Locomotor, Nutrition, Developmental problems Flashcards
(126 cards)
1
Q
Kocher criteria for Septic arthritis
A
WCC>12000
ESR/CRP elevated
Non-Wx bearing
Temp>38
ALL 4= 99% Septic Arthritis
2
Q
Epidemiology of septic arthritis
A
50% in first 2 years of life
2x more common in Boys
Underlying joint disease or prosthetic joints or bacteraemia increase risk
3
Q
Presentation of septic arthritis
A
Likely < 3 years old 75% Lower limb (Knees>Hip>Ankle) Acute, hot swollen joint Pain on passive movement Pseudoparalysis Cannot weight bear Systemic symptoms
4
Q
Diagnosis of septic arthritis
A
Joint aspiration under GA + USS guided
Then Gram stain and culture of synovial fluid
+/- FBC, ESR, CRP, Blood cultures
5
Q
X-ray findings in septic arthritis
A
Initially normal +/- Widened joint spaces B/C effusion
Later will have space narrowing, erosive changes, subluxation, dislocation
6
Q
Management of septic arthritis
A
Abx after aspiration
-IV up to 3/52 followed by oral for 4-6/52
Surgical involvement if recurrent or affecting hip
Splintage improves pain
Physio to avoid stiffness
7
Q
Indications for a LP in septic arthritis
A
If H.Influ then do an LP as there is increased incidence of meningitis
8
Q
What is developmental dysplasia of the hip
A
Abnormal formation of the hip joint where there is a shallow acetabulum that doesn’t cover the femoral head sufficiently
9
Q
Risk Factors for DDH
A
FEMALE (6X more likely) Breech delivery FHx 1st born Oligohydramnios Other joint problems High birth Wx
10
Q
Screening for DDH
A
1st day- Hips examined
6 weeks USS
11
Q
How are Breech babies screened for DDH
A
All have USS
Same if 1st degree relative with DDH
12
Q
Presentation of DDH
A
From birth or shortly after
Delay in walking
Waddling gait (like a pregnant lady)
Shortened affected leg
13
Q
Barlow and Ortolani tests
A
Tests for DDH
Barlow- Press hips posteriorly when flexed to attempt to dislocate
Ortolani- Hips flexed and then abducted to try and relocate the dislocated hip
14
Q
Management of DDH
A
Most spontaneously stabilise at 3-6 weeks therefore use double nappies until this point
No success + <6 months= Bracing with Pavlik harness for 3/12
Then consider surgery if above fails
15
Q
Complications of DDH
A
OA, Lower back pain
Also a risk of re-dislocation and/or avascular necrosis
16
Q
Commonest cause of hip pain in 3-10 years
A
Reactive arthritis/Irritable hip
17
Q
Presentation of irritable hip/reactive arthritis
A
Slight limp and hip pain Hx viral infection No systemic symptoms Likely single joint No pain at rest but pain O/E
18
Q
What features would likely indicate septic arthritis over reactive arthritis in a child with limp
A
Systemically unwell Fever Night pain and pain on rest Cannot Wx bear > 2 weeks Very elevated inflammatory markers
19
Q
When would you discharge a child with reactive arthritis?
A
Non-dramatic physical signs
X-rays and bloods normal
Advise NSAIDS and rest
20
Q
Reiter’s syndrome
A
Form of reactive arthritis
“Cant see, can’t wee, can’t climb a tree”
Uveitis, urethritis and arthritis
21
Q
Classification of JIA
A
Objective arthritis in >/= 1 joint for at least 6 weeks \+/- Swelling, warmth, reduced movement < 16 years Nil other cause found Most common in girls under 4 years
22
Q
Oligoarticular/Pauarticular JIA vs Polyarticular JIA vs Still’s disease
A
Oligo/Pau= Up to 4 joints affected. Most common. Poly= >4 joints affected Still's= Systemic onset JIA
23
Q
Presentation of JIA
A
Joints- Painful, swollen, stiff on mornings, cartilage erosion
Walk on toes
Hepato/Splenomegaly
Still’s= + Fever, salmon-pink rash, Uveitis, Wx loss, Anorexia
24
Q
Likely Blood result changes in Still’s disease
A
Leukocytes, ESR, CRP and platelets can be raised
HB can be low
Can be similar in non-systemic JIA
25
Rh and Anti-nuclear factor in JIA
Rh can be -ve or +ve
Anti-nuclear factor +ve in 70% Pauarticular JIA
26
Management of JIA
Mild exercise alongside rest each day
Physio and splints
NSAIDS and hot baths +/- Steroid injections
Long term: Methotrexate, Sulfasalazine, oral corticosteroids
Surgery to preserve joint function
27
Osteomyelitis presentation
Fever, Swelling, erythema and severe bony pain
Child will stop using the affected limb
Lucency and periosteal thickening can sometimes be seen on an X-ray
28
What does a child under 3 years with an acute limp need?
A secondary care assessment
29
Benign idiopathic nocturnal limb pain of childhood (Growing pains)
Preschool children (~3-5 years) or 8-12 years
Pain at night and no limp by the day
No interference with normal activities
Meeting motor milestones
30
Most common age range irritable hip is seen
2-8 years
31
When are Bow legs normal
< 3 years
| Surgical referral for Blout's disease if > 4 years
32
ALL and limp
ALL can cause pathological fractures and thereby lead to limp/pain/tenderness
Therefore always have malignancy as a differential
33
Osgood Schlatters
Knee pain in active children
34
Red flags indicating an organic cause of limp
```
Day and night pain
There on weekends and vacations
Interruption of normal activities- ask about play
Unilateral
Localised to a join
Unremitting
Refusal to walk
Systemic manifestations
Wx loss, bruising, night sweats, hepatosplenomegaly
Pain on passive internal rotation
```
35
Reassuring features indicating a non-organic cause of limp
```
Painless passive internal rotation
Pain only at night/school days
No interference with normal activities
Bilateral
Pain located between joints
Not systemic
Pain without limp is also reassuring
```
36
What is Perthe's disease
Osteochondritis of the femoral head
| Can be caused by or develop into avascular necrosis
37
Risk factors for Perthe's disease
MALE
Short
Trisomy 21
Think a child in Primary school
38
Presentation of Perthe's disease
Short child 4-8 years who is hyperactive
Progressive hip pain over weeks
Reduced movement, discrepancy in leg length
Limp
Can be bilateral
39
What gait is classically seen in Perthe's disease
Trendelenberg gait- Unaffected side rises above affected side
40
X-ray of perthe's disease
Sub-chondral linear lucency
Widened joint space early on
Collapsed deformity later on
41
Management of Perthe's disease
< 6 years= Observation
If older then try physio and strengthening then callipers (non-wx bearing device) if good imaging
surgery if above fails
42
What is Slipper upper femoral epiphysis
Femoral head epiphysis displaced postero-inferiorly
43
Risk factors for SUFE
```
Secondary school age (10-16 years)
Obese
Hypothyroidism
Trauma
Pelvic RT
```
44
Presentation of SUFE
Pain, Limp, Reduced movement
Externally rotated hip +/- shorter length
Can be bilateral and thereby look like a 'normal hip on x-ray'
If Unilateral look for Klein's line on X-ray- Inferolateral displacement "melting ice cream appearance"
45
Management of SUFE
Surgical fixation/closure to prevent AVN and chondrolysis
46
Normal calorie requirements
150mls/kg/day until around 6/12
47
How many mls per oz
30mls: 1 oz
48
Maintenance fluids
1st 10kg= 100mls/kg/day
2nd 10kg= 50mls/kg/day
subsequent kgs= 20mls/kg/day
49
Common causes of malabsorption
```
GORD
Chronic infection
CF
Immunodeficiency
Eating disorder
```
50
Definition of malnutrition
BMI<18.5
or
>10% Wx loss over 3/12
Indicated by falling across two centile lines on serial Hx and Wx (or <3rd centile)
51
Kwashiokor vs Marasmus malnutrition
Kwashiokor- Severe protein/AA deficiency: Abd distension and growth retardation
Marasmus- Severe calorie deficiency where height is preserved but they have a wasted appearance
(Generally a mix of the two)
52
Refeeding syndrome
Respiratory and cardiac failure induced by electrolyte imbalance as a consequence of rapid large feeding after a period of minimal feeding
53
Feeding options for severe malnutrition
Parenteral (IV) or enteral (GI) feeding
54
What is Ricket's
Vitamin D deficiency that occurs before fusion of epiphysial plates during growth
Disrupts mineralisation of said plates
55
What happens to Calcium and Phosphate levels during progression of Vit D deficiency/ Rickets
Initially- Low Ca2+ and normal Phos
Then Normal Ca2+ as compensatory hyperparathyroidism
Finally low Ca2+ and low phosphate
This is advanced bone disease with clinical features
56
Radiological findings in rickets/Vit D deficiency
Widening at the end of the long bones
| Cupped and ragged surfaces
57
Key features of Rickets
```
Frontal bossing
Ankle and Wrist swelling
Delayed closure of fontanelles
Harrison's sulcus below ribs
Dental hypoplasia
Leg bowing
Pectus carinatum
Craniotabes (bones in cranium collapse under pressure)
Rachitic rosary (expansion of the anterior rib ends at the costochondral junctions)
```
58
Treatment of Vit D deficiency/Rickets
Colacalciferol- 6 weeks
| Then need maintenance
59
Genetics of vitamin D dependent rickets
Type 1 and 2 are autosomal recessive
Type 1 cannot activate vit D due to enzyme deficiency
Type 2 is end organ resistance to vitamin D
Both present early in life
60
Strongest RF for Down's syndrome
High maternal age
61
Tone features in Down's syndrome
Hypotonia and marked head lag
62
Facial features in Down's syndrome
```
Small low set ears
Upslanting palpebral fissures
Prominent epicanthic folds
Protuding tongue
White Brushfield's spots on iris
Flat occiput
Short neck
```
63
Limb/Motor features in Down's syndrome
```
Short broad hands
Single palmar crease
Wide sandle gap
Atlantoaxial instability
Short
```
64
Most common heart defect associated with Down's syndrome
AVSD
65
Conditions associated with Down's syndrome
```
Congential HD
GI- Pyloric stenosis, Atresia, Hirschsprung's, Umbilical hernias, GORD, Coeliac's
DDH
Eczema
Deafness
Cataracts
Leukaemia (1%)
Infections
Hypo/Hyperthyroidism
Alzheimer's disease + other dementias
```
66
Referrals needed in a newly diagnosed child with Down's syndrome
Cardiac assessment
Hip USS for DDH (~6 weeks)
Audiology for ?Deafness
Ophthalmic assessment
67
Median age of death for Down's syndrome and prognostic information
Mid-50s
Much improved as ,10yrs in 1970s
Majority semi-independent
Big risk of AD in 40+
68
Amblyopia
Eye fails to achieve visual acuity even with prescription glasses/lenses
Feature of squint when eye has not received clear images in a sensitive period of development
69
3 key features of squint
Eye misalignment (Stabismus)
Diplopia
Amblyopia
70
Causes of squint
Number 1 is idiopathic
Also consider: Retinoblastoma, Glaucoma, CN palsy, Retinal disease
71
Paralytic vs Non-paralytic squint
Non-paralytic= Squint constant in all directions of gaze typically an imbalance of extraocular muscles, convergent or divergent but can be latent where it manifests when tired
Paralytic (Rare)= CN palsy, CN3 is down and out therefore squint varies with direction of gaze
72
Past what age should a squint always be investigated?
Beyond 12 weeks
73
How do you investigate a squint?
Full Ophthalmic examination including cover test
74
What is involved in an ophthalmic examination?
```
Acuity
Colour
Fields
Pupils + Reflexes
Cover test
Movements
Fundoscopy
```
75
Assessing visual acuity
Snellen chart at 6m
| Fine print reading
76
Assessing colour in ophthalmic examination
Ishihara to identify number
77
Assessing visual fields
Red hot pin
1) Blind spot
2) Peripheral vision
78
Assessing pupils in an ophthalmic examination
Size, shape, symmetry
Direct and consensual pupillary reflex
Accommodation
RAPD- look for dilatation
79
Assessing eye movements in an ophthalmic examination
Draw H
80
Cover test
Shine light in eye- can they see one or multiple sources of light
Cover one eye and observe for movement
81
Temporal movement in cover test
Esotropia
| Convergent squint
82
Nasal movement in cover test
Exotropia
| Divergent squint
83
Fundoscopy
1% Tropicamide
Red reflex at 30cm
Then look closer
84
Hypertropia
One eye misaligned superiorly
85
Management of squint
Correct refractive error with spectacles
Patching good eye prevents ambylopia
Surgery to realign rectus muscle
86
Features of CN3 palsy
Pupil dilated
Partial ptosis
Eye is "down and out"
87
Key features of ASD
Abnormal impaired development before 3 years
Poor verbal and non-verbal communication
Obsessive repetitive interests
Reduced imaginative play
Difficulties with reciprocal social interaction
88
Problems associated with ASD
```
Epilepsy
Visual/Auditory impairment
Mental health problems
Learning disability
PKU, FXS, TS, TORCHES
```
89
What does 3/60 mean in term of visual acuity?
Would have to stand 3 metres to see what a normal person would see at 60 metres
90
Definition of partially sighted and blindness
Partially sighted= <6/60
Blind= <3/60
91
Causes of blindness
```
Genetic- Retinoblastoma, cataracts etc
Congenital Rubella syndrome
Perinatal insult
Post-natal insult
Vitamin A deficiency
```
92
Key signs of blindness in a newborn/infant
Not smiling by 6 weeks
Delayed reaching/Pincer grip (Fine pincer >12 months)
Eye rubbing/irritation
Eyes move and/or look abnormal
93
Auditory impairment screening
Newborns have otoacoustic emission test
Can also use auditory brainstem response test
Audiology assessment at 7-9 months if abnormal
94
How does hearing impairment manifest?
Nil response to sound
Delayed speech
Behavioural problems
Associated neurology/pathology like LD or blindness
95
Most mild-moderate hearing loss is caused by...
Otitis media
| Therefore conductive
96
Causes of sensorineural deafness
```
Mostly genetic
Rubella
Perinatal insult
Post-natal infections like meningitis
Some drugs like Amnioglycosides
```
97
Management of sensorineural hearing loss
Sit at front of classroom etc
Hearing aids
Cochlear implants
Makaton if associated learning difficulty
98
Causes of conductive deafness
Middle ear disease + Glue ear
| ET dysfucntion
99
Management of Conductive deafness
Can try Grommets
| Amplification with hearing aids
100
Cause of FXS
Repeat expansion on the FMR1 gene (>200 CGC repeats)
| X-linked and dominant
101
Features of FXS
LD (IQ<70) therefore delayed milestones
High forehead, large testicles, large jaws/ears, facial asymmetry, prominent ears
Connective tissue problems= MV prolapse
Echolalia and Perseveration
Epilepsy
102
Causes of developmental delay
```
Genetic/Syndromes- Down's, Fragile X, ASD etc
Perinatal injury
Fetal alcohol syndrome
TORCHES
Congential hypothyroidism
PKU
Leucomalacia
Neurofibromatosis, TS, Sturge-Weber
Post-natal insult- Meningitis etc
NTDs and Hydrocephalus
```
103
Dealing with temper tantrums/aggression
```
Stay calm
Ignore bad behaviour
Reward good behaviour- them not doing it initially
Avoid precipitants like hunger/tiredness
Star chart with child involvement
```
104
Managing anxiety in children
CBT is best... hierachial desensitisation and skills acquisition alongside family involvement
105
Between what ages is normal attachment present
6-36 months
106
What are the two types of attachment disorder?
Disinhibited
| Reactive
107
Disinhibited attachment disorder
Caused by early institutional style care or care by a variety of carers
Child is unduly friendly with strangers and forms superficial relationships early
108
Reactive attachment disorder
Caused by abuse
Fearful and hypervigilant, not responsive to reassurance
Does not respond appropriately to social interaction
109
What are the 4 types of behavioural interaction seen in attachment disorder
A- Insecure avoidant- no reaction to separation/union, suppresses distress
B-Securely attached- distress upon separation, happy upon reunion
C- Insecure ambivalent- stressed upon separation, angry upon reunion
D- Disorganised- mix of A and C
110
Key features of ADHD
Inattention
Hyperactivity
Impulsivity
111
Diagnostic features of ADHD
Presents at a young age
Impulsivity, Hyperactivity, Inattention
Pervasive (>1 setting) and excessive vs norm for that age
112
Management of ADHD
```
Strict routines
Praise concentration
Positive reinforcement
Mindfullness/CBT
Family involvement
Ritalin
```
113
Ritalin/Methyphenidate in ADHD
Stimulates inhibitory output
Inhibits re-uptake of Dopamine and NorA
Monitor growth 6/12 as it can perturb this and also cause Wx loss
114
Self-harm red flags
```
Significant suicidal ideation
Hopelessness
Violent methods
Escalating frequency/severity
Disengagement from services
No support system
```
115
Epidemiology of self harm/suicide
self harm more common in females
| Suicide more common in males
116
Hx of a self-harm event
```
Explore acute event- Before, During, After
Background of self harm
Suicidal screen and ongoing intent
MSE
SHx/DHx etc
```
117
Management of ODs/Self-harm in children
Admit all ODs overnight to be seen by CAHMS next day
<16 years + self-harm= Admit overnight
16+= Admit to adult ward
118
What 3 features typically make up an eating disorder?
Low Wx
Fear of gaining Wx
Desire to be thin
119
Diagnostic criteria for Anorexia Nervosa
Restriction of energy intake
Intense fear of gaining Wx despite being underweight
Disturbance in the way one's body shape/Wx is experienced
120
Common sequela of Anorexia Nervosa
```
Hypokalaemia
Low Sex hormones
Impaired Glucose tolerance
Hypercholesterolaemia
Hypercarotenemia= Yellow Skin
Low T3
```
121
1st line management for Anorexia Nervosa/ Bulimia Nervosa
Family therapy
122
Epidemilogy of eating disorders
Bulimia more common than Anorexia
| Bulimia rare in <13s
123
Diagnostic features of Bulimia
Recurrent binges with no control
Recurrent purges to compensate
Above >/=1 time a week for >/=3 months
Self-evaluation entirely based on body shape
124
Below what age can people not refuse treatment?
<18 years
Although can still consent
125
Trisomy 18
Edward's syndrome
| 2nd most common autosomal trisomy
126
Trisomy 13
Patau's syndrome
