis

may have aches and pains in joints and muscles (arthralgia/myalgia) but initially no arthritis

228
Q

What are 7 extra-articular features of JIA systemic arthritis?

A
  1. Acute illness
  2. Malaise
  3. High daily fever
  4. Salmon-pink, macular rash
  5. Lymphadenopathy
  6. Hepatosplenomegaly
  7. Serositis
229
Q

What are 4 laboratory findings in JIA systemic arthritis?

A
  1. Anaemia
  2. Raised neutrophils
  3. Raised platelets
  4. High acute phase reactants
230
Q

What is the typical age of onset and sex ratio of JIA psoriatic arthritis?

A
  • 1-16 years
  • 1:1
231
Q

What is the typical articular pattern of JIA psoriatic arthritis?

A

usually asymmetrical distribution of large and small joints, dactylitis

232
Q

What are 3 extra-articular features of JIA psoriatic arthritis?

A
  1. Psoriasis
  2. Nail pitting or dystrophy
  3. Chronic anterior uveitis
233
Q

What is the typical age of onset and sex ratio of enthesitis-related arthritis?

A
  • 6-16 years
  • F:M 1:4
234
Q

What is the typical articular pattern of JIA enthesitis-related arthritis?

A

lower limb, large joint arthritis initially, mild lumbar spine or sacroiliac invovlement later on

235
Q

What are 2 extra-articular features of JIA enthesitis-related arthritis?

A
  1. Enthesitis: localised inflammation at insertion of tendons/ligaments into bone, often in feets, Achilles insertion
  2. Acute uveitis (occasional)
236
Q

What is the key laboratory finding in enthesitis-related arthritis?

A

HLAB27+

237
Q

What is the typical age of onset and sex ratio of JIA undifferentiated arthritis?

A
  • 1-16 years
  • F:M 2:1 (variable)
238
Q

What is the typical articular pattern of JIA undifferentiated arthritis?

A

overlapping articular and extra-articular patterns between 2 or more subtypes or insufficient criteria for subclassification

239
Q

What is classification of JIA based on?

A

number of joints affected in first 6 months; polyarthritis is more than 4, oligo is up to and including 4, systemic means fever and rash associated

240
Q

What are 6 features that may be present in the history of JIA?

A
  1. Gelling: stiffness after periods of rest e.g. long car rides
  2. Morning joint stiffness
  3. Pain
  4. Intermittent limp
  5. Deterioration in behaviour or mood
  6. Avoidance of previously enjoyed activities
241
Q

What are 5 examination/clinical features of juvenile idiopathic arthritis?

A
  1. Swelling of joint due to fluid
  2. Inflammation
  3. Chronic arthritis
  4. Proliferation (thickening) of synovium
  5. Swelling of periarticular soft tissues
242
Q

What can make the diagnosis of JIA difficult?

A

in most common forms baseline investigations initially normal - FBC, inflammatory markers, negative RF and radiographs

and presentation can be indolent, especiall in young children

243
Q

What are 3 things which long-term uncontrolled disease activity in JIA can lead to?

A
  1. Bone expansion from overgrowth - may cause leg lengthening in knee or valgus deformity
  2. Discrepency in digit length in hands
  3. Advancement of bone age in the wrist
244
Q

If there are systemic features present in JIA, what 2 other diagnoses must always be considered?

A
  1. Malignancy
  2. Sepsis
245
Q

What must be done as soon as JIA is suspected?

A

referral to paediatric rheumatology - early treatment radically improves outcome

246
Q

What are 7 complications of JIA?

A
  1. Chronic anterior uveitis
  2. Flexion contracture of the joints
  3. Growth failure
  4. Anaemia of chronic disease
  5. Delayed puberty
  6. Osteoporosis
  7. Amyloidosis
247
Q

What can chronic anterior uveitis lead to if undetected/untreated?

A

severe visual impairment due to cataract and glaucoma

248
Q

What is done to try and prevent the complications of chronic anterior uveitis in JIA (glaucoma, cataract)?

A

regular ophthalmological screening using slit lamp (especially oligoarticular disease, + ANA positive)

249
Q

What causes flexion contractures of joints to occur in JIA?

A

when joint is helf in most comfortable position, thereby minimising intra-articular pressure; chronic untreated disease can lead to joint destruction and need for joint replacement

250
Q

What are 3 things which may contribute to growth failure in juvenile idiopathic arthritis?

A
  1. Anorexia
  2. Chronic disease
  3. Systemic corticosteroid therapy
251
Q

What are 2 types of localised growth problems which may be seen in JIA?

A
  1. Localised overgrowth such as leg lenth discrepency due to prolonged active knee synovitis
  2. Localised undergrowth, such as micrognathia - if long-standing/suboptimally treated arthritis due to premature fusion of epiphyses
252
Q

What are 4 things which can contribute to osteoporosis as a complication of JIA?

A
  1. Diet
  2. Reduced weight bearing
  3. Systemic corticosteroids
  4. Delayed menarche
253
Q

What are 4 ways to minimise osteoporosis as a complication of JIA?

A
  1. Dietary supplements of calcium and vitamin D
  2. Regular weight-bearing exercise
  3. Minimise oral corticosteroid use
  4. Sometimes bisphosphonates
254
Q

What is the management aim of JIA?

A

induce remission as soon as possible

255
Q

What are 4 broad elements of the management of JIA?

A
  1. education and support for child and family
  2. physiotherapy to maintain joint function
  3. paediatric rheumatology multidisciplinary teams, working with ophthalmology, dentistry and orthopaedics
  4. medical therapy
256
Q

What activities should a child with JIA be encouraged to do?

A

all activities apart from contact sport during active flares

257
Q

What are 5 types of medical therapies which can be used to treat JIA?

A
  1. NSAIDs and analgesics
  2. Intraarticular corticosteroid injections, increasingly under US guidance
  3. Methotrexate
  4. Systemic corticosteroids
  5. Cytokine modulators (biologics) and other immunotherapies
258
Q

When are intrarticular corticosteroid injections used for JIA?

A

first line treatment for oligoarticular JIA; in polyarticular disease, multiple joint injections used as bridging agent when starting methotrexate

259
Q

What is often required when giving intraarticular steroid injections to children with JIA?

A

sedation or inhaled anaesthesia (entonox)

260
Q

What is the benefit of using methotrexate in JIA?

A

early use reduces joint damage

effective in approximately 70% wth polyarthritis, less effective in systemic features of JIA

261
Q

How is methotrexate given to children with JIA? What is a key side effect?

A

weekly dose: tablet, liquid or injection

Nausea is common

262
Q

What monitoring is required for children on methotrexate for JIA and why?

A

regular monitoring of LFTs and FBC for abnormal liver function and bone-marrow suppression

263
Q

How commonly should systemic corticosteroids be given in JIA?

A

avoided if possible to minimise risk of growth suppression and osteoporosis

264
Q

How can systemic corticosteroids be administered in JIA?

A

pulsed IV methylprednisolone

265
Q

What are 3 situations when systemic corticosteroids may be useful for JIA?

A
  1. Induction agent for severe polyarthritis
  2. Severe systemic arthritis
  3. Macrophage activation syndrome
266
Q

What are 4 examples of cytokine modulators (biologics) which may be used for JIA?

A
  1. Anti-TNF alpha
  2. IL-1
  3. CTLA-4
  4. IL-6
267
Q

What situation in JIA might cytokine modulators (biologics) be used in?

A

severe disease refractory to methotrexate

268
Q

Under what conditions must cytokine modulators be given for JIA?

A

strict national guidance with registries for long-term surveillance

269
Q

What is another option for refractory JIA disease in addition to cytokine modulators?

A

T-cell depletion coupled with autologous haemotopoetic stem cell rescue (bone marrow transplant)

270
Q

What are 3 examples of morbidity caused by JIA if good disease control is not achieved?

A
  1. Joint damage requiring joint replacement
  2. Visual impairment from uveitis
  3. Fractures from osteoporosis
271
Q

In what proportion of children with JIA is ongoing treatment into adult years needed to maintain remission?

A

1 in 3

272
Q

What are 3 things that transitional care programmes for JIA are focused on?

A
  1. Helping young people learn how to self-manage their chornic disease
  2. Live independently
  3. Engage in shared decision making
273
Q

What is the most common vasculitis of childhood and what are 5 clinical features?

A

Henoch Schönlein purpura

  1. Purpuric rash over lower legs and buttocks
  2. Arthritis of ankles or knees
  3. Abdominal pain
  4. Haematuria
  5. Proteinuria
274
Q

In what group of children is SLE most likely to present?

A

adolescent females

275
Q

What are 4 possible features of childhood systemic lupus erythematosus?

A
  1. Malaise
  2. Arthralgia
  3. Malar rash - often photosensitive
  4. Organ involvement is a serious complication - kidneys, lung, CNS
276
Q

What are 8 key features of juvenile dermatomyositis?

A
  1. Insidious - malaise
  2. Progressive weakness (often difficulty climbing stairs)
  3. Facial rash with erythema over bridge of nose and malar areas
  4. Violaceous (heliotropic) discoloration of eyelids
  5. Skin over metacarpal and proximal IP joints may be hypertrophic and pink
  6. Nailfold capillaries may be dilated and tortuous
  7. Muscle pain
  8. Arthritis - 30%
277
Q

What is the biggest risk to children with juvenile dermatomyositis?

A

Respiratory failure and aspiration pneumonia if untreated due to muscle weakness - life-threatening

Paeds: Acute Presentation (14 decks)

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