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a Paediatrics by themes > Musculoskeletal Disorders > Flashcards

Musculoskeletal Disorders Flashcards

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
Q

What is the management of DDH?

A
  • 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
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26
Q

What are the complication of Pavlik harnesses?

A
  • Avascular necrosis
  • Temporary femoral nerve palsy
  • Used as 1st line treatment for DDH
27
Q

Why do fractures in children follow a unique pattern?

A
  • Compressibility of bones
  • Increased fibrous strength of periosteum
  • Presence of physes (growth plates)
28
Q

What needs to be considered in every child with a fracture?

A

Non-Accidental Injury

29
Q

What are the common neonatal fractures?

A
  • Clavicle – from shoulder dystocia → great prognosis, no specific treatment needed
  • Humerus or femur – from breech delivery → heals rapidly with immobilisation
30
Q

What is the general fracture management in children?

A
  • 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
Q

What is the management of radial fractures?

A

Elbow plaster cast or k-wire fixation

32
Q

What is the management of femoral shift fractures?

A
  • 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
Q

What is Perthe’s disease?

A

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
Q

What are the risk factors for Perthe’s disease?

A
  • Hyperactivity
  • Short stature
35
Q

What are the signs and symptoms of Perthe’s disease?

A
  • Insidious presentation of
    • Limp
    • Hip/knee pain → limb shortening
36
Q

What are the appropriate investigations for suspected Perthe’s disease?

A
  • 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
Q

What is the management of Perthe’s disease?

A
  • Simple analgesia for pain management
  • <6 years = observation - mobilisation and monitoring as healing potentials are good at this age
  • >6 years = surgery
38
Q

What is Osgood-Schlatter Disease?

A

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
Q

What are the signs and symptoms of Osgood-Schlatter Disease?

A
  • Knee pain after exercise (gradual onset)
    • Pain is relieved by rest
  • Localised tenderness and swelling over tibial tuberosity
  • Hamstring tightness
40
Q

What are the appropriate investigations for suspected Osgood-Schlatter disease?

A
  • Clinical diagnosis
  • X-Ray - if indicated by Ottawa knee rules
    • Fragmentation of the tibial tubercle
    • Overlying soft tissue swelling
41
Q

What is the management of Osgood-Schlatter disease?

A
  • 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
Q

What is Chondromalacia Patellae?

A

Anterior knee pain from degeneration of articular cartilage on posterior surface of patella

  • Common in young adults from overuse in physical activity
43
Q

What are the signs and symptoms of chondromalacia patellae?

A
  • 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
Q

What is the management of chondromalacia patellae?

A

Physiotherapy → strengthen the quadriceps

45
Q

What is Osteochondritis Dissecans?

A
  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
Q

What are the signs and symptoms of Osteochondritis Dissecans?

A
  • Pain after exercise
  • Catching, locking and giving way
47
Q

Define Osteomyelitis.

A

Infection of the metaphysis of long bones - commonly the distal femur and proximal tibia

48
Q

How can the spread of osteomyelitis be slowed / stopped in children?

A
  • 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
Q

What are the causes of osteomyelitis?

A
  • Staphylococcus aureus = most common
  • Often due to haematogenous spread → can be from direct insult)
  • Normally <5yo
50
Q

What are the signs and symptoms of osteomyelitis?

A
  • 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
Q

What are the appropriate investigations for suspected osteomyelitis?

A
  • 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
Q

What is the management of acute osteomyelitis?

A
  • 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
Q

What is the management of chronic osteomyelitis?

A
  • Clinical assessment with disease staging
  • Optimisation of comorbidities
  • Surgical debridement
  • IV antibiotics
  • Functional rehabilitation
54
Q

What is Slipped Upper Femoral Epiphysis (SUFE)?

A

Displacement of epiphysis of femoral head postero-inferiorly, requiring prompt treatment to prevent avascular necrosis

55
Q

What are the risk factors for Slipped Upper Femoral Epiphysis (SUFE)?

A
  • Obesity
  • Metabolic endocrine disease (i.e. hypothyroid, hypogonadism)
  • Adolescents / during growth spurts
  • Male
56
Q

What are the signs and symptoms of Slipped Upper Femoral Epiphysis (SUFE)?

A
  • 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
Q

What are the appropriate investigations for Slipped Upper Femoral Epiphysis (SUFE)?

A
  • Hip X-Ray in AP and frog-lateral view
    • Trethowan sign
    • Loss of triangular sign of Capener
    • Metaphyseal blanch sign
58
Q

What is the management of Slipped Upper Femoral Epiphysis (SUFE)?

A
  • Analgesia
  • Bed-bound
  • Surgical internal fixation at growth plate
59
Q

What is the commonest cause of Slipped Upper Femoral Epiphysis (SUFE)?

A

Transient Synovitis

60
Q

What is Slipped Upper Femoral Epiphysis (SUFE)?

A

Irritable hip in 3-10yo

  • If age <3yo with an acute limp → urgent hospital assessment
61
Q

What are the signs and symptoms of transient synovitis?

A
  • Acute hip pain associated with a viral infection
  • Low-grade fever
62
Q

What are the appropriate investigations for suspected transient synovitits?

A

Clinical diagnosis

63
Q

What is the management of transient synovitis?

A

Self-limiting

a Paediatrics by themes (26 decks)

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