Musculoskeletal

Question 1

What age does hand preference develop? (1)

What is the implication of a dominant hand before this age? (1)

Answer 1

18m-24m

Indicates a problem eg weakness on the non-dominant side.

Question 2

Name 3 risk factors for developmental dysplasia of the hip. (3)

Answer 2

Breech delivery, first born, family history, female sex, oligohydramnios, congenital foot abnormalities.

Question 3

If a child demonstrates delayed walking, waddling gait or painless limp what diagnosis would you want to exclude? (1)

Answer 3

Developmental dysplasia of the hip - despite screening 40% may be missed.

Question 4

What 2 manoeuvres are used to screen for DDH in newborns? (2)

Answer 4

Ortolani’s (out) and Barlow (back) manoeuvres. Ultrasound test is diagnostic.

Question 5

How is DDH managed in children? (2)

Answer 5

Under 8 months can use a Pavlik harness to fix the hip in abduction addicted every 2 weeks.
In older children, open reduction and derogation femoral osteotomy needs to be performed.

Question 6

What is Perthe’s disease? (2)

Answer 6

Idiopathic osteonecrosis of the femoral head prior to skeletal maturity.
=> growth disturbance and associated ischaemia of upper femoral epiphysis
=> cycle of avascular necrosis and flattening and fragmentation of the femoral head.

Question 7

Which children are most likely to be affected by Perthe’s disease? (3)

Answer 7

Boys (5x)
Ages 3-12 (most 5-7y)
Previous family history

Question 8

How may Perthe’s disease present? (2)

Answer 8

Insidious onset of limpPain in hip, thigh or knee (may be intermittent)
Abduction and rotation are limited on examination.
10-20% are bilateral

Question 9

How is Perthe’s disease diagnosed? (1)

Answer 9

Hip X-rays

Question 10

What is talipes equinovarus? (1) What is the position? (3)What is the less severe version and how does it occur? (2)

Answer 10

Club foot - complex abnormality- foot is inverted and supinated, forefoot is adducted, heel rotated inward and plantar flexion. Affected foot is shorter and calf muscles thinner. Foot is fixed.
Positional talipes, caused by intrauterine compression. It is less severe as it can be corrected by neutral position and passive manipulation.

Question 11

Name 2 risk factors for talipes equinovarus. (2)What are the treatment? (2)

Answer 11

Males (2:1), family history, oligohydramnios.

Ponsetti method-plaster casting and bracing over months. Surgery if severe

Question 12

What is osgood-schlatter disease? (1)Who is affected? (2)What are the symptoms? (2)What is treatment? (1)

Answer 12

Osteochondritis at the insertion of the patellar tendon.
Adolescent males who are physically active.
Knee pain after exercise.
Localised tenderness and swelling over tibial tuberosity.
Physiotherapy.

Question 13

What is chondromalacia patellae and what are the symptoms? (2)Name 2 risk factors. (2)What is the management? (1)

Answer 13

Softening of the articular cartilage of the patella causing pain when standing up from sitting or walking up stairs.
Mainly adolescent females, associated with hypermobility and flat feet.
Treat with rest and physio.

Question 14

A 15 year old girl attends with pain in the L knee on using the stairs, and a 15 year old boy has knee pain after playing football. For each name the most likely diagnosis. (2)

Answer 14

Girl- chrondromalacia patellae- adolescent female, pain on using stairs.
Boy- osgood-schlatter disease- adolescent male, pain after exercise.

Question 15

A 15 year old boy who is training with Arsenal youth squad presents with knee pain. There is no history of trauma, and examination shows localised tenderness over the femoral condyles. What is the most likely diagnosis? (1)How does this cause his symptoms? (2)

Answer 15

Osteochondritis dissecans

Pain is caused by separation of bone ad cartilage from medial femoral condyle following avascular necrosis.

Question 16

Name 3 red flag symptoms of back pain in children. (3)

Answer 16

Young age, high fever, night waking, painful scoliosis, focal neurological signs and weight loss, systemic malaise.

Question 17

Name 3 medical causes of obesity in children. (3)

Answer 17

Hypothyroidism, Cushing’s disease, Prader-Willi, Down’s syndrome, GH deficiency.

Question 18

What is the best method of ascertaining wheher a child is obese? (1)

Answer 18

BMI percentile charts adjusted for sex and age.

Question 19

What does SUFE stand for? (1)What age group is most commonly affected? (1)

Answer 19

Slipped upper femoral epiphysis

Adolescents

Question 20

In SUFE which way does the epiphysis displace? (1)Which movements of the hip are affected? (2)What imaging is best for diagnosing? (2)What is the management and what is the purpose? (2)

Answer 20

Postero-inferiorly
Abduction and external rotation are restricted
Xray- frog lateral view
Internal fixation with pins to prevent avascular necrosis

Question 21

A 15-year-old girl presents with a palpable purpuric rash over her lower limbs accompanied by polyarthralgia following a recent sore throat. What is the most likely diagnosis?

Answer 21

Henoch-Schloein purpura

Question 22

What is HSP? (1)What areas does the purpura usually affect? (3)

Answer 22

Small vessel IgA mediated vasculitis

Buttocks and extensor surfaces of arms and legs

Question 23

What is Duchenne muscular dystrophy? (2)Why are boys mainly affected? (1)

Answer 23

Rapidly degenerative muscle disorder characterised by progressive muscle weakness and wasting.
X-linked recessive

Question 24

Why is Duchenne’s referred to as a muscular dystrophy? (1)

Answer 24

Disease is caused by mutations in gene coding for Dystrophin. This is a protein that forms part of muscle sarcolemma.

Question 25

What is the usual presentation of symptoms caused by Duchenne's muscular dystrophy? (3)

Answer 25

Appears healthy at birth. Onset of symptoms between 1-6 years old, with waddling gait, toe walking, difficulty running, climbing stairs, or getting up from a seated position. By age 12, most are wheelchair bound.

Question 26

On examination of a child with Duchenne's muscular dystrophy, what findings might you expect to see? (3)

Answer 26

Symmetrical muscle weakness, most prominent in the pelvic and shoulder girdle. Calf muscle pseudohypertrophy, caused by adipose replacement of muscle fibres. Gower's sign - pushes hands against thighs to overcome proximal and pelvic girdle weakness to stand from seated.

Question 27

What is Gower's sign? (2)

Answer 27

Pushing with hands on thighs in order to overcome proximal and pelvic girdle weakness to stand up from seated floor position.

Question 28

A concerned mother brings her 18 month old boy to your GP surgery worried that he is not yet walking. What is the most important diagnosis to exclude and what one blood test will help diagnose this condition? (2)

Answer 28

Duchenne Muscular dystrophy CK very high from birth, only starts to drop once muscle bulk diminished e.g. in already wheelchair users. If CK normal then DMD is excluded.

Question 29

What combination of tests are best used to diagnose Duchenne's? (3)

Answer 29

Serum CK Genetic testing Muscle biopsy and assay for dystrophin protein.

Question 30

What is the definition of juvenile idiopathic arthritis? (1) | Why is it important? (1)

Answer 30

Joint inflammation in a child persisting for more than 6 weeks in the absence of another cause. Purely clinical diagnosis.

Question 31

What is the most common type of juvenile idiopathic arthritis? (2) How does it present? (2)

Answer 31

Oligoarticular affecting 1-4 joints in the first 6 months. Usually girls under 6 years old. Most commonly knee or ankle stiffness and reduced movement but not much pain.

Question 32

Heidi is a 4 year old girl brought to the GP surgery by her mother with a 4 month history of stiffness in some of her joints and reduced movement. You suspect juvenile idiopathic arthritis. What is the most likely diagnosis if there are 4 joints affected? (1) What is the most likely diagnosis if there are 6 joints affected? (1)

Answer 32

Oligoarticular JIA (up to 4 joints affected in first 6 months) Polyarticular JIA (RF negative more common than RF positive) (more than 5 joints affected in first 6 months)

Question 33

Name 3 sub types of juvenile idiopathic arthritis. (3)

Answer 33

``` Oligoarticular JIA Polyarticular JIA (RF negative) Polyarticular JIA (RF positive) Systemic JIA Enthesis related JIA Juvenile Psoriatic Arthritis Undifferentiated ```

Question 34

You are a doctor in a GP surgery and have a child complaining of stiff joints. What investigations would you perform? (3)

Answer 34

FBC: normocytic normochromic anaemia Rf, ANA, HLA B27 for classification of JIA ESR or CRP are usually raised Blood cultures if considering septic arthritis Aspiration of joint if considering septic arthritis Joint x-ray to look for destructive changes

Question 35

Holly has juvenile idiopathic arthritis in both her knees. | What management would you arrange? (2)

Answer 35

Physiotherapy Occupational therapy Play specialist Clinical psychology Analgesia (NSAIDs) Intra-articular steroids Methotrexate