what is the term for bow legs
genu varum
pathological cause bow legs
rickets, blounts disease
what do bow legs look like
knees far apart
what is the term for knock knees
genu valgum
what does knock knees look like
feet wide apart
usual age of genu varum (bow leg)
1-3 y. normal toddler broad based gait
usual age of genu valgum (knock knees)
2-7y
what is the term for flat feet
pes cavus
when are flat feet common
in hypermobility
how do flat feet children present
standing on tiptoe
3 main causes of in toeing
metatarses varus (infants), medial tibial torsion, persistent anteversion of the femoral head
what is out toeing
uncommon, may occur in infants 6-12m
associations out toeing
hypermobility, Ehlers Danlos, Marfans
what can be a cause of toe walking
mild cerebral palsy, tightness of the Achilles tendon, inflammatory athritis
how do you check for DDH
neonatal screening- see if hip can be dislocated posterior out of the acetabulum (barlow manoeuvre) or relocated back in (ortolani)
presentation DDH
limp, abnormal gait, asymmetry skinfolds around hip, limited abduction of hip, shortening of affected leg
management DDH
splint or harness to keep hip flexed and abducted for a few months. surgery if fails
complications DDH
necrosis of femoral head
when do growing pains affect children
3-12 years. (nocturnal idiopathic pain)
presentation growing pains
wake in the night with pain, symmetrical pain in lower limbs doesnt radiate. never presents at the start of the day on waking
are physical activities affected in growing pains
no- no limp. physical exam normal
presentation hypermobility
MSK pain in the lower limbs often worse after exercise, join swelling absent. hyperextendable thumbs, elbows, knees, flat feet
advice for hypermobility
footwear, exercises, orthotics
associations hypermobility
downs, collagen- Ehlers Danlos, Marfans
causes of acute onset limb pain
trauma, NAI, osteomyelitis, tumour
what is osteomyelitis
infection of metaphysis of long bones. distal femur and proximal tibia
how is the infection spread in osteomyelitis
haem or direct spread from infected wound
what may osteomyelitis lead to
septic arthritis
what is the main cause of osteomyelitis
staph aureus (others- strep, H influenza)
presentation of osteomyelitis
painful immobile limb, acute febrile illness, swelling and tender over site, erythematous and warm, moving the limb causes severe pain
investigations in osteomyelitis
cultures, MRI, WCC and acute phase reactant increased, X ray, radionuclide bone scan increases uptake
treatment osteomyelitis
antibiotics. initially in a splint then mobilise the affected limb
what do you want to prevent in osteomyelitis
necrosis, chronic infection, limb deformity
bone pain due to malignant disease
ALL, neuroblastoma, osteogenic sarcoma, osteoid osteoma
what is a benign tumour present in teenagers especially males
osteoid osteoma
what is important when assessing a painful knee
check the hip as pain from the hip can be referred to the knee
what is osgood schlatter disease
osteochondritis of the patellar tendon inserting into knee
who does osgood schlatter disease affect
adolescent active males
presentation osgood schlatter disease
knee pain after exercise, tender, swelling, hamstring tenderness.
management osgood schlatter
decreased activity, physio, strengthening, hamstring stretches, orthotics
what is chondromalacia patellae
softening of articular cartilage of patella
who does chondromalacia patellae typically affect
adolescent females
presentation chondromalacia patellae
pain when standing up from sitting, walking up the stairs
associations chondromalacia patellae
flat feet and hypermobility
is back pain worrying in young
yes
mechanical causes back pain
muscle spasm, soft tissue pain- sport related, poor posture, abnormal loading
causes back pain
mechanical, tumours, vertebral osteomyelitis, spinal cord/root entrapment, spondylosis, complex regional pain syndrome
red flags back pain
young age, high fever, night waking, persistent pain, painful scoliosis, focal neuro signs, weight loss, systemic malaise
causes of acute limp in 1-3 yr
infection, transient synovitis, trauma, malignancy
causes chronic limp 1-3 y
DDH, talipes, neuromusc eg CP, JIA
causes acute limp 3-10 yrs
transient synovitis, septic arthritis/osteomyelitis, trauma, perthes, JIA, malignancy, complex regional pain syndrome
causes chronic limp 3-10 yrs
perthes, NMD eg DMD, JIA, tarsal coalition
causes acute limp 11-16 yrs
mechanical- trauma, sport, slipped capital femoral epiphyses, avascular necrosis of femoral head, reactive arthritis, JIA, septic arthritis, bone tumours/malignancy, CRPS
what is the most common cause of acute hip pain in children 2-12yr
transient synovitis
what does transient synovitis usually accompany
viral infection
presentation transient synovitis
sudden onset, no pain at rest, decreased range of movement, may be referred to the knee, afebrile or mild fever, doesn’t appear ill
what can transient synovitis precede in some children
perthes disease
what is perthes disease
avascular necrosis of capital femoral epiphysis of femoral head due to interruption of blood supply
who does perthes disease mainly affect
boys. 5-10y
how does recovery take place in perthes
revascularisation and reossification follows it over 18-36m.
presentation perthes disease
insidious onset- limp, hip or knee pain. bilat in 10-20%.
what signs are seen on x ray in perthes
early- increased density femoral head. fragments and irregularities
management perthes
early- bed rest and traction. if seen late- maintain hip in abduction with plaster or calpers. pelvic or femoral osteotomy
what is the prognosis of perthes
good. but if older, and more extensive involvement can have deformity of femoral head
signs of an acute arthritis
pain, redness, swelling, heat, restricted movement, systemically unwell with fever
what is the most common form arthritis in children
reactive arthritis
presentation reactive arthritis
transient joint swelling
what does reactive arthritis follow
extra articular infection. in children- enteric bacteria- shigella, salmonella, campylobacter, yersinia
other causes reactive arthritis
viral infections, STI, mycoplasma
treatment reactive arthritis
NSAIDs
when is septic arthritis common
what organism is implicated beyond the neonatal period in septic arthritis
staph aureus
what can lead to septic arthritis
osteomyelitis
presentation septic arthritis
erythematous, warm, acutely tender joint, reduced range of movement, acutely unwell febrile child, infants often hold limbs still (pseudoparesis), usually affects only one joint
what may initial presentation be in septic arthritis
limp referred to knee
investigations in septic arthritis
incr WCC, incr acute phase reactant, cultures, ultrasound, x ray, bone scan, MRI
management septic arthritis
joint aspiration- definitive investigation. prolonged course of antibiotics
what is juvenile idiopathic arthritis
joint swelling >6 weeks before 16yrs in absence of infection or other cause
features JIA
gelling (stiff after periods of rest), morning joint stiffness and pain. in the young child- limp or behaviour change
long term results of JIA
may be expansion of bone from overgrowth- leg lengthening causing valgus deformity, hands, wrist.
complications JIA
chronic anterior uveitis, flexion contractures of joints, growth failure, osteoporosis, constitutional, amyloidosis
management JIA
NSAIDs, joint injections (1st line oligoarthritis) , methotrexate (polyarthritis), corticosteroids, biologics and immunotherapies
how many patients go on to have active adult disease in JIA
1/3
