Rheumatology + Orthopaedics Flashcards
What are differentials of joint pain / limp in toddler
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
What are differentials of joint pain in a child
Same as above
Rheumatic fever
Perthes
What are differentials of joint pain in adolescent
Same
Overuse
SUFE
What is important in the history of joint pain / limping child
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
What are benign symptoms / growing pain signs
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
What are red flag symptoms
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
How do you investigate joint pain
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
What will bloods show
Increased WCC, neutrophils, CRP if infection
What may USS show
Effusion
What will MRI show / when do you do
OM
Perthes
Malignancy
When do you do bone scan
OM
When do you do bone marrow / film
If suspect malignancy e.g. leukaemia which can present in bone
If child has sore knee but examination normal what should you do
What else do you look for in examination
Examine hip and ankle
Observe - gait / movement
PEWS
Erthema / swelling / rash / heat
Effusion?
Why
Obturator nerve supplies knee and hip so get referred pain
DDx
DDH SUFE Perthes Infection JIA Lymphoma
What causes septic arthritis
Staph
How does septic arthritis present
Limp Swollen red joint Limited ROM Pain Fever Often has effusion Unable to examine Not weight bearing
How do you Dx
Bloods - FBC, CRP, ESR Culture if fever USS - effusion MRI Joint aspiration if suspect
How do you treat
Refer orthopaedics Low threshold IV Ax Urgent aspiration and wash out Arthroscopy
When is SA more likely than transient synovitis
Kocher's criteria Temp >38.5 - TS has no fever Refusal to weight bear Raised inflammatory- CRP Very high WCC
When does transient synovitis occur
Following viral infection
What is transient synovitis
Inflammation rather than infection of synovium of the hip
How does transient synovitis present
Limb / hobble
Manage to walk
Can be unwell from viral illness so can be difficult to different from SA
What is most common cause of acute hip pain
Transient synovitis
What age group
2-10
How do you Dx
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
How do you treat
Rest Analegisa Safety net Document you've considered - SA / OM - Malignancy of bone or blood - Trauma / NAI - Perthes - SUFE
If child presents with limp in <3
Rare to have transient synovitis
Urgent hospital
High risk of SA or abuse
What causes OM
S.Aureus
Typically metaphysics
How does OM present
Pain Fever Reduced ROM Limp More willing to move than SA Less unwell than joint infection but more unwell than transient synovitis
What increases risk
Blunt trauma Recent infection Open bone fracture Recent surgery Immunocompromised Sickle HIV TB
How do you Dx
Bloods USS X-ray MRI = best Biopsy
What bloods
CRP
CK
Culture
May need bone biopsy
How do you treat
Antibiotics
Responds quickly as good vascular supply to bone
Surgery
What surgery
Aspiration for culture
Drain abscess
Debridement
What cancer is common and where
Osteosarcoma
Femur = most
Tibia
Humerus
How does it present
Bone pain Night pain Incidental trauma Swelling Palpable mass Unable to move Sweating Fatigue Abnormal bloods Pathological fracture Mets
How do you Dx
X-ray within 48 hours if unexplained bone pain or swelling Urgent specialist if X-ray suggestive Bloods - Anaemia - Raised ALP
How do you treat
Surgical resection
Often need amputation
Adjuvant chemo
What is bone or joint pain at night
Infection or tumour until proven otherwise
What is SUFE
Fracture through physis resulting in slippage of end of femur (epiphysis) along growth plate
Posterior medial displacement of femoral epiphyses
What is chronic
> 3 weeks
What causes SUFE
Increased load
Weak physis
What are primary causes
Delayed bone age
Overweight
Adolescence
Trauma
What are secondary rare causes
Hypothyroid
Hypogonadism
Renal osteodystrophy
Growth hormone
How does SUFE present
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
What is normal in SUFE
Knee
No indicators of infection
Who is SUFE common in
M>F
Secondary school age
Trauma
Deformity
How do you Dx
X-ray
Do both sides as 20% bilateral
What does X-ray show
Widened physis Femoral head displaced Mild <1/3 Moderate 1/2 Severe >1/2
How do you treat
Refer ortho
Bed rest
Surgical pin to allow it to fuse if severe
What do you do if unstable
Fix
What do you do if stable
Fix in situ
How long do you leave pin in
Until physis stops growing
Does SUFE affect growth
No
Most growth from tibia / fibula
What are complications of SUFE
AVN - if unstable
Chondrolysis
Deformity
Early OA
What are signs of DDH
May pick up on baby check Ortolani's Barlow Piston motion Leg length discrepancy Discrepancy between skin creases Limp
What is ortolani
Hip pops in
What is Barlow
Hip pops out
Who is at risk of DDH
F>M First born Oligohydrmnios Breech FH Limb deformities Heavy birth weight
What hip is more affected
L
How do you Dx
USS
Why do you use USS
Can’t see bones on X-ay
When do you do USS
If abnormal examination
Breech delivery
1st degree relative with hip issues early life
Within 6 weeks as most will resolve
What do you look for
Shenton line
How do you treat
Abduction brace
Surgery if hip completely out or older child
What are the complications
Early onset arthritis
Reduced abduction
Limp
Painful knee / hip
What is Perthes
Avascular necrosis leading to death at femoral head
What is the disease process of Perthes
Fragmentation Revascularisation (painful) Reossification of bone Residual deformity of femur head in hip USUALLY PROGRESS OVER 2 YEARS
How does it present
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
What is most suggestive
M>F
Hyperacitivty
Short stature
Primary school age
How do you Dx
X-ray = flattened femoral head and joint widening BOTH SIDES AS 10% BILATERAL Whiter and sclerotic Bloods = normal MRI = reduced perfusion
How do you treat
Maintain hip motion Analgesia Restrict activities No active treatment Physio Regular X-ray to assess healing
What do you do <6 and >6
<6 = observe >6 = surgery / arthroplasty if non healing to improve alignment
What are complications
OA if severe
Premature fusion of growth plates
Unilateral hip pain
SA
JIA
SUFE
Lymphoma
Bilateral
Hypothyroid
Sickle cell
Epiphyseal dysplasia
What is used to classify growth plate fractures
SH
SH1
Straight through physis
Can cause complete disruption
SH2
Most common
Through physis then up metaphysysis
SH3
Through middle of epiphysis and along metaphysis
SH4
Through metaphysics, physis and epiphysis
SH5
Physis crushed
What suggests NAI
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
Who is at increased risk of fractures
Boys Age Physeal injury Previous Metabolic bone disease - Osteogenesis imperfecta
What do adults need more than kids
Fixation
What is most likely to cause deformity
SH5
What are complications
Compartment Non-union Refracture Nerve injury Growth arrest
What is Osgood Schlatter
Painful tender tibial tuberosity due to inflammation at insertion Visible lump Worse after exercise Unilateral Gradual onset Highly active adolescent
How do you Rx
Rest Ice NSAID Physio can be used Rare complication = avulsion fracture requiring surgery
What is patellar subluxation
Medial knee pain due to lateral subluxation of patella
What os osteochondirits Dissecan
Pain after exercise
Intermittent swelling and locking
What is chondromalacia patellae
Softening of cartilage
Common in teenage girls
Causes anterior knee pain walking up and down stairs
How do you Rx
Physio
What is club foot
Foot is plantar flexed
Midtarsal adduction
What is club foot associated with
Spina bifida
How do you treat
Cast
Achilles lengthening
What causes Ricketts
Vit D deficiency
Same as osteomalacia in adults
How does it present
Bone pain
FTT
Bowed legs
Thickened joints
How do you treat
Vit D supplements
Annual injections
What do you have a high degree of suspicion of in limping child
Hip issue
What type of growth plate fractures usually require surgery
3,4,5
What fracture affects growth
SH 5
What should you assume if growth plate tenderness
Fracture even if normal X-ray
What is a complete fracture
Both sides of cortex affected
What is a toddler fracture
Oblique fracture of tibia in infants
What is plastic deformity
Stress on bone causing deformity with no fracture
What is a green stick fracture
Unilateral cortical breach only
Fracture in young soft bone
What is a buckle fracture
Incomplete cortical disruption causing periosteum haematoma but no break
Usually distal radius
What can cause pathological fracture
Osteogenesis imperfecta
Osteopetrosis
Malignancy
What does any limping child require
Further investigation
SA until proven otherwise
What must you rule out
Septic arthritis first then Perthes SUFE Inflammatory arthritis OM
What can yo do once you’ve done this
Transient synovitis
What are 4 signs that if 3+ present suggests SA
Temp >38.5
WBC>12
CRP >20
Non weight bearing
What do you do if suspect SA
Urgent blood culture
USS guieded aspiration
Growing pain RED FLAG
If lump. / unwell infection or examination = not normal refer as malignancy / SA
Who is radial buckle common in and what causes
Children
Fall on outstretch hand
How do you Dx
Examination normal apart from tender
X-ray show bulge in cortex
How do you Rx if uni or bicortical
Analgesia
Elevation
Split 3 weeks if unicortical
Cast if bicortical
What should you always do with fracture
Examinae for neuromuscular compromise
How do you manage fracture
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
Pain management in children
1st line = paracetamol and Ibuprofen
2nd line = morphine
Why is codeine / tramadol not used
Can’t predict metabolism
When can you use X-ray in a child
> 4.5 months
What is positional talipes
Valgus or varus deformity of foot
How do you Rx
Physio
What is fixed talipes
Vigorous malformation
What is required
Strap / cast
Surgery
What are normal variants in children
Metartarus adductus Out-toeing Posterior tibial bowing - Bow legs Curly toes Knock knes Flat feet
When is flat feet pathological
If no arch reforms on tip toes
What is metatarsus adducts
Persistent femoral anterversion
Cause intoeing / front half of foot to turn in
What causes out toeing
External tibial torsion
Usually resolves by 2
May be panful
What is another cause of metatarsus adducts
Cerebral palsy but rare
What is Posterior tibial bowing
Bow legs
Most resolve
Can be a symptom of underlying disease - Rickets / Blounts
What are other common UL injuries in children
Pulled elbow
Buckle (distal radius) fracture
Shaft radial or ulnar fracture
Supracondylar fracture
How do supracondylar fractures present
Fracture of distal humerus just above elbow
Very sore
See fat pad on X-ray even if no bone abnormality = definite break
What class-action
Gartland
What must you do in UL injury
Assess neurovascular
- Median, radial and ulnar nerve
