| K |

An acute multisystemic vasculitis of unknown aetiology (? infective) in children usually <5 yrs presenting with an acute febrile illness.

Diagnostic features and criteria

Fever persisting for more than 5 d plus at least 4 of:

• bilateral conjunctival congestion (non-purulent)

• dryness, redness and cracking of the lips ± erythema of tongue, buccal mucosa

• maculopapular polymorphic rash esp. trunk, genitalia

• cervical lymphadenopathy >1.5 cm

• erythema and swelling of palms and soles

Followed by desquamation of fingertips (a characteristic)

Diagnosis with 5/6 features or 4/6 plus evidence of coronary aneurysm (plus exclusion of other diseases).

Above features may be variable/incomplete and not all present concurrently.

No specific test but elevated ESR, neutrophilia, thrombocytosis and various +ve antibody tests (e.g. antiendothelial cell). Generally benign and self-limiting but early diagnosis is important to prevent complications, esp. coronary aneurysms (15–30% in untreated) and also myocardial infarction, pericarditis and myocarditis.

Management

• Echocardiography and ECG are indicated.

• Treat with aspirin (start ASAP) and high-dose normal gammaglobulin.

• Avoid corticosteroids.

• Most children recover and the overall mortality is <3%.

Various treatment methods

Prevention: Avoid procedures on Keloid-prone individuals. Use compression and silicone dressings.

Multiple pressure injections

• First ‘soften’ with application of liquid nitrogen.

• Spread film of corticosteroid solution over scar.

• Apply multiple pressure through solution with a 21-gauge needle held tangentially (about 20 superficial stabs per cm²).

• Avoid bleeding.

• Repeat in 6 wks or Intralesional injection of triamcinolone (after liquid nitrogen) or topical class III–IV corticosteroid ointment with occlusion.

Consider:

• X-ray treatment of surgical wounds within 2 wks of operation

• intralesional cytotoxics (esp. fluorouracil)

• re-excision of hypertrophic scar

Management

• Remove by excision perform biopsy (at least 2–3 mm margin)

• If clinically certain—curettage/diathermy

• Treat as SCC (by excision) if on lip/ear

Note: Can be misdiagnosed instead of SCC.

Seborrhoeic keratoses

Management

• Usually nil apart from reassurance

• Does not undergo malignant change

• Can be removed for cosmetic reasons

• Light cautery to small facial lesions

• May drop off spontaneously

• If diagnosis uncertain, remove for histopathology

Decolourisation or removal:

• liquid nitrogen (regular applications, e.g. every 3 wks) or

• concentrated phenol solution (with care) repeat in 3 wks or

• trichloracetic acid: apply to surface and instil with multiple small needle pricks (25 g). Repeat twice wkly for 2 wks.

Solar keratoses

Management

• Reduce exposure to sunlight

• Can disappear spontaneously

• Liquid nitrogen if superficial or

• 5-fluorouracil 5% cream daily for 3–4 wks

• Surgical excision for suspicious and ulcerating lesions

• Biopsy if doubtful

A common skin disorder of rough horny stippled papules mainly on the extensor surfaces of the upper arms and thighs. Worse in winter months—resembles ‘goose pimples’.

Management (options)

• Urea containing moisturisers (e.g. Calmurid)

• 3% salicyclic acid ointment

• Topical retinoid cream

Facts

• Chronic kidney disease (CKD) is a rapidly evolving major clinical problem.

• Diabetes is the main cause; others include hypertension, glomerulonephritis esp. IgA nephropathy, drugs, CTDs.

• Consider the diagnosis of CKD in patients presenting with:

  • unexplained poor health esp. fatigue, malaise, anv

  • unexplained anaemia

  • history of diabetes, hypertension, coronary heart disease, CTDs

  • neurological disturbances, e.g. confusion, coma

• An improved laboratory reporting method is the estimated glomerular filtration rate (e GFR) using the CKD–EPI (chronic kidney disease–epidemiology) collaboration. Laboratories now report this with every request for s. creatinine clearance.

• ACE inhibitors or ARB agents are the key drugs in management of renal failure but monitor with care.

Definition of CKD

• GFR <60 mL/min/1.73 m² for ≥3 mths ± evidence of kidney damage or

• Evidence of kidney damage (±↓ GFR) for ≥3 mths, as evidenced by the following:

  • microalbuminuria (urinary albumin excretion rate 30–300 mg/d)

  • macroalbuminuria (urinary albumin excretion rate >300 mg/d)

  • persistent haematuria (where other causes such as urologic conditions have been excluded)

  • pathologic abnormalities (e.g. abnormal renal biopsy)

  • radiologic abnormalities (e.g. scarring or polycystic kidneys) on renal US scan

Proteinuria

Can be confirmed with a 24-h urine protein estimation or (preferably) an albumin creatinine ratio (ACR).

Guidelines:

• normal albuminuria: ACR ♀ <3.5 mg/mmol; ♂ <2.5 mg/mmol

• microalbuminuria: ACR ♀ 3.5–35 mg/mmol; ♂ 2.5–25 mg/mmol

• macroalbuminuria: ACR ♀ >35; ♂ >25

The ‘triple whammy’

• NSAIDs/COX2s

• ACE inhibitor

• Diuretic

These 3 agents, individually or in combination, are implicated in >50% of cases of iatrogenic kidney failure.

Targets: management goals

The following are the optimal targets for patients with CKD.

Key facts and checkpoints

• A ruptured anterior cruciate ligament (ACL) is the most commonly missed injury of the knee.

• A rapid onset of painful knee swelling (mins to 1–4 h) after injury indicates blood in the joint—haemarthrosis: the main causes are torn cruciate ligaments, capsular tears with collateral ligament tears, peripheral meniscal tears, fractures and dislocations.

• Swelling over 1–2 days after injury indicates synovial fluid—traumatic synovitis.

• Acute spontaneous inflammation of the knee may be part of a systemic condition such as rheumatoid arthritis, rheumatic fever, gout, pseudogout (chondrocalcinosis), a spondyloarthropathy (psoriasis, ankylosing spondylitis, Reiter syndrome, bowel inflammation), Lyme disease and sarcoidosis.

• Consider Osgood-Schlatter disorder in the prepubertal child (esp. boys 10–14) presenting with knee pain.

• Disorders of the lumbosacral spine (esp. L3–S1 nerve root problems) and of the hip joint (L3 innervation) refer pain to the region of the knee joint.

• Osteoarthritis of the hip often presents as knee pain.

Knee: diagnostic strategy model

Probability diagnosis

• Ligament strains and sprains ± traumatic synovitis:

  • osteoarthritis

  • patellofemoral syndrome

  • prepatellar bursitis

Serious disorders not to be missed

Vascular disorders:

• deep venous thrombosis

• superficial thrombophlebitis

Neoplasia/cancer:

• primary in bone

• metastases

Infection:

• septic arthritis

• tuberculosis

Rheumatic fever

Rheumatoid arthritis

Acute cruciate ligament tear

Juvenile chronic arthritis

Pitfalls (often missed)

• Referred pain: back or hip

• Foreign bodies

• Intra-articular loose bodies

• Osteochondritis dissecans

• Osteonecrosis

• Synovial chondromatosis

• Osgood–Schlatter disorder

• Meniscal tears

• Fractures around knee

• Pseudogout (chondrocalcinosis)

• Gout→patellar bursitis

• Ruptured popliteal cyst

• Rarities:

  • Sarcoidosis

  • Paget disease

  • Spondyloarthropathy

Osgood–Schlatter disorder

Most common at 10–14 yrs; ♂ : ♀ = 3:1

Management

This is conservative as it is a self-limiting condition (6–18 mths: av. 12 mths).

• If acute, use ice packs and analgesics.

• Main approach is to abstain from or modify active sports.

• Avoid steroid injections and POP immobilisation.

• Surgery (rarely) if irritating long-term ossicle.

• Physiotherapy: gentle quadriceps stretching.

Chondrocalcinosis of knee (pseudogout)

• Calcium pyrophosphate deposition

• In older people >60

• Can present with hot, red, swollen joint.

• Aspirate knee to search for crystals.

• Treat with NSAIDs or IA steroid injection.

• Colchicine can be used.

Meniscal tears

• Can occur with described injury (abduction or adduction force with twisting usually on a weight-loaded flexed knee).

• Joint line pain ± locking is main symptom.

Signs

• Localised tenderness over joint line

• Pain on hyperextension and hyperflexion of joint

• Pain on rotation of lower leg

Treatment

Arthroscopic meniscectomy (partial or complete)

Anterior cruciate ligament rupture

• Sudden onset severe pain

• Haemarthrosis/gross effusion

• Ligament tests

  • anterior draw: −ve or +ve

  • pivot shift test: +ve (only if instability)

  • Lachman test (at 15–20° flexion): lacking an endpoint

Refer for surgery.

Medial collateral ligament rupture

Mechanism (main): direct valgus force to knee (lateral side knee) (e.g. Rugby tackle from side).

Causes medial knee pain; aggravated by twisting. Usually responds to 6 wks in limited motion brace then knee rehabilitation.

Patellofemoral pain syndrome

Most common overuse injury of knee (usu. due to chondromalacia):

• pain behind patella or deep in knee

• pain aggravated during activities that require flexion of knee under loading (e.g. climbing stairs)

Treatment

• Correct any underlying biomechanical abnormalities by use of orthotics and correct footwear.

• Give reassurance and supportive therapy.

• Employ quadriceps exercises with enthusiasm (very effective).

Patellar tendonopathy (‘jumper's knee’)

• Gradual onset of anterior pain.

• Pain localised to below knee.

• Pain eased by rest, returns with activity.

Management

Early conservative treatment inc. rest from the offending stresses is effective. Avoid impact activity. Chronic cases invariably require surgery.

Localised tendonopathy or bursitis

(e.g. prepatellar bursitis, infrapatellar bursitis, biceps femoris tendonopathy, anserinus tendonopathy/bursitis)

Generally (apart from patellar tendonopathy), the treatment is an injection of local anaesthetic and long-acting corticosteroids into and deep to the localised area of tenderness. In addition it is important to restrict the offending activity with relative rest and refer for physiotherapy for stretching exercises. Attention to biomechanical factors and footwear is important.

Osteoarthritis

Management

• Relative rest

• Weight loss

• Analgesics and/or judicious use of NSAIDs inc. COX-2 inhibitors (14–21 d)

• Consider oral glucosamine

• Walking aids and other supports

• Physiotherapy (e.g. hydrotherapy, quadriceps exercises, mobilisation and stretching techniques)

• IA injections of corticosteroids are generally not recommended but a single injection for severe pain can be very effective

• Consider intra-articular hylan G-F 20, a course of 3 injections

• Surgery: indicated for severe pain and stiffness; includes total joint replacement or hemiarthroplasty; usually excellent results