BONE AND CONNECTIVE TISSUE DISORDERS 1.2 (AB) Flashcards
“What is spondylolysis?”
A defect in the pars interarticularis, often caused by repetitive hyperextension stresses.
“What part of the vertebra is affected in spondylolysis?”
The pars interarticularis.
“What is the main cause of spondylolysis?”
Repetitive hyperextension stresses that transmit compressive forces to the pars interarticularis.
“What types of stress fractures are seen in spondylolysis?”
Unilateral or bilateral stress fractures, which may lead to pseudoarthrosis.
“What is pseudoarthrosis in spondylolysis?”
A false joint that forms when a stress fracture does not heal properly, allowing abnormal motion.
“What sports are commonly associated with spondylolysis?”
Gymnastics, football (interior linemen), weightlifting, and wrestling.
“What are the clinical manifestations of spondylolysis?”
Mechanical low back pain that may radiate to the buttocks, with or without hamstring spasm; neurologic symptoms are rare.
“Can spondylolysis be asymptomatic?”
Yes, it may be found incidentally on imaging.
“What physical exam findings are associated with spondylolysis?”
Discomfort with spinal extension or hyperextension, tenderness over the affected vertebra, and pain provoked by maintaining extension.
“What provocative test is used for spondylolysis?”
Keeping the spine extended for 10-20 seconds to see if back pain is reproduced.
“What is spondylolisthesis?”
Forward slippage of one vertebra on another.
“What percentage of the population has spondylolisthesis?”
Approximately 4-5%.
“What are the main causes of spondylolisthesis?”
Dysplastic/congenital, isthmic (due to pars stress fracture), traumatic, and neoplastic.
“What are the most common types of spondylolisthesis in children and adolescents?”
Dysplastic and isthmic.
“What percentage of patients with spondylolysis develop spondylolisthesis?”
Between 5% and 15%.
“What neurologic symptoms can occur with spondylolisthesis?”
Radiculopathy and, in severe cases, cauda equina syndrome with bowel/bladder dysfunction.
“What physical exam findings are associated with high-grade spondylolisthesis?”
Loss of lumbar lordosis, flattening of the buttocks, and a vertical sacrum due to posterior pelvic rotation.
“What is the preferred imaging modality for spondylolysis and spondylolisthesis?”
High-quality AP and lateral radiographs of the lumbar spine.
“What additional radiographic view can help diagnose spondylolysis?”
Oblique radiographs.
“What is the ‘Scotty dog’ sign?”
A radiographic finding where the posterior elements of the lumbar spine resemble a dog, and a pars defect appears as a ‘collar’ on the dog’s neck.
“What is the initial management for asymptomatic spondylolysis?”
No treatment is required.
“What is the initial management for symptomatic spondylolysis?”
Activity modification, core-strengthening physical therapy, and anti-inflammatory medication.
“What medications can be used for pain management in spondylolysis?”
NSAIDs such as mefenamic acid, celecoxib, and Alaxan®.
“What is the role of lumbosacral orthosis in spondylolysis treatment?”
Immobilizes the spine in slight flexion to relieve stress on the posterior elements, potentially speeding up symptom resolution.
“How long is a lumbosacral orthosis typically worn?”
3-4 months.
“When should sports participation be restricted in spondylolysis?”
Until symptoms have resolved.
“Does spondylolysis heal in most cases?”
No, but symptoms resolve in most patients even without healing.
“When is surgery indicated for spondylolysis?”
For chronic, refractory back pain that does not improve with conservative measures.
“What is the surgical treatment for spondylolysis at L5?”
Posterior spinal fusion from L5 to S1.
“Why is L5-S1 fusion preferred for spondylolysis?”
Because mobility at this level is naturally limited compared to higher lumbar levels.
“What surgical options exist for spondylolysis at higher lumbar levels?”
Techniques to repair pseudoarthrosis without fusion.
“What factors determine the management of spondylolisthesis?”
Patient age, presence of pain or neurologic symptoms, and degree of deformity.
“What is the recommended treatment for low-grade spondylolisthesis?”
Similar to spondylolysis management: activity modification, physical therapy, and NSAIDs.
“Should asymptomatic high-grade spondylolisthesis always be treated surgically?”
No, nonoperative management is safe and does not lead to significant problems.
“Does delayed surgery for spondylolisthesis worsen outcomes?”
No, delayed surgical treatment does not significantly affect outcomes.
“What is the surgical treatment for symptomatic low-grade spondylolisthesis?”
In situ posterior spinal arthrodesis (spinal fusion).
“What is in situ posterior spinal arthrodesis?”
A surgical procedure that joins two or more vertebrae to promote bone growth and fusion.
“How does kyphotic slip angle affect spondylolisthesis prognosis?”
Patients with a more kyphotic slip angle have a poorer prognosis, but surgery does not necessarily improve outcomes.
“What is the main principle of surgical management for high-grade spondylolisthesis?”
Stabilize the unstable segment of the spine while avoiding neurologic complications.
Why are most connective tissue diseases considered systemic?
Because connective tissue is present throughout the body, affecting multiple organs.
What term does Nelson’s textbook use for connective tissue diseases in children?
Rheumatic Diseases of Childhood.
Why is rheumatic disease considered a diagnosis of exclusion?
Because missing it may lead to improper treatment, and it must be distinguished from other conditions like infections or malignancy.
What are the components used to define rheumatic diseases?
Physical exam, autoimmune markers, serologic tests, tissue pathology, and imaging.
Why is recognition of clinical patterns essential in rheumatic disease diagnosis?
Because no single diagnostic test exists and test results may be positive in the absence of disease.
What complicates the diagnosis of rheumatic diseases in children?
Children may present with partial criteria or features of multiple diseases (overlap syndromes).
What are the primary mimics of rheumatic diseases?
Infection and malignancy.
Why must mimicking disorders be excluded before starting treatment for rheumatic disease?
Because treatment (especially corticosteroids) differs significantly and could worsen non-rheumatic conditions.
What are common symptoms of rheumatic diseases?
Joint pain, fever, fatigue, and rash.
How does arthralgia differ from arthritis?
Arthralgia is joint pain without physical findings; arthritis includes swelling observed in physical exam.
What conditions are suggested by arthralgia without physical findings of arthritis?
Infection, malignancy, orthopedic conditions, benign syndromes, or pain syndromes like fibromyalgia.
What does arthritis indicate in a pediatric patient?
A strong predictor of rheumatic disease and reason for referral.
What might nighttime joint pain with abnormal blood counts suggest?
Malignancy such as leukemia or neuroblastoma.
What mechanical condition is suggested by knee pain worsened by stairs in an adolescent girl?
Patellofemoral syndrome.
What is the Patellar Grind Test used for?
Evaluating patellofemoral pain syndrome.
What is a characteristic feature of growing pains?
Night pain relieved by rubbing, no morning limp, common in ages 3-10.
What is suggested by joint pain with hyperextensible joints in a 3–10-year-old girl?
Benign hypermobility syndrome.
What should be suspected if arthralgia occurs with dry skin, fatigue, or cold intolerance?
Thyroid disease.
What symptoms may suggest pediatric SLE or JIA?
Arthralgia or arthritis.
What symptoms are more specific to arthritis than arthralgia?
Morning stiffness, swelling, limited ROM, gait issues, gelling phenomenon.
What must be present on PE to diagnose JIA?
Arthritis.
Is there a specific lab test diagnostic for JIA?
No.
What does fatigue in rheumatic diseases also commonly occur with?
SLE, JDM, vasculitis, and chronic childhood arthritis.
What does overwhelming fatigue with school absence suggest?
Chronic fatigue syndrome or fibromyalgia.
What rheumatic diseases cause fevers?
Systemic JIA, SLE, vasculitis, ARF, sarcoidosis, MCTD.
What non-rheumatic conditions can mimic fever in rheumatic diseases?
Malignancies, infections, IBD, Kawasaki, HSP, periodic fevers.
What does a malar rash suggest in rheumatic diseases?
SLE or JDM.
What condition is Gottron papules a sign of?
Juvenile Dermatomyositis (JDM).
What non-rheumatic conditions mimic oral ulcers seen in SLE or Behçet disease?
HSV infection, PFAPA syndrome.
Why is ANA testing done in suspected rheumatic diseases?
It’s a nonspecific marker to guide further evaluation if positive.
What is the role of radiographs in arthralgia?
They reassure in benign syndromes and detect malignancy, osteomyelitis, or chronic arthritis.
What does MRI detect better than plain radiographs?
Early erosive arthritis, joint fluid, synovial enhancement, and trauma sequelae.
What imaging is used to localize diffuse pain in systemic arthritis?
Radionucleotide bone scans.
What additional evaluations are recommended for systemic rheumatic diseases affecting the heart or lungs?
Echocardiogram, PFT, HRCT, and possibly bronchoalveolar lavage.
Why is treatment of rheumatic diseases multidisciplinary?
Because they are systemic and affect multiple organs.
Who are typically included in the multidisciplinary team for childhood rheumatic diseases?
Pediatric rheumatologist, pediatrician, nurse, social worker, therapists, consultants.
What are the roles of occupational therapy in rheumatic diseases?
Splinting, reducing stress on joints, aiding ADLs.
Why is eye screening important in childhood rheumatic diseases?
To detect uveitis and medication-related ocular toxicity.
What are some nutrition-related concerns in childhood rheumatic diseases?
Undernourishment from illness and obesity from glucocorticoids.
Why is treatment of rheumatic diseases in childhood multidisciplinary?
Because rheumatic diseases are systemic and can affect the kidneys
Who are the key healthcare providers involved in treating pediatric rheumatic diseases?
Pediatric rheumatologist
What are the nurse’s roles in pediatric rheumatic disease management?
Disease-related education
What is the role of a social worker in pediatric rheumatic disease care?
Facilitating school services
What does physical therapy address in pediatric rheumatic diseases?
Deficits in joint or muscle mobility
What is the role of occupational therapy in pediatric rheumatic diseases?
Splinting to reduce joint contractures and deformities
Why is ophthalmology involved in pediatric rheumatic disease management?
To screen for uveitis and ocular toxicity from medications like hydroxychloroquine and glucocorticoids.
Why is nutrition important in managing pediatric rheumatic diseases?
To address undernourishment from systemic illness and obesity/overnourishment from glucocorticoids.
What are examples of school integration in pediatric rheumatic care?
Individualized Educational Plan (IEP) or 504 plan.
What psychosocial supports are recommended in pediatric rheumatic disease care?
Peer group relationships
What elements are part of coordination of care in pediatric rheumatic diseases?
Patient and family involvement as team members
What is the specificity of anti-dsDNA antibodies?
High specificity for SLE; associated with lupus nephritis.
What condition is anti-Sm antibody highly specific for?
Systemic lupus erythematosus (SLE); associated with lupus nephritis.
What autoantibody is associated with autoimmune hepatitis?
Anti-smooth muscle (Sm) antibody.
What is the disease association of anti-Pm-Scl antibody?
Sclerodermatomyositis.
Which antibodies are associated with Sjögren syndrome?
SSA (Ro) and SSB (La).
Which antibody usually coexists with anti-SSA?
Anti-SSB (La).
Which autoantibodies are suggestive of MCTD?
Anti-RNP and sometimes anti-dsDNA.
What is the prevalence of anti-centromere antibodies in limited cutaneous systemic sclerosis?
0.7
Which antibody is associated with systemic sclerosis and rare in children?
Anti-topoisomerase I (Scl-70).
Which antibody is associated with drug-induced lupus?
Anti-histone antibody.
What are cytoplasmic ANCA (PR3-ANCA) associated with?
Granulomatosis with polyangiitis (Wegener’s)
What are perinuclear ANCA (MPO-ANCA) associated with?
Microscopic polyangiitis
What is anti-CCP specific for?
Juvenile idiopathic arthritis (RF+); may be positive before RF.
What is the initial evaluation for suspected SLE or MCTD?
CBC
What further evaluation is done if ANA test is positive in SLE/MCTD?
SSA
What subspecialty evaluations are considered for SLE/MCTD?
Antiphospholipid Abs
What is the initial evaluation for juvenile dermatomyositis?
CBC
What further test is considered for juvenile dermatomyositis?
MRI of muscle.
What subspecialty evaluation is done for juvenile dermatomyositis?
Electromyography
What labs and imaging are part of granulomatosis with polyangiitis workup?
CBC
What is the gold standard imaging for suspected granulomatosis with polyangiitis?
Bronchoscopy with lavage
What is the initial workup for JIA?
CBC
What antibodies should be considered for JIA evaluation?
Anti-streptolysin O
