Musculoskeletal Disorders Flashcards
Define Slipped Upper Femoral Epiphysis
Occurs when weakness in the proximal femoral growth plate allows displacement of the
epiphysis of the femoral head postero-inferiorly
What is the pathophysiology of SUFE
• Rare hip condition mainly seen in OBESE BOYS
• Pathophysiology
o Normally femur consists of 4 parts
▪ Diaphysis (shaft of the bone)
▪ Metaphysis
▪ Neck
▪ Physis/growth plate: contains cell which divide and allow bone to grow in length→growth plate eventually ossifies and fuses with the epiphysis (~age 16 in females and age 19 in males)
o During growth spurt, the growth plate is relatively weak and vulnerable to shearing forces
o Before the growth plate ossifies, it is supported by the perichondrial ring (dense connective tissue that extends from the metaphysis to the epiphysis). The perichondrial ring helps resist shearing forces so that the femoral head and femoral neck don’t slip away from one another
o In slipped capital femoral epiphysis, the perichondrial ring becomes too weak to resist the shearing forces between the femoral head and neck causing the two gradually slip away from each other
o It is not actually the epiphysis that slips away→it is the neck that displaces anterolaterally and superiorly
o If the displacement is severe, it can tear the epiphyseal blood vessels interrupting the blood supply to the femoral head. If this happens, it can lead to avascular necrosis of the femoral head
• Requires prompt treatment to prevent avascular necrosis
What are the RFs of SUFE?
• Most common at ages 10-15 years during adolescent growth spurt, particularly in obese boys
• Risk factors
o OBESITY: the extra weight increases pressure on the epiphysis-physis junction
o Rapid growth during adolescence
o There is an association with metabolic endocrine abnormalities e.g. hypothyroidism
and hypogonadism o Family history
What are the clinical features of SUFE?
- May present acutely following trauma or more commonly with chronic, persistent symptoms
- Acute (after minor trauma) or insidious onset of pain and limp
- Bilateral in 20%
- Hip, groin, medial thigh or knee pain
- Examination shows restricted abduction and internal rotation of the hip
What investigations would you do for a suspect SUFE
X-ray including frog lateral view
o Bilateral AP X-ray will show Klein’s line, which is drawn along the superior aspect of the femoral neck, not intersecting the femoral head (normally intersects some part of the femoral head) - Trethowan’s sign
o Frog-leg lateral X-ray will show Bloomberg’s sign (physis will be blurred or widened), widened joint space and displaced femoral head
MRI if high suspicion - can detect early SUFE or features consistent with a risk of slipping in the contralateral hip.
What is the management of SUFE?
Don’t let the patient walk, analgesia- Period of rest with limited weight bearing
Surgical repair - In situ screw fixation across the growth plate - immediate orthopaedic referral
Physiotherapy post surgery to regain normal function
How does arthritis present?
Acute arthritis presents with pain, swelling, heat, redness and restricted movement in a joint
What are the type of arthritis?
Monoarthritis and polyarthritis
What are the causes of monoarthritis?
o Septicarthritis
o Osteomyelitis
What are the causes of poly arthritis?
What is the most common arthritis in childhood?
Reactive arthritis.
What is reactive arthritis?
An inflammatory arthritis that occurs following exposure to certain gastrointestinal and genitourinary infections
What are the preceding extra-articular infections in reactive arthritis?
o Common preceding infections in childhood are enteric bacteria including Salmonella,
Shigella, Campylobacteria, Yersinia
o Other causes:
▪ Viral infections
▪ STIs in adolescents: chlamydia, gonococcus
▪ Mycoplasma
▪ Borrelia burgdorferi (Lyme disease)
▪ Rheumatic fever and post-streptococcal reactive arthritis, particularly in developing countries
What are the clinical features of reactive arthritis?
- History of gastrointestinal or genitourinary infection 1-4 weeks before onset of arthritis
- Transient joint swelling of ankles or knees usually
- Low grade fever
Characterised by transient joint swelling (usually < 6 weeks) often of the ankles or knees
What would investigations for reactive arthritis show?
ESR/CRP: mildly elevated
Urogenital/stool culture
X-ray: normal
What are the clinical features of septic arthritis?
- PAINFUL, HOT, SWOLLEN, RESTRICTED JOINT
- Acutely unwell, febrile child
- Infants may hold the limb still (pseudoparesis, pseudoparalysis)
- Infants will cry when the affected limb is moved
- Joint effusion may be visible in peripheral joints
- Co-existent osteomyelitis (15%) - marked tenderness over bone
- Pain may be referred to the knee
- May present with limp initially
- Often diagnosed late due to poor localisation of symptoms and normal plain X-ray findings
What is the criteria used for assessing septic arthritis?
What is the management of JIA? What is the prognosis?
- Joint injections – effective, first-line treatment for oligoarticular JIA; in polyarticular disease multiple joint injections are used as a bridging agent when starting methotrexate. Often requires sedation or inhaled anaesthesia (Entonox). Depending on the joint, guidance with ultrasound or X-rays may be needed.
- Cytokine modulators (‘ biologics ’) and other immunotherapies – many agents (e.g. anti-TNF alpha, IL-1, CTLA-4, or IL-6) are now available and useful in severe disease refractory to methotrexate. They are expensive and given under strict national guidance with registries for long-term surveillance. T-cell depletion coupled with autologous haematopoietic stem cell rescue (bone marrow transplant) is an option for refractory disease. Selecting the most suitable medication remains problematic.
SUFE
