The child with an abnormal gait

Question 1

Musckuloskeletal examination

Answer 1

1. Observation
Growth
Inflammation
Limp/function
CP, spina bifida
NFM, marfan;s
HSP
Dermatomyosistis
Spinal scoliosis
Ligamentous hyperlaxity
2. Joints
Compare
Palpate
ROM->passive and active
Hip stability
Lengths
Pain
3. Gait analysis
4. Organomegaly

Question 2

Key MSK history

Answer 2

1. Newborn- risks for breech
Female
Breech
First born
2. Inflammation->pain, redness, swelling
3. Limitation in activities
4. Gait problems->limping, plegias, waddling, dislocation of the hip
Tip toe walking
5. Fever or skin rash

Question 3

Etiology of leg pain and limp in children

Answer 3

Benign causes
1. Growing pains
2. Transient synovitis
More serious
1. Septic arthritis
2. Trauma
3. Osteomyelitis
4. Legg-Perthes
5. Slipped capital femoral epiphyses
6. Neoplastic disease
Other
1. Reactive
2. IBD
3. Juvenile rheumatoid arthitis
4. HSP
5. Rheumatic fever

Question 4

Key features in growing pains, counselling to parents

Answer 4

1. Most commonly in pre-school aged children
2. Pain most common at night, no limp by day
3. Often bilateral in shins or thighs
4. Pain mostly in muscles, not bone
5. In a healthy child with no physical signs
6. No interference with daily activities

Question 5

Key features in transient synovitis

Answer 5

1. Common and benign in boys 2-8
2. Sudden onset limp
3. No systemic features
4. Commonly following URTI
5. Normal investigations and radiographs

Question 6

Key features in septic arthritis

Answer 6

1. Appear septic
2. Infants and toddlers
3. Painful, swollen, tender joint
4. Serious
5. Pain of movement

Question 7

Key features in osteomyelitis

Answer 7

1. Fever
2. Swollen, erythema, tenderness
3. Decreased movement of limb, refusal to weight bear
4. High CRP and high WCC
5. Diagnosed by radiograph, bone scan or MRI.

Question 8

Key features in Legg-Perthes

Answer 8

1. Osteochondritis->avascular necrosis
2. May follow transient synovitis
3. 4 X more common in boys, peaks 4-7
4. Initially painless->pain when fracture
5. Diagnose by radiograph or MRI

Question 9

Key features in SCFE

Answer 9

1. Obesity
2. Males
3. Gradual onset
4. Diagnosis by radiograph

Question 10

History in limp/swollen joint

Answer 10

1. Organic->
Persistent
Day and night
School
Unilateral
Located in joint
2. Limp, refusal to walk is significant
3. Weight loss, fever, night sweats, rash, diarrhea, psoriasis
4. Duration
5. Trauma
6. Morning stiffness
7. New medications
8. Family history->arthritis, IBD, autoimmune conditions, blood dyscriasis, psoriasis

Question 11

Investigations in limp/swollen

Answer 11

If thought to be organic
1. FBC
Collagen
Infection
Leukemia
2. ESR/CRP
Infection
Collagen
IBD
Tumor
3. Radiograph
Tumor
Infection
Trauma
AVN
Leukemia
Slipped epiphyses
4. MRI/bone scan
Osteomyelitis
5. Blood culture
6. RF/ antiCCP
7. ASOT

Question 12

Most common bacteria in septic arthritis and osteomyelitis

Answer 12

1. Staph Aureus
2. GAS
3. H influenzae

Question 13

Investigations in septic/osteomyelitis

Answer 13

1. FBC
2. ESR/CRP
3. Blood culture
4. Xray (usually normal)
5. Bone scan

Question 14

Management of septic/osteomyelitis

Answer 14

1. Refer to orthopaedics
2. Urgent aspiration in septic +/- arthotomy and washout w/ Flucloxacillin
3. Elevate and immobilise limb
4. Analgesia
5. Manage fluid input/output
6. Admission
7. Patient handout
8. F/U with GP

Question 15

Risk factors for osteomyelitis (in adults)

Answer 15

1. Pentrating injuries
2. Surgical contamination
3. IVDU
4. HIV
5. DM
6. Periodinitis

Question 16

Management in transient synovitis

Answer 16

1. Rest
2. Regular analgesia
   Paracetamol
   Ibuprofen
3. Gentle skin traction
4. R/V w. GP 3 days
5. Return if febrile, unwell or getting worse
6. If ongoing >4 weeks->OPD to rheumatology

Question 17

Advice to parents about prognosis of transient synovitis

Answer 17

1. Typically a benign course
2. Recurrence is uncommon
3. Close f/u recommended
4. If pain worsens at any time or persists beyond 7-10 days, further F/U is warranted.
5. May be the presenting feature sin a chronic inflammatory disease in 10% of cases

Question 18

Approach to an acutely swollen joint

Answer 18

1. Injury
Trauma
Acute joint bleed
2. Pain and fever
Septic arthritis
Osteomyelitis
3. Recent diarrhea, viral, tonsillitis
Reactive/post infective
4. History of IBD
5. Rash
Vasculitis
HSP
6. Recent drug ingestion
Serum sickness
7. Bone pain, LN, hepatosplenomegaly
Malignancy
8. >6 weeks, morning irritability, stiffness, gradual refusal to partake in usual activties
Juvenile chronic arthritis
9. No clear diagnosis
Symptomatic w/ rest and NSAID
Review
Re-evaluate diagnosis if not improved after 4 weeks

Question 19

Etiology of acute swollen joint

Answer 19

1. Trauma
2. Acute joint bleed
3. Septic A
4. OsetoM
5. Reactive
6. IBD
7. HSP, vasculitis
8. Serum sickness
9. Malignancy
10. Chronic juvenile arthritis

Question 20

Investigations in acute swollen joint

Answer 20

1. Trauma-> Xray
   Uncommon in very young, caution diagnosis. Prevents activity immediately
2. Acute joint bleed->Coagulation studies
   May be first presentation of hemophilua
3. Septic->FBC, BC, aspirate, ESR/CRP, Xray
4. Reactive->FBC, ESR/CRP, stool/urine/throat swab
5. IBD->FBE, ESR, albumin, stool
6. Vasculitis->ESR/CRP
7. Malignany->FBE, ESR, Xray
8. Juvenile arthritis->FBE, ESR, serum to store

Question 21

Key features in reactive

Answer 21

1. Monoarthritis of large joint
2. If poly/migration->consider RF
3. Parvo, rubella, EBV, mumps, Salmonella, shigella, CampyloB. Consider Reiters if conjuntivitis/uretrhitis
4. Onset 7-14 dyas post

Question 22

Important features in juvenile arthritis

Answer 22

1. Peaks age 1-5 years
2. ++Pain
3. May affect any joint, multiple joints
4. Rarely in hip as first presentation

Question 23

Important considerations with FBE->leukocytosis/left shift, normal, -ve PLT/mild anemia, cytopenia/absent +PLT

Answer 23

1. Leukocytosis/left shift often found in sepsis and in many reactive arthritides
2. Usually normal in HSP and serum sickness
3. Often have thrombocytosis and mild anaemia in JCA
4. Cytopenias and absence of thrombocytosis in presence of elevated inflammatory markers suspicious of malignancy

Question 24

When is ESR/CRP usually normal

Answer 24

1. HSP

Question 25

When do patients needs to be referred for inpatient

Answer 25

1. Trauma->orthopedics 2. Intra-articular bleeds->ortho/hematology 3. Joint sepsis->ortho 4. Suspected malignancy-> haem/oncology 5. Other->general medicine

Question 26

When to refer for OP rheumatology

Answer 26

1. >4 weeks duration 2. Significant joint effusion 3. Limitation of activity 4. Multiple joints involved 5. Joint contractures 6. Vasculitis other than HSP

Question 27

Etiology of non-weight bearing by age

Answer 27

``` 1. Aged 1-4 years Congenital dysplasia of the hip Toddler fracture Transient synovitis Child abuse 2. Aged 4-10 Transient synovitis Perthe 3. >10 years Overuse Slipped upper femoral epiphyses 4. All children Trauma, NAI Bleed Infection Rheumatological, vasculitis Reactive Malignancy Intra-abdominal->appendicitis Inguinscrotal->testicular torsion ```

Question 28

Examining child with refusal to weight-bear or limp

Answer 28

1. General appearance, vitals/Temp, anemia, murmurs, rash. 2. Gait 3. Neurological 4. Generalised lymphadenopathy (viral, hematological), look for focus of infections 5. Excessive bruising, bruising in unusual (NAI, hematological) 6. Abdomen, scrotum, inguinal 7. Bony tenderness 8. All joints Knee can be from spine or hip Include sacroiliac/spine Scoliosis, lordosis ROM

Question 29

What conditions does bone scan show

Answer 29

1. Osteomyelitis 2. Discitis 3. Perthes 4. Occult fracture

Question 30

What conditions does plain xray show

Answer 30

1. Perthes/SUFE 2. Chronic OM 3. Tumors 4. DDH

Question 31

Specific causes of hip pain

Answer 31

1. Transient synovitis 2. Perthes disease 3. SUFE Hip externally rotates and shortened Decreased internal rotation

Question 32

Counselling in transient synovitis

Answer 32

1. Most common cause of limp in children, also called irritable hip 2. Inflammation of lining of the hip 2. Cause is unknown, but may have had a recent viral illness 3. Most commonly in those aged 3-10 4. May have limp/difficulty crawling or standing 5. Mild, usually gets better on its own, complete rest is all that's needed. Starts to improve in 3 days, better in 2 weeks. 6. If in pain can use paracetamol or NSAIDs 7. Aspiring should not be give under the age of 16. Use ibuprofen catiously if history of asthma 8. No tests or antibiotics required 9. Encourage rest at home, no school until recovered. WIll walk in most comfortable way. Allow them to gradually do normal activties. 10. See doctor if: fever, swelling, redness, persistent/increasing, not improving in 3 days or recovered in a week

Question 33

Counselling about developmental dysplasia of the hip

Answer 33

1. Abnormal development of hip joint 2. Ball of hip not stable in socket, ligaments stretched/loose. Hips can dislocate and may not be obvious until walking. 3. Stiff joint, different lengths, lean when standing, turning outward, uneven skin folds on buttock 4. Mums hormones which loosen ligaments can get into baby's bloodstream and loosen, the way they lie in utero, girls, first born, breech, family history 5. Treatment may involve splints (Pavlik harness, for several months), closed reduction (move into correct position, hip spica plaster), open reduction- small cut in groin, with hip spica (plaster cast), osteotomy- when diagnosed late 6. Staying in hospital Splint, bracing, havlick->OPD Closed/open->anaesthetic and hspital 1-3 days Pain relief: panadol, morphine Observed, examined frequently checking blood flow Xray, MRI, CT done Education to look after Bring pram, car seat 7. Care, pain relief 8. F/U MRI, CT 9. Wound checked every 7-14 days 10. 6 wekk r/v, plaster changed 11. Regular xrays until has stopped growing 12. Information can be found on RCH kids health informatio

Question 34

What is hip spica

Answer 34

1. Plaster from ankles to belly button

Question 35

Historical features important if considering ricketts

Answer 35

1. Bowing of legs 2. Onset of walking->progression 3. Symptoms now 4. Limitation on activity 5. Evidence of malabsorption 6. Exposure outside

Question 36

Juvenile idiopathic arthritis: presentation, classification

Answer 36

1. Group of conditions, >6 weeks, no cause found 2. 1 in 1000 3. Classification Systemic (Still's) Polyarticular Pauciarticular Spondyloarthopathies (HLA B27) Juvenile psoriatic arthritis Other

Question 37

Pauciarticular JIA: presentation, features and prognosis

Answer 37

1. Presentation needs regular slip lamp review 80% resolves

Question 38

Still's disease: presentation, features and prognosis

Answer 38

``` 1. Presentation Spiking fever, malaise, anemia, hepatosplenomegaly Salmon-pink rash Weight loss Can look like malignancy Arthritis, arthralgia: may have minimal joint symptoms 2. Clinical Large and small 25% severe arthritis RF -ve TMJ may be involved Associated with DR4 3. Prognosis 25% arthritis in adulthood with disability May need joint replacement ```

Question 39

Polyarticular: presentation, features, prognosis

Answer 39

``` 1. Presentation >4 joints Small and large Morning stiffness Poor weight gain anemia Irritability 2. Features RF -ve ANA may be negative' No eye involvement 12% severe arthritis, but generally good prognosis ```

Question 40

Goals of treatment in JIA

Answer 40

1. Preserve joint function 2. Manage complications, including those of treatment 3. Psychological adjustment to potentially chronic condition

Question 41

Considerations for management in JIA

Answer 41

``` 1. Pharmacological NSAIDS Steroids DMARDs (methotrexate, ciclosporin, azathioprine) TNF->infliximab, etanercept 2. Non pharmacological Physiotherapy Hydrotherapy Splints Occupational therapist Psychological Carers ```

Question 42

Investigations in KIA

Answer 42

1. ESR/CRP->raised in systemic 2. RF, ANA 3. LFTs 4. Xrays/MRI 5. EchoC->to exclude pericarditis 6. FBE->microcytic anaemia of chronic disease

Question 43

Complications of JIA

Answer 43

1. Flexion contractures 2. Joint destruction 3. Growth failure Chronic illness Anorexia Growth suppression 4. Chronic anterior uveitis leading to visual impairment