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UON Paediatric Society Teaching Series - Week 4 – MSK Made by: Holly Spencer Feedback Form:Warm up 01 02 03 List as many Is the cause Acute Can you identify causes of a limp in & Painful or Chronic which age groups paediatrics patients and Intermittent? these conditions as you can affect? T-y3-10 yearsit by: - 11-16 years Types of Limp UKMLA Age Acute Painful Limp Chronic and Intermittent Limp 1 - 3 years ● Infection (septic arthritis, osteomyelitis etc) ❏ Developmental dysplasia of the hip ● Transient synovitis ❏ Neuromuscular - cerebral palsy ● Trauma ❏ Juvenile idiopathic arthritis ● Malignant disease - leukaemia, neuroblastoma 3-10 years ● Transient synovitis ❏ Perthes disease (chronic) ● Septic arthritis/ osteomyelitis ❏ Neuromuscular disorders - Duchenne ● Trauma/ overuse ❏ Juvenile idiopathic arthritis ● Perthes disease (acute) ❏ Tarsal coalition ● Juvenile idiopathic arthritis ● Malignant disease - leukaemia ● Complex regional pain syndrome 11-16 years ● Mechanical - trauma, overuse, sports ❏ Slipped capital femoral epiphysis ● Osgood Schlatters ❏ Juvenile idiopathic arthritis ● Slipped capital femoral epiphysis (acute) ❏ Tarsal coalition ● Avascular necrosis of the femoral head ● Reactive arthritis ● Juvenile idiopathic arthritis ● Septic arthritis/ osteomyelitis ● Osteochondritis dissecans of the knee ● Bone tumours and malignancy ● Complex regional pain syndromeThe Acutely Painful Limp Common Bacteria • Staph Aureus CLINICAL SIGNS & DEFINITION • Strep Pyogenes (Group A) • Haem. Influenza SYMPTOMS • Causes an acutely painful limp • E. Coli • Fever • An infection of the joint fluid and joint tissues • Tenderness • Reaches joints through blood stream • Effusion Septic Arthritis • Warmth • Limited RoM • “Guards” Joint MANAGEMENT • Joint swelling & pain • Refusal to bear weight • Low threshold for treatment • Kocher criteria -fever, ESR, WBCs, inability to weight bear. • Hospital admission and Ortho Involvement COMMON LOCATIONS • Empirical IV Abx, ?sepsis six • Knee • Abx for 3-6 weeks once septic arthritis confirmed • Hip • Surgical drainage and washout • Shoulder • Ankle INVESTIGATIONS • Wrist • FBC, CRP, ESR, Blood Cultures • Joint Aspiration REMEMBER: The most important differential diagnosis to exclude is septic arthritis DEFINITION CLINICAL SIGNS & SYMPTOMS • Aka “Irritable hip” Transient Synovitis • Most common cause of hip pain ● Sudden painful limp and limping in children ● No fever • Pain and limp are due to ● No trauma inflammation of the lining of the hip ● Hip pain joint and increased fluid inside the ● Recent URTI joint ● Well-appearing ● Hip abducted & externally rotated • Most common in 2-10 year olds ● Limited internal rotation • Generally mild MANAGEMENT INVESTIGATIONS ● Simple analgesia ● Exclude septic arthritis ● FBC, CRP & ESR ● Safety net advice ● Bilateral Hip Ultrasound ● Follow up in 48 hours and 1 weekAny QuestionsQ/A A 5-year-old boy presents to the emergency department with a 2-day history of right hip pain and a limp. His mother reports that he had a mild upper respiratory infection one week ago but is otherwise well. On examination, he has a temperature of 37.8°C, and his right hip is held in slight flexion and abduction. There is limited range of motion due to pain, particularly in internal rotation. Blood tests reveal the following: ● White Blood Cell count: 10,000/mm³ (normal: 4,000–11,000/mm³) ● Erythrocyte Sedimentation Rate (ESR): 25 mm/hr (normal: <20 mm/hr) ● C-Reactive Protein (CRP): 20 mg/L (normal: <10 mg/L) What is the most likely diagnosis? A) Septic arthritis B) Transient synovitis C) Osteomyelitis D) Juvenile idiopathic arthritis E) Slipped capital femoral epiphysisQ/A B - TRANSIENT SYNOVITIS Option A: Septic arthritis is a more serious condition characterized by severe pain, high fever, and significant elevation in inflammatory markers. Other options are less likely: ● Osteomyelitis (option C): Usually presents with localized bone pain rather than joint pain and may have systemic signs of infection. ● Juvenile idiopathic arthritis (option D): More chronic and less likely to have an acute onset with fever. ● Slipped capital femoral epiphysis (option E): Typically presents in older children (adolescents) and with more chronic symptoms. The clinical presentation of the following strongly suggest transient synovitis: ● mild fever ● hip pain; and ● mildly elevated inflammatory markers following a recent viral infection. ● Remember, careful monitoring is required as transient synovitis is a diagnosis of exclusion, and septic arthritis must be ruled out, particularly if symptoms worsen.Acutely Painful and Chronic Intermittent Limp DEFINITION KEY FACTS • Disrupted blood supply causes ● Occurs in under 8s deformation of the femoral head ● More common in males ● Family Hx is important! • Ultimately leads to osteonecrosis MANAGEMENT Perthes Disease ● Conservative management: CLINICAL SIGNS & SYMPTOMS NSAIDS, limited weight bearing, ● Painless limp (unilateral usually) physical therapy ● +/- Pain - hip, groin, thigh or knee ● Paediatric orthopedics ● Limited internal rotation & abduction involvement ● Trendelenburg sign ● Petrie casting (abduction brace, keeps femoral head position in ● Tender on palpation acetabulum as it heals) ● Affected leg may be shorter ● Femoral or pelvic osteotomy ● Smaller thigh circumference INVESTIGATIONS ● Bilateral hip/pelvic XR ● XR: see widening of the joint space. In severe cases see flattening or fragmentation of the femoral head. ● MRI: shows decreased perfusion of the femoral head DEFINITION KEY FACTS CLINICAL SIGNS • Weakness of growth plate ● Normally occurs in over 10 year olds ● Limp causes displacement of the ● Pain in hip, groin, thigh or knee femoral head from the ● Limited internal RoM, abduction and femoral neck flexion Slipped Capital Femoral Epiphysis ● Child's leg externally rotates with passive flexion of the hip MANAGEMENT ● Hip tender on palpation ● Make patient non weight bearing ● Surgical - in situ fixation of femoral head to femoral neck INVESTIGATIONS ● Bilateral hip/ pelvic XR RISK FACTORS ● XR Shows: displacement of the ● Obesity femoral head in relation to the ● Hypothyroidism ● Endocrinopathies femoral neck, Klein’s line ● Trauma ● Radiation ● MRI (for early detection) ● Family Hx ● MRI Shows: widening of the physis (growth plate) and surrounding oedemaQ/A A 13-year-old overweight boy presents to the clinic with a 3-week history of intermittent pain in his left hip, groin, and knee. He has been limping and finds it difficult to bear weight on his left leg. There is no history of trauma. On examination, his left leg is externally rotated, and there is limited internal rotation of the hip. An X-ray of the pelvis shows displacement of the left femoral head relative to the femoral neck. What is the most appropriate next step in management? A) Advise non-weight bearing and schedule follow-up in 2 weeks B) Prescribe analgesics and physiotherapy C) Immediate referral to orthopedic surgery for in-situ pinning D) MRI of the hip to assess the extent of the epiphyseal slip E) Observation and repeat X-ray in 4 weeksQ/A Answer: C) Immediate referral to orthopedic surgery for in-situ pinning The patient has slipped capital femoral epiphysis (SCFE). The management of SCFE is an orthopedic emergency because delaying treatment can lead to further slippage, avascular necrosis of the femoral head, and long-term joint dysfunction. The standard treatment is immediate referral to orthopedic surgery for in-situ pinning of the femoral head to prevent further slippage. This procedure stabilizes the growth plate and prevents complications. Key considerations: ● Non-weight bearing: The child should be made non-weight bearing immediately to prevent worsening of the slip while awaiting surgery. ● Inappropriate options: ○ A) Advise non-weight bearing and schedule follow-up in 2 weeks: Delaying intervention increases the risk of further slippage and complications. ○ B) Prescribe analgesics and physiotherapy: Pain management alone is insufficient, and physiotherapy may worsen the slip. ○ D) MRI of the hip: Although MRI can assess the extent of the slip and detect early avascular necrosis, it should not delay urgent surgical intervention. ○ E) Observation and repeat X-ray in 4 weeks: Observation without intervention is inappropriate, as further displacement can occur.DEFINITION Age Group CLINICAL SIGNS & Broad group of autoimmune conditions. ● Under 16 years old SYMPTOMS ● 6+ weeks of joint swelling Leads to bony erosion and joint destruction. ● Warm/ painful joints Subtypes: ● Stiffness lasting more than 30 • Oligoarticular (4 or less joints) Juvenile Idiopathic Arthritis minutes in morning or after inactivity • Polyarticular (5 or more joints) • Systemic ● Joint effusion • Enthesitis-related ● Tenderness • Psoriatic ● Limited ROM ● Assess for Quotidian fever MANAGEMENT ● Stepwise fashion COMPLICATIONS ● Immunosuppression (IL-1 or IL-6 inhibitors) Diagnose and treat promptly to limit ● Methotrexate INVESTIGATIONS damage, preserve functionality and ● Other biologics ● FBC prevent chronic pain ● Systemic corticosteroids ● CRP/ ESR ● Serum ferritin ● TNF inhibitors (psoriatic and enthesitis) ● NSAIDS ● RF ● Intraarticular corticosteroid injections ● Anti CCP Antibodies ● Anti Nuclear antibodies ● HLA-B27 (+ve in oligoarticular) Q/A A 7-year-old boy is brought to the pediatric clinic by his parents due to a high-grade fever that has been persistent for the past two weeks. The fever is associated with a salmon-pink rash, which comes and goes. He has also been complaining of joint pain, especially in the knees and wrists. Upon examination, the boy appears ill, with noticeable lymphadenopathy and hepatosplenomegaly. His parents report that he has been irritable and more fatigued than usual. Blood tests show ESR and CRP, anemia and thrombocytosis. Based on the clinical findings, what is the most likely diagnosis? A) Psoriatic Juvenile Idiopathic Arthritis B) Systemic Lupus Erythematosus (SLE) C) Systemic Juvenile Idiopathic Arthritis D) Oligoarticular Juvenile Idiopathic Arthritis E) Polyarticular Juvenile Idiopathic Arthritis Q/A Systemic Juvenile Idiopathic Arthritis (sJIA) is the most likely diagnosis given the presentation of a child with daily spiking fevers, a salmon-pink macular rash, arthritis, lymphadenopathy, and hepatosplenomegaly. The key clinical and laboratory features that point toward sJIA include: - Raised inflammatory markers - Thrombocytosis Polyarticular JIA will show +ANA, raised inflammatory markers, anaemia but no thrombocytosis and no salmon-pink rash Oligoarticular JIA will show +ANA only Psoriatic JIA will show +ANA and a silvery scaly dry patch (psoriasis) will be presentChronic and Intermittent LimpDEFINITION KEY FACTS • Inflammation of the patellar ligament ● Affects 9-15 year olds causing a painful swelling of the knee. ● Pt has a Hx of engaging in sports. • In severe cases, the ossification center on the tibial tuberosity can crack which results in a callus forming below tAka traction apophysitis knee. CLINICAL SIGNS ● Palpable lump below knee ● Painful with physical activity and going up and down stairs. MANAGEMENT ● Decrease physical activity ● Ice to reduce swelling ● Pain medication ● Surgery INVESTIGATIONS ● USS COMPLICATIONS ● XR ● Usually self resolves DEFINITION SCREENING CLINICAL SIGNS • Misalignment of the femoral head and ● Critical to screen all infants as In <6 months: acetabulum. early treatment ensures better • Leads to an unstable joint, subluxation, outcomes and prevents ● Ortolani/ Barlow maneuvers and dislocation. osteoarthritis Developmental Dysplasia of the Hip MANAGEMENT ● <6 months: Surgical team - abduction splint (pavlik harness) ● 6 m - 2 years: closed reduction and abduction splinting (spica cast) RISK FACTORS In >6 months: ● 2+ years: surgical open reduction followed by ● Family Hx of DDH ● Limited hip abduction abduction splinting ● Breech orientation after 34 ● Thigh length discrepancy (galeazzi weeks of gestation test), ● Require routine XR of hips until developmentally ● Oligohydramnios ● Asymmetry of the thigh or gluteal folds mature ● Uneven gait INVESTIGATIONS ● USS ● XRQ/A A 2-month-old girl is brought to the pediatric clinic by her parents for a routine check-up. She was born via vaginal delivery at 39 weeks after a pregnancy complicated by oligohydramnios. The parents have noticed that her left leg appears slightly shorter than the right. On physical examination, there is a noticeable asymmetry in the gluteal folds, and the Barlow test is positive on the left side. What is the most appropriate next step in the management of this patient? A) Reassurance and routine follow-up B) Immediate Pavlik splint by orthopaedic surgeons C) Hip ultrasound D) Initiation of physical therapy E) Observation and repeat examination at 6 monthsQ/A Answer: C) Hip ultrasound Explanation: The clinical findings in this case are most consistent with Developmental Dysplasia of the Hip (DDH). DDH encompasses a range of hip abnormalities, from a shallow acetabulum to complete dislocation of the femoral head. It is particularly common in infants with risk factors such as oligohydramnios, breech presentation, or family history. Key clinical signs of DDH include: ● Asymmetry in the gluteal or thigh folds: This can indicate a dislocated or subluxated hip. ● Apparent leg length discrepancy: This occurs when one hip is dislocated, causing the affected leg to appear shorter. ● Positive Barlow test: This maneuver assesses the ability to dislocate an unstable hip by gently adducting the hip while applying pressure posteriorly. A "clunk" or palpable movement indicates a dislocatable hip, strongly suggestive of DDH. The next appropriate step in management is to confirm the diagnosis with imaging, and in a child under 6 months of age, a hip ultrasound is the preferred diagnostic tool. Ultrasound is non-invasive and effective at visualizing the hip joint in infants, where the bones are not yet fully ossified. Early detection and treatment are crucial to prevent long-term complications such as gait abnormalities and osteoarthritis. If DDH is confirmed, further management may include bracing with a Pavlik harness or referral to an orthopedic specialist.Thank You!