Orthopaedics And Rheumatology Flashcards by Shaili Kadambande

Juvenile idiopathic arthritis

Autoimmune inflammation occurs in the joints
Arthritis without any other cause
Lasting >6 weeks
<16s

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Key features of inflammatory arthritis

Joint pain
Swelling
Stiffness

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Subtypes of juvenile idiopathic arthritis

Systemic JIA
Polyarticular JIA
Oligoarticular JIA
Enthesitis related arthritis
Juvenile psoriatic arthritis

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Systemic juvenile idiopathic arthritis features

Still’s disease
Systemic illness
Subtle salmon-pink rash
High swinging fevers
Enlarged lymph nodes
Weight loss
Joint inflammation and pain
Splenomegaly
Muscle pain
Pleuritic and pericarditis

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Systemic JIA (Stills disease) investigations

ANA and RF negative
Raised inflammatory markers
Raised CRP, ESR, platelets, serum ferritin

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Complications of systemic juvenile idiopathic arthritis

Macrophage activation syndrome:
Acutely unwell child 
DIC
Anaemia
Thrombocytopenia
Bleeding
Non-blanching rash
Life-threatening
Low ESR key finding

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Polyarticular juvenile idiopathic arthritis presentation

Idiopathic inflammatory arthritis in 5 joints or more
Symmetrical and can affect small joints of hands and feet
Can also affect hips and knees
Mild fever, anaemia, reduced growth
Mild systemic symptoms

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Polyarticular JIA investigations

Rf negative, seronegative in younger

Seropositive patients are older

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Oligoarticular JIA presentation

<4 joints
Usually only affects a single joint, mono arthritis
Tends to affect larger joints, often knee or ankle
Occurs more frequently in <6year old girls
Anterior uveitis, refer to ophthalmology, follow-up for uveitis
No systemic symptoms usually

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Oligoarticular JIA investigations

Inflammatory markers normal or mildly elevated
ANA often positive
Rf often negative

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Enthesitis- related arthritis presentation

Males >6 years
Inflammation of point where tendon inserts into bone
Check for psoriasis, IBD, anterior uveitis

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Seronegative spondyloarthropathies

Ankylosing spondylitis 
Psoriatic arthritis
Reactive arthritis
Inflammatory bowel disease- related arthritis
Inflammatory arthritis 
Enthesitis

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Causes of enthesitis

Traumatic stress

Repetitive stress during sporting activities, caused by autoimmune inflammatory process

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Investigations enthesitis-related arthritis

MRI

HLA B27

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Key areas to palpate to elicit tenderness of entheses

Interphalangeal joints in hand
Wrist
Over greater trochanter on lateral aspect of hip
Quadriceps insertion at anterior superior iliac spine
Quadriceps and patella tendon insertion around patella
Base of Achilles, at calcaneus
Metatarsal heads on base of foot

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Juvenile psoriatic arthritis presentation

Symmetrical poly arthritis affecting small joints

Asymmetrical arthritis affecting large joints in lower limb

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Juvenile psoriatic arthritis signs on examination

Plaques of psoriasis on skin
Nail pitting
Onycholysis: separation of nail from nail bed
Dactylitis; inflammation of full finger
Enthesitis: inflammation of entheses

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Management of JIA

Paediatric rheumatology
MDT
NSAIDs: ibuprofen
Steroids: oral, intramuscular, intra-articular in oligoarthritis
DMARD: methotrexate, sulfasalazine, leflunomide
Biologic therapy: TNFi, etanercept, infliximab, adalimumab

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Ehler-Danlos syndrome

Genetic condition
Defects in collagen
Hyper mobility of joints
Abnormalities in connective tissue

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Hyper mobile Ehlers-Danlos syndrome presentation

Hyper mobility in joints
Joint pain after exercise or inactivity
Joint dislocations, shoulders or hips
Soft- stretchy skin
Easy bruising
Poor healing of wounds
Bleeding
Headaches
Autonomic dysfunction causing dizziness and syncope
Abdominal pain 
IBS
Menorrhagia and dysmenorrhea
Premature rupture of membranes in pregnancy
Urinary incontinence
Pelvic organ prolapse
Temporomandibular joint dysfunction 
Myopia and other

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Beighton score for hyper mobility

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Palms flat on floor with straight legs 
Elbows hyperextend
Knees hyperextend
Thumb can bend to touch forearm 
Little finger hyper extends past 90 degrees

Management of Ehlers Danlos

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Physiotherapy: strengthen and stability joints
Occupational therapy: maximise function
Maintaining good posture in joints
Moderating intensity of activity to minimise flares
Psychology

Postural orthostatic tachycardia syndrome

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Autonomic dysfunction in hyper mobile Ehlers-Danlos syndrome
Inappropriate tachycardia on sitting or standing up
Distressing symptoms: pre-syncope, syncope, headaches, disorientation, nausea and tremor

Types of Ehlers-Danlos

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Hyper mobile
Classical
Vascular
Kyphoscoliotic

Salter Harris classification

``` TY1: straight across growth plate TY2: above TY3: below TY4: through TY5: crush ```

Fracture management

Mechanical alignment via reduction | Provide relative stability

Pain ladder for children

Paracetamol or ibuprofen | Morphine

Causes of hip pain 0-4 years

Septic arthritis DDH Transient synovitis

5-10 years hip pain

Perthes Septic arthritis Transient synovitis

10-16 years joint pain

Septic arthritis SUFE Juvenile idiopathic arthritis

Red flags for hip pain

``` Child <3 years Fever Waking at night with pain Weight loss Anorexia Night sweats Fatigue Persistent pain Stiffness in morning Swollen or red joint ```

Criteria for urgent referral for assessment in a limping child

``` Child under 3 years Child older than 9 with a restricted or painful hip Not able to weight bear Evidence of neurovascular compromise Severe pain or agitation Red flags for serious pathology Suspicion of abuse ```

Investigations for hip pain

Blood tests including inflammatory markers (CRP and ESR) for JIA and septic arthritis Xrays are used to diagnose fractures, SUFE and other boney pathology Ultrasound can establish an effusion (fluid) in the joint Joint aspiration is used to diagnose or exclude septic arthritis MRI is used to diagnose osteomyelitis

Septic arthritis presentation

``` Most common in <4s Hot, red, swollen and painful joint Refusing to weight bear Stiffness and reduced range of motion Systemic symptoms: fever, lethargy, sepsis ```

Bacteria in septic arthritis

Staph aureus most common Neisseria gonorrhoea (gonococcus) in sexually active teenagers Group A streptococcus (Streptococcus pyogenes) Haemophilus influenza Escherichia coli (E. coli)

DD for septic arthritis

Transient sinovitis Perthes disease Slipped upper femoral epiphysis Juvenile idiopathic arthritis

Septic arthritis management

Admission Involve orthopaedics Aspirate joint prior to giving antibiotics Send sample for gram staining, Crystal microscopy, culture and antibiotic sensitivities Joint fluid may be purulent Empirical IV antibiotics 3-6weeks Surgical drainage and joint washout

Transient synovitis presentation

``` Recent URTI 3-10 years Limp Refusal to weight bear Growing or hip pain Mild low grade temperature ```

Management of transient synovitis

Symptomatic management | Resolve in 1-2weeks

Perthes disease

Avascular necrosis of femoral head Revascularisiation and healing, remodelling Complication: hip osteoarthritis

Perthes presentation

``` Pain in hip or groin Limp Restricted hip movements Referred pain to knee No history of trauma ```

Perthes investigations

XRAY Blood tests normal Technetium bone scan MRI

Perthes management

Bed rest, traction, crutches, analgesia Physiotherapy Regular X-rays Surgery in severe case

Slipper upper femoral epiphysis presentation

``` 8-15 years Obese children Minor trauma Hip, groin, thigh or knee pain Restricted range of hip movement Painful limp Restricted movement in the hip Restricted internal rotation ```

SUFE diagnosis

``` XRAY Blood tests normal Technetium bone scan CT MRI ```

Management of SUFE

Screw surgery

Development dysplasia of hip risk factors

First degree family history Breech presentation from 36 weeks onwards Breech presentation at birth if 28 weeks onwards Multiple pregnancy

DDH screening

Neonatal examination Birth 6-8 weeks

Features of DDH

Different leg lengths Restricted hip abduction on one side Significant bilateral restriction in abduction Difference in the knee level when the hips are flexed Clunking of the hips on special tests Ortolans Barlow

DDH diagnosis

Ultrasound | XRAY

DDH management

Pavlik harness 6-8 weeeks Surgery Hip spica cast post surgery

Orthopaedics And Rheumatology Flashcards

(51 cards)