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Musculoskeletal Disorders Flashcards

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1
Q

Define Septic Arthritis.

A

Infectious arthritis of the synovial joint usually due to haematogenous spread however can occur following puncture around or infected skin lesions.

  • Osteomyelitis = bone infection
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2
Q

What are the risk factors for septic arthritis?

A
  • Joint prosthesis
  • Crystal arthritis
  • Chronic disease
  • Immunosuppression
  • Rheumatoid arthritis
  • Osteoarthritis
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3
Q

What is the most common cause of septic arthritis?

A

S. aureus

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4
Q

What are the signs and symptoms of septic arthritis?

A
  • Single joint affected → usually hip (75% of case)
  • Erythematous, warm, tender affected joint
  • Reduced range of movement
  • Pseudoparalysis - flexed, abducted and externally rotated
  • Pain / crying
  • Acute unwell / Febrile child
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5
Q

What are the appropriate investigations for suspected septic arthritis?

A
  • Septic screen
  • Blood cultures and FBC → ↑ WCC, CRP/ESR
  • Joint aspiration and MC&S
  • 1st = X-Ray - not evident until >2-3w of symptoms → children often present late so is possible
  • 2nd = MRI - shows soft tissue and effusions/collections
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6
Q

What is the management of septic arthritis?

A
  • Antibiotics - IV for 2 weeks → oral for 4 weeks
    • 1st line = Flucloxacillin
    • 2nd line
      • Penicillin-allergic = Clindamycin
      • MRSA = Vancomycin
      • Gram-negative = 3rd generation cephalosporin (e.g. cefotaxime)
  • Washing out / Surgical drainage to dryness may be required
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7
Q

What is the most common cause of childhood arthritis?

A

Reactive arthritis

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8
Q

Define Reactive Arthritis.

A

Joint inflammation in response to an infection elsewhere in the body → can affect a multiple of joints

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9
Q

What are the causative organisms for reactive arthritis?

A
  • Enteric bacteria – Salmonella, Shigella, Campylobacter, Yersinia
  • Viral infections
  • STIs (adolescents) – chlamydia, gonococcus
  • Mycoplasma
  • Borrelia burgdorferi / Lyme disease
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10
Q

What are the signs and symptoms of reactive arthritis?

A
  • Transient joint swelling (<6w duration) – often ankles or knees
  • Follows evidence of extra-articular infection
  • Low-grade fever
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11
Q

What are the appropriate investigations for suspected reactive arthritis?

A
  • Diagnosis of exclusion as no +ve findings
    • Bloods → CRP normal or mildly elevated
    • X- ray → normal
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12
Q

What is the management of reactive arthritis?

A
  • Self-limiting
  • Analgesia / NSAIDs
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13
Q

Define Juvenile Idiopathic Arthritis.

A

Persistent joint swelling (>6w duration) presenting before 16yo, in the absence of infection or other defined cause.

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14
Q

How is juvenile idiopathic arthritis defined?

A
  • Number of joints affected in first 6m
    • Polyarthritis = >4 joints
    • Oligoarthritis = ≤4 joints
  • Presence of rheumatoid factor and HLA B27 tissue type
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15
Q

What is the most common cause of joint disease in children?

A

Juvenile Idiopathic Arthritis

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16
Q

What are the signs and symptoms of juvenile idiopathic arthritis?

A
  • Stiffness after periods of rest / Morning joint stiffness/pain
  • Intermittent limp
  • Limited movement
  • Late signs
    • Inflammation ± bone expansion → overgrowth with leg lengthening/valgus in systemic onset - Genu valgum / “Knock Knees”
    • Salmon-coloured rash → pathogenomic of systemic JIA
    • Fever → systemic
    • Intermittent fever → RF -ve polyarthritis
    • Visual impairment / Chronic anterior uveitis → persistent oligoarthritis
    • Swan-neck deformity and hand problems → RF +ve polyarthritis
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17
Q

What are the appropriate investigations for suspected juvenile idiopathic arthritis?

A

Clinical diagnosis

  • Bloods and imaging provide classification and prognostic information
    • ANA, FBC, RhF, CRP/ESR, anti-CCP
    • USS ± MRI
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18
Q

What is the management of juvenile idiopathic arthritis?

A
  • Rheumatological MDT management
  • OT and PT → inactivity leads to deconditioning, disability and decreased bone mass
  • NSAID analgesia
  • Corticosteroids - whilst waiting for second-line agents to have an effect
    • Intra-articular
    • High dose to induce a remission-state → switch to low dose oral to maintain
  • DMARDs - when disease fails to respond to conventional treatments
    • 1st line = oral/SC methotrexate
    • 2nd line = sulfasalazine
      • DMARDs require regular blood tests
  • Biologics / cytokine modulators (i.e. TNF-a inhibitors)
  • Interleukin receptor antagonists
  • Anti-emetics
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19
Q

What are the complications of juvenile idiopathic arthritis?

A
  • Chronic anterior uveitis (often insidious)
  • Constitutional problems (i.e. anaemia)
  • Flexion contractures of the joints
  • Osteoporosis
  • Growth failure
  • Amyloidosis
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20
Q

What is the prognosis of juvenile idiopathic arthritis?

A
  • Most children can expect good disease control and quality of life
  • With poor disease control → significant morbidity from joint damage, visual impairment leading to anterior uveitis and fractures from osteoporosis
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21
Q

Define Developmental Dysplasia of the Hip (DDH).

A

Spectrum of conditions affecting proximal femur and acetabulum, ranging subluxation to frank dislocation.

  • True DDH = femoral head has a persistently abnormal relationship with acetabulum → abnormal bony development, premature arthritis and significant disability
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22
Q

What are the risk factors for DDH?

A
  • Female (5x)
  • FHx
  • Breech presentation
  • First born
  • Multiple pregnancy
  • Oligohydramnios
  • High BW / Macrosomia
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23
Q

What are the signs and symptoms of DDH?

A
  • Neonatal screening - Barlow and Ortolani +ve
    • Barlow manoeuvre = dislocate posteriorly out of the hip
    • Ortolani manoeuvre = relocate back into acetabulum on hip abduction
  • Limp or Abnormal gait
  • Delayed crawling/walking / Toe-walking
  • Asymmetrical skin folds
  • Limb-length discrepancy - Galeazzi sign – baby on back, legs together and knees flexed – look at leg length)
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24
Q

What are the appropriate investigations for suspected DDH?

A
  • <6m old = Barlow and Ortolani manoeuvre at neonatal screen ± USS (if suspicion remains)
  • >6m old = X-ray
  • USS regardless of presentation at 6 weeks if
    • Born breech
    • FHx (1st degree family member)
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25
What is the management of DDH?
* Most unstable hips will resolve spontaneously by 3-6 weeks * 1st line / Newborn = **Pavlik harness** * Harness keeps hips flexed and abducted * Worn constantly for several weeks * Progress is monitored by repeat ultrasound or X-ray * Complications: * Avascular necrosis * Temporary femoral nerve palsy * 2nd line / \>6 months old = **Surgery**
26
What are the complication of Pavlik harnesses?
* Avascular necrosis * Temporary femoral nerve palsy * *Used as 1st line treatment for DDH*
27
Why do fractures in children follow a unique pattern?
* Compressibility of bones * Increased fibrous strength of periosteum * Presence of physes *(growth plates)*
28
What needs to be considered in every child with a fracture?
Non-Accidental Injury
29
What are the common neonatal fractures?
* **Clavicle** – from shoulder dystocia → great prognosis, no specific treatment needed * **Humerus** or **femur** – from breech delivery → heals rapidly with immobilisation
30
What is the general fracture management in children?
* **Pain management** * \<16yo = oral ibuprofen/paracetamol (IV if severe) * \>16yo à paracetamol ± codeine ± IV morphine * Manipulation and reduction ± IV local anaesthetic or sedation * Sedation * 1st line → intranasal/oral midazolam or NO * 2nd line / severe → intranasal ketamine
31
What is the management of radial fractures?
Elbow plaster cast or k-wire fixation
32
What is the management of femoral shift fractures?
* Neonates (0-28 days) = padded splints or Pavlik’s harness * \<18 months = Gallows traction * 1-6 years = straight leg skin traction * \>4 years = intramedullary nail (+ more support if \>11y)
33
What is Perthe's disease?
**Avascular necrosis of femoral epiphysis** from an interruption of blood supply (osteochondritis) → revascularisation and re-ossification over 18-36m * Complication = premature fusion of growth plates ± osteoarthritis * Epidemiology = mainly boys (5x) 4-8yo * Bilateral in 10-20% * Commonly mistaken for transient synovitis *SUFE in Secondary school aged children*
34
What are the risk factors for Perthe's disease?
* Hyperactivity * Short stature
35
What are the signs and symptoms of Perthe's disease?
* Insidious presentation of * Limp * Hip/knee pain → **limb shortening**
36
What are the appropriate investigations for suspected Perthe's disease?
* **X-Ray ± MRI** - *early stages might not show up on X-ray* * “Increased density of femoral head” * “Fragmented and irregular” / “Flattened femoral head” * **Roll test** – *pt. supine, roll affected hip internally and externally → guarding or spasm*
37
What is the management of Perthe's disease?
* **Simple analgesia** for pain management * **\<6 years = observation** - mobilisation and monitoring as healing potentials are good at this age * **\>6 years = surgery**
38
What is Osgood-Schlatter Disease?
Osteochondritis (inflammation of cartilage or bone) of the patellar tendon insertion at the knee. * Often caused by multiple small avulsion fractures from contractions of quadriceps muscle at their insertion into proximal tibial apophysis (ossification centre) → during growth spurt * Epidemiology = 4% of 10-15yo physically active * Bilateral in 25-50%
39
What are the signs and symptoms of Osgood-Schlatter Disease?
* Knee pain after exercise (gradual onset) * Pain is relieved by rest * Localised tenderness and swelling over tibial tuberosity * Hamstring tightness
40
What are the appropriate investigations for suspected Osgood-Schlatter disease?
* **Clinical diagnosis** * **X-Ray** - *if indicated by Ottawa knee rules* * Fragmentation of the tibial tubercle * Overlying soft tissue swelling
41
What is the management of Osgood-Schlatter disease?
* **Analgesia** - paracetamol or NSAIDs * **Ice packs** - 10-15 minutes after exercise * **Protective knee pads** * **Stretching** * **Reassure** → will resolve over time but may persist until the end of a growth spurt * **Advise stopping/reducing all sporting activity** * *Could change type of exercise to limit running and jumping requiring powerful quadriceps contraction* * *As symptoms decrease, they can gradually increase their exercise levels* * *Introduce low-impact quadriceps exercises (e.g. straight leg raises, cycling or swimming)*
42
What is Chondromalacia Patellae?
Anterior knee pain from degeneration of articular cartilage on posterior surface of patella * Common in young adults from overuse in physical activity
43
What are the signs and symptoms of chondromalacia patellae?
* **Anterior knee pain** * **Pain exacerbated by exercise** → running, climbing stairs or getting up from a chair * Painless passive movements but repeated extension = pain and **grating sensation**
44
What is the management of chondromalacia patellae?
Physiotherapy → strengthen the quadriceps
45
What is Osteochondritis Dissecans?
1. Reduced blood flow 2. Cracks form in the articular cartilage and subchondral bone 3. Avascular necrosis 4. Fragmentation of bone and cartilage with free movement of fragments 5. Activity-related joint pain
46
What are the signs and symptoms of Osteochondritis Dissecans?
* Pain after exercise * Catching, locking and giving way
47
Define Osteomyelitis.
Infection of the metaphysis of long bones - commonly the distal femur and proximal tibia
48
How can the spread of osteomyelitis be slowed / stopped in children?
* **Growth plates in children can prevent further spread into joints** * In infants, before maturation of the growth plates, there can still be possible joint destruction
49
What are the causes of osteomyelitis?
* **Staphylococcus aureus** = most common * Often due to haematogenous spread → can be from direct insult) * Normally \<5yo
50
What are the signs and symptoms of osteomyelitis?
* Fever * Acute onset limb pain, immobile limb, skin swollen, tender and erythematous * *Chronic in onset and less severe than septic arthritis* * *Over a week rather than a day*
51
What are the appropriate investigations for suspected osteomyelitis?
* **Septic screen** * **Blood cultures** - before starting IV antibiotics * **FBC** = ↑ WCC, ↑ CRP/ESR * **Joint aspiration and MC&S** * **X-Ray** → **MRI** of the joint (shows soft tissue) * \>7 days = osteopaenia, bone destruction * *X-Ray often normal until late disease progress*
52
What is the management of acute osteomyelitis?
* **High-dose IV empirical → Narrow spectrum antibiotics → Oral once CRP is normal -** usually for 2-4 weeks * 1st line = Flucloxacillin * 2nd line * Penicillin-allergic = Clindamycin * MRSA = Vancomycin * **Surgical debridement** may be necessary if there is dead bone or a biofilm
53
What is the management of chronic osteomyelitis?
* Clinical assessment with disease staging * Optimisation of comorbidities * Surgical debridement * IV antibiotics * Functional rehabilitation
54
What is Slipped Upper Femoral Epiphysis (SUFE)?
Displacement of epiphysis of femoral head postero-inferiorly, requiring prompt treatment to prevent avascular necrosis
55
What are the risk factors for Slipped Upper Femoral Epiphysis (SUFE)?
* **Obesity** * Metabolic endocrine disease (i.e. hypothyroid, hypogonadism) * Adolescents / during growth spurts * Male
56
What are the signs and symptoms of Slipped Upper Femoral Epiphysis (SUFE)?
* Limp/hip pain * Referred to the knee * Insidious or acute onset - *i.e. after minor trauma* * **Loss of internal rotation of a flexed hip** * Trendelenburg gait +ve (lean on one side)
57
What are the appropriate investigations for Slipped Upper Femoral Epiphysis (SUFE)?
* **Hip X-Ray** in AP and frog-lateral view * Trethowan sign * Loss of triangular sign of Capener * Metaphyseal blanch sign
58
What is the management of Slipped Upper Femoral Epiphysis (SUFE)?
* Analgesia * Bed-bound * Surgical internal fixation at growth plate
59
What is the commonest cause of Slipped Upper Femoral Epiphysis (SUFE)?
Transient Synovitis
60
What is Slipped Upper Femoral Epiphysis (SUFE)?
Irritable hip in 3-10yo * If age \<3yo with an acute limp → urgent hospital assessment
61
What are the signs and symptoms of transient synovitis?
* Acute hip pain associated with a viral infection * Low-grade fever
62
What are the appropriate investigations for suspected transient synovitits?
Clinical diagnosis
63
What is the management of transient synovitis?
Self-limiting

a Paediatrics by themes (26 decks)

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