Bones, Joints And Rheumatic Disorders

Question 1

Genu varum

Answer 1

Bow legs seen in rickets

Question 2

Pes planus

Answer 2

Flat feet

Common in hyper mobility

Question 3

Two causes of in-toeing

Answer 3

Medial tibial torsion - self corrects by aged 5

Persistent anteversion of the femoral neck - joint hyper-mobility, usually self corrects

Question 4

Toe walking is often from habit but what four things must you rule out?

Answer 4

Achilles tendon tightness
Inflammatory arthritis in foot/ankle
Mild cerebral palsy
Duchenne muscular dystrophy (in an older male)

Question 5

What is talipes equinovarus and what causes it?

Answer 5

Fixed inversion and supination of the foot
May be idiopathic or secondary to ologohydramnios/spina bifida
Associated with DDH

Question 6

Barlow test

Answer 6

Dislocate the hip posteriorly

Question 7

Ortolani test

Answer 7

Relocate a dislocated hip back into acetabulum

Question 8

What is osteomyelitis and what causes it

Answer 8

Infection of the metaphysis of long bones due to haematogenous pathogen spread

Usually staph aureus, but can be strep/haemophilus influenza

Question 9

Young chap with an acutely painful limb which is tender to touch and immobile. X-ray is unremarkable. WCC count is raised.
What is the next investigation and step in management?

Answer 9

MRI - may show subperiosteal pus/purple to debris indicative of osteomyelitis.

Needs parenteral antibiotics for several weeks to prevent bone necrosis

Question 10

Osgood-Schlatter disease

Answer 10

Osteochodritis of the patellar tendon insertion at the knee

Question 11

Active adolescent male who has come in with localised tenderness of the knee and swelling of the tibial tuberosity. This is a recurrent problem which resolves if he rests.

Answer 11

Osgood-Schlatter disease

Question 12

Chondromalacia patella

Answer 12

Softening of articulate cartilage of patella seen in females with hypermobility

Question 13

Adolescent female with known hypermobility and flat feet presents with pain in her knees when standing up or going up stairs. The pain goes away with rest.

Answer 13

Chondromalacia patella

Question 14

Persistent knee pain in a very active male teenager with localised tenderness more marked over the femoral condyles

Answer 14

Osteocondritis dissecans

Question 15

Osteochondritis dissecans

Answer 15

Separation of bone and cartilage (avascular necrosis) from the medial femoral condyle

Question 16

Four conditions to consider in a child 1-3 years with an acute limp

Answer 16

Infection - septic arthritis/osteomyelitis

Transient synovitis

Trauma

Malignancy - leukaemia/neuroblastoma

Question 17

Six conditions to consider in a child ages 3-10 with an acute limp

Answer 17

Transient synovitis

Infection - septic arthritis/osteomyelitis

Mechanical - trauma/overuse

Perthes disease

Juvenile idiopathic arthritis

Malignancy - leukaemia

Question 18

Five conditions to consider in a teenager with an acute limp

Answer 18

Mechanical - trauma/overuse

Slipped capital femoral ephysis

Avascular necrosis of the femoral head

Reactive arthritis

Infection - septic arthritis/osteomyelitis

Question 19

Six causes of a chronic or intemittent limp

Answer 19

1-3 years : DDH/JIA

3-10 years: Chronic Perthes/Duchenne muscular dystrophy/JIA

11-16 years: JIA/tarsal coalition/SUFE (chronic)

Question 20

Six red flags for back pain

Answer 20

Young age
High fever
Night waking/persistent - osteoid osteoma
Painful scoliosis - malignancy
Focal neurological signs (bladder/bowel) - cord compression
Weight loss/systemic malaise

Question 21

Scheuermann disease

Answer 21

Osteochondrosis of the vertebral body resulting in fixed thoracic kyphosis +/- back pain

Question 22

Spondylolysis

Answer 22

Stress fracture of the par interarticularis of the vertebra

Pain on spine extension and localised tenderness

Question 23

Teenager with an acute limp and restricted abduction and internal rotation of the hip. Mother thinks it is just so he can avoid doing sport which he hates. No trauma or swelling to the site and no obvious deformity.

Answer 23

Slipped capital femoral epiphysis

Needs X-ray and surgery

Question 24

Acute limp in a well looking child who is comfortable at rest.

Answer 24

Transient synovitis

Resolves in under a week

Question 25

Acute onset limp with the hip held flexed, in a child who is uncomfortable at rest.

Answer 25

Septic arthritis

Question 26

Perthes disease

Answer 26

Avascular necrosis of capital femoral ephysis due to interruption of blood supply

Question 27

Transient joint swelling in a child with salmonella gastroenteritis and a low grade fever

Answer 27

Reactive arthritis

Question 28

Common causative organism of septic arthritis in under 2s

Answer 28

Staph aureus

Question 29

Child with persistent joint swelling for more than 6 weeks with stiffness after long rests and pain.
A leg length discrepancy is noticed due to bone overgrowth.
A salmon pink rash is also noted.

Answer 29

Juvenile idiopathic arthritis

Question 30

Four main complications from juvenile idiopathic arthritis

Answer 30

1. Chronic anterior uveitis –> common. Can cause severe visual impairment
2. Flexion contractures –> can lead to destruction
3. Growth failure –> localised overgrowth = leg length discrepancy. Or undergrowth due to premature fusion of epiphysis
4. Osteoporosis –> not weight bearing and steroid use

Question 31

Child with abdominal pain and haematuria presents with painful ankles as well as a rash over the legs

Answer 31

Henoch-Schonlein purpura

Question 32

Achondroplasia inheritance and signs

Answer 32

Autosomal dominant

Marked limb shortening. Frontal bossing. Broad and short hands

Question 33

A baby is born and you can bring his shoulders together so that they touch each other

Answer 33

Cleidocranial dystosis - absence of clavicles

Question 34

Osteogenesis imperfecta

Answer 34

Recurrent fractures and bowing of bones due to fragility. Disorder of collagen metabolism
Blue sclera

Question 35

Red flags in a child with nocturnal waking in pain

Answer 35

Anaemia, bruising or irritable –> leukaemia/lymphoma