MSK - Ortho and Rheum - 2019 Updated! Flashcards
You are seeing an 18 month old baby with a femur fracture. The baby has not had any previous long bone fractures, but there is a history of rib fractures in the past. You are concerned about non-accidental trauma, but feel that you should rule our Osteogenesis Imperfecta.
a. Name 3 physical features that would support a diagnosis of OI.
Blue sclera Conductive hearing loss Short stature Wormian bones Poor dentition Easy bruising Joint laxity Bowing of long bones Hernia Thin skin Scoliosis
Child presents with abdominal pain and arthritis. Picture of purpura on buttocks.
A) What is the diagnosis?
B) What is the MOST likely cause of long-term morbidity?
A) Henoch-Schonlein purpura
B) Renal disease and hypertension (needs to be monitored for 1 year after episode)
Child with monoarticular JRA involving one knee. List 3 long-term orthopedic complications of arthritis.
- leg length discrepancy
- Short stature
- Joint destruction
- flexion contractures
- osteoporosis (from glucocorticoid use)
Other jt problems : TMJ
A 13 year old girl comes to you with a complaint of hip pain for the last month and a slight limp. You do the following hip XR. What is the diagnosis (shows dislocation of femoral head):
a. SCFE
b. AVN
c. JIA
a. SCFE
Classic presentation is limp with externally rotated, adducted leg - external rotation increases as hip is flexed
What is true in this child. Hip x-ray shown = SCFE
a) sports-related trauma
b) more frequent in females
c) associated with steroid use
d) subsequent bone necrosis
d) subsequent bone necrosis
(AVN); other complication is chondrolysis (acute dissolution of articular cartilage in hip) ● Classic: obese, African American boy btwn 11-16 y.o. ● RF/ Trends o Black o Obesity o Male o Left > Right o Bilateral in 60% of cases
How do you classify a SCFE as stable vs unstable?
If they can walk on it, it is stable - but they should not walk on it because this can cause it to become unstable
28 week baby currently ventilated for severe RDS. Also has associated anomaly (picture of club foot). What to do:
- Refer to ortho immediately for serial plastic (did not say plaster) casting
- Refer to ortho once off ventilator
- Refer to ortho at discharge
- Refer to ortho at 3 months of age
- Refer to ortho at discharge
- ideally casting should be started within the first month of life
- One article stated not to start in the NICU
? Consider referral once off ventilator
What are the components of a club foot and what is it’s medical name?
Talipes equinovarus
Cavus - plantar flexion of first metarsal
Adductus - of forefoot and midfoot
Varus - hindfoot
Equinus - hindfoot
CAVE is also the order it is corrected in
Child with achondroplasia. Which is true:
a. decreased life expectancy
b. despite small foramen magnum, they rarely get cord compression
c. borderline to mild developmental delay
d. spinal stenosis commonly occurs in childhood
b. despite small foramen magnum, they rarely get cord compression
- intelligence is normal unless CNS complications develop (e.g. hydrocephalus)
- with appropriate intervention and monitoring risk of cord compression at foramen magnum can be minimized
Babe with clubfoot - name ONE part of the treatment.
Weekly casting using Ponsetti technique
Most need tenotomy for equinus at end of casting
Then bracing (boots and bars)
Which feature is typical for achondroplasia?
a. proximal limb shortening
b. distal limb shortening
c. short mid-portion of the bone
d. non-specific shortening
a. proximal limb shortening aka rhizomelic shortening of the arms and leg
A 12 year old boy comes to you with a complaint of left knee pain and swelling for the past month. He has also had pain over the right heel. Which of the following would you expect to find on family history:
a. Psoriasis
b. Ankylosing spondylitis
c. Rheumatoid arthritis
b. Ankylosing spondylitis
- enthesitis (inflammation at tendon insertion point) common
- juvenile ankylosing spondylitis:
- boys > girls
- begins often with oligoarthritis and enthesitis
- arthritis commonly in lower extremities and often hips
In an adolescent with pain below the knee after running, the x-ray shows changes compatible with Osgoode-Schlater’s disease. All are done except :
a. Protective gear
b. Ice may be used to reduce swelling
a. Only stop activities which cause pain
c. Quadriceps strengthening exercises when pain resolves
d. Cast for 3-4 weeks
d. Cast for 3-4 weeks
- mgmt:
- rest and gradual reintroduction of activity (maintain activity level for 1-2 weeks before advancing)
- activity modification to avoid exacerbating symptoms (avoid squats)
- if more severe, can use knee immobilizer or crutches until pain resolves
- stretching quads and hamstrings while resting can help prevent recurrence once exercising again
Child with 6 wk history of severe ankle pain. Unable to weight bear. Unable to do physiotherapy. The foot is swollen, red, and warm. What is the most likely cause?
a) Reflex sympathetic dystrophy (now called CRPS)
b) Osteomyelitis
c) Munchaussen
b) Osteomyelitis (no hx of fever, systemic unwell? BUT WARM joint is not CRPS and most likely osteo > CRPS epidemiology wise)
?chronic osteo?
14 year old boy presents with groin discomfort. X-ray shown shows femoral neck and femoral head not aligned in the middle. What is your diagnosis (1)? What are two steps in management ?
What are two risk factors
for this disease (2)?
- SCFE (slipped capital femoral epiphysis)
- admit and put on bed rest - no weight bearing
- consult ortho (who will pin in the OR) - RF: obesity, male, pubertal, endocrine disease (hypothyroid, hypopituitary, renal osteodystrophy)
What child with a SCFE would need further investigation for an underlying cause? What causes would you worry about?
Child under age 10 years - r/o endocrinopathy -hypothyroid, hypopituitarism, renal osteodystrophy)
What are risk factors for Legg-Calve-Perthes?
AKA AVN - trauma, family history, low birth weight
Description of a 4 yr old girl who refuses to weight bear. On exam, the only finding is there is tenderness over the proximal tibia (on both sides), What are
your two differential diagnoses.
- leukemia
- tibial stress fractures
- toddler’s fracture (9months - 3 years, and distal tibia)
- enthesitis/arthritis
AOM on Amox for 7 days. Presents with joint pain, anemia, rash, hematuria, edema. Management:
a) Pulse pred
b) IVIG
c) high dose NSAIDS
d) plasmapheresis
e) Hydroxyzine + Ibuprofen
Serum Sickness Like reaction:
a) Pulse pred - appropriate for severe reaction (severe jt / extensive rash)
or
e) Hydroxyzine + Ibuprofen
- manifests as annular, urticarial, sharply marginated, coalescing plaques, often with a lavender hue to the center
- acral erythema/edema, arthritis/arthralgia, lymphadenopathy, and fever are often present
Picture of SCFE, how to treat:
a. trial of NSAIDS
b. “nail the hip”
c. traction
d. casting
e. arthrocentesis
b. “nail the hip”
1 year old child presents with a metaphyseal femur fracture. What is the next step?
a) calcium, phosphate and alkaline phosphatase levels
b) full skeletal survey
c) bone scan
d) no further investigations
b) full skeletal survey
CML’s= classic metaphyseal lesions= chip or corner #; bucket handle (high specificity for abuse)
o Looks like chip off corner of long one
o Thought to happen when pulled or swung violently and relatively weaker
growing point of bones break
- skeletal survey should be done in any child under 2 years with suspicion for abuse or under 5 years with suspicious fracture
A 6-month-old child has not been moving her left leg. An x-ray demonstrates a fracture at the corner of her distal tibia (metaphyseal bucket-handle fracture). What
should be done:
a) calcium, phosphate, and alkaline phosphatase levels
b) screen for osteogenesis imperfecta
c) skeletal survey
d) bone scan
e) no further investigations
c) skeletal survey
A 3 yo child develops left hip pain following URTI. What is the best way to rule out osteomyelitis?
a) Lack of fever
b) Normal WBC
c) Negative blood culture
d) Bone scan
d) Bone scan
- WBC may be increased or normal
- ESR and CRP are usually elevated
- 50% of cases have positive blood culture
- sensitivity of bone scan 90%, MRI more specific
A 2 yo boy is brought in by mom not moving left arm. He’s holding it pronated. Mom admits she pulled on Left wrist during horseplay. Pt not cooperative with exam. Next test:
a) sling with xray
b) sling then orthopedics referral
c) orthopedics referral
d) skeletal survey
e) manipulate at elbow until arm function restored
e) manipulate at elbow until arm function restored
- rotate arm into supination while maintaining pressure over radial head until click is felt
Xray of a child/infant’s elbow…story goes that it is painful, but there is no swelling and the parents brought the child in (I think he was 10 months old?) no hx of trauma. No fever.
- What is your diagnosis?
- What could have caused
this? - How do you correct this?
- Pulled elbow (Nursemaid elbow) ( annular ligament slips proximally between radial head and distal humerus).
- Caused by longitudinal traction force applied at elbow (e.g. someone pulling on child’s arm to stop them from falling)
- Rotate into supination and flexion with pressure over radial head
Dad brings toddler to ED for shoulder pain, xray shows spiral fracture. List the next three things you do.
Assuming there is no clear mechanism of injury…
- skeletal survey
- contact child protective services
- immobilize fracture, consider advice from ortho if needed
- pain control
9 month old boy who has come in with a story of an accident. Nurse mentions he has been in her 5 times previously with other injuries. He is a well child
otherwise. . Picture of Xray of bones with bony chip off the distal humerus.
(1) What does the xray show
(2) What could have caused this
- classic metaphysical lesion of distal humerus
- physical abuse
- accidental trauma
- this type of fracture is caused by accumulation of multiple micro fractures across the metaphysics perpendicular to the axis of the long bone (from shaking/shearing forces)
What is the most common childhood wrist fracture
a. Colles fracture
b. Greenstick
c. Buckle fracture
d. Salter Harris
b. Greenstick
c. Buckle fracture - unclear which is correct
● 80% of forearm fractures involve the distal radius and ulna
● majority of forearm fractures are buckle or greenstick fractures
- buckle (or torus): compression fracture
- greenstick: bone bends, but only breaks on the convex side, not all the way through
You are seeing an 8 month old female with a femur fracture and are concerned about non-accidental trauma:
a. What are the next 3 investigations that you will do to support your diagnosis?
- skeletal survey
- liver enzymes (screen for abdominal trauma)
- 25-OH-vitamin D, serum calcium, phosphorus, alkaline phosphatase (may be elevated with healing fractures), parathyroid hormone
- U/A (for hematuria)
Young girl who has flat feet. Mum is concerned. When she stands the feet are flat and you note that they are valgus and that her forefoot is abducted. When she sits down with her feet in the air, her arches look normal.
What is her diagnosis (1) ?
What kind of intervention is needed for her (1)?
- Dx: flexible pes planus
- generally no treatment needed - common in young children and they generally outgrow it
- if pain, abnormal wearing down of shoes, or fatigue after walking can consider treatment with non prescription orthotics (will help symptoms but not correct pes planus)
Child presents to ER with fever, sore hip what do you do?
a. aspirate joint
b. Xray hip
c. order CBC
a. aspirate joint (concern for septic arthritis)
dx: blood culture
- aspiration of joint for gram stain and culture
- WBC, CRP and ESR generally elevated but non specific and normal tests do not rule out septic arthritis
- imaging - X-ray at least
- surgical emergency
14 year old being treated for osteomyelitis. Severe pain despite naproxen and tylenol. Best analgesic:
a. narcotic
b. tricyclic
c. higher dose of NSAID
a. narcotic
- follow pain ladder - if giving regular tylenol and NSAID and not achieving good control then escalate to narcotic
A 14-year-old girl with spina bifida at the T12 level presents with a one-day history of a swollen leg and foot with erythema over the anterior tibia. Temp 37.8. WBC 16. ESR 22. Most likely:**
a) fracture
b) cellulitis
c) osteomyelitis
d) deep venous thrombosis
e) erythema nodosum
b) cellulitis
- sounds most like cellulitis - may have decreased sensation so less aware of developing infection
- other thought was DVT as may be immobilized from spina bifida
18 mo M high fever, irritable, not moving hip. Next management issue?
a. IV ABx and blood culture
b. Needle aspiration
c. X-ray
b. Needle aspiration
What is the position of the septic hip in a patient with septic arthritis?
a) Abducted and internally rotated
b) Abducted and externally rotated
c) Adducted and internally rotated
d) Adducted and externally rotated
b) Abducted and externally rotated
You are seeing a 19 month old boy who has a swollen right knee. A joint aspirate is positive on C&S for S. Aureus. He also has a history of a pneumococcal meningitis
at 9 months of age. You order a CBCd, blood C&S and CT scan of the knee, and start him on IV antibiotics.
a. What 4 further tests will you order?
Concern for immunodeficiency:
- recurrent bacterial infections - think B cell, phagocytic and complement defects
1. immunoglobulins (IgG, IgM, IgA, IgE)
2. C3, C4, CH50
3. vaccine titres for antibody responsiveness
4. Lymphocyte subsets
5. Mitogen stimulation assay
6. Delayed skin testing (candida)
5. Neutrophil oxidative burst index
Child with hip pain for 3 days. Today fever to 39, significant increase in pain. He is sitting with leg flexed and ext rotated. What are the 2 most important diseases on your differential diagnosis. List 3 investigations you would do to differentiate.
- septic arthritis of hip
- osteomyelitis
- abscess (deep pelvic) - MRI of hip
- joint aspirate
- U/S (for effusion and fluid collection)
- Xray HIp
Child presents with 6 week history of pain after mild ankle injury – now won’t bear weight, hurt to touch, hot, no objective signs of arthritis. What is the diagnosis? Treatment?
Dx: osteomyelitis
Tx: IV antibiotics - depends on age but cefazolin a general good choice
- tx duration 3-4 weeks - depends on clinical response
5 year old fever 38.5 degrees, had a recent URTI. Hip was externally rotated and child not weight bearing. ESR was 40. Diagnosis?
a) Transient synovitis
b) JIA
c) Septic arthritis
c) Septic arthritis Kocher Criteria For septic arthritis ● T >38.5 ● WBC >12 ● ESR >40 ● Inability to weight bear ● CRP >23
A 2 y/o child with in-toeing. Father reports having had the same problem as a child for which he was fitted with immobilization boots. On exam, child has a searching toe, metatarsus adductus, and internal tibial torsion. What to do:
- Observe
- Discourage W sitting
- Cast
- Refer to ortho
- Observe
*note: internal tibial torsion doesn’t need anything done
but the metatarsus adductus should at least be treated with stretching (though most resolve spontaneously), and potentially casting depending on if it’s flexible or not. W sitting is related to internal femoral torsion, but you could still discourage it to prevent that from happening later
- internal tib torsion: starts to correct as child begins walking - may correct as early as 4 years or up to
10 years
Parents bring 3 year old for intoeing gait. You find tibial torsion and flexible metatarsus adductus. His father had a similar condition. Neurologic examination is
normal. You advise:
a. stop W sitting
b. ortho referral for in shoe prosthesis
c. no treatment necessary as this invariably resolves
d. Dennis splint
e. x-ray of lower limbs
c. no treatment necessary as this invariably resolves
Make sure metatarsus adductus is flexible and recommend stretching exercises
2-year-old child with flexible flat feet. Father and aunt had the same abnormality. You suggest:
a) no intervention is necessary
b) must wear shoes all the time
c) needs orthotics
d) foot exercises
e) orthopedics referral
a) no intervention is necessary
Treatment reserved for small subset who have symptoms
- flexible soled shoes
- non Rx orthosis
- PT
An 18 month old infant of African immigrant parents presents to you because he is not cruising or walking. He was exclusively breastfed until the age of 6 months, and now eats mainly purees, fruits and vegetables. On examination there is prominence at his distal radius and ulna and medially at his proximal tibia. Which of the
following lab abnormalities will support your diagnosis:
a. Low PTH
b. High ionized Ca
c. Low 25-OH vit D
d. Low ALP
c. Low 25-OH vit D
Expecting Low Ca and Vitamin D in diet
● PTH high
● High Alk Phos (compensation)
Rickets
An 8 year old boy with an unremarkable past medical history comes to you because his mother notices that he walks on his toes.
a. Name 4 causes of bilateral toe walking.
- should walk heel-toe by age 4 - refer to ortho if still toe walking by 4
- Causes
o Idiopathic (no abnormalities on exam, just when walking), +/- Heel cord contracture
o Cerebral Palsy
o Duschenne Muscular Dystrophy
o Tethered spinal cord
o Autism spectrum disorder
Best determinant of scoliosis on Physical Exam.
- leg length discrepancy
- asymmetric shoulder height
- asymmetric ribcage on bending over
- asymmetry on lateral flexion
- asymmetric ribcage on bending over
Adam’s Forward Bend Test
14 yo girl with idiopathic scoliosis. Give 3 indications for referral to ortho.
Ix: standing PA and lateral of entire spine and calculate Cobb angle
Referral:
- Progression of curve > 5
- Curve >20 degrees in prepubertal girls or boys 12-14
- Curve >30 degrees (any age)
- Pain
- Abnormal PFTs
14 yr old who hasn’t been to see you in 2 yrs. She has scoliosis with Cobb angle of 50 degrees. What is the most appropriate management?
a. observe
b. refer for brace/ orthosis
c. refer for posterior spinal fusion
d. electrical muscle stimulation
c. refer for posterior spinal fusion
- Braces are offered to skeletally immature patients with curves >30 at first visit, or in patients who are being followed and have developed progression of their curvature beyond 25 degrees
- Bracing is ineffective in curves >45
- Surgery recommended for progressive curves >45 degrees and skeletally mature patients with curves >50
Teen post op scoliosis repair. Day 6. Billious vomiting. Weight loss. ABdo pain. What is most likely complication?
a) Superior mesenteric artery syndrome
b) Adhesions
c) Volvulus
a) Superior mesenteric artery syndrome
Superior mesenteric artery syndrome:
- Typically due to the loss of mesenteric fat pad (significant weight loss caused by medical, psychological d/o or surgery) - duodenum gets squished between the SMA and the Aorta leading to bilious vomiting
- In young patients it most commonly occurs after corrective spinal surgery for scoliosis
3 yo girl generally well but has had 3 weeks of right knee swelling. Best initial treatment?
a. Steroids
b. Methotrexate
c. NSAIDS
c. NSAIDS
- tx for transient synovitis: NSAIDs and limitation of activity - can take up to 2 weeks for resolution of symptoms
- ddx to consider:
- septic arthritis
- reactive arthritis (following enteropathic or urogenital infection)
- post-infectious arthritis (following some other infection like viral URTI)
- acute rheumatic fever
- lyme arthritis
- JIA
3 y/o with mono arthritis for a few weeks. What is the most likely test result:
- Positive RF
- Positive ANA
- Increased WBC
- Increased ESR
- Decreased Hgb
- Increased ESR
- most likely transient synovitis which can have mild increased in ESR and CRP
12 yo girl with arthritis, some blood in the urine. Three things on differential?
SLE
HSP
Post strep GN
Systemic vasculitis
Child recovered from recent reactive arthritis. Has residual 30 degree painless flexion contracture of knee. Name 3 non-pharmacologic treatment modalities.
- Physio for stretch + strengthening
- bracing / splinting
- Heat therapy
- surgery
- botox
Child with monoarthritis. Name 3 medications from different classes of medications that are used for treatment.
- NSAIDs: ibuprofen
- Intra-articular corticosteroid injections
- DMARDs: methotrexate
- Biologics: infliximab, rituximab,etancercept
Boy had recent illness - fever, diarrhea, conjunctivitis, urethritis now with sacroilitis. You diagnose him with Reiter syndrome. List 4 organisms that could cause Reiter syndrome.
Reiter syndrome: reactive arthritis with bilateral purulent conjunctivitis and urethritis - following GI or GU infection
- “can’t see, can’t pee, can’t climb a tree”
- salmonella
- shigella
- yersinia
- campylobacter
- chlamydia
- e coli
Post infectious arthritis - not GU/GI specific
- strep, Hep B, rubella, parvo B19, varicella, CMV
Symptoms worse if HLA-B27
Which of the following is the best confirmatory test for juvenile dermatomyositis?
a. EMG
b. CK
c. ANA
b. CK
- key features are proximal muscle weakness and heliotrope rash and Gottron’s papules
Either CK or EMG would meet a criteria, however EMG is very painful and is rarely done today. MRI is now more common.
Dx: Must have classic rash plus 3 of:
- Symmetric proximities weakness
- Muscle enzyme elevation
- EMG changes
- Positive Bx
What are the diagnostic criteria for juvenile dermatomyositis?
heliotrope rash/Gottron’s papules + 3 of:
- symmetric proximal muscle weakness
- elevated of 1+ muscle enzymes (CK, AST, LDH)
- EMG changes
- muscle biopsy showing inflammation (only indicated if diagnosis is uncertain or to grade severity)
