Rheum Flashcards
Paucitarticular JIA
MC!!!!!
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4 or less joints
ANA +
RF -
Young females
Uveitis- slit lamp
No other systemic
~~~
Poly arthritis JIA
5+ joints
+ RF= RARE= SEVERE
+ ANA = MILDER- younger
Systemic onset stills disease
Recurrent high fever
HSM
salmon macular rash
- ANA
- RF
Tx JIA
NSAIDS= #1
STEROIDS
IMMUNOSUPPRESSIVE
Definition JIA
Autoimmune arthritis with morning stiffness
Gradual LOM
for at least 6 weeks
Bow legs genu varum associated with
Rickets
OI
Blount disease
Age genu varus
1-3 years
XR genu varum
Beaking of medial tibial epiphysis
Blount disease
SEVERE GENU VARUM
(Tibia vara)
UNILATERAL
BLACKS
Knock knees genu valgum associated with
JIA
Age genu valgum
2-7 years old
Tx genu valgum
Resolves spon
Pes planus associated with
Hyper mobility
Congenital tarsal fusion
When is flat feet normal and why?
Toddlers
Since fat pad covering the medial longitudinal arch
AGE of pets planus
1-2 years old
Tx of pets planus
arch support and footwear
AGE of in toeing
1-2 years old
in toeing associated with
- metatarsus varus
- medial tibial torsion
- persistent anteversion femoral neck
Metatarsus varus
Adduction highly mobile forefoot
age of metatarsus varus
infants;
tx metatarsus varus
since heel held in normal position…
- passively correctable
- no treatment unless > 5 yo and symptomatic
medial tibial torsion
tibia laterally rotated LESS than normal wrt femur
AGE medial tibial torsion
TODDLERS
Medial tibial torsion associated with
bowing of the tibia
Tx of medial tibial torsion
self corrected within 5 years
Persistent anteversion femoral neck
at hip when femoral neck twisted forward MORE than normal
AGE of persistent ante version of femoral neck
childhood
persistent anteversion femoral neck a/w
hypermobile joints
tx persistent anteversion femoral neck
self corrects by 8 years old
W sitting
persistent ante version of femoral neck
OUT-toeing age
6-12 months
OUT-toeing a/w
- ED
- Marfans
- hypermobile joints
AGE toe walking
1-3 years
toe walking a/w
- spastic diplegia
- muscular dystrophy
- JIA
EXCLUDE toe walking
- mild CP
- tight achilles
- arthritis of foot and ankle
- OLDER— DUCHENNES
VARIATION of NORMAL POSTURE PC: 6-12 months
out toeing
VARIATION of nORMAL POSTURE PC: 1-2 yo
pes planus
in-toeing
VARIATION of NORMAL POSTURE PC: 1-3 yo
bow legs genu varum
toe walking
VARIATION OF NORMAL POSTURE PC: 2-7 yo
knock knees
TALIPES EQUINOVARUS=
club foot
types of talipes equinovarus
positional talipes
talipes equinovarus
talipes equinovarus a/w
BOYS (2:1)
olgiohydramnios, spina bifida
DDH
tx talipes equinovarus
PONSETTI METHOD– plaster casting and brace
…… if unsuccessful= sx
ROCKER BOTTOM FEET=
VERTICAL TALUS
Talipes calcaneovalgus
dorsiflexes and everted
Talipes equinovarus
- think calf
- short foot
- heel plantarflexed
- supination
- inversion
Talipes calcaneovalgus associated with
DDH
what two abnormal postures are a/w DDH
talipes calcaneovalgus
talipes equinovarus
FLAT FEET= PATHO– OLDER KIDS…. A/W
TJT
- tendon achilles contraction
- JIA
- tarsal coalition
Tarsal coalition
symptomatic once ossifies– PRE-ADOLESCENT
PES CAVUS A/W
- friederich’s ataxia
- peroneal muscular atrophy (type 1 hereditary motor sensory neuropathy)
which leg more common for DDH
LEFT
Risk factors for DDH
7
- breech
- oligohydramnios
- females 4:1
- first born
- race [chinese protected]
- fam hx
- a/w: NTD/NM/foot deformities: talipes calcaneovalgus, and talipes equinovarus
PC DDH > 8 weeks
Limited AB
Limp
Length leg discrepancy
Asymmetric leg folds
Tx DDH
newborn- pavlik- 6 weeks 6weeks-pavlik- 8 weeks 4 months- spica cast 18 months- triple acetabular osteotomy teen- Ganz procedure= periacetabular osteotomy
Ganz procedure
periacetabular osteotomy
Scoliosis mild
painfree
Scoliosis severe
cardioresp compromise
Causes of scoliosis
- Idiopathic
-
Tx– surgery for scoliosis when…
neuromuscular disorder
respiratory disease
MCC TORTICOLLIS
SCM TUMOR= congenital muscular torticollis
PC congenital muscular torticollis
first few weeks of life, resolves spontaneously by 2-6 months
LATER CHILDHOOD CAUSES TORTICOLLIS
- muscular spasm
- ENT infection spread
- C- spine arthritis/ deformity
- Spinal tumor= osteoid osteoma
- Posterior fossa tumor
Nocturnal idiopathic pain=
GROWING PAINS
PC GROWING PAINS
- at night
- 3-12yo
- LL pain, symmetric [may be other]
NO- pain with walking/ activity
NO- limp
WELL OTHERWISE :)
MSK pain (generalised or local) WORSE after exercise
hypermobility
AGE hypermobility
older kids/ adolescents
Hyper mobility foot deformities
- pes planus
- anteversion femoral neck
- out-toeing
Hyper mobility associated pathology
Downs
ED
Marfans
Idiopathic pain syndrome=
CRPS:
congenital reigonal pain syndrome
Age of CRPS
adolescent females
Local CRPS
foot and ankle hyperesthesia allodynia cool to touch distract--> normal
Diffuse CRPS
SEVERE PAIN
night disturbance–day time fatigue
MCC ACUTE LIMB PAIN
TRAUMA!
Causes of OM
- S.aureus
- Strep pneumo (multi)
- Haemophilus (multi)
- Salmonella– SICKLE CELL
- TB
INSIDIOUS PC OM INFANT
decrease limb movement or swelling (harder to appreciate)
Dx OM:
- blood cultures
- increase ESR/CRP
- imaging:
XR: normal at first, soft tissue swelling
US: periosteal elevation
MRI: subperiosteal pus and debris
RAI/Bone scan
Tx OM:
- IV antibiotics
- aspiration
- Sx decompression of subperiosteal space
- Sx drainage
Malignancies presenting with acute limb pain
- ALL
- Neuroblastoma
- Bone tumors
- osteosarcoma
- ewing’s sarcoma
- osteoid osteoma
PC ALL
- night pain
- arthritis
PC Neuroblastoma
INFANT
- bone mets
- septic arthritis
PC Osteoid osteoma
NIGHT pain– resolves with NSAID’s
- joint swelling
- joint tenderness
- joint effusions
- scoliosis – SPINE INVOLVED
Dx osteoid osteooma
XR: radiolucent core, sclerotic rim
Ddx acute limb pain
- TRAUMA
- OM
- Malignancy
Ddx knee pain
- osgood schlatter
- chondromalacia patellae
- Subluxation and dislocation patella
- osteochondritis dissecans
- injuries
PC: male adolescent active, with knee pain after exercise
Osgood schlatter
Defn osgood
osteochondritis of the patella tendon as inserts into the tibia
Knee pain adolescent male
osgood
knee pain adolescent female
osteonchondromalacia patellae
PC osgood
knee pain AFTER exercise
+ hamstring tightness
+ local tenderness
_ SWELLING over tibial tuberosity
Tx osgood
- decrease activity
- physio- quads
- hamstring stretching
- orthotics
- knee immobiliser
Defn chondromalacia patellae
softening of the cartilage of patella
PC: female adolescent, pain with sitting–>standing, and going up the stairs
Chondromalacia patellae PC
chondromalacia patellae a/w
- hypermobility
- flat feet
PC: subluxation patella
instability, giving way
PC: dislocation patella
SUDDEN SEVERE PAIN,
LATERAL DISLOCATION
Tx: patella
quads exercises
sx– realign pull of quads on patellar tendon
Osteochondritis dissecans defn
= segmental AVN subchondral bone
—–> thus get separation of bone and cartilage from medial epicondyle
PC: active adolescent with persistent knee pain
osteochondritis dissecans PC
[can also get loose bodies: thus locking and giving way]
younger kids: bone or ligaments stronger?
ligaments stronger– thus fracture more often
RED FLAG SIGNS BACK PAIN
- weight loss/malaise
- night pain
- fever
- scoliosis
- neuro symptoms
- YOUNGER
Ddx back pain
- mechanical
- tumors
- vertebral OM or discitis
- spinal cord/ nerve entrapment
- scheuermann disease
- spondylosis/ spondylosthisesis
Scheuermann disease
= osteochondrosis of vertebral body
PC: fixed thoracic KYPHOSIS– +/- pain
often asymptomatic
Spondylosis/ spondylosthesis
stress fracture of pars interarticularis of vertebra
increased risk
- gymnastics
- cricket bowlers
Transient synovitis
ACUTE pain, non wt bearing no/mild fever normal child comfy at rest; mov't--> limited IR, and pain WCC= normal ESR= normal/ ^ US: fluid in joint XR= normal mgmt: - rest - analgesia
lasts perthes
MCC acute hip pain kids 2-12 years old
transient synovitis; post viral or a/w viral
Septic arthritis
ACUTE pain, non weight bearing fever sick looking child pain at rest; mov't--> SEVERE pain; d: FABER WCC= ^^^/normal ESR= ^^^^ US: fluid in joint XR: normal----> WIDE joint space
mgmt:
- joint aspirate with US
- prolonged antibiotics
- rest
- analgesia
- wash out
- immobliize
AGE OM
CAUSES OF OM:
- S.aureus (1 joint)
2. H influ (1+ joints)
5-10 year old with hip/knee pain and limp
PERTHES DISEASE
Tx perthes
- bed rest and analgesia
- maintain AB
- plasters
- calipers
- femoral or pelvic osteotomy
Direction of displacement SUFE
posteroinferior
PC SUFE
10-15yo
OBESE
HYPOgonadism
HYPOthyroidism
+ LIMP OR HIP PAIN–> KNEE
- acute post minor trauma
- chronic
RESTRICTIONS IN SUFE
AB
IR
Tx SUFE
pin fixation in situ
CAUSES OF REACTIVE ARTHRITIS….post extra-articular infection
- enteric bacteria: salmonella/ camp/ shigella/ yersinia
- viral
- STI’s
- mycoplasma
- borrelia burdorferi
+ rheumatic fever
+ post-strep RA
Tx reactive arthritis
NONE,
NSAID’s
PC HSP:
palpable purpura butt and legs arthritis: knees and ankles abdo pain haematuria proteinuria
MCC VASCULITIS KIDS
HOW OFTEN DO SLE AND DERMATOMYOSITIS OCCUR IN KIDS?
RARE!!!!!!!!!!!!
death in juvenile dermatomyositis
resp F
asp pneumonia
still birth
large head
very short limbs
small chest
Than-ato-phoric dysplasia
XR: DX
Antenatal US
ABSENCE of all or part of clavicles
DELAYED closure fontanelles/ ossification of skull
can bring shoulders in front of chest to touch
Cleido-cranial dys-os-to-sis
Arthro-gry-posis
STIFFNESS and CONTRACTORS of joints
Arthro-gry-posis a/w
- oligohydramnios
- widespread congenital anomalies
- chromosomal disorders
skin= thin, decrease sc, muscle atrophy around joints
Tx arthrogryposis
- physio
2. correct deformities: splints/plaster/ sx
