SUFE, Osgood-Schlatter, DDH, JIA

Question 1

What is SUFE? Ex and RF?

Answer 1

• Slipped upper femoral epiphyses, most common at 10-15yrs during adolescent growth spurt.
• Most common disorder affecting adolescent hips.
• Some times bilateral.
• Posteroinferior slip of the epiphysis of the femoral head.
• Prompt treatment required to prevent avascular necrosis.

Question 2

Presentation of SUFE? Ddx?

Answer 2

1) Onset may be acute (due to minor trauma) or insidious.
2) Limb or hip pain may be referred to the knee
3) Restricted abduction and internal rotation of the hip

Ddx: Perthe’s disease, osteomyelitis.

Question 3

Diagnosis of SUFE? and Treatment?

Answer 3

1) X-Ray - DIAGNOSTIC (frog lateral view)

Tx:

• Surgical percutaneous pinning in situ.
• Fixation of contralateral hip if initial slip at young age (<10), obese males, endocrine disorders (hypothyroidism).

Question 4

Osgood-Schlatter’s disease Ex and Sx?

Answer 4

• Osteochondritis of the patellar tendon insertion - typically affects adolescent males who are physically active (basketball/football).

Sx:

1) Knee pain and localised tenderness after exercise.
2) Sometimes swelling over the tibial tuberosity
3) Hamstring tightness
4) Can be bilateral

Question 5

Osgood-Schlatter’s disease Dx and Tx?

Answer 5

Dx: Clinical

Tx: Most self-resolve with reduced activity and physiotherapy.
Ultimate resolution occurs when patients reach skeletal maturity.

Question 6

What is developmental dysplasia of the hip?

Answer 6

• Spectrum of disorders ranging from dysplasia to subluxation (partial dislocation) through to frank dislocation of the hip.
• 1-3% newborns affects, MORE COMMON IN FEMALES.

Question 7

Risk factors of DDH?

Answer 7

1) Female
2) Family history
3) Breech position
4) First born
5) Birth weight >5kg

Question 8

Detection of DDH?

Answer 8

• Early detection is important + responds to conservative treatment.
• Late detection associated with hip dysplasia requires complex treatment involving surgery.

Question 9

Presentation of DDH?

Answer 9

1) Neonatal screening part of routine examination of newborn.
2) If not picked up in examination - may present with limp or abnormal gait.
3) Asymmetry of skin folds around hip
4) Limited hip abduction/shortening of affected leg

Question 10

Diagnosis of DDH?

Answer 10

1) Barlow manoeuvre and Ortolani manoeuvre done in neonatal screening exam and routine surveillance at 8 weeks.
- Barlow manoeuvre: check if hip can be dislocated posteriorly out of acetabulum (femoral head felt with clunk if positive).
- Orlotani manoeuvre: Check if hip can be relocated back into acetabulum on abduction (palpable clunk as hip relocates).
2) Ultrasound (<6m) - shows degree of dysplasia/dislocation of hip.
3) Hip X-ray (>6m)

Question 11

Treatment of DDH?

Answer 11

1) For infants <2m observation recommended as spontaneous resolution can occur.
2) If hip remains unstable for 6 weeks, prompt treatment: Infant placed in a splint/Pavlik harness to keep hip flexed and abducted - progress monitored by ultrasound or X-ray. (Necrosis of femoral head is a potential complication).
3) Open surgery reduction required if delayed presentation or if closed techniques fail?

Question 12

What is Juvenile Idiopathic Arthritis?

Answer 12

• Persistent joint swelling for >6 weeks duration presenting before 16 years of age in the absence of infection or any other defined cause.
• 7 subtypes
• Oligoarticular - 4 or less joints involved
• Polyarticular - >4 joints involved
• the KNEE is mostly involved
• AUTOIMMUNE

Question 13

Subtypes of JIA?

Answer 13

1) Oligoarticular (persistant)
2) Oligoarticular (extended - >4 joints involved after 6m)
3) Polyarticular (RF negative)
4) Polyarticular ( RF positive)
5) Systemic arthritis/Still’s disease (systemic upset and spiking fevers once or twice a day, arthralgia, salmon-pink macular rash on trunk and limbs)
6) Psoriatic arthritis (psoriasis, nail-pitting or dystrophy, dactylitis).
7) Enthesitis-related arthritis

Question 14

Clinical presentation of JIA?

Answer 14

1) Gelling - stiffness after long period of rest (long car rides)
2) Morning stiffness - CARDINAL - struggle to get up from cot, down stairs, ‘walking like old man’
3) Joint swelling
4) Young children - intermittent limp or deterioration in behaviour/mood, avoidance of previously enjoyed activities.

Question 15

Complications of JIA?

Answer 15

1) Chronic anterior uveitis - can lead to severe visual impairment, ophthalmological screening required.
2) Flexion contractures - in most comfy position where intra-articular pressure is minimised.
3) Growth failure - anorexia, chronic disease and systemic corticosteroid therapy.
4) Anaemia of chronic disease/delayed puberty
5) Osteoporosis - Reduced weight bearing, systemic corticosteroids, poor diet: give dietary supplements of calcium and Vitamin D and encourage weight-bearing exercise. (CONSIDER BISPHOSPHONATES).

Question 16

Ddx and Dx of JIA?

Answer 16

Ddx: Septic arthritis, Osteomyelitis

Dx:

1) Clinical features - initially less evidence of joint swelling - later more swelling, inflammation, proliferation of synovium.
2) FBC, CRP, ESR, ANA, RF

Question 17

Treatment of JIA?

Answer 17

1) Paeds Rheumatology MDT management, education/support, physiotherapy to maintain joint function.
2) REFER to ophthalmology for anterior Uveitis.
3) NSAIDs - Naproxen
4) Intra-articular corticosteroids - joint injection
5) DMARD - Methotrexate (early use to reduce joint damage)
6) Systemic corticosteroids - Prednisolone (avoid if possible to reduce growth failure/osteoporosis S/E)
7) IV Corticosteroids - IV Methylprednisolone - only for SEVERE polyarthritis
8) Cytokine modulators/TNF-a inhibitor - Etanercept (if DMARDS fail).

Question 18

Prognosis for JIA?

Answer 18

• At least 1 in 3 will have ongoing active disease in adult life.
• Significant morbidity from joint damage - requiring joint replacement surgery, visual impairment from anterior uveitis, fractures from Osteoporosis.