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Musculoskeletal Notes

Medicine Notes > Paediatrics Notes

This is an extract of our Musculoskeletal document, which we sell as part of our Paediatrics Notes collection written by the top tier of University Of Nottingham students.

The following is a more accessble plain text extract of the PDF sample above, taken from our Paediatrics Notes. Due to the challenges of extracting text from PDFs, it will have odd formatting:

Musculoskeletal

pGALS

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Screening Questions "Do you (or you child) have any..."

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Pain or stiffness in your muscles, joints or back?

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Difficulty getting dressed without help?

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Difficulty going up and downstairs?

Posture and Gait

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Observe standing

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Observe walkingHeel walking*Tiptoes*

Arms

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Put your hands out straight in front of you

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Turn your hands over

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Make a fist

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Pincer grip

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Touch the tips of your fingers to your thumb

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Squeeze the MCP joints for tenderness

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Put your hands behind your head

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Hands together palm to palm*

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Hands together back to back*

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

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Feel for effusion of the knee

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Bend and straighten your knee feel for crepitus

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Passive movement of hip

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Open mouth and move about

Legs

TMJ

Neck and Spine

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Touch ear to shoulder lateral flexion of cervical spine

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Bend forward and touch your toes observe curve of spine

* Differences from adult GALS

Regional MSK Assessment

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Look

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Signs of discomfort

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Skin abnormalities

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Limb alignment, muscle bulk, asymmetry

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Bone deformity, swelling

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Each joint, bone and neighbouring soft tissue

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Warmth - infection or inflammation

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Delineate swelling

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Check for effusion at knee

Feel

Move

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Active followed by passive

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Compare sides

Function

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Gait

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Grip

Arthritis

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Causes of Polyarthritis

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InfectionBacterialViral rubella, mumps, adenovirus, herpes, hep, parvovirusOther mycoplasmaReactive GI infection, streptococcalRheumatic fever

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Inflmmatory Bowel Disease

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Vasculitis HSP, Kawasaki disease

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Haematological Disorders haemophilia, sickle cell

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Malignant leukaemia, neuroblastoma

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Connective Tissue DisordersJuvenile idiopathic arthritis

oSLEDermatomyositisPolyarteritis nodosa

Other CF

Reactive Arthritis

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Clinically

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Transient joint swlling (<6 weeks)

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Often ankles or knees

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Typically follows extraarticular infection

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*Enteric bacteria in children salmonella, shigella, camplyobacter, yersiniaIn adolescents chlamydia, gonococcus, mycoplasma, Lyme diseaseRheumatic fever in developing countries

Low grade fever

Investigations

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Fever

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Acute phase reactants are normal or mildly elevated

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XR normal

Treatment

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Supportive

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NSAIDs

Septic Arthritis

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Serious infection of the joint space

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Common in children <2 years

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Typically one joint, hip is common

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Pathogenesis

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Typically results from haematogenous spread

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May occur following puncture wound or infected skin lesion

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

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Causative Organisms

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

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15 years; S aureus, Hib, Group A strep, Strep pneumoniae

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512 years; S. aureus, Group A strep

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1218 years; S. aureus, Gonorrhoeae

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Consider underlying illness immunodeficiency and sickle cell

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Presentation

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

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Erythamatous, warm, tender joint

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Reduced range of movement

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Unwell, febrile child

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Pseudoparesis Characteristis posture to reduce intracapsular pressure*

Investigation

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Increased WCC, acute phase reactants

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Blood cultures

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USS to identify effusion

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XR exclude trauma and other bony lesions*

Leg is held flexed, abducted and externally rotated

In septic arthritis XR is initially normal except widened joint space

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MRI scan may demonstrate adjacent osteomyelitis

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

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(? lumbar puncture if septic joint with Hib)

Treatment

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IV antibiotics for 3 weeks followed by oral for a total of 46 weeks

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Surgical irrigation and debridement

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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)

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

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

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1 in 1000 children

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

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Polyarthritis; >4 joints

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Oligoarthritis; up to and including 4 joints

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Systemic; with fever and rash

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Psoriatic arthritis

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Enthesitis

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

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Features in the history

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Gelling (stiffness after periods of rest)

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Morning joint stiffness and pain

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

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Swelling and inflammation of the joint

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Proliferation of the synovium

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Periarticular swelling

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

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Complications

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Chronic anterior uveitis

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Flexion contractures of the joints

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

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Constitutional problems anaemia of chronic disease, delayed puberty

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

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Amyloidosis v. rare, causes proteinuria and renal failure

Management

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Physio

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

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Medical managementNSAIDs and analgesia

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

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Weekly

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Monitor bloods abnormal LFTs and bone marrow suppression

Systemic corticosteorids

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Avoid if necessary to avoid growth suppression and osteoporosis

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Pulsed IV methylprednisolone for severe polyarthrtitis

Biologics - cytokine modulators and other immunotherapies

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In severe disease refractory to methotrexate

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T cell depletion coupled with autologous haematopoetic stem cell rescue is an option for refractory disease

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