MSK/Ortho/Rheumatology Flashcards
What findings are present with a clubfoot?
What is the initial recommended treatment for this?
“CAVE”
- Cavus
- Adductus of forefoot
- Varus
- Equinus
Serial manipulation and casting using Ponseti method (<10% require surgery)
- Treatment should be initiated in all infants and should be started as soon as possible following birth
What is the diagnosis?
What kind of x-rays should you order?
List common radiographical findings for this presentation.
List 3 risk factors for this presentation
Slipped Capital Femoral Epiphysis (SCFE)
Radiographic findings:
- Widening of the joint space
- Femoral head is displaced posteriorly and inferiorly in relation to the femoral neck
Risk Factors
- Obesity
- Hypothyroidism
- GH deficiency
- Chronic renal failure 2˚ hyperparathyroidism
- Femoral retroversion
What is the diagnosis?
List common radiographical findings for this presentation.
What are 2 associations seen with this diagnosis?
What is generally the recommended treatment if slight restriction in ROM and minimal pain?
Legg-Calvé-Perthes disease
Radiographic findings
- Increased lucency of femoral head
- Widening of medial joint space compartment
- Flattened femoral epiphyseal ossification centre
ADHD, delayed bone age
Treatment
- Restricted activity
- ROM physical therapy
- Abduction bracing/casting
What is the diagnosis?
What screening examinations can be done for this diagnosis?
List 5 risk factors for this condition
Developmental Dysplasia of the Hip
Ortolani/Barlow <3 mo, then Galeazzi ≥3 mo (if bilateral, you lose the ability to compare the two)
Risk Factors
- Female
- First born
- Frank breech (really any breech in 3rd trimester)
- Family history
- Tight lower extremity swaddling
- Torticollis
- Foot abnormalities
- Large for gestational age
- Oligohydramnios
What are expected symptoms or signs associated with developmental dysplasia of the hip?
What are the screening recommendations for DDH?
What are indications for referral to orthopedic surgery?
How is DDH initially treated?
- Leg length discrepancy
- Asymmetric thigh or gluteal folds
- Limited or asymmetric abduction
- Abnormal gait (Trendelenberg)
- Positive Galeazzi sign (≥3mo)
- Positive Ortolani/Barlow (<3mo)
Screening
- Hip US between 6wks and 6mo for HIGH RISK with normal exam
- Hip XR (AP/frog pelvis views) >4mo
- Either test can be used between 4-6mo
Referral to orthopedic surgery
- Urgently: Unstable (positive Ortolani) or dislocated hip on clinical exam
- Limited hip abduction or asymmetric hip abduction after the neonatal period (4 weeks)
- Parental or pediatrician concern
Treatment
- Early(≤6mo): Pavlik harness
- Late (>6mo): Surgical intervention
List 2 possible diagnoses for a painless limp in a toddler.
List 2 additional diagnoses in a painless limp in a child (4-10yo).
Toddler
- Developmental dysplasia of the hip
- Congenital limb deficiencies
- Neuromuscular conditions
Child
- Developmental dysplasia of the hip
- Congenital limb deficiencies
- Neuromuscular conditions
- Leg length discrepancy
- Discoid meniscus
List 4 possible diagnoses for a painful limp in a toddler.
List 4 diagnoses for a painful limp in a child (4-10yo).
List 4 diagnoses for a painful limp in an adolescent (10-18yo)
Toddler
- Toddlers fracture
- Osteomyelitis
- Septic arthritis
- Transient synovitis
- Reactive arthritis
- Juvenile idiopathic arthritis
- Tumours
Child
- Septic arthritis
- Transient synovitis
- Legg-Calvé-Perthes
- Osteomyelitis
- Discitis
- Juvenile idopathic arthritis
- Trauma
- Tumour
- Overuse apophysitis
- Osteochondritis dissecans
Adolescent
- Tumour
- SCFE
- Juvenile idiopathic arthritis
- Osteomyelitis
- Septic arthritis
- Osteochondritis dissecans
- Discoid meniscus
- Overuse syndromes
List 3 bone lesions located in each of the following areas:
Metaphyseal
Epiphyseal
Diaphyseal
Metaphyseal
- Nonossifying fibroma
- Unicameral bone cyst
- Osteochondroma
- Osteomyelitis
- Osteosarcoma
Epiphyseal
- Chondroblastoma (most common)
- Eosinophilic granuloma
- Osteomyelitis
Diaphyseal
- Ewings sarcoma
- Eosinophilic granuloma
- Fibrous dysplasia
What is this lesion
Osteochondroma
- One of the most common benign bone tumours in children
- Many are completely asymptomatic
- Can have a genetic component (multiple hereditary exostoses)
- Usually in distal femur, proximal humerus or proximal tibia
- Enlarges with child until skeletal maturity
- XR: “stalks” or broad-based projections from the surface of the bone
- Complications: Foot drop
- Treatment is based on symptoms
What is this diagnosis?
Where is it most commonly located?
Where can it go?
Osteosarcoma - “sunburst appearance” - periosteal new bone formation
Metaphysis (Distal femur > Proximal tibia > humerus)
Lungs, bones
What is this diagnosis?
Where is it most commonly located?
Where can it go?
What is associated with poor prognosis?
Ewing’s sarcoma - “onion peel” appearance on XR
Diaphysis (lower extremity > pelvis > chest wall)
What is this diagnosis?
Where is it most commonly located?
How is it managed?
Osteoid osteoma
Most common benign bone tumour
Long bones in lower extremities
Observation (most resolve on their own)
If painful: NSAIDs, CT-guided radiofrequency ablation
What is this?
How does it present?
Sever’s disease (calcaneal apophysitis)
2˚ high impact sports - sharp lingering pain under the heel with activity and loading
What is this?
What is the name of a similar disorder with a different location?
How does it occur?
Give 3 treatment recommendations.
Osgood-Schlatter Syndrome (tibial tubercle)
Sinding-Larson-Johansson Syndrome (inferior patellar pole)
Overuse (repetitive strain) from jumping or kneeling
- Limit activities that exacerbate pain and reach pain-free state x 1-2 weeks before reintroduction and advancement
- Knee pads if chronic kneeling
- Self-directed stretching regimen, concentrating on quadriceps and hamstrings to address contributing factors (muscle tightness) during the rest period
- NSAIDs
What is this diagnosis
What are the exacerbating factors?
Where is the injury most commonly located?
What 2 ways would you treat this?
Spondylolysis
Repetitive spinal hyperextension (gymnasts, football interior linemen, weight lifters, wrestlers)
Most common at L5 - defect in pars interarticularis
- Restriction from exacerbating activities until pain free, then gradual reintroduction
- Physical therapy for core strengthening
What are 3 grades and their respective management.
List 4 indications for surgical referral.
- Mild (10 to <25˚): observation
- Moderate (25-45˚): bracing if growing; if growth completed, observation
- Severe (>45˚): spinal fusion considered (>50˚ thoracic, 40-45˚ lumbar and thoracolumbar)
Surgical Referral
- >45˚ Cobb angle
- Young age <11yo
- Double curves
- Failed medical intervention (bracing)
What are the Ottawa ankle rules for children?
What age can they be applied to?
- Must have pain in the malleolar zone AND ≥1 of:
- Tender along posterior aspect of lateral malleolus (distal 6cm)
- Tender along posterior aspect of medial malleolus (distal 6cm)
- Inability to bear weight IMMEDIATELY after injury AND in the emergency room
≥6 years old
What is the injury?
How is it caused?
How is it treated?
When should you consider XR?
Nursemaid’s elbow - Radial head subluxation
Traction on an extended and pronated forearm
Reduction = apply pressure to subluxed radial head while manually supinating the forearm and then maximally flexing the elbow
Consider XR if not using arm after maneuver
What 5 criteria do you look at to assess probability of a septic arthritis?
How high would you expect the WBC count to be on aspiration?
- ESR >40
- CRP >20
- Fever >38.5˚C
- WBC >12
- Inability to weight bear
>50,000 WBC with >75% PMNs
What is this diagnosis?
List 2 risk factors
What is the common radiograph finding
Tibia vara (Blount disease) - Infantile <3yo, Adolescent >10yo
Risk factors: obesity, early walking, Black or Hispanic ethnicity
XR: medial metaphyseal beak, internal tibial torsion, leg-length discrepancy
What are 2 complications associated with Pavlik harnesses?
List 2 ways to diminish these complications
Complications
- Avascular necrosis
- Temporary femoral nerve palsy
- Obturator (inferior) hip dislocation)
Diminish complications
- Stop treatment after 3 weeks if hip does not reduce
- Avoid forced abduction in the harness
- Ensure proper strap placement with weekly monitoring
Describe the expected course of lower extremity alignment (genu varum/valgum) with normal growth and development
Genu varum is at maximal point from 6-12 months
Neutral by 18-24 months
Maximum genu valgum is reached by 4yo (should not increase based 7yo)
What is the diagnostic criteria for SLE?
≥4/11. - “SOAP BRAIN MD”
- Serositis (pleuritis, pericarditis)
- Oral ulcers (or nasal; usually painless)
- Arthritis
- Photosensitivity
- Blood (hemolytic anemia or cytopenia [pancytopenia possible])
- Renal (nephritis; proteinuria >0.5g/day or cellular casts)
- ANA
- Immunologic (+ve ds-DNA or anti-Smith Ab or antiphospholipid antibodies)
- Neurologic (seizure or psychosis)
- Malar rash
- Discoid rash
What is the most sensitive test for lupus?
What is the most specific test for lupus?
What are other laboratory findings outside of the diagnostic criteria?
Sensitive: ANA
Specific: anti-ds DNA
- Hypogammaglobulinemia
- Hypergammaglobulinemia
- False-positive RPR and VDRL tests
What are clinical symptoms of macrophage activation syndrome?
What are characteristic laboratory findings?
What is the management (3)?
- High-spiking fevers
- Lymphadenopathy
- Hepatosplenomegaly
- Encephalopathy
Labs (s-JIA MAS ↑ferritin + ≥2 of bolded):
- Thrombocytopenia
- Leukopenia
- Elevated liver enzymes, LDH, ferritin, triglycerides
- Prolonged coagulation testing: PTT/PT
- Low ESR
- Low fibrinogen
Treatment
- High-dose IV steroids
- Cyclosporine
- Anakinra
- Consider etoposide
What are the most common findings with HSP?
What is the management?
List 2 complications of HSP
IgA vasculitis
- Age >8yo
- Abdominal pain
- Recurrent palpable purpuric rash (can recur up to 4mo after initial presentation)
- Nondeforming arthritis/arthralgias (oligo-, large joints)
- Nephritis (Normal C3)
- Normal platelet count
- Mild anemia
- Elevated: Leukocytosis, thrombocytosis, ESR/CRP, IgA
Management
- Supportive
- Ensure adequate hydration, nutrition and analgesia
- Severe manifestations: corticosteroids, IVIG, plasmapheresis
- BP and UA monitoring for at least 6mo after diagnosis
Complications
- Intussusception
- Renal disease (can develop up to 6mo after diagnosis)
- Stroke
- Myocardial Infarction
- Mesenteric ischemia
What is the diagnostic criteria for systemic JIA?
Fever ≥2 weeks (daily “quotidian” for ≥3 days)
AND
Arthritis in ≥1 joint (follows fever)
AND ≥1 of:
Rash (evanescent)
Lymphadenopathy
Hepatomegaly or splenomegaly
Serositis
How long do you need to have symptoms to obtain a diagnosis?
List the different types of JIA + typical age presentation
Which is the only type of arthritis more common in males?
≥6 weeks
- Systemic (childhood)
- Enthesitis-related arthritis (late childhood/adolescence)
- Psoriatic (biphasic [2-4yo, 9-11yo])
- Oligoarthritis (1-4 joints during first 6mo) (early childhood 2-4y)
- Persistent (never >4 joints)
- Elevated (after first 6mo, more joints affected)
- Polyarthritis (≥5 joints during first 6mo)
- RF positive (≥2 occasions, ≥3mo apart) (late childhood/adolescence)
- RF negative (biphasic [2-4yo, 6-12yo])
- Undifferentiated
More common in males = Enthesitis-related arthritis
What is the diagnostic criteria for psoriatic arthritis?
Arthritis + Psoriasis
OR
Arthritis AND ≥2 of:
Dactylitis
Nail pitting
Family history of psoriasis in 1˚ relative
What is the diagnostic criteria for enthesitis-related psoriasis?
Arthritis or enthesitis AND ≥2:
SI tenderness or lumbosacral pain
Presence of HLA-B27 antigen
Onset in male >6yo
Acute anterior uveitis
FMHx 1˚ relative of HLA-B27 associated disease
What are the ophthomological screening recommendations for JIA?
Who is the highest risk?
-
High Risk (q3-4 months)
- Oligoarticular or polyarticular <7yo + ANA positive
-
Medium Risk (q6 months)
- Oligoarticular or polyarticular <7yo + ANA negative
- Onset >7yo regardless of ANA status
-
Low Risk (q1 year)
- Systemic JIA
Risk factors
- ANA positive
- Female
- Oligoarthritis
- Younger age
List 3 complications associated with JIA
- Iridocyclitis (chronic anterior uveitis) - can lead to permanent blindness
- Growth disturbances (leg length discrepancy)
- Micrognathia (TMJ arthritis)
- Osteopenia/osteoporosis
- Permanent joint damage requiring joint replacement
- Anxiety
When should a referral to orthopedics be considered for:
Metatarsus adductus
Tibial Torsion
Femoral anteversion
-
Metatarsus adductus:
- Persistent deformity and functional deficit
-
Tibial Torsion (>15˚ internal rotation):
- Persistence ≥7yo WITH deficit
-
Femoral Anteversion (>70˚ internal w/<20˚ external):
- Persistence ≥9yo WITH deficit
What are the clinical findings associated with Familial Mediterranean Fever?
What complication is associated with this periodic fever syndrome?
What is the recommended prophylaxis?
What is unique about the period in between their illnesses?
- Fever (brief) 1-3 days
- Painful Polyserositis
- Peritonitis
- Arthritis (mono-hip, knee, ankle)
- Pleuritis (unilateral) or pericarditis
- Erysipeloid rash (over ankle or dorsum of foot)
Complication: Amyloidosis → Renal Failure
Prophylaxis: Colchicine (decreases frequency, duration and intensity of flares + prevents development of systemic AA amyloidosis)
In between illnesses: infalmmatory markers remain elevated
What does PFAPA stand for?
When does it usually start?
How is it usually managed?
- Periodic Fever
- Aphthous ulcers
- Pharyngitis (exudative-appearing)
- Adenitis
<5yo; predictable recurrent fevers, lasting 4-6 days, occuring q3-6wks
During episodes: mild HSM, mild leukocytosis, elevated acute phase reactants
Management:
- Glucocorticoids (can increase frequency) - single PO dose (0.6-2mg/kg)
- Cimetidine (30% effective)
- Colchicine (30% effective) - may extend time between flares
- Tonsillectomy if medical management refractory
What is the diagnostic criteria for Juvenile dermatomyositis?
What is the recommended management?
- ≥2 of:
- Proximal symmetrical muscle weakness
- Elevated muscle enzymes (CK, AST, LDH or aldolase)
- EMG → myopathy and denervation
- Muscle biopsy → evidence of myositis (has largely been replaced with MRI showing proximal muscle inflammation)
Management
- High-dose glucocorticoids
- IVIG
- MTX for milder disease
- Hydroxychloroquine for cutaneous disease
What’s this finding?
What diagnosis is it associated with?
Gottron’s papules
Juvenile Dermatomyositis
What’s this finding?
What diagnosis is it associated with?
Heliotrope
Juvenile dermatomyositis
What’s this finding?
What diagnosis is it associated with?
Nail bed telangiectasias
Juvenile Dermatomyositis
List the diagnostic criteria for Kawasaki disease
List 3 supportive laboratory findings.
What is your management plan? Provide dosing.
What is the most common complication associated with this diagnosis? List 2 populations at increased risk for this.
- Fever ≥5 days AND ≥4:
- Bilateral non-exudative conjunctivitis
- Polymorphous rash
- Peripheral extremity changes (Plantar/palmar erythema or swelling, periungual desquamation)
- Changes in lips and oral cavity (oropharyngeal erythema, strawberry tongue, lip cracking or erythema)
- Cervical lymphadenopathy (>1.5cm, usually unilateral)
Labs: Elevated WBC w/left shift, Anemia, Thrombocytosis, Low albumin, elevated transaminases, sterile pyuria
Management:
- ASA high-dose 80-100mg/kg/day divided q6h until fever resolves, then 3-5mg/kg/day until inflammatory markers, platelet count and f/u echo are normal
- IVIG 2g/kg x 1 dose (monitor for hemolysis w/Hgb)
- Echocardiogram, repeated at 6-8 weeks following defervescence
Complication: Coronary artery lesions (dilatations, aneurysms)
Risk factors for coronary aneurysms:
- Male sex
- Extremes of age
- Prolonged fever
What is the difference between CRPS1 and CRPS2?
What are key features of these disorders?
What is the best treatment for these disorders?
- CRPS1 (formally reflex sympathetic dystrophy): no evidence of nerve injury
- CRPS2 follows a prior nerve injury
Key Features
- Pain disproportionate to inciting event
- Persisting allodynia (heighted pain response to normally non-noxious stimuli)
- Hyperalgesia (exaggerated pain reactivity to noxious stimuli)
- Swelling of distal extremities
- Indicators of autonomic dysfunction (cyanosis, mottling, hyperhidrosis)
Treatment
- Multistage approach:
- Aggressive physical therapy (initiated ASAP once diagnosis made) 3-4 times/wk
- May require analgesic prior to session
- Initially desensitization → weight-bearing, ROM→ functional activities
- CBT PRN
- Aggressive physical therapy (initiated ASAP once diagnosis made) 3-4 times/wk
- Pharmacologic
- Low-dose amitryptiline
- Sympathetic/epidural nerve blocks
What diagnosis is associated with:
Infant with a sudden onset of irritability, swelling of soft tissue and painful, wood-like induration with minimal warmth or redness and lack of suppuration overlying the mandible, clavicle or ulna.
Which bones are spared from this diagnosis?
List 2 complications.
What is the management?
Caffey disease (aka Infantile cortical hyperostosis)
Bones spared: phalanges, vertebral bodies
Complications
- Pseudoparalysis of limb
- Pleural effusions
- Torticollis
- Mandibular asymmetry
- Bone fusion
- Bone angulation deformities
Management: Indomethacin, corticosteroids (prednisone if indomethacin not effective)
When to treat Adolescent Idiopathic Scoliosis?
Treatment:
- Mild curves (<25 degrees) = Observation
- Moderate curves (25–45 degrees)
- If no growth remaining = Observation
- If still growing = spinal bracing to try to prevent/slow curve progression
- Severe deformity (>50 degrees) = spinal fusion surgery
