Ortho/Rheum

Question 1

Idiopathic avascular necrosis of the femoral head in children due to ischemia of capital femoral epiphysis – usually unilateral

Answer 1

Legg-Calve-Perthes Disease

Question 2

RF of Legg-Calve-Perthes Disease

Answer 2

Children 4-10 years old, 4x M>F, obesity, coagulation abnormalities (Factor V Leiden)

Decreased risk factors: lower incidence in African-Americans

Question 3

Painless limping for weeks (worsen w/ continued activity especially @ the end of the day)

Answer 3

Legg-Calve-Perthes Disease

Question 4

Tx of Legg-Calve-Perthes Disease

Answer 4

Observation: activity restriction (non-weight bearing initially) with orthopedic follow up is initial treatment in most cases
(usually self-limiting w/ revascularization within 2 years)
• May advocate for protected weight bearing during early stages until reossification is complete

• Physical therapy or brace/cast, NSAIDs for pain management
• Surgical: pelvic osteotomy may be indicated in some children >8 years of age, more advanced disease (lateral pillar B and B/C

Question 5

Abnormality in the shape &/ stability of the shape of the femoral head & acetabulum

Answer 5

Congenital hip dysplasia

Question 6

RF for congenital hip dysplasia

Answer 6

Breech position @ delivery, first-born children, females, positive family history

Question 7

PE findings associated with congenital hip dysplasia

Answer 7

Barlow maneuver: gentle adduction without downward pressure to feel for dislocatability, resulting in a click, clunk or jerk

Ortolani maneuver: abduction & elevation to feel for reducibility, resulting in a click, clunk or jerk

Question 8

Tx of congenital hip dysplasia

Answer 8

< 6 months of age: Pavlik harness

6 months-2 years: closed reduction in the OR (may need athrogram)

Question 9

Autoimmune mono or polyarthritis in children under 16 years old for 6+ weeks

Answer 9

Juvenile (Idiopathic) Rheumatoid Arthritis

Question 10

3 types of juvenile idiopathic RA

Answer 10

1) Systemic (Still’s disease): daily/diurnal high fever, daily arthritis, salmon-colored pink migratory rash

No iridocyclitis (anterior uveitis) but associated w/ systemic symptoms (hepatosplenomegaly, lymphadenopathy),

20% of all cases

2) Pauci (oligo) articular: under 5 joints involved, most commonly affects medium to large joints (knees, ankle)

Iridocyclitis (anterior uveitis)

50% of all cases

3) Polyarticular: 5 or more small joints (usually symmetric)

• Iridocyclitis (anterior uveitis)
• Most similar to RA – includes morning stiffness; worst prognosis if RF (+)

Question 11

Dx of juvenile idiopathic RA

Answer 11

Increased ESR & CRP, (+) ANA in oligoarticular, inc. ferritin

Systemic (Still’s) usually associated with a negative RF & ANA

(+) Rheumatoid factor in only 15%

Question 12

Tx of juvenile RA

Answer 12

First-line therapy: NSAIDs, glucocorticoids if no response to NSAIDs, physical therapy

2nd line or severe disease: Anakinra (interleukin-1 receptor inhibitor), Methotrexate, Leflunomide

ANA (+) associated w/ increased risk of Iridocyclitis so routine eye exam every 3 months is recommended

Question 13

MC primary bone malignancy in children & young adults; Malignant tumor of osteoblastic proliferation

90% occur in the **metaphysis of the long bones (distal femur MC), then proximal tibia & proximal humerus

Answer 13

Osteosarcoma

Question 14

MCC of death in pts with osteosarcoma

Answer 14

MC METs to the lung (MCC of death)

Gene is associated with familial retinoblastoma

Question 15

Localized bone pain (may occur after injury) and can be worse @ night, progressively worsening

Joint swelling without systemic symptom

Answer 15

Osteosarcoma

Question 16

Dx of Osteosarcoma

Answer 16

Radiographs: “hair on end” or “sunburst” appearance (see photo) d/t tumor spicules of calcified bone radiating in right angles is classic (not specific)

Other findings: mixed sclerotic & lytic lesions

Codman’s triangle: ossification of raised periosteum (can be seen in Ewing sarcoma)

• Biopsy: definitive diagnosis – malignant osteoid within the tumor & malignant sarcomatous stroma

Question 17

2nd MC primary bone malignancy in children & young adults (after osteosarcoma)

Answer 17

Ewing Sarcoma

Question 18

MCC of Ewing Sarcoma

Answer 18

Due to translocation between chromosomes 11 & 22

Question 19

Where is Ewing Sarcoma MC found?

Answer 19

50% found in **diaphysis of long bones – femur (most common), pelvis, tibia, fibula are common sites

Question 20

Radiographs: layered periosteal reaction “onion skin” appearance (see photo to R), lytic lesions with a “moth-eaten” appearance

Answer 20

Ewing Sarcoma

Question 21

Cartilage-capped benign chondrogenic bony overgrowth arising on the external surface of a bone & areas of tendon insertion (proximal tibia, femur, and proximal hemurus)

MC benign bone tumor

Answer 21

Osteochondroma

Question 22

Xray findings of Osteochondrome

Answer 22

Radiographs: often pedunculated (narrow stalk) that grows away from the growth plate & involves the medullary tissue

Biopsy: definitive

Question 23

Benign bone tumor characterized by a small radiolucent nidus (less than 1-

1.5 cm in diameter)

Answer 23

Osteoid Osteoma

Question 24

Radial head is wedged into the stretched annular ligament, MC in children 2-5 y/o

Lifting, swinging or pulling a child (longitudinal traction) while the forearm is pronated & extended

Answer 24

Radial head sublaxation – Nursemaids elbow

Question 25

Tx of Radial head subluxation aka nursemaids elbow

Answer 25

Closed reduction: place pressure on the radial head w/ supination of the elbow followed by flexion of the elbow (supination-flexion technique)

Observe the child for normal function, if the child uses the arm after 15 minutes, no XR needed

If no use after 15 minutes, consider XR to r/o fracture or reattempt reduction

Question 26

Apophysitis of the tibial tuberosity (inflammation of the patellar tendon @ the insertion of the tibial tubercle) due to overuse (repetitive stress microtrauma) or small avulsions from repetitive knee extension & quadriceps contraction

Answer 26

Osgood-Schlatter Disease

Question 27

Activity-related anterior knee pain & swelling (running, jumping, kneeling) & relieved with rest

Prominence, swelling & tenderness to the anterior tibial tubercle

Answer 27

Osgood-Schlatter Disease

Question 28

Tx of Osgood-Schlatter Disease

Answer 28

Conservative: mainstay of treatment – RICE, NSAIDs, quadriceps stretching, knee immobilization – most syx resolve within

12-24 months

Surgery only in refractory cases (if done, usually performed after growth plate has closed)

Question 29

Dx of scoliosis

Answer 29

Adams forward bend test: most sensitive physical finding – thoracic or lumbar prominence on one side is seen w/ scoliosis

Scoliometer: a 7 degree curve = abnormal

Forward bending sitting test

Radiographs: Cobb’s angle > 10 degrees measured on AP & lateral films

MRI: not part of the initial evaluation without red flags or abnormal curve types – MRI may be indicated if rapid curve

progression, left thoracic curve, abnormal reflexes, excessive kyphosis, or foot abnormalities Management

Question 30

Tx of scoliosis

Answer 30

Observation: Cobb angle under 25 degrees: & Risser grade 0 to 2 @ time of presentation – regular follow up to monitor progression every 6-9 months, bracing may be recommended if Cobb angle increases 5 degrees or more over a 3-6 month period

Bracing may be needed to stop progression in patients with a flexible deformity & still skeletally immature: 1) if Cobb angle increases 5+ degrees over a 3-6 month period or 2) some patients with Cobb angle 30-39 degrees

Question 31

Displacement of the femoral head (epiphysis) from the femoral neck through the growth plate

Answer 31

Slipped Capital Femoral Epiphysis

Question 32

Pathophys of slipped epiphysis

Answer 32

Femoral head epiphysis slips posterior & inferior @ growth plate