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TAS MSK > Limping Child ✅ > Flashcards

Limping Child ✅ Flashcards

1
Q

What is the most common cause of limp in 0-3 years old?

A

Trauma

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2
Q

What causes of limp in 0-3 years old require urgent intervention?

A
  • Osteomyelitis
  • Septic arthritis
  • Non-accidental injury
  • Malignancy
  • Testicular torsion
  • Inguinal hernia
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3
Q

What are the other causes of limp to consider in 0-3 years old?

A
  • Developmental dysplasia of the hip
  • JIA
  • Metabolic
  • Haematological disease
  • Reactive arthritis
  • Lyme arthritis
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4
Q

Give an example of a malignancy causing limp in 0-3 year olds?

A

Neuroblastoma

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6
Q

Give an example of a metabolic cause of limp in 0-3 year olds?

A

Rickets

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7
Q

Give an example of a haematological cause of limp in 0-3 year olds?

A
  • Sickle cell anaemia
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8
Q

What are the most common causes of limp in 4-10 years?

A
  • Trauma
  • Transient synovitis
  • Perthes disease
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9
Q

Give an example of a malignancy causing limp in 4-10 year olds?

A

Acute lymphoblastic leukaemia

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10
Q

What other causes of limp should be considered in 4-10 year olds?

A

JIA

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11
Q

What are the most common causes of limp in 11-16 year olds?

A
  • Trauma

- Osgood-Schlatter disease

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12
Q

What causes of limp in 11-16 year olds require urgent intervention?

A
  • Osteomyelitis
  • Septic arthritis
  • Slipped upper femoral epiphysis
  • Malignancy, e.g. bone tumours
  • Testicular torsion
  • Appendicitis
  • Inguinal hernia
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13
Q

What are the other important causes of limp to consider in 11-16 year olds?

A

JIA

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14
Q

What is septic arthritis?

A

Bacterial infection of the joint

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15
Q

At what age is septic arthritis most common?

A

First 2 years of life

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16
Q

What is osteomyelitis?

A

Infection of bone

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17
Q

At what age is osteomyelitis most common?

A

Under 2 years

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18
Q

What are the categories of osteomyelitis?

A
  • Acute
  • Subacute
  • Chronic
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19
Q

How do most bone infections spread?

A

Via the haematogenous route

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20
Q

Are organisms always isolated in bone infections?

A

No

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21
Q

Do septic arthritis and osteomyelitis occur alone or together?

A

Either

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22
Q

How can infection spread in young children?

A

Directly from the bony metaphysis to the joint space

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23
Q

Why can infection spread directly from the bony metaphysis to the joint space in young children?

A

In young children, the synovial membrane of the hip, ankle, shoulder, and radial head inserts distally to the epiphysis

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24
Q

What proportion of neonates with septic arthritis have concomitant osteomyelitis?

A

Around half

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25
Q

What proportion of infants with septic arthritis have concomitant osteomyelitis?

A

1/5

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26
Q

In what joint is sepsis from adjacent osteomyelitis particularly common?

A

Hip

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27
Q

What joint is septic arthritis most common in?

A

Low limb joins - knee > hip > ankle

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28
Q

What are the common causative organisms of septic arthritis?

A
  • Staph aureus
  • Group A strep
  • Gram -ve bacilli
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29
Q

When should mycobacterial infection be considered in septic arthritis?

A
  • Immunocompromised

- Endemic areas

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30
Q

How does septic arthritis present?

A
  • Fever and associated constitutional symptoms
  • Joint pain, swelling, warmth, and/or redness
  • Guarding of the affected area, e.g. refusal to weight bear
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31
Q

Why might the diagnosis of septic arthritis be difficult?

A

Signs and symptoms may be subtle and non-specific

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32
Q

Why is septic arthritis a medical emergency?

A

Bone and joint infections can be rapidly destructive

33
Q

What can delay in diagnosis or treatment lead to in septic arthritis?

A

Irreversible damage to the joint, with associated long-term pain and functional impairment

34
Q

How useful are blood tests in septic arthritis?

A

They are not diagnostic, and can only be used in the context of clinical findings

35
Q

What factors predict septic arthritis (according to Kocher)?

A
  • Fever >38.5
  • Non-weight bearing, or pain with passive motion of the joint
  • ESR >40mm/hour
  • WBC >12
36
Q

What investigations are helpful in septic arthritis?

A
  • FBC, ESR, CRP
  • Blood cultures
  • Joint aspiration
  • X-ray
  • USS
37
Q

What might be found on FBC in septic arthritis?

A

Markedly elevated neutrophil and platelet count

38
Q

Is ESR or CRP a better predictor of acute infection?

A

CRP

39
Q

Are blood cultures always positive in septic arthritis?

A

No

40
Q

Are blood cultures always positive in osteomyelitis?

A

No, frequently negative

41
Q

What tests are done on joint aspirate in septic arthritis?

A

Gram stain microscopy and culture

42
Q

What is the limitation of x-ray in septic arthritis?

A

May be normal in early stages of infection, and bony changes can take up to 21 days to evolve

43
Q

Why might USS be useful in septic arthritis? §

A

To demonstrate joint effusion and guide aspiration

44
Q

When is MRI useful in septic arthritis?

A

If diagnosis is unclear

45
Q

What is an alternative to MRI in septic arthritis?

A

Radionucleotide bone scanning

46
Q

What is often the first-line antibiotic in septic arthritis?

A

Cefuroxime

47
Q

Why is cefuroxime often the first line antibiotic in septic arthritis?

A

Broad spectrum with good bone penetration

48
Q

How long should antibiotics be continued for in septic arthritis?

A

10-14 days IV, then switch to oral if adequate response

49
Q

What is the most common cause of hip pain between 3-10 years?

A

Transient synovitis

50
Q

Which gender is transient synovitis more common in?

A

Boys

51
Q

What kind of diagnosis is transient synovitis?

A

Diagnosis of exclusion

52
Q

What is the aetiology of transient synovitis?

A

Unclear, but viral, autoimmune, and allergic associations have been suggested

53
Q

What proportion of children with transient synovitis report a viral infection during the preceding week?

A

Around half

54
Q

How does transient synovitis most commonly present?

A

Painless limp in relatively well child

55
Q

What features suggest an alternative diagnosis when considering transient synovitis?

A
  • High fever
  • Markedly elevated inflammatory markers
  • Severe pain
  • Functional impairment
56
Q

What is found on hip x-ray in transient synovitis?

A

Normal

57
Q

What is found on USS in transient synovitis?

A

May be small effusion

58
Q

What happens in most cases of transient synovitis?

A

Settle quickly

59
Q

When is review necessary in transient synovitis?

A

If limp persists

60
Q

Why is review needed if the limp persists in transient synovitis?

A

To exclude Perthe’s disease or evolving JIA

61
Q

What is rickets?

A

Defective ossification of the bony matrix

62
Q

What can cause rickets?

A
  • Deficiency of active form of vitamin D
  • Deficiency of phosphate
  • (Rarely) deficiency of calcium
63
Q

What is the active form of vitamin D?

A

1,25-dihydroxyvitamin D, or 1,25-vitamin D

64
Q

What conditions causing limp in 4-10 year olds require urgent intervention?

A
  • Osteomyelitis
  • Septic arthritis
  • Non-accidental injury
  • Malignant disease
  • Testicular torsion
  • Appendicitis
  • Inguinal hernia
65
Q

How does rickets present?

A
  • Bone tenderness
  • Joint pain
  • Proximal muscle weakness
  • Delayed dentition
  • Increased frequency of fractures
  • Growth delay
  • Skeletal deformities
66
Q

What skeletal deformities may be present in rickets?

A
  • Bowing of long bones
  • Persistent genu varum
  • Splaying of rib cabe
  • Costochondroal swelling (rachitic rosary)
67
Q

What is the most common cause of rickets?

A

Vitamin D deficiency

68
Q

What is the normal source of 1,25-vitamin D?

A

The skin

69
Q

What % of bioavailable vitamin D is produced by the skin?

A

90%

70
Q

How is vitamin D produced in the skin?

A

UV light converts 7-dehydroxycholesterol into vitamin D prohormone, which is then converted to 25-hydroxyvitamin D (calcidiol) in the liver, and then 1,25-dihydroxyvitamin D in the kidneys

71
Q

Is cutaneous vitamin D production higher in lighter skin or darker skin individuals?

A

Lighter

72
Q

What can deficiency of 1,25-dihydroxyvitamin D result from?

A
  • Low exposure to UV light rays
  • Nutritional deficiency
  • Liver or kidney disease
73
Q

Who is at higher risk of vitamin D deficiency?

A

Breastfed infants whose mothers are not exposed to sunlight, or themselves are not exposed to sunlight

74
Q

What has happened to the incidence of vitamin D deficiency in the UK over the last few years?

A

Increased

75
Q

What has potentially caused the increased incidence of vitamin D deficiency in the past few years?

A

Increased use of sunblock, preventing UV light from reaching the surface of the skin

76
Q

How is vitamin D deficiency treated?

A

Between 3000-10,000 units daily (depending on age) for 4-8 weeks

77
Q

What is found on x-rays in rickets?

A
  • Impaired mineralisation of growth plates

- Cupping and fraying of margins of metaphyses

TAS MSK (3 decks)

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