Musculoskeletal 3

Question 1

JIA: General (3)

Answer 1

1. Arthritis in one joint for at least six weeks, age of onset less 16 years
2. Pain, limitation of ROM or increased warmth
3. Must rule out Lyme disease

Question 2

JIA: Lab Testing (3)

Answer 2

1. Systemic Lupus Erythematosus
   a. Can present with arthralgias
   i. Arthralgia: joint pain
   ii. Arthritis: joint deformity
2. ANA
   a. Up to 20-31% of adult blood donors are positive
   i. Abnormal results in children require further testing
   b. Can be elevated for a variety of reasons (ex: syphilis)
3. Anti- CPP (anti-cyclic Citrullinated peptide Antibody)
   a. Sensitivity is 70-75%
   b. Specificity is 99%
   c. Particularly useful in Rheumatoid factor negative arthritis
   d. Not a first line test

Question 3

Soft Tissue Tumors (2)

Answer 3

1. More common for these to be benign (e.g., lipomas)

a. Needs surgery if over a joint
i. Ex: if it’s at the elbow, it must come out
b. Lipomas in children account for nearly 4% of all soft tissue tumors
c. Classified as superficial (which are often diagnosed clinically) or deep (frequently requiring imaging)

2. Malignant (e. g., liposarcomas)

Question 4

Myositis ossificans (MO) (5)

Answer 4

1. Rare benign disorder
2. More common in Adolescent
3. Pathophysiology: Involving formation of heterotrophic bone in skeletal muscles and soft tissues
   * Often the result of soft tissue injury (in which case it is referred to as myositis ossifican scircumscripta or traumatic),
4. MO develops in areas that are exposed to trauma, such as the anterior thighs or arms.
5. Diagnosis by plain x-ray or CT, although MRI and ultrasound can also be useful evaluation tools

Question 5

Ollier Disease: General (2)

Answer 5

1. Rare, nonfamilial disorder (one in one millions
2. Characterized by multiple enchondromas (or enchondromatoses), which are distributed asymmetrically with areas of dysplastic cartilage.
   a. Enchondroma = cartilage tumor that involves growth plates
   b. Can get shortening of extremities

Question 6

Ollier Disease: Patho

Answer 6

Enchondromas are benign cartilage tumors that frequently affect long tubular bones along the metaphyses in proximity to the growth plate.

Question 7

Ollier Disease: Clinical Presentation (3)

Answer 7

1. Asymmetric shortening of one extremity and th eappearance of palpable bony masses on their fingers or toes, which may or may not be associated with pathologic fractures.
2. In 20% to 50% of patients with Ollier disease, enchondromas are at risk for malignant transformation into chondrosarcomas
3. Result in significant growth abnormalities

Question 8

Maffucci Syndrome

Answer 8

Multiple enchondromas in association with hemangiomas.

Question 9

Transverse Myelitis: Patho (2)

Answer 9

1. Segmental spinal injury caused by acute inflammation
2. Maybe cell mediated immune response to viral infection, a direct viral infection of the spinal cord, or autoimmune vasculitis

Question 10

Transverse Myelitis: History (2)

Answer 10

1. Viral infection with fever
2. Associated with multiples clerosis
   * hallmark of MS = diplopia

Question 11

Transverse Myelitis: Presentation (5)

Answer 11

1. Must palpate spine
2. Acute onset of weakness with sensory deficits
3. Usually lower extremities
4. Association with HIV and maybe the initial presentation of AIDS
5. May have: stool incontinence, decreased appetite, fever, change in urinary frequency and stream

Question 12

Legg-Calve-Perthes Disease: General (4)

Answer 12

1. Idiopathic avescular necrosis of the femoral head
2. Most common in 5-8 year olds who present with knee or hip pain or a limp
3. boys are more commonly affected than girls
4. Occasionally associated with urinary tract abnormalities or undescended testes

Question 13

LCPD Prognostic Factors (3)

Answer 13

1. Age of onset: If it occurs by age six, restoration of the spherical femoral head is likely and degenerative osteoarthritis can be avoided
2. Girls have more extensive disease
3. Degree in which femoral head maintains spherical shape

Question 14

LCPD Patho (5)

Answer 14

1. Impaired blood supply to femoral head
2. Tamponade from increased joint pressure during synovitis
   * Constitutional factors
3. Patients have a mutation in factor V Leiden gene which results in resistance to activated protein C
4. Clinical thrombosis could be triggered off in these susceptible individuals by prothrombotic insults such as passive smoking, ultimately leading to LCPD.
   * Must ask about history of thrombosis in family
   * Think about coagulopathy
5. Will have easier clotting; don’t give OCPs with estrogen

Question 15

LCPD Presentation (6)

Answer 15

1. History: Gradual limp, pain in groin, thigh or knee
2. PE: Tenderness of anterior hip or decreased internal rotation or abduction
3. Lab: not helpful

IMAGING
4. Radiology: Plain films - Widening of joint space

5. Ultrasound: Joint effusion
6. MRI

Question 16

LCPD Treatment (5)

Answer 16

1. Bedrest
2. Crutches
3. Traction
4. 40% will require surgery
5. Natural progression is 18-24 months

Question 17

Wrist fractures (2)

Answer 17

1. Most common scenario involves a buckle or transverse fracture of the distal radial metaphysis with or without involvement of the distal ulnar metaphysis.
2. Roughly 25-30% of all physeal fractures occur in the wrist

Question 18

Toddler’s Fractures (4)

Answer 18

1. Non-displaced oblique or spiral fractures of the mid-shaft of the tibia.
2. Children who have just recently begun to walk.
3. Children present refusing to bear weight or walk on the involved extremity.
4. These fractures are often best viewed on oblique images (must do PA, lateral, oblique)

Question 19

Tarsal Coalition (4)

Answer 19

1. Congenital fusion of two of the tarsal bones of the foot.
2. This union can be either a complete or partial bony fusion, or a cartilaginous/fibrous fusion.
3. Tarsal coalition will often manifest itself as chronic foot pain
4. Most patients will present during adolescence

Question 20

Benign Cortical Defects (5)

Answer 20

1. Seen in up to 40% of all children at some time in their development.
2. Most prevalent in children between ages 4-6.
3. The term non-ossifying fibroma is used for lesions >2 cm.
4. Found emanating from the cortex of long bone metaphyses.
5. Most common location is the distal femur