Musculoskeletal Notes

Musculoskeletal

pGALS

• Screening Questions “Do you (or you child) have any…”

  • Pain or stiffness in your muscles, joints or back?

  • Difficulty getting dressed without help?

  • Difficulty going up and downstairs?

• Posture and Gait

  • Observe standing

  • Observe walking

    • Heel walking*

    • Tip-toes*

• Arms

  • Put your hands out straight in front of you

  • Turn your hands over

  • Make a fist

  • Pincer grip

  • Touch the tips of your fingers to your thumb

  • Squeeze the MCP joints for tenderness

  • Put your hands behind your head

  • Hands together palm to palm*

  • Hands together back to back*

  • Reach up and touch the sky now look at the ceiling*

• Legs

  • Feel for effusion of the knee

  • Bend and straighten your knee feel for crepitus

  • Passive movement of hip

• TMJ

  • Open mouth and move about

• Neck and Spine

  • Touch ear to shoulder lateral flexion of cervical spine

  • Bend forward and touch your toes observe curve of spine

* Differences from adult GALS

Regional MSK Assessment

• Look

  • Signs of discomfort

  • Skin abnormalities

  • Limb alignment, muscle bulk, asymmetry

  • Bone deformity, swelling

• Feel

  • Each joint, bone and neighbouring soft tissue

  • Warmth – infection or inflammation

  • Delineate swelling

  • Check for effusion at knee

• Move

  • Active followed by passive

  • Compare sides

• Function

  • Gait

  • Grip

Arthritis

• Causes of Polyarthritis

  • Infection

    • Bacterial

    • Viral rubella, mumps, adenovirus, herpes, hep, parvovirus

    • Other mycoplasma

    • Reactive GI infection, streptococcal

    • Rheumatic fever

  • Inflmmatory Bowel Disease

  • Vasculitis HSP, Kawasaki disease

  • Haematological Disorders haemophilia, sickle cell

  • Malignant leukaemia, neuroblastoma

  • Connective Tissue Disorders

    • Juvenile idiopathic arthritis

    • SLE

    • Dermatomyositis

    • Polyarteritis nodosa

  • Other CF

Reactive Arthritis

• Clinically

  • Transient joint swlling (<6 weeks)

  • Often ankles or knees

  • Typically follows extra-articular infection

    • Enteric bacteria in children salmonella, shigella, camplyobacter, yersinia

    • In adolescents chlamydia, gonococcus, mycoplasma, Lyme disease

    • Rheumatic fever in developing countries

  • Low grade fever

• Investigations

  • Fever

  • Acute phase reactants are normal or mildly elevated

  • XR normal

• Treatment

  • Supportive

  • NSAIDs

Septic Arthritis

• Serious infection of the joint space

• Common in children <2 years

• Typically one joint, hip is common

• Pathogenesis

  • Typically results from haematogenous spread

  • May occur following puncture wound or infected skin lesion

  • In young children if may result from spread from adjacent osteomyelitis into joints where the capsule inserts below the epiphyseal growth plate

• Causative Organisms

  • <12 months old; Staph, Group B strep, gram nevative bacilli

  • 1-5 years; S aureus, Hib, Group A strep, Strep pneumoniae

  • 5-12 years; S. aureus, Group A strep

  • 12-18 years; S. aureus, Gonorrhoeae

• Consider underlying illness immunodeficiency and sickle cell

• Presentation

  • 75% of cases involve the lower limb (knee>hip>ankle)

  • Erythamatous, warm, tender joint

  • Reduced range of movement

  • Unwell, febrile child

  • Pseudoparesis Characteristis posture to reduce intracapsular pressure

    • Leg is held flexed, abducted and externally rotated

• Investigation

  • Increased WCC, acute phase reactants

  • Blood cultures

  • USS to identify effusion

  • XR exclude trauma and other bony lesions

    • In septic arthritis XR is initially normal except widened joint space

  • MRI scan may demonstrate adjacent osteomyelitis

  • USS guided aspiration from the joint space and culture is GOLD standard

  • (? lumbar puncture if septic joint with Hib)

• Treatment

  • IV antibiotics for 3 weeks followed by oral for a total of 4-6 weeks

  • Surgical irrigation and debridement

  • May require immobilisation

Onset – acute, non weight bearing

Fever – moderate, high

Child’s appearance – looks ill

Hip movement – held flexed, severe pain at rest and worse on attempts to move

WCC – normal/high

CRP/ESR – raised

USS – fluid in joint

Radiograph – normal / increased joint space

Rx – joint aspiration, prolonged antibiotics, rest and analgesia

Course – progressive and severe joint damage if untreated

Juvenile Idiopathic Arthritis (JIA)

• Commonest chronic inflammatory joint disease in children and adolescents in the UK (1/1000)

• Defined as persistent joint swelling (>6 weeks) presenting before 16 years of age. In the absence of infection or any other defined cause

• 1 in 1000 children

• Seven subtypes based on the number of joints affected in the first 6 months:

  • Polyarthritis; >4 joints

  • Oligoarthritis; up to and including 4 joints

  • Systemic; with fever and rash

  • Psoriatic arthritis

  • Enthesitis

• Subtype is further classified according to the presence of rheumatoid factor and HLA B27

• Features in the history

  • Gelling (stiffness after periods of rest)

  • Morning joint stiffness and pain

  • In the young child intermittent limp or deterioration in behaviour, mood or avoidance of once enjoyed activities

  • Swelling and inflammation of the joint

  • Proliferation of the synovium

  • Periarticular swelling

  • Long term in uncontrolled disease bone expansion from overgrowth leg lengthening or valgus deformity, discrepancy in digit length. Etc.

• Complications

  • Chronic anterior uveitis

  • Flexion contractures of the joints

  • Growth failure generalised from anorexia, chronic disease and systemic corticosteroid therapy

  • Constitutional problems anaemia of chronic disease, delayed puberty

  • Oseroporosis multifactorial – diet, reduced weight bearing, systemic corticosteroids and delayed menarche

  • Amyloidosis v. rare, causes proteinuria and renal failure

• Management

  • Physio

  • Links with opthalmology, dentistry (risk of caries) and orthopaedics

  • Medical management

    • NSAIDs and analgesia

    • Joint injections esp in oligoarticular JIA. Bridging assesst before methotrexate in polyarticular disease

    • Methotrexate

      • Weekly

      • Monitor bloods abnormal LFTs and bone marrow suppression

    • Systemic corticosteorids

      • Avoid if necessary to avoid growth suppression and osteoporosis

      • Pulsed IV methylprednisolone for severe polyarthrtitis

    • Biologics – cytokine modulators and other...

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