Paediatric MSK problems Signs and symptoms MSK signs and symptoms: Limp. Joint pain and swelling. Remember that hip pain may be referred to the knee. Morning stiffness. Gelling: stiffness following period of inactivity. Weakness and instability. Pseudoparalysis: limb fixed in pain. Associated systemic symptoms: Fever ↓Feeding or growth. Rash. Poor sleep. History of trauma: Incongruous signs might suggest non-accidental injury. Functional limitations. Differential diagnosis General: First exclude trauma – which may be missed/unwitnessed (especially in young e.g. toddler's fracture) – and infection – septic arthritis, osteomyelitis, or discitis. Consider general causes of MSK pain such as growing pains (often nocturnal), hypermobility, and complex regional pain syndrome. Acute: irritable hip, neuroblastoma, leukaemia. Chronic: developmental dysplasia of the hip, talipes, cerebral palsy, juvenile idiopathic arthritis (JIA).

1. Paediatric MSK problems
This slide is made with the assistance of Medicos PDF
app:https://bookapp.page.link/slideshare

2. Signs and symptoms

3. MSK signs and symptoms:
 Limp.
 Joint pain and swelling.
 Remember that hip pain may be referred to the knee.
 Morning stiffness.
 Gelling: stiffness following period of inactivity.
 Weakness and instability.
 Pseudoparalysis: limb fixed in pain.

4. Associated systemic symptoms:
 Fever
 ↓Feeding or growth.
 Rash.
 Poor sleep.
History of trauma:
 Incongruous signs might suggest non-accidental injury.

5. Functional limitations.
Differential diagnosis
General:
 First exclude trauma – which may be
missed/unwitnessed (especially in young e.g.
toddler's fracture) – and infection – septic arthritis,
osteomyelitis, or discitis.
 Consider general causes of MSK pain such as growing
pains (often nocturnal), hypermobility, and complex
regional pain syndrome.

6. General:
 Acute: irritable hip, neuroblastoma, leukaemia.
 Chronic: developmental dysplasia of the hip, talipes,
cerebral palsy, juvenile idiopathic arthritis (JIA).
5-10 years old:
 Acute: irritable hip, Perthes, osteosarcoma, Ewing's
sarcoma, leukaemia.
 Chronic: JIA, Perthes, Duchenne, cerebral palsy,
discoid meniscus.

7. >10 years old:
 Acute: slipped upper femoral epiphysis (SUFE),
reactive arthritis, osteosarcoma, Ewing's sarcoma,
leukaemia.
 Chronic: JIA, SUFE, Osgood-Schlatter's disease
(inflammation of tibial tuberosity).

8. Inherited skeletal problems

9. Presentation
May present with growth problems, bone deformities, and/or
motor delay.
Achondroplasia
A common cause of disproportionate dwarfism.
Genetics:
 Autosomal dominant mutation of fibroblast growth factor
receptor 3 (FGFR-3) gene.
 Usually a de novo mutation, linked to sperm changes in older
fathers.

10. Signs and symptoms:
 Short limbs causing short stature.
 Short fingers and broad hands.
 Large head and frontal bossing, with flattened
nasal bridge.
 Lumbar lordosis

11. Osteogenesis imperfecta
 Aka brittle bone disease.
 Autosomal dominant collagen defect.
 Type 1 is commonest, presenting with frequent
fractures, blue-tinted sclerae, and sometimes hearing
loss. Bisphosphonates can help prevent fractures.
 Type 2 is lethal, either prenatally or in early life.

12. Developmental
dysplasia of the hip

13. Pathophysiology and epidemiology
 Hip instability and dislocation, due to lax joint
capsule or intrauterine problem such as breech or
oligohydramnios.
 Commoner in girls.
 Usually unilateral (L>R), but 20% bilateral.

14. Signs and symptoms
 Leg length discrepancy.
 Asymmetric gluteal folds.
 Reduced abduction.
 When older, waddling gait and hyperlordosis.

15. Investigations
 Newborns screened with Ortolani's test – leg
elevated and abducted to try and return to hip
joint – and Barlow's test – leg depressed and
adducted to try and dislocate.
 USS hip
 Hip XR if >6 months old.

16. Management
 >6 months: surgery.
Paediatric fractures
The developing skeleton is at risk of a range of unique fracture
types.
Incomplete fractures
 The increased flexibility of children's long bones mean that
longitudinal stress (e.g. from FOOSH) may result in
bending/buckling of the bone without complete fracture.

17. Incomplete fractures
 Buckle (aka torus) fracture: no fracture line but
buckle/bulge of cortex may be seen. Commonly
affects distal radial metaphysis.
 Greenstick fracture: fracture line on inner (convex)
cortex, which does not extend to the opposite
cortex. Less common than buckle fracture.
Commonly affects radial mid-diaphysis.
 Managed with cast/splint.

18. Salter-Harris fractures
Fractures that involve the cartilaginous growth
plate (aka physis, epiphysial plate), classified
from 1-5, SALTR:
1. Straight across whole growth plate.
2. Away from joint i.e. extends into metaphysis.
Commonest (75%).
3. Loves the joint i.e. extends into epiphysis (and
hence intra-articular).

19. Salter-Harris fractures
4. Through everything i.e. extends into metaphysis and
epiphysis.
5. Rammed: crush injury without displacement. Rare.
Management:
 SH 1-2: closed reduction and cast/splint. Good
outcome.
 SH 3-4: risk of growth impairment (as affects
epiphysis) and arthritis (as intra-articular), so usually
require open reduction and internal fixation.

20. Toddler's fracture
 Undisplaced spiral fracture of tibial shaft, usually
distal, in ambulatory toddler (9-36 months).
 Typically follows twisting injury, often low energy.
 X-ray: initially may be normal, with injury only
apparent from new periosteal bone formation 7-10
days later.
 Managed with cast/splint.

21. Irritable hip

22. Aka transient synovitis of the hip (TSOH).
Epidemiology
 Commonest cause of acute hip pain if 2-12 years old.
 Commoner in boys.
Signs and symptoms
 Sudden onset of hip pain (on movement) and/or limp.
 Pain may be referred to knee.
 Reduced internal rotation.

23. Signs and symptoms
 May be triggered by viral infection, so there may be
a history of fever.
 Consider JIA if other joints are affected too.
Investigations
 USS may show fluid, but XR is normal.
 TSOH is a diagnosis of exclusion, so if imaging and
bloods are -ve (i.e. ruled out septic arthritis, JIA
etc.), TSOH is more likely.

24. Management
 Rest and ibuprofen until able to mobilize.
 Resolves 1-2 weeks.
Perthes' disease
Aka Legg-Calve-Perthes disease.
Pathophysiology and epidemiology
 Avascular necrosis of the femoral head
 Usually affects boys, 5-10 years old.

25. Signs and symptoms

26. Signs and symptoms
 Gradual onset of hip and/or knee pain and limp. May
radiate to groin or buttocks. Worse with activities.
 May appear as transient synovitis initially, but persists
>2 weeks.
 Bilateral in 10%.
Investigations
 Hip XR – AP and frog-leg lateral – may show widening
joint space, sclerosis, fragmentation, and eventually
flattening of femoral head (loss of the 'dome').
 XR may be normal in early disease, so MRI or bone scan
may be needed.

27. Management
 Simple analgesia and rest (followed by early
mobilisation) if mild and/or
 Plaster or surgery to secure femoral head in
acetabulum if severe (>50% femoral head necrosis) or
≥6 years old.

28. Slipped upper femoral
epiphysis (SUFE)

29. Slipped upper femoral epiphysis (SUFE)
Displacement of the rounded head of the femur.
Epidemiology and risk factors
 Usually affects boys, 10-16 years old.
 Risk factors: obesity, hypogonadism (as it causes
delayed bone maturation).

30. Signs and symptoms
 Pain in the groin, thigh, and/or knee, and limp.
 Reduced internal rotation.
 Onset is usually gradual, but can be acute and very painful.
 Bilateral in 20%.

31. Investigations
Hip XR – AP and frog-leg lateral – shows displacement
of femoral head.
Management
Surgical fixation to prevent further slippage and
avascular necrosis of the femoral head.

32. Juvenile idiopathic arthritis (JIA)

33. Juvenile idiopathic arthritis (JIA)
Aka juvenile rheumatoid arthritis (JRA),
although it's pathophysiology is distinct from adult
RA.
Definition and epidemiology
 Persistent (>6 weeks) joint swelling in children
 Most commonly affects girls, 1-10 years old.

34. Sub-types
 Oligoarticular JIA (60%): ≤4 joints, commonly knee,
ankle, and wrist. Asymmetrical.
 Polyarticular JIA (30%): ≥5 joints, commonly the
fingers. Usually symmetrical.
 Systemic-onset JIA (aka Still's disease). Arthritis plus
2 weeks of fever and systemic symptoms.
 Psoriatic JIA.
 Enthesitis-related JIA: HLA-B27-linked.

35. Signs and symptoms
 Pain
 Reduced function.
 Chronic anterior uveitis (iridocyclitis), especially with
oligoarticular JIA.
 Leg-length discrepancy.
 Flexion contracture.
 Systemic symptoms: acutely ill, malaise, fever, pink macular
rash, lymphadenopathy, hepatosplenomegaly, serositis
(pericarditis, pleuritis, peritonitis).

36. Investigations
 Diagnosis is clinical, but standard bloods (e.g. ↑ESR/CRP) and
X-rays (often normal) are usually done.
 Autoantibodies may be checked. 20% of polyarticular JIA is RF
+ve and has a worse prognosis. ANA +ve suggests uveitis risk.
Management
Stepwise treatment:
1. Regular NSAIDs – ibuprofen or naproxen – and physiotherapy.
2. Steroids: intra-articular injections, systemic (PO/IV) if severe.
3. DMARDs e.g. methotrexate.
4. Biologics e.g. etanercept.

37. Prognosis
30% continue into adulthood.
Analgesia in children
Basic principles
 Be proactive, pain should be prevented not treated.
 Like all medications in kids, PO can be given in oral
solution.
 Same 3 point ladder as for adults including morphine.

38. Extra options
 Local anaesthetic cream.
 Nitric oxide gas.
 Mild sedation – e.g. intranasal midazolam – for minor
procedures like suturing.
 GA for invasive procedures like endoscopy.

39. Thank you
KEep supporting medicos pdf app. To find lots
of books, slides and news visit the
app:https://bookapp.page.link/slideshare