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RC Study Cards > MSK/Ortho/Rheumatology > Flashcards

MSK/Ortho/Rheumatology Flashcards

1
Q

What findings are present with a clubfoot?

What is the initial recommended treatment for this?

A

“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
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2
Q

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

A

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

  1. Obesity
  2. Hypothyroidism
  3. GH deficiency
  4. Chronic renal failure 2˚ hyperparathyroidism
  5. Femoral retroversion
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3
Q

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?

A

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
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4
Q

What is the diagnosis?

What screening examinations can be done for this diagnosis?

List 5 risk factors for this condition

A

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
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5
Q

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?

A
  • 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
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6
Q

List 2 possible diagnoses for a painless limp in a toddler.

List 2 additional diagnoses in a painless limp in a child (4-10yo).

A

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
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7
Q

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)

A

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
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8
Q

List 3 bone lesions located in each of the following areas:

Metaphyseal

Epiphyseal

Diaphyseal

A

Metaphyseal

  1. Nonossifying fibroma
  2. Unicameral bone cyst
  3. Osteochondroma
  4. Osteomyelitis
  5. Osteosarcoma

Epiphyseal

  1. Chondroblastoma (most common)
  2. Eosinophilic granuloma
  3. Osteomyelitis

Diaphyseal

  1. Ewings sarcoma
  2. Eosinophilic granuloma
  3. Fibrous dysplasia
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9
Q

What is this lesion

A

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
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10
Q

What is this diagnosis?

Where is it most commonly located?

Where can it go?

A

Osteosarcoma - “sunburst appearance” - periosteal new bone formation

Metaphysis (Distal femur > Proximal tibia > humerus)

Lungs, bones

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11
Q

What is this diagnosis?

Where is it most commonly located?

Where can it go?

What is associated with poor prognosis?

A

Ewing’s sarcoma - “onion peel” appearance on XR

Diaphysis (lower extremity > pelvis > chest wall)

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12
Q

What is this diagnosis?

Where is it most commonly located?

How is it managed?

A

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

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13
Q

What is this?

How does it present?

A

Sever’s disease (calcaneal apophysitis)

2˚ high impact sports - sharp lingering pain under the heel with activity and loading

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14
Q

What is this?

What is the name of a similar disorder with a different location?

How does it occur?

Give 3 treatment recommendations.

A

Osgood-Schlatter Syndrome (tibial tubercle)

Sinding-Larson-Johansson Syndrome (inferior patellar pole)

Overuse (repetitive strain) from jumping or kneeling

  1. Limit activities that exacerbate pain and reach pain-free state x 1-2 weeks before reintroduction and advancement
  2. Knee pads if chronic kneeling
  3. Self-directed stretching regimen, concentrating on quadriceps and hamstrings to address contributing factors (muscle tightness) during the rest period
  4. NSAIDs
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15
Q

What is this diagnosis

What are the exacerbating factors?

Where is the injury most commonly located?

What 2 ways would you treat this?

A

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
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16
Q

What are 3 grades and their respective management.

List 4 indications for surgical referral.

A
  • 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)
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17
Q

What are the Ottawa ankle rules for children?

What age can they be applied to?

A
  • 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

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18
Q

What is the injury?

How is it caused?

How is it treated?

When should you consider XR?

A

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

19
Q

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?

A
  1. ESR >40
  2. CRP >20
  3. Fever >38.5˚C
  4. WBC >12
  5. Inability to weight bear

>50,000 WBC with >75% PMNs

20
Q

What is this diagnosis?

List 2 risk factors

What is the common radiograph finding

A

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

21
Q

What are 2 complications associated with Pavlik harnesses?

List 2 ways to diminish these complications

A

Complications

  1. Avascular necrosis
  2. Temporary femoral nerve palsy
  3. Obturator (inferior) hip dislocation)

Diminish complications

  1. Stop treatment after 3 weeks if hip does not reduce
  2. Avoid forced abduction in the harness
  3. Ensure proper strap placement with weekly monitoring
22
Q

Describe the expected course of lower extremity alignment (genu varum/valgum) with normal growth and development

A

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)

23
Q

What is the diagnostic criteria for SLE?

A

≥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
24
Q

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?

A

Sensitive: ANA

Specific: anti-ds DNA

  • Hypogammaglobulinemia
  • Hypergammaglobulinemia
  • False-positive RPR and VDRL tests
25
Q

What are clinical symptoms of macrophage activation syndrome?

What are characteristic laboratory findings?

What is the management (3)?

A
  • 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
26
Q

What are the most common findings with HSP?

What is the management?

List 2 complications of HSP

A

​​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
27
Q

What is the diagnostic criteria for systemic JIA?

A

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

28
Q

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?

A

≥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

29
Q

What is the diagnostic criteria for psoriatic arthritis?

A

Arthritis + Psoriasis

OR

Arthritis AND ≥2 of:

Dactylitis

Nail pitting

Family history of psoriasis in 1˚ relative

30
Q

What is the diagnostic criteria for enthesitis-related psoriasis?

A

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

31
Q

What are the ophthomological screening recommendations for JIA?

Who is the highest risk?

A
  • 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

  1. ANA positive
  2. Female
  3. Oligoarthritis
  4. Younger age
32
Q

List 3 complications associated with JIA

A
  1. Iridocyclitis (chronic anterior uveitis) - can lead to permanent blindness
  2. Growth disturbances (leg length discrepancy)
  3. Micrognathia (TMJ arthritis)
  4. Osteopenia/osteoporosis
  5. Permanent joint damage requiring joint replacement
  6. Anxiety
33
Q

When should a referral to orthopedics be considered for:

Metatarsus adductus

Tibial Torsion

Femoral anteversion

A
  • 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
34
Q

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?

A
  • 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

35
Q

What does PFAPA stand for?

When does it usually start?

How is it usually managed?

A
  • 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
36
Q

What is the diagnostic criteria for Juvenile dermatomyositis?

What is the recommended management?

A
  • ≥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
37
Q

What’s this finding?

What diagnosis is it associated with?

A

Gottron’s papules

Juvenile Dermatomyositis

38
Q

What’s this finding?

What diagnosis is it associated with?

A

Heliotrope

Juvenile dermatomyositis

39
Q

What’s this finding?

What diagnosis is it associated with?

A

Nail bed telangiectasias

Juvenile Dermatomyositis

40
Q

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.

A
  • 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:

  1. Male sex
  2. Extremes of age
  3. Prolonged fever
41
Q

What is the difference between CRPS1 and CRPS2?

What are key features of these disorders?

What is the best treatment for these disorders?

A
  • 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
  • Pharmacologic
    • Low-dose amitryptiline
    • Sympathetic/epidural nerve blocks
42
Q

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?

A

Caffey disease (aka Infantile cortical hyperostosis)

Bones spared: phalanges, vertebral bodies

Complications

  1. Pseudoparalysis of limb
  2. Pleural effusions
  3. Torticollis
  4. Mandibular asymmetry
  5. Bone fusion
  6. Bone angulation deformities

Management: Indomethacin, corticosteroids (prednisone if indomethacin not effective)

43
Q

When to treat Adolescent Idiopathic Scoliosis?

A

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

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