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Paeds MSK/Rhem Flashcards

1
Q

Define DDH

A

Structural abnormality in the hips leading to instability and potential for subluxation or dislocation

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2
Q

What are the 6 RF for DDH

A
  • First degree Fx
  • Female
  • Breech presentation
  • High birth weight
  • Oligohydramnios
  • Prematurity
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3
Q

When is DDH screened for ?

A

-Neonatal examination at birth and at 6-8 weeks

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4
Q

What findings on a NIPE may suggest DDH?

A
  • Different leg lengths
  • Restricted hip abduction on one side
  • Significant bilateral restriction in abduction
  • Difference in the knee level when hips are flexed
  • Clunking of the hips on special tests
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5
Q

What are the 2 special tests to look for DDH?

A
  • Ortolani test

- Barlow test

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6
Q

What is the ortolani test ?

A
  • Looks for DDH
  • With the hips and knees flexed, gentle pressure is used to abduct the hips and apply pressure behind the legs to see if the hips will dislocate anteriorly
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7
Q

What is the barlow test ?

A
  • Looks for DDH
  • Gentle downward pressure is placed on the knees through the femur to see if the femoral head with dislocate posteriorly.
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8
Q

What is the diagnostic test for DDH?

A

-USS

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9
Q

How is DDH managed if presents at <6 mnths ?

A
  • Pavlik harness
  • Keeps the baby’s hips flexed and abducted.
  • Usually on for 6-8 weeks.
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10
Q

How is DDH managed if presents >6 mnths or if harness fails?

A
  • Surgery

- After surgery an hip spica cast is used to immobilise the hips

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11
Q

Define osteogenesis imperfecta

A

-Genetic condition resulting in brittle bones that are prone to fracture

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12
Q

What causes osteogensis imperfecta ?

A
  • Genetic mutations that affect the formation of collagen

- 8 different genetic abnormalities with varying severities

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13
Q

How does osteogenesis imperfecta present ?

A
  • Recurrent and inappropriate fractures
  • Hyper-mobility
  • Blue/grey sclera
  • Triangular face
  • Short stature
  • Deafness from early childhood
  • Dental problems
  • Bone deformities : esp bowed legs and scoliosis
  • Joint and bone pain
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14
Q

How is osteogenesis imperfecta diagnosed ?

A
  • Usually clinical

- X-ray used in fractures and for bone deformitis

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15
Q

How is osteogenesis imperfecta managed ?

A
  • Bisphosphonates to increased bone density (e.g. alendronate)
  • Vit D supplementation to prevent deficiency
  • Physio and occupational therapy
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16
Q

Define rickets

A

-Defective bone mineralisation causing ‘soft’ and deformed bones

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17
Q

What 2 vitamin deficiencies cause rickets ?

A
  • Vitamin D

- Calcium

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18
Q

What are the sources of vitamin D?

A
  • Sunlight

- Eggs, oily fish or forified cereals

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19
Q

What are the sources of calcium ?

A
  • Dairy productes

- Green vegetables

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20
Q

What is a rare form of rickets?

A
  • Hereditary hypophosphataemic rickets
  • Genetic defect causing low phosphate
  • Most common : X-linked dominant
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21
Q

What are the potential symptoms of rickets ?

A
  • Lethargy
  • Bone pain
  • Swollen wrists ! widening of joint space
  • Bone deformity
  • Poor growth
  • Dental problems ! no teeth development
  • Muscle weakness
  • Pathological or abnormal fractures
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22
Q

What 5 bone deformities can occur in rickets?

A
  • Bowing of the legs
  • Knock knees
  • Rachitic rosary : ribs expand at the costochondral junctions causing lumps along the chest
  • Craniotabes : soft skull with delayed closure of sutures and frontal bossing
  • Delayed teeth
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23
Q

What are the RF for rickets ?

A

Anything that increases the risk of vit d deficiency

  • Darker skin
  • Low exposure to sunlight
  • Live in colder climates
  • Spend majority of their time indoors
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24
Q

What are the 5 common blood results in rickets ?

A
  • Serum 25-hydroxyvitamin D of less than 25 nmol/L
  • Calcium : low
  • Phosphate : low
  • Alkaline phosphatase : high
  • Parathyroid hormone : high
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25
What investigation is required to diagnose rickets ?
- X ray | - May show joint widening and osteopenia (more radiolucent bones)
26
How is rickets prevented ?
- Breastfeeding women should taken vitamin D supplements (10 micrograms per day) - Formula fed babies are at lower risk as it is fortified with vitamin D
27
How is rickets managed ?
- Vitamin D (ergocalciferol) : 6mnths to 12 yrs is 6,000 IU per day for 8-12 wks - Calcium supplementation
28
Explain the pathophysiology behind rickets
- Low vitamin D - This leads to malabsorption of calcium and phosphate - Low calcium and phosphate leads to defective bone mineralisation - Low calcium leads to secondary hyperparathyroidism - Increased parathyroid hormone leads to increased calcium reabsorption from bone and further issues with bone mineralisation
29
What is transient synovitis ?
-Temporary irritation and inflammation in the synovial membrane of the joint
30
What age group is transient synovitis most common in ?
3-10 years
31
How does transient synovitis present ?
- Usually occurs within a few weeks of a viral illness - Limp - Refusal to weight bear - Groin or hip pain - Mild low grade temperature
32
What is a serious differential in a child with joint pain and fever ?
-Septic arthritis
33
How is transient synovitis managed ?
- Simple analgesia | - Safety net to attend A&E if symptoms worsen or they develop a fever !
34
Define septic arthritis
-Infection inside a joint
35
when is septic arthritis most common ?
<4 yrs of age
36
How does septic arthritis usually present ?
- Single joint - Rapid onset : hot red swollen painful joint - Refusing to weight bear - Stiffness and reduced range of motion - Systemic Sx : fever, lethargy, sepsis
37
What is the most common bacterial cause of septic arthritis ?
-Staph aureus
38
What 4 other bacteria can cause septic arthritis ?
- Neisseria gonorrhoea (sexually active teenagers) - Group A strep - Haemophilus influenza - E.coli
39
Give 4 other differential diagnosis for septic arthritis
- Transient synovitis - Perthes - Slipped upper femoral epiphysis - JIA
40
How is septic arthritis managed ?
- Joint aspiration for gram staining, crystal microscopy, culture and Abx sensitivities. - Empirical IV abx - Sugical drainage and washout where necessary
41
What is perthes disease?
- Idiopathic, avascular necrosis of the femoral head due to disruption of blood flow - Affecting the epiphysis of the femur
42
At what age does perthes most commonly occur?
- Boys aged 5-8 | - Can occur between 4-12 yrs
43
How does perthes disease present?
-Slow onset of : pain in the hip or groin, limp, restricted hip movements and possible referred pain to knee
44
How is perthes diagnosed ?
- X ray - Technetium bone scan or MRI if sx persist
45
How is perthes managed ?
- <6 = conservative - Older : surgical management
46
What is the main complication of perthes?
- Soft and deformed femoral head leading to early hip osteoarthritis - this is due to the revascularisation and neovascularisation that occurs over time
47
What is a slipped upper femoral epiphysis (SUFE) ?
-Where the head of the femur is displaced along the growth plate
48
Who is SUFE more likely to occur in ?
- Boys (8-15 with an average age of 12) | - Obese children
49
What is the typical exam q for SUFE?
- Usually in an adolescent obese male going through a growth spurt - Hx of mild trauma causing symptom onset -> pain is usually disproportionate to the trauma
50
How does SUFE present ?
- Hip, groin, thigh or knee pain - Restricted range of hip movement - Painful limp - Restricted movement in the hip : particularly restricted internal rotation
51
On examination, what movement will be restricted in SUFE?
- > Internal rotation | - > They will prefer external rotation
52
How is SUFE diagnosed ?
X-ray ! Plain X-ray of BOTH hips (AP and frog-leg views) Both hips as its bilateral in 20% of cases
53
How is SUFE managed ?
-Surgery
54
What is osteomyelitis ?
-Infection in the bone and bone marrow, typically in the metaphysis of long bone
55
What bacteria is the most common cause of osteomyelitis ?
-Staph aureus
56
Give 5 risk factors for osteomyelitis
- Male - <10 yrs - Open bone fracture - Orthopaedic surgery -Sickle cell anaemia : salmonella
57
What is chronic osteomyelitis ?
-Deep seated, slow growing infection with more subtle features
58
How with acute osteomyelitis present ?
- Fever - Refusing to use the limb or weight bear - Pain - Swelling - Tenderness
59
How is osteomyelitis investigated ?
-MRI -Blood culture - Bone marrow aspiration or bone biopsy if necessary
60
How is osteomyelitis managed ?
- Antibiotics | - May require drainage and debridement
61
What is an osteosarcoma and where does it most commonly affect ?
- Bone cancer - Femur = most common - Tibia and humerus also commonly affected
62
What age group are usually affected with osteosarcomas ?
10-20 yrs
63
How does an osteosarcoma present ?
- Persistent bone pain - Bone pain worse at night and may wake from sleep - Bone swelling - Palpable mass - Restricted joint movement
64
How is an osteosarcoma diagnosed ?
-Urgent direct access xray within 48 hrs
65
What would an xray show in an osteosarcoma ?
- Poorly defined lesion in the bone with destruction of the normal bone and a 'fluffy' appearance - Periosteal reaction = 'sun-burst' appearance due to irritation of the lining of the bone.
66
What may be raised in blood tests in an osteosarcoma ?
-Raised alkaline phosphatase (ALP)
67
What is the main complication of an osteosarcoma ?
- Pathological bone fractures and metastasis | - Surgical resection also often leads to limb amputation
68
What is Talipes ?
- Clubfoot : fixed abnormal ankle position | - Fixed abnormal ankle position presenting at birth
69
What is talipes equinovarus ?
-Ankle in plantar flexion and supination
70
What is talipes calcaneovalgus ?
-Ankle in dorsifelxion and pronation
71
How is clubfoot managed ?
-Ponseti method
72
What is the ponseti method ?
- Used to treat club foot - The foot is manipulated towards a normal position and a cast used to hold it in position. This is repeated until the foot is in the correct position - A brace is then used to hold the feet in the correct position when not walking until around 4 yrs of age
73
What is positional talipes ?
- The ankle is in a plantar flexion and supination position but is not fixed - The muscles around the ankle are tight but the boney structure is not affected - Managed using physio
74
What is achondroplasia ?
- Most common common cause of disproportionate short stature (dwarfism) - It is a type of skeletal dysplasia
75
What is the cause of achondroplasia?
-Genetic mutations in the FGFR3 gene (fibroblast growth factor receptor 3) on chromosome 4 leading to abnormal function of the epiphyseal plates.
76
What kind of genetic inheritance leads to achondroplasia ?
- Autosommal dominant -> heterozygous | - > Homozygous gene mutations are fatal in the neonatal period
77
What are the main features of achondroplasia ?
- Average height of 4 feet - Short digits - Bow legs - Disproportionate skull - Foramen magnum stenosis - Frontal bossing
78
Give 6 associations with achondroplasia
- Recurrent otitis media - Kyphoscoliosis - Spinal stenosis - Obstructive sleep apnoea - Obesity - Cervical cord compression and hydrocephalus as a result of foramen magnum stenosis
79
What is osgood-schlatters disease?
Inflammation at the tibial tuberosity where the patella ligament inserts leading to anterior knee pain in adolescents
80
When does osgood-schlatters typically occur?
- 10 to 15 yrs old | - More common in males
81
How does osgood-schlatters present ?
Gradual onset : - Pain at the anterior aspect of the knee - Pain exacerbated by physical activity, kneeling and extension of the knee - Visible or palpable heard and tender lump at the tibial tuberosity
82
How is Osgood-Schlatters managed ?
- Reduction in physical activity - Ice - NSAIDs - Once symptoms have settled : stretching and physio
83
What is a rare complication of Osgood-Schlatters?
-Full avulsion fracture where the tibial tuberosity is separated from the rest of the tibia
84
Explain the pathophysiology behind Osgood-Schlatters
- Stress from running, jumping etc + growth in the epiphyseal plate results in inflammation on the tibial epiphyseal plate - Multiple small avulsion fractures occur, where the patella ligament pulls away tiny pieces of bone - This leads to growth of the tibial tuberosity = visible lump - This lump is tender due to inflammation but as the bone heals it becomes hard and non-tender
85
What is kawasaki disease ?
Systemic medium-sized vessel vasculitis
86
Who does kawasaki disease typically affect?
- Children <5 yrs - Asian children (japanese or korean) - Boys
87
What is a key complication of kawasaki disease ?
-Coronary artery aneurysm
88
What are the key features of kawasaki disease ?
CRASH AND BURN - C : conjunctivitis (bilateral) - R : rash (widespread erythematous maculopapular) - A : adenopathy (cervical & usually unilateral) - S : strawberry tongue and cracked lips - H : hands (desquamation) -BURN : high fever >5 days
89
Give 3 investigation results usually seen in kawasaki disease
- FBC : anaemia, leukocytosis and thrombocytosis - LFTS : hypoalbuminaemia and elevated liver enzymes - Raised ESR
90
How is kawasaki disease managed ?
- High dose aspirin - IV immunoglobulins - Echo
91
What is a risk of using aspirin in children ?
-Reye's syndrome
92
What is rheumatic fever ?
- Autoimmune condition caused by group A beta-haemolytic streptococcal (typically streptococcus pyogenes causing tonsilitis). - The antibodies to target the bacteria also target antigens on the cells of the person's body (e.g. myocardium of the heart) - Leads to type 2 hypersensitivity reaction where the immune system begins attacking cells through the body.
93
What is the diagnostic criteria for rheumatic fever
- Evidence of strep infection + two major criteria or 1 major and 2 minor - Major : - J : Joint arthritis - O : Organ inflammation (e.g. carditis) - N : Nodules - E : Erythema marginatum rash - S : Sydenham chorea - Minor : - F : Fever - E : ECG changes(prolonged PR interval) without carditis - A : Arthralgia without arthritis - R : Raised inflammatory markers
94
What should be given for tonsilitis caused by streptococcus to prevent rheumatic fever ?
-Phenoxymethylpenicillin (penicillin V) for 10 days
95
What is Ehlers-Danlos syndrome ?
- Autosommal dominant | - Defect in collagen, resulting in hyper-mobility causing joint pain and soft and stretchy skin
96
What score is used to assess hypermobility on EDS
-Beighton score : palms flat on floor, elbows, knees, thumb and little finger hyperextend
97
What is a common cardiac involvement of EDS?
- Aortic regurgitation | - Postural Orthostartic tachycardia Syndrome
98
What is Henoch-Schonlein Purpura ?
-IgA vasculitis affecting the skin, kidneys and GI tract
99
What can tigger Henoch-Schonlein purpura and what are the 4 common features ?
- URTI or gastroenteritis - Common in <10 yrs - Purpura - Joint pain - Abdo pain : can lead to GI haemorrhage, intussusception and bowel infarction - IgA nephritis : haematuria and proteinuria !
100
What would be a common exam presentation in henoch-scholein purpura
-8 yr old, recent gastroenteritis. Purpura starting on legs and speading to buttock. Arthralgia in knees and ankles. Abdo pain. Haematuria and proteinuria on dipstick.
101
What would be a common exam presentation in henoch-scholein purpura
-8 yr old, recent gastroenteritis. Purpura starting on legs and speading to buttock. Arthralgia in knees and ankles. Abdo pain. Haematuria and proteinuria on dipstick.
102
Give 4 non infective causes of a fever lasting >5 days in a child
- Stills Disease - Leukaemia - Rheumatic fever - Kawasaki
103
How does systemic JIA present ?
- Subtle salmon-pink rash - Joint pain - High swinging fevers
104
What medications can be used to treat JIA?
- NSAIDs - Steorid injections - DMARDS (e.g methotraxate, sulfasalazine) - Biologics : adalimumab, infliximab

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