Bone And Rheumatology Flashcards
A 3 year old is brought to accident and emergency by his parents because he has not been walking for the past day and refuses to stand. He is normally fit and healthy but he did have antibiotics for tonsillitis 2 weeks ago. They do not think he has had any injuries but he attends daycare and something could have happened there. He is up to date with his immunizations and his parents have no concerns with his development. On examination he looks well, is apyrexial, with a heart rate of 120 and respiratory rate of 26 with no bruising. His knees are normal on examination and the hips have a full range of movement except he cries on external rotation of the right hip. There are no deformities seen on x-ray of the hips and knees. After some paracetamol he manages to stand and take a few antalgic steps with encouragement, limping on the right leg. What is the most likely diagnosis?
A. Reactive arthritis
B. Non-accidental injury
C. Growing pains D. Osteomyelitis
E. Septic arthritis
A. Reactive arthritis
1 AThe most likely answer is reactive arthritis (A) which typically follows an upper respiratory tract infection 1–2 weeks later, usually affecting the large weight bearing joints. This is unlikely to be osteomyelitis (D) or septic arthritis (E) because he is well and apyrexial. Having said this, a full blood count and differential and acute phase markers should be checked before concluding this is reactive arthritis. Growing pains (C) are usually more troublesome at night and do not stop children from weight bearing. Non-accidental injury (B) should always be kept in mind; however, he has no physical evidence of injury and the x-ray shows no fractures, making this less likely.
A 6-year-old girl is taken to see her GP because she is complaining of knee and elbow pains frequently. Her mother thinks it is worst after her ballet classes and when she gets home from school. She denies stiffness or pain in the mornings. Her mother has been administrating paracetamol several times a week and is worried that this is too much to be giving a child. On examination, the child looks well and has full range of movement of her joints with evidence of hyperextension. There are no swollen joints or effusions present and she is non-tender on examination. What is the most likely diagnosis?
A. Repetitive strain injury
B. Marfan’s syndrome
C. Hypermobile joints
D. Osteoarthritis
E. Juvenile idiopathic arthritis (JIA)
C. Hypermobile joints
2 CHer joint pain does not stop her from activities and she has normal joint assessment except for hyperextension of the joints, making the most likely cause of her joint pain being simply hypermobile joints (C). Sometimes physiotherapy may be helpful to strengthen the muscles supporting joints. While Marfan’s syndrome (B) may feature hypermobile joints, it is not the most prominent feature and tall stature, high arched palate and long limbs should be present to suggest this as a possible diagnosis. There is no history to support repetitive strain injury (A) and a child’s ballet class should not cause this. There are no swollen joints on examination to support a diagnosis of osteoarthritis (D) or JIA (E).
A 14-year-old slightly overweight boy is brought into accident and emergency from a football match where he slipped and fell but was unable to get back up due to pain in his right leg, which is now looking shortened and externally rotated. X-rays show the right femur to be disconnected from the femoral head almost completely at the level of the epiphysis. What is the most appropriate management?
A. Analgesia, nil by mouth until emergency internal fixation can be performed
B. Antibiotics and nil by mouth while waiting for an open reduction operation
C. Analgesia and bed rest with traction until healed
D. Analgesia and a hip spica cast
E. Reassure and mobilize with physiotherapy as tolerated
A. Analgesia, nil by mouth until emergency internal fixation can be performed
3 AThis child has presented with a slipped upper femoral epiphysis, which is more common in teenage boys who are obese and often occurs with a minor injury. The management requires internal fixation (A) typically with a pin. It is rare for open reduction (B) to be used as this approach is associated with an increased incidence of avascular necrosis of the femoral head. Bed rest and traction (C) are not the best option as the risk of avascular necrosis is too high. The femur needs to be urgently pinned to the femoral head and therefore mobilization (E) is wrong. A hip spica cast (D) is used for developmental hip dysplasia.
What is a greenstick fracture?
A. The classic pattern of vertebral column fractures associated with abuse by being hit with a cane or ‘green stick’
B. A fracture of the distal radius and ulna with dorsal displacement associated with a fall on the outstretched hand
C. A fracture of the distal radius and ulna with ventral displacement
D. A fracture of the long bones in young children where only one cortex is broken and the other is buckled
E. A fracture of the long bones in young children where the cortex is buckled on one side of the bone with no cortex separation on the opposite side
D. A fracture of the long bones in young children where only one cortex is broken and the other is buckled
4 DIn young children the bones are soft and flexible so a forceful impact may bend the bone rather than break it. This results in a buckle in the cortex. In a torus fracture (E) only buckling of the cortex is seen just on one side of the long bone whereas in a greenstick fracture (D) a buckle is seen on one side with the opposite cortex interrupted. The greenstick fracture takes longer to heal than the torus fracture. A Colles fracture (B) results in the distal end of the ulna and radius sliding backwards and shortening; it is unusual in children and would more commonly occur through the growth plate, known as a Salter–Harris fracture. The reverse of a Colles fracture occurs in a Smith’s fracture (C) with ventral displacement of the radial fragment. There is no classic fracture pattern of the spine associated with child abuse (A).
A 2-year-old boy is brought to accident and emergency for the sixth time and is found to have a right-sided non-displaced transverse fracture of his tibia. His parents state that he was running in the living room and tripped landing on a toy truck. He has broken his other leg twice, several fingers and his right arm previously. He appears healthy, is well dressed and his growth is normal. His mother is very upset, she is 5 months pregnant with their second child and her anomaly scan yesterday suggested the baby has a broken leg. What is the most likely explanation for these fractures?
A. Osteogenesis imperfecta
B. Domestic violence and child abuse
C. Osteopetrosis
D. Achondroplasia
E. Clumsy child
A. Osteogenesis imperfecta
5 AOsteogenesis imperfecta (A), also known as brittle bone disease, is a collagen metabolism disorder which is typically autosomal dominantly inherited and has variable penetration where the most severe forms may develop fractures in utero. While risks for child abuse (B) should always be explored in any injury and repeated injuries are a worrying sign, this does not explain the fetus with a broken bone. Osteopetrosis (C) is an autosomal recessive disorder of dense brittle bones associated with frequent fractures, failure to thrive, recurrent infections, hypocalcaemia and thrombocytopenia. This is not the correct answer, as his growth is normal. Achondroplasia (D) results in short stature due to marked shortening of the limbs but is not associated with fractures. Stating that a child is clumsy (E) is not an adequate diagnosis to explain repeated injuries; either there is an underlying diagnosis as to why the child is so unsteady and injuring themselves repeatedly, or there is a bone abnormality or there is child abuse, all of which need to be investigated.
A 2-month-old baby is brought in by the babysitter because he has been crying since she arrived to look after him and his right leg looks swollen. He is the only child living in the household. She does not think he is moving it and is worried it is injured. On examination he is miserable, his heart rate is 160, respiratory rate of 56, and capillary refill is less than 2 seconds. He has a swollen right thigh. He cries more when that leg is examined. You note a yellow bruise on his left thigh and two purple bruises on either arm. X-rays show a fracture of the right femur but the arms appear intact. A chest x-ray shows three healing posterior rib fractures. You are highly suspicious of non-accidental injury. What is the most appropriate management?
A. Give analgesia and plaster the leg fracture. Ask the babysitter to bring him back with the parents because he needs to be admitted
B. Give analgesia. Call the duty social worker on-call to get permission to discharge him once his leg has been plastered
C. Give analgesia and plaster the leg fracture. Contact the parents and inform them that he needs to be admitted. Ask them to come to the hospital and inform social services once they have arrived and been updated
D. Give analgesia and plaster the leg fracture. Call the police to bring the parents to hospital
E. Give analgesia and plaster the leg fracture. Call the police to arrest the babysitter for child abuse
C. Give analgesia and plaster the leg fracture. Contact the parents and inform them that he needs to be admitted. Ask them to come to the hospital and inform social services once they have arrived and been updated
6 CThe most appropriate action is to bring the parents to the hospital to take a full history (C). The child’s safety is paramount and he should not be discharged until a full safety assessment is made and all of his injuries have been assessed and treated. Once the parents are there and have been updated it is then important to inform them of the social services referral, but they cannot refuse it. The child must be kept in a place of safety so discharge is not an option (A). The parents should be informed prior to social services referral (B) unless there are other children in the community that may also need protection, in which case, social services need to be informed and will liaise with the police to bring those children in to a place of safety. It would be inflammatory and counter-productive to bring the parents into hospital by police, although the police will be involved as part of child-safeguarding enquiries (D). There are injuries of several different ages on this child, different colour bruises and healing rib fractures making it unlikely that the babysitter is at fault (E), although it is important to keep an open mind regarding potential perpetrators. An accurate, well-documented history from each person who has cared for the child is crucial.
On a newborn baby screening examination, you see a baby girl born by elective caesarean section for breech presentation. This is her mother’s first child. The examination is normal except for a clunk felt on Barlow’s test and a relocation click on Ortolani’s manoeuvre on the right side. What is the next step in management?
A. Refer to orthopaedics
B. Arrange an ultrasound for 6 weeks of age
C. Refer to physiotherapy
D. Ask a midwife to put on a plaster hip spica
E. Explain to the parents a watch and wait management is most appropriate as most self-resolve
B. Arrange an ultrasound for 6 weeks of age
7 B This child has several risk factors for developmental hip dysplasia: female, first child, breech presentation. Other risk factors include clubbed foot, family history of hip dysplasia, oligohydramnios and macrosomia. Barlow’s examination of the hips involves pushing the flexed hip backwards testing for dislocation while the Ortolani test starts with the hips flexed and abducted: the examiner’s fingers lift the greater trochanters forward in an attempt to relocate a dislocated hip; if a click is felt, the test is positive. The most appropriate management is to request an ultrasound as an outpatient follow-up at 6 weeks of age (B). This is a sensitive test, and waiting until 6 weeks improves the specificity as many unstable hips self-resolve. If the ultrasound is positive then a referral to orthopaedics (A) would be appropriate at that time. First line therapy would be a Pavlik harness which is put on by specially trained physiotherapists (C) and worn for 6 weeks. Midwives are not trained in administering plasters and a hip spica would be put on post-surgery when first line therapy has failed. Many services would ultrasound all babies with breech presentation even without clinical findings to support hip dysplasia. Left untreated this child may walk with a limp, never walk or develop avascular necrosis of the femoral head and therefore should be actively managed. A watch and wait management plan (E) is therefore inappropriate.
Which of the following is not a correct match?
A. Systemic JIA – acute illness with daily fevers, malaise, failure to thrive, rash, muscle and joint aches for greater than 6 weeks associated with raised inflammatory markers
B. Extended oligoarthritis – an arthritis originally affecting one or two joints for the first 6 weeks and over time has spread to multiple joints
C. Psoriatic arthritis – presents with interphalangeal joint swelling, scaly skin rash, nail pitting and dactylitis
D. Polyarticular arthritis – more common in boys, affecting multiple small joints for more than 6 weeks
E. Enthesitis-related arthritis – associated with HLA-B27 tissue type, and presents in older boys with large joint arthritis, swollen tender tendons, sacro-iliitis and bamboo spine on x-ray. It is associated with anterior uveitis which if left untreated may cause blindness
D. Polyarticular arthritis – more common in boys, affecting multiple small joints for more than 6 weeks
8 DAll of the above definitions are true except for polyarticular arthritis (D) which is more common in girls and presents with symmetrical arthritis of the wrists, hands, ankles and knees. Occasionally the spine and jaw may be affected as well. By definition, polyarticular arthritis affects more than four joints at presentation for more than 6 weeks. Oligoarthritis (B) presents with less than five affected joints in the first 6 weeks and even if other joints become involved later it is still referred to as oligoarthritis but becomes extended. If the oligoarthritis persists beyond 6 months without extension to five or more joints it is called persistent. Option (A) is a classic description of systemic juvenile idiopathic arthritis, which should be considered in the differential diagnosis of prolonged fever in children, even when minimal or no joint symptoms or signs are evident. Option (C) is a classic description of the findings in psoriatic arthritis. Enthesitis-related arthritis (E) is also called juvenile spondylitis, and refers to inflammation of the entheses, which are the areas where tendon and other connecting tissues join to bone.
A 4 year old is brought to accident and emergency acutely unwell and refusing to walk for the past 2 days. Her parents are not aware of any recent injuries. On examination, she is pyrexial (T = 39.2°C), capillary refill 3 seconds centrally, heart rate 150 beats per minute, respiratory rate 40 breaths per minute. Her right thigh is swollen and slightly erythematous but too tender to examine fully. An x-ray of the hip and femur shows soft tissue swelling surrounding the proximal femur but the bones look normal. An urgent MRI shows a periosteal reaction in the proximal femur with extensive inflammation in the surrounding soft tissues. What is the most likely diagnosis?
A. Osteomyelitis
B. Non-accidental injury
C. Cellulitis
D. Reactive arthritis
E. Juvenile idiopathic arthritis
A. Osteomyelitis
9 AThis child’s presentation is worrying for osteomyelitis (A) or septic arthritis, in view of the high fever, tachycardia, tachypnoea and a swollen painful leg. This is why the MRI was arranged so quickly. X-rays do not show osteomyelitis changes until about 2–3 weeks later, but the soft tissue swelling may be noticed. An MRI is required to see the inflammatory bone changes early on, which include periosteal reactions. If her x-ray showed a fracture with no known history of trauma, that would raise concerns of non-accidental injury (B), which would need to be explored further. This is not just cellulitis (C) as there is extensive involvement of the soft tissues and bone on the MRI. A reactive arthritis (D) would not present with a high fever and a systemically unwell child. If the hip were involved this would be a septic arthritis. The history is too short for juvenile idiopathic arthritis (E), which requires a 6-week history with no infection identified, and no MRI periosteal reactions supporting osteomyelitis.
A 5-year-old is referred to paediatrics due to concerns initially raised by his school teacher that he is weak and clumsy. On examination he has wasting of his quadriceps and walks in a waddling gait. His blood creatine kinase is 1600 mmol/L (normal is 24–190). What is the most likely diagnosis?
A. Muscular dystrophy
B. Neglect with failure to thrive
C. Malnutrition with failure to thrive
D. Acute myositis
E. Spinal muscular atrophy
A. Muscular dystrophy
10 A This child presents with a waddling gait and wasting of proximal muscles which points to a muscular dystrophy (A), which is strongly supported by the raised creatine kinase. You would expect a positive Gower’s sign, in which the child is unable to get up from the floor without walking his hands up his legs for support. Spinal muscular atrophy (E) would present in infancy with decreased tone and the child would never be able to walk. There is no information in the question stem about the child’s growth, and unless you are given serial weights and centiles it is impossible to say there is failure to thrive ((B) and (C)). There is no mention of pain, which makes acute myositis (D) an unlikely diagnosis.
