Ortho/Rheumatology

Question 1

Growing Pains

Answer 1

• Often bilateral, at night (may wake them), poorly localized
• No signs inflammation
• No daytime sx
• Tx - NSAIDs and heat

Question 2

Diagnosis of Psoriatic Arthritis

Answer 2

• Arthritis + psoriasis (scale on extensors)
• OR arthritis + 2 of following …
  • Dactylitis
  • Nail abnormalities - pits or onycholysis
  • Family hx psoriasis in first degree relative

Question 3

SLE Diagnostic Criteria

Answer 3

4/11

• Malar rash
• Discoid rash (annular, scaly rash on scalp face or extremities)
• Photosensitivity
• Oral or nasal ulcerations
• Arthritis
• Renal abnormalities - 3+ protein or cellular casts
• Neuro abnormalities - sz or psychosis
• Serositis - pericarditis +/- pleuritis
• ANA pos
• Heme abnormalities - Coomb’s positive anemia, thrombocytopenia, leukopenia
• Auto-antibody pos (anti-dbl stranded DNA, anti-phospholipid, anti-Smith)

Question 4

Henloch-Schlonlen Purpura

Answer 4

• Viral/ URI / strep infection –> IgA deposition –> vasculitis
• Manifestations
  
  • Skin - palpable purpura
  • Arthritis
  • GI - inc risk intussusception (get US of abdomen)
  • Kidney - hematuria, proteinuria (get UA)
• Tx
  
  • NSAIDs and hydration
  • Prednisone if severe
  • Should resolve in 1-2 mo

Question 5

Kawasaki Presentation and Tx

Answer 5

VASCULITIS

• Bilateral conjunctiva sparing the iris (limbic-sparing)
• Red, dry, cracked and swollen lips; strawberry tongue
• Maculopapular rash of trunk, face, extremities, diaper area
• Unilateral cervical lymphadenopathy > 1.5 cm

TX = ASA (to prevent coronary artery aneurysm) +/- IVIG initially

Question 6

Kawasaki Diagnostic Criteria

Answer 6

• “crash and burn”
• 4/5 CRASH criteria + 5 or more days of fever (burn)
  • C -conjunctiva
  • R - rash
  • A - adenopathy
  • S - strawberry tongue (or other mucous membrane changes)
  • H - hand and foot changes (EDEMA)

Question 7

Dermatomyositis

Answer 7

• Proximal Musc Weakness + Rash
• Pos Gower sign (ask to stand from sitting position - pos if use hands to walk up body)
• Skin - heliotrope (eyelids), gottron papules, nail bed teleangiectasias
• Can also have arthritis
• If no rash then likely muscular dystrophy
• Tx = Prednisone (2mg/kg/day); slowly taper over 1-2 yrs

Question 8

Club Foot v. Metatarsus Adductus

Answer 8

Clubfoot (talipes equinovarus) = rigid; contact ortho right away

Metatarsus Adductus = flexible and usually self-corrects by 12-18 mo

Question 9

How do you fix a nursemaid’s elbow?

Answer 9

• extend elbow all the way then fully supinate and flex elbow putting pressure on radial head
• Child should use hand again in 15-20 min (if not get Xray to r/o fracture)

Question 10

When should you refer to ortho for scoliosis? (4)

Answer 10

• Scoliometer > 7 degrees and cannot get Cobb angle
• Cobb angle (from std Xray) > 20 degree in pre-pubertal child age 12-14
• Cobb angle > 30 degree
• Progression of Cobb angle by 5 degrees

Question 11

Blount Disease

Answer 11

• Disorder of medial proximal tibial physis –> bow-legged (varum)
• Use brace in kids < 3 yo

Question 12

Patellar Grind Test

Answer 12

• Displace patella inferiorly then ask pt to contract quads against resistance; if reproduces pain then pos for patellofemoral syndrome
• NSAIDs, ice, PT

Question 13

Osteogenesis Imperfecta

Answer 13

• Caused by type 1 collagen mutation (COL1A1 or COL1A2)
• Manifestations - BITE
  
  • B - bone fractures (may happen in utero)
  • I - “eye” - blue sclera
  • T - teeth (brittle)
  • E - ear (hearing loss)
• Tx - pamidronate (bisphosphonate) + adequate Vit D and Ca