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Paediatrics > Rheumatology + Orthopaedics > Flashcards

Rheumatology + Orthopaedics Flashcards

1
Q

What are differentials of joint pain / limp in toddler

A 
Transient synovitis - usually after viral, low grade fever 
JIA 
SA / OM - high grade fever + unwell 
Trauma / frature 
Growing pain 
Child abuse
DDH
Malignnacy - ALL / neuro / bone sarcoma 
Neuromuscular
Referred
Haemophilia 
HSP
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2
Q

What are differentials of joint pain in a child

A

Same as above
Rheumatic fever
Perthes

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3
Q

What are differentials of joint pain in adolescent

A

Same
Overuse
SUFE

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4
Q

What is important in the history of joint pain / limping child

A 
Age
Trauma - limp before or after 
Vital signs inc temperature 
Mode of onset - acute / insidious
Any previous episodes 
Any current illness
Location, pattern, duration
Swelling
Fever / systemic symptoms / rash / weight loss 
Any Travel
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5
Q

What are benign symptoms / growing pain signs

A 
Intermittent 
Never at start of day
Worse at end of day 
No limp
No limitation
Systemically well
Normal physical exam / strength
Normal motor milestone
Worse after exercise
Better with rest 
Bilateral 
Shins and ankles 
Night pain relived with simple analgesia
No swelling 
Normal height and growth
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6
Q

What are red flag symptoms

A 
Fever
Malaise / lethargy
Morning stiffness or pain
Night pain refractory to analgesia
Rest has no effect
Refractory analgesia 
Joint swelling
Tenderness
Muscle weakness
Fall in height
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7
Q

How do you investigate joint pain

A 
NEED TO RULE OUT SA 
Bloods - increased WBC, neutrophil, ESR, CRP
Blood film / bone marrow for malignnacy
Blood culture
Repeat X-Ray of any areas of tenderness 
SURGICAL REVIEW 
USS 
MRI -
Bone scan - OM
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8
Q

What will bloods show

A

Increased WCC, neutrophils, CRP if infection

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9
Q

What may USS show

A

Effusion

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10
Q

What will MRI show / when do you do

A

OM
Perthes
Malignancy

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11
Q

When do you do bone scan

A

OM

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12
Q

When do you do bone marrow / film

A

If suspect malignancy e.g. leukaemia which can present in bone

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13
Q

If child has sore knee but examination normal what should you do
What else do you look for in examination

A

Examine hip and ankle

Observe - gait / movement
PEWS
Erthema / swelling / rash / heat
Effusion?

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14
Q

Why

A

Obturator nerve supplies knee and hip so get referred pain

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15
Q

DDx

A 
DDH
SUFE
Perthes
Infection
JIA
Lymphoma
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16
Q

What causes septic arthritis

A

Staph

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17
Q

How does septic arthritis present

A 
Limp 
Swollen red joint
Limited ROM
Pain
Fever
Often has effusion 
Unable to examine
Not weight bearing
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18
Q

How do you Dx

A 
Bloods - FBC, CRP, ESR
Culture if fever 
USS - effusion
MRI
Joint aspiration if suspect
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19
Q

How do you treat

A 
Refer orthopaedics 
Low threshold 
IV Ax 
Urgent aspiration and wash out 
Arthroscopy
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20
Q

When is SA more likely than transient synovitis

A 
Kocher's criteria 
Temp >38.5 - TS has no fever 
Refusal to weight bear
Raised inflammatory- CRP 
Very high WCC
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21
Q

When does transient synovitis occur

A

Following viral infection

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22
Q

What is transient synovitis

A

Inflammation rather than infection of synovium of the hip

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23
Q

How does transient synovitis present

A

Limb / hobble
Manage to walk
Can be unwell from viral illness so can be difficult to different from SA

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24
Q

What is most common cause of acute hip pain

A

Transient synovitis

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25
Q

What age group

A

2-10

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26
Q

How do you Dx

A

USS - mild effusion
X-ray if suspect trauma
Normal or slightly raised inflammatory

Don’t need to go investigations if child is well
Review in 10 days if still unwell

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27
Q

How do you treat

A 
Rest
Analegisa
Safety net
Document you've considered
- SA / OM
- Malignancy of bone or blood
- Trauma / NAI
- Perthes
- SUFE
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28
Q

If child presents with limp in <3

A

Rare to have transient synovitis
Urgent hospital
High risk of SA or abuse

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29
Q

What causes OM

A

S.Aureus

Typically metaphysics

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30
Q

How does OM present

A 
Pain
Fever
Reduced ROM
Limp
More willing to move than SA
Less unwell than joint infection but more unwell than transient synovitis
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31
Q

What increases risk

A 
Blunt trauma
Recent infection
Open bone fracture
Recent surgery 
Immunocompromised
Sickle
HIV
TB
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32
Q

How do you Dx

A 
Bloods 
USS
X-ray 
MRI = best 
Biopsy
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33
Q

What bloods

A

CRP
CK
Culture
May need bone biopsy

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34
Q

How do you treat

A

Antibiotics
Responds quickly as good vascular supply to bone
Surgery

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35
Q

What surgery

A

Aspiration for culture
Drain abscess
Debridement

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36
Q

What cancer is common and where

A

Osteosarcoma
Femur = most
Tibia
Humerus

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37
Q

How does it present

A 
Bone pain 
Night pain
Incidental trauma
Swelling 
Palpable mass 
Unable to move
Sweating
Fatigue
Abnormal bloods
Pathological fracture
Mets
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38
Q

How do you Dx

A 
X-ray within 48 hours if unexplained bone pain or swelling 
Urgent specialist if X-ray suggestive 
Bloods 
- Anaemia
- Raised ALP
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39
Q

How do you treat

A

Surgical resection
Often need amputation
Adjuvant chemo

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40
Q

What is bone or joint pain at night

A

Infection or tumour until proven otherwise

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41
Q

What is SUFE

A

Fracture through physis resulting in slippage of end of femur (epiphysis) along growth plate
Posterior medial displacement of femoral epiphyses

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42
Q

What is chronic

A

> 3 weeks

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43
Q

What causes SUFE

A

Increased load

Weak physis

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44
Q

What are primary causes

A

Delayed bone age
Overweight
Adolescence
Trauma

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45
Q

What are secondary rare causes

A

Hypothyroid
Hypogonadism
Renal osteodystrophy
Growth hormone

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46
Q

How does SUFE present

A 
Pain in hip / groin / thigh
External rotation
Reduced internal 
Referred pain in knee 
Limp
Stiff hip 
ROM limited by pain in hip
Leg length discrepancy
Abnormal gait
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47
Q

What is normal in SUFE

A

Knee

No indicators of infection

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48
Q

Who is SUFE common in

A

M>F
Secondary school age
Trauma
Deformity

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49
Q

How do you Dx

A

X-ray

Do both sides as 20% bilateral

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50
Q

What does X-ray show

A 
Widened physis
Femoral head displaced
Mild <1/3 
Moderate 1/2
Severe >1/2
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51
Q

How do you treat

A

Refer ortho
Bed rest
Surgical pin to allow it to fuse if severe

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52
Q

What do you do if unstable

A

Fix

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53
Q

What do you do if stable

A

Fix in situ

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54
Q

How long do you leave pin in

A

Until physis stops growing

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55
Q

Does SUFE affect growth

A

No

Most growth from tibia / fibula

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56
Q

What are complications of SUFE

A

AVN - if unstable
Chondrolysis
Deformity
Early OA

57
Q

What are signs of DDH

A 
May pick up on baby check
Ortolani's
Barlow
Piston motion 
Leg length discrepancy
Discrepancy between skin creases
Limp
58
Q

What is ortolani

A

Hip pops in

59
Q

What is Barlow

A

Hip pops out

60
Q

Who is at risk of DDH

A 
F>M
First born
Oligohydrmnios
Breech
FH
Limb deformities
Heavy birth weight
61
Q

What hip is more affected

A

L

62
Q

How do you Dx

A

USS

63
Q

Why do you use USS

A

Can’t see bones on X-ay

64
Q

When do you do USS

A

If abnormal examination
Breech delivery
1st degree relative with hip issues early life
Within 6 weeks as most will resolve

65
Q

What do you look for

A

Shenton line

66
Q

How do you treat

A

Abduction brace

Surgery if hip completely out or older child

67
Q

What are the complications

A

Early onset arthritis
Reduced abduction
Limp
Painful knee / hip

68
Q

What is Perthes

A

Avascular necrosis leading to death at femoral head

69
Q

What is the disease process of Perthes

A 
Fragmentation
Revascularisation (painful) 
Reossification of bone
Residual deformity of femur head in hip
USUALLY PROGRESS OVER 2 YEARS
70
Q

How does it present

A 
Hip pain progress over weeks and resolves in years
Worse on activity 
Short stature
Chronic limb
Knee pain on exercise referred from hip 
Stiff hip
Hip pain
Systemically well / no sepsis
71
Q

What is most suggestive

A

M>F
Hyperacitivty
Short stature
Primary school age

72
Q

How do you Dx

A 
X-ray = flattened femoral head and joint widening 
BOTH SIDES AS 10% BILATERAL 
Whiter and sclerotic
Bloods = normal 
MRI = reduced perfusion
73
Q

How do you treat

A 
Maintain hip motion
Analgesia
Restrict activities 
No active treatment
Physio
Regular X-ray to assess healing
74
Q

What do you do <6 and >6

A 
<6 = observe
>6 = surgery / arthroplasty if non healing to improve alignment
75
Q

What are complications

A

OA if severe

Premature fusion of growth plates

76
Q

Unilateral hip pain

A

SA
JIA
SUFE
Lymphoma

77
Q

Bilateral

A

Hypothyroid
Sickle cell
Epiphyseal dysplasia

78
Q

What is used to classify growth plate fractures

A

SH

79
Q

SH1

A

Straight through physis

Can cause complete disruption

80
Q

SH2

A

Most common

Through physis then up metaphysysis

81
Q

SH3

A

Through middle of epiphysis and along metaphysis

82
Q

SH4

A

Through metaphysics, physis and epiphysis

83
Q

SH5

A

Physis crushed

84
Q

What suggests NAI

A 
Incongurent Hx
Patterend bruising
Burns
Multiple fracture
Metaphysyeal or humeral shaft / unusual place 
Delayed presentation
Delayed milestones 
Rib
Non-ambulant unless genetic / metabolic disease 
At risk register
85
Q

Who is at increased risk of fractures

A 
Boys
Age
Physeal injury
Previous
Metabolic bone disease
- Osteogenesis imperfecta
86
Q

What do adults need more than kids

A

Fixation

87
Q

What is most likely to cause deformity

A

SH5

88
Q

What are complications

A 
Compartment 
Non-union
Refracture
Nerve injury
Growth arrest
89
Q

What is Osgood Schlatter

A 
Painful tender tibial tuberosity due to inflammation at insertion 
Visible lump
Worse after exercise 
Unilateral
Gradual onset
Highly active adolescent
90
Q

How do you Rx

A 
Rest
Ice
NSAID 
Physio can be used
Rare complication = avulsion fracture requiring surgery
91
Q

What is patellar subluxation

A

Medial knee pain due to lateral subluxation of patella

92
Q

What os osteochondirits Dissecan

A

Pain after exercise

Intermittent swelling and locking

93
Q

What is chondromalacia patellae

A

Softening of cartilage
Common in teenage girls
Causes anterior knee pain walking up and down stairs

94
Q

How do you Rx

A

Physio

95
Q

What is club foot

A

Foot is plantar flexed

Midtarsal adduction

96
Q

What is club foot associated with

A

Spina bifida

97
Q

How do you treat

A

Cast

Achilles lengthening

98
Q

What causes Ricketts

A

Vit D deficiency

Same as osteomalacia in adults

99
Q

How does it present

A

Bone pain
FTT
Bowed legs
Thickened joints

100
Q

How do you treat

A

Vit D supplements

Annual injections

101
Q

What do you have a high degree of suspicion of in limping child

A

Hip issue

102
Q

What type of growth plate fractures usually require surgery

A

3,4,5

103
Q

What fracture affects growth

A

SH 5

104
Q

What should you assume if growth plate tenderness

A

Fracture even if normal X-ray

105
Q

What is a complete fracture

A

Both sides of cortex affected

106
Q

What is a toddler fracture

A

Oblique fracture of tibia in infants

107
Q

What is plastic deformity

A

Stress on bone causing deformity with no fracture

108
Q

What is a green stick fracture

A

Unilateral cortical breach only

Fracture in young soft bone

109
Q

What is a buckle fracture

A

Incomplete cortical disruption causing periosteum haematoma but no break

Usually distal radius

110
Q

What can cause pathological fracture

A

Osteogenesis imperfecta
Osteopetrosis
Malignancy

111
Q

What does any limping child require

A

Further investigation

SA until proven otherwise

112
Q

What must you rule out

A 
Septic arthritis first
then 
Perthes
SUFE
Inflammatory arthritis 
OM
113
Q

What can yo do once you’ve done this

A

Transient synovitis

114
Q

What are 4 signs that if 3+ present suggests SA

A

Temp >38.5
WBC>12
CRP >20
Non weight bearing

115
Q

What do you do if suspect SA

A

Urgent blood culture

USS guieded aspiration

116
Q

Growing pain RED FLAG

A

If lump. / unwell infection or examination = not normal refer as malignancy / SA

117
Q

Who is radial buckle common in and what causes

A

Children

Fall on outstretch hand

118
Q

How do you Dx

A

Examination normal apart from tender

X-ray show bulge in cortex

119
Q

How do you Rx if uni or bicortical

A

Analgesia
Elevation
Split 3 weeks if unicortical
Cast if bicortical

120
Q

What should you always do with fracture

A

Examinae for neuromuscular compromise

121
Q

How do you manage fracture

A 
Mechanical aligment
- Closed reduction via manipulation
- Open via surgery
Fix bone to keep in position whilst heals 
- Cast
- K wire
- Intramedullary nail
- Plates and screw
122
Q

Pain management in children

A

1st line = paracetamol and Ibuprofen

2nd line = morphine

123
Q

Why is codeine / tramadol not used

A

Can’t predict metabolism

124
Q

When can you use X-ray in a child

A

> 4.5 months

125
Q

What is positional talipes

A

Valgus or varus deformity of foot

126
Q

How do you Rx

A

Physio

127
Q

What is fixed talipes

A

Vigorous malformation

128
Q

What is required

A

Strap / cast

Surgery

129
Q

What are normal variants in children

A 
Metartarus adductus
Out-toeing
Posterior tibial bowing - Bow legs 
Curly toes
Knock knes
Flat feet
130
Q

When is flat feet pathological

A

If no arch reforms on tip toes

131
Q

What is metatarsus adducts

A

Persistent femoral anterversion

Cause intoeing / front half of foot to turn in

132
Q

What causes out toeing

A

External tibial torsion
Usually resolves by 2
May be panful

133
Q

What is another cause of metatarsus adducts

A

Cerebral palsy but rare

134
Q

What is Posterior tibial bowing

A

Bow legs
Most resolve
Can be a symptom of underlying disease - Rickets / Blounts

135
Q

What are other common UL injuries in children

A

Pulled elbow
Buckle (distal radius) fracture
Shaft radial or ulnar fracture
Supracondylar fracture

136
Q

How do supracondylar fractures present

A

Fracture of distal humerus just above elbow
Very sore
See fat pad on X-ray even if no bone abnormality = definite break

137
Q

What class-action

A

Gartland

138
Q

What must you do in UL injury

A

Assess neurovascular

- Median, radial and ulnar nerve

Paediatrics (35 decks)

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