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Flashcards in The child with an abnormal gait Deck (43):
1

Musckuloskeletal examination

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

2

Key MSK history

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

3

Etiology of leg pain and limp in children

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

4

Key features in growing pains, counselling to parents

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

5

Key features in transient synovitis

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

6

Key features in septic arthritis

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

7

Key features in osteomyelitis

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.

8

Key features in Legg-Perthes

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

9

Key features in SCFE

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

10

History in limp/swollen joint

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

11

Investigations in limp/swollen

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

12

Most common bacteria in septic arthritis and osteomyelitis

1. Staph Aureus
2. GAS
3. H influenzae

13

Investigations in septic/osteomyelitis

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

14

Management of septic/osteomyelitis

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

15

Risk factors for osteomyelitis (in adults)

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

16

Management in transient synovitis

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

17

Advice to parents about prognosis of transient synovitis

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

18

Approach to an acutely swollen joint

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

19

Etiology of acute swollen joint

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

20

Investigations in acute swollen joint

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

21

Key features in reactive

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

22

Important features in juvenile arthritis

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

23

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

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

24

When is ESR/CRP usually normal

1. HSP

25

When do patients needs to be referred for inpatient

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

26

When to refer for OP rheumatology

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

27

Etiology of non-weight bearing by age

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

28

Examining child with refusal to weight-bear or limp

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

29

What conditions does bone scan show

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

30

What conditions does plain xray show

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

31

Specific causes of hip pain

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

32

Counselling in transient synovitis

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

33

Counselling about developmental dysplasia of the hip

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

34

What is hip spica

1. Plaster from ankles to belly button

35

Historical features important if considering ricketts

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

36

Juvenile idiopathic arthritis: presentation, classification

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

37

Pauciarticular JIA: presentation, features and prognosis

1. Presentation
needs regular slip lamp review
80% resolves

38

Still's disease: presentation, features and prognosis

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

39

Polyarticular: presentation, features, prognosis

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

40

Goals of treatment in JIA

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

41

Considerations for management in JIA

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

42

Investigations in KIA

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

43

Complications of JIA

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

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