Rheum + Ortho Flashcards
Hip pain
2-6 yo
4-10 yo
10-14 yo
2-6 yo: transient synovitis
4-10 yo: legge calves perthe dz
10-14 yo: SCFE
Septic arthritis
- Cocher criteria
- Bugs
– Fever > 38
– Refusal to wt bear
– WBC > 12
– ESR > 40
Staph aureus
Strept
Meningococcus
Kingella
HLA B27 - assoc w?
Spondyloarthritis
Enthesitis JIA
Oligoarthritis
- how many
- joints
F>M Max 4 joints Asymmetric Large joints Knee>ankle, elbow
ANA +ve 80%
RF -ve always
Complications of oligoarthritis (6)
Uveitis Flexion contracture Muscle Wasting Leg length discrepancy TMJ joint dz Growth Discrepancy
Uveitis - most common in what type of arthritis \+ risk factors Usually asymptomatic When is it symptomatic complications
Oligo ANA + RF: < 6 yo at onset of JIA symptoms During first 4 years of diagnosis Negative RF girls
Sx’atic in enthesitis
Synechiae
Glaucoma
Cataract
Visual Loss
Polyarthritis - Tx
DMARD (Methotrexate)
with adjuncts NSAIDS
+/- jnt injections
Biologics (TNFa)
Enthesitis related arthritis
M»F
>6yo
Assym
Lower limb
Arthritis + Enthesitis Tarsitis Daktylitis Sakroiliitis Uveitis (acute)
IBD
HLA B27
Psoriatic arthritis
Arthritis + Psoriasis OR Arthritis + 2 of: - Nail pits - Dactylitis - FHx of psoriasis
Systemic JIA
- definition
- assoc w?
1) > two weeks spiking fever (daily, predictable)
2) Arthritis
3) + at least one of:
• Rash
• Lymphadenopathy
• HSmegaly
• Serositis
MAS
MAS
- causes
- clinical
- labs
Infection (EBV)
Malignancy
Meds
Rheum/autoinflamm
Persistant fevers HSmeg LAD hemorrhagic skin rash CNS dysfunction
Cytopenias High Ferritin High lipids Low Fibrinogen High D-Dimers Low ESR High CRP Transaminitis
Systemic JIA - tx
NSAID (if mild)
Prednisone (more severe or persistent mild)
If dependent: Biologic (IL1 and IL6)
Acute Rheumatic fever
- diagnostic criteria
Dx = recent GAS + 2 MAJOR
or 1 MAJOR and 2 MINOR
MAJOR Joint - arthritis, migratory Carditis Nodules, subcut Erythema marginatum Sydenhams chorea
MINOR Fever Arthralgia Incr CRP/ESR ECG change - prol. PR
Acute rheumatic fever
- treatment
- prophylaxis
Penicillin x 10 days
(or IM benzathine x1)
ASA/NSAIDs for arthritis
ASA/Steroids for carditis
Prophylaxis with Penicillin (or IM benzathine)
w/o carditis: up to 21 years or 5 years post
w/ carditis: up to 21 years or 10 years post
residual heart dz: up to 40 yo
Arthritis definition
Joint swelling/effusion \+ 2 of: limited ROM tenderness/pain w motion incr heat
Familial Mediterranean Fever
Short duration < 72hr
Irregular
Hallmark = Erysipeloid erythematous rash
Serositis
Abdo pain
Complications: Amyloidosis
Tx: Colchicine
PFAPA
- features
- treatment
Periodic Fever, Aphtous stomatitis, Pharingitis, Adenitis
Start < 5yo Regularly recurring fevers 3-6 days URTI sx – Aphthous stomatitis – Cervical lymphadenopathy – Pharyngitis WELL BETWEEN
Exclusion of cyclic neutropenia
Treatment
Supportive
Steroids - one dose at start
SLE
F»M
4/11 (4 skin, 4 organ, 3 lab) Malar rash Discoid rash Photosensitivity Oral/nasal ulcers
Arthritis
Serositis (Pleuritis/Pericarditis)
Neurologic dz (seizures, psychosis)
Nephritis
+ ANA
Cytopenias (anemia is hemolytic)
Immunologic D/O (Abs)
Abs:
+ANA
+Anti dsDNA
+Anti Sm
False + RPR
Ro, La
Low complement
SLE
marker:
most sensitive
most specific
sensitive: ANA
Specific: DNA
Neonatal lupus
Congenital heart block
Cutaneous
Liver dz - hepatitis
Cytopenia (thrombocytopenia > anemia/neutropenia)
CNS abnormalities
Mother: anti Ro and La
Erythema nodosum
NO cause (idiopathic) Drugs OCP Sarcoidosis UC/Crohn's or Bechets Micro: GAS, TB
Also:
SLE
Dermatomyositis
- features
- investigations (spell it out)
- Symmetric prox. muscle weakness
- Cutaneous changes – heliotrope (eyelids) or Gottron’s papules
- Elevated muscle enzymes (CK, AST, LDH, aldolase)
Dysphonia, Dysphagia, Dyspnea
Abnormal EMG - electromyograph
Muscle biopsy
Henoch Scholein Purpura
dx
bx
complications
- palpable purpura
- arthritis
- abdominal pain
- kidney involvement
IgA nephropathy, renal failure <5%
edema, orchitis
Dx:
clinical if above
or bx:
leukocytoclastic vasculitis w IgA deposition
Kawasaki Disease
Dx
Other features
5 days fever + 4/5:
- rash polymorphous
- nonsuppurative conjunctivitis
- oral mucosal inflammation
- cerv. LAD
- swelling/erythema of hands/feet
Other • Peeling in the perineal area (acute phase) • Aseptic meningitis • Arthritis • Anterior uveitis in up to 80% • Hydrops of the gallbladder • Sterile pyuria • Lung involvement • Diarrhea in approx 25% • Gamma-GT elevation
Kawasaki Disease
Labs
neutrophilic leukocytosis thrombocytosis initially anemia elevated transaminases decreased albumin sterile pyuria elevated ESR/CRP
Causes of rectal prolapse
Ehlers Danlos Cystic fibrosis Idiopathic Chronic constipation \+++ Coughing (Pertussis)
Ehlers Danlos
rectal prolapse, mitral valve prolapse and joint hyperextensibility
HSP - what to monitor after
U/A and BP for one year
Erythema nodosum
- ddx
IBD Sarcoidosis GAS OCP Tuberculosis
JIA - how often to screen w ophthalmo
Oligo ana+ <6: q3 months
>6: q6 months
?? need to recheck
MAS tx
high dose steroids IVIG Cyclosporin Etoposide ATG IL-1 inhibition
Renal complications of SLE
Htn Proteinuria Hematuria Edema Nephrotic syndrome Renal failure
SCFE
- location of pain
- age
- RF
- inner medial thigh or knee
- age > 10yo
RF
- male
- obese
- African American
- renal failure
- endocrinopathies
- hx radiation therapy
SCFE
- investigations
- tx
XRAY - AP, lat, frog leg
Call Ortho STAT
Surgery - per cut. fixation
Perthes
- presentation
- tx
AVN
males age 4-8
limp, decr. ROM, hyperactive
restrict activities
maintain ROM
antiinflamm
physio
DDH
- presentation
- RF
painless limp (painful in adolescence if missed)
RF: - 1st born - female - FHx - Frank breech - Postnatal position - Laplanders Native - Syndrme
DDH
- best screening
- investigations
- Treatment
Serial P/E
Dynamic U/s
Xray - AP and frog leg
Early - Pavlik harness
Late - Surgical intervention
Urgent causes of limp
- Septic arthritis hip
- SCFE
- Osteomyelitis
- Discitis
- Fracture
- Neoplasia
Osteosarcoma
metaphysis
sunburst appearance
periosteal elevation
Femur>Tibia>humerus
mets: lung, bone
tx: chemo, surgery
Ewing Sarcoma
diaphysis
onion skinning
periosteal elevation
Femur>Tibia>fibula, humerus
mets: lung, bone, BM
whom, surgery +/- RT
Toddler’s fracture
oblique # distal tibia
minor injury
age 1-5
cast leg
repeat ray in 10-14 days
Osgood Slatter
overuse syndrome
apophysitis of tibial tuberosity
(patellar tendon)
tender and prominent tub tuberosity
symptomatic treatment with NSAID, rest and activity modification, PT, protective gear!
Sever’s Disease
overuse syndrome
apophysitis of achilles tendon
symptomatic treatment with NSAID, rest and activity modification, PT
Patello Femoral Syndrome
overuse syndrome
dull/aching under patella/peripatellar region
Scoliosis
- dx
- best clinical findings
- who to refer
Angle > 10 degrees
Adams test
- Atypical curves (left sided)
- Skeletally immature, curve ≥ 20 at presentation
- Skeletally immature, progressive curve
- Rapid progression / pain
- Skeletally mature, curve > 45
club feet
Talipes Equinovarus
Complex, congenital, contractural malalignment of the bones and joints of the foot and ankle
Deformity • Cavus • Adductus • Varus • Equinus
Treatment
• Ponsetti Method
Intoeing by age
Infant – metatarsus adductus
Foot
Toddler – internal tibial torsion
Leg
Child / Adolescent – increased femoral anteversion (internal hip rotation)
Hip
Spondylolysis
Gymnastics (repeated back extension)
L5
rest 4-6weeks minimum until pain free
then brace on return
Achondroplasia - assoo w ?
spinal stenosis - small foramen magnum
spinal cord compression can occur at the foramen magnum and in the lumbar spine in adulthood
metaphyseal shortening
fractures high suspicion for child abuse
metaphyseal corner lesions posterior rib fracture scapular fracture sternal fracture spinous process fracture first rib fracture
Nursemaid’s elbow
what is it
treatment
Radial head subluxation
supinate extended arm and then flexion (audible/palpable click)
Reiter syndrome
= reactive arthritis
→ classic triad of conjunctivitis (bilateral purulent), urethritis, and arthritis after infection
(particularly those in the urogenital or GI tract);
→ boys»_space; girls;
→ symptoms worse if HLA-B27 positive;
→ present a few days to 6 weeks after initial infection
Kawasaki Dz
tx w dose
IVIG 2g/kg IV now
ASA 80mg/kg daily PO until afebrile for 48 hours
2 renal complications of SLE
- nephritis (hematuria, proteinuria)
- hypertension
Behcet disease
Recurrent oral and genital ulcers
arthritis
skin rash
Time frames for diagnosing and categorizing JIA
Dx JIA at 6 weeks
Can’t say oligo until 6 months
Oligo
- treatment
NSAIDS
+/- jnt injections
DMARD (Methotrexate)
Biologics (TNFa)
Management of JIA
Meds PT OT SW Psychology
What are the muscle enzymes to test for in dermatomyositis?
CK, AST, LDH, aldolase
scleroderma
- treatment
High dose steroids and MTX
Physiotherapy
HSP
- dx
Purpura or petechiae w lower limp predominance
Plus one of:
1) Diffuse abdominal colicky pain with acute onset (may include intussusceptions and gastrointestinal bleeding)
2) Skin biopsy showing leukocytoclastic vasculitis with predominant IgA deposits, or kidney biopsy showing proliferative glomerulonephritis with predominant IgA deposits
3) Arthritis or arthralgias of acute onset
4) Renal involvement (proteinuria >0.3 g in 24 hrs, hematuria, or red blood cell casts, impaired renal function)
Treatment of HSP
- Largely supportive
- NSAIDs may be used for joint pain (caution required due to potential renal involvement)
- Prednisone in select patients
(severe sx - GI or renal)
How long after HSP do you need to monitor closely
6 months
cANCA
Granulomatosis with Polyangiitis
Sarcoidosis
- skin rash - papular
- uveitis
- arthritis
Ectopis lentis
- upwards
- downwards
Upward = marfans Down = homocystinuria
Marfans
- features
Aortic root dilation Ectopia lentis (upwards)
How to treat uveitis
- acute
- chronic
- acute: topical steroids
- chronic: MTX
biologics/PO steroids as a second line or if posterior uveitis
Club foot
- medical name
- treatment
Congenital Talipes Equinovarus (clubfoot)
Tx ASAP after birth with ponseti casting followed by bracing +/-tenotomy of achilles tendon
Rickets findings
frontal bossing craniotabes delayed suture and fontanelle closure defective tooth enamel rachitic rosary (enlarged costochondral junctions) Harrison groove (rim of rib indentation at insertion of diaphram pectus carinatum widened physes of wrists and ankles bowing of the legs (femoral and tibial)
