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MRCPCH Clinicals > Musculoskeletal and rheumatology > Flashcards

Musculoskeletal and rheumatology Flashcards

1
Q

What are the causes of a toe-heel gait?

A

idiopathic, pyramidal dysfunction, foot drop, tight tendoachilles

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2
Q

What are the causes of a broad based gait?

A

Toddler, cerebellar

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3
Q

What are the causes of a waddling gait?

A

Proximal muscle weakness at hip girdle

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4
Q

What are the causes of a. circumducting gait

A

corticospinal tract lesions (internal hip rotation and flexion at the hip and knee and plantar flexion at the ankle)

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5
Q

What is the main cause of fluctuating lower limb tone?

A

Extrapyramidal lesions

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6
Q

What questions should you ask as part of pGALS?

A

Any pain or stiffness in joints, muscles or back?
Any difficulty getting yourself dressed without help?
Any difficulty going up and down stairs?

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7
Q

How do you assess posture and gait in pGALS?

A

Observe standing in 360 degrees
Walk on your tip toes
Walk on your heels

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8
Q

How do you assess the arms in pGALS?

A

Put your hands out straight in front of you
Turn your hands over and make a fist
Pinch your index finger and thumb together
Touch the tips of your fingers with your thumb
Squeeze the metacarpophalangeal joints for tenderness
Put your hands together palm to palm
Put your hands back to back
Reach up and touch the sky
Look at the ceiling
Put your hands behind your neck

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9
Q

How do you assess the legs in pGALS

A

Feel for effusion at the knee
Bend and then straighten your knee - feel for crepitus
Passive movement of the hip

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10
Q

What should you assess after the legs and before the neck and spine in pGALS?

A

TMJ - open your mouth and put three fingers in your mouth

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11
Q

How do you assess the spine in pGALS?

A

Touch your shoulder with your ear - observe lateral flexion of the cervical spine
Bend forward and touch your toes - observe curve of the spine

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12
Q

What is the salter Harris classification for?

A

Growth plate fractures

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13
Q

What is a Monteggia fracture?

A

ulnar shaft fracture with dislocation of radial head

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14
Q

What is a Galeazzi fracture?

A

radial shaft fracture and disruption of the inferior radioulnar joint

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15
Q

What is Osgood-Schlatter disease?

A

Osteochondrosis of the patellar tendon insertion at the knee

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16
Q

Who usually gets Osgood-Schlatter disease?

A

Physically active adolescent males

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17
Q

How does Osgood-Schlatter disease present?

A

Knee pain after exercise
Localised tenderness
Sometimes swelling over the tibial tuberosity
Hamstring tightness

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18
Q

How is Osgood Schlatter disease managed?

A

Resolves with reduced activity and quadriceps strengthening, hamstring stretches and occasionally orthotics

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19
Q

What is chondromalacia patellae?

A

Softening of the articular cartilage of the patella

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20
Q

Who gets chondromalacia patellae?

A

Most often affects adolescent females

Associated with hypermobility and flat feet

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21
Q

How does chondromalacia patellae present?

A

Causes pain when the patella is tightly apposed to the femoral condyles e.g. standing up from sitting or walking up stairs

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22
Q

How is chondromalacia patellae managed?

A

Rest and quad strengthening

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23
Q

What is osteochondritis dissecans?

A

Segmental avascular necrosis of the subchondral bone

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24
Q

How does osteochondritis dissecans present?

A

Persistent knee pain in very active adolescents

Localised tenderness over femoral condyles

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25
Q

What causes the pain in osteochondritis dissecans?

A

separation of bone and cartilage from the medial femoral condyle following avascular necrosis

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26
Q

What is a possible sequelae of osteochondritis dissecans?

A

Complete separation of articular fragments can cause loose body formation and symptoms of knee locking or giving way

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27
Q

How is osteochondritis dissecans treated?

A

Rest and quadriceps exercises; surgery occasionally needed

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28
Q

What is the defect in osteogenesis imperfecta?

A

Type 1 collagen

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29
Q

How many types of osteogenesis imperfecta are there and which is the mildest?

A

4 types - 1 mildest

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30
Q

What are the features of osteogenesis imperfecta?

A 
Increased fragility of bones, but fracture healing process is unaffected
Short stature
 Scoliosis
Defective dentinogenesis
Conductive deafness
Ligamentous laxity
Blue sclerae and tympanic membranes
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31
Q

What is Perthes disease?

A

Avascular necrosis of the capital femoral epiphysis of the femoral head due to interruption of blood supply, followed by revascularisation and reossification over 18-36 months

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32
Q

Who gets Perthes disease?

A

Boys age 5-10

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33
Q

How does Perthes disease present?

A

Insidiously
Limp, hip or knee pain
Bilateral in 10-20%

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34
Q

What investigation findings would you expect in Perthes disease?

A

XR of both hips including frog views - May show increased density in the femoral head which then becomes fragmented and irregular

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35
Q

How is Perthes disease managed?

A

Bed rest and traction
If severe, may need to maintain the hip in abduction with plaster or calipers
Femoral or pelvic osteotomy

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36
Q

What is the problem in SUFE?

A

displacement of the epiphysis of the femoral head postero-inferiorly - Needs prompt treatment to avoid avascular necrosis

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37
Q

Who gets SUFE?

A

1-15 year old obese boys

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38
Q

What are the examination findings in SUFE?

A

Restricted abduction and internal rotation of the hip

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39
Q

How is SUFE managed?

A

Usually surgically

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40
Q

What are the main types of JIA?

A 
Oligo
Polyarthritis: RF -ve and RF +ve
Systemic
Enthesitis-related
Psoriatic
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41
Q

How is oligoarticular JIA defined?

A

=4 or fewer joints involved within the first 6 months

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42
Q

Who gets oligoarticular JIA?

A

females between 12 months and 5 years

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43
Q

What are the common features of oligoarticular JIA?

A

Chronic uveitis (almost always symptomatic but can cause blindness)
Associated with ANA positivity
Knees most commonly affected

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44
Q

What is the prognosis for oligoarticular JIA?

A

Exacerbations and remissions but long term prognosis is good unless develops into polyarthritis

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45
Q

Who gets polyarticular RF -ve JIA?

A

Any age

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46
Q

How is polyarticular JIA defined?

A

= 5 or more joints during the first 6 months

RF must be positive on at least 2 occasions 3 months apart to be RF positive

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47
Q

What are the features of polyarticular RF-ve JIA?

A 
Involves large and small joints, cervical spine, temporomandibular joints
Can be symmetrical or asymmetrical
Can remit in late childhood
ANA may be positive
Requires screening for uveiti
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48
Q

Who gets polyarticular RF positive JIA?

A

Females

Late childahoodearly teens

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49
Q

What are the features of RF positive JIA?

A

Symmetrical polyarthritis affecting upper and lower limbs

Also features subcutaneous rheumatoid nodules and early erosive radiological changes

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50
Q

What’s the prognosis for RF positive polyarticular JIA?

A

Unremitting severe disease and poor functional outcome in over 50%

51
Q

Who gets systemic JIA?

A

1-4 year olds most often, equal sex incidence

52
Q

What are the systemic symptoms of systemic JIA?

A

Fever - typically single or double quotidian pattern with high spikes daily, at similar times every day
Rash - evanescent, coming and going with fever spikes, discrete salmon pink macules usually around upper trunk and axillae; show Koebner phenomenon, rarely pruritic
Polyarticular arthritis - can be a late feature

53
Q

What are the non-articular features associated with systemic JIA?

A 
Lymphadenopathy
Hepatosplenomegaly
Serositis (pericarditis, pleuritis)
Inflammatory ascites
Haematological changes (anaemia, leucocytosis, macrophage activation syndrome)
Occasional myocarditis
54
Q

Which comes first in systemic JIA - the systemic features or the arthritis?

A

Systemic features can precede by months

55
Q

What is the prognosis for systemic JIA?

A

Approx 50% remit in 2-3 years
Untreated, joint destruction occurs in most cases
Most mortality is in this subgroup - Death is due to infection, myocardial involvement or macrophage activation syndrome

56
Q

Who gets enthesitis-related arthritis?

A

Pre teenage males

57
Q

What are the features of enthesitis related arthritis?

A

Lower limb involvement, especially hips and sacroiliac joints
Many show features common to spondyloarthropathies e.g. enthesitis, decreased lumbar flexion
Involvement of the spine is uncommon in childhood
Can get uveitis, but is usually symptomatic with red eye with pain and photophobia, in contrast to other forms

58
Q

Which tests are positive/negative in enthesitis related arthritis?

A

HLA-B27 in 80%

ANA and RF negative

59
Q

What are the extra-articular features of enthesitis related arthritis?

A 
Anterior uveitis
Aortitis
Aortic incompetence
Muscle weakness
Low grade fever
60
Q

Who gets psoriatic JIA?

A

Females, mid childhood

61
Q

What are the features of psoriatic JIA?

A

Arthritis is asymmetrical and can be oligoarticular or polyarticular
Dactylitis is seen in younger patients and DIP joint involvement is common
Inflammation can involve tendon sheaths- If severe is called arthritis mutilans, which is very destructive
Often a family history of psoriasis
Nail changes - pitting, onycholysis
Psoriasis
Uveitis

62
Q

Who gets IBD related arthritis?

A

> 4 years of age, males and females equal

63
Q

What are the clinical features of IBD related arthritis?

A

Usually after onset of bowel symptoms

Usually oligoarticular

64
Q

What are the 2 forms of IBD related arthritis?

A

Benign peripheral arthritis coinciding with active bowel disease
In older patients in spondylitic group, joint activity doesn’t necessarily link with bowel activity

65
Q

What are the non-articular features seen in IBD related arthritis?

A 
Erythema nodosum
Pyoderma gangrenosum
Mucosal ulcers
Fever
Weight loss
Growth retardation
Acute iritis in the spondylitic group
66
Q

Which tests are positive/negative in IBD related arthritis?

A

HLA-B27 in many

RF and ANA negative

67
Q

How does juvenile sarcoidosis present?

A 
Painless swelling of joints
Marked tenosynovitis
Rash
Panuveitis
Renal disease
68
Q

What test is often raised in juvenile sarcoidosis?

A

ACE - in 50%

69
Q

What is rheumatic fever?

A

Inflammatory reaction in joints, skin, heart and CNS following group A haemolytic strep infection

70
Q

Who gets rheumatic fever?

A

Girls, >3 years

71
Q

What are the criteria called for diagnosis of rheumatic fever?

A

Revised jones criteria

72
Q

What are the major criteria for diagnosis of rheumatic fever?

A 
Carditis
Polyarthritis
Subcutaneous nodules
Chorea
Erythema marginatum
73
Q

What are the minor criteria for diagnosis of rheumatic fever?

A 
Fever
Arthralgia
Previous rheumatic fever and rheumatic heart disease
Raised acute phase reactants
Prolonged P-R
74
Q

How long does rheumatic fever usually last?

A

6 weeks

75
Q

How is rheumatic fever managed

A

Bed rest
Penicillin
Salicylates
Corticosteroids with significant carditis
Prophylactic oral or IM penicillin after an attack required into adult life

76
Q

What is dermatomyositis?

A

small-vessel vasculopathy involving arterioles and capillaries

77
Q

What are the diagnostic criteria for dermatomyositis called?

A

Bohan and peter

78
Q

What are the criteria for diagnosis of dermatomyositis?

A

Characteristic rash
Plus 3/4 of:
Symmetrical proximal muscle weakness
Elevated muscle-derived enzymes: E.g. CK, aldolase, LDH, transaminases
Muscle histopathology confirming the typical pattern of myofibre atrophy and drop out necrosis with fibre regeneration, and chronic inflammatory infiltrate involving blood vessels
EMG changes of inflammatory myopathy: Fasciculations at rest, bizarre high-frequency discharges

79
Q

What are the characteristic rashes of dermatomyositis?

A 
Gottron's papules
Heliotrope rash
Scaly red rash on sunexposed areas
Shawl sign
Rash on extensor tendons - can be mistaken for psoriasis
80
Q

What are some general, non-diagnostic features of dermatomyositis?

A 
Generalised tissue oedema
Skin ulceration
Fever
Hypernasal voice
GI involvement
Cardiopulmonary involvement including myocarditis and dilated cardiomyopathy
Pulmonary fibrosis
Respiratory muscle weakness
CNS vasculitis
Ophthalmological complications e.g. retinopathy, glaucoma, cataracts
Renal failure
Raynaud's
Lipodystrophy
81
Q

Which tests can be done in dermatomyositis?

A

Muscle enzymes
ESR
CRP

Autoantibodies
ANA
Anti-ds-DNA
Anti-Sm
Anti-RNP
Anti-Jo1
Myositis specific antibodies
Imaging
Pulmonary function tests
ECG
Nail fold capillaroscopy
\+/- biopsy
82
Q

What is the principal problem in SLE?

A

dysregulation of the innate and adaptive immune system including production of autoantibodies and hypergammaglobulinaemia

83
Q

Which investigations can be sent in SLE?

A 
ANA
Anti-ds-DNA
Anti-U1 RNP Antibodies
Anti-cardiolipin
Complement
84
Q

What is Behcet?

A

Clinical triad of:
Recurrent oral aphthous ulcers
Recurrent genital ulcers
Uveitis - severe and can lead to glaucoma and blindness

85
Q

Who gets Behcet?

A

Male predominance, Japan, Middle East and Mediterranean

86
Q

What are some other features of Behcet?

A

Arthritis
Rash - skin hypersensitivity
Bowel involvement
Meningoencephalitis, brainstem lesions and dementia

87
Q

How is Behcet treated?

A

Steroids
Thalidomide
Anti TNF

88
Q

What are the clinical features of Sjogren syndrome?

A

Dry eyes (keratoconjunctivitis sicca)
Dry mouth and carious teeth
Parotitis

89
Q

What causes Sjogren?

A

May occur alone or in association with other rheumatological conditions
Occasional complication of renal disease or lymphoreticular malignancy

90
Q

What are the two kinds of scleroderma?

A

Localised and diffuse/CREST

91
Q

What are the features of localised scleroderma?

A

Morphea: thickened shiny pale skin then darkens as resolves with loss of subcutaneous tissue, Can be single or multiple

Linear: thickened plaque which causes loss of subcutaneous tissues and contractures over joints and loss of bone growth:
Face, forehead and scalp (en coup de sabre)
Limb (en bande)

92
Q

What are the features of CREST?

A 
Calcinosis cutis
Raynaud phenomenon
Oesophageal hypomobility
Sclerodactyly
Telangiectasia
Systemic problems include respiratory, gastrointestinal, and renal disease
93
Q

What is Henoch-Schonlein purpura?

A

Small vessel vasculitis that can be precipitated by infection

94
Q

Which infection classically causes HSP?

A

Haemolytic strep

95
Q

Who gets HSP?

A

Boys >3 years

96
Q

What are the clinical features of HSP?

A

Petechiae
Rash: urticarial lesions evolving into purpuric macules, usually on legs, feet and buttocks
Cutaneous nodules over the elbows and knees
Localised areas of subcutaneous oedema that affect the forehead, spine, genitalia, hands and feet
Arthritis: transient, involving large joints
GI involvement: colicky abdominal pain and/or GI bleeding
Renal involvement: nephritis, occasionally nephrosis

97
Q

Which marker is often raised in HSP?

A

Serum IgA

98
Q

What is the prognosis/management of HSP?

A

Episodes usually self limiting but can occur
Long term morbidity is related to renal involvement
Severe disease may need corticosteroids

99
Q

What will you find in an FBC in Kawasaki disease?

A

polymorph leucocytosis, raised platelets

100
Q

What are the diagnostic features of Kawasaki?

A 
≥5 days fever
Bilateral conjunctival injection
Changes in lips and oral cavity
Changes in extremities: reddening and oedema of palms and soles followed by desquamation
Polymorphous erythematous rash
Cervical lymphadenopathy
101
Q

What are the non-diagnostic features that can be associated with Kawasaki?

A 
Irritability
Pericarditis
Valvular dysfunction
Coronary artery disease
Arthritis and/or arthralgia
GI symptoms
Urethritis
Aseptic meningitis
Iritis
102
Q

What is the usual course of Kawasaki?

A

Acute and convalescent stage lasts up to 10 weeks

103
Q

What are the possible complications of Kawasaki?

A

Coronary aneurysms or widening in 20%

Death due to coronary vasculitis causing MI or aneurysm rupture occurs in about 1%

104
Q

How is Kawasaki managed?

A 
Supportive care
Careful observation
Salicylates
IV gamma globulin
Steroids
Anti-TNF
105
Q

What is polyarteritis nodosa?

A

Small to medium vessel vasculitis

106
Q

Who gets polyarteritis nodosa?

A

3-16 years

107
Q

What are the clinical features of polyarteritis nodosa?

A 
Fever
Abdo pain
Arthralgia/myalgia
Rash:
-Petechiae/purpura in generalised form
-Tender subcutaneous nodules and livedo reticularis in the cutaneous form
Hypertension
Renal involvement
Neurological disease
108
Q

What would be the investigation findings in polyarteritis nodosa?

A 
High ESR
Low Hb
Leucocytosis
ASOT elevated in some
Focal necrosis in small and medium sized arteries
109
Q

What is the prognosis in polyarteritis nodosa?

A

Cutaneous form usually benign but can relapse

Prognosis is worse in generalised form depending on organ involvement

110
Q

How is polyarteritis nodosa managed?

A

High dose steroids
Immunosuppression
Penicillin prophylaxis if streptococcal aetiology proven

111
Q

What is takayasu disease?

A

aka giant cell arthritis: a panarteritis of the aorta and its large branches leading to thrombosis, stenosis or occlusion

112
Q

Who gets takayasu disease?

A

Primarily affects young adult women, more common in East Asian and Black people

113
Q

What are the clinical features of takayasu disease?

A 
Claudication
Myalgia
Hypertension
Malaise 
Fever
114
Q

How is takayasu disease managed?

A

Steroids +/- cytotoxic and reconstructive surgery when the disease is inactive

115
Q

What is Churg-Strauss syndrome?

A

Systemic necrotising vasculitis of small arteries and veins, accompanying asthma and eosinophilia

116
Q

What are the clinical features of Churg-Strauss syndrome?

A

Lungs: asthma and transient pulmonary infiltrates
Rash: palpable purpuras and tender subcutaneous nodules
Peripheral neuropathy
Renal involvement

117
Q

What is Wegener granulomatosis?

A

Necrotising granulomatous vasculitis of the upper and lower respiratory tracts, accompanied by glomerulonephritis

118
Q

What are the clinical features of Wegener granulomatosis?

A 
Pulmonary granulomas
Destructive granulomas of the ears, nose and sinuses
Rash
Glomerulonephritis
Eye lesions
119
Q

Which antibodies are positive in Wegener granulomatosis?

A

Anti neutrophil cytosolic antibodies

120
Q

How is Wegener granulomatosis treated?

A

Steroids and cyclophosphamide

121
Q

What are the features of Poland syndrome?

A 
Absent or hypoplastic pectoral muscle
Shoulder abnormalities
Limb abnormalities
Hypoplasia or aplasia of the breast or nipple
Aplasia of ribs
Syndactyly/bradydactyly
Absent fingers
Short middle phalanges
122
Q

Which side is commoner in Poland syndrome?

A

Right

123
Q

What is associated with left sided Poland syndrome?

A

Dextrocardia

124
Q

Which conditions are associated with Poland syndrome?

A

Moebius
Klippel Fiel
Non Hodgkins lymphoma
Acute leukaemia

MRCPCH Clinicals (17 decks)

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