Paediatric joint disease Flashcards
(48 cards)
1
Q
What are some examples of normal paediatric conditions usually referred?
A
- Flat feet: usually self-limiting
- Toe walkers: children often take first steps on their tip toes, but examination required to exclude tight Achilles tendon and cerebral palsy
- In-toeing gait: can be due to femoral torsion, tibial torsion, or metatarsus (inwardly pointing forefoot), all usually self-limiting
- Bow legs (genu varum): usually self-limiting, sometimes caused by Rickets
- Knock knees (genu valgum): usually self-limiting
- (in general, if symmetrical issue then usually normal, but if asymmetrical then pathology should be suspected)
2
Q
Child sitting in the W position in excessive femoral anteversion…
A
3
Q
What are the 3 paediatric hip disorders?
A
- Developmental dysplasia of the hip (DDH)
- Perthes disease
- Slipped upper femoral epiphysis (SUFE)
4
Q
What is the pathology of DDH (developmental dysplasia of the hip)?
A
- DDH is due to failure of the normal development of the acetabulum and the femoral head and acetabulum do not articulate properly
- joint can dislocate easily
5
Q
What is the aetiology of DDH? (what is DDH associated with)
A
DDH is associated with:
- breech presentation (baby born feet first rather than head first)
- family history
- other congenital deformities / twins
6
Q
Normal hip anatomy VS DDH hip anatomy…
A
7
Q
What are the clinical features of DDH?
A
(majority are picked up on routine baby checks)
Late presenting DDH can present with:
- loss of abduction
- leg length discrepancy
- child will have a limp
8
Q
What are the 2 special tests for dysplastic hips?
A
- Barlow test (attempt to dislocate a reduced hip): with child’s hip flexed to 90 degrees, try to dislocate hip by gently adducting, a clunk is felt if +ve
- Otrolani test (attempt to reduce a dislocated hip): with hips at 90 degrees, gently abduct hip, +ve test if hip reduces with a clunk
9
Q
Barlow test diagram…
A
10
Q
What is the management for DDH?
A
- most are self-limiting
- conservative: abduction splint holds hips in abduction (Pavlik harness)
- surgical: reduction, osteotomies to pelvis/hip to restore normal anatomy
11
Q
Pavlik harness (holds hips in abduction)…
A
12
Q
What is Perthes disease?
A
- blood supply to the femoral head is interrupted, causing avascular necrosis and collapse of the femoral head
13
Q
What are the clinical features of Perthes disease?
A
- child with knee or hip pain and a limp
- aged 4 to 8yrs
14
Q
What investigations should be done for suspected Perthes?
A
- Plain x-ray: sclerosis and fragmentation of epiphysis
- (MRI also very sensitive for diagnosis and staging)
15
Q
What does involvement of femoral head mean about prognosis of Perthes disease?
A
- if less than 50% of femoral head involved: good prognosis and usually self-limiting
- if more than 50% of femoral head involved: poor prognosis, high risk for OA in later life
16
Q
What is the single biggest risk factor for a SUFE and what are the 2 main groups affected by SUFE?
A
- obesity
- (2 groups affected: athletic children, overweight boys with delayed puberty)
17
Q
What are the clinical features of a SUFE?
A
- typically adolescents
- hip pain and limp (history can be acute or gradual), pain may be referred to knee
- examination: reduced hip flexion, +ve Trendelenburg gait
18
Q
What investigation should be done for suspected SUFE?
A
- X-ray: AP, frog-lateral view
19
Q
X-ray of SUFE (frog-lateral view)…
A
20
Q
What is the treatment for a SUFE?
A
- Surgical: epiphysis should be pinned in situ to prevent further displacement
- note: treatment should be prompt to prevent avascular necrosis of the femoral head
21
Q
What is congenital talipes equinovarus (clubfoot)?
A
- a deformity of the lower limb with calf-wasting and the classic inward-pointing foot (equinus deformity due to tight Achilles tendon and associated contraction of soft tissues on medial side of ankle)
22
Q
Untreated talipes equinovarus showing inversion contracture…
A
23
Q
Intraoperative view of talipes equinovarus surgery showing release of soft tissues…
A
24
Q
Post-operative image from talipes equinovarus surgery showing corrected deformity and soft tissue coverage…
A
25
What is the management for talipes equinovarus?
- Conservative: manipulation and casting for 3 months
- Surgical: severe cases only, soft tissue release
- (prognosis: foot and limb will never be normal in terms of appearance but patient will live a normal life)
26
What is osteogenesis imperfecta and what is the pathology?
- aka. brittle bone disease
- OI is a type 1 collagen disorder predisposed to multiple fractures
Pathology:
- 4 different types of OI
- OI is usually inherited as an autosomal dominant condition (types 1 and 4)
- types 2 and 3 are sporadic and recessive but rare (type 2 is lethal)
27
What are the clinical features of osteogenesis imperfecta?
- fragile bones and low-energy fractures
- (blue sclerae occur in types 1 and 2 OI)
- associated features: deafness, joint laxity, brownish teeth, face dysmorphia, valvular defects
28
Blue sclera (occurs in types 1 and 2 osteogenesis imperfecta)...
29
What is the treatment for osteogenesis imperfecta?
- Conservative: gentle handling, IV bisphosphonates to improve bone strength
- Surgical: intramedullary telescoping rods for prevention of deformity and further fracture (established deformity is treated with osteotomy)
30
What is cerebral palsy?
- a non-progressive upper motor neurone, neuromuscular disorder that results from injury to an immature brain
- (can be caused by perinatal infection such as meningitis)
31
What are the clinical features of cerebral palsy?
- muscle weakness and spasticity
- ataxic gait, cognitive impairment and emotional disturbance
32
What is the management for cerebral palsy?
- (diagnosis is a clinical one)
- Conservative: physio, OT, SALT
33
What are some clinical features of a non-accidental injury (NAI)?
- vague and inconsistent history
- children <2 yrs: fractures are rare
- delayed presentation
- may be other bruises (may be old bruises)
- child may be withdrawn, particularly when parents are present
- (note: OI can sometimes be mistaken for NAI)
34
What is the management for NAI?
- social workers should be involved
- fractures/bruises should be treated as normal
35
What are the 2 paediatric knee conditions?
- Osgood-Schlatter disease
- Osteochondritis dissecans
36
What is the pathology of Osgood-Schlatter disease?
- inflammation of the insertion point of the patella tendon at the tibial tuberosity
37
Osgood-Schlatter disease diagram...
38
What are the clinical features of Osgood-Schlatter disease?
- localised pain over the tibial tuberosity (tender/swollen)
- pain worse with activity, relieved by rest
39
What is the management for Osgood-Schlatter disease?
- Conservative: rest, analgesia, activity modification (activity will not make it worse)
40
What is Osteochondritis dissecans?
- a small area of avascular bone on an articular surface (usually in the knee, medial femoral condyle)
- caused due to repeated trauma in a susceptible patient
41
What are the clinical features of osteochondritis dissecans?
- adolescents and young adults
- intermittent ache, swelling, joint locking
42
What investigations should be done for suspected osteochondritis dissecans?
- X-ray: shows variably sized lesion on medial femoral condyle (fragmented in children), lesion may be attached or loose
- MRI: can also be used to help define lesion
43
What is the management for osteochondritis dissecans?
- Conservative: activity modification to allow to heal (usually self-limiting)
- Surgical: surgical stabilisation for loose lesions, or removal of loose body
44
What is juvenile idiopathic arthritis (JIA)?
- JIA is a persistent autoimmune inflammatory arthritis lasting > 6 weeks in patients younger than 16 yrs (it is a diagnosis of exclusion)
45
What are the clinical features of JIA?
- systemic: fevers, malaise, salmon pink rash
Joint disease: pain, stiffness, swelling ( > 6 weeks ), can cause stunted growth
46
What investigations should be done for suspected JIA?
- diagnosis is clinical and that of exclusion
- X-ray: can help
- Blood tests: can help (FBC, ESR/CRP, RhF, ANA)
47
What is the management for JIA?
- MDT approach
- pharmacological: NSAIDs, corticosteroids, biologics
48
What is transient synovitis (aka. irritable hip)?
- cause of limp in children from inflammation of the synovial lining of the hip joint
- **symptoms:** usually preceded by a viral infection (URTI common), acute onset limp, fever
- **management:** bloods, joint aspirate and culture to rule out septic arthritis
