the painful limb, knee & back

Mind Map by , created over 5 years ago

Paediatrics (MSK) Mind Map on the painful limb, knee & back, created by v.djabatey on 02/01/2014.

Created by v.djabatey over 5 years ago
Limp- causes
genetic skeletal condition
Summary of AS Psychology Unit 1 Memory
Britain and World War 2
Sarah Egan
Variations of normal posture
Abnormal posture
clinical features of transient synovitis & septic arthritis of hip
Arthritis 2
the painful limb, knee & back
1 growing pains
1.1 aka nocturnal idiopathic pain
1.2 =episodes of generalised pain in lower limbs
1.3 common in preschool & school-aged kids
1.4 pain often wakes child from sleep
1.5 pain settles w/ massage or comforting
1.6 features needed for diagnosis
1.6.1 age range 3-12 years
1.6.2 pains symmetrical in lower limbs & not limited to joints
1.6.3 pains NEVER present @ start of day after waking
1.6.4 physical activities not limited; NO LIMP
1.6.5 physical exam normal & otherwise except for some w/ joint hypermobility
2 hypermobility
2.1 older kids or teens
2.1.1 MSK pain confined mainly lower limbs worse after exercise
2.1.2 joint swelling absent/transient
2.2 distribution
2.2.1 generalised
2.2.2 limited to peripheral joints hands & feet
2.3 upper limb findings
2.3.1 symmetrical hyperextension of thumbs
2.3.2 fingers that can be hyperextended onto forearms
2.3.3 elbows that can be hyperextended beyond 10 deg
2.3.4 palms can be placed flat on floor w/ knees straight
2.4 lower limb finding
2.4.1 knees that can be hyperextended beyond 10 deg
2.4.2 flat feet w/ normal arches on tip toe feet over-pronated secondary to ankle hypermobility
2.5 mild degrees are a normal finding in younger female kids
2.6 many are asyptomatic
2.6.1 helps for dancing & gymnastics
2.7 some experience recurrent mechanical joint & activity-related mm pain
2.7.1 specialist assessment needed
2.7.2 advice about footwear exercises orthotics
2.8 a feature of other conditions
2.8.1 chromosomal disorders Down syn
2.8.2 inherited collagen disorders Marfan syn Ehlers-Danlos syn
3 complex regional pain syndromes
3.1 aka idiopathic pain syndromes
3.2 localised or generalised
3.2.1 localised clinical features extreme & incapacitating pain trigger= minor trauma, can be w/o clear precipitant foot & ankle involvement often unlit cool to touch swelling & mottling held in flexion w/ minimal (if any) active movement normal range of passive movements possible w/ distraction bizarre posturing hyperaesthesia (increased sensitivity to stimuli) allodynia (pain from a stimulus that doesn't normally cause pain) present in a wheelchair
3.2.2 generalised clinical features severe widespread pain disturbed sleep patterns feeling exhausted extreme tenderness over soft tissues absent or fewer tender points like those found in adults with fibromyalgia
3.3 usually present in teen females
3.4 otherwise well
3.4.1 physical exam otherwise normal
3.5 unknown cause
3.5.1 but pts often have sig stresses in lives
3.6 need to exclude organic pathology
3.7 MDT approach needed
3.7.1 mostly physical therapy based community or inpt
4 acute-onset limb pain
4.1 osteomyelitis
4.1.1 infection of metaphysis of long bones
4.1.2 commonest sites distal femur proximal tibia
4.1.3 route usually due to haematogenous spread of pathogen direct spread from infected wound
4.1.4 swollen skin directly over affected site
4.1.5 can spread to cause septic arthritis in areas where joint capsule is inserted distal to epiphyseal plate- e.g. hip, elbow, shoulder
4.1.6 causative pathogens Staph .aureus causes most infections in the unimmunised H. influenzae TB Streptococcus if sickle cell anaemia Staph Salmonella
4.1.7 presentation markedly painful immobile limb (pseudoparesis) in child w/ acute febrile illness swelling & exquisite tenderness over infected site erythematous & warm over infected site moving limb causes severe pain possible sterile effusion of adj joint more insidious presentation in infants swelling & reduced limb movement initial sign outside infancy back pain vertebral infection groin pain pelvic infection multiple foci disseminated Staph or H. influenze infection
4.1.8 Ix blood cultures usually +ve raised WCC ESR/CRP raised X-rays normal takes 7-10 days for subperiosteal new bone formation & localised bone refraction to be visible may show soft tissue swelling characteristic changes (chronic osteomyelitis) periosteal rxn along lateral shaft of tibia multiple hypodense areas within metaphyseal regions US periosteal elevation @ presentation MRI allow IDn of subperiosteal pus & purulent debris (i.e. infection) in bone radionuclide bone scan helpful if site of infection unclear
4.1.9 Rx parental Abx promptly for several weeks prevention of bone necrosis chronic infection w/ discharging sinus iv Abx given until clinical recover & ESR/CRP normal fb oral therapy for several weeks aspiration or surgical decompression of subperiosteal space if atypical px if immunodef kid surgical drainage if not responding quickly to Abx affected limb initially rested in splint then subseq mobilised
4.2 malignant disease
4.2.1 acute lymphoblastic leukaemia bone pain in kids sometimes primarily @ night frank arthritis
4.2.2 neuroblastoma usually young kids presentation of mets- sx hard to localise systemic arthritis bone pain
4.2.3 bone tumours osteogenic sarcoma Ewing tumour rare present w/ swelling or pathological fracture
4.3 osteoid sarcoma
4.3.1 benign tumour
4.3.2 affects teens esp boys
4.3.3 involves femur or tibia or spine
4.3.4 presentation pain more severe @ night improves w/ NSAIDs involves femur or tibia or spine if near a joint localised tenderness soft tissue swelling joint effusion scoliosis if in spine
4.3.5 X-ray usually diag sharply demarcated radiolucent nidus of osteoid tissue w/ sclerotic bone around it if normal, CT or MRI
4.3.6 Rx- surgical removal
5 the painful knee
5.1 hip pain often referred to knee
5.2 Osgood-Schlatter disease
5.2.1 osteochondritis of the patellar tendon insertion @ knee
5.2.2 often affects physically active teen males esp football or basketball
5.2.3 presentation knee pain after exercise localised tenderness over knee swelling over tibial tuberosity
5.2.4 Mx reduced activity physiotherapy for quadriceps mm strengthening hamstring stretches orthotics knee immobiliser splint
5.3 chondromalacia patellae
5.3.1 softening of articular cartilage
5.3.2 often teen females
5.3.3 causes pain when patella tightly apposed to femoral condyles i.e. standing up from sitting on walking up stairs
5.3.4 assoc w/ hypermobility & flat feet suggests biomechanical component to aetiology
5.3.5 Rx rest physiotherapy for quadriceps mm strengthening
5.4 osteochondritis dissecans (segmental avascular necrosis of subchondrial bone)
5.4.1 presents as knee pain in physically active teen w/ localised tenderness over femoral condyles pain caused by separation of bone & cartilage from medial femoral condyle ff avascular necrosis complete separation of articular fragments may -> loose body formation & sx of knee locking or giving way
5.4.2 Rx rest & quadriceps exercises arthroscopic surgery
5.5 subluxation & dislocation of patella
5.5.1 subluxation produces feeling of instability/giving way of knee often assoc w/ general hypermobility
5.5.2 dislocation usually laterally sudden rare severe pain reduction occurs spontaneously or on gentle extension of knee Rx quadriceps exercises surgery to realign pull of quadriceps on patellar tendon
5.6 injuries
5.6.1 contact sports -> acute knee inj inj to menisci & ligaments common in teens MRI to determine extent of damage conservative mx these inj in infants & young kids-> fractures cos ligaments stronger than their bone
5.6.2 non-contact sports w/ sustained activity-> chronic inj &over syndromes
6 back pain
6.1 concerning in very young & pre-teen girls
6.1.1 cause can often be IDed (unlike adults) mechanical causes muscle spasm or soft tissue pain from sports-rel in poor posture abnormal loading tumours: benign or malignant spine is common site for osteoid osteoma spine can be primary site for many tumours vertebral osteomyelitis or discitis localised tenderness infants reluctance to walk or bear weight pain on spine flexion fever systemic upset plain x-ray +/- MRI Rx= iv Abx spinal cord or nerve root entrapment from tumour or prolapsed iv disc often assoc w/ trauma or heavy lifting Scheuermann disease osteochondrosis of vertebral body may present w/ fixed thoracic kyphosis +/- back pain diag on X-ray radiographic changes often incidental finding & pt often asymptomatic complex regional pain syn diagnosed when no physical cause found exacerbated by psychological stress spondylolysis/spondylolisthesis stress fracture of pars interarticularis of vertebra increased risk w/ certain sports bowling in cricket gymnastics if bilat-> spondylolisthesis forward slip of vertebral body & potential cord or nerve root compression X-ray + CT
6.2 red flag clinical features
6.2.1 young age pathology more likely
6.2.2 high fever infections
6.2.3 night waking, persistent pain osteoid sarcoma tumours
6.2.4 painful scoliosis- infection or malignancy
6.2.5 focal neuro signs- suggest nerve root/spinal cord compression nerve root irritation loss of bladder/bowel control
6.2.6 assoc weight, systemic malaise- malignancy

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