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Rheumatology + Orthopaedics Flashcards

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1
Q

What are differentials of joint pain / limp in toddler

A 
Transient synovitis - usually after viral, low grade fever 
JIA 
SA / OM - high grade fever + unwell 
Trauma / frature 
Growing pain 
Child abuse
DDH
Malignnacy - ALL / neuro / bone sarcoma 
Neuromuscular
Referred
Haemophilia 
HSP
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2
Q

What are differentials of joint pain in a child

A

Same as above
Rheumatic fever
Perthes

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3
Q

What are differentials of joint pain in adolescent

A

Same
Overuse
SUFE

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4
Q

What is important in the history of joint pain / limping child

A 
Age
Trauma - limp before or after 
Vital signs inc temperature 
Mode of onset - acute / insidious
Any previous episodes 
Any current illness
Location, pattern, duration
Swelling
Fever / systemic symptoms / rash / weight loss 
Any Travel
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5
Q

What are benign symptoms / growing pain signs

A 
Intermittent 
Never at start of day
Worse at end of day 
No limp
No limitation
Systemically well
Normal physical exam / strength
Normal motor milestone
Worse after exercise
Better with rest 
Bilateral 
Shins and ankles 
Night pain relived with simple analgesia
No swelling 
Normal height and growth
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6
Q

What are red flag symptoms

A 
Fever
Malaise / lethargy
Morning stiffness or pain
Night pain refractory to analgesia
Rest has no effect
Refractory analgesia 
Joint swelling
Tenderness
Muscle weakness
Fall in height
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7
Q

How do you investigate joint pain

A 
NEED TO RULE OUT SA 
Bloods - increased WBC, neutrophil, ESR, CRP
Blood film / bone marrow for malignnacy
Blood culture
Repeat X-Ray of any areas of tenderness 
SURGICAL REVIEW 
USS 
MRI -
Bone scan - OM
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8
Q

What will bloods show

A

Increased WCC, neutrophils, CRP if infection

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9
Q

What may USS show

A

Effusion

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10
Q

What will MRI show / when do you do

A

OM
Perthes
Malignancy

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11
Q

When do you do bone scan

A

OM

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12
Q

When do you do bone marrow / film

A

If suspect malignancy e.g. leukaemia which can present in bone

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13
Q

If child has sore knee but examination normal what should you do
What else do you look for in examination

A

Examine hip and ankle

Observe - gait / movement
PEWS
Erthema / swelling / rash / heat
Effusion?

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14
Q

Why

A

Obturator nerve supplies knee and hip so get referred pain

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15
Q

DDx

A 
DDH
SUFE
Perthes
Infection
JIA
Lymphoma
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16
Q

What causes septic arthritis

A

Staph

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17
Q

How does septic arthritis present

A 
Limp 
Swollen red joint
Limited ROM
Pain
Fever
Often has effusion 
Unable to examine
Not weight bearing
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18
Q

How do you Dx

A 
Bloods - FBC, CRP, ESR
Culture if fever 
USS - effusion
MRI
Joint aspiration if suspect
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19
Q

How do you treat

A 
Refer orthopaedics 
Low threshold 
IV Ax 
Urgent aspiration and wash out 
Arthroscopy
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20
Q

When is SA more likely than transient synovitis

A 
Kocher's criteria 
Temp >38.5 - TS has no fever 
Refusal to weight bear
Raised inflammatory- CRP 
Very high WCC
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21
Q

When does transient synovitis occur

A

Following viral infection

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22
Q

What is transient synovitis

A

Inflammation rather than infection of synovium of the hip

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23
Q

How does transient synovitis present

A

Limb / hobble
Manage to walk
Can be unwell from viral illness so can be difficult to different from SA

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24
Q

What is most common cause of acute hip pain

A

Transient synovitis

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25
What age group
2-10
26
How do you Dx
USS - mild effusion X-ray if suspect trauma Normal or slightly raised inflammatory Don't need to go investigations if child is well Review in 10 days if still unwell
27
How do you treat
``` Rest Analegisa Safety net Document you've considered - SA / OM - Malignancy of bone or blood - Trauma / NAI - Perthes - SUFE ```
28
If child presents with limp in <3
Rare to have transient synovitis Urgent hospital High risk of SA or abuse
29
What causes OM
S.Aureus | Typically metaphysics
30
How does OM present
``` Pain Fever Reduced ROM Limp More willing to move than SA Less unwell than joint infection but more unwell than transient synovitis ```
31
What increases risk
``` Blunt trauma Recent infection Open bone fracture Recent surgery Immunocompromised Sickle HIV TB ```
32
How do you Dx
``` Bloods USS X-ray MRI = best Biopsy ```
33
What bloods
CRP CK Culture May need bone biopsy
34
How do you treat
Antibiotics Responds quickly as good vascular supply to bone Surgery
35
What surgery
Aspiration for culture Drain abscess Debridement
36
What cancer is common and where
Osteosarcoma Femur = most Tibia Humerus
37
How does it present
``` Bone pain Night pain Incidental trauma Swelling Palpable mass Unable to move Sweating Fatigue Abnormal bloods Pathological fracture Mets ```
38
How do you Dx
``` X-ray within 48 hours if unexplained bone pain or swelling Urgent specialist if X-ray suggestive Bloods - Anaemia - Raised ALP ```
39
How do you treat
Surgical resection Often need amputation Adjuvant chemo
40
What is bone or joint pain at night
Infection or tumour until proven otherwise
41
What is SUFE
Fracture through physis resulting in slippage of end of femur (epiphysis) along growth plate Posterior medial displacement of femoral epiphyses
42
What is chronic
>3 weeks
43
What causes SUFE
Increased load | Weak physis
44
What are primary causes
Delayed bone age Overweight Adolescence Trauma
45
What are secondary rare causes
Hypothyroid Hypogonadism Renal osteodystrophy Growth hormone
46
How does SUFE present
``` Pain in hip / groin / thigh External rotation Reduced internal Referred pain in knee Limp Stiff hip ROM limited by pain in hip Leg length discrepancy Abnormal gait ```
47
What is normal in SUFE
Knee | No indicators of infection
48
Who is SUFE common in
M>F Secondary school age Trauma Deformity
49
How do you Dx
X-ray | Do both sides as 20% bilateral
50
What does X-ray show
``` Widened physis Femoral head displaced Mild <1/3 Moderate 1/2 Severe >1/2 ```
51
How do you treat
Refer ortho Bed rest Surgical pin to allow it to fuse if severe
52
What do you do if unstable
Fix
53
What do you do if stable
Fix in situ
54
How long do you leave pin in
Until physis stops growing
55
Does SUFE affect growth
No | Most growth from tibia / fibula
56
What are complications of SUFE
AVN - if unstable Chondrolysis Deformity Early OA
57
What are signs of DDH
``` May pick up on baby check Ortolani's Barlow Piston motion Leg length discrepancy Discrepancy between skin creases Limp ```
58
What is ortolani
Hip pops in
59
What is Barlow
Hip pops out
60
Who is at risk of DDH
``` F>M First born Oligohydrmnios Breech FH Limb deformities Heavy birth weight ```
61
What hip is more affected
L
62
How do you Dx
USS
63
Why do you use USS
Can't see bones on X-ay
64
When do you do USS
If abnormal examination Breech delivery 1st degree relative with hip issues early life Within 6 weeks as most will resolve
65
What do you look for
Shenton line
66
How do you treat
Abduction brace | Surgery if hip completely out or older child
67
What are the complications
Early onset arthritis Reduced abduction Limp Painful knee / hip
68
What is Perthes
Avascular necrosis leading to death at femoral head
69
What is the disease process of Perthes
``` Fragmentation Revascularisation (painful) Reossification of bone Residual deformity of femur head in hip USUALLY PROGRESS OVER 2 YEARS ```
70
How does it present
``` Hip pain progress over weeks and resolves in years Worse on activity Short stature Chronic limb Knee pain on exercise referred from hip Stiff hip Hip pain Systemically well / no sepsis ```
71
What is most suggestive
M>F Hyperacitivty Short stature Primary school age
72
How do you Dx
``` X-ray = flattened femoral head and joint widening BOTH SIDES AS 10% BILATERAL Whiter and sclerotic Bloods = normal MRI = reduced perfusion ```
73
How do you treat
``` Maintain hip motion Analgesia Restrict activities No active treatment Physio Regular X-ray to assess healing ```
74
What do you do <6 and >6
``` <6 = observe >6 = surgery / arthroplasty if non healing to improve alignment ```
75
What are complications
OA if severe | Premature fusion of growth plates
76
Unilateral hip pain
SA JIA SUFE Lymphoma
77
Bilateral
Hypothyroid Sickle cell Epiphyseal dysplasia
78
What is used to classify growth plate fractures
SH
79
SH1
Straight through physis | Can cause complete disruption
80
SH2
Most common | Through physis then up metaphysysis
81
SH3
Through middle of epiphysis and along metaphysis
82
SH4
Through metaphysics, physis and epiphysis
83
SH5
Physis crushed
84
What suggests NAI
``` Incongurent Hx Patterend bruising Burns Multiple fracture Metaphysyeal or humeral shaft / unusual place Delayed presentation Delayed milestones Rib Non-ambulant unless genetic / metabolic disease At risk register ```
85
Who is at increased risk of fractures
``` Boys Age Physeal injury Previous Metabolic bone disease - Osteogenesis imperfecta ```
86
What do adults need more than kids
Fixation
87
What is most likely to cause deformity
SH5
88
What are complications
``` Compartment Non-union Refracture Nerve injury Growth arrest ```
89
What is Osgood Schlatter
``` Painful tender tibial tuberosity due to inflammation at insertion Visible lump Worse after exercise Unilateral Gradual onset Highly active adolescent ```
90
How do you Rx
``` Rest Ice NSAID Physio can be used Rare complication = avulsion fracture requiring surgery ```
91
What is patellar subluxation
Medial knee pain due to lateral subluxation of patella
92
What os osteochondirits Dissecan
Pain after exercise | Intermittent swelling and locking
93
What is chondromalacia patellae
Softening of cartilage Common in teenage girls Causes anterior knee pain walking up and down stairs
94
How do you Rx
Physio
95
What is club foot
Foot is plantar flexed | Midtarsal adduction
96
What is club foot associated with
Spina bifida
97
How do you treat
Cast | Achilles lengthening
98
What causes Ricketts
Vit D deficiency | Same as osteomalacia in adults
99
How does it present
Bone pain FTT Bowed legs Thickened joints
100
How do you treat
Vit D supplements | Annual injections
101
What do you have a high degree of suspicion of in limping child
Hip issue
102
What type of growth plate fractures usually require surgery
3,4,5
103
What fracture affects growth
SH 5
104
What should you assume if growth plate tenderness
Fracture even if normal X-ray
105
What is a complete fracture
Both sides of cortex affected
106
What is a toddler fracture
Oblique fracture of tibia in infants
107
What is plastic deformity
Stress on bone causing deformity with no fracture
108
What is a green stick fracture
Unilateral cortical breach only | Fracture in young soft bone
109
What is a buckle fracture
Incomplete cortical disruption causing periosteum haematoma but no break Usually distal radius
110
What can cause pathological fracture
Osteogenesis imperfecta Osteopetrosis Malignancy
111
What does any limping child require
Further investigation | SA until proven otherwise
112
What must you rule out
``` Septic arthritis first then Perthes SUFE Inflammatory arthritis OM ```
113
What can yo do once you've done this
Transient synovitis
114
What are 4 signs that if 3+ present suggests SA
Temp >38.5 WBC>12 CRP >20 Non weight bearing
115
What do you do if suspect SA
Urgent blood culture | USS guieded aspiration
116
Growing pain RED FLAG
If lump. / unwell infection or examination = not normal refer as malignancy / SA
117
Who is radial buckle common in and what causes
Children | Fall on outstretch hand
118
How do you Dx
Examination normal apart from tender | X-ray show bulge in cortex
119
How do you Rx if uni or bicortical
Analgesia Elevation Split 3 weeks if unicortical Cast if bicortical
120
What should you always do with fracture
Examinae for neuromuscular compromise
121
How do you manage fracture
``` Mechanical aligment - Closed reduction via manipulation - Open via surgery Fix bone to keep in position whilst heals - Cast - K wire - Intramedullary nail - Plates and screw ```
122
Pain management in children
1st line = paracetamol and Ibuprofen | 2nd line = morphine
123
Why is codeine / tramadol not used
Can't predict metabolism
124
When can you use X-ray in a child
>4.5 months
125
What is positional talipes
Valgus or varus deformity of foot
126
How do you Rx
Physio
127
What is fixed talipes
Vigorous malformation
128
What is required
Strap / cast | Surgery
129
What are normal variants in children
``` Metartarus adductus Out-toeing Posterior tibial bowing - Bow legs Curly toes Knock knes Flat feet ```
130
When is flat feet pathological
If no arch reforms on tip toes
131
What is metatarsus adducts
Persistent femoral anterversion | Cause intoeing / front half of foot to turn in
132
What causes out toeing
External tibial torsion Usually resolves by 2 May be panful
133
What is another cause of metatarsus adducts
Cerebral palsy but rare
134
What is Posterior tibial bowing
Bow legs Most resolve Can be a symptom of underlying disease - Rickets / Blounts
135
What are other common UL injuries in children
Pulled elbow Buckle (distal radius) fracture Shaft radial or ulnar fracture Supracondylar fracture
136
How do supracondylar fractures present
Fracture of distal humerus just above elbow Very sore See fat pad on X-ray even if no bone abnormality = definite break
137
What class-action
Gartland
138
What must you do in UL injury
Assess neurovascular | - Median, radial and ulnar nerve

Paediatrics (35 decks)

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