MSK/Rheum Flashcards
An 11-year-old boy is being evaluated for bilateral anterior knee pain. He reports gradual onset of pain after beginning training with a local soccer development program. He denies any acute injury. The pain is progressive, and over the past several weeks he has developed focal swelling several inches below his kneecaps. His medical history is remarkable for multiple episodes of chronic heel and lower leg pain over the past several years. He is otherwise healthy with normal growth and development. The boy began training year round with a soccer travel league last year. In addition, he enjoys participating in basketball and baseball. His soccer coach recently recommended that the boy focus more on soccer and give up other sports activities.
On physical examination, the boy has a significant limp. There is focal swelling and tenderness bilaterally over the tibial tuberosities and pain with resisted extension of the knees. His examination findings are otherwise unremarkable. The boy is counseled on ways to address his current knee pain and minimize his risk of future injury.
Of the following, the BEST recommendation for this boy would be to
A. comply with his coach’s recommendation regarding sports participation
B. obtain cushioned orthotics for use with his cleats
C. seek additional training with a certified fitness specialist
D. spend at least 2-3 months per year away from structured sports participation
spend at least 2-3 months per year away from structured sports participation
Osgood-Schlatter disease is an overuse syndrome that occurs with repetitive traction of the patellar tendon on the open apophysis. Overuse occurs when periods of recovery are insufficient to support the volume and intensity of physical training. Rigorous physical activity results in microtrauma of bones and soft tissue, and at the end of a given training session, overall strength and tissue integrity are compromised. A subsequent period of rest and recovery is necessary for the body to repair this damage.
Young athletes need 1 to 2 days per week and 2 to 3 months per year of recovery time away from structured sports participation.
A mother brings her 6-year-old daughter for an evaluation for concerns about “knock knees.” Her parents noticed that her knees seem to bump together when she runs. The girl denies any pain. She is otherwise healthy with normal growth and development. Physical examination reveals full range of motion and normal strength throughout both lower extremities. Genu valgum is apparent on stance and gait evaluation. Supine intermalleolar measurement is 7 cm.
Of the following, the BEST next management step for this girl is
A. orthopedic referral
B. physical therapy
C. reassurance D. reevaluation in 6 months
reevaluation in 6 months
Physiologic genu valgus (“knock knee”) peaks in early childhood and then regresses to adult values over the next several years.
Radiography should be performed in children older than 7 years with intermalleolar distances greater than 8 cm
intermalleolar distance of 7 cm in a 6-year-old girl is at the upper limits of normal and should be re-evaluated in 6 months.
Measurement of knee alignment by measuring intercondylar or intermalleolar distances (see Item C28A ).
The child should stand or lie supine with knees fully extended and patellae facing forward (patellar positioning is important to ensure accuracy)
In children with varus alignment, the medial malleoli of the ankles are placed together, and the intercondylar distance is measured between the bony prominences of the medial femoral condyles
In children with valgus alignment, the medial femoral condyles are placed next to each other, and the intermalleolar distance is determined
A 2-month-old male infant is seen for his health supervision visit. He is tracking, smiling socially, and holding his head up without support for a few seconds. He has a 4-year-old sister who is developmentally normal. His mother’s brother died at 20 years of age with complications related to a muscle disease. He had calf hypertrophy and used his hands to crawl from a lying to a standing position. He required the use of a wheelchair by 10 years of age. The mother reports that she has no muscle weakness or cramps. The mother underwent echocardiography 5 years ago for chest pain that showed mild dilated cardiomyopathy felt to be related to her brother’s disorder. The parents are concerned about their son’s risk of experiencing the same condition.
Of the following, the MOST accurate percentage chance that this infant has the same condition as his uncle is
A. 25%
B. 50%
C. 75%
D. 100%
50%
Duchenne muscular dystrophy is an X-linked recessive disorder.
Males with Duchenne muscular dystrophy have calf pseudohypertrophy, elevated creatine kinase level, proximal muscle weakness leading to Gowers sign when standing from a lying position, and cardiomyopathy.
Cardiac surveillance is recommended for female carriers, who may develop cardiomyopathy.
Female carriers are reported to have mild muscle weakness and dilated cardiomyopathy; hence, cardiac surveillance also should be offered to female carriers in the family. In the vignette, the patient’s uncle had DMD, the mother is symptomatic with dilated cardiomyopathy, and the maternal grandmother is an obligate carrier because two of her children are affected. The risk of the infant’s having DMD is 50%, because the mother could pass on either the mutated or the normal DMD allele to her son.
A 15-year-old adolescent girl is seen for evaluation of hair loss. She first noted hair loss several months ago. At that time, the area was slightly itchy, tender, and pink. She has no significant past medical or family history and has no other signs or symptoms. She is afebrile with age-appropriate vital signs. Her scalp is shown (Item Q40). The remainder of her physical examination findings are normal, including full range of motion of all of her joints with no evidence of effusion and no other skin lesions.
Of the following, the MOST likely diagnosis is
A. alopecia areata B. linear scleroderma C. tinea capitis D. trichotillomania
linear scleroderma
Localized scleroderma (also called morphea) involves cutaneous tissue and sometimes underlying muscle and bone, whereas systemic sclerosis is a multisystem disorder that includes nervous system and visceral organ abnormalities.
Active localized scleroderma lesions have a red border and a white “waxy” center. As the lesions become inactive, they can be either hyper- or hypopigmented.
typically treated with systemic corticosteroids and/or methotrexate to reduce the chances of permanent disfigurement, though sometimes small lesions that do not involve joints or the face can be treated with localized phototherapy, topical corticosteroids, or topical immunomodulators.
A 17-year-old adolescent boy is seen for evaluation of lower back pain that has been present for several months. He has no history of trauma or back injury. He reports that his back is stiff and painful when he wakes in the morning and that he has intermittent bilateral hip pain. His symptoms improve over the course of the day. His medical history is significant for plantar fasciitis and anterior uveitis. He appears well and has age-appropriate vital signs. He has tenderness over his sacroiliac joints and limited back flexion and extension. The remainder of his physical examination, including joint and skin examinations, has normal findings.
Of the following, the laboratory result MOST commonly associated with the adolescent’s condition is the presence of
A. anti–double-stranded DNA antibody B. antinuclear antibody C. human leukocyte antigen-B27 D. rheumatoid factor
human leukocyte antigen-B27
Enthesitis-related arthritis is a subtype of juvenile idiopathic arthritis defined as arthritis with enthesitis or arthritis and at least 2 of the following: presence or history of sacroiliac joint tenderness and/or inflammatory lumbosacral pain; human leukocyte antigen-B27 antigen; onset of arthritis in a boy older than 6 years; anterior uveitis; and positive family history of ankylosing spondylitis, enthesitis-related arthritis, sacroiliitis with inflammatory bowel disease, reactive arthritis, or acute anterior uveitis.
The majority of children with enthesitis-related arthritis have human leukocyte antigen-B27 antigens.
In patients with enthesitis-relat
categories of juvenile idiopathic arthritis:
Systemic arthritis
Polyarthritis (rheumatoid factor + and -)
Oligoarthritis
ERA
Psoriatic arthritis
Undifferentiateded arthritis, rheumatoid factor is usually negative, and anti–double-stranded DNA antibodies and antinuclear antibodies are uncommon.
A 6-year-old girl with a 1-day history of fever, limp, and pain in the right lower extremity is brought to the emergency department. Two weeks ago, she had a mild upper respiratory tract infection. There has been no recent trauma. She is alert and interactive and has a temperature of 39.5°C. She is lying with her right lower extremity abducted and externally rotated. Examination of the musculoskeletal system reveals discomfort with internal and external rotation of the right hip. The remainder of the physical examination findings are normal. Laboratory findings are notable for a white blood cell count of 18,000/μL (18 × 109/L) with 70% segmented neutrophils and an elevated C-reactive protein level. Plain radiography of the right hip has normal findings, and a blood culture is obtained.
Of the following, the BEST next step in management is to
A. administer ibuprofen
B. administer intravenous clindamycin
C. perform ultrasonography of the right hip
D. schedule orthopedic consultation for the next day
perform ultrasonography of the right hip
taphylococcus aureus is the most common cause of joint infections in all age groups; microbial invasion of the synovial space typically results from hematogenous seeding.
Early diagnosis via needle aspiration of the affected joint and prompt initiation of appropriate antimicrobial therapy, in conjunction with drainage of the affected joint, are critical to avoid destruction of the articular cartilage and prevent disability.
Empiric antibiotic regimens should always include adequate antistaphylococcal coverage.
Ultrasonography is the initial step in management of suspected septic arthritis of the hip.
Septic arthritis is usually accompanied by fever, malaise, poor appetite, and irritability. In the infant or neonate, there may be fever, poor feeding, lethargy, and pseudoparalysis of the extremity
A 14-year-old basketball player is being evaluated for a recurrent left ankle injury. Several days ago he sustained his third inversion injury to this ankle over the past several months. These injuries result in mild swelling over the lateral ankle for several days, which he treats with a compression wrap, ice, and several doses of ibuprofen. He was able to return to full basketball participation within 7 to 10 days after each injury. However, with the current injury, the ankle feels unstable and he tapes it before practice. The patient is otherwise healthy.
On physical examination, the adolescent’s left ankle is slightly swollen and minimally tender inferior to the lateral malleolus. He has full and pain-free strength and range of motion in both ankles. There is increased laxity with anterior drawer testing on the left compared with the right. His gait is normal and he moves comfortably throughout the evaluation. The adolescent has some difficulty with single leg hop and balance testing on the left leg compared with the right.
Of the following, the BEST next step in management for this patient is
A. anteroposterior and lateral ankle radiography B. magnetic resonance imaging of the left ankle C. referral to a physical therapist D. use of an ankle-stabilizing brace
use of an ankle-stabilizing brace
Full recovery of an ankle sprain includes restoration of normal range of motion, strength, and balance.
Risk of recurrent injury is markedly increased with premature return to activity after ankle sprain.
The single leg hop is a good method for assessing strength and the single leg stance with eyes closed is a good test for balance in the office setting.
Treatment: address swelling, compression/ice, protection, normalizing gait, may include crutches, a brace, or a walking boot. Restore range of motion, strength, and balance - home of PT. Graduated return to sports.
