BRS Rheumatology and Ortho Flashcards
URI –> skin, GI, renal, and joint manifestations
- skin: petechiae and palpable purpura on buttocks and legs, edema of extremities and face
- joint: arthritis, arthralgia
- GI: colicky abd pain, GI bleeding, intussusception
- renal: ranges from mild hematuria to ESRD
henoch Schönlein purpura- IgA mediated vasculitis
how to dx HSP
what are the plts like?
H&P
may see IgA immune complexes in serum or kidney
**note: plt counts are normal! this is a nonthrombocytopenic purpura
how to tx HSP
prognosis?
supportive care
steroids for abd pain and arthritis
most recover in 4 weeks- some might recur, morbidity depends on severity of nephritis
median age of HSP
age 5 years
______ is an acute febrile vasculitis of childhood
most common cause of acquired heart disease in kids in US
-mean age of presentation? MC ethnicity affected?
kawasaki disease (mucocutaneous lymph node syndrome)
mean age 18-24 months
Asian
diagnostic criteria of kawasaki disease
- fever for at least 5 days
AND - 4/5 of the following:
-conjunctivitis- limbic sparing, no exudate
-oropharyngeal changes- red cracked swollen lips, strawberry tongue
-cervical adenopathy- unilateral, nonsuppurative
-rash- trunk
-changes in extremities- brawny edema, erythematous palms and soles –> peeling around nail beds
AND - it’s not caused by something else
other features of kawasaki disease
coronary artery aneurysm in the subacute phase of the disease (days 7-14) low grade myocarditis CHF urethritis (sterile pyuria) aseptic meningitis *hydrops of the gallbladder arthritis or arthralgias anterior uveitis
3 phases of kawasaki disease
- acute phase (1-2 weeks): fever, conjunctivitis, oropharyngeal changes, cervical adenopathy, rash, swollen hands
- increased ESR and CRP - subacute phase (weeks to months): defervescence of inflammation, peeling from nail beds or distal extremities, *coronary artery aneurysms
- decreasing ESR and CRP, increasing plt count - convalescent phase (weeks to years): gradual resolution of aneurysms
- normalization of labs
tx for kawasaki disease
acute phase: high dose IVIG, hight dose aspirin
subacute phase: low dose aspirin
convalescent phase: low dose aspirin only if aneurysms remain
prognosis of kawasaki disease
if coronary artery disease is absent, no long term sequelae occur
diagnostic criteria for JRA
- age of onset < 16 years
- arthritis in at least 1 joint (swelling or effusion OR limitation of motion, tenderness, increased warmth)
- duration of disease > 6 weeks
- exclusion of other causes of arthritis
mean age of onset of JRA
1-3 years
for the most part, JRA is more common in females except for the following two instances:
- M = F for systemic onset JRA
2. M > F for late-onset oligoarticular JRA
two types of oligoarticular JRA (less than or equal to 4 joints)
- early onset: females, majority are ANA+, high risk for developing chronic uveitis
- late onset: males, HLA-B27+, hips and SI joints involved
- in both types, arthritis is usually not symmetric and involves knees and hips most commonly
two types of polyarticular JRA (>4 joints)
- RF negative: both early and late childhood
- RF positive: more in older children, more severe than RF (-) disease, higher risk of severe arthritis
- symmetric polyarthritis of both small and large joints
- high spiking fevers that are worse at night
- transient salmon colored rash when fevers are present, nonpruritic
- HSM
- LAD
- fatigue, anorexia, weight loss, FTT, serositis, CNS involvement, myositis, tenosynovitis
systemic onset JRA (Still’s disease)
what type of anemia do you see in JRA
microcytic and hypochromic- anemia of chronic dz
when is ANA+ with JRA
75% of early-onset oligoarticular
50% of polyarticular
unlike adult inflammatory arthritis, in JRA, RF is ____ in the majority of patients
negative
how to tx JRA
- NSAIDs
- immunomodulatory meds (steroids, methotrexate, etc) for more severe dz
- PT and OT
- surgery if joint issues are awful
- psychosocial support
diagnostic criteria for SLE
4/11 of the following (SOAP BRAIN MD):
- Serositis (pleurites or pericardial inflammation)
- Oral or nasal mucocutaneous ulcers
- Arthritis, nonerosive
- Photosensitivity
- Blood cytopenias (leukopenia, hemolytic anemia, thrombocytopenia)
- Renal disease (hematuria, proteinuria, HTN)
- ANA positive
- Immunoserology- dsDNA, Smith, false + RPR or VDRL
- Neurologic sxs- seizures, psychosis, encephalopathy
- Malar rash
- Discoid lupus
demographic for SLE
teen girls
describe the arthritis in SLE
transient and migratory
rarely causes joint deformity or erosion (unlike JRA)
what are libman-sacks endocarditis?
sterile valvular vegetations
can be seen in SLE
neonates born to mothers with SLE might have this
congenital heart block
which rheum factors are often (+) in SLE but are not specific?
ANA
RF
_____ are specific for SLE and can be used as markers for active disease (esp nephritis)
anti-dsDNA
_______ are very very specific for SLE but are less prevalent
anti-Smith antibodies
these are NOT used as a measure of disease activity
_____ found in SLE predispose you to thrombotic events
antiphospholipid antibodies
these complement findings are present in lupus
decreased C3 and C4
how to tx SLE
-NSAIDs for myalgias and arthralgias
-steroids are the mainstay of therapy!!
+/- cyclophosphamide and other more potent immunomodulators
2 major complications of SLE
- if there’s thrombosis and antiphospholipid antibodies –> LMWH or warfarin
- renal failure –> tx like any other renal failure
prognosis of SLE
survival rate 90% at 5-10 years
major causes of mortality: infection, renal failure, CNS complications
demographic of dermatomyositis in kids
6 year old female
- fatigue, malaise, weight loss
- periorbital violaceous heliotrope rash
- gottron’s papules
- proximal muscle weakness with (+) Gower’s sign
dermatomyositis
neck flexor weakness calcinosis nail bed telangiectasias constipation dysphagia cardiac involvement
dermatomyositis
how to dx dermatomyositis
H&P
abnormal EMG and muscle bx
increased muscle enzymes (CPK, LDH, aldolase)
how to tx dermatomyositis
steroids are the mainstay
vitamin D and Ca to prevent osteopenia
may need more intense immunosuppressants
3 complications of dermatomyositis
aspiration pneumonia 2/2 decreased gag reflex
intestinal perforation 2/2 GI vasculitis
osteopenia 2/2 steroids and muscle weakness
with pediatric dermatomyositis, you must look for a malignancy (T/F)
F
prognosis of dermatomyositis is in general better in kids
rheumatic fever is caused by _______
GABHS strains that cause pharyngitis (the skin infection strains don’t cause rheumatic fever)
Jones criteria for rheumatic fever
2 major or 1 major and 2 minor
major:
- joints
- carditis
- nodules
- erythema marginatum
- sydenham chorea
minor: fever, arthralgia, previous rheumatic fever, leukocytosis, elevated ESR, elevated CRP, prolonged PR interval
cardiac manifestations in rheumatic fever
- endocarditis (most common) –> insufficiency of left sided valves
- myocarditis- tachycardia out of proportion to extent of fever
- pericarditis less common
describe the arthritis in rheumatic fever
migratory asymmetric and painful polyarthritis
-does not result in chronic joint disease
sydenham chorea caused by rheumatic fever is 2/2 involvement of these 2 brain structures
basal gnaglia and caudate nuclei
pink to red macules –> coalesce and spread centripetally with central clearing over the trunk and proximal limbs
erythema marginatum of rheumatic fever
how to look for GABHS infection in rheumatic fever
ASO
anti-DNase
anti-hyaluronidase
how to tx rheumatic fever
- benzathine PCN (IM) one dose or PCN (PO) for 10 days
- NSAIDs for joint pain and swelling, but only give these after the dx is for sure
- steroids if severe cardiac involvement
- tx the CHF if present, tx chorea if severe with haldol
what to do long term for rheumatic fever
long term antimicrobial ppx to prevent further episodes
watch out for heart valve dysfunction
Lyme disease is caused by _______, which is carried on ______
borrelia burgdorferi
deer ticks- ixodes scapularis
infected tick must be attached at least ______ for high chance of lyme transmission
36-48 hours
stages of Lyme disease
early disease (1-4 months)
-early localized
-early disseminated
late disease (5-12 months)
early localized Lyme disease
erythema migrans- annular and taret-like with variable central clearing
constitutional symptoms
early disseminated Lyme disease
- multiple secondary erythema migrans
- constitutional sxs
- neuro: aseptic meningitis, facial nerve palsy (uni and bilateral), encephalitis
- carditis is rare but could cause heart block
late disease of Lyme disease
5-12 months after transmisssion
hallmark is arthritis
how to dx lyme
classic rash
serology- ELISA then confirm with Western blot
how to tx Lyme disease
prognosis
- early localized or late disease with arthritis only: doxycycline (age >9 years) or amoxicillin
- carditis and meningitis require IV ceftriaxone or PCN
prognosis is excellent if treated, even if it’s late tx
triad of arthritis, urethritis, and conjunctivitis
what is it and what precedes it
reiter’s disease (a type of reactive arthritis)
usually preceded by chalmydia trachomatis infection
arthritis of small and large joints
scaly skin plaques
nail pitting
onycholysis (separation of nail from nailbed)
psoriatic arthritis
characterized by enthesitis
males with late onset oligoarticular JRA are at high risk for this later on
ankylosing spondylitis (HLA B27)
IBD pts may have this type of arthritis
HLA B27 positive, involvement of axial skeleton that looks exactly like ankylosing spondylitis
large vessel vasculitis affecting young Asian females
-aneurysmal dilation or thrombosis of the aorta, carotid, or subclavian arteries
takayasu’s arteritis
aneurysms and thrombosis of the small and medium sized vessels
a type of vasculitis
polyarteritis nodosa (PAN)
necrotizing granulomas in multiple organs
-severe sinusitis, hemoptysis, and glomerulonephritis
wegener’s granulomatosis
what is crest syndrome
calcinosis Raynaud's phenomenon esophageal involvement sclerosis of the skin telangiectasias
skin thickening (tightened skin), loss of dermal ridges everywhere in the body
systemic sclerosis
most brachial plexus injuries are during ______
the birthing process
_____ is a brachial plexus palsy affecting the ___ and _____ roots
it is the most common brachial plexus injury
what are some clinical features?
erb’s palsy, C5 and C6 roots
flaccid arm and asymmetric moro reflex
waiter’s tip
_____ is due to injury to nerve roots C7 and C8
what are the clinical features
klumpke’s palsy
claw hand- unopposed finger flexion and decreased ability to extend the elbow and flex the wrist
Horner’s syndrome may be present
what to do when you suspect brachial plexus injury: dx and tx
H&P
may possibly get xray, EMG, nerve conduction studies…
observation and ROM PT and monitor for improvement
nursemaid’s elbow is _________
it is caused by ________
subluxation of the radial head
pulling a toddler upward by the hand
clinical features of nursemaid’s elbow
how to tx it?
- sudden onset of pain, elbow is held flexed, no swelling, normal hand function
- reduce it by flexing the elbow and supinating the hand simultaneously
how to dx and tx anterior shoulder dislocation
dx based on xrays
tx by closed reduction then immobilization
**note: in teens, recurrence of dislocation approaches 90%
congenital vs. acquired torticollis
which is more common and what is it caused by
congenital is way more common and is usually 2/2 uterine constraint or birth trauma causing SCM contracture
head is tilted to affected side
torticolli
how to dx and tx torticollis
prognosis?
complications
dx with physical exam
tx with stretching exercises +/- helmet therapy if head asymmetry is present
prognosis is good- 90% resolution at 6 months
complications- skull deformity, facial asymmetry
what is atlantoaxial instability
what’s the issue here?
- unstable joint between occiput and first cervical vertebrae or between C1 and C2 vertebrae
- most ppl are asymptomatic but if they get injured, they could easily have a bad spinal cord injury
how to dx and tx atlantoaxial instability
dx with flex-ex films
tx with fusion of C1 and C2 if instability is severe
failure of normal vertebral segmentation that results in relative fusion of the involved vertebrae
klippel-feil syndrome
sprengel’s deformity
congenital scapula problem in which the scapula is rotated laterally –> shoulder asymmetry and diminished shoulder motion
-can be seen with klippel-feil syndrome
when can you see abnormal C1 and C2 vertebrae?
Down syndrome
skeletal dysplasia
klippel-feil syndrome
lateral curvature of the spine
most cases are _______
scoliosis
idiopathic
how to screen and dx scoliosis
adam’s forward bending test for screen
dx with PA and lateral xrays –> calculate Cobb angle
how to tx scoliosis
before and during growth spurt:
- 10-20: get f/u scoliosis film in 4-6 months
- 20-40: bracing
- greater than 40: surgery
after growth has concluded: surgery if > 50
bracing and surgery for scoliosis
bracing prevents progression of curvature
surgery is for very severe curves or to stop progression
progression of scoliosis occurs only during growth or if curve > 50
note: almost all growth in females ceases within 6 months of menarche
most adolescents with kyphosis have ________
flexible kyphosis- they can voluntarily correct the rounded area
scheuermann’s kyphosis
stiff idiopathic kyphosis in which 3 or more vertebrae are wedged
-develops in previously normal teens
you need to take back pain seriously in kids (T/F)
T
b/c it’s an infrequent peds complaint
_____ is the MCC back pain in children
back strain
tx with rest and analgesics
stress fracture of pars interarticularis 2/2 repetitive ______ of the spine (gymnastics, tennis, diving)
spondylolysis
hyperextension
pain increases with hyperextension
how to dx spondylolysis and spondylolisthesis
lumbar xrays- broken scottie dog neck in spondylolysis
may need bone scan or SPECT to be more sensitive
how to tx spondylolysis and spondylolisthesis
rest and analgesics for pain
casting, bracing may be necessary if pain persists
if neuro sxs in spondylolisthesis, may need surgery
body of the vertebra involved in spondylolysis slips anteriorly (subluxation of the vertebra)
spondylolisthesis
this may cause impingement on nerve roots
infection or inflammation of the intervertebral disk
if infectious, what’s the most common organism
diskitis
staph aureus is most common
clinical feature of diskitis
typically begins with signs of URI or mild trauma
back pain with tenderness over the involved disk
+/- fever
children refuse to flex the spine
how to dx diskitis
elevated ESR
confirm with MRI and bone scan
how to tx diskitis
bed rest
abx against staph if you think it’s infectious
cause of herniated disk in teens
what’s the tx
repetitive activity > trauma
tx is conservative
what is developmental dysplasia of the hip (DDH)
acetabulum is abnormally flat –> easy dislocation of the head of the femur
risk factors for DDH
first born girl, breech presentation, fhx, oligohydramnios
DDH physical exam
- barlow (dislocate)
- ortolani (reduce)
- galeazzi (affected femur is posteriorly shifted)
- asymmetric abduction of the hips and asymmetric thigh or buttock folds in older infants
how to confirm DDH dx
young infants (6 months): AP xrays
how to tx DDH
- if caught early (<6 weeks), pavlik harness
- if caught later, hips are bilaterally displaced, hips are not reducible, or pavlik harness fails, then surgery
complications of DDH
AVN of the femoral head
limb length discrepancy, painful abnormal gait, osteoarthritis
septic arthritis usually affects the _____ in younger children and the _____ in older children
hip
knee
peak age of septic arthritis
age 1-3 years
common organisms of septic arthritis
staph aureus and strep pyogenes… in teens also meningococcus
how do kids hold their hips in septic arthritis
fexion, abduction, external rotation to relieve the pressure in the joint
labs in septic arthritis
elevated WBC, ESR, CRP
-bcx, cx and gram stain of synovial fluid
imaging and treatment for septic arthritis
ultrasound can show fluid collection
tx with surgical decompression and empiric IV abx for 4-6 weeks
complications of septic arthritis
AVN and cartilaginous damage
______ is a common self limited, post infectious (URI, diarrhea) response of the hip joint
it is a dx of exclusion but the MCC of painful limp in toddlers
what are some clinical features
transient synovitis (toxic synovitis) -low grade fever, limp, mild irritability but mostly well appearing, hip pain
how to dx and tx transient synovitis
WBC and ESR can be normal or mildly high
if there is an effusion in the hip, aspirate it to r/o septic arthritis
tx with NSAIDs, bed rest, observation
prognosis is great!
_______ is idiopathic AVN of the femoral head
it’s peak age of onset is ______
typical person this happens to
legg-calve-perthes
4-9 years
active thin boys who are small for their age
dx of legg-calve-perthes
PE: decreased internal rotation and abduction of the hip (log roll them) with referred pain to groin or knee
crescent sign on xrays
how to tx legg-calve-perthes
PT and restriction of vigorous exercise (may include traction, casting, crutches, etc)
surgery if > 50% damage to femoral head or femoral head moves out of the acetabulum
prognosis of legg-calve-perthes
complete resolution in younger patients older kids (>9 years) will probably get OA of the hips as adults
obese adolescent boy with a limp
SCFE- slipping of the femoral head off the femoral neck
patients with _____ are especially prone to develop bilateral SCFE
hypothyroidism
how to dx SCFE
Klein line is abnormal
how to tx SCFE
pin the femoral head to the femoral neck
don’t force it back into place 2/2 risk of avascular necrosis
complications of SCFE
AVN
chondrolysis
limb length discrepancy
OA
MCC of osteomyelitis
what if someone has SS disease
what if it’s due to someone stepping on a nail
staph aureus and strep pyogenes
salmonella
pseudomonas
MC way children get osteomyelitis
hematogenous spread
lab studies in osteomyelitis
increased WBC, CRP, ESR
bcx positive, aspirated fluid cx positive
imaging for osteomyelitis
bone scan or MRI
plainfilm is not useful/sensitive
how to manage osteomyelitis
abx for 6 weeks
once ESR is decreasing, switch to oral abx
may need surgery if fever and swelling persist for 48 hours after abx
complications of osteomyelitis
- spread of infection
- chronic osteomyelitis- sequestrum (focus of necrotic bone), involucrum (formation of new bone or fibrosis surrounding the necrotic infected bone)
- pathologic fx
- angular deformity or limb length discrepancy if it involves the growth plate
you need to intervene if a kid has in-toeing
F
most is normal and will correct with growth
metatarsus adductus
medial curvature of the mid-foot (metatarsals)
C shaped foot
dorsiflexion is intact
how to manage metatarsus adductus
prognosis
- flexible foot that can over-correct with passive motion- obs only
- flexible foot that can correct with passive motion but will not overcorrect- stretching exercises
- stiff foot that cannot be straightened- ortho consult, cast for 3-6 wks
prognosis: resolution in all patients
fixed foot in inversion with no flexibility
ankle is held in plantarfelxion and inversion… there is also metatarsus adductus
talipes equinovarus (clubfoot)
risk factor for clubfoot
FHx
how to tx clubfoot
casting within first week of life
if deformity is severe or if there’s no improvement with casting, then surgery
medial rotation of the tibia causing the foot to point inward
MCC in-toeing in kids younger than 2 years
what is it called, clinical features, management
internal tibial torsion
- foot points medially but patella faces forward
- obs only with excellent prognosis (resolution by age 5 years)
inward angulation of the femur
MCC in-toeing in kids > 2 yars
what is it called, clinical features, management
femoral anteversion/medial femoral torsion
- both feet and patella point medially
- hips internally rotate more –> child likes sitting in W position
- obs only with resolution by age 8 years
MCC out-toeing in kids
what causes it
clinical features
calcaneovalgus foot (flexible foot held in a lateral position) caused by uterine constraint restricted plantar flexion, excessive dorsiflexion
how to tx calcaneovalgus foot (out-toed foot)
stretching +/- rarely casting
prognosis is excellent
symmetric bowing of the legs in children younger than 2 years of age
clinical features
dx
management
bowed legs (genu varum)
cowboy stance with normal gait
dx with PE
prognosis is good with no intervention; will resolve by age 2 years
progressive angulation at the proximal tibia in obese AA boy
clinical features
blount’s disease (tibia vara)
angulation just below the knee with lateral thrust with gait
how to dx and tx blount disease
- dx: suspect it in any child with progressive bowing, unilateral bowing, or persistent bowing after 2 years of age –> get standing AP film
- treatment is bracing (age 2-3 years) or surgical osteotomy (no improvement with bracing, > 4 years of age, etc)
complications of blount’s disease
OA
recurrence of angulation esp in obese children or if tx is started after age 4 yars
______ is idiopathic angulation of the knees toward the midline
age of onset
clinical features
knock knees (genu valgum)
3-5 years
knock kneed with swinging of legs laterally when walking
how to dx, tx, and prognosis of knock knees
- dx with PE
- tx is observation; only do surgery if it persists past 10 years or causes knee pain
- prognosis: excellent with spontaneous resolution, if it doesn’t resolve then risk for OA
inflammation or microfx of the tibial tuberosity caused by overuse injury
osgood-schlatter disease
osgood schlatter age of onset
what causes it
10-17 years
repetitive jumping like basketball or soccer
apophysitis
inflammation of a tuberosity (ex. osgood schlatter)
osgood schlatter
clinical features
dx
management
- swelling of the tibial tuberosity, knee pain with point tenderness over tibial tubercle, pain with extension of knee against resistance
- dx based on H&P, no xrays
- manage with rest, stretching, analgesics
slight malalignment of the patella that causes knee pain
patellofemoral syndrome
patellofemoral syndrome:
- demographic
- clinical features
- dx
- management
- teen girls
- knee pain directly under or around patella, pain with walking up and down stairs, patella in lateral position
- dx with H&P +/- sunrise view xray
- tx with rest, stretching and strengthening
growing pains can interfere with play
F
_______ occurs if the soft bony cortex buckles under a compressive force
what is it, where does it most commonly occur, how to tx
compression fx (torus or buckle fx) most often in the metaphysis tx with 3-4 weeks of splinting
_____ occurs if only one side of the cortex is fractured with the other side intact
incomplete fx (greenstick fx) *reduction may involve fracturing the other side of cortex to prevent angulation
when you see this type of fx, suspect child abuse
spiral fx
Salter Harris classification
which ones might affect bone growth
looking at the distal femur…SALTR
I: Same- in the physis
II: Above- physis and above into the metaphysis
III: Low- physis and below into the epiphysis
IV: Through and through- through physis, epiphysis, and metaphysis
V: Crushing of the physis
II-III may affect bone growth
IV-V definitely affect bone growth
clavicular fxs usually caused by ______ in older kids and ______ in neonates
falling onto the shoulder
birth injury
infant with asymmetric moro or pseudoparalysis
kid holding affected limb with the opposite hand, head tilted toward affected side
clavicular fx
how to dx and manage clavicular fxs
what part of the clavicle is most often affected in trauma
- dx with plain xray
- middle and lateral aspects are most often affected in trauma
- tx with sling for 4-6 weeks +/- figure 8 bandage
- for neonates, you may not need tx
______ occur when child falls onto outstretched arm or elbow… esp kids < 10 years
supracondylar fxs- fi displaced and angulated, this is an ortho emergency!!!
how to assess supracondylar fx
if there is pain with passive extension of the fingers, think _______
what imaging would you use?
look for point tenderness, swelling, deformity of the elbow
assess neurovascular function
think comparment syndrome
xrays
posterior fat pad sign on elbow xray suggests ______
supracondylar fx
how to manage supracondylar fx
never passively move the arm b/c you might damage nerves/vessels more!
- nondisplaced and nonangulated –> casting
- displaced or angulated –> surgical reduction and pinning
compartment syndrome might lead to ______ in the UE
volkmann’s contracture (flexion deformity of the fingers and wrist)
nerve injury in supracondylar fx usually resolves (T/F)
what is cubitus varus
T
decreased or absent carrying angle as a result of poor positioning of the distal fragment
fx of distal radius
colles fx
fx of proximal ulna with dislocation of the radial head
monteggia fx
fx of radius with distal radioulnar joint dislocation
galeazzi fx
how to manage colles, monteggia, and galeazzi fxs
reduction and splinting –> cast replaces splint in a week after swelling goes down
femur fxs require _____ of casting
8 weeks
toddler’s fx
where is it and what causes it
clinical features
how to tx
spiral fx of the tibia after very mild or no trauma, fibula is intact
- often age 9 months to 3 years when kids are tripping and falling
- refuses to bear weight but will crawl
- long leg cast 3-4 weeks
which fxs make you suspicious for child abuse
what do you do?
-metaphyseal fxs (corner or bucket handle fxs)
-posterior or first rib fxs
-multiple fxs at various stages of healing
-complex skull fxs
-scapular, sternal, vertebral spinous process fxs
-mechanism doesn’t fit history
do a skeletal survey!!
