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Paediatrics > Orthopaedics and Rheumatology > Flashcards

Orthopaedics and Rheumatology Flashcards

1
Q

What is genu varum/bow legs?

A

Knees wide apart
Pathological cause is rickets
Blount disease - severe progressive and unilateral bow legs

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2
Q

What is genu valgum?

A

Knock knees

Seen in many young children, resolves spontaneously

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3
Q

What is metatarsus varus?

A 
Adduction deformity 
Occurs in infants
Highly correctable
Heel held in normal position
No treatment required unless persists/symptomatic
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4
Q

What is medial tibial torsion?

A

Tibia laterally rotated less than normal in relation to femur
Occurs in toddlers
May be due to bowing
Self corrects within 5 years

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5
Q

What is persistent ante version of the femoral neck?

A

At the hip, femoral neck twisted more than normal
Presents in childhood
Usually self corrects by 8
Children sit between fit, hips fully internally rotated

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6
Q

What are causes of toe walking?

A 
Between ages 1-3
Mild cerebral palsy
Tightness in achilles or inflammatory arthritis
Spastic diplegia
In boys - exclude Duchennes
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7
Q

What is talipes equinovarus?

A 
Clubfoot
Entire food inverted and supinated, heel rotated in
Affected foot shorter
Calf muscles thinner
Position of foot is fixed
Often bilateral
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8
Q

What are the causes of talipes equinovarus?

A

Can be familial
Usually idiopathic
May be secondary to oligohydramnios
Or feature of malformation syndrome or neuromuscular disorder e.g. spina bifida

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9
Q

What is the treatment for club foot?

A

Ponsetti method

Plaster cating and bracing

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10
Q

What is vertical talus?

A

Where the foot is stiff and rocker bottom in shape

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11
Q

What is talipes calcaneovalgus?

A

Foot dorsiflexed and everted
Usually results from intrauterine moulding and self corrects
Association with DDH

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12
Q

What is pes cavus associated with?

A

High arched foot

In older children - neuromuscular disorders e.g. Friedreich ataxia and type 1 hereditary motor sensory neuropathy

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13
Q

What is DDH?

A

Developmental dysplasia of the hip

Spectrum from dysplasia to subluxation to dislocation

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14
Q

What tests of the NIPE check from DDH?

A

Barlow’s - hip can be dislocated posteriorly out of acetabulum
Ortolani’s - relocated back into acetabulum on abduction

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15
Q

What is the presentation of DDH?

A 
Usually spotted on NIPE
Thereafter - limp or abnormal gait
Asymmetry of skin folds around hip
Limited abduction of hip
Shortening of affected leg
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16
Q

What is the management of DDH?

A

USS shows detail, degree of dysplasia

Infant may be placed in splint or harness to keep hip flexed and abducted

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17
Q

What are the causes of scoliosis?

A

Idiopathic - early onset <5 or late onset girls 10-14 during pubertal growth spurt

Congenital - structural defect e.g. hemivertebra, spina bifida

Secondary - related to other disorders e.g. cerebral palsy, muscular dystrophy, Marfan’s

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18
Q

What is torticollis?

A

Wry neck - twisting of neck causes it to be held on one side
Most common cause is sternomastoid tumour
Present with mobile non vendor nodule
Condition resolves in 2-6 months

Or later in childhood due to muscle spasm, secondary to ENT infection or spinal tumour

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19
Q

What is the presentation of growing pains?

A

Wakes child from sleep
Settles with massaging
Age range 3-12 years
Symmetrical in lower limbs
Not limited to joints
Never present at start of day after waking
Physical activities not limited - no limp
Physical examination normal and otherwise well

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20
Q

What are the types of paediatric fractures?

A 
Buckle
Transverse
Oblique
Spiral 
Segmental
Salter-Harris - at growth plate
Comminuted
Greenstick
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21
Q

What is the Salter-Harris classification?

A 
SALTR
Straight across
Above
BeLow
Through
Crush
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22
Q

What pain medication is not used in children?

A

Codeine and tramadol as there is unpredictability in their metabolism
Aspirin contraindicated under 16 due to risk of Reye’s syndrome except in certain circumstances e.g. Kawasaki

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23
Q

What else might a child present with alongside hip pain?

A 
Limp
Refusal to use affected leg
Refusal to weight bear
Inability to walk
Pain
Swollen or tender joint
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24
Q

What are common causes of joint pain 0-4 years?

A

Septic arthritis
DDH
Transient sinovitis

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25
Q

What are common causes of joint pain 5-10 years?

A

Septic arthritis
Transient sinovitis
Perthes disease

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26
Q

What are common causes of joint pain 10-16 years?

A

Septic arthritis
Slipped upper femoral epiphysis SUFE
Juvenile idiopathic arthritis

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27
Q

What are the red flags for hip pain?

A 
Child under 3 years
Fever
Waking at night with pain
Weight loss
Anorexia
Night sweats
Fatigue
Persistent pain
Stiffness in the morning
Swollen or red joint
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28
Q

What is the criteria for an urgent referral in a limping child?

A 
Child under 3
Older than 9 with restricted or painful hip
Unable to weight bear
Evidence of neuromuscular compromise
Severe pain or agitation
Red flags of serious pathology
Suspicion of abuse
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29
Q

What are investigations for hip/joint pain?

A 
Bloods, including inflammatory markers ESR + CRP for JIA and septic arthritis
X-Rays for fractures, SUFE
US for effusion in joint
Joint aspiration - septic
MRI - osteomyelitis
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30
Q

What is the presentation of septic arthritis?

A

Infection inside a joint
Most common under 4
Important complication of joint replacement

Often a knee or hip

Hot, red, swollen, painful
Refusing to weight bear
Stiffness, reduced range of motion
Systemic symptoms e.g. fever, lethargy, sepsis

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31
Q

What are common bacteria causing septic arthritis?

A

Staph aureus most common

Neisseria gonorrhoea in sexually active teens
Group A strep/strep pyogenes
H influenza
E Coli

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32
Q

What are the differentials of septic arthritis?

A

Transient sinovitis
Perthes
Slipped upper femoral epiphysis
Juvenile idiopathic arthritis

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33
Q

What is the management of septic arthritis?

A

Aspiration before antibiotics
Gram stain, crystal microscopy, culture, sensitivities
Empirical abx - flucloxacillin or clindamycin if penicillin allergy
If gonococcal - cefotaxime or ceftriaxone
4-6 weeks

May require surgical drainage and washout

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34
Q

What is transient synovitis?

A

Irritable hip
Temporary irritation and inflammation in the synovial membrane of the joint
Most common cause of hip pain in children 3-10
Often associated with recent viral URTI

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35
Q

What is the presentation of transient synovitis?

A

Do not have a fever - if so consider septic arthritis!

Occurs within few weeks of viral illness
Acute or gradual onset
Limp
Refusal to weight bear
Groin or hip pain
Mild low grade temperature
Should otherwise be well
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36
Q

What is the management of transient synovitis?

A

Symptomatic - simple analgesia to ease discomfort
Managed in primary care aged 3-9 if limp is present for less than 48 hours and otherwise well
Safety net to attend A&E immediately if worsen or develop a fever

Typically symptoms improve after 24-48 hrs, resolve within 1-2 weeks without any lasting problems

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37
Q

What is the presentation of septic arthritis in the hip in infants?

A

Leg held flexed, abducted, externally rotated
No spontaneous movement
Marked tenderness over head of the femur
Swollen thigh

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38
Q

What is reactive arthritis?

A

Most common form of arthritis in children
Triggered by infection elsewhere in the body
Transient joint swelling <6 weeks - often ankles or knees
Usually follows extra-articular infection

Low grade fever
No treatment or only NSAIDs required

Can’t see - conjunctivits
Can’t pee - urethritis
Can’t climb a tree - arthritis

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39
Q

What are common causes of reactive arthritis?

A

Enteric bacteria - salmonella, shigella, campylobacter
Viral infections, STIs e.g. chlamydia, gonococcus
Mycoplasma
Borrelia - Lyme disease

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40
Q

What is osteomyelitis?

A

Infection of bone and bone marrow

Mostly occurs in metaphysic of long bones

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41
Q

What is the most common bacterial cause of osteomyelitis?

A

Staphylococcus aureus

May have been introduced directly into bone e.g. fracture, or entered through another route e.g. skin or gums

Can also be due to Streptococcus or Haemophilus influenza

In sickle cell - there is an increased risk of staphylococcal and salmonella

42
Q

What are the risk factors for osteomyelitis?

A 
More common in boys and under 10
Open bone fracture
Orthopaedic surgery
Immunocompromised
Sickle cell anaemia
HIV
TB
43
Q

What is the presentation of osteomyelitis?

A 
Can present acutely in an acutely unwell child, or chronically with subtle features
Refusing to use limb
Will not weight bear
Pain
Swelling
Tenderness

May be afebrile or have low grade fever
Children with acute osteomyelitis may have high fever, particularly if spread to joint causing septic arthritis

44
Q

What are the investigations for osteomyelitis?

A 
X-rays, btu could be normal
MRI
Bone scan
Bloods - raised CRP, ESR and WCC
Blood culture
Bone marrow aspiration or bone biopsy with histology
45
Q

What is seen on x-ray in chronic osteomyelitis?

A

Periosteal reaction along lateral shaft of tibia

Multiple hypotenuse areas within the metaphysical regions

46
Q

What is the management of osteomyelitis?

A

Flucloxacillin, 6 weeks for acute infection
Consider adding fusidic acid or rifampicin for initial 2 weeks
Or clindamycin, or vancomycin

Aspiration or surgical decompression of subperiosteal space may be needed
Surgical drainage
Rested in splint and then mobilised

47
Q

What is Perthes disease?

A

Disruption of blood flow to the femoral head causing avascular necrosis

48
Q

Who is Perthes most common in?

A

Children aged 4-12
Mostly between ages 5-8
More common in boys

49
Q

What is the main complication of Perthes?

A

Revascularisation or neovascularisation and healing, leads to remodelling and a soft and deformed head can lead to early hip osteoarthritis

50
Q

What is the presentation of Perthes?

A

Slow onset
Pain in hip or groin
Restricted hip movements
Referred pain to knee

No history of trauma (or think SUFE)

51
Q

What are the investigations for perthes?

A

Xray, but could be normal
Bloods normal
Technetium bone scan
MRI scan

52
Q

What is the management of perthes?

A 
Maintain healthy position and alignment to reduce damage or deformity
Bed rest
Traction
Crutches
Analgesia
Physio
Regular xrays
Surgery
53
Q

What is SUFE?

A

Slipped upper femoral epiphysis

Head of femur displaced and slips along the growth plate

54
Q

Who is SUFE more common in?

A

8-15 years
Presents slightly earlier in females, more common in boys
More common in obese kids

55
Q

What is the presentation of SUFE?

A

May have growth spurt
May have hx of minor trauma

Hip, groin, thigh, knee pain
Restricted range of hip movement
Painful limp
Restricted movement in the hip

Will prefer to keep hip in external rotation
Limited movement of hip, restricted internal rotation

56
Q

What is the diagnosis and management for SUFE?

A

xray
Bloods normal, use of inflammatory markers to exclude other diagnoses
Technetium bone scan
CT scan, MRI scan

Surgery required to return femoral head to correct position

57
Q

What is rickets?

A

Defective bone mineralisation
Osteomalacia in adults
Due to deficiency in Vit D or calcium

Or can be hereditary hypophosphataemic rickets - rare, low phosphate, x-linked

58
Q

What are the symptoms associated with rickets?

A 
May be asymptomatic 
Lethargy
Bone pain
Swollen wrists
Bone deformity
Poor growth
Dental problems
Muscle weakness
Pathological or abnormal fractures
59
Q

What bone deformities can occur in rickets?

A

Bowing of legs
Knock knees
Rachitic rosary - ends of ribs expand at costochondral junctions causing lumps along the chest
Craniotabes - soft skull, delayed closure of sutures, frontal bossing
Delayed teeth, underdevelopment of the enamel

60
Q

What are some of the risk factors for rickets?

A

Darker skin
Low exposure to sunlight
Live in cold climates
Spend majority of time inside

61
Q

What are the investigations for rickets?

A

Serum 25 hydroxyvitamin D
<25 nmol/l = Vit D deficient

Xrays show osteopenia - more radiolucent bones

Serum calcium low
Serum phosphate low
Serum alkaline phosphatase high
Parathyroid hormone high

FBC and ferritin for iron deficiency anaemia
Inflammatory markers
U&Es, LFTs
Malabsorption screen e.g. anti-TTG for coeliac
Autoimmune and rheumatoid tests

62
Q

What is the management of rickets?

A

Breastfeeding women and all children should take Vitamin D supplement
Formula feed fortified

Ergocalciferol for children with Vit D deficiency, for 6 mnths-12 years dose is 6000 IU per day for 8-12 weeks

63
Q

What is Osgood-Schlatters?

A

Inflammation of the patellar ligament at its insertion at the tibial tuberosity
Typically affects adolescent males
Presents with knee pain after exercise, localised tenderness
Most resolve with reduced activity and physio to strengthen muscles

64
Q

What is chondromalacia patellae?

A

Softening of the articular cartilage of the patella
Often associated with hyper mobility and flat feet
Treatment is rest and physio for quadriceps strengthening

65
Q

What is osteochondritis dissecans?

A

Persistent knee pain in physically active adolescent
Localised tenderness over femoral condyles
Pain due to separation of bone and cartilage from medial femoral condyle, following avascular necrosis
Rest, exercises, surgery

66
Q

What are some of the causes of back pain?

A

Mechanical pain - muscle spasm or soft tissue injury, poor posture, heavy loading

Tumours - benign or malignant
Spine is common site for osteoid osteoma

Vertebral osteomyelitis or discitis - localised tenderness, resistance to walk or weight bear, IV antibiotics

Spinal cord or nerve root entrapment

Scheuermann disease - osteochronditis of the vertebral body

Spondylolysis or spondylolisthesis - stress fracture

Complex regional pain syndrome

67
Q

What are the red flags of back pain?

A

Young age - pathology more likely
High fever - infection
Night waking, persistent pain - osteoid osteoma or tumours
Painful scoliosis - malignancy or infection
Focal neurological signs including nerve root irritation, loss of bowel or bladder control, compression
Associated weight loss, systemic malaise

68
Q

What are causes of an acute painful limp in a child?

A

1-3 years - infection, osteomyelitis, septic arthritis, transient synovitis, trauma, malignancy

3-10 years - trauma, infection, perthes, JIA, malignancy, CRPS

11-16 years - mechanical, SUFE, JIA, arthritis, infection, malignancy

69
Q

What are some causes of a chronic and intermittent limp?

A

DDH
Neuromuscular e.g. cerebral palsy
JIA, perthes, Duchenne, tarsal coalition

70
Q

What is osteogenesis imperfecta?

A

Genetic condition, results in brittle bones, due to collagen

71
Q

What is the presentation of osteogenesis imperfecta?

A 
Hypermobility
Blue sclera
Triangular face
Short stature
Deafness from early childhood
Dental problems particularly with formation of teeth
Bone deformities e.g. bowed legs, scoliosis
Joint and bone pain
72
Q

What is the management of osteogenesis imperfecta?

A

Bisphophonates to increase bone density
Vit D supplementation to prevent deficiency
Physio and occupational therapy
MDT support

73
Q

What is JIA?

A

Juvenile idiopathic arthritis
Autoimmune inflammation

> 6 weeks in patient under the age of 16

Systemic, polyarticular, oligoarticular, enthesitis related, juvenile psoriatic

74
Q

What are the key features of systemic JIA?

A 
Systemic - Still's disease:
Subtle salmon pink rash
High swinging fevers
Enlarged lymph nodes
Weight loss
Joint inflammation and pain
Splenomegaly
Muscle pain 
Pleuritis, pericarditis

Antinuclear antibodies and rheumatoid factors negative
Raised inflammatory markers

75
Q

What are the differentials for a fever lasting more than 5 days?

A

Aside from non infectious causes - Kawasaki disease, Still’s disease, rheumatic fever, leukaemia

76
Q

What is a key complication of systemic JIA?

A

Macrophage activation syndrome - severe activation of immune system
DIC, anaemia, thrombocytopenia, bleeding, non blanching rash.
There is a low ESR

77
Q

What is polyarticular JIA?

A

Idiopathic inflammatory arthritis in 5 joints or more
Systemic symptoms are mild
May have mild fever, anaemia, reduced growth
Can be seropositive or negative

78
Q

What is oligoarticular JIA?

A

In 4 joints or less
Usually only affects a single joint
Classically associated with anterior uveitis
Antinuclear antibodies positive

79
Q

What is enthesitis related arthritis?

A

More common in male children over 6 years
Where muscle inserts into bone
Type of seronegative spondyloarthropathy
Have HLA B27 gene - look for psoriasis, IBD, anterior uveitis

Tenderness in IPJs, wrist, over greater trochanter, quadriceps, base of achilles, metatarsal

80
Q

What is seen in juvenile psoriatic arthritis?

A 
Can be symmetrical or asymmetrical
Plaques of psoriasis
Pitting of nails
Onycholysis
Dactylitis - inflammation of full finger
Enthesitis
81
Q

What is the management of JIA?

A

NSAIDs and analgesia relieves symptoms
Steroids
DMARDs e.g. methotrexate, sulfasalazine
Biological therapy - TNF inhibitors e.g. infliximab

82
Q

What is Ehlers-Danlos?

A

Umbrella term of genetic conditions that causes defects in collage - hyper mobility in joints and connective tissue

83
Q

What are the types of Ehlers-Danlos?

A

Hypermobile - hyper mobility and soft and stretchy skin
Classic - also have abnormal wound healing, autosomal dom
Vascular - thin translucent skin, vessels prone to rupture
Kyphoscoliotic - hypotonia, then kyphoscoliosis, tall and slim

84
Q

What is the presentation of hyper mobile EDS?

A 
Joint pain, hypermobility
Joint dislocations
Soft stretchy skin
Poor healing of wounds, bleeding
Headaches
GORD, abdo pain, IBS
Dysmenorrhoea, menorrhagia
PROM
Incontinence
85
Q

What is the Beighton score?

A

One point for each side of the body - max of 9 points

Palms flat on floor with straight legs - 1 point
Elbows hyperextended
Knees hyperextended
Thumb can bend to touch forearm
Little finger hyperextends past 90 degrees

86
Q

What is the management of EDS?

A

Diagnosis with Beighton
Exclude Marfan’s by examining high arch palate, arachnodactyly, arm span

Follow ups, physio, OT
Maintain good posture
Moderating exercise
Psychology for chronic condition

87
Q

What is POTS?

A

Postural orthostatic tachycardia syndrome
Can occur with hypermobile EDS
Inappropriate tachycardia on sitting or standing, results in presyncope, syncope, headaches, disorientation, nausea and tremor

88
Q

What is Henoch-Schonlein purpura?

A

IgA vasculitis, presents with purpuric rash affecting lower limbs and buttocks
Due to IgA deposits in blood vessels

Affects skin, kidneys, GI tract
Often triggered by URTI or gastroenteritis

89
Q

What is the presentation of Henoch-Schonlein?

A

Most common in children under age of 10

Purpura, joint pain, abdominal pain, renal involvement

Abdo pain indicative of GI involvement; can lead to gastrointestinal haemorrhage, intussusception, bowel infarction

HSP can cause nephritis, leading to microscopic or macroscopic haematuria and proteinuria - nephrotic syndrome

90
Q

What is key in diagnosis of HSP and differentials?

A

Exclude meningococcal septicaemia and leukaemia

Other differentials include ITP and haemolytic uraemic syndrome causing non blanching rash

FBC and blood film
Renal profile
Serum albumin - nephrotic syndrome
CRP for sepsis
Blood cultures - exclude sepsis
Urine dipstick for proteinuria
Protein:creatinine ratio to quantify proteinuria
BP for hypertension
91
Q

What is the PRES criteria?

A

For diagnosis of HSP
Patient must have
Palpable purpura (not petechiae) plus:

Diffuse abdominal pain
Arthritis or arthralgia
IgA deposits on histology
Proteinuria or haematuria

92
Q

What is the management of HSP?

A

Supportive; simple analgesia, rest, hydration
Could use steroids, considered in severe GI pain or renal involvement

Close monitoring of urine dipstick and blood pressure

93
Q

What is a key complication of Kawasaki disease?

A

Coronary artery aneurysm

94
Q

What are the features of Kawasaki disease?

A

Persistent high fever more than 5 days
Child unhappy and unwell
Widespread erythematous maculopapular rash
Desquamation on palms and soles

Strawberry tongue - red tongue with large papillae
Cracked lips
Cervical lymphadenopathy
Bilateral conjunctivitis

95
Q

What is Kawasaki disease?

A

Mucocutaneous lymph node syndrome, systemic medium sized vessel vasculitis

96
Q

What are the stages of Kawasaki disease?

A

Acute phase - most unwell with fever, rash, lymphadenopathy lasting 1-2 weeks.

Subacute phase - acute symptoms settle, desquamation and arthralgia, risk of coronary artery aneurysms. 2-4 weeks

Convalescent stage - remaining symptoms settle, blood tests return to normal, 2-4 weeks

97
Q

What is the management of Kawasaki disease?

A

High dose aspirin to reduce risk of thrombosis
IV immunoglobulins to reduce risk of coronary artery aneurysms

Follow up with ECHO to motor for coronary artery aneurysms

98
Q

What causes acute rheumatic fever?

A

Autoimmune
Antibodies to streptococcus bacteria
Affects joints, heart, skin, nervous system

Group A beta haemolytic strep, strep progenies causing tonsillitis, antibodies then cause type 2 hypersensitivity reaction
Process usually delayed 2-4 weeks after infection

99
Q

What is the presentation of rheumatic fever?

A

2-4 weeks after streptococcal infection, usually tonsillitis
Fever, joint pain, rash, SOB
Chorea, nodules

Joint involvement - migratory arthritis (different joints affected at different times)

Heart involvement
Carditis, pericarditis, myocarditis, endocarditis:
tachycardia or bradycardia
murmurs - valvular heart disease
Pericardial rub, heart failure

Skin involvement
Subcutaneous nodules
Erythema marginatum rash - pink rings of varying size on torso and proximal limbs

Nervous system involvement
Chorea - uncontrolled rapid movements of the limbs

100
Q

What are the investigations for rheumatic fever?

A

Throat swab - bacterial culture
ASO anti streptococcal antibodies titres
ECHO, ECG, CXR to assess heart involvement

Jones criteria:
2 major or one major and two minor:

Major:
J - joint arthritis
O - organ inflammation
N - nodules
E - erythematous rash
S - sydenham chorea
Minor:
F - fever
E - ECG - prolonged PR 
A - arthralgia without arthritis
R - raised CRP, ESR
101
Q

What is the management of rheumatic fever?

A

Tonsillitis with phenoxymethylpenicillin penicillin V for 10 days

NSAIDs for joint pain
Aspirin and steroids - carditis
Prophylactic abx
Treat complications

102
Q

What are the complications of rheumatic fever?

A

Recurrence
Valvular disease e.g. mitral stenosis
Chronic heart failure

Paediatrics (17 decks)

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