rheum Flashcards
You see a child with fever, arthralgias, and a rash on his lower limbs (see picture below). What test needs to be done now?
a) Abdominal ultrasound
b) Urinalysis
c) IgA
urinalysis HSP diagnosis Palpable purpura \+ one of the following: 1) abdo pain 2) arthritis/arthralgia 3) bx of tissue showing IgA deposition
- recommends no lab work as its clinical diagnosis but RECCOMEND BP and urinalysis for 6 months after diagnosis, especially those who had HTN/urine abn at presentation as 1-2% can have renal disease and 8% that have HSP nephritis get ESRD
A 3 year old has a history of recurrent fevers for the past year. They occur every 4-12 weeks for 1-4 days each. He has been treated for numerous otitis media and pharyngitis. She is growing well. The likely underlying cause is:
a. multiple viral infections
b. familial med fever
c. CVID
d. Ig deficiency (
viral infxn
The onset of fever and pain (due to serositis at one or more sites) is usually abrupt, peaking soon after onset. Some patients have a stereotypic prodrome before their attacks [2]. Episodes last for one to three days and then resolve spontaneously. Patients are asymptomatic between attacks. The frequency of attacks is highly variable, even in a given patient. The intervals between episodes are irregular, ranging from one week to several months or years.
2 year old child with fever for the past 2-3 weeks (up to 39 C), lymphadenopathy and mild hepatosplenomegaly presents complaining of joint pain. There is no true arthritis, but complains of pain with movement of joints. Hgb 91, WBC 9 (45% lymp, 55% PMN), platelets of 110. What is your next step in establishing diagnosis?
a. BMA
b. Blood culture
c. ANCA, ESR and RF
d. EBV serologies
BMA
the combination of two abnormal parameters on complete blood count (WBC count <4000/microL; platelet count 150,000 to 250,000/microL; hemoglobin <11 g/dL) was 96 percent sensitive and 88 percent specific for ALL.
Criteria for JIA
age onset <16yo
arhtirits
duration for more then 6w
onset type (poly more then 5, oligo 4 or less, systemic if rash and fever)
10 year old girl with migratory arthritis for last 10 days, now affecting left wrist. She is febrile, and has an ESR of 40. Most LIKELY diagnosis is
a. SLE
b. Rheumatic fever
c. JIA
d. Septic arthritis
RF (need GAS)
Jones criteria for RF
JONES CAFE PAL
major
Joint, O =mycarditis, N nodule, E erythema marginatum, Sydenham chorea
MINOR : CRP inc, Arthalria, Fever, elevated ESR, prolonged PR, anamess of rheumatism, leulocutosis
NEED
GAS/ASOT+ 2 major, OR 1 major 2 minor
Rhuematic fever diagnosis
JONES CAFE PAL
major
Joint, O =mycarditis, N nodule, E erythema marginatum, Sydenham chorea
MINOR : CRP inc, Arthalria, Fever, elevated ESR, prolonged PR, anamess of rheumatism, leulocutosis
NEED
GAS/ASOT+ 2 major, OR 1 major 2 minor
2 year old with mild metatarsus adductus and tibial torsion who has had intoeing since birth. There has been no improvement. They are presenting to your office today. The best advice is:
- Reassurance
- Hip, knee, tibia, foot x-rays
- Referral to orthopedics
- Advise them not sit in W position (common in femoral anteversion)
reassurance
INTOEING caused by the following (all, or seperate) 1) metatarsus adductus, tibial torsion and femoral anteversion
Increased femoral anteversion — The natural history of in-toeing secondary to increased femoral anteversion is that of spontaneous resolution, usually by 11 years of age.
TIbial torsion should go by 5yo
-metatarsus adductus - goes away by itself
You are treating a teenage boy with pericarditis. You suspect that his pericarditis might be secondary to SLE. Which of the following is most supportive of this diagnosis?
a. Positive RPR
b. Positive ANCA (
c. Positive HLAB27
d. Thrombocytosis
RPR - (test for syphillis, falsely elevated/positive in pt who have lupus due to elevated antintiphospholipid antibodies (lupus anticoagulant [LA], IgG and IgM anticardiolipin [aCL] antibodies; and IgG and IgM anti-beta2-glycoprotein [GP] I)
ANCA=usually GPA - granulomatosis polyangitis, can also be positive with lupus)
SLE diagnosis
SLE “SOAP BRAIN MD” need 4/11 Serositis – Pleurisy, pericarditis Oral ulcers Arthritis Photosensitivity Blood disorders Renal involvement Antinuclear antibodies (positive in <95%) Immunologic phenomena Neurologic disorder Malar rash Discoid rash
17 year old male with history of enthesis related JIA comes to your office. Just had a new baby girl with his girlfriend and would like to quit smoking for her sake. What puts him MOST at risk of not being able to quit
1) Chronic illness
2) Male gender
3) Older adolescent
4) Parenthood
chronic illness
5yo M with intermittent abdominal pain and purpuric rash on thighs. He has joint pains and hematuria. Which of the following lab abnormalities would likely be present?
a. Thrombocytopenia
b. Schistocytes
c. Elevated IgA
elevated IgA
4yo F with one very inflamed joint for over 1 month, ANA negative, no uveitis. What is the first line treatment for her condition?
a. Methotrexate
b. Systemic steroids
c. NSAIDs
d. IVIg
NSAID
Oligoarthritis defined as involving ≤4 joints within first 6 months of disease onset, often only single joint involved. Predominantly large joints of lower extremities such as knees and ankles.
Positive ANA = increased risk for asymptomatic anterior uveitis, requires periodic slit-lamp exam.
Positive ANA correlated with younger age at onset, female, asymmetric arthritis, and lower number of joints over time.
try injection of intraarticular steroids. Next line would be DMARDs, MTX, and last resort is TNF inhibitors.
NSAIDs rarely induce remission in polyarthritis or systemic JIA.
A 7 year old girl has oligoarticular JIA and has been on methotrexate as maintenance therapy for her disease. She has sudden onset high fever, anemia, thrombocytopenia, and hepatomegaly with elevated liver enzymes. Which of the following is the cause of her current condition?
a. Methotrexate toxicity
b. Macrophage activation syndrome
MAS
dec fibrinogen
dec counts plt/WBC
inc lfts
6-year-old with clinical and laboratory evidence consistent with systemic JIA develops persistent fever, extensive and fixed rash, thrombocytopenia and hyponatremia. What is most likely to decrease:
a) Triglyceride
b) Fibrinogen
c) LDH
d) Ferritin
fibrinogen
You want to start an 11 year old boy with JIA on Infliximab. Which is most important prior to starting this medication?
a) VZV vaccine
b) MMR vaccine
c) Checking for Mycobacterium Tuberculosis
check for mycobacterium
Do not initiate TNF blockade in subjects with history of chronic or frequent recurrent infections. TB should be tested for prior to initiation of therapy with TNF antagonists. If test results are positive, anti-TB treatment must be administered before starting anti-TNF therapy.
Child with recurrent fever, cervical adenitis, aphthous ulcers, pharyngitis. Normal immune work-up. Best treatment
a) oral colchicine x 5 days (FMF treatment)
b) oral prednisone x 1 day
oral predx1 day
PFAPA = periodic fever, aphthous stomatitis, pharyngitis, adenitis
Most common recurrent fever syndrome in children. Recurring episodes of fever, malaise, exudative tonsillitis with negative throat cultures, cervical lymphadenopathy, oral aphthae, and less commonly headache, abdo pain, and arthralgia. Episodes last 4-6 days regardless of treatment (antipyretic/antibiotic), occur regularly on 3-6 week cycles. During episode - mild HSM, mild leukocytosis, elevated acute-phase reactants.
Majority of patients show dramatic response to single oral dose of prednisone (0.6-2.0 mg/kg) although does not prevent recurrent and may shorten interval between flares.. Cimetidine (20-40 mg/kg/day) prevents recurrence in ⅓ of cases. Resolution possible after tonsillectomy.
Girl had fever then swollen extremities, cracked lips. Treated with IVig and ASA then developed anemia and hematuria.
a) Kawasaki IVIG hemolytic reaction
kawasaki IVIG hemolytic
Kid with fevers, salmon rash, HSM (no joint pain).
a) Systemic JIA
b) ALL
systemic JIA
Systemic JIA characterized by:
arthritis - classically polyarticular and destructive
fever - spiking to >39 1-2X/day and returning to normal quickly, often in evenings
rash - classic evanescent salmon-colored lesions which are linear/circular and on trunk and proximal extremities
visceral involvement - HSM, lymphadenopathy, and serositis (pericarditis)
Girl walked and tripped on a curb now has cold, extremity painful to touch
a) CRPS
b) osteomyelitis
CRPS complex regional painn syndrome
noxious event/immbilization with continued pain,allodynia, hyperalgesia, out of proprtion to event
evidence of edema, skin blood flow abnormality, atrophy of hair and weakness
treat with OT/PT
Ankle injury-when to XR
a) Posterior tip of medial malleolus tenderness for XR
b) Anterior tip of lateral malleolus
c) Cant weight bare right after injury
ankle x-ray - if there is pain in the malleolar zone and any of the following:
1 Bone tenderness at the posterior edge or tip of the lateral malleolus, or
2 Bone tenderness at the posterior edge or tip of the medical malleolus, or
3 Inability to weight bear both immediately and in the emergency department
A foot x-ray series is only necessary if there is pain in the midfoot zone and any of the following:
1 Bone tenderness at base of fifth metatarsal, or
2 Bone tenderness at the navicular bone, or
3 Inability to bear weight both immediately and in the emergency department
Girl with JDM, what is the best diagnostic test
a) EMG
b) CK
EMG
Diagnostic criteria:
classic rash (heliotrope rash of eyelids or gottron papules)
plus 3 of the following:
weakness: symmetric, proximal
muscle enzyme elevation (≥1): CK, AST, LDH, aldolase
EMG changes: short small polyphasic motor unit potentials, fibrillations, positive sharp waves, insertional irritability, bizarre high frequency repetitive discharges
muscle biopsy: necrosis, inflammation
JDM criteria
Diagnostic criteria:
classic rash (heliotrope rash of eyelids or gottron papules)
plus 3 of the following:
weakness: symmetric, proximal
muscle enzyme elevation (≥1): CK, AST, LDH, aldolase
EMG changes: short small polyphasic motor unit potentials, fibrillations, positive sharp waves, insertional irritability, bizarre high frequency repetitive discharges
muscle biopsy: necrosis, inflammation
1. Boy with lupus. Most likely test consistent with this Dx A. ANCA+ B. Thrombocytosis C. HLAB27+ D. positive RPR
D. positive RPR
Child in rhythmic gymnastics. Has back pain that is worse on extension. On exam has exaggerated lumbar lordosis, hamstring tightness. Bone scan is positive. What does she have? Spondylolysis Posterior overuse sydnrome Herniated disc ring apophositis
Spondylolysis
14 year old female gymnasts presents with a 2months history of lower back pain on extension. She has tight hamstrings, spasm of her paraspinal muscles, normal sensations and motor function. A bone scan lights up her lumber vertebrae. What is the diagnosis? Spondylosis Posterior Element Overuse syndrome Disk herniation Vertebral body avulsion fracture
spondyloysis
treamtnet with JDM
MUSCLE ENZYMES -elevated alanine aminotransferase most commonly elevated on initial presentation and CK may be normal. Usually ANA positive in 80% of patients
MRI T2 = can be used to help with EMG and muscle biopsy location determination
Treatmentet- steroids and MTX +/- IVIG
. A term baby is born to a mother with maternal lupus. He is noted to have congenital heart block.
a) Name the 2 most common antibodies in congenital heart block.
Anti-Ro (SSA)
Anti-La (SSB)
Name 3 other manifestations of neonatal lupus.
characteristic annular/macular rash affecting face (especially periorbital area), trunk, scalp
hematologic manifestations: anemia, neutropenia, thrombocytopenia
hepatic manifestations: asymptomatic elevated LFTs, mild HSM, cholestasis, hepatitis
neurologic manifestations: hydrocephalus, macrocephaly, neuropsychiatric dysfunction
stippling of epiphyses (chondrodysplasia punctata) on radiographs
18 month old with missed developmental dysplasia of the hip:
a) Name two clinical features of this diagnosis (not sure exact wording)
b) Name one physical exam finding.
Breech presentation Female First born Family history of DDH Any condition that leads to tighter intrauterine space and consequently less room for normal fetal motion: oligohydramnios large birth weight multiples (twins/triplets/etc) Tight swaddling
which ECG change is characteristic of acute rheumatic fever?
A. Peaked T waves
B. Prolonged PR interval
C. Sinus tachycardia
Prolonged PR interval
A 3 year old girl presents with 7 day history of fever. She has bony pain but no arthritis on exam, but she has HSM and diffuse generalized lymphadenopathy. Her blood work shows WBC 18, Plt 110 and anemia. What is the next best step?
A. Bone Marrow Aspirate
B. EBV Serology
C. Work up for systemic JIA
bma
A kid has had 6 days of fever despite treatment with amoxicillin, with no response. He also has cracked lips, nonpurulent bilateral conjunctivitis, and a polymorphous rash. What would you expect to see on his labs?
a. Neutropenia
b. Hypoalbuminemia
c. Elevated ASOT
d. Elevated EBV titres
Hypoalbuminemia
KD-
Fever persisting at least 5 days †
Presence of at least 4 principal features:
Changes in extremities:
Acute: Erythema of palms, soles; edema of hands, feet
Subacute: Periungual peeling of fingers, toes in weeks 2 and 3
Polymorphous exanthem
Bilateral bulbar conjunctival injection without exudate
Changes in lips and oral cavity: erythema, lip cracking, strawberry tongue, diffuse injection of oral and pharyngeal mucosa
Cervical lymphadenopathy (>1.5 cm diameter), usually unilateral
Toddler comes to the ED refusing to weight bear. Xray of leg shows non-displaced spiral fracture of left tibia. Which is most likely? NAI Ricketts Toddler’s fracture Osteogenesis Imperfecta
Toddler’s fracture
8y boy had URTI two weeks ago; now presents with fever >40, unable to weight bear on right leg. WBC is 18, ESR 40 (? I think) and CRP 80. What is next step in management?
Admit and start IV abx
Nsaids
Urgent orthopedic consultation
Urgent orthopedic consultation
13 y.o. Girl presents with antalgic gait and pain for 2 weeks. She has difficulty with rotation and adduction of her leg. X-ray was similar to the one below. What is the diagnosis?
a) Septic joint
b) Calve-Perthes
c) SCFE
d) Fracture
e) Post-infectious
SCFE
14 year old adolescent girl who you haven’t seen in the last 2 years comes in for routine check-up. When she bends forward, you note a large thoracic asymmetry. Spine X-ray shows a Cobb angle of 50 degrees. What do you do next? Repeat X-ray in 3 months Custom thoracolumbar spine brace Spinal fusion Electro-something stimulation
spinal fusion
40 – 50 degrees or more: Surgery may be required to correct the curve. There are several surgical procedures. A frequent recurring procedure is the “spinal fusion”, to link the vertebrae together so that the spine cannot longer continue to curve
Those with Cobb angle of more than 60° usually have respiratory complications
6 yo girl with diagnosis of JIA and pain in one knee. CRP 58. Sedimentation 25. ANA negative. No uveitis. What is the next step in management
a. NSAIDS
b. Methotrexate
c. Intra-articular corticosteroids
d. Oral steroids
nsaids
Girl with systemic JIA well-controlled on methotrexate then re-presents with fever, unwell, rash, liver 3 cm below costal margin. What is the most likely diagnosis MAS Sepsis Methotrexate toxicity Autoimmune hepatitis
MAS
- Kid with JIA and MAS features, what is it?
a. MAS
b. Sepsis
mas
Picture of a 7y boy with completely erythematous face. He’s on fluticasone and phenytoin. What is the most likely diagnosis?
a. Drug hypersensitivity
b. SLE
c. JDM
d. JIA
a. Drug hypersensitivity
. Ankle injury. Indication for xray: [CPS]
a. posterior malleolus tenderness
b. can’t wt bear immediately
c. anterior medial malleolus
posterior mallelos
Kid with FMF, what to give?
a. Colchicine
colc
FMF attacks can last between 12 and 72 hours and consist of inflammation involving the peritoneum, pleura, joints, or skin; sometimes in combination. Between episodes, patients usually feel completely well and remain so for a few days to a few months.
In children, fever may be the only sign of FMF, although other symptoms typically develop progressively with time
Colchicine therapy is highly effective for most patients in preventing febrile episodes and systemic amyloidosis.
A 6y girl presents with arthritis of 3-4 joints at a time. Her ANA is positive. Which is the most likely associated finding?
a. Eye pain
b. Photophobia
c. Unequal pupil
unequal pupil
Synechiae - iris adheres to the cornea. Patients presenting with synechiae typically have an underlying inflammatory disease process such as uveitis
12y gymnast presents with 2mo of lower back pain. The pain is worse for 2-3 days after practice. Her sleep is ok. She gets spasms in her paraspinal muscles. On exam, she has tight hamstrings, normal sensation and motor function in her legs with normal anal tone and sensation. A bone scan lights up in her lumbar vertebra over the location of her pain. What is the diagnosis?
a. Spondylolysis
b. Posterior element overuse
c. Disk herniation
d. Vertebral body avulsion fracture
a. Spondylolysis
- Kid w knee pain
a. Patellofemoral syndrome
Most common symptom - pain beneath or near patella
Classically walking up/down stairs aggravates it
Pain after prolonged sitting with the knee in flexion (“theatre sign”)
(repeat) 148. 5 year old child with Kawasaki disease. What lab finding would you expect
a. Hypoalbuminemia
b. Thrombocyotpenia
c. Low liver enzymes
d. Leukopenia
hypoalbunimiea
A 10 yr old girl presents with 10 days of fever and a migratory arthritis. On exam, she has a swollen left wrist. Her WBC is 18 and her ESR is 75. Diagnosis:
a. SLE
b. JRA
c. Rheumatic fever
d. Septic arthritis
RF
14 year old boy with Duchenne’s, who is in a wheelchair, has recently seen his FVC fall from 30% to 21% predicted. What symptom will he MOST likely complain of?
a. Headache early in morning
b. Headaches in the afternoon
c. Tingling of his fingers
d. Dyspnea with exertion
h/a
Headache early in morning (due to carbon dioxide retention with ineffective ventilation while sleeping)
DMD - progressive weakness, intellectual impairment, hypertrophy of calves, proliferation of connective tissues in muscles. X-linked recessive. Abnormal gene at Xp21 locus.
Most patients walk with increasing difficulty until age 10
Respiratory involvement weak ineffective cough, frequent pulmonary infections, decreasing respiratory reserve.
Progression to severe hypotonia, chest wall muscles shorten and lose elasticity. Lung volumes decrease = becomes restrictive. Chronic hypercapnea
Boy with recurrent pharyngitis. Episodic jerking of shoulders and head over past 6 weeks. Most likely diagnosis?
a. Rheumatic fever
b. Transient tic disorder
c. Tourettes
d. Some sort of seizure disorder
RF
PANDAS: pediatric autoimmune neuropsychiatric disorders associated with strep pyogenes
neuropsychiatric disorders: OCD, tic disorder, Tourette syndrome
hypothesized relationship with GAS infections but not proven
autoimmune antibodies in response to GAS infection cross-react with brain tissue similar to autoimmune response responsible for sydenham chorea
JDM question, what most likely to make dx.
a. CK
b. EMG
emg
Diagnostic criteria:
Rash: heliotrope rash of eyelids (blue-violet discoloration of eyelids), Gottron papules (bright pink or pale, shiny thickened atrophic plaques for PIPs, DIPs, and sometimes knees, elbows and small joints)
PLUS 3 of
Weakness: symmetric, proximal
Muscle enzyme elevation (>1): CK, AST, LD, aldolase
EMG changes: short, small, polyphasic motor unit potentials, fibrillations, positive sharp waves, insertional irritability, bizarre, high-frequency, repetitive discharges
Muscle biopsy: necrosis, inflammation
*nerve conduction studies typically normal unless severe necrosis
ESR typically normal, ANA positive in >80%, RF negative
. What is the most common childhood wrist fracture?
a. Colles fracture
b. Greenstick
c. Buckle fracture
d. Salter Harris
buckle #
A 7 year old boy has a history of recurrent fevers, evanescent pink rash, lymphadenopathy, and hepatomegaly. His MSK exam is normal. What’s the diagnosis?
a. Leukemia
b. Scarlet fever
c. Lyme disease
d. Systemic JIA
systemic jia
Evanescent rash, lymphadenopathy, hepatomegaly without joint pain in 6 yo boy. What is your diagnosis?
a. systemic JIA
b. ALL
Definition of systemic JIA (Table 155-2):
Arthritis in 1+ joint, with or preceded by, fever of at least 2 weeks in duration that is documented to be daily (“quotidien”) for at least 3 days, accompanied by 1+ of:
Evanescent (nonfixed) erythamtous rash
Generalized lymph node enlargement
Hepatomegaly, or splenomegaly, or both
Serositis (pericarditis, pleuritis, or peritonitis)
14 yo girl with scoliosis. Measurements of Cobb angle = 50 degrees. What is management of choice?
a. spinal fusion
b. electrical muscular stimulation
c. molded brace
spinal fusion
14 yr old who hasn’t been to see you in 2 yrs. She has scoliosis with Cobb angle of 50 degrees. What is the most appropriate management?
a. observe
b. refer for brace/ orthosis
c. refer for posterior spinal fusion
d. electrical muscle stimulation
refer for post spine fusion
. 4 yr old boy with fever of 40 degrees despite amoxcil. Maculopapular rash, bilateral conjunctivitis,dry cracked lips. What is the most likely lab finding?
a. hypoalbuminemia
b. neutropenia
c. EBV monospot +
d. + ASOT
hypoalbuminia
5 yo with fever 40 degress x 6days, bilateral conjunctivitis, cervical lymphadenopathy, cracked lips. Has not responded to 3 days of amoxicillin. What finding is most consistent with this diagnosis?
a. Hypoalbuminemia
b. neutropenia
c. positive ASOT
d. positive monospot
hypoalbuminmia
Kid with >=6 day of fever, non purulent conjuctiviits, MP rash. Clinical picture c/w Kawaski’s dx. Most likely lab abnormality?
a. Low albumin
b. Neutropenia
c. Monospot +
d. Positive ASOT
low albuminia
14 yr old with fevers, polyarthralgia, wt loss. Appears pale. No arthritis on exam. Urine + for protein and blood. Decreased WBC and lymphs. Normal platelets. What is the most likely diagnosis.
a. SLE
b. Systemic JIA
sle
Child with wt loss anemia, normal plts, low WBC, protein/blood in urine. Dx?
a. SLE
b. RF
c. PSGN
SLE
6 days post scoliosis surgery. Presents with bilious vx. Etiology?
a. SMA
b. Small bowel adhesions
c. Pancreatitis
SMA
Boy with proximal muscle weakness, difficulty climbing stairs, easily fatiguable and scaly rash on dorsum of hands. What is the diagnosis:
a. JIA
b. SLE
c. JDM
d. Myesthenia gravis
JDM Classic rash Heliotrope rash of eyelids Gottron papules Plus 3 of the following: Weakness (symmetric, proximal) Muscle enzyme elevation (1+ of CPK, AST, LDH, aldolase) EMG changes (short small polyphasic motor unit potentials, fibrillations, positive sharp waves, insertional irritability) Muscle biopsy (necrosis, inflammation)
*Fever, dysphagia or dysphonia, arthritis, muscle tenderness and fatigue are also commonly reported at diagnosis
3 year old with refusal to walk for 3 days. Temp 38.1C, mildly tachycardic, very irritable when you examine right leg which is held in slight abduction and external rotation. Right hip has decreased ROM and he is in pain when you move his hip. He refuses to walk. Bloodwork shows ESR 48, CRP 20, WBC 14, normal Hgb and platelets. Most likely diagnosis:
a. transient synovitis
b. osteomyelitis
c. septic arthritis
d. Legg-Calve-Perthes disease
septic arhtritis
5 year old fever 38.5 degrees, had a recent URTI. Hip was externally rotated and child not weight-bearing. ESR was 40. Diagnosis?
a. transient synovitis
b. JIA
c. septic arthritis
septic arthritis
marked facial erythema pic ? dx
a. Drug hypersensitivity
b. Dermatomyositis
c. SLE
drug hypersensitivty
(Picture of a kid with a malar rash). Has fever, joint pain, diffuse rash. Only meds are fluticasone and phenytoin for a seizure disorder. What is the most likely?
a. drug hypersensitivity reaction
b. Juvenile dermatomyositis
c. Systemic lupus erythematosus
d. Juvenile idiopathic arthritis
drug hypersentivity
drug-induced lupus
Classically triggered by anticonvulsants, minocycline, hydralazine, anti-TNF
Tx is to stop drug and symptoms go away
- Patient with ankle injury. Can wt bear in er. Reason to x-ray?
a. swollen ankle
b. tenderness anterior to medial malleolus
c. tenderness posterior to lateral malleolus
d. inability to wt bear immediately after injury
c. tenderness posterior to lateral malleolus
A 10 year boy hurts his ankle while playing soccer. He is able to weight bear in the emergency with significant pain. Which of the following would make you more inclined to do an ankle x-ray?
a. Inability to weight bear immediately after the injury
b. Pain at the anterior edge of the lateral malleolus
c. Pain at the posterior edge of the medial malleolus
d. Swelling
pain at posteror edge of medial malleolos
8 year old girl tripped over a curb two weeks ago. She now complains of left leg pain. On exam the leg is cool and pale and she complains of pain even with light touch. Her X-ray is normal. What is the likely diagnosis?
a. Fracture
b. Conversion disorder
c. Reflex sympathetic dystrophy (now called complex regional pain syndrome)
reflex sympathetic dystrophy
AKA CPRS
Diagnosis requires the following:
An initiating noxious event or immobilization
Continued pain, allodynia and hyperalgesia out of proportion to the inciting event
Evidence of edema, skin blood flow abnormalities or sudomotor activity
Exclusion of other disorders
13 yo boy presents with intermittent and recurrent hip and heel pain. What is likely to be found on review of family history?
a. psoriasis
b. ankylosing spondylitis
c. SCFE
ankylosis spondylitis
ILAR Criteria for Enthesitis Related Arthritis
Arthritis and enthesitis
OR
Arthritis, or enthesitis and at least 2 of:
Presence or history of SI joint tenderness and/or inflammatory back pain
HLA B27 positive
Onset arthritis in male >6 years old
Acute (symptomatic) anterior uveitis
Hx ankylosing spondylitis, enthesitis-related arthritis, sacroiliitis with IBD or acute anterior uveitis in first degree family member
Exclusions: Presence of systemic JIA, psoriasis or hx of psoriasis in the patient or 1st degree relative, presence of IgM rheumatoid factor on at least 2 occasions
12 year old athletic girl complains of knee pain that she notices when walking down the stairs. On exam you note pain on palpation behind her patella. What is her most likely diagnosis
a. Osgoode Schlatter
b. Patella fracture
c. Patellofemoral syndrome
patellorfemoral syndrome
- Child with spiking fevers and evanescent pink rash, lymphadenopathy, hepatomegaly, splenomegaly, and MSK exam normal, for about 3 weeks Diagnosis.
a. Scarlet fever
b. Lyme disease
c. Systemic onset JIA
d. Leukemia
systemic onset JIA
A 2 year old boy with 2 days fever, now irritable, elevated inflammatory markers, and refusing to move right leg. Tender area over right tibia. Which of the following investigations will most likely make the diagnosis?
a. x ray tibia
b. x ray hip
c. bone scan
d. blood culture
bone scan
MRI is the imaging modality of choice when imaging other than plain radiography is needed to establish the diagnosis of osteomyelitis. We suggest scintigraphy (also known as radionuclide scanning or bone scan) when MRI is not available a
Teenager presents with left sided hip pain and decreased range of motion, and right sided heel pain; what question on family hx would most likely be positive?
a. Rheumatoid arthritis
b. Ankylosing spondylitis
c. Psoriasis
d. LCP disease
ankylosing spondylitis
Boy comes in to your office with left hip pain for 8 months, decreased and painful range of motion, with pain in the left heel. What disease is most likely in his family medical history:
a. rheumatoid arthritis
b. ankylosing spondylitis
c. psoriasis
d. inflammatory bowel disease
ankylosing spondylitis
Teen boy with pain to the right knee, above the joint. No effusion. No trauma. X-ray shows mottling in bone, and periosteal reaction. The likely diagnosis:
a. osteosarcoma
b. osteoid osteoma
c. osteochondroma
d. Ewings sarcoma
osteosarcoma
The classic radiographic appearance of osteosarcoma is the sunburst pattern, night awakening
ewing - primarily lytic bone lesion with periosteal reaction, the characteristic onion-skinnin
osteochondroma- stalks or broad-based projections from the surface of the bone,
osteoid osteoma oval metaphyseal or diaphyseal lucency (0.5-1.0 cm diameter) surrounded by sclerotic bone.
Child with 6 wk history of severe ankle pain. Unable to weight bear. Unable to do physiotherapy. The foot is swollen, red, and warm. What is the most likely cause? (1 or 2 depending on stem)
a. Reflex sympathetic dystrophy
b. Osteomyelitis
c. Manchaussen
reflex sympathetic dystrophy
A 3 yo child develops left hip pain following URTI. What is the best way to rule out osteomyelitis?
a. Lack of fever
b. Normal WBC
c. Negative blood culture
d. Bone scan
bone scan
12 yo girl with arthritis, some blood in the urine
diagnostic criteria
S - serositis O - oral ulcers A - arthritis P - photosensitivity B - blood disorders (leukopenia, thrombocytopenia, hemolytic anemia) R - renal (proteinuria, cellular casts) A - ANA I - immunologic (antibodies - ENA) N - neuro (sz, psychosis) M - malar rash D - discoid rash
What is the position of the septic hip in a patient with septic arthritis?
a. Abducted and internally rotated
b. Abducted and externally rotated
c. Adducted and internally rotated
d. Adducted and externally rotated
Abducted and externally rotated
2 year old has fever of 40 degrees and is irritable. He refuses to move his left hip. What is the first thing you do?
a. Aspirate the left hip with needle
b. X-ray
c. Bone scan
d. Admit, do blood culture and start antibiotics
xray FIRST
aspirate most important
10yo Lebanese girl with recurrent self limited abdominal pain and fever for one day. During an episode you do some labs and find increased ESR (60-80 range), AST and ALT slightly elevated, increased CRP and decreased albumin. What is a likely diagnosis?
a. Paroxysmal nocturnal hemoglobinuria
b. Familial Mediterranean fever
c. SLE
d. Cyclic neutropenia
FMF
The hallmark cutaneous finding is an erysipeloid erythematous rash that overlies the ankle or foot dosrum
Best determinant of scoliosis on physical exam
a. Leg length discrepancy
b. Asymmetric shoulder height
c. Asymmetric rib cage on bending over
asx shoulder height
Kawasaki disease and parents refuse treatment with IVIG. Which of the following is an acceptable alternative treatment?
a. ASA
b. ASA + steroids
c. ASA + cyclophosphamide
d. Steroids alone
ASA and steroid
ASA - IVIG with aspirin is more effective than aspirin alone in decreasing the risk of CA aneurysms (UTD)
2 year old M with intoeing present since walking 1 year ago and not improving. On exam the big toe is deviated medially, tibial torsion and mild metatarsus adductus on both sides. What to do?
a. Reassurance/observation
b. Refer to Ortho for for special shoes
c. X-rays
reassruance
If tibial torsion will correct by age 8
Child has a history of recurrent fevers, evanescent pink rash, lymphadenopathy, hepatomegaly. His musculoskeletal exam is normal. What’s the diagnosis?
a. Leukemia
b. Scarlet fever
c. Lyme disease
d. Systemic JIA
systemic JIA Systemic JIA diagnostic criteria: Arthritis in >/=1 joint with or preceded by fever x 2 week duration, that is daily (quotidian) for at least 3 days PLUS >/= 1 of the following: Evanescent erythematous rash Generalized lymphadenopathy Hepatomegaly, splenomegaly or HSM Serositis Initial symptoms [of arthritis] may be subtle or acute, and often include morning stiffness with a limp or gelling after inactivity
10 yo female with 3 weeks of antalgic gait. On exam she has decreased internal rotation and pain. There is an XR of a hip. (we think it showed scfe but it was VERY ambiguous with no other side to compare it too – but ? SCFE). What is your initial management?
a. NSAIDS
b. nail it
c. cast it
d. arthrocentesis
nail it
The classic patient presenting with a SCFE is an obese, African-American boy between the ages of 11 and 16 yr. Girls present earlier, usually between 10 and 14 yr of age. Patients with chronic and stable SCFEs tend to present after weeks to months of symptoms. Patients usually limp to some degree and have an externally rotated lower extremity. Physical examination of the affected hip reveals a restriction of internal rotation, abduction, and flexion.
28 week baby currently ventilated for severe RDS. Also has associated anomaly (picture of club foot). What to do:
a. Refer to ortho immediately for serial plastic (did not say plaster) casting
b. Refer to ortho once off ventilator
c. Refer to ortho at discharge
d. Refer to ortho at 3 months of age
Refer to ortho once off ventilator Talipes equinovarus (also known as clubfoot) describes a deformity involving malalignment of the calcaneotalar-navicular complex. Components of this deformity may be best understood using the mnemonic CAVE (cavus, adductus, varus, equinus).
2 y/o child with in-toeing. Father reports having had the same problem as a child for which he was fitted with immobilization boots. On exam, child has a searching toe, metatarsus adductus, and internal tibial torsion. What to do:
a. Observe
b. Discourage W sitting
c. Cast
d. Refer to ortho
obserev
. 3 y/o with mono arthritis for a few weeks. What is the most likely test result:
a. Positive RF
b. Positive ANA
c. Increased WBC
d. Increased ESR
e. Decreased Hgb
positive ANA
Elevated ANA titers are present in 40-85% of children with oligoarticular or polyarticular JIA but are rare with systemic onset JIA. ANA seropositivity is associated with increased risk of chronic uveitis in JIA.
14 yo girl with , pain above knee to palpation, radiograph shows lesion in the distal femur with periosteal elevation. What is the likely cause?
a. osteoid osteoma
b. ewing’s sarcoma
c. osteogenic sarcoma
d. aneurismal bone cyst
osteogenic sarcoma
Child presents to ER with fever, sore hip what do you do?
a. aspirate joint
b. Xray hip
c. order CBC
CBC
a. aspirate joint -? Yes but Ortho not us **if this was right, would need to do U/S first, consult ortho to drain
b. Xray hip -? x-ray doesn’t r/o septic arthritis
c. order CBC - part of the criteria to differentiate septic hip from transient synovitis
Kocher criteria to differentiate septic hip vs transient synovitis Non-weight-bearing on affected side Erythrocyte sedimentation rate > 40 Fever > 38.5 °C White blood cell count > 12,000
15yo with generalized malaise, violaceous rash on knuckles. You order?
a. CK
b. ANA
c. urinalysis
d. ESR
CK
Description of a child with Osgood Schlatter. What is the management?
a. temporary restriction of physical activities
b. ice
c. NSAIDs prn
d. when feeling better, do quad strengthening exercises
e. cylindrical casts for 3-4 wk
NSAID PRN
temporary restrict exercise
then quad exercise
9 to 14 years of age who have undergone a rapid growth spurt
-occurs most frequently in participants of sports that involve running, cutting, and jumping
-overuse injury caused by repetitive strain and chronic avulsion of the secondary ossification center (apophysis) of the tibial tubercle
-The most common presenting complaint is anterior knee pain that increases gradually over time, from a low-grade ache to pain that causes a limp and/or impairs activity
A 3mo old with tender swelling over the mandible bilaterally for one week, with fever and irritability. There is hyperostosis on x-ray. Diagnosis?
a. parotitis
b. osteomyelitis
c. hypervitaminosis A
d. Caffey’s disease
Caffey’s disease:
- Infantile cortical hyperostosis (Caffey disease, Caffey-Silverman disease) is characterized by fever (sometimes as high as 40°C [104ºF]), irritability, subperiosteal bone hyperplasia, and swelling of overlying soft tissues.
- The bone changes typically begin before six months of age and resolve by two years.
- Leukocytosis, elevated ESR, and elevated alkaline phosphatase are common laboratory findings.
What is correct about IVIG in Kawasaki disease?
a. decreases cytokine release
b. interacts with antibodies causing vasculitis
c. monthly IVIG regresses giant coronary artery aneurysm
decreases cytokine release
3yo girl well, has 3 weeks of right knee swelling, best initial treatment:
a. steroids
b. methotrexate
c. NSAIDS
nsaid
Which of the following is the best confirmatory test for juvenile dermatomyositis
a. EMG
b. CK
c. ANA
EMG
nerve conduction studies are typically normal, but this is part of the diagnostic
. 14y old with leg pain, radiograph shows lesion in the distal femur with sunburst appearance. What is the likely cause?
a. Osteoid osteoma
b. Ewing’s
c. Osteogenic sarcoma
d. Aneurismal bone cyst
osteogenic sarcoma
aggressive lesions
Poor definition
●Cortical destruction (“moth-eaten” or permeative pattern)
●Spiculated or interrupted periosteal reaction; however, the absence of these findings does not exclude an aggressive lesion [8]
●Extension into the soft tissue
●Large size
12y female with 2w hx of fever, arthralgia and myalgia. She is pale but otherwise looks well. She has blood and protein in the urine.WBC 18. Plat : normal
a. Acute rheumatic fever
b. Wegners granulomatosis
c. SLE
d. JIA
SLE
In a child with myopathy, which of the following could help distinguish dermatomyositis from duchenne’s MD?
a. Proximal muscle weakness
b. rash on face and knuckles
c. abnormal muscle enzymes
d. onset before age 5
e. more commonly affect girls than boys
. rash on face and knuckles
See above about JDM. Heliotrope and Gottron’s papules are characteristic of JDM.
DMD typically presents 2-3 years of age, JDM presents 5-10 years of age.
DMD is X-linked, JDM is more common in girls.
Which of the following statement is true about Kawasaki:
a. Coronary artery thrombosis is a rare complication
b. serologic tests are helpful
c. Iv gamma globulin increase the acute phase of illness
d. Initial manifestation of KS shares many similarities with scarlet fever
coronary artery thrombous nad scarlet fever
if it said coronary artery aneurysm that is not THAT rare, up to 25%; but thrombosis is definitely rare)
Dr. Schneider says thrombosis is rare especially when treated but can also have features in common with Scarlet fever.
4y old male adolescent is referred for evaluation because of pain and swelling below his right knee. He is very active in sports. PE: reveals point tenderness over the anterior tubercle of the right knee. Diagnosis :
a. Osgood schlatter disease
b. patellar tendonitis
c. tear of the collateral ligament
d. tear of the medial meniscus
osgoode schlatter
Which of the following statements is true about osteomyelitis in children?
a. the most common site is proximal humerus
b. most infections are cause by H.Flue
c. The epiphyseal growth plate limits the spread of metaphyseal infection
d. radiologic examination is useful to confirm a diagnosis
radiologic examination is useful to confirm a diagnosis
A 2 yo boy is brought in by mom not moving left arm. He’s holding it pronated. Mom admits she pulled on Left wrist during horseplay. Pt not cooperative with exam. Next test:
a. sling with xray
b. sling then orthopedics referral
c. orthopedics referral
d. skeletal survey
e. manipulate at elbow until arm function restored
e. manipulate at elbow until arm function restored
radial head sublux
Children with RHS may hold the affected arm close to the body with the elbow either fully extended or slightly flexed and the forearm pronated
2-year-old child with flexible flat feet. Father and aunt had the same abnormality. You suggest:
a. no intervention is necessary
b. must wear shoes all the time
c. needs orthotics
d. foot exercises
e. orthopedics referral
no internvetion necesary
An 8-year-old boy has a 6 month history of right hip pain. Hip x-ray shown = AVN
a. slipped capital femoral epiphysis
b. avascular necrosis of the capital femoral epiphysis
c. juvenile rheumatoid arthritis
d. hip dysplasia
avascular necrosis of the capital femoral epiphysis
What is true in this child. Hip x-ray shown = SCFE
a. sports-related trauma
b. more frequent in females
c. associated with steroid use
d. subsequent bone necrosis
subsequent bone necrosis
A child has been receiving IV Penicillin for meningococcemia for the past 7 days. He has now developed a warm swollen right knee. What should be done:
a. provide NSAIDs
b. add a second antibiotic
c. change to a different antibiotic
d. aspirate and culture
e. bone scan
d. aspirate and culture
Primary purulent arthritis caused by N. meningitidis is a rare event when compared with arthritis due to immune complexes. I
A 3-month-old child has had tender swelling over the mandible bilaterally for 1 week, along with fever and irritability. There is hyperostosis on x-ray. Most likely diagnosis: [REPEAT]
a. Caffey’s
b. parotitis
c. cherubism
d. osteomyelitis
e. hypervitaminosis A
caffey
A 12-year old female presents with a two-week history of fevers, arthralgias, and myalgias. She is pale but otherwise looks well. She has blood and protein in her urine. WBC 18. Platelets normal. [REPEAT]
a. acute rheumatic fever
b. Wegener’s granulomatosis
c. systemic lupus erythematosus
d. juvenile rheumatoid arthritis
systemic lupus erythematosus
Features of Kawasaki disease include all EXCEPT:
a. elevated WBC
b. ANA negative
c. platelet count 75
d. urine with 10-15 WBC/hpf
plt 75
this more consistent with MAS
Parents bring 3 year old for intoeing gait. You find tibial torsion and flexible metatarsus adductus. His father had a similar condition. Neurologic examination is normal. You advise:
a. stop W sitting
b. ortho referral for in shoe prosthesis
c. no treatment necessary as this invariably resolves
d. Dennis splint
e. x-ray of lower limbs
no treatment necessary as this invariably resolves
. In an adolescent with pain below the knee after running, the x-ray shows changes compatible with Osgoode-Schlater’s disease. All are done except:
a. Protective gear
b. Ice may be used to reduce swelling
c. Only stop activities which cause pain
d. Quadriceps strengthening exercises when pain resolves
e. Cast for 3-4 weeks
cast 3-4w
14 year old female presents with pain above the right knee which is worse at night and with activity. On exam there is no fever, but there is tenderness to palpation above the knee. X-ray shows periosteal elevation and mottling of the distal femur. The most likely diagnosis is:
a. osteomyelitis
b. osteosarcoma
c. osteoid osteoma
d. subperiosteal hematoma
osteosarcoma
Sunburst appearance
Mg’t of LCP - legg calge perthes
Legg-Calve-Perthes (LCP)
AVN of the hip that occurs in children between 3-12 years.
Peak incidence is 5-7y.
Bilateral in 10-20%
Male: Female 4:1
Present with limp of insidious onset and a trendelenburg gait.
Pain is mild and often referred to the anteromedial thigh or knee.
May have limited internal ROM and abduction of the hip
Treatment: non weight-bearing and referred to orthopedics
Caffey disease
age of onset
treatment
prognosis
5 months can have high alp - plt, anemia. pge
indomethacin, steroids
self resolve - if have fusion of ribs can have scoliosis
DOES NOT involve vertebrae and phalanges
