Rheum And Ortho Flashcards
Which fractures are common in neonates? Causes?
Clavicle
▪ From shoulder dystocia
▪ “snap” heard at delivery or
infant may show decreased arm movement on affected side or lump from callus formation may be noticed
▪ Great prognosis, no specific treatment needed
Humerus or femur
▪ Usually mid shaft, with breech delivery
▪ Deformity, decreased movemen and pain
▪ Heal rapidly with immobilisation
How are non-complex fractures managed?
Pain management
o If older than 16y – offer paracetamol ± codeine ± IV morphine
o If younger than 16y – oral ibuprofen or paracetamol (IV or intranasal opioids if severe)
- X-ray – review by radiologist
- Consider IV local anaesthetic – then REDUCE fracture before:
• Can use elbow plaster cast or k-wire fixation for radial fractures
• For femoral shaft fractures
o Neonates – padded splints or Pavlik’s harness - to immobilise fracture
o <18 months – Bryant Gallows traction
o 1-6 years – straight leg skin traction
o >4 years – intramedullary nail (+ more support if >11y)
What are the types of traction? How long they stay on for?
Skeletal - metal etc screwed into bone
Skin - bandages casts etc on external surface
Cervical
Length - depends : 1 week per year of life.
What is Perthe’s disease and it’s epidemiology? Presentation?
• Avascular necrosis of capital femoral epiphysis of femoral head – due to interruption of blood supply
very little understanding about WHY it happens
- Followed by revascularisation and re- ossification over 18-36 months
- Mainly boys 5-10y
Presentation:
Insidious presentation but each time it comes on its sudden
Limp
Hip/knee pain ; Pain on hip abduction and medial rotation
On and off for months
No associated trauma. Better with rest, worse with exercise
Perthes - Primary school kids - Pain in hip
What is the ivx for perthe disease?
• X-ray of hip shows Increased density in femoral head, subsequently becomes fragmented and irregular
• Roll test
o Patient in supine position, roll hip of affected extremity into external and internal rotation – guarding or spasm especially with internal rotation
Pain on hip abduction and medial rotation
What is the mx of Perthe’s disease?
If less than half of femoral is affected BUT hip pain and reduced motion or poorly positioned femur head:
- may be admitted for bed rest and traction and physiotherapy + analgesia
Traction helps to reduce pain by resting the hip joint.
It is applied using bandages and light weights. until resolution of pain then discharged into regular outpatient check ups (xrays every 3-4months).
May be dsicharged with crutches.
More severe disease - Surgery
o Intervention to cover femoral head with acetabulum to act as mould for re-ossifying epiphysis (with plaster cast or callipers or osteotomy)
“ operation to reshape head of femur”
there are diff surgical options depending on abnormality.
What is OSGOOD-SCHLATTER DISEASE?
- Osteochondritis of patellar tendon insertion at the knee
- May be caused by multiple small avulsion fractures from contractions of quadriceps muscle at their insertion into proximal TIBIAL TUBEROSITY/ apophysis (ossification centre) – during growth spurt
or simply caused by inflammation of TIBIAL TUBEROSITY
How does OSGOOD-SCHLATTER DISEASE present?
- Often affects adolescent males, who are physically active (football, basketball) with strong quads
- Presents as knee pain after exercise, gradual onset
- Pain relieved by rest, made worse by running or jumping
- Localised tenderness, swelling over tibial tuberosity
• Often hamstring tightness
• 25-50% bilateral
• Rule out hip problems leading to referred pian
to knee
How do we manage OSGOOD-SCHLATTER DISEASE ?
• Often resolves with decreasing activity, icing and physiotherapy (stretching hamstrings + orthotics + knee immobiliser splint)
- Analgesia for pain relief
- Usually self-limiting but may not fully resolve until end of growth spurt
What are the most common sites of infection in OSTEOMYELITIS IN A CHILD?
- Infection of metaphysis of long bones
- Commonly distal femur, proximal tibia
• Either due to haematogenous spread or direct spread from infected wound – majority is Staph Aureus
How does childhood osteomyelitis present?
- Acute onset limb pain
- Markedly painful and immobile limb
- acute febrile illness (they could be afebrile)
past history skin graze/cut
- Skin is swollen and tender over site
- ± erythematous and warm
• May present as back pain, limp, decreased mobility
How do we ivx childhood osteomyelitis?
- Bloods: ↑ WCC ↑ CRP/ESR
- Blood cultures
Also blood urate, clotting, and autoimmunology to rule out gout, haemarthroses, RhA etc
Imaging:
• 1st line - Xray:
may be normal apart from soft tissue
swelling <7 days → later shows osteopenia, bone destruction, ± sequestra
• 2nd line (if nothing seen on xray) - MRI:
MRI imaging is modality of choice - highly sensitive even in early days
The following: You can do, but can treat based on +ve results from imaging:
- Can aspirate deep fluid collections, and send for culture
- Can do bone samples & biopsy - shows infectious organism / if its a tumour vs other stuff.
• not on guideline but: US may show periosteal elevation
How is childhood osteomyelitis managed?
• Urgent referral for assessment if fever, unable to weight bear, painful or restricted movement
Initially Empirical abx (Cefuroxime – benzyl pen if >5) until MCS results arrive then:
- Parental ABX for 6 weeks to prevent bone necrosis
- Fluclox ± rifampicin (clindamycin if pen allergic and vanco if MRSA)
• IV first until clinical recover and ↓ CRP/ESR, then ORAL
• Rest limb in a splint - immobilisation then mobilise
SUpportive - painkillers
SURGERY:
-> if the limb deteriorates or imaging suggests progressive bone destruction
What is the aetiology and presentation of SEPTIC ARTHRITIS ?
Risk factors?
mus know very well
Rheumatological emergency!!
Causative organisms:
• Commonly Staph aureus, or Hib before vaccine
• Infectious arthritis of the synovial JOINT
• Most common in children <2y
• Usually due to haematogenous spread, may
occur following puncture around or infected skin lesions
• Can spread from adjacent osteomyelitis (15% coexist) – leads to bone destruction
Risk factors:
- Osteomyelitis - infection of long bone which CAN then spreads to joint
- Diabetes + Immnunocompromise
- Sickle cell anaemia
Clinically •Sudden onset, acute pain in joint • Usually one joint, commonly hip • Looks very unwell, Very high fever • Erythematous, warm, acutely tender joint - Pain at rest AND movement
• Reduced range of movement
- child holds hip: Flexed, Abducted & Externally rotated!!
• Infants will hold limb still AND resist movement of hip (pseudoparalysis). cry if moved
How do we ivx and manage SEPTIC ARTHRITIS ?
First line ivx:
1a. US guided aspirate of the joint effusion + culture - Gold Std
1b. Blood cultures
take any necessary swabs or samples for biological processing -> START empirical abx
• ↑WCC, ↑ CRP/ESR
• XR may be normal, but use to exclude other
causes - ↑ joint space and soft tissue swelling
• ± MRI / bone scan
Management
• Urgent referral for assessment if child is <3y, limp, fever, unable to weight bear
1. Accessible joint - aspirate rest of fluid and long course antibiotics
o Inaccessible joint -> orthopaedics
- Empirical antibiotics before blood cultures arrive then:
- Targeted prolonged course of ABX
o initially IV Fluclox for 2 weeks, followed by 4 weeks of oral antibiotics
o clindamycin if pen allergic,
o vanc if MRSA, cefotaxime if Gneg - ± washing out of joint or surgical drainage
If systemic involvement/ signs of sepsis - sepsis 6 protocol !!
What is the presentation aetiology and Mx of REACTIVE ARTHRITIS?
• Most common arthritis of childhood
Clinically
Asymmetrical oligoarthritis. However, polyarticular and monoarticular arthritis can occur.
Peripheral arthritis:
painful, swollen, warm, red, and stiff joints, especially in the morning.
Swelling of entire digits (fingers or toes), termed dactylitis,
chronic ReA when joint symptoms have been present for more than 6 months
Axial arthritis:
non-specific low back pain and/or buttock pain and stiffness, especially during times of inactivity. relieved by exercise
• Transient joint swelling for <6 weeks, often ankles or knees
• Follows evidence of extra-articular infection
• Enteric bacteria – salmonella, shigella, campylobacter,
most common in children
• Can also be viral infections, STI, mycoplasma, lyme disease, rheumatic fever
Arthritis after STI or gastroenteritis
IX : low grade fever + normal X-ray (early stages of disease/ not chronic)
Management – no treatment, just NSAIDS, usually make a complete recovery.
2nd Line - steroids
Persistent/chronic - DMARD - methotrexate
Which classical triad is frequently described but found only in a minority of cases of REACTIVE ARTHRITIS and is not required for diagnosis?
post-infectious arthritis, non-gonococcal urethritis, and conjunctivitis
REACTIVE ARTHRITIS has which genetic associations?
HLA-B27 genotype - may be positive or negative as low sensitivity
To rule out otherr causes of arthritis:
RHeumatoid factor - negative
ANA - negative
