Paediatrics (MSK) Flashcards

Question

A 7 year old patinet prenets with: * Limp * Refusal to weight bear * Groin or hip pain * Mild low grade temperature * Seems otherwise well From the Hx you discover that they had a viral URTI 2 weeks ago. Possible diagnosis?

Answer 1

Transient synovitis

Answer 2

Symptomatic treatment → simple analgesia * + safety net advice (develops fever → A&E )

Answer 3

Symptoms fully resolve within **1-2 weeks** (Typically significant improvement after 24-48 hours)

Answer 4

**Inflammation** at the **tibial tuberosity** where the **patella ligament inserts** (Usually **unilateral**)

Answer 5

Osgood-Schlatters disease

Answer 6

Osgood-Schlatters disease

Answer 7

* Stress from running, jumping etc at same time as growth in the epiphyseal pale → results in inflammation on the tibial epiphyseal plate * Multiple small **avulsion fractures** occur where the patella ligament pulls away tiny pieces of bone * Leads to tibial tuberosity growth → visiable lump below knee * Lump is intially tender due to inflammation → heals and inflammation settles → becomes hard

Answer 8

Osgood-Shlatters disease

Answer 9

Initial mangement → reducing pain + inflammation: * Ice * NSAIDs * Reduction in physical activity After symptoms settle: * Stretching + physiotherapy → strengthen the joint

Answer 10

A hard boney lump on their knee

Answer 11

A **full avulsion fracture** (the tibial tuberosity is separated from the rest of the tibia) * Requires surgicical intervention

Answer 12

Where the **head of the femur** is displaced ('slips') along the **growth plate**

Answer 13

Obese children: * Boys → 8-15 years * Girls → 11 years

Answer 14

An adolescent obese male undergoing a **growth spurt**

Answer 15

Slipped upper femoral epiphysis (SUFE)

Answer 16

First line: **X-ray** Second line: * Blood test (ESR, CRP → exclude other causes of joint pain) * Technetium bone scan * CT scan * MRI scan

Answer 17

**Surgery** (return the femoral head to correct position + fix it into place)

Answer 18

Perthes disease = disruption of blood flow to the **femoral head** → causing **avascular necrosis** of the bone → affecting the femur epiphysis ## Footnote The epiphysis = the bone distal to the growth plate (physis)

Answer 19

4-12 years Mostly between 5-8 years (more common in boys)

Answer 20

No clear cause (idiopathic)

Answer 21

A **soft + deformed femoral head** → leading to **early hip osteoarthitis** (Requires **total hip replacement**) ## Footnote (Over time there is **revascularisation** or **neovascularisation** and healing of the femoral head → **remodelling of the bone**

Answer 22

Perthes disease

Answer 23

* Perthes disease * SUFE (if triggered by minor trauma + older children)

Answer 24

First line: **X-ray** (can be normal) Others to establish diagnosis: * **Blood tests** (rule out other causes) * **Technetium bone scan** * **MRI scan**

Answer 25

Initial management (younger + less severe) → maintain a healthy position + alignment, reduce risk of damage + deformity to the femoral head * Bed rest * Traction * Crutches * Analgesia Second line: * Physiotherapy * Regular x-rays * Surgery (improve alignment + function of the femoral head + hip)

Answer 26

A genetic condition that affects the production of **collagen** resulting in **brittle bones** that are **prone to fractures**

Answer 27

Brittle bone syndrome

Answer 28

Essential for maintaining the **structure + function** of bone, skin, tendons and connective tissues

Answer 29

Osteogenesis imperfecta

Answer 30

Osteogenesis imperfecta

Answer 31

* **Hypermobility** * **Blue / grey sclera** (the “whites” of the eyes) * Triangular face * Short stature * Deafness from early adulthood * Dental problems, particularly with formation of teeth * Bone deformities, such as bowed legs and scoliosis * Joint and bone pain

Answer 32

**Clinical diagnosis** * **X-ray**: to help diagnose fractures * **Genetic testing**: not always done

Answer 33

* **Bisphosphonates** (increase bone density) * **Vitamin D supplementation** (prevent deficiency) Management is done by the multidisciplinary team, with: * **Physiotherapy** and **occupational therapy** to maximise strength and function * **Paediatricians** for medial treatment and follow up * **Orthopaedic** **surgeons** to manage fractures * **Specialist nurses** for advice and support * **Social workers** for social and financial support

Answer 34

**Infection in the bone + bone marrow** (Typically occurs in the **metaphysis** of the **long bones**)

Answer 35

* Chronic osteomyelitis = deep seated, slow growing infection → slowly developing symptoms * Acute osteomyelitis = presents more quickly with an acutely unwell child

Answer 36

Staphylococcus aureus

Answer 37

* Direct → open fracture * Indirect → through blood after entering the body via different route e.g. skin or gums

Answer 38

Boys under 10 years

Answer 39

* Open bone fracture * Orthopaedic surgery * Immunocompromised * Sickle cell anaemia * HIV * Tuberculosis

Answer 40

Acutely with an unwell child or more chronically with subtle features * **Refusing to use the limb or weight bear** * **Pain** * **Swelling** * **Tenderness** Also: * Afebrile/low grade fever * Acute osteomyelitis may have high fever (particularly if it has spread to joint → causing septic arthritis)

Answer 41

Ix: * **First line: X-ray (can be normal)** * **Gold standard: MRI** * Alternative: Bone scan * Bloods (Raised CRP, ESR, WBC) * **Blood culture (establish causative organism)** * **Bone marrow aspiration** or **bone biopsy** with histology + culture

Answer 42

* Extensive + prolonged **antibiotic therapy** * May require: **Drainage + debridement** of infected bone

Answer 43

Rickets = paediatric condition in which there is **defective bone mineralisation** → causing **'soft' + deformed bones** ## Footnote In adults → osteomalacia

Answer 44

Vitamin D or calcium deficiency ## Footnote There is a rare genetic form of rickets called hereditary hypophsophatamemic rickets (most commonly x-linked dominant) Vitamin D is either produced by the body in response to sunlight or obtained through foods such as eggs, oily fish or fortified cereals or nutritional supplements. Calcium is found in dairy products and some green vegetables.

Answer 45

* Lethargy * Bone pain * Swollen wrists * Bone deformity * Poor growth * Dental problems * Muscle weakness * Pathological or abnormal fractures

Answer 46

* **Bowing of legs** → legs curve outwards * **Knock knees** → legs curve inwards * **Rachitic rosary** → ends of ribs = expand at the costochondral juntcions → causing lumps along the chest * **Craniotabes** → = soft skull, with **delayed closure of the sutures + frontal bossing** * **Delayed teeth** → with underdevelopment of the enamel

Answer 47

* Darker skin * Low exposure to sunlight * Live in colder climates * Spend majority indoors

Answer 48

Serum 25-hydroxyvitamin D A result of **less than 25 nmol/L** = **establishes a diagnosis vitamin D deficiency** - which can lead to rickets.

Answer 49

Diagnostic: * **Serum 25-hydroxyvitamin D** (diagnoses a vit D deficiency) * **X-ray** (gold-standard) Other (serum) (may): * Calcium (low) * Phosphate (low) * Alkaline phosphatase (high) * Parathyroid hormone (high) NICE clinical knowledge summaries suggest additional investigations to look for other pathology: * **Full blood count** and **ferritin**, for iron deficiency anaemia * **Inflammatory markers** such as ESR and CRP, for inflammatory conditions * **Kidney function tests**, for kidney disease * **Liver function tests**, for liver pathology * **Thyroid function tests**, for hypothyroidism * **Malabsorption** screen such as anti-TTG antibodies, for **coeliac disease** * **Autoimmune and rheumatoid tests**, for **inflammatory autoimmune conditions** ## Footnote Xray = required to diagnose rickets. X-rays may also show **osteopenia** (more **radiolucent bones**).

Answer 50

**Breastfed babies** (Breastfeeding mums and children should take **10 mg Vit D supplements** per day)

Answer 51

**Ergocalciferol** (Vitamin D) ## Footnote * The doses for treatment of vitamin D deficiency depend on the age (see the BNF). * The dose for children between 6 months and 12 years is 6,000 IU per day for 8 – 12 weeks.

Answer 52

Vitamin D + calcium supplementation

Answer 53

**Infection** inside of a **joint**

Answer 54

Children under 4

Answer 55

The infection can quickly **destroy a joint** and cause **serious systemic illness**

Answer 56

Septic arthritis

Answer 57

Septic arthritis

Answer 58

* Usually only affects **one joint** → often **knee** or **hip** * Rapid onset of below: * Hot, red, swollen and painful joint * Refusing to weight bear * Stiffness and reduced range of motion * Systemic symptoms such as fever, lethargy and sepsis ## Footnote Septic arthritis can be subtle in young children, so always consider it as a differential when a child is presenting with joint problems.

Answer 59

**SEPTIC ARTHRITIS** (Can be subtle in younger children)

Answer 60

**Staphylococcus aureus** * Neisseria gonorrhoea (gonococcus) in sexually active teenagers * Group A streptococcus (Streptococcus pyogenes) * Haemophilus influenza * Escherichia coli (E. coli)

Answer 61

* Transient sinovitis * Perthes disease * Slipped upper femoral epiphysis (SUFE) * Juvenile idiopathic arthritis

Answer 62

Before IV antibiotics

Answer 63

* Gram staining * Crystal microscopy * Culture * Antibiotic sensitivities (The joint fluid may be **purulent** (full of pus)

Answer 64

- First line: **Flucloxacillin + rifampicin** - Vancomycin + rifampicin → penicillin, MRSA, prosthetic joint 3-6 weeks in total

Answer 65

* 3-6 weeks of antibiotics * Surgical drainage * Surgical washout ## Footnote Surgical drainage and washout = to clear the infection

Answer 66

* **Clicking** → due to **soft tissue moving over bone (no concern)** → doesn't require ultrasound * **Clunking** → more likely to **indicate DDH** → requires ultrasound

Answer 67

Juvenile idiopathic arthritis

Answer 68

**Juvenile idiopathic arthritis (JIA)** = an **autoimmune inflammation** in the joints . * It is diagnosed where there is arthritis **without any other cause** - **lasting more than 6 weeks** in a patient **under the age of 16**. * It has also been known as juvenile chronic arthritis and juvenile rheumatoid arthritis. The key features of inflammatory arthritis = **joint pain + swelling + stiffness**

Answer 69

* Systemic JIA * Polyarticular JIA * Oligoarticular JIA * Enthesitis related arthritis * Juvenile psoriatic arthritis

Answer 70

**Systemic JIA = Still's disease** * **Systemic JIA** = a **systemic illness** that can occur throughout childhood in boys and girls Typical features: * **Subtle salmon-pink rash** * High swinging fevers * Enlarged lymph nodes * Weight loss * Joint inflammation and pain * Splenomegaly * Muscle pain * Pleuritis and pericarditis

Answer 71

* Antinuclear antibodies (ANA) + rheumatoid factors (RF) = typically negative * **Raised inflammatory markers (CRP + ESR)** * **Raised platelets + serum ferritin**

Answer 72

**Macrophage activation syndrome (MAS)** **MAS** = Where there is **severe activation of the immune system** with a **massive inflammatory response**. It presents with an **acutely unwell child** with : * **Disseminated intravascular coagulation (DIC)** * **Anaemia** * **Thrombocytopenia** * **Bleeding** * **A non-blanching rash**. It is **life threatening**. A key investigation finding is a **low ESR**.

Answer 73

Thinks of systemic JIA (Still's disease) when a patient presents with: * Salmon-pink rash * Fevers * Joint pain

Answer 74

* Kawasaki disease * Still's disease * Rheumatic fever * Leukaemia

Answer 75

* **Polyarticular JIA** = idiopathic inflammatory arthritis in **5 joints or more**. * The inflammatory arthritis tends to be **symmetrical** and can affect the small joints of the hands and feet, as well as the large joints such as the hips and knees. * There are **minimal systemic symptoms**, but there can be mild fever, anaemia and reduced growth. Systemic symptoms are mild, unlike systemic onset JIA. * **Polyarticular JIA** = the equivalent of **rheumatoid arthritis in adults**. * Most children = negative for rheumatoid factor → “**seronegative**”. * When rheumatoid factor is positive → “**seropositive**”. * Seropositive patients tend to be older children and adolescents and the disease pattern is more similar to rheumatoid arthritis in adults.

Answer 76

**Oligoarticular JIA** = **involves 4 joints or less** * Usually it **only affects a single joint** → described as a **monoarthritis**. * It tends to affect the** larger joints**, (**knee** or **ankle**). * It occurs more frequently in **girls** under the **age of 6 years**. * **Patients tend not to have any systemic symptoms** and inflammatory makers will be normal or mildly elevated.

Answer 77

**Anterior uveitis** (Patients should be referred to opthalmologist)

Answer 78

**Oligoarticular JIA = Antinuclear antibodies (ANA) positive** * = Rheumatoid factor negative

Answer 79

* Arthritis occurring in the hips, knees, ankles, feet * More common in boys over 6 (unlike rest of JIA types) * Associated with acute anterior uveitis

Answer 80

* **Enthesitis = inflammation** of the **insertion** of the **ligament** or **tendon** to the bone (enthesis) * Occurs in the **knees**, **heels**, **plantar region** of the **feet** * Patients have **inflammatory arthritis** in the joints (as well as **enthesitis**) Enthesitis-related arthritis = thought as paediatric version **of seronegative spondyloarthropathy group** of conditions that affect adults (ankylosing spondylitis, psoriatic arthritis, reactive arthritis, inflammatory bowel disease -related arthritis) - so might be worth checking for signs of these: * **Psoriasis (psoriatic plaques + nail pitting)** * **Inflammatory bowel disease (intermitted diarrhoea + rectal bleeding)** Patients with enthesitis-related arthritis are prone to **anterior uveitis**, and should see an ophthalmologist for screening, even if they are asymptomatic.

Answer 81

Patients with **enthesitis** will be tender to localised palpation of the entheses. Therefore it is worth palpating key areas to elicit tenderness of the entheses: * Interphalangeal joints in the hand * Wrist * Over the greater trochanter on the lateral aspect of the hip * Quadriceps insertion at the **anterior superior iliac spine** * Quadriceps and patella tendon insertion around the patella * Base of achilles, at the calcaneus * Metatarsal heads on the base of the foot

Answer 82

**Juvenile psoriatic arthritis = seronegative inflammatory arthritis** - associated with **psoriasis** Pattern of joint involvement varies - patients can have: * **Symmetrical polyarthritis** - affecting the **small joints** similar to rheumatoid * Or an **asymmetrical arthritis** affecting the **large joints** in the **lower limb**

Answer 83

* **Plaques of psoriasis** on the skin * Pitting of the nails (**nail pitting**) * **Onycholysis** (separation of the nail from the nail bed) * **Dactylitis** (inflammation of the full finger) * **Enthesitis** (inflammation of the entheses, which are the points of insertion of tendons into bone)

Answer 84

First line: * **NSAIDs** * **Intra-articular corticosteroids** * **Intravenous corticosteroids** (Short-term to control severe symptoms - or in systemic JIA) * **Methotrexate** (DMARD (slow the progression + prevent joint damage) (Avoided if presence of sacro-ilitis or macrophage activation syndrome (MAS)) * **Physiotherapy + occupational therapy** * Biologic therapy - such as the **tumour necrosis factor inhibitors (etanercept (anti-TNF), infliximab)** ## Footnote Etanercept = should be avoided in presence of sacro-ilitis, MAS and uveitis

Answer 85

* **Joint deformities and functional disability** * **Growth disturbances** * **Uveitis** * **Osteoporosis** * **Secondary amyloidosis**: with systemic JIA only * **Pericarditis, pleuritis, peritonitis**: with systemic JIA only * **Macrophage activation syndrome (MAS)**: a life-threatening condition seen in 10% of JIA cases, caused by uncontrolled activation and proliferation of T lymphocytes and macrophages. It presents as a sepsis-like condition with fever, hepatosplenomegaly and haemorrhagic manifestations

Answer 86

* **Definition**: **Fixed abnormal ankle position** at **birth** (aka clubfoot). * **Causes**: Can occur spontaneously or with other syndromes. * **Diagnosis**: Seen at birth or on newborn exam.

Answer 87

* Causes: Can occur spontaneously or with other syndromes. * Diagnosis: Seen at birth or on newborn exam.

Answer 88

* Non-surgical, started soon after birth. * **Foot gently manipulated and cast applied repeatedly**. * **Achilles tenotomy often performed to release tendon.** * After casting: boots and bars brace until ~4 years old. * Surgery only if Ponseti fails or unsuitable.

Answer 89

* Foot rests in plantar flexion + supination, but **not fixed.** * **No bony abnormality**; muscles slightly tight. * **Foot movable** to normal position. * Managed with **physiotherapy + exercises; resolves over time.**

Answer 90

Most common cause of **disproportionate short stature** (**skeletal dysplasia**).

Answer 91

* Caused by **FGFR3 gene** mutation on **chromosome 4.** * **Autosomal dominant** inheritance. * **Homozygous mutation → fatal** in neonatal period. * Mutation → **abnormal growth plate function** → **short bones.**

Answer 92

* **Disproportionate short stature** (~4 ft average). * **Short limbs **(proximal > distal). * **Normal trunk length, intelligence, and lifespan.** * **Short digits, bow legs (genu varum).** * **Disproportionate skull**: - **Flattened mid-face & nasal bridge** (abnormal skull base growth). - **Frontal bossing** (normal cranial vault growth). - **Foramen magnum stenosis.**

Answer 93

* **Recurrent otitis media** * Kyphoscoliosis * **Spinal stenosis** * **Obstructive sleep apnoea** * Obesity * Foramen magnum stenosis → cervical cord compression / **hydrocephalus**

Answer 94

* **No cure. Multidisciplinary support:** paediatrics, physio, OT, dietician, orthopaedics, ENT, genetics. * Leg lengthening surgery possible but controversial – risk of pain, reduced function.

Answer 95

* **Normal life expectancy** (if no major complications). * Tendency to **gain weight** due to short stature. * **Psychosocial challenges** common.

Answer 96

**Osteosarcoma** = type of **bone cancer** * This usually presents in **adolescents** and **younger adults** aged **10 – 20 years**. * The most common bone to be affected is the **femur**. * Other common sites are the **tibia** + **humerus**.

Answer 97

**PERSISTENT BONE PAIN** - particularly worse at night time (This may **disturb or wake them from sleep**)

Answer 98

* **Persistent bone pain** (**worse at night**, may wake child). * **Bone swelling** or **palpable mass.** * **Restricted joint movement**.

Answer 99

* **Urgent X-ray (within 48h) for unexplained bone pain/swelling (NICE)**. * If **suspicious → urgent specialist referral (within 48h).** * X-ray findings: - **Poorly defined bone lesion**. - **Bone destruction** with **“fluffy” appearance.** - **Periosteal reaction → “sunburst” pattern**. - Possible soft tissue mass. * Bloods: **↑ ALP**. * Further imaging: - CT - MRI - **Bone scan** - **PET** - **Biopsy**

Answer 100

A **very urgent direct access xray** **within 48 hours** for **children** If the x-ray suggests a possible sarcoma they need very urgent specialist assessment within 48 hours.

Answer 101

* **Surgical resection** (may require amputation). * **Adjuvant chemotherapy.** * Multidisciplinary support: oncology, surgery, physio, OT, psychology, dietician, prosthetics, social work.

Answer 102

* **Pathological fractures** * Mestastasis

Answer 103

* **Poorly defined lesion in the bone** - with **destruction** of the normal bone and a **“fluffy” appearance** * There will be a **periosteal reaction** (**irritation of the lining of the bone**) that is classically described as a **“sun-burst” appearance**

Answer 104

* Child under 3 years * Fever * Waking at night with pain * Weight loss * Anorexia * Night sweats * Fatigue * Persistent pain * Stiffness in the morning * Swollen or red joint

Answer 105

* Child under 3 years * Child older than 9 with a restricted or painful hip * Not able to weight bear * Evidence of neurovascular compromise * Severe pain or agitation * Red flags for serious pathology * Suspicion of abuse

Answer 106

* **Blood tests** including **inflammatory markers (CRP and ESR)** → JIA and septic arthritis * **X-rays** → diagnose **fractures**, **SUFE** and other **boney pathology** * **Ultrasound** → establish an **effusion (fluid)** in the joint * **Joint aspiration** → used to diagnose or exclude **septic arthritis** * **MRI** → **osteomyelitis**

Answer 107

* **Growth Plates = Epiphyseal Plates** * Found only in children, between epiphysis & metaphysis. * Made of **hyaline cartilage**; allow bone growth in length. * **Fuse in teens → epiphyseal lines.** * **Weaker than bone** → prone to specific fracture types.

Answer 108

* **Children**: **More cancellous (spongy) bone** → flexible, fast healing. * **Adults**: More **cortical (hard)** bone → stronger but slower healing. * Children prone to: - **Greenstick fractures** – one side breaks, other bends. - **Buckle** (**torus**) fractures – compression injury. * **High remodelling ability** → can correct mild deformities over time. Fracture Healing: * **Younger child = faster healing.** * **Bone remodelling: reshapes bone along lines of stress**.

Answer 109

* Buckle (torus) * Transverse * Oblique * Spiral * Segmental * Comminuted * Greenstick * Salter-Harris (growth plate)

Answer 110

Fractures through the growth plate can **cause issues with growth in that bone**. Growth plate fractures are graded using the **Salter-Harris classification.** The higher the Salter-Harris grade, the more likely the fracture is to disturb growth. Growth Plate (Salter-Harris) Fractures – SALTR mnemonic: * Type I – **S**traight across (through growth plate) * Type II – **A**bove (through metaphysis) * Type III – be**L**ow (through epiphysis) * Type IV – **T**hrough (metaphysis + epiphysis) * Type V – c**R**ush (crush injury to plate) → Higher type = higher growth disturbance risk.

Answer 111

* **Safeguarding check**: Does the story fit the injury? * **Step 1 – Align bone:** - **Closed reduction** (**manipulation**) or **open reduction** (**surgery**). * **Step 2 – Stabilise fracture:** - Cast, K-wires, intramedullary nails/wires, screws, plates. ## Footnote Step 2 is to provide **relative stability** for a period of time, to allow healing. This can be done by fixing the bone in the correct position while it heals.

Answer 112

Pain Management (WHO 2-step ladder): 1. **Paracetamol** or **ibuprofen** 2. **Morphine** (if severe → admit child) * **Avoid: Codeine, tramadol (unpredictable metabolism).** * **Avoid aspirin <16 yrs** → risk of **Reye’s syndrome** (except in **Kawasaki disease**). ## Footnote Reye's syndrome: * Rare but serious condition causing **acute encephalopathy (brain swelling)** and **liver** **dysfunction.** * Typically occurs in children **after a viral infection** (e.g., influenza, varicella). * **Strongly associated with aspirin use** during or after viral illness.

Answer 113

Umbrella term for genetic condition that causes the **gradual weakening + wasting of muscles**

Answer 114

A specific technique used by children with **proximal muscle weakness** to stand up from the lying position

Answer 115

Duchennes muscular dystrophy

Answer 116

No cure - Occupational therapy, physiotherapy, medical appliances (wheelchairs) - Treatment of complications e.g. spinal scoliosis and heart failure

Answer 117

X-linked recessive (girls can be carriers)

Answer 118

**Dystrophin** gene on the **X-chromosone** (protein that helps hold muscles together)

Answer 119

If the child is a: - Girl → 50% carroer - Boy → 50% having the condition

Answer 120

- 3-5 years: Muscle weakness around pelvis - Weakness = progressive - Teenager: Wheelchair bound - Life expectancy: 25-35 years with good management of cardiac + respiratory complications

Answer 121

- **Oral steroids** → slow muscle weakness progression - **Creatine** → slight improvement in muscle strength

Answer 122

Dystrophin (Very similar to Duchennes, but less severly affected and maintains some of its function) (Management is similar Duchennes)

Answer 123

Myotonic dystrophy

Answer 124

Myotonic dystrophy

Paediatrics (MSK) Flashcards

(149 cards)