Rheumatology Flashcards
1
Q
This is a chronic, slowly progressive, erosive damage to joint surfaces; this loss of articular cartilage causes increasing pain with minimal or absent inflammation
A
Osteoarthritis
2
Q
This is the more commonly affected joint in the hand in Osteoarthritis
A
Distal interphalangeal (DIP) joints
3
Q
DIP enlargement
A
Heberden nodes
4
Q
PIP enlargement
A
Bouchard nodes
5
Q
What is the most accurate test for Osteoarthritis?
A
X-Ray of the affected joint
6
Q
What would you see in an X-Ray of the affected joint in Osteoarthritis?
A
Joint space narrowing
Osteophytes
Dense subchondral bone
Bone cysts
7
Q
What are your treatment options for Osteoarthritis?
A
- Weight loss and moderate exercise
- Acetaminophen - best initial analgesic
- NSAIDS - if symptoms are not controlled with acetaminophen
- Capsaican cream
- Intraarticular sterods - if other medical therapy does not control pain
- Hyaluronan injection in joint
- Joint replacement if function is compromised
8
Q
What is the etiology of Gouty arthritis?
A
defect in urate metabolism with 90% of cases in men. This can be from overproduction or underexcretion
9
Q
Patient comes in with sudden, excruciating pain, redness, and tenderness of the big toe at night after binge drinking with beer. Temperature is 38C. What is the most likely diagnosis?
A
Gouty Arthritis
10
Q
What is the frequently affected site in Gouty Arthritis?
A
Metatarsal phalangeal (MTP) joint of the great toe
11
Q
This are tissue deposits of urate crystals with foreign body reaction. MOst oftehn it occurs in cartilage, subcutaneous tissues, bone, and kidney. They often take years to develop.
A
Tophi
12
Q
This is the most accurate test for Gouty Arthritis?
A
Aspiration of the joint showing needle-shaped crystals with negative birefringence on polarized light microscopy
White cells count would be 2000 to 50,000/ul and are predominantly neutrophils
13
Q
What would you expect in the lab result of an acute attack of Gouty Arthritis?
A
Elevated ESR and Leukocytosis
14
Q
What would you give for an acute attack of Gout?
A
- NSAIDS (Ibuprofen)
- Corticosteroids if no response to NSAIDS and if there is renal insufficiency
- Colchicine is used in those who cannot use either NSAIDS or steroids
15
Q
Give adverse effects of Colchicine
A
Diarrhea and bone marrow (neutropenia)
16
Q
What us your drug of choice for hypertension in patients with Gouty Arthritis?
A
Losartan
17
Q
What drugs should you stop if patient has gouty arthritis?
A
Thiazides, Aspirin, Niacin
18
Q
This drug decreases production of uric acid
A
Allopurinol
19
Q
This is a xanthine oxidase inhibitor that is used of allopurinol is contraindicated.
A
Febuxostat
20
Q
This drug dissolves uric acid by accelerating uric acid metabolism.
A
Pegloticase
21
Q
These drugs increase the excretion of uric acid in the kidney (uricosuric). They are contraindicated in renal insufficiency.
A
Probenecid and Sulfinpyrazone
22
Q
What is the adverse effect of Allopurinol?
A
Toxic epidermal necrolysis or Stevens-Johnson syndrome
23
Q
This disease arise from calcium-containing salts deposit6ing in the articular cartilage. It is associated with diabetes, hypothyroidism, and Wilson disease.
A
Calcium Pyrophosphate Deposition Disease or ‘Pseudogout’
24
Q
Give 2 risk factors for CPPD
A
Hemochromatosis
Hyperparathyroidism
25
How does CPPD diiffer from gout and osteoarthritis in terms of presentation?
Knee and Wrist are affected but not particulary first MCP of foot; the DIP and PIP are not affected
26
What is the most accurate test for CPPD?
Arthrocentesis
27
What will you see in the synovial fluid analysis in CPPD?
2,000-50,000 WBCs, positively birefringent rhomboids
28
What is the best initial therapy for CPPD?
NSAIDS
29
Where does disk herniations usually occur?
L4/5 and L5/S1 level account for 95% of all disk herniations.
30
Give the motor deficit, reflex affected, and sensory area affected if the herniation involves the L4 nerve root?
Dorsiflexion of foot
Knee jerk
Inner calf
31
Give the motor deficit, reflex affected, and sensory area affected if the herniation involves the L5 nerve root?
Dorsiflexion of toe
None
Inner forefoot
32
Give the motor deficit, reflex affected, and sensory area affected if the herniation involves the S1 nerve root?
Eversion of foot
Ankle jerk
Outer foot
33
What is the most accurate test for Disk Herniation?
MRI
34
What is the treatment for cord compression?
Systemic Glucocorticoids
Chemotherapy for Lymphoma
Radiation for many solid tumors
Surgical decompression if steroids and radiation are not effective
35
What are your treatment options for Epidural abscess?
Steroids - to control acute neurological deficit
| Vancomycin or Linezolid until the sensitivity of the organism is known
36
What is the treatment for Cauda equina syndrome?
Surgical decompression
37
What is the treatment for disk herniation?
NSAIDs with CONTINUATION of ordinary activities (bed rest is wrong answer)
38
A man with a history of prostate cancer comes to the emergency department with severe back pain and leg weakness. He has tenderness of the spine, hyperreflexia, and decreased sensation below his umbilicus.
What is the most appropriate next step in the management of this patient?
a. Dexamethasone
b. MRI
c. X-ray
d. Radiation
e. Flutamide
f. Ketoconazole
g. Finasteride
h. Leuprolide
i. Biopsy
j. Orchiectomy
A. When there is obvious cord compression, the most important step is to begin steroids urgently in order to decrease the pressure on the cord.
39
Patient is over 60 years old with back pain while walking, radiating into the buttocks and thighs bilaterally. The pain is described as worse when walking downhill, and better when sitting, but the pedal pulses and ankle/brachial index are normal. Unsteady gait while walking also occur. What is the most likely diagnosis?
Lumbar Spinal Stenosis
40
What is the diagnostic test for Lumbar Spinal Stenosis?
MRI
41
What are the initial treatment for Lumbar Spinal Stenosis?
```
Weight Loss
Pain meds (NSAIDs, Opiates, Aspirin)
```
42
Patient is typically a young woman with chronic musculoskeletal pain and tenderness with trigger points of focal tenderness at the trapezius, medial fat pad of the knee, and lateral epicondyle. What is the most likely diagnosis?
Fibromyalgia
43
What is the best initial therapy for Fibromyalgia?
Dual Reuptake Inhibitors such as Duloxetine or Venlafaxine
Steroids are WRONG answer for Fibromyalgia
44
This is defined as a peripheral neuropathy from the compression of the median nerve as it passes under the flexor retinaculum.
Carpal Tunnel Syndrome
45
This is done to reproduce pain and tingling with tapping or percussion of the median nerve.
Tinel sign
46
This is done to reproduce symptoms of carpal tunnel with flexion of the wrists to 90 degrees
Phanel sign
47
What is/are the most accurate diagnostic test for Carpal Tunnel Syndrome?
Electromyography
| Nerve Conduction Testing
48
What is the best initial therapy for Carpal Tunnel Syndrome?
Wrist Splints
49
What are other treatment options for Carpal Tunnel Syndrome aside from wrist splints?
Steroid injection is used if splints and NSAIDs do not control symptoms
Surgery can be curative
50
This is the hyperplasia of the palmar fascia leading to nodule formation and contracture of the fourth and fifth fingers. There is a genetic predisposition and an association with alchoholism and cirrhosis.
Dupuytren Contracture
51
This treatment helps early Dupuytren contracture.
Collagenase injection
52
What is the most accurate test for rotator cuff injury?
MRI
53
This is an autoimmune disorder predominantly of the joints but with many systemic manifestations of chronic inflammation. This is more common in women.
Rheumatoid Arthritis
54
The is the key to the diagnosis of Rheumatoid Arthritis
morning stiffness of multiple small, inflamed joints.
55
What joint is spared in Rheumatoid Arthritis?
DIP
56
This syndrome is defined as dry eyes, mouth, and other mucous membranes
Sicca syndrome
57
What is the most common cause of death in Rheumatoid Arthritis?
Coronary Artery Disease
58
This is a syndrome with the triad of right atrium, splenomegaly, neutropenia
Felty syndrome
59
This is a syndrome with the triad of right atrium, pneumoconiosis, lung nodules
Caplan syndrome
60
How would you establish a diagnosis of Rheumatoid Arthritis?
A total of 6 or more points
```
Joint involvement (up to 5 points)
ESR or CRP (1 point)
Duration for longer than 6 weeks (1 point)
RF or anti-CCp (1 point)
```
61
What should you give to an erosive Rheumatoid Arthritis?
Methotrexate
62
What does erosive disease means in RA?
Joint space narrowing
Physical deformity of joints
X-ray abnormalities
63
A patient with long-standing RA is to have coronary bypass surgery. Which of the following is most important prior to surgery?
a. Cervical spine x-ray
b. Rheumatoid factor
c. Extra dose of methotrexate
d. ESR
e. Pneumococcal vaccination
A. RA is associated with C1/C2 subluxation. Cervical spine imaging to detect possible instability of the vertebra is essential prior to the hyperextension of the neck that typically occurs with endotracheal intubation.
64
What are the adverse effects of Methotrexate?
Liver toxicity
Bone marrow suppression
Pumonary toxicity
65
If patient with Rheumatoid arthritis is not responding to Methotrexate, what can you give him instead?
Tumor Necrosis Factor Inhibitors (Infliximab, Adalimumab, Etanercept, Golimumab, Certolizumab)
66
What is the toxicity of anti-TNF drugs?
Reactivation of TB: screen with a PPD prior to their use
| Infection
67
This is an agent that is originally developed for non-Hodgkin lymphoma, is effective in RA as a DMARD by removing CD20 positive lymphocytes from circulation. It is used in combination with methotrexate in those not responding to anti-TNF medications.
Rituximab
68
This agent can be used as a monotherapy as a DMARD in cases of mild disease in which to avoid toxicity of methotrexate.
Hydroxychloroquine
69
Hydroxychloroquine is toxic to the _________.
retina
70
These agents are alternative DMARDs to add to methotrexate if anti-TNF agents do not control disease.
Sulfasalazine
Leflunomide
Abatacept
Anakinra
71
GIve adverse effects of Sulfasalazine
Bone marrow toxicity
Hemolysis with G6PD
Rash
72
What are the best initial therapy for the pain of RA?
NSAIDs
73
What is/are adverse effect of Gold Salts in RA?
Nephrotic Syndrome
74
This patient is young, comes in with high, spiking fever that has no clearly identified etiology and is associated with salmon colored rash on chest and abdomen. What is the MOST LIKELY diagnsosis?
Juvenile Rheumatoid Arthritis or Adult Still Disease
75
What is markedly elevated in a patient with Juvenile Rheumatoid Arthritis?
Ferritin
76
What is your treatment strategy for Juvenile Rheumatoid Arthritis?
Aspirin/NSAIDs ---> Steroids (if no response) --> TNF drugs (if resistant to steroids)
77
Give 4 manifestations of SLE in the skin.
Malar rash
Discoid rash
Photosensitivity
Oral ulcers
78
This is a joint manifestation of SLE.
Arthritis (often the first symptom that brings patient to seek medical attention) SLE gives joint pain without deformation or erosion, that is why the x-ray is normal
79
This is the inflammation of the pleura and pericardium that gives chest pain potentially with both pericardial and pleural effusion associated with SLE?
Serositis
80
What is the most common glomerulonephritis in SLE?
Membranous Glomerulonephritis
81
These are ocular findings you may appreciate in a patient with SLE.
Photophobia
Retinal lesions (cotton wool spots)
Blindness
(Not part of formal diagnostic criteria)
82
This is a hematologic finding that is part of the diagnostic criteria of SLE.
Hemolytic anemia
however, Anemia of Chronic Disease is more commonly found
83
These are markers you will find in SLE.
ANA
Anti-double-stranded (DS) DNA and anti-Sm
Decreased complement levels
Anti-SSA and anti-SSB
84
A 34-year-old woman with a history of SLE is admitted with pneumonia and confusion. As you are wrestling with the decision over a bolus of high-dose steroids in a person with an infection, you need to determine if this is a flare of lupus, or simply an infection with sepsis causing confusion.
Which of the following will help you the most?
a. Rise in anti-Sm
b. Rise in ANA
c. Decrease in complement
d. Decrease in complement and rise in anti-DS DNA
e. MRI of the brain
f. Response to steroids
D. Although anti-SM is specific for SLE, the level does not change in an acute flare. ANA levels do not tell severity of disease. MRI of the brain is most often normal in lupus celebrities unless there has been a stroke. In an acute lupus flare, complement levels drop and anti-DS DNA levels rise. The SSA, SSB, and anti-SM tests are most useful when the ANA is positive and DS-DNA test is negative
85
How would you treat an acute lupus flare?
High-dose boluses of steroids
86
How would you determine the severity of lupus nephritis?
Kidney Biopsy
87
What is the most common cause of death for young patients with SLE?
Infection
88
What is the most common cause of death for older patients with SLE?
Accelerated atherosclerosis --> Myocardial Infarction
89
This is an idiopathic disorder with IgG or IgM antibodies made against negatively charged phospholipids.
Antiphospholipid syndrome
90
What are the two main types of Antiphospholipid Syndrome?
Lupus anticoagulant
| Anticardiolipin antibodies
91
How does Antiphospholipid Syndrome presents?
thromboses of both arteries and veins and recurrent spontaneous abortions
92
What is the best initial test for Antiphospholipid Syndrome??
Mixing study (patient's plasma is mixed with an equal amount of normal plasma)
93
What will you expect from the mixing study of Antiphospholipid Syndrome?
elevated aPTT
normal PT
normal INR
94
This is the most specific test for lupus anticoagulant.
Russell viper venom test (RVVT)
95
How would you treat clots in APL?
NOAC or heparin and warfarin
96
What should be investigated for anticardiolipin antibody as a cause of spontaneous abortion?
Two or more first-trimester events or a single second-trimester event
97
What is the treatment to prevent recurrence of spontaneous abortion in APL?
Heparin and Aspirin
98
What is another term for Limited Scleroderma?
CREST Syndrome
```
Calcinosis
Raynaud
Esophageal dysmotility
Sclerodactyly
Telangiectasia
```
99
Patient is a young woman (20-40s) with fibrosis of the skin and internal organs such as the lung, kidney, and GI tract. What is the MOST LIKELY diagnosis?
Scleroderma (Systemic Sclerosis)
100
What is the most specific test for Scleroderma?
SCL-70 (Anti-topoisomerase)
101
This antibodies are extremely specific for CREST syndrome.
Anticentromere antibodies
102
This drug can slow underlying process of limited scleroderma.
Methotrexate
103
What will you use for renal crisis in Limited Scleroderma?
ACE inhibitors
104
Limited scleroderma presents with GERD. What can you give the patient?
PPIs
105
What can you give for Raynaud phenomenon in Limited Scleroderma?
Calcium Channel blockers
106
What can you give for Pulmonary Fibrosis in Scleroderma?
Cyclophosphamide
107
Crest Syndrome + involvement of lungs, kidney, heart = __________
Scleroderma
108
This is an inflammatory myopathies that present with malar involvement, shawl sign, heliotrope rash, and gottron papules.
Dermatomyositis
109
This is an inflammatory myopathy that present as progressive proximal muscle weakness without the presence of rash.
Polymyositis
110
What is the best initial test for Polymyositis/Dermatomyositis?
CPK and Aldolase
111
What is the most accurate test for Polymyositis/Dermatomyositis?
Muscle Biopsy
112
What immunologic markers will you expect for Polymyositis/Dermatomyositis?
Positive ANA
| Anti-Jo antibodies (assoc. with lung fibrosis)
113
What are your treatment options for Polymyositis/Dermatomyositis?
Steroids
If unresponsive:
- Methotrexate
- Azathiprine
- Intravenous Immunoglobulin
- Mycophenolate
Hydroxychloroquine helps skin lesion
114
This is an idiopathic autoimmune disorder secondary to antibodies predominantly against lacrimal and salivary glands; 90% of those affected are women. It is also associated with RA, SLE, Primary biliary cirrhosis, Polymyositis, and Hashimoto thyroiditis.
Sjogren Syndrome
115
How does Sjogren syndrome presents?
dryness of mouth and eyes
116
This is an ocular abnormality that gives the feeling of "sand in the eyes" as well as burning and itching.
keratoconjunctivitis sicca
117
What is the most dangerous complication of Sjogren syndrome?
Lymphoma
118
What is the best initial test for Sjogren syndrome?
Schirmer test
-a piece of filter paper is placed against the eye and observed for the amount of tears produced by the amount of wetness on the filter paper
119
What is the most accurate test for Sjogren syndrome?
Lip or Parotid gland biopsy
120
What is the best initial test on blood for Sjogren Syndrome?
SS-A and SS-B / Ro and La
121
What is the best initial therapy for Sjogren Syndrome?
Water the Mouth
122
This 2 drugs increases acetylcholine; increases rates of saliva production
Pilocarpine and Cevimeline
123
It is a disease of small and medium-sized arteries leading to a diffuse vasculitis that inexplicably spares the lungs.
Polyarteritis nodosa (PAN)
124
What organ is spared in PAN?
Lungs
125
What is the most accurate test for PAN?
Biopsy of a symptomatic site
126
What is the most common neurological abnormality in PAN?
Peroneal neuropathy leading to Foot drop
| Look for a stroke in a young person
127
How would you treat PAN?
Prednisone and Cyclophosphamide
128
This disease occurs in those over age 50 with pain and stiffness in shoulder and pelvic girdle muscles, difficulty combing hair and rising from a chair, elevated ESR, normochromic, normocytic anemia
Polymyalgia Rheumatica
129
Treatment for Polymyalgia Rheumatica
Steroids
130
This disease seems to be on a spectrum with PMR but there are visual symptoms, jaw claudication, scalp tenderness, headache, and other symptoms such as decreased arm pulses, bruits near the clavicles or aortic regurgitation.
Giant Cell (Temporal) Arteritis
131
What will you see in the diagnosis of Giant Cell Arteritis?
Elevate ESR and C-reactive protein
132
What is the most accurate test for Giant Cell Arteritis?
Biopsy of Temporal Artery
133
How would you treat Giant Cell Arteritis?
High-dose Prednisone
134
You see a patient with upper and lower respiratory tract findings such as sinusitus, otitis media, mastoiditis, oral and gingival involvement, in association with renal insufficiency. What is the MOST LIKELY diagnosis?
Wegener Granulomatosis (Granulomatosis with Polyangitis)
135
What is the best initial test for Wegener Granulomatosis?
C-ANCA
136
What is the best test for Wegener Granulomatosis?
Lung Biopsy
137
How would you treat Wegener Granulomatosis?
Prednisone and Cyclophosphamide
138
This is a pulmonary-renal syndrome presenting with asthma and eosinophilia/ There can be fever, weight loss, joint pain, and skin findings.
Churg-Strauss Syndrome (Allergic Angitis)
139
What is an initial test for Churg-Strauss Syndrome?
P-ANCA
140
What is the most accurate test for Churg-Strauss Syndrome?
Biopsy
141
This is a vasculitis that is more frequently seen in children. It is characterized by pain and bleeding in the GIT, purpura, arthralgia, and hematuria.
Henoch-Schonlein Purpura
142
What is the most accurate test for HSP?
Biopsy
143
What will you see in the biopsy of HSP?
Leukocystoclastic Vasculitis
144
How would you treat HSP?
Most cases resolve spontaneously.
Steroids are the answer for severe abdominal or progressive renal insufficiency.
145
This is mostly associated with chronic hepatitis C. It is also found with endocarditis and other connective tissue disorders such as Sjogren Syndrome. It manifests as joint pain, glomerulonephritis, purpuric skin lesions, and neuropathy.
Cryoglobulinemia
146
How would you treat Cryoglobulinemia?
Hepatitis C medications
147
This is an Asian or Middle Eastern person with painful oral and genital ulcers in association with erythema nodosum-like lesions of the skin. Ocular lesions leading to uveitis and blindness can also occur, as well as arthritis and CNS lesions mimicking multiple sclerosis. What is the most likely diagnosis?
Behcet Syndrome
148
What is the pathergy of Behcet Syndrome?
sterile skin pustules from minor trauma like a needle stick
149
The patient is a young man with low backache and stiffness of his back and pain that radiates to the buttocks with flattening of the normal lumbar curvature and decreased chest expansion. Enthesopathy occurs at the Achilles tendon. What is the most likely diagnosis?
Ankylosing Spondylitis
150
What is the best initial test for Ankylosing Spondylitis?
X-Ray of the Sacroiliac joint
151
What is the most accurate test for Ankylosing Spondylitis?
MRI
152
What is the best initial treatment for Ankylosing Spondylitis?
Exercise program and NSAIDs
153
This patient presents with joint pain, more often starting in men under the age of 40, involvement of the spine and large joints, negative rheumatoid factor, + HLA-B27, uveitis, has a history of Psoriasis and nail pitting. What is the most likely diagnosis?
Psoriatic Arthritis
154
What is the best initial test for Psoriatic Arthritis?
X-Ray of the joint showing a "pencil in a cup" deformity
155
What is the best initial therapy for Psoriatic Arthritis?
NSAIDs
| Methotrexate if no response to NSAIDs. Anti-TNF agents if methotrexate does not control disease. DO NOT give Steroids.
156
This type of seronegative spondyloarthropathy occurs secondary to inflammatory bowel disease, STI, or GI infection. What is the most likely diagnosis?
Reactive Arthritis (Reiter Syndrome)
157
What is the triad of Reiter Syndrome?
```
Joint pain
Ocular findings (uveitis, conjunctivitis)
Genital abnormalities (urethritis, balanitis)
```
158
What is/are your treatment options for Reactive Arthritis?
NSAIDs and correct underlying cause
| Sulfasalazine if NSAIDs cannot control symptoms. Steroid injections into joints also help.
159
This patient is most often an older woman, with vertebral fractures leading to loss of height or wrist fracture. Many are asymptomatic. What is the most likely diagnosis?
Osteoporosis
160
What is the most accurate test for Osteoporosis?
Bone densitometry (DEXA) scanning
161
How can you differentiate osteopenia vs osteoporosis?
Osteopenia - bone density (T-score) is between 1 and 2.5 standard deviations below normal
Osteoporosis - T-score more than 2.5 deviations below normal. All blood tests are normal in osteoporosis
162
What are the best initial therapy for Osteoporosis?
Vitamin D and Calcium
163
What are adverse effects of Bisphosphonates?
Prolonged contact with esophagus
164
When multiple options are presented for Osteoporosis treatment, what would be the best answer?
Vitamin D, Calcium, Bisphosphonates
165
What are the most common etiology for Septic Arthritis?
Staphylococcus (40%)
Streptococcus (30%)
Gram-negative rods (20%)
166
What is the best initial and most accurate test for Septic Arthritis?
Arthrocentesis - aspiration of the joint with a needle
167
What are the best initial empiric therapy for Septic Arthritis?
Ceftriaxone and Vancomycin
If culture shows that staph sensitive, switch vancomycin to oxacillin or cefazolin
168
What will you see in the synovial analysis of Septic Arthritis in terms of Leukocytosis?
>50,000-100,000 cells/ul
169
What will you see in the synovial analysis of Gonococcal Arthritis in terms of Leukocytosis?
30,000-50,000 cells/ul
170
This triad differentiate Gonococcal Arthritis from Septic Arthritis.
Polyarticular involvement
Tenosynovitis (inflammation of the tendon sheats, making finger movement painful)
Petechial rash
171
What is the diagnostic test for Gonococcal Arthritis?
Synovial Fluid Analysis
```
Culture MULTIPLE sites:
Pharynx
Rectum
Urethra
Cervix
```
172
What is the best empiric therapy for Gonoccocal Arthritis?
Ceftriaxone, Cefotaxime, or Ceftizoxime
173
What will you test for recurrent gonorrhea infection?
Terminal complement deficiency
174
What is the most common cause for Osteomyelitis?
Staphylococcus aureus
175
What is the most commonly identified organism in patients with sickle cell disease?
Salmonella
176
Patient is a diabetic patient with an ulcer from peripheral neuropathy or vascular disease with warmth, redness, and swelling in the area. There may also be a draining "purulent sinus tract" in the lesion. Most patients are afebrile. What is the most likely diagnosis?
Osteomyelitis
177
What is the best initial test for Osteomyelitis?
X-Ray
178
What is the most accurate test for Osteomyelitis?
Biopsy
179
How would you treat Osteomyelitis?
Confirm sensitivity of organism.
Sensitive staphyloccoci - best treated with oxacillin, cefazolin, nafciliin, or ceftriaxone
Resistant staphyloccoci - vancomycin or linezolid
E. Coli - Ciprofloxacin
180
What is the adverse effect of Fluroquinolones?
It can cause Achilles tendon rupture
Contraindicated in pregnancy and in children because they interfere with bone growth.
