Week 3 - MSK and Minor illness Flashcards

Question

List some points of advice for patients with self-limiting illnesses

Answer 1

- Why prescribing antimicrobials may not be appropriate, including benefits and harms - Alternative options to prescribing antimicrobials - How long they should expect the symptoms to last - Safety netting: what they should do if their condition gets worse - If applicable, how to minimise spreading the infection to others e.g. good hand hygiene

Answer 2

- Symptoms typically peak at 1–3 days and last 7–10 days, however they occasionally persist for up to 3 weeks - If symptoms don't improve after 3 weeks, contact the surgery for a follow up Safety netting advice: - Symptoms that worsen or fail to improve - Fever greater than 38.5 C, lasting more than three days - Fever returning after a fever-free period - Shortness of breath or wheezing (difficulty breathing)

Answer 3

Pathophysiology: - Direct invasion of the upper airway mucosa by by a variety of bacteria or viruses - Because a variety of patient diseases including acute bronchitis, the common cold, influenza and respiratory distress syndromes - Irritation and swelling of the upper airways with associated cough (with no proof of pneumonia or underlying condition) Presentation: - Cough and sneezing - Sore throat - Runny nose / congestion - Headache - Low-grade fever - Facial pressure - Malaise - Myalgia Investigations: - Mainly a clinical diagnosis which is self-limiting - May require a chest x-ray if unsure Management: Mainly symptom relief (self-limiting) - Rest - Fluid intake - Analgesia (Paracetamol)

Answer 4

- Allergic rhinitis (hay fever) - Sinusitis - Tracheobronchitis - Pneumonia - Influenza - Atypical Pneumonia - Whooping cough - Epiglottitis - Tonsillitis / Streptococcal Pharyngitis - Infectious Mononucleosis (EBV)

Answer 5

Pathophysiology: - Infection of the urinary tract with bacteria (urethra, bladder or kidneys) Risk factors: - Female - > 65 years / post-menopausal - Sexual intercourse - Spermicide use - Indwelling / long term catheter - History of UTIs - Poor bladder emptying Presentation: Cystitis - Suprapubic pain - Dysuria - Increased urinary frequency and nocturia - Cloudy urine - Low-grade fever Pyelonephritis - Flank pain - Haematuria - High-grade fever - Nausea & vomiting Investigations: - Urine dipstick - Urine MC&S May need further investigations if unresolving Management: Antibiotics - Nitrofurantoin and Trimethoprim (depending on local sensitivities) - Can give back-up abx (3 days) to women with mild uncomplicated symptoms - Men and pregnant women (7-10 days)

Answer 6

Pathophysiology: - Painful, walled-off collection of pus - Generally occurs secondary to a bacterial infection - Can occur in 2 main ways: skin abscesses and internal abscesses Presentation: - Painful swelling - Fever - Malaise Investigations: - Mainly a clinical diagnosis based on presenting symptoms and examination Management: - If small, may resolve spontaneously - Larger abscesses may need antibiotics and drainage of pus

Answer 7

Pathophysiology: - Colonisation by candida albicans yeast - Caused by an overgrowth of the yeast, normally balanced out by the acidity of lactobacillus bacteria in the vagina Risk factors: - Extremes of age - Immunocompromised / HIV - Pregnancy - Diabetes - Broad-spectrum antibiotics - Stress - Dentures (oral) - Inhaled corticosteroids (oral) Presentation: - Itching - Burning - White "cottage cheese" discharge Management: - Antifungals e.g. Clotrimazole, Nystatin, Fluconazole

Answer 8

Pathophysiology: - Reflux of the gastric contents into the oesophagus - Can occur with or without oesophageal erosions Risk factors: - Family history of heartburn or GORD - Obesity - Hiatus hernia - Older age - Smoking - NSAIDs - Alcohol Presentation: - Heart burn - Acid reflux - Dysphagia - Bloating / early satiety - Halitosis Investigations: - PPI trial for 1-2 months (observe if symptoms are better on PPIs) - If unresolving, consider further tests e.g. OGD, oesophageal manometry, or barium swallow Management: Main goals: control symptoms and prevent complications Conservative - Lifestyle modifications e.g. weight loss, smaller meals, avoid triggering food/drink, smoking cessation Medical - Offer OTC Gaviscon - PPI (Omeprazole or Lansoprazole) minimal needed

Answer 9

- Lifestyle/benign: low fibre diet / lack of mobility / poor toileting - Haemorrhoids - Medications e.g. opioids - Depression - Abdominal hernia - Hypothyroidism - Parkinson’s disease / MS - Electrolyte imbalances: hypocalcaemia / hypomagnesemia - Large bowel obstruction - Adhesions - Bowel or rectal cancer

Answer 10

- IBD (Crohn’s or UC) - IBS - Coeliac disease - Lactose intolerance - Clostridium difficile - Anxiety - Gastroenteritis - Hyperthyroidism - Medications - Overflow diarrhoea / bowel or rectal cancer

Answer 11

- IBS - Bowel cancer - Rectal cancer

Answer 12

- Lifestyle e.g. poor hygiene, skin changes and irritation - Haemorrhoids - Anal fissure - Thrush (spreading posteriorly)

Answer 13

Fresh red: - Anal fissures - Haemorrhoids - IBD (Crohn's or UC) - Malignancy - Diverticular disease Malaena: - Upper GI bleed - Iron tablets (malaena looking) - Malignancy

Answer 14

- Anal fissures - Haemorrhoids (thrombosed) - Perianal abscess - Perianal fissure - Malignancy - Cryptitis, ischemia - Rectocele - Proctalgia fugax

Answer 15

Cluster Tension Migraine

Answer 16

Medication-overuse Raised ICP e.g. tumour or intracranial haemorrhage Trigeminal neuralgia Giant cell arteritis

Answer 17

Presentation: Pattern of onset: generalised, especially frontal and occipital Quality of pain: tight band, radiates to neck Severity of pain: mild-moderate Duration/pattern of headache: recurrent (30min-60min) Triggers: lack of sleep, stress, poor posture Respond to simple analgesics? yes Associated symptoms: none, may have nausea Clinical findings on examination: normal Management: - Generally reassure - Pain relief but advise on the risk of medication overuse headache (if use > 15 days of month) - Consider use of Amitriptyline if chronic

Answer 18

Presentation: Pattern of onset: unilateral, around eye Quality of pain: sharp, stabbing, penetrating Severity of pain: severe, often at night Duration/pattern of headache: 15min-3hr clusters, with periods of remission Triggers: alcohol, smoking, volatile smells, warm temperature, lack of sleep Respond to simple analgesics? often no, oxygen and triptans Associated symptoms: ipsilateral autonomic symptoms e.g. red eye, blocked runny nose Clinical findings on examination: autonomic symptoms during attack Management: - Triptans e.g. Sumitriptan and oxygen (acute attacks) - Verapamil or steroids (preventative) - Avoid triggers - Emotional support may be needed

Answer 19

Presentation - Pattern of onset: unilateral (temporal or frontal) - Quality of pain: throbbing, pulsating - Severity of pain: moderate-severe - Duration/pattern of headache: prolonged headache (4-72hrs) - Triggers: menstrual cycle, lack of sleep, certain foods - Respond to simple analgesics? can do, may need additional interventions - Associated symptoms: aura, photophobia, phonophobia - Clinical findings on examination: normal Management: - In dark room - Avoid triggers if possible - Paracetamol or NSAIDs (best taken at start of attack) - May need Triptan drugs e.g. Sumatriptan - Prophylaxis with Propranolol or Topiramate if having significant effect on QOL or not responding to treatment

Answer 20

Taking analgesics > 10 days per month - History of taking analgesics > 10 days per month - Variable character, dull headaches (tension-like or migraine-like) - Constant headaches > 15 days per month

Answer 21

Causes of raised ICP: - Brain tumour - Intracranial haemorrhage - Aneurysm - Hydrocephalus - Meningitis or encephalitis - Venous sinus thrombosis

Answer 22

Presentation: - Pattern of onset: gradual, worsening progression - Quality of pain: dull and variable - Severity of pain: mild - Duration/pattern of headache: progressive, but worse in mornings - Triggers: leaning forward, straining or valsalva maneuver - Respond to simple analgesics? yes in early stages - Associated symptoms: red flag symptoms, N&V, focal neurological symptoms, visual changes Management: - Further investigations to cause - Treat the underlying cause

Answer 23

Presentation: - Pattern of onset: random - Quality of pain: sharp, stabbing, electric shock - Severity of pain: severe - Duration/pattern of headache: brief episodes (seconds-mins) - Triggers: light touch, eating, cold wind, brushing hair - Respond to simple analgesics? no, difficult to treat - Associated symptoms: tingling, numbness, pain in cranial nerve 5 distribution Management: - Can give Carbamazepine

Answer 24

Cardiovascular: - AF - Arrythmias - Aortic stenosis - Vasovagal - Orthostatic hypotension - Stroke / TIA Neurological: - Parkinson’s - Epilepsy Infection: - UTI - Meningitis Metabolic: - Hypoglycaemic event

Answer 25

A strain: stretch or tear of muscle fibres or tendon A sprain: stretch or tear of a ligament

Answer 26

1. Tenderness over either malleolus PLUS either: - Inability to bear weight - Bone tenderness along the proximal 6 cm to lateral malleolus or medial malleolus

Answer 27

1. Pain in the midfoot PLUS either - Inability to bear weight - Tenderness at the base of the 5th metatarsal - Tenderness of the navicular

Answer 28

Any of the following: - Inability to bear weight - Inability to flex the knee to 90 degrees - > 55 years - Tenderness at the head of the fibula - Tenderness of the patella

Answer 29

- Pain / tenderness over the scaphoid bone

Answer 30

Pathophysiology: - Common inflammatory disease that peaks in adolescence - Presence of non-inflammatory comedones and inflammatory papules, pustules, nodules, and cysts Presentation: - Comedones, papules, pustules, nodules and scarring - Skin tenderness Management: Depends on type of acne Comedonal: mainly topical retinoid Mild inflammatory: topical retinoid plus topical antibiotic

Answer 31

Pathophysiology: - Common viral infection of the skin mainly affecting children, caused by Poxvirus - Normally resolves within a few months, but can > 18 months Presentation: - Several - many firm, skin-coloured or pink-red, dome-shaped spots with a depressed centre Contagious? - Close direct contact, touching contaminated objects and sexual contact - Children do NOT need to be kept off school but minimise contact Management: - Majority of cases are self-resolving and no treatment is required - Further steps if unresolving

Answer 32

Pathophysiology: - Chronic inflammatory skin disease - Hyperproliferative disorder of basal cells, leading to erythematous, circumscribed scaly papules and plaques Presentation: - Red, inflamed, silvery-white scaly and circumscribed papules and plaques - Often affects elbows, knees, extensor limbs, and scalp - May have features of psoriatic arthritis e.g. joint pain Management: - Combination: topical steroids / topical vitamin D analogue - Topical calcineurin inhibitors

Answer 33

Pathophysiology: - Scabies skin infestation caused by mites - Quite contagious and spread by direct contact Presentation: - Multiple firm bumps, usually very itchy which is often worse at night - Rash over affected area Management: - Topical insecticide treatments e.g. Permethrin - Requires two treatments, one week apart with everyone affected being treated at the same time

Answer 34

Pathophysiology: - Hypersensitivity reaction - Generally associated infections e.g. herpes simplex virus and Mycoplasma pneumoniae (also medications and vaccinations) 2 categories (seriousness) - Erythema multiforme major - Erythema multiforme minor Presentation: - Target lesions that resemble a bull's eye - Usually erupt over 24-48 hours and last for 1-2 weeks - Usually affects the oral mucosa only (if minor) but can affect multiple areas (if major) - May have crusting of the lips Investigations - aim to find underlying cause: - Herpes simplex virus serology - Chest x-ray if suspect mycoplasma pneumonia Management: - Analgesia - Adequate hydration - Topical emollients - Oral/topical corticosteroids (oral/IV if major) - Treat underlying cause

Answer 35

Pathophysiology: - Caused by varicella zoster virus - Usually presents in childhood and is self-limiting - Tends to be more severe in adults with a higher risk of developing complications - Can be reactivated as Shingles Presentation: - Generalised pruritic, vesicular rash - Fever - Malaise - Headache - Sore throat Management: - If low-risk, supportive care - Patients in high-risk categories e.g. pregnant women, immunosuppressed patients, and neonates, should receive treatment with antiviral therapy (oral or IV) - Individuals should stay isolated until last vesicle has burst (no longer contagious) around 5-6 days after rash begins

Answer 36

Pathophysiology: - Viral infection that is most commonly caused by a coxsackie virus - Highly infectious - Most common in young children (particularly < 10) Presentation: - Oral vesicles and ulcers - Rash and/or vesicles on the hands and feet - Low-grade fever Management: - Infection typically resolves spontaneously within 10-14 days - Treatment is mainly supportive e.g. analgesia and anti-pyrexic medications

Answer 37

Pathophysiology: - Common bacterial infection of the skin that typically occurs in children: usually Staphylococcus aureus and/or Streptococcus pyogenes - Bullous and non-bullous forms Presentation: - Vesicles (non-bullous impetigo) or bullae (bullous impetigo) - Yellow crusting Management: - Reassure - Explain good hygiene measures (see next slide) - Stay away from school / work until lesions are healed, dry and crusted over or 48 hours after initiation of antibiotics (food handlers required by law to inform employers immediately) Non-bullous - Localised: Topical Fusidic acid 2% or topical hydrogen peroxide - Widespread: Topical or oral antibiotic e.g. Flucloxacillin Bullous - Oral / IV Flucloxacillin

Answer 38

Good hygiene advice: - Wash affected areas with soap and water - Wash hands regularly, in particular after touching a patch of impetigo. - Avoids scratching affected areas - Avoids sharing towels, face cloths, and other personal care products and thoroughly cleans potentially contaminated toys and play equipment Isolation advice: - Stay away from school / work until lesions are healed, dry and crusted over or 48 hours after initiation of antibiotics - Food handlers required by law to inform employers immediately

Answer 39

Pathophysiology: - Caused by measles virus - Levels are low due to success of MMR vaccine Presentation: - Maculopapular rash - Cough - Coryza (cold-like symptoms) - Conjunctivitis - Pathognomonic Koplik's spots Investigation of choice: - Measles-specific IgM and IgG serology (ELISA) Management: - No specific treatment of measles except for supportive care - Immediately inform Public health england - Advise to avoid contact with people until mostly recovered (minimum 4 days after rash develops)

Answer 40

Chicken pox: - Vesicular rash (raised and fluid filled) - Usually starts on face, chest and back - Separate vesicles Measles: - Mostly flat red rash - Usually starts at the head and works down - Presence of pathognomonic Koplik spots - More likely to have conjunctivitis - Rash can merge together as it progresses

Answer 41

Pathophysiology: - Superficial fungal infection of hair, skin, and nails Types (areas) of ringworm: - Tinea corporis (body) - Tinea capitis (scalp) - Tinea barbae (beard) - Tinea manuum (hands) - Onychomycosis (nails) Presentation: - Erythema - Scaling skin lesions with central clearing Management: - Limited tinea corporis (body) infection can usually be managed with topical antifungals e.g. topical Clotrimazole - Other types may need oral antifungals - May need to confirm fungal nail infection with potassium hydroxide microscopy

Answer 42

Scarlet fever: - Exotoxin-mediated infection commonly resulting from group A streptococcus (GAS) infection of the throat or, less commonly, the skin - Mainly affects children aged 1-10 years Presentation: Key triad of - Sore throat - Fever - Scarlatiniform abdominal rash (like sandpaper) May also have a strawberry tongue or cervical lymphadenopathy and absence of a cough Mainly a clinical diagnosis Management: - Always prescribe antibiotics e.g. Phenoxymethylpenicillin (Penicillin)

Answer 43

Reduces the risk of complications such as rheumatic fever and invasive group A streptococcus (GAS) infection

Answer 44

Fifth disease or Parvovirus B19

Answer 45

Pathophysiology: - Viral infection caused by Parvovirus B19 - Most common in children - Once you've had the infection, you're usually immune to it for life, however can be more serious for some people e.g. pregnancy or immunocompromised Presentation: - Distinctive bright red rash on both cheeks - Mild fever - Coryzal symptoms - Upset stomach - General malaise Management: - Should be self-resolving unless high-risk

Answer 46

How to explain a condition to a patient: - Wear and tear of the cartilage which sits over the surface of most joints - Leads to bone wearing on bone and can lead to painful and stiff joints - Most commonly affects the larger, weight bearing joints like the hips and knees Management options: Conservative - Physiotherapy - Weight loss - Activity modification - Joint support or other supportive measures - Acupuncture or TENS machine Medical - Topical NSAIDs - Oral analgesia: Paracetamol, oral NSAIDs, Tramadol or Duloxetine - Steroid injections - Joint replacement Safety netting advice: - Acute severe worsening of joint pain (fracture or septic arthritis) then present to A&E - Worsening over time, present to GP to consideration of treatment escalation

Answer 47

How to explain condition to a patient: - Autoimmune condition where the immune system attacks the membrane that produces fluid in the joints - Causes joints to become stiff, swollen and painful - Most commonly affects the small joints like those in the hands and feet Management options: - Early treatment with DMARDs e.g. Sulfasalazine (mild), Methotrexate (moderate) - Add biologics - Consider NSAIDs - Consider corticosteroids What is the recommended follow up period: - Regular follow ups with rheumatology (referral) - Can use DAS28-ESR to monitor effectiveness of treatment Safety netting advice: - Acute severe worsening of joint pain (fracture or septic arthritis) then present to A&E

Answer 48

How to explain condition to a patient: - Incredibly common, experienced by up to 50% of adults during a lifetime - Pain in your lower back that generally varies with certain positions or activities and so can comes and go Management options: Conservative - Weight loss - Physiotherapy - Activity modification - Education regarding posture and prevention - Smoking cessation - Heat or Cold Packs Medical - Topical NSAIDs, Paracetamol or oral NSAIDs What is the recommended follow up period: - Usually resolves in a few weeks - Get back in contact if it doesn't Safety netting advice: Sudden onset of any of the following (cauda equina syndrome) - Tingling sensation / weakness down both legs - Loss of sensation in the area normally where you sit on a bike - Urinary incontinence - Faecal incontinence - Erectile dysfunction

Answer 49

Pathophysiology: - Inflammation of the lining of the eyelids and eyeball (conjunctiva) Caused by: - Bacteria or viruses - Allergic reaction or immunological reactions - Mechanical irritation - Medicines e.g. Atropine or Neomycin Presentation: - Itchy, gritty eye - Watery / purulent discharge - Red eye - Eyelids stuck together in morning - Tender preauricular lymphadenopathy - Presence of risk factors Management: Usually resolves without treatment after 1-2 weeks Supportive: - Damp cold towel - Analgesia - Advise on good hygiene to avoid spreading - Avoid contact lenses Bacterial - topical broad spectrum antibiotics e.g. Chloramphenicol and Fuscidic acid If allergic conjunctivitis - antihistamines (oral or topical) or topical mast-cell stabilisers (chronic seasonal symptoms)

Answer 50

Pathophysiology: - Type of irritant contact dermatitis in the area of the body covered by a nappy - Common in under 2 / anyone wearing a nappy Presentation: - Acute onset erythematous rash in nappy area - Baby seeming uncomfortable or distressed Management: Generally conservative - Frequent nappy changes (every 2 hours, more if there is diarrhoea) - Periods of nappy-free time - Application of barrier cream - Topical antifungal if > 3 days - Topical corticosteroid if severe or if painful - Topical antibiotic if secondary bacterial infection

Answer 51

Pathophysiology - Inflammation of the plantar fascia Presentation: - Gradual onset of pain on the plantar aspect of the heel - Tenderness over plantar aspect of heel - Worse on walking or standing for prolonged periods Management: - Rest and ice - Analgesia e.g. NSAIDs - Physiotherapy - Steroid injections (painful and can cause rupture or fat pad atrophy)

Answer 52

Pathophysiology: - Infection by the epstein barr virus (human herpes virus 4) - Usually acquired in childhood but produce more severe symptoms in young adulthood Presentation: - Lymphadenopathy - Fever - Sore throat - Fatigue - Tonsillar enlargement - Splenomegaly (rare cases splenic rupture) EBV causes an intensely itchy maculopapular rash in response to Amoxicillin or Cephalosporins Investigations: - Test for EBV antibodies (IgM and IgG) - Heterophile antibodies (test for by Monospot test or Paul-Bunnell test) Management: - Usually self-limiting and lasts 2-3 weeks - Can leave pt with fatigue for several months after infection is cleared - Avoid alcohol (EBV impacts ability of liver to cope with alcohol) - Avoid contact sports (splenic rupture)

Answer 53

- Splenic rupture - Chronic fatigue - Glomerulonephritis - Haemolytic anaemia - Thrombocytopenia - EBV infection associated with certain cancers, notable: Burkitt’s lymphoma

Answer 54

- Epstein barr virus (caused by this) - Glandular fever - Kissing disease

Answer 55

Pathophysiology: - Inflammation of the GI tract (stomach and bowel) Common causes: - Viral: Rotavirus, Norovirus, Adenovirus - Bacterial: E Coli, Campylobacter, Shigella, Salmonella Presentation: - Nausea and vomiting - Diarrhoea (+/- blood depending on cause) - Fever Management: - Isolate patient, until 48 hrs after condition has completely resolved - Stool MC&S - Assess hydration and give oral rehydration solution

Answer 56

- Lactose intolerance - IBS - Reactive arthritis - Guillain–Barré syndrome - Toxic megacolon - Dehydration and hypovolaemia, may lead to an AKI - Haemolytic uraemic syndrome

Answer 57

Presentation: - Itchy, red and swollen eyes - Runny, blocked and itchy nose - Sneezing - Associated family history with atopy Management: - Avoid the triggers if possible - Oral antihistamines (taken prior to exposure) 1. Non-sedating antihistamines e.g. Cetirizine, Fexofenadine 2. Sedating antihistamines e.g. Chlorphenamine (Piriton) and Promethazine - Can use a nasal anti-histamine or corticosteroid spray e.g. Fluticasone

Answer 58

- Transient synovitis - Perthes disease - Juvenile rheumatoid arthritis - Slipped capital femoral epiphysis - Hip dysplasia

Answer 59

Pathophysiology: - Inflammation of synovial lining, leading to transient hip joint effusion - Often related to a previous viral infection - Most common cause of limping in children (common in ages 3-10) Presentation: - Unilateral hip pain - Protective limp - Limited ROM in the affected hip joint - Sometimes reluctant to weight-bear - Otherwise well in themselves Investigations: - Generally a diagnosis of exclusion, important to exclude septic arthritis of hip - Bloods for infection: FBC, CRP and ESR - Hip x-ray (rule out other causes) Management: - Rest - Analgesia (NSAIDs recommended)

Answer 60

Pathophysiology: - Interrupted blood supply to the femoral head leading to avascular necrosis - Self-limiting disease of the femoral head whereby there is necrosis, collapse and compression, repair and finally, remodelling - Can lead to hip pain and mobility issues later in life Presentation: - Hip pain, sometimes referred to the hip and worse on activity (especially abduction and internal rotation) - Limp - Limited ROM at the affected hip joint - Muscle atrophy Investigations: - Hip x-ray - May do a perfusion MRI Management: Conservative - Rest during acute episodes (may be able to do limited activity) - Avoidance of axial loading (may be unable to walk) - Analgesia - More complex management depends on the age of the child (may need surgical containment)

Answer 61

Pathophysiology: - Rheumatoid arthritis of hip joint in a child (< 16 years old) Presentation: - Hip swelling or effusion - Warmth in the joint - Painful or limited ROM movement, +/- tenderness - Morning stiffness in affected hips Investigations: - FBC, ESR, CRP - ANA antibodies - RF antibodies - Ultrasound - Hip x-ray Management: - Analgesia e.g. NSAIDs - DMARD e.g. Methotrexate or biologics therapy - Consider steroids (intra-articular or oral)

Answer 62

Pathophysiology: - Weakness in the proximal femoral growth plate allows for displacement of the femoral epiphysis - Most common hip disorder in the adolescent age group Risk factors: - Obesity - Male - Endocrine disorders such as panhypopituitarism or hypothyroidism - Period of rapid growth Presentation: - Bilateral hip pain - Protective limp - Limited ROM in affected hip - Trendelenburg's gait - Obesity present Investigations: - Hip x-ray Management: - Surgical fixation of epiphyses by a screw

Answer 63

Pathophysiology: - Malformed hip joint, where the acetabulum and femoral head do not have good articulation - Higher risk of subluxation and arthritis later in life - Most cases are congenital but patients don’t experience symptoms until adulthood Presentation: - Reduced ROM in the hip, particularly abduction - Groin pain that increases with activity - Limping - Catching, snapping or popping sensation - Difficulty sleeping on the hip Screening test for newborns: - Barlow and Ortolani hip test Investigations: - Ultrasound - Hip x-ray Management: - Orthopaedic referral - Management depends on age, may need Spica casting