Orthopedics/Rheumatology Flashcards
1
Q
osteosarcoma
A
- malignant bone tumor, MC primary ped bone tumor, MC in metaphyses of long bones
- sxs: pain and swelling in LONG BONE (50% in knee joint - dist femur or prox tibia; persistent bone pain that worsens at night or with activity), may present with loss of fn, mass, or limp
- dx: XR (lytic lesion with cortical destruction near metaphysis (sunburst appearance), bx required for dx
- tx: NO IMPROVEMENT WITH CONSERVATIVE TX: chemo (radiation resistant), limb sparing surg (excision) or amputation
- 20% have mets at time of dx - lungs, bone
2
Q
ewing sarcoma
A
- malignant bone tumor, MC older children and adolescents
- MC sites: long bones (femur, tibia, humerus) and axial skeleton (pelvis, ribs, spine)
- sxs: inc pain and swelling at tumor site (no prior hx of inj or trauma), wakes child up at night, fever
- signs: tenderness, swelling
- dx: XR (lytic mass with multi-laminated periosteal “onion skin” rxn (or moth eaten appearance), CBC shows leukocytosis, bx required
- tx: no improvement with conservative tx: chemo, radiation, surg, mets in 25% (lungs, bone marrow
3
Q
osteochondroma
A
- benign (MC benign tumor in children), bone mass capped with cartilage, M>F
- sxs: painless mass (pain caused by bursitis or tendinitis), single or multiple
- dx: XR shows stalk or broad-based projeciton from surface of bone
- tx: excise if interfering with fn, good prognosis
4
Q
osteoid osteoma
A
- benign bone forming lesion of unclear etiology, children 5-20y
- sxs: inc pain, worse at night (relieved by NSAIDs or ASA), upper femur can cause referred pain to knee
- signs: tenderness over lesion
- dx: XR shows round lucency surrounded by sclerotic bone, CT scan confirms
- tx: surgical excision or radiofrequency ablation, good prognosis
5
Q
osteoblastoma
A
- benign, rare, presents in 20s, M>F, MC location = posterior column of spine, unkown etiology
- sxs: spine, dull aching chronic pain (no change at night), nonresponsive to NSAIDs, limp or neuro sxs secondary to cord compression
- dx: XR shows variable findings, CT, MRI (appears similar to osteoid osteoma, but larger)
- tx: curettage and bone grafting, en block excision for aggressive lesions, radiation for spinal lesions that cannot be fully resected
- prognosis: untreated, may cause progressive neuro sxs, good prognosis if removed completely, 20% recurrence if expansion outside bone
6
Q
juvenile idiopathic arthritis (JIA)
A
- MC arthritis is children <17yo, Rheum factor + in infxn, lupus, liver dz, malig, but most common cause is viral infxn
- ANA in liver dz, infxn, malig, and healthy
- sxs: arthritis lasting >6wk to 3mo in any one joint (DIP), onset 16y or less, pain, joint swelling, +/-gait disturb, difficulty with ADLs, joint stiffness, morning stiffness
- dx: dx of EXCLUSION, RF (-) in 95% with arthritis, ANA + in 95% of lupus, 80% pauciarthritis, esr + inxn, malig, preg, obesity
- XR are least helpful for ruling out
- tx: control pain, improve fn, prevent jnt damage
- complications: uveitis, growth inhib
7
Q
systemic JIA (still disease) etiology, RF, sxs
A
- difficult to dx, arthritis not always evident early on, systemic sxs not always typical, no dx tests, mimics infxn or malig first with no response to abx
- etiology: any age, white, M = F, can start as early as 1yo or less, refers to pts with rash and intermittent fever in addition to arthritis of any number of joints
- autoinflammatory, unrelated to other forms of childhood arthritis, 10-15% of JRA, adult-onset Still dz = begins 16+yo
- sxs: intermittent daily fever (>38.5) for at least 2wk, persistent arthritis 6+ wks, most oligoarthritis or polyarthritis, affects wrists, ankles, knees mostly, may start in hips and rapidly progress, arthritis required for dx
- rash, LAD, arthralgias, no response to abx
- signs: high grade fever 102-106, macular, salmon-pink rash (round to oval macules of differing size, found in axillae and around waist, prominent with fever, fades when afebrile, koebnerizes), multiple swollen joints or no arthritis for mos, micrognathia, cervical spine fusion
- complications: pericarditis (effusion), HSM, pleural effusion, Kawasaki dz, LAD, uveitis
8
Q
systemic JIA dx and tx
A
- dx of exclusion (WBC >15k, left shift, agranulocytosis), anemia, thrombocytosis, ESR/ferritin very elevated, ANA and RF neg, UA normal
- tx: NSAIDs, then refer to rheum, adjunct biologics (IL-1 receptor antag, anti IL-6, anti-IL-1), steroids if persistent, if refractory use DMARDs
- health maint: limited steroid use, PT, OT, nutrition, psychosocial support
- prognosis: better if response to adequate tx, poor prognosis with pulm complications
- MC complications: macrophage activation system (MAS), severe growth retardation, osteoporosis; others include ILD< pulm HTN, lipoid PNA, alveolar proteinosis
9
Q
scoliosis
A
- F, 8-10yo, lateral curvature of the spine associated with rotation of the involved vertebrae and classified by its anatomic location, in either the thoracic, in either the thoracic or lumbar spine, with rare involvement of the cervical spine, 80% idiopathic, 5-7% congenital
- sxs: no significant pain (if pain, r/o infection or tumor), deformity of rib cage or asymmetry of waistline
- signs: forward bending test, scoliometer or inclinometer (good screening tool for angle of rotation)
- dx: calculate cobb angle using AP and lateral x-ray films of entire spine, 60-90 degrees; resp complaints or neuromuscular cause: PFT, especially if surgery being considere; at high risk for cardiopulm compromise and secondary restrictive lung dz
- tx: tx-based on cobb angle and sxs, <10 degrees (obs only), <20 degrees (no tx unless they show progression), 20-40 degrees (bracing), 40-60 degrees (surg fusion)
10
Q
nursemaids elbow
A
- radial head subluxation
- mech of injury = fall onto dorsiflexed hand, MC fracture of elbow in adults
- nursemaid’s elbow: subluxation of radial head in children is caused by excessive longitudinal traction (MC before age 4y, radial head slips ant)
- sxs: arm pain, crying with any mvmt, holding arm at side, motionless, refuses to move arm, forearm, or wrist
- signs: forearm extended and in pronation, no edema, deformity, or erythema, distal pulses and capillary refill normal
- dx: AP and lat XR of elbow (displacement of posterior fat pad implies hemarthrosis, r/o fracture in children)
- tx: subluxations can be reduced (hold affected arm above wrist and just below elbow, place the thumb of the proximal hand over the radial head, while fully supinating and flexing the forearm, apply direct posterior pressure)
11
Q
osgood-schlatter dz (osteochondritis of tibial tubercle)
A
- inflamm of tibial tubercle apophysis
- MC: adolescents (boys 9-14 yo), rapid growth spurt, most commonly very active or “overuse” syndrome, caused by repetitive strain and chronic avulsion of apophysis of tibial tubercle
- RF: sports involving running, cutting, or jumping
- ddx: jumper’s knee (sinding-larsen-johansson) - apophysis at inf pole of patella gets inflamed
- sxs: ant knee pain (gradually increases over time - impairs activity; worse with direct pressure, running, squatting, jumping, climbing stairs, walking uphill, relieved with rest, 25-50% bilateral), visible and palpable prominence of tibial tubercle, tenderness and soft tissue or bony prominence over tibial tubercle, paine reproduced by: extending knee against resistance, stressing quads, squat with knee fully flexed, straight leg raise is painless
- dx: clinical dx (XR not necessary but shows soft tissue swelling ant to tibial tubercle), MRI for staging)
- tx: conservative tx (Ice, anti-inflamm, PT, continue activity, protective pad over tubercle), surg for pts who fail to respond to conserv tx
- prognosis: waxes and wanes over 6-18mo, subsides completely by 14-18y
- complications: avulsion fx (rare), genu recurvatum (rare), persistent prominent tubercle, persistent pain
12
Q
SCFE etiology, RF, sxs
A
- adolescent, obese males, age 11-13y
- RF: endocrine disorders, obesity, coxa profunda, femoral or acetabular retroversion, femoral epiphysis always: posterior and some medially relative to fem neck, slipping of femoral head off neck at physis - displacement of proximal femoral epiphysis due to disruption of growth plate, chronic SCFE is MC presentation: >3 wk of vague sxs, no preceding trauma
- sxs: painful limp and referred pain to thigh/medial knee (acute onset, minor trauma, nonradiating, dull, aching pain), inability to walk (stable = child able to bear weight, unstable = unable to bear weight)
- signs: limitation of internal rotation and abduction of the hip, intense pain with passive motion, affected limb abducts and externally rotates with passive flexion from extended position, standind on the affected leg (trendelenburg test) causes pelvic tilt
13
Q
SCFE dx and tx
A
- dx: XR (dxic - bilat AP and frog-leg-bilat) - displacement of femoral head and rotation of femoral neck ant, widening of prox femoral physis, metaphyseal remodeling +/- joint effusion, “ice cream slipping off cone”
- tx: if acute, make pt non-wt bearing on crutches and immediated ortho referral, percut pinning across epiphysis, screw fixation
- prognosis: determined by degree of slippage (mild <30, moderate 30-50, severe >50) inc rate of AVN with inability to bear weight, inc risk of osteoarthritis
- complications: arthrofibrosis leading to froxen joint with thickened contracted capsule, femoroacetabular impingement, AVN of femoral head
14
Q
avascular necrosis of proximal femur
A
- can be a complication of corticosteroid use, alcoholism, trauma, SLE, pancreatities, gout, sickle cell dz, knee menisectomy, and infiltrative dz (i.e. gaucher dz)
- MRI, CT scan, and bone scan are all more sensitive techniques than XR
- tx = avoidance of weight bearing on affected joint for at least several weeks
- value . of surgical core decompression = controversial
- vascularized and nonvascularized bone grafting procedures are therapuetic
- most effective in avoiding or forestalling need for total hip arthroplasty in young pts who dont have advanced dz
- total hip replacement is the usual outcome for all pts who are candidates to do so
