Rheum/Ortho SAQ Flashcards
1
Q
- 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.
A
A.
- Infant:
- limited hip abduction
- Asymmetric gluteal or thigh folds
- Walking child
- limp with toe-walking on affected side
- leg-length discrepancy
- excessive lordosis
B.
- Positive Barlow/Ortolani (most SN before 4-6mo)
- Decreased hip abduction (most SN after 4-6mo)
- Positive Galeazzi sign (apparent shortening of thigh)
2
Q
- Photo of gottron’s papules and heliotrope rash. Child has recent difficulty walking up the stairs.
A. What is the diagnosis (1)
B. What are two investigations required for diagnosis (2)
A
A. Juvenile dermatomyositis
B.
- EMG
- Muscle biopsy
Clinical criteria for JDM
- Classic rash
- Heliotrope
- Gottron papules
- Photosensitivity - shawl sign
- Mechanic hands
- AND 3 of
- Proximal symmetric weakness (stairs, hair, Gower)
- Elevated muscle enzymes (>=1): CK, AST, LDH, aldolase
- EMG changes (denervation + myopathy)
- Muscle Bx: inflammation, necrosis
3
Q
- 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.
b) Name 3 other manifestations of neonatal lupus.
A
a) Anti-Ro (SSA), anti La (SSB)
b)
- Cytopenias
- Hepatitis
- Rash (annular or macular on face, trunk, scalp)
4
Q
- A 12 year old girl comes into your office with her mother. She has thoracic scoliosis (this was bolded on the real exam) and her mother is interested in surgical interventions.
Name 4 indications for surgical management.
A
- If skeletally immature and cobb’s angle >45
- If skeletally mature and cobb’s angle >50
- If having symptoms or signs of restrictive lung disease
- If fails to improve or progressive despite bracing
- Limiting activities, causing significant pain
5
Q
- 4 yo girl diagnosed with JIA.
A. Which type of JIA is most associated with uveitis?
B. What blood test would we do to see if a patient is at increased risk?
C. How often do we screen these patients with an eye appointment?
A
A. Oligoarthritis
B. ANA positive
C. Q3mo
- ANA pos
- If <6yo:
- <4y of disease duration, then Q3mo
- >4y of disease, then Q6mo
- >7y of disease, then Q12mo
- If >6yo:
- <4y of disease duration, then Q6mo
- >4y of disease duration, then Q12mo
- If <6yo:
- ANA neg
- Q6mo if <6yo and <4Y disease duration
- Q12mo if <6yo and >4Y disease duration OR >6yo
6
Q
- 15 yo gymnast with hyperlordosis and insidious back pain.
A. Name the condition
B. What investigation
C. 2 management steps for this child.
A
A. Spondylolysis
B. AP+Lateral spine Xray (If pain persistent, abN Xray, red flags: MRI or SPECT bone scan)
C. Mgmt
- Activity modification. Avoid acitivities leading to pain with exension.
- PT for core strengthening + stretching of hip flexors + hamstrings
- Nonnarcotic analgesics
7
Q
- Description of teenage girl with MAS.
A. 2 noninfectious acquired causes
B. Name 3 management
A
A.
- SLE
- systemic JIA
B.
- High dose methylprednisone
- Anakinra
- Cyclosporin
- Supportive management
8
Q
- Name 5 risk factors for DDH
A
- FHx!
- First born
- Female
- Breech (regardless of delivery method)
- left hip
- Oligohydramnios
9
Q
- 4 years old girl with sudden onset of inability to turn head to one side; no history of trauma; name 5 causes (5 causes of acquired torticollis)
A
- Retropharyngeal abscess
- Lemierre syndrome = IJV thrombophlebitis, fusobacterium
- Inflammation of SCM (viral myositis)
- Atlantoaxial rotary subluxation
- Dystonic reaction
- Benign paroxysmal torticollis
- CNS tumour
- Cervical spine injury
10
Q
- Name 3 major criteria for skeletal manifestations of Marfans.
A
- Arachnodactyly
- Scoliosis
- Protrusion acetabuli
- Pes planus
- Pectus excavatum or carinatum
- Reduced elbow extension
- Hindfoot deformity
11
Q
- Kid with rheum condition (JIA or SLE). Then develops pancytopenia, heptosplenomegaly and is unwell. Associated condition.
A
MAS
12
Q
- Picture seen below (foot). State what is the most likely associated diagnosis.
A
Rocker bottom foot
T18
Eighteen = Edward
- E - elongated skull
- D - digits overlapping (clenched fist)
- W - Wide spread nipples, VSD
- A - apnea (cause of death)
- R - rocker bottom feet
- D - dysplastic ears
13
Q
- Babe with clubfoot - name ONE part of the treatment. (1 point)
A
- Ponseti method to correct deformities in order:
- Forefoot Cavus
- Midfoot Adductus
- Heel Varus
- Hindfoot Equinus
- Tenotomy of heel cord 3. Bracing
14
Q
- An 8 year old boy is referred to you for persistent hip and knee pain for 2 months duration. No history of trauma. Walks into office with an antalgic gait. You note decreased abduction and internal rotation on exam. Xray done (picture showed left hip with small femoral head, scalloped edges). Diagnosis?
A
Legg-Calve-Perthes
15
Q
- A 3 year old child comes into emergency. Mom says not using the right arm. There is no history of falls or trauma. The child is holding the arm slightly flexed and pronated. Refusing to move the arm.
A. What is the likely diagnosis?
B. How do you manage?
A
A. Radial head subluxation
- Pulled elbow or nursemaid’s elbow (e.g. holding kid and swinging between parents)
- most common 1-4yo
- Annular ligament interposed between radial head + capitellum
B. Closed reduction
- Supination technique: use thumb to apply pressure over radial head, maximally flex supinated elbow. Often hear palpable click with reduction of radial head
- Hyperpronation technique: hyperpronate forearm in flexed position
- Ensure no fracture before doing this
- Should be able to move arm within minutes after
16
Q
- Description of a young girl with weakness, clumsy. Has a rash on her body and over her hands and knuckles. Mom concerned. Likely diagnosis?
A
Juvenille dermatomyositis
17
Q
- Baby fell off change table and not using arm. Xray with corner fracture? What is diagnosis?
A
Non-accidental injury b/c metaphyseal corner fracture (bucket handle fracture)
Fractures suggestive of inflicted injury
- Femur # in nonambulatory children
- Distal femoral metaphyseal corner #
- Posterior rib #s
- Scapular spinous process #s
- Proximal humeral #s
18
Q
- What are four diagnostic criteria for JDM?
A
- Classic rash
- Heliotrope
- Gottron papule
- Photosensitivity - Shawl sign
- Mechanics hands
- Weakness: symmetric, proximal
- Elevated muscle enzyme (CK, AST, LDH, aldolase)
- EMG changes (myopathy, denervation)
- Muscle Bx (necrosis, inflammation)
19
Q
- Picture of a child with purpuric lesions on the lower limbs.
A. What is the diagnosis?
B. What long-term complication would you monitor for?
A
A. HSP
- Skin: Palpable purpura
- GI: abdo pain, bloddy diarrhea
- Renal: proteinuria, hematuria, red cell casts
- MSK: arthritis or arthralgia
B. Renal disease
- can range from microscopic hematuria to severe, progressive glomerulonephritis
- Monitor Sx, BP, U/A for 6-12mo after diagnosis
20
Q
- Picture of a girl with a butterfly rash. This 15 year old girl presents with hypertension.
A. What do you think the diagnosis is?
B. What are two other renal complications of this disease?
A
A. Lupus nephritis
B. Microscopic hematuria, proteinuria
21
Q
- Young girl presenting with pain and widening of the wrist and bowing of the legs:
a) What is the diagnosis?
b) What are 3 physical findings on exam
A
A. Rickets
B.
- Craniotabes
- Frontal bossing
- Rachitic rosary
- Harrison groove
- Anterior bowing of tibia + femur
- Enlarged wrists + ankles
- Hypocalcemia: 1) tetany, 2) sz, 3) stridor from laryngospasm
22
Q
- Name 4 causes of persistent toe walking.
A
- CP
- DMD
- Tight heelcords
- Spinal dysraphism
- DDH
- Autism Spectrum Disorder
23
Q
- Child with monoarticular JRA involving one knee. List 3 long-term orthopedic complications of arthritis.
A
- Leg length discrepancy
- Flexion contractures
- Popiteal cysts
- Thigh muscle wasting
24
Q
- Give 2 differential diagnoses LCH for congenital torticollis other than sternocleidomastoid tumor
A
- Congenital muscular torticollis (if it doesn’t say SCM mass in the question)
- Pterygium colli
- Unilateral absence of SCM
- Vertebral anomalies
- Klippel-Feil syndrome
25
Q
- Child with SLE presenting with hypertensive encephalopathy – list 3 medications and routes of administration
A
- Labetolol IV
- Hydralazine IV
- Nifedipine PO
- Amlodipine PO
26
Q
- List the diagnostic features of Kawasaki disease (6 lines)
A
- Fever for >=5d
- Conjunctivitis - bilateral, nonsuppurative
- Rash
- Edema
- Adenopathy (>1.5cm, cervical)
- Mucous membrane (dry cracked lips, strawberry tongue)
27
Q
- Young boy (?6 yo) with history of four weeks of decreased energy. He has recently started to complain about leg pain. On exam, you find bilateral tenderness over his proximal tibia. There is no erythema and no warmth? What are two diseases that could cause this (2)?
A
- Leukemia
- Osteomyelitis
- Lymphoma
- Langerhans cell histiocytosis
- Tibial stress fractures
28
Q
- Young girl who has flat feet. Mum is concerned. When she stands the feet are flat and you note that they are valgus and that her forefoot is abducted. When she sits down with her feet in the air, her arches look normal. What is her diagnosis (1)? What kind of intervention is needed for her (1)?
A
A. Hypermobile pes planus
B. Nothing if she is asymptomatic
- May not have fully developed arches yet (common for flat feet <6yo)
29
Q
- 14 year old boy presents with groin discomfort. X-ray shown shows femoral neck and femoral head not aligned in the middle
A. What is your diagnosis?
B. What are two steps in management?
C. What are two risk factors for this disease?
A
A. SCFE
B.
- Admit and bed rest
- Pin it
C.
- Obesity
- Endocrinopathy
30
Q
- Child not using arm after playing with older brother.
A. What is the diagnosis (be specific)?
B. What do you do to correct the problem?
A
A. Radial head subluxation
B.
- Supination technique
- Hyperpronation technique
31
Q
- Child with monoarthritis. Name 3 medications from different classes of medications that are used for treatment.
A
- NSAIDs
- Intraarticular corticosteroids
- DMARD (MTX)
- Biologics (infliximab)
32
Q
- Boy had recent illness - fx, dx, conjunctivitis, urethritis now with sacroiliitis. You diagnose him with Reiter syndrome. List 4 organisms
A
Reiter = reactive arthritis
- Can’t see, can’t pee, can’t climb a tree
- 1) Conjunctivitis, 2) urethritis, 3) postinfectious arthritis
- Chlamydia
- Salmonella
- Shigella
- Yersinia
- Campylobacter
- C diff
33
Q
- What are 2 surgical complications of HSP.
A
- Intussusception
- Intestinal perforation
- Bowel ischemia/infarction
Other complications
- GI hemorrhage
- Pancreatitis
- Protein losing enteropathy
- Bowel obstruction/ileus
