MSK Flashcards
(99 cards)
1
Q
A
1
Q
What is osteogenesis imperfecta?
A
A genetic condition that affects the production of collagen resulting in brittle bones that are prone to fractures
2
Q
What is osteogenesis imperfecta also called?
A
Brittle bone syndrome
3
Q
What is collagen used for in MSK system?
A
Essential for maintaining the structure + function of bone, skin, tendons and connective tissues
4
Q
An infant presents with unusual and recurrent fractures, you think about safegaurding. When examining the child you notice a blue discolouration of the sclera. Possible diagnosis?
A
Osteogenesis imperfecta
5
Q
A child presents with recurrent fractures and
* Hypermobility
* Blue/grey sclera
He also has:
* Triangular face
* Short stature
* Dental problems (formation of teeth)
* Bone deformaties (e.g. bowed legs + scoliosis)
Possible underlying diagnosis?
A
Osteogenesis imperfecta
6
Q
What is the pharmacological management of osteogenesis imperfecta?
A
- Bisphosphonates (increase bone density)
- Vitamin D supplementation (prevent deficiency)
7
Q
What is transient synovitis also referred to as?
A
Irritable hip
8
Q
What is most common cause of hip pain in children aged 3-10 years?
A
Transient synovitis
9
Q
What is transient synovitis and what it is associated with?
A
Transient synovitis = temporary irritation + inflammation in the **synovial membrane **of the joint (synovitis)
Transient synovitis = associated with viral upper respiratory tract infection
10
Q
If a child (3-10 yrs) presents with mainfestations below, what are the most probable diagnoses/concerns?
A
- Hip pain + no fever –> transient synovitis
- Hip pain + fever –> septic arthritis (urgent treatment)
11
Q
What is a red flag differential for transient synovitis?
A
Septic arthritis
(Hip pain + fever)
12
Q
A 7 year old patinet prenets with:
* Limp
* Refusal to weight bear
* Groin or hip pain
* Mild low grade temperature
* Seems otherwise well
From the Hx you discover that they had a viral URTI 2 weeks ago.
Possible diagnosis?
A
Transient synovitis
13
Q
What is the management for transient synovitis?
A
Symptomatic treatment → simple analgesia
* + safety net advice (develops fever → A&E )
14
Q
When does transient synovitis tend to resolve?
A
Symptoms fully resolve within 1-2 weeks
(Typically significant improvement after 24-48 hours)
15
Q
What is osteomyelitis?
A
Infection in the bone + bone marrow
(Typically occurs in the metaphysis of the long bones)
16
Q
What is the difference between chronic and acute osteomyelitis?
A
- Chronic osteomyelitis = deep seated, slow growing infection → slowly developing symptoms
- Acute osteomyelitis = presents more quickly with an acutely unwell child
17
Q
What is the most common bacteria that causes osteomyelitis?
A
Staphylococcus aureus
18
Q
How can the bacteria get into the bone in osteomyelitis?
A
- Direct → open fracture
- Indirect → through blood after entering the body via different route e.g. skin or gums
19
Q
What child is osteomyelitis more commonly found in?
A
Boys under 10 years
20
Q
What are some risk factors for osteomyelitis?
A
- Open bone fracture
- Orthopaedic surgery
- Immunocompromised
- Sickle cell anaemia
- HIV
- Tuberculosis
21
Q
How does a child with osteomyelitis present?
A
Acutely with an unwell child or more chronically with subtle features
* Refusing to use the limb or weight bear
* Pain
* Swelling
* Tenderness
Also:
* Afebrile/low grade fever
* Acute osteomyelitis may have high fever (particularly if it has spread to joint → causing septic arthritis)
22
Q
What are the 3 investigations for osteomyelitis in children?
A
Ix:
* First line: X-ray (can be normal)
* **Gold standard: MRI **
* Alternative: Bone scan
- Bloods (Raised CRP, ESR, WBC)
- Blood culture (establish causative organism)
- Bone marrow aspiration or bone biopsy with histology + culture
23
Q
What is the management for osteomyelitis?
A
- Extensive + prolonged **antibiotic therapy
- Drainage + debridement** of infected bone
24
What is Osgood-Schlatters disease?
**Inflammation** at the **tibial tuberosity** where the **patella ligament inserts**
(Usually **unilateral**)
25
A boy aged 10-15 year old boy presents with pain in one anterior knee. Possible diagnosis?
Osgood-Schlatters disease
26
What is the most common cause of anterior knee pain in adolescents?
Osgood-Schlatters disease
27
What is the pathophysiology underlying Osgood-Schattlers?
* Stress from running, jumping etc at same time as growth in the epiphyseal pale → results in inflammation on the tibial epiphyseal plate
* Multiple small **avulsion fractures** occur where the patella ligament pulls away tiny pieces of bone
* Leads to tibial tuberosity growth → visiable lump below knee
* Lump is intially tender due to inflammation → heals and inflammation settles → becomes hard
28
A 12 yr old child presents with:
* Visible or palpable hard and tender lump at the tibial tuberosity
* Pain in the anterior aspect of the knee
* The pain is exacerbated by physical activity, kneeling and on extension of the knee
He says that its been going on for a while (gradual onset). Possible diagnosis?
Osgood-Shlatters disease
29
What is the management for Osgood-Sclatters disease?
Initial mangement → reducing pain + inflammation:
* Ice
* NSAIDs
* Reduction in physical activity
After symptoms settle:
* Stretching + physiotherapy → strengthen the joint
30
What does a kid's knee look like after Osgood-Schlatters disease?
A hard boney lump on their knee
31
What is rare complication of Osgood-Schlatters diease?
A **full avulsion fracture**
(the tibial tuberosity is separated from the rest of the tibia)
* Requires surgicical intervention
32
What is a slipped upper femoral epiphysis (SUFE)?
## Footnote
Also known as slipped capital femoral epiphysis (SCFE)
Where the **head of the femur** is displaced ('slips') along the **growth plate**
33
What is the typical patient for a SUFE?
Obese children:
* Boys → 8-15 years
* Girls → 11 years
34
When is a SUFE most likely to occur?
An adolescent obese male undergoing a **growth spurt**
35
An obese 12 year old boy presents with:
* Hip, groin, thigh or knee pain
* Restricted range of hip movement
* Painful limp
* Restricted movement in the hip
He also prefers to keep his hip in **external rotation** and has **restricted internal rotation**
Possible diagnosis?
Slipped upper femoral epiphysis (SUFE)
36
What are the investigations you want to request when you suspect a SUFE?
First line: **X-ray**
Second line:
* Blood test (ESR, CRP → exclude other causes of joint pain)
* Technetium bone scan
* CT scan
* MRI scan
37
What is the mangement of a SUFE?
**Surgery**
(return the femoral head to correct position + fix it into place)
38
What is Perthes disease?
Perthes disease = disruption of blood flow to the **femoral head** → causing **avascular necrosis** of the bone → affecting the femur epiphysis
## Footnote
The epiphysis = the bone distal to the growth plate (physis)
39
What age does Perthes disease usually occur at?
4-12 years
Mostly between 5-8 years
(more common in boys)
40
What causes Perthes disease?
No clear cause (idiopathic)
41
What is the main complication of Perthes disease?
A soft + deformed femoral head → leading to early hip osteoarthitis
(Requires total hip replacement)
## Footnote
(Over time there is **revascularisation** or **neovascularisation** and healing of the femoral head → **remodelling of the bone**
42
A 7 year old resents presents with a slow onset of:
* Pain in the hip or groin
* Limp
* Restricted hip movements
* Referred pain to the knee (maybe)
No history of trauma. Possible diagnosis?
Perthes disease
43
What are two differentials for:
* Pain in the hip or groin
* Limp
* Restricted hip movements
* Perthes disease
* SUFE (if triggered by minor trauma + older children)
44
What are the investigations for Perthes disease?
First line: **X-ray** (can be normal)
Others to establish diagnosis:
* **Blood tests** (rule out other causes)
* **Technetium bone scan**
* **MRI scan **
45
Management for Perthes disease?
Initial management (younger + less severe) → maintain a healthy position + alignment, reduce risk of damage + deformity to the femoral head
* Bed rest
* Traction
* Crutches
* Analgesia
Second line:
* Physiotherapy
* Regular x-rays
* Surgery (improve alignment + function of the femoral head + hip)
46
What is Rickets?
Rickets = paediatric condition in which there is **defective bone mineralisation** → causing **'soft' + deformed bones**
## Footnote
In adults → osteomalacia
47
What is rickets caused by?
Vitamin D or calcium
## Footnote
There is a rare genetic form of rickets called hereditary hypophsophatamemic rickets (most commonly x-linked dominant)
48
What are the potential symptoms of rickets?
## Footnote
Some children may be asymtomatic
* Lethargy
* Bone pain
* Swollen wrists
* Bone deformity
* Poor growth
* Dental problems
* Muscle weakness
* Pathological or abnormal fractures
49
Name some deformities in rickets
* **Bowing of legs** → legs curve outwards
* **Knock knees** → legs curve inwards
* **Rachitic rosary** → ends of ribs = expand at the costochondral juntcions → causing lumps along the chest
* **Craniotabes** → = soft skull, with **delayed closure of the sutures + frontal bossing**
* **Delayed teeth** → with underdevelopment of the enamel
50
Name 2 risk factors for rickets
* Darker skin
* Low exposure to sunlight
* Live in colder climates
* Spend majority indoors
51
You suspect rickets in a chid. What laboratory investigation do you request to check their vitamin D levels?
Serum 25-hydroxyvitamin D
52
What investigations do you perform when you suspect a child has rickets?
Diagnostic:
* **Serum 25-hydroxyvitamin D**(diagnoses a vit D deficiency)
* **X-ray** (gold-standard)
Other (serum) (may):
* Calcium (low)
* Phosphate (low)
* Alkaline phosphatase (high)
* Parathyroid hormone (high)
53
Which babies are most at risk of votamin D deficiency?
**Breastfed babies **
(Breastfeeding mums and children sould take 10 mg Vit D supplements per day)
54
What is the treatment for children witha vitamin D deficiency?
Ergocalciferol
(Vitamin D)
55
What is the management for rickets?
Vitamin D + calcium supplementation
56
What is septic arthritis?
**Infection** inside of a **joint**
57
At what age does septic arthritis commonly occur in children?
Children under 4
58
Why is septic arthritis an emergency?
The infection can quickly **destroy a joint** and cause **serious systemic illness**
59
What is an importnat complication of joint replacement?
Septic arthritis
60
A child presents with a hot, red and swollen right knee, he is refusng to weight bear and cannot mve it like he usually does. He is also feelling not himself (quite tired) and a fever. Possible diagnosis?
Septic arthritis
61
What are the clinical mainfestations of septic arthritis?
* Usually only affects **one joint** → often **knee** or **hip**
* Rapid onset of below:
* Hot, red, swollen and painful joint
* Refusing to weight bear
* Stiffness and reduced range of motion
* Systemic symptoms such as fever, lethargy and sepsis
62
When a child is presenting with joint problems (especially under 4 years) what is an important differential you should consider?
**SEPTIC ARTHRITIS**
(Can be subtle in younger children)
63
What are the most common organisms in septic arthritis?
**Staphylococcus aureus**
* Neisseria gonorrhoea (gonococcus) in sexually active teenagers
* Group A streptococcus (Streptococcus pyogenes)
* Haemophilus influenza
* Escherichia coli (E. coli)
64
Name 2 differential diagnoses to septic arthritis
* Transient sinovitis
* Perthes disease
* Slipped upper femoral epiphysis (SUFE)
* Juvenile idiopathic arthritis
65
When should you aspirate a joint with septic arthritis?
Before IV antibiotics
66
What will you test the joint aspirate of a joint with suspected septic arthritis?
* Gram staining
* Crystal microscopy
* Culture
* Antibiotic sensitivities
(The joint fluid may be **purulent** (full of pus)
67
What empirical Abx are given to children with suspected arthritis? How long are they given for?
(Before you get back sensitivities)
- First line: **Flucloxacillin + rifampicin**
- Vancomycin + rifampicin → penicillin, MRSA, prosthetic joint
3-6 weeks in total
68
# ```
```
What is the management for severe septic arthritis?
* 3-6 weeks of antibiotics
* Surgical drainage
* Surgical washout
## Footnote
Surgical drainage and washout = to clear the infection
69
What is developmental dysplasia of the hip?
A condition where there is a **structural abnormality** in the hips → caused by **abnormal development** of the fetal bones during pregnancy
70
What does developmental dysplasia of the hip (DDH) cause in the child and adult>
* **Instability in the hips**
* Potential for **subluxation** or **dislocation**
If persist into adulthood:
* Weakness, recurrent subluxation or dislocation
* Abnormal gait
* Early degenerative changes
71
When is DDH picked up?
* Newborn examinations (NIPE)
* When child presents with hip asymmetry, reduced range of movement in the hip or a limp
72
# a
Name 2 risk factors of DDH
* **First degree family history**
* **Breech presentation** from 36 weeks onwards
* **Breech presentation** at birth if 28 weeks onwards
* **Multiple pregnancy**
73
What screening process can pick up DDH? What features are looked at?
NIPE
Symmetry in the:
* Hips
* Leg length
* Skin folds
* Hip movements
74
Name 2 findings on a NIPE that are indicate DDH?
* Different leg lengths
* Restricted hip abduction on one side
* Significant bilateral restriction in abduction
* Difference in the knee level when the hips are flexed
* Clunking of the hips on special tests
75
What are the 2 special tests used to check for DDH?
* **Ortolani test** (dislocate the hips anteriorly)
* **Barlow test** (dislocate the hips posteriorly)
76
What is the difference between **clicking** and **clunking** when examining a newborns hips on a NIPE
* **Clicking** → due to** soft tissue moving over bone (no concern)** → doesn't require ultrasound
* **Clunking** → more likely to **indicate DDH** → requires ultrasound
77
How do you diagnose DDH?
* **Ultrasound** of the hips
* X-rays (especially in older infants)
78
What is the management for DDH?
* First line (under 6 months) → **Pavlik harness**
* Second line: Surgery
(after surgery a **hip spica cast** = used to immobilse the hib for a prolonged period)
79
A 7-year-old girl presents to the paediatric clinic with a 6-month history of morning joint stiffness, swelling, and pain in her knees and wrists. On examination, there is evident joint swelling, warmth, and limited range of motion in the affected joints. Possible diagnosis?
Juvenile idiopathic arthritis
80
What is juvenile idiopathic arthritis?
**Juvenile idiopathic arthritis (JIA)** = an **autoimmune inflammation** in the joints .
* It is diagnosed where there is arthritis **without any other cause** - **lasting more than 6 weeks** in a patient **under the age of 16**.
* It has also been known as juvenile chronic arthritis and juvenile rheumatoid arthritis.
The key features of inflammatory arthritis = **joint pain + swelling + stiffness**
81
What are the 5 key subtypes of juvenile idiopathic arthitis (JIA)?
* Systemic JIA
* Polyarticular JIA
* Oligoarticular JIA
* Enthesitis related arthritis
* Juvenile psoriatic arthritis
82
How does systemic JIA present?
**Systemic JIA = Still's disease**
* **Systemic JIA** = a **systemic illness** that can occur throughout childhood in boys and girls
Typical features:
* **Subtle salmon-pink rash**
* High swinging fevers
* Enlarged lymph nodes
* Weight loss
* Joint inflammation and pain
* Splenomegaly
* Muscle pain
* Pleuritis and pericarditis
83
What do blood test results look like for someone with systemic JIA?
* Antinuclear antibodies (ANA) + rheumatoid factors (RF) = typically negative
* **Raised inflammatory markers (CRP + ESR)**
* **Raised platelets + serum ferritin**
84
What is the key complication of systemic JIA?
**Macrophage activation syndrome (MAS)**
**MAS** = Where there is **severe activation of the immune system** with a **massive inflammatory response**.
It presents with an **acutely unwell child** with :
* **Disseminated intravascular coagulation (DIC)**
* **Anaemia**
* **Thrombocytopenia**
* **Bleeding**
* **A non-blanching rash**.
It is **life threatening**. A key investigation finding is a **low ESR**.
85
Info: Tom Tip
Thinks of systemic JIA (Still's disease) when a patient presents with:
* Salmon-pink rash
* Fevers
* Joint pain
86
In children that have fevers for more than 5 days, what are the key non-infective differentials?
* Kawasaki disease
* Still's disease
* Rheumatic fever
* Leukaemia
87
What is polyarticular JIA?
* **Polyarticular JIA** = idiopathic inflammatory arthritis in **5 joints or more**.
* The inflammatory arthritis tends to be **symmetrical** and can affect the small joints of the hands and feet, as well as the large joints such as the hips and knees.
* There are **minimal systemic symptoms**, but there can be mild fever, anaemia and reduced growth. Systemic symptoms are mild, unlike systemic onset JIA.
* **Polyarticular JIA** = the equivalent of **rheumatoid arthritis in adults**.
* Most children = negative for rheumatoid factor → “**seronegative**”.
* When rheumatoid factor is positive → “**seropositive**”.
* Seropositive patients tend to be older children and adolescents and the disease pattern is more similar to rheumatoid arthritis in adults.
88
What is oligoarticular JIA?
**Oligoarticular JIA** = **involves 4 joints or less**
* Usually it **only affects a single joint** → described as a **monoarthritis**.
* It tends to affect the** larger joints**, (**knee** or **ankle**).
* It occurs more frequently in **girls** under the **age of 6 years**.
* **Patients tend not to have any systemic symptoms** and inflammatory makers will be normal or mildly elevated.
89
What is the main associated feautures with oligoarticular JIA?
**Anterior uveitis**
(Patients should be referred to opthalmologist)
90
What do the blood tests look like for oligioarticular JIA?
**Oligoarticular JIA = Antinuclear antibodies (ANA) positive**
* = Rheumatoid factor negative
91
How does enthesitis-related present?
* Arthritis occurring in the hips, knees, ankles, feet
* More common in boys over 6 (unlike rest of JIA types)
* Associated with acute anterior uveitis
92
What is enthesitis-related arthritis?
* **Enthesitis = inflammation** of the **insertion** of the **ligament** or **tendon** to the bone (enthesis)
* Occurs in the **knees**, **heels**, **plantar region** of the **feet**
* Patients have **inflammatory arthritis** in the joints (as well as **enthesitis**)
Enthesitis-related arthritis = thought as paediatric version **of seronegative spondyloarthropathy group** of conditions that affect adults (ankylosing spondylitis, psoriatic arthritis, reactive arthritis, inflammatory bowel disease -related arthritis) - so might be worth checking for signs of these:
* **Psoriasis (psoriatic plaques + nail pitting)**
* **Inflammatory bowel disease (intermitted diarrhoea + rectal bleeding)**
Patients with enthesitis-related arthritis are prone to **anterior uveitis**, and should see an ophthalmologist for screening, even if they are asymptomatic.
93
What gene variant do patients with enthesitis-related arthritis usually have?
HLA-B27
94
Info: Enthesitis-related arthritis
Patients with **enthesitis** will be tender to localised palpation of the entheses. Therefore it is worth palpating key areas to elicit tenderness of the entheses:
* Interphalangeal joints in the hand
* Wrist
* Over the greater trochanter on the lateral aspect of the hip
* Quadriceps insertion at the **anterior superior iliac spine**
* Quadriceps and patella tendon insertion around the patella
* Base of achilles, at the calcaneus
* Metatarsal heads on the base of the foot
95
What is juvenile psoriatic arthritis?
**Juvenile psoriatic arthritis = seronegative inflammatory arthritis** - associated with **psoriasis**
Pattern of joint involvement varies - patients can have:
* **Symmetrical polyarthritis** - affecting the **small joints** similar to rheumatoid
* Or an **asymmetrical arthritis** affecting the **large joints** in the **lower limb**
96
What are the clinical features of juvenile psoriatic arthritis?
* **Plaques of psoriasis** on the skin
* Pitting of the nails (**nail pitting**)
* **Onycholysis** (separation of the nail from the nail bed)
* **Dactylitis** (inflammation of the full finger)
* **Enthesitis** (inflammation of the entheses, which are the points of insertion of tendons into bone)
97
Management of juvenile idiopathic arthritis
First line:
* **NSAIDs**
* **Intra-articular corticosteroids**
* **Intravenous corticosteroids** (Short-term to control severe symptoms - or in systemic JIA)
* **Methotrexate** (DMARD (slow the progression + prevent joint damage) (Avoided if presence of sacro-ilitis or macrophage activation syndrome (MAS))
* **Physiotherapy + occupational therapy**
* Biologic therapy - such as the **tumour necrosis factor inhibitors (etanercept (anti-TNF), infliximab)**
## Footnote
Etanercept = should be avoided in presence of sacro-ilitis, MAS and uveitis
98
Complications of juvenile idiopathic arthritis
* **Joint deformities and functional disability**
* **Growth disturbances**
* **Uveitis**
* **Osteoporosis**
* **Secondary amyloidosis**: with systemic JIA only
* **Pericarditis, pleuritis, peritonitis**: with systemic JIA only
* **Macrophage activation syndrome (MAS)**: a life-threatening condition seen in 10% of JIA cases, caused by uncontrolled activation and proliferation of T lymphocytes and macrophages. It presents as a sepsis-like condition with fever, hepatosplenomegaly and haemorrhagic manifestations
