Orthopaedics/Rheumatology Flashcards
1
Q
Slipped capital femoral epiphysis overview
A
Epidemiology
- incidence is approx 1/1,000
- usually presents at beginning of puberty (rapid growth)
- more common in boys
- bilateral disease in majority
Aetiology
- factors that weaken physis
- > physiological changes associated with pubertal growth
- > obesity
- > endocrine (hypothyroidism, GHD)
- > trauma
- > genetic disorder (Down)
- > radiation therapy
Pathophys
- displacement of proximal femor distal to capital physis
- shearing forces exceed strength of capital physis
Clinical manifestations
- usually chronic
- > can be acute/acute on chronic (associated with trauma)
- classic/chronic
- > dull, aching, non radiating pain in hip (can be in knee)
- > worse with exercise, relieved with rest
- > gait may be antalgic, trendelenburg or waddling
- > foot externally rotated
- > ROM reduced (flexion, abduction, internal rotation)
- > tender anterior hip
- > obligatory external rotation during passive flexion
- > weakness
Classification
- stable
- > weight bearing
- unstable
- > non weight bearing
- > evidence of displacement
Imaging
- AP and flog leg lateral radiograph
- > posterior displacement of epiphysis on lateral view
- > kleins line on AP view
- > widened or lucency of physis
Treatment
- non weight bearing
- refer to orthopaedic surgeon
- stabilisation surgery
2
Q
DDH epidemiology, aetiology, pathophys
A
Epidemiology
- incidence = 5/1,1000
- most common neonatal orthopaedic condition
- left hip most common
- > often bilateral
Aetiology
- spectrum of disease
- > dislocation/subluxation
- > dysplasia
- > teratologic hip (eg. connective tissue disorder)
- risk factors
- > family history
- > female
- > breech positioning
- > swaddling (adduction and extension)
- associations
- > first pregnancy
- > oligohydramnios
- > multiple pregnancies
- > high birth weight
Pathophys
- initial instability due to
- > genetic laxity
- > intrauterine or post natal positioning
- > normal femoral head is <50% covered by acetabulum
- instability leads to dysplasia
- > normal development of femoral head/acetabulum needs normal contact
- > laxity of joint capsule
- > lengthening of ligament tires
- > eversion of labrum
- > shallow acetabulum
- dysplasia leads to dislocation/prevents relocation
- > hypertrophied ligamentum teres
- > thickened labrum (neolimbus)
- > pulvinar thickens
- > iliopsoas pulled against capsule (hourglass contracture)
3
Q
DDH diagnosis
A
Hx
- risk factors
- associated factors
- family hx
- child = most walk/reach milestones as usual with no pain
- adolescent = pain
- adult = osteoarthritis/scoliosis/knee pain
Exam <3 months -ortolani ->reducibility -barlow ->dislocatable = palpable clunk ->subluxable = sliding posteriorly -asymmetry ->galeazzi ->skin folds >3 months -hip stabilised (no ortolani/barlow) -asymmetry ->galeazzi ->skin folds -klisic ->fingers on ASIS and GT ->line along fingers should pass through umbilicus ->passes below umbilicus in DDH -limited ROM ->reduced abduction (most sensitive) ->reduced internal rotation Walking -trendelenburg/waddling gait -trendelenburg sign -asymmetry ->toe walking on affected side ->vaulting on unaffected side
Imaging
- ultrasound (best for first 3 months)
- > static = abnormal morphology
- > dynamic = instability with stress manoeuvres
- AP xray (best after 3 months when hips ossified)
- > abnormal morphology
4
Q
treatment DDH
A
0-4 weeks
- laxity is very common
- > vast majority normalise by 2 months without intervention
- > serial examinations
- > refer to surgeon if still unstable at 4 weeks
- dislocated
- > refer to surgeon
1-6 months
- ongoing instability/dislocated
- > pavlik harness for several months
- pavlik harness
- > dynamic
- > prevents adduction and extension
- > permits abduction and flexion
6-18 months
- by now the hip will be dislocated and stable
- closed reduction under anaesthesia
- > open reduction if unsuccessful
- spica cast for several months
- > flexion and slight abduction
> 18 months
- consider open reduction
- > benefit compared to natural hx reduces with age
5
Q
Osteochondrosis overview
A
Kohler’s disease
- idiopathic avascular necrosis of navicular bone
- epidemiology
- > primary school aged children
- > 4x more common in boys
- pathophys
- > central zone of navicular blood supply is watershed
- > last bone to ossify (vulnerable to compression)
- clinical manifestation
- > progressive pain in mid foot
- > antalgic gait on lateral foot
- > point tenderness over navicular
- imaging
- > xray
- > flattening, sclerosis and fragmentation of navicular
- management
- > non operative
- > NSAIDs
- > short leg walking cast for 6 weeks
Freibergs disease
- infarction and fracture of metatarsal head
- epidemiology
- > high school aged children
- > 4x more common in girls
- pathophys
- > repetitive trauma/exercise disrupts blood supply
- clinical manifestations
- > gradual onset pain in forefoot on weight bearing
- > worse while barefoot
- > tender over metatarsal head
- > swelling of MTP
- > crepitus with passive MTP movement
- imaging (xray)
- > flattening of metatarsal head
- > subchondral sclerosis
- management
- > non-operative initially
- > NSAIDs
- > short leg walking cast for 6 weeks
- > orthotics after cast
- > surgery indicated if non operative fails
Leg-Calve-Perthe’s
6
Q
Overview viral myositis and arthritis
A
Myositis
- aetiology
- > influenza A and B
- > enteroviruses
- clinical manifestations
- > preceding viral illness
- > bilateral myalgia (typically lower limb and back)
- > tenderness on palpation
- > muscle swelling
- > weakness
- > myoglobinuria (in rhabdo)
- laboratory findings
- > elevated CK
- > lymphocytosis
- > evidence of viral infection
- > rhabdo (transaminitis and myoglobinuria)
- management
- > supportive
- > vigilance for rhabdo
Arthritis
- aetiology
- > enteroviruses
- > hepatitis A,B,C
- > parvovirus B19
- rubella (including vaccine)
- > alphaviruses (ross river/barmah forest/chikungunya)
- > dengue
- > herpes viruses (mainly EBV)
- > HIV
- clinical manifestations
- > abrupt onset (suspect when symptoms <6 weeks)
- > symmetric, polyarticular
- > arthralgia alone or arthritis
- > often associated with rash
- lab findings
- > usually unnecessary
- > targeted serologic testing
- > synovial fluid analysis is non specific (excludes ddx’s)
- > consider CBC/ESR/CRP/LFTs/RF/CCP
- management
- > NSAIDs/paracetamol
- > treat serious underlying disease
7
Q
Overview traction apophysitis
A
Osgood-Schlatter
- epidemiology
- > occurs with pubertal growth spurt
- > much more common in athletic children
- > more common in boys
- > often bilateral
- pathophys
- > over-use injury
- > ossicle of patella tendon chronically avulsed
- > area of separation becomes fibrous with healing
- clinical manifestations
- > chronic progressive anterior knee pain
- > worse with exercise/relieved by rest
- > antalgic gait when severe
- > soft or bony enlargement of tuberosity
- > tender over tuberosity
- > reproducible pain with knee extension against resistance
- management
- > non operative
- > may take 1-2 years to resolve
- > NSAIDs
- > no need to avoid activities (avoid extended squatting)
- > physio (tight hamstrings and quadriceps)
- > operative (ossicle excision) is rarely needed
Servers
- epidemiology
- > occurs during pubertal growth spurt
- > more common in athletic children
- pathophys
- > over-use injury of calcaneal apophysis
- clinical manifestations
- > gradual onset pain with exercise/relieved by rest
- > pain when heel strike more pronounced (eg. barefoot)
- > pain when squeezing sides of heel
- > tender over calcaneal apophysis
- > tight achilles tendon
- treatment
- > heel cup
- > NSAIDs
- > physio
- > some rest
- > no indication for surgery
Investigations
-guided by ddx’s
8
Q
Overview transient synovitis
A
- epidemiology
- > life time prevalence 3%
- > pre to primary school age
- > more common in boys
- aetiology
- > unknown
- > often follows URTI or trauma
- pathophys
- > inflammation of synovium of large joints (usually hip)
- > rarely bilateral clinically (may be on imaging)
- > recurrence is common
- clinical manifestations
- > acute or insidious hip pain
- > refusal to walk
- > improves over the day
- > afebrile or low fever
- > doesn’t appear systemically unwell
- > hips flexed, abducted, ext. rot. (least capsular pressure)
- > restricted internal rotation
- > painless arc of motion
- investigations
- > only if suspicious for septic arthritis
- > FBC/CRP/ESR
- > arthrocenesis and synovial fluid analysis
- imaging
- > ultrasound = synovial thickening, intracapuslar effusion (often bilateral which counts against septic arthritis)
- > AP and frog leg xray = normal
- > MRI if suspicious for osteomyelitis
- management
- > NSAIDs
- > rest
- > usual resolution within 2 weeks
9
Q
Legg-Calve-Perthes disease overview
A
-epidemiology
->common cause of paediatric hip pain
->mostly primary school aged
->more common in boys
->most common in caucasians
->can be bilateral but rarely synchronous
-aetiology
->unknown
-risk factors
->family hx
->delayed bone age
->clotting disorder
->obesity
->low SES
-pathophys
->avascular necrosis of proximal femoral epiphysis
->collapse then remodelling
-clinical manifestations
->insidious onset hip pain
->worse with activity/sometime better with rest
->antalgic or trendelenburg gait
->loss of internal rotation and abduction
-imaging
->bone scan = decreased perfusion of femoral head
->xray = early is normal, then fragmentation and deformity
->MRI = marrow changes
-management
<8 yrs = NSAIDs, non weight bearing, physio for ROM
>8 yrs = pelvic or femoral osteotomy (seats femoral head in acetabulum)
10
Q
Evaluation child with limp
A
Hx
- age (diseases more common in certain age groups)
- SOCRATES
- > hip -> knee
- > abdo -> hip
- > back -> lateral or posterior thigh
- trauma
- > soft tissue/ fractures
- > may be minimal in toddlers
- > consider abuse
- associated symptoms
- > fever
- > rash
- > incontinence and weakness
- > abdo/back pain
- past history
- > respiratory illness = synovitis
- UI/GI infection = reactive arthritis
- > antibiotics = serum sickness
- > endocrine disorder = SCFE
Exam
- general appearance
- gait
- lower limb exam
- > look/feel/move
- special tests
- > leg log roll = pain with infective/inflammhip pathology
- > supine/knees flexed then IR = limited in SCFE/LCP/DDH
- > galeazzi = SCFE/LCP/DDH
- > trendelenburg = SCFE/LCP/DDH
- > FABERE = sacroiliac joint pathology
- spinal exam
- > abnormal posture/deformity
- > limited ROM
- > tenderness
- > evidence of spinal dysraphism
- still undifferentiated
- > inspect skin
- > abdomen
- > genitalia
- > neuro exam
11
Q
causes limp children
A
Emergency (RANSOM)
- Radiating pain
- > back (discitis, spinal epidural abscess, psoas abscess)
- > abo (PID, appendicitis, ovarian torsion)
- > GU (testicular torsion)
- Abuse
- > multiple fractures at different stages of healing
- > metaphyseal corner fracture
- Neoplasia
- Septic arthritis
- Osteomyelitis
- Meningitis
Common (ADMIT TONS)
- Apophysitis
- DDH
- Myositis
- Inflammatory arthritis
- > rheumatological
- > reactive
- > serum sickness
- Trauma
- > fracture
- > soft tissue injury
- Transient synovitis
- Osteochondrosis
- Neuromuscular disease
- > peripheral neuropathies
- > neuromuscular junction
- > muscular dystrophy
- Slipped capital femoral epiphysis
12
Q
causes of hip pain in children
A
Infectious
- septic arthritis
- osteomyelitis
Inflammatory
- transient synovitis
- ARF
- post strep reactive arthritis
Rheumatology
- JIA
- spondyloarthropathies (GI associated)
Mechanical
- SCFE
- Legg-Calve-Perthes
Neoplastic
-osteoid osteoma
13
Q
septic arthritis background
A
epidemiology
- most common in before school age
- risk factors for adults
- > advanced age
- > pre-existing arthropathy
- > immunosuppression
- > IV drug use
- risk factors for children
- > younger age
- > prematurity
- > cannulisation
aetiology
- adults
- > staph aureus (most common)
- > strep species (healthy adults)
- > gram negative rods (GIT infection/immunocomp)
- children
- > staph aureus (most common)
- > strep species (GBS=neonates/pneumococcal=toddler/GAS=older kids)
- > kingella (toddlers)
- > neisseria (disseminated in newborn/sexual active)
- > haemophilus in unvaccinated
pathophys
- route
- > haematogenous most common
- > direct inoculation with trauma
- > contiguous spread with osteomyelitis (kids)
- synovium
- > highly vascular
- > no basement membrane
14
Q
Evaluation septic arthritis
A
Clinical manifestations
- acute onset
- single joint (polyarticular does occur)
- > red
- > hot
- > swollen
- > painful (any amount of active/passive movement)
- > tender
- > loss of ROM
- large joint
- > usually lower limb (including sacroiliac)
- > knee and hip most common
- systemically unwell
- fever
- neonate
- > intolerance of handling/posture changes
- > pseudoparalysis of limb
- children
- > refusal to walk
- > consider referred pain
- consider
- > hx of trauma
- > rashes
- > recent antibiotic use
- > recent or concurrent illness (haematogenous/reactive)
- > immunisation status
- > family hx of rheumatological disease/IBD
Investigations
- FBC
- > leukocytosis common
- CRP/ESR
- > elevated
- aspiration before abx (into blood culture bottle)
- > cell count = high WCC with neutrophils
- > culture = moderate sensitivity
- > gram stain = increased sensitivity/rapid results
- > polarised microscopy = crystals may co-occur
- xray
- > usually normal
- > excludes ddx’s (fracture/osteomyelitis)
- ultrasound
- > very high sensitivity
- > used to guide aspiration
15
Q
management septic arthritis
A
Drainage
- needle aspiration
- arthoscopic or arthrotomy
- > allows irrigation
- > preferred for hips and shoulders
- repeat drainage may be necessary
Monitor
- clinical condition
- WCC and ESR/CRP
- consider repeat synovial fluid analysis
Supportive
- analgesia
- > opioids inpatient
- > NSAIDs and paracetamol on discharge
- physiotherapy
- > prevent contractures
Antibiotics (guided by gram stain)
- gram +ive cocci in clusters (s. aureus)
- > flucloxacilin 2g (50mg/kg child) IV
- gram +ive cocci in chains (strep) or gram -ive
- > cefotaxime 2g (50mg/kg child) IV
- no gram stain results
- > assume staph aureus
