Rheumatology/MSK Flashcards
1
Q
List diagnostic criteria of JDM
A
- Proximal, symmetric muscle weakness
(Neck flexors, shoulder girdle, hip flexors) - Classic rash: Heliotrope rash, Gottrons Papules
- Elevated muscle enzymes
- EMG changes
- Muscle biopsy
Other symptoms/signs: Nailfold capillary changes Fevers Dysphagia Arthritis Muscle tenderness Fatigue
2
Q
List 2 long term complications of JDM
A
Lipodystrophy-progressive loss of subcutaneous and visceral fat
Calcinosis
3
Q
What tests would you order to diagnose JDM?
A
Diagnosis is clinical!
But if uncertain, order CK, EMG, MRI (T2 fat-suppressed images show inflammation)
Muscle biopsy is last resort!
4
Q
Treatment of JDM
A
Steroids
Methotrexate
PT/OT
Avoid sun exposure, sun screen
5
Q
What is the pathophysiology of periodic fever syndromes?
A
-Autoinflammatory
-Exaggerated innate immune response
-Excess release of pro-inflammatory cytokines
(especially IL-1β)
6
Q
What are the different types of periodic fever syndromes?
A
- FMF
- PFAPA
- TRAPS (TNF receptor associated periodic fever syndrome)
- MVK (Mevalonate kinase deficiency)/HyperIgD
- FCAS (familial cold autoinflammatory syndrome)
- MWS (Muckle Wells)
7
Q
What are the features of FMF?
A
Fever 1-3 days duration*** Irregular interval <10 years (80%) Serositis (peritonitis***, pleuritis, pericarditis), Synovitis Erysipelas-like rash Monoarthritis***
8
Q
What are the features of PFAPA?
A
Fever 3-5 days duration Regular (every 3-6 wks)*** < 5 years of age in most*** Aphthous ulcers Pharyngitis Cervical adenitis
9
Q
What are the features of TRAPS?
A
Fever 1-3 weeks duration*** Irregular interval At least 2-6x per year <10 years in 75% Exercise may trigger*** Abdominal pain Severe myalgia Arthralgia (large joints) Migratory erythematous plaques Periorbital edema Conjunctivitis*** Serositis
10
Q
What are the features of MVK/HyperIgD syndrome?
A
3-7 days duration Every 4-6 weeks Triggered by vaccination, minor trauma, stress Onset <1 year in 70%*** Headache Mucosal aphthous Abdominal pain Vomiting Diarrhea Painful adenopathy Arthritis Splenomegaly Polymorphic rashes;
11
Q
What are the features of FCAS?
A
1-24 hours duration*** < 1 year of age**** Irregular interval Triggered by cold Migratory urticarial rash Conjunctivitis, Headache Fatigue Myalgia Arthralgia Joint stiffness
12
Q
What are the features of MWS?
A
1-3 days duration Variable age of onset Irregular interval Urticaria-like rash*** Arthralgia or non-erosive arthritis Conjunctivitis Progressive sensorineural hearing loss***
13
Q
What a reasonable initial workup of periodic fevers?
A
Bloodwork when well and with fever:
CBC with differential (exclude cyclic neutropenia)
ESR
CRP
Blood culture (early on in course)
Other investigations selectively:
Creatinine, liver function, serum Ig, ANA, ANCA, RF
14
Q
What are the diagnostic criteria for PFAPA?
A
1) Regularly occurring fever episodes with an early age of onset (<5 years)
2) Constitutional symptoms in the absence of URTI with at least one of the following ▫ Aphthous stomatitis ▫ Cervical adenopathy ▫ Pharyngitis
3) Exclusion of cyclic neutropenia
4) Completely asymptomatic interval between episodes
5) Normal growth and development
15
Q
What is the treatment for PFAPA?
A
1) Prednisone single dose at onset of symptoms
2) Consider tonsillectomy
16
Q
How do you diagnose FMF?
A
Clinical features
Genetic testing-80% have MEFV mutation (autosomal recessive)
17
Q
How do you treat FMF and what is the purpose of treatment?
A
Colchicine
- Reduces attack rate
- Normalizes acute phase reactants
- Prevents amyloidosis)
18
Q
What is the most common long term complication of untreated FMF?
A
Amyloidosis (50%)
-Proteinuria–>renal failure
Other complications:
Joint contractures
Abdominal adhesions
19
Q
In what ethnicities is FMF more common?
A
Sephardic Jews, Turks, Armenians, Arab
20
Q
List 4 poor prognostic factors in Kawasaki Disease
A
- Young age
- Male
- Prolonged fever
- Lab abnormalities →neutrophilia, thrombocytopenia, transaminitis, hyponatremia, hypoalbuminemia, elevated CRP
- Asian, Pacific Islander, Hispanic ethnicities (higher risk of coronary artery abnormalities)
21
Q
Criteria for Classic Kawasaki Disease
A
5 days of fever + 4/5 of:
- Bilateral non-exudative bulbar conjunctival injection
- Oral/mucosal changes (strawberry tongue, dry cracked lips, injection of mucosa/pharynx)
- Polymorphous exanthema (anything BUT vesicular)
- Cervical LAD >1.5 cm (nonsuppurative, usually unilateral)
- Extremity changes (palmar/plantar erythema/edema)
22
Q
What are the 3 clinical phases of KD?
A
- Acute:
- Febrile phase, usually lasts 1-2 weeks
- Perineal desquamation - Subacute:
- Lasts ~2 weeks
- Fever resolves
- Desquamation (periungual–>entire hand/foot)
- Thrombocytosis
- Development of coronary aneurysms
- Highest risk of sudden death - Convalescent:
- All clinical signs have disappeared
- Lasts until the ESR returns to normal (6-8 weeks after onset)
23
Q
List 3 clinical features of KD that are not in the diagnostic criteria
A
Irritability (aseptic meningitis) Meatitis, dysuria, sterile pyuria Oligo/polyarthritis Hepatitis Anterior uveitis Gallbladder hydrops
24
Q
What percentage of untreated patients with KD develop coronary aneurysms and WHEN?
A
Untreated 25%
Treated <5%
Typically develop week 2-3 of illness
25
List 10 laboratory findings consistent with KD
↑WBC, predominantly neutrophils
Normocytic, normochromic anemia
Platelets normal then rapidly ↑↑ after day 7
↑ESR/CRP
Sterile pyuria
↓Na
↓Albumin
↑AST/ALT
↑Bilirubin
CSF pleocytosis
26
As per AHA guidelines, when should echocardiograms be done in KD (if results are normal)?
At diagnosis
2-3 weeks
6-8 weeks
At 1 year (with lipid profile!)
27
List 3 conditions in the differential for KD and how do you differentiate them?
Adenovirus-exudative pharyngitis/conjunctivitis
Measles-koplik spots, leukopenia
Scarlet fever-conjunctivitis not common
Toxic shock syndrome-renal insufficiency, coagulopathy, pancytopenia
Drug hypersensitivity reactions-periorbital edema, minimally elevated ESR
SJIA-diffuse LAD and HSM
28
Treatment of KD
IVIg 2g/kg
Low dose ASA (3-5 mg/kg/day)
(No longer using high dose ASA)
29
Define IVIg resistant KD
Fever 36 h after IVIG
30
How do you treat IVIg resistant KD?
2nd dose IVIg
| Other options: methylpred
31
What is the natural history of coronary aneurysms in KD?
50% of coronary aneurysms regress to normal diameter by 1 to 2 years
Giant aneurysms are unlikely to resolve and are most likely to lead to thrombosis or stenosis
32
Diagnostic criteria for HLH
Need 5/8:
1. Fever ≥38.5°C
2. Splenomegaly
3. Cytopenias: ≥2 of anemia (<100), thrombocytopenia (< 100); ANC <1.0
3. Hypertriglyceridemia and/or hypofibrinogenemia
4. Hemophagocytosis in bone marrow, spleen, lymph node, or liver
5. Low or absent NK cell activity
6. Ferritin >500 ng/mL
7. Elevated soluble CD25 (soluble IL-2 receptor alpha; reflector of NK fxn)
33
List the 3 most common rheumatologic causes of MAS
1. Systemic JIA
2. Lupus
3. Kawasaki disease
34
List clinical features of HSP
```
Rash (palpable purpura, low extremities)
Edema
Arthralgias
GI symptoms (including intussuseption, perforation)
Renal
```
```
Others:
Orchitis
Testicular torsion
Carditis
Pulmonary hemorrhage
```
35
What is acute hemorrhagic edema of infancy?
Isolated cutaneou sleukocytoclastic vasculitis affecting infants < 2 yrs with fever and no other organ involvement
36
Indication for steroids in HSP
Significant GI symptoms
NOT for renal disease
37
What % of patients with HSP have recurrence?
30%
| Often within 6 months
38
List laboratory abnormalities in HSP
```
Leukocytosis
Thrombocytosis
Anemia
ESR/CRP elevated
Elevated IgA
```
39
What are the diagnostic criteria for JIA (in general)
Onset <16 years of age
Duration >=6 weeks
Exclusion of other causes of arthritis
40
Xray findings in JIA
```
Growth acceleration/inhibition
Peri-articular osteoporosis
Subchrondral erosions
Loss of cartilage
Eventually bone fusion
```
41
List 3 risk factors for uveitis in JIA
+ANA
Girl
Monoarticular arthritis
Onset <6 years
42
List long term complications associated with JIA
```
Leg length discrepancy
Flexion contractures
Scoliosis
Delayed motor development
Muscle atrophy
```
43
List 3 complications of uveitis
Synechiae (can result in small, irregular pupil)
Glaucoma
Cataract
Vision loss
44
List features of oligoarticular JIA
```
<=4 joints in 1st 6 months
Asymmetric
Knee, ankle, elbow
Uveitis (30-50%)
ANA+ (70%)
```
45
List features of polyarticular JIA
```
>4 joints in 1st 6 months
Symmetric
Small and large joints
Slowly progressive (unless RF +)
Uveitis (5%)
ANA + 40-50%
```
46
Diagnostic criteria for enthesitis related arthritis
Arthritis ± enthesitis with ≥2 of:
- Sacroiliac tenderness or spinal pain
- HLA-B27+
- Arthrithis in male > 6
- Acute anterior uveitis
- FamHx in 1st or 2nd degree relative of confirmed HLA-B27-associated disease
47
Differential diagnosis of polyarthritis
• Inflammatory
- JIA
- SLE, other connective tissue diseases
- Vasculitis – HSP
- IBD
- Serum sickness
- CRMO
• Infection
- Acute – viral (parvovirus), bacterial (gonococcal)
- Post-infectious – reactive/rheumatic fever
• Malignancy (systemic)
• Mechanical
-Hypermobility, skeletal dysplasia
• Pain syndrome
-Fibromyalgia
48
Treatment of polyarticular JIA
NSAIDs
Methotrexate
Biologics
49
Diagnostic criteria for psoriatic arthritis
Arthritis plus 2 of the following
– Nail pits
– Dactylitis
– Family history of psoriasis
50
Diagnostic criteria for psoriatic arthritis
Arthritis plus 2 of the following
– Nail pits
– Dactylitis
– Family history of psoriasis
Can have uveitis
51
Diagnostic criteria for systemic JIA
1. >2 weeks spiking fever
2. Arthritis + at least one of:
• Rash (evanescant, correlates with fever spikes, salmon-coloured)
• Generalized lymphadenopathy
• Hepatosplenomegaly
• Serositis
52
List 3 clues that MAS is developing in a child with a rheumatologic disorder
```
Dropping cell lines
Elevated ferritin >1000
Falling fibrinogen
Falling ESR
Neurologic symptoms
```
53
Diagnostic criteria for sJIA
1. Fever >2 weeks and daily x 3 days
2. Arthritis
3. At least one of:
• Rash
• Generalized lymphadenopathy
• Hepatosplenomegaly
• Serositis
54
What is the classic fever pattern in SJIA?
Quotidian
1-2 spikes/day
Associated with evanescent rash
55
List 4 organisms that cause reactive arthritis
```
Chlamydia
Shigella
Campylobacter
Yersinia
Giardia
Salmonella
```
56
How often should you screen patients with JIA with eye exams?
Eye exam q 3-12 months depending on ANA status, age, duration of disease
e.g. ANA+, <6 years, <4 years after diagnosis=every 3months
ANA-, <6 years, <4 years after diagnosis=every 6 months
57
How often should you screen patients with JIA with eye exams?
Depends on 4 factors:
- Type of JIA
- Age of onset
- Duration of disease
- ANA status
e.g. ANA+, <6 years, <4 years after diagnosis=every 3months
ANA-, <6 years, <4 years after diagnosis=every 6 months
(THIS NIT PICKY STUFF WAS AN OLD QUESTION)
58
Before starting biolgoic response modifier therapy, what test should be done? (CPS)
TST
59
When should inactivated vaccines be administered before starting biologics? (CPS)
Inactivated vaccines should be administered 14 or more days before starting BRM
60
When should inactivated vaccines be administered before starting biologics? (CPS)
Inactivated vaccines should be administered 14 or more days before starting BRM
61
Should patients receiving biologics get the inactivated influenza vaccine? (CPS)
YES
| But can have diminished immune response
62
When should live vaccines be administered before starting biologics? (CPS)
4 weeks or more before starting BRM
63
List 3 adverse effects of methotrexate
```
Cytopenias
Oral ulcers
Hepatotoxicity
Infection
Pneumonitis
Teratogenic
```
64
What percentage of healthy individuals are ANA positive?
20%
| More significant if >1:160
65
List one disease associated with the following antibodies:
i) Anti-dsDNA
ii) Anti-smith antibody
iii) Anti-RNP
iv) APLA
v) Antihistone antibodies
vi) APLA
i) Anti-dsDNA***: SLE
ii) Anti-smith antibody***: SLE
iii) Anti-RNP: SLE, mixed connective tissue disorder, Raynauds
iv) Anti-Ro/La: sicca, Sjogren, SLE, neonatal lupus
v) Antihistone antibodies: drug induced lupus
vi) APLA: SLE, thrombosis
***specific for SLE
66
What is one thing you should monitor in patients on hydroxychloroquine?
Retinal toxicity
| Need eye exam 6-12 months
67
Diagnostic criteria for SLE
Diagnosis: >4 of 11 features:
- Malar rash
- Discoid rash
- Serositis
- Oral/nasal ulcers
- Arthritis
- Photosensitivity
- Hematologic (hemolytic anemia, lymphopenia, thrombocytopenia <100)
- Renal (nephritis)
- ANA positive
- Immunologic (autoantibodies, low C3/C4)
- Neuro (seizures, psychosis)
Other features:
- Constitutional sx
- Alopecia
- Raynaud
- LAD, HSM
68
List 3 differences between idiopathic SLE and drug induced lupus
Drug induced lupus
- Antihistone antibody positive
- Anti-dsDNA negative
- Normal C3/C4
- CNS, renal, hematologic manifestations rare
69
List medications associated with drug-induced lupus
Minocycline
Anticonvulsants (phenytoin on past exam!)
Sulfonomides
Anti-arrhythmics
70
List the 3 cardinal systems involved Granulomatosis with polyangiitis (Wegener's)
1. Upper airway
- Sinusitis
- Nasal ulceration
- Saddle nose deformity
- Epistaxis
- Hearing loss
2. Lower airway
- Cavitary lesions
- Pulmonary nodules
- Pulmonary hemorrhage
3. Renal
- Nephritis
Other:
- Eye (conjunctivitis, scleritis, uveitis, optic neuritis, orbital pseudotumour)
- Skin (palpable purpura***, ulcers)
71
How do you diagnose Wegeners?
- CT chest (lung nodules, cavitary lesions)
- Lung biopsy
- C-ANCA
72
What is spondylolysis?
Stress fracture of the pars interarticularis
73
What causes spondylolysis?
Repetitive spinal extension and rotation
| Increased risk in dance, figure skating, gymnastic
74
How do you diagnose spondylosis? (CPS)
1. Anterolateral and oblique spinexrays
| 2. Bone scan (increased uptake)
75
List 3 steps in management of spondylosis (CPS)
1. Activity limitation (extension movements)
2. Physiotherapy-abdominal strengthening, hip flexor and hamstring stretches)
3. Bracing-consider lumbar brance to limit spinal extension
76
How long should you recommend activity limitation in spondylosis with and without a brace (CPS)
With brace-4-8 weeks or until pain free, then gradually increase activity until IN BRACE with no pain, then wean brace over months
Without brace-3-6 months/until pain free, then gradual increase activity
77
List 3 exam findings consistent with spondylosis (CPS)
Hyperlordosis
Paraspinal muscle spasm
Hamstring tightness
78
List 4 causes of scoliosis other than idiopathic
1. Congenital
2. Neuromuscular
3. Syndromes (e.g. NF-1, Ehlers Danlos, OI, PWS)
4. Compensatory (e.g. leg length discrepancy)
79
List 3 anomalies associated with congenital scoliosis
Genitourinary
Cardiac
Intraspinal anomalies
80
How do you treat congenital scoliosis?
SURGERY
| Bracing has minimal role
81
List 2 serious complications of severe scoliosis
1. Restrictive lung disease
| 2. Cor pulmonale
82
Best determinant of scoliosis on physical exam
Adam's test
| Asymmetric rib cage on bending over
83
When do you simply observe idiopathic scoliosis?
Curves <20 degrees
| Consider follow up X-rays and monitor for progression
84
Indications for bracing for treatment of scoliosis
1. Curve 30-45 degrees
| 2. Curve 20-25 that has progressed 5 degrees in skeletally immature patient
85
Indications for surgery for scoliosis
1. Skeletally immature with curve >45 degrees
2. Skeletally mature with curve >50
3. Lumbar curves with marked trunk shift
4. When deformity progressing despite bracing
86
When does congenital scoliosis typically present?
<10 years
87
What 3 things are required to make a diganosis of adolescent idiopathic scoliosis?
- Age ≥10 years
- Cobb angle ≥10°
- Exclusion of other causes (congenital, neuromuscular, syndromic)
88
List 5 risk factors for progression of idiopathic scoliosis
1. Patients <12 years
2. Severity of curve (>20 degrees)
3. Double and thoracic curves
4. Girls
5. Premenarchal
89
What is the benefit of bracing for idiopathic scoliosis?
Reduces risk of progression
Decreases likelihood of needing surgery
DOES NOT fix scoliosis
90
What is the most common pattern seen on X-ray in neuromuscular scoliosis?
C-shaped curve
91
What is a complication of scoliosis surgery resulting in bilious vomiting?
```
SMA syndrome (is due to the result of spinal elongation, which decreases the superior mesenteric/aortic
angle)
```
92
List 3 HLA-B27 associated diseases
Enthesitits related arthritis
Reactive arthritis
IBD arthritis
Acute anterior uveitis
93
What is the one cardiac complication of ankylosing spondylitis?
Aortic insufficiency
94
What is Osgood Schlatter?
Traction apophysitis of tibial tubercle
95
List clinical features of Osgood Schlatter
- Pain and swelling over the tibial tubercle in a growing child
- Pain aggrevated by activity, resolves with rest
- Point tenderness over tibial tubercle on exam
- Common in athletes (repetitive trauma).
96
How do you treat Osgood Schlatter?
1. Stop activities that cause pain
2. Ice
3. Consider knee immbolization
4. Physiotherapy
- Quad strengthening when pain resolves
Self-limited (but can take 1-2 years for symptoms to resolve)
97
Describe the pathophysiology of patellofemoral syndrome
Three potential causes:
1. Overload-**most common
2. Malalignment
3. Trauma
98
List 3 clinical features suggestive of Patellofemoral syndrome as a cause of knee pain
```
Worse with squatting
Running
Prolonged sitting
Ascending/descending stairs
Poorly localized (under/around the patella)
Knee ‘giving away/buckling’
```
99
Treatment of patellofemoral syndrome
1. NSAIDs only for short term
2. Physiotherapy
- Focus on improving the strength of the knee, hip, and core muscles, including the hip abductors and quadriceps
100
Treatment of patellar dislocation
Knee immobilizer
Physiotherapy
May need surgery
101
List the Kocher criteria for septic arthritis
Non-weight-bearing on affected side
ESR > 40
Fever > 38.5 °C
WBC > 12
102
What is SCFE?
Displacement of the femoral head relative to the neck
103
List 5 risk factors for SCFE
```
Obesity***
Male
Hypothyroidism
Hypopituitarism
Renal osteodystrophy
Down syndrome
Rubenstein Taybi
```
104
Physical exam finding consistent with SCFE
Restriction of hip internal rotation, abduction and flexion
105
How do you diagnose SCFE?
AP and frog leg views of hips
Klein line = a straight line drawn along the superior cortex of the femoral neck on the AP radiograph, should intersect some portion of the lateral capital femoral epiphysis
106
What percentage of SCFE presents with contralateral slip on XR?
Bilateral involvement has been reported in as many as 60% of cases
~25% of patients have a contralateral slip on initial presentation
107
List 2 serious complications of SCFE
1. Osteonecrosis
| 2. Chondrolysis (acute dissolution of articular cartilage in the hip)
108
How do you treat SCFE (2 steps in management)?
1. Admit to hospital for bed rest
| 2. Pin fixation
109
What is Legg-Calve-Perthes?
Idiopathic AVN
Disruption of the vascular supply to the femoral epiphysis, which results in ischemia and osteonecrosis
110
What % of LCP has bilateral involvement?
Bilateral involvement in 10%
111
How can you diagnose early LCP?
MRI or Bone scan
112
List 2 poor prognostic factors for LCP
1. Age >9 years
| 2. Greater involvement of femoral head
113
List treatments for LCP
1. Activity limitation
2. Protected weight-bearing
3. Nonsteroidal anti-inflammatory medications
4. PT to maintain hip range of motion
5. Abduction devices →used to achieve containment of the femoral head within the acetabulum
(e. g. Petrie casts)
5. Surgery-varus osteotomy of the proximal femur
114
What is DDH?
Abnormal development of the acetabulum and proximal femur and mechanical instability of the hip joint
115
List 5 risk factors for DDH
```
First pregnancy
Female
Family history
Breech
Oligohydramnios
LGA
```
116
Until what age are Ortolani and Barlow tests reliable in screening for DDH?
Until 2-3 months of age
117
List 4 physical exam findings of DDH in a child
```
Limited hip abduction
Galeazzi sign
Klisic test
Asymmetry of the gluteal or thigh folds
Leg length discrepancy
Waddling gait
Excessive lordosis
```
118
For what age groups is hip US the diagnostic modality of choice for DDH?
4 weeks to 6 months
0-4 weeks: high rate of false positive
After 4-6 months:appearance of the femoral head ossific nucleus
119
Which newborns should get a screening ultrasound for DDH at 4-6 weeks?
1) Clinical examination consisent with hip instability
| 2) Infants with risk factors for DDH (even without clinical findings)
120
After 4-6 months of age, what is the diagnostic modality of choice for DDH?
AP xrays of the pelvis
121
Treatment of DDH for infants <6 months
Pavlik harness x 6 weeks
122
Treatment of DDH for infants 6 months-2 years
Closed reduction in OR
Spica cast x 12 weeks
+/- Abduction orthosis
123
Treatment of DDH for children >2 years
Open reduction
Femoral shortening osteotomy
Spica cast 6-12 weeks
124
What is the most serious complication of DDH and what increases the risk?
AVN of femoral epiphysis
Increased risk with:
- Extreme abduction
- <4-6 months of age
125
List 3 MSK diagnostic criteria for Marfans (past question)
1. Wrist AND thumb sign
2. Pectus Carinatum
3. Hindfoot Deformity
4. Protrusio acetabuli
5. Reduced US/LS AND increased arm/height AND no severe scoliosis
5. Scoliosis or thoracolumbar kyphoses
6. Reduced elbow extension
126
What is the most common cause of intoeing in children <1 year?
Metatarsus adductus
127
What is metatarsus adductus?
Adduction of forefoot relative to hindfoot
128
List physical exam features consistent with metatarsus adductus
1. Heel bisector line-Line through midpoint of heel normally extends through 2nd toe – in MA extends through 3rd-5th (depending on severity)
2. Deep medial crease
3. Intoeing gait
4. Ankle and subtalar ROM normal
129
What is the treatment for metatarsus adductus?
1. If mild/flexible-most resolve with observation by 2 yo
| 2. If rigid-serial casting, start <8 months of age for best results, if unsuccessful, surgery at >4 years of age
130
What is congenital vertical talus?
Rockerbottom feet
| Fixed dislocation of the navicular dorsolaterally on the head of the talus
131
What is the difference between calcaneovalgus feet from congenital vertical talus?
Look the same
| BUT, with calcaneovalgus feet you can correct the deformity with gentle pressure
132
What conditions is rockerbottom feet associated with?
Neuromuscular and genetic disorders
| Classic=Trisomy 18
133
What investigations should you do for congenital vertical talus?
X-rays-for taking measurements
134
What is the treatment of congenital vertical talus?
Serial casting
| Majority need surgery usually at 6-12 months
135
What are the physical exam findings in congenital talipes equinovarus (clubfoot)?
Foot excessively plantar flexed, with the hindfoot in excessive varus, and forefoot/midfoot adducted medially with sole facing inward
136
What is the treatment of congenital talipes equinovarus?
1. Ponseti method
- Manipulation and serial casting ASAP after birth
- Weekly cast changes
- Usually 5-10 weeks
2. Percutaneous tenotomy of heel cord
- Required in 90% of patients to correct residual hindfoot equinus
- Followed by leg cast x 3 weeks and brace x 3-5 years
137
Physical exam features consistent with tibial torsion
1. Medially deviated foot when the patella is facing directly forward
2. Thigh-foot angle
- Examine prone with knees flexed 90 degrees
- Degree of torsion=angular difference between the axis of the foot and the axis of the thigh
138
What is the most common cause of intoeing in children 1-3 years?
Internal tibial torsion
139
What is the treatment for internal tibial torsion?
Observation
| Corrects by 5 years of age
140
What is the most common cause of intoeing in children 3-6 years?
Internal femoral torsion (anteversion)
141
What are the 3 most common causes of intoeing in children and how do you differentiate between them?
1. Metatarsus adductus
2. Internal tibial torsion
3. Increased femoral anterversion
Differentiate based on the following factors:
1. Age
- Metatarsus adductus-<1 year
- Internal tibial torsion 1-3 years
- Increased femoral anteversion >3 years
2. Exam
- Metatarsus adducts-heel bisector line
- Internal tibial torsion-thigh foot angle
- Increased femoral anteversion-symmetrically increased internal hip rotation
142
Clinical features findings consistent with femoral anteversion
1. Symmetrically increased internal hip rotation
2. Sits in W position
3. Runs with egg beater or wind mill pattern
143
What is the treatment of femoral anteversion?
Observation
Avoid abnormal sitting habits (e.g. W sitting)
Corrects by 11 years of age
144
List 3 indications of orthopedic referral for intoeing
1. Unilateral/asymmetric intoeing
2. Internal tibial torsion >8 years with activity limitation or cosmetically unacceptable
3. Femoral anteversion >11 years with activity limitation or cosmetically unacceptable
4. Intoeing that does not follow expected course
145
What condition is external femoral torsion associated with?
Post-SCFE
146
What is the natural history of external femoral torsion and external tibial torsion?
Will get worse with time
147
When should you refer genu varus or valgus to orthopedics?
If persists >8 years OR causes functional impairment
148
Is there any role for orthotics or insoles in treatment of genu varus/valgus?
No
149
What is the differential diagnosis for pathologic bowing?
Rickets and other metabolic bone diseases
Renal osteodystrophy
Skeletal dysplasia
Blount disease
Asymmetric growth (eg, following unilateral trauma, infection, or neoplasia)
NF-1-anterolateral tibial bowing
150
What is Blount disease?
Developmental deformity from abnormal endochondral ossification of medial aspect of proximal tibial physis leading to varus angulation and medial rotation of tibia
151
2 Risk factors for Blount's disease
African american
| Overweight toddlers
152
What is the difference between:
i) Genu varum
ii) Blount disease
iii) Rickets
Blount disease:
- Can be asymmetric
- Focal angulation at the proximal tibia
- Lateral thrust
Rickets:
- Bones themselves are bowed
- Short stature
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Characteristics of physiologic bowing
1. Age between birth and two years
2. Bilateral and symmetric
3. Bowing of both femurs and tibias
4. Normal stature
5. No lateral thrust with ambulation
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How do you treat Blount's disease
Managed with bracing in children <3 – 1 yr trial before consider Sx
Children >4 yo need surgery
155
How do you tell the difference between rigid and flexible flat foot?
In flexible flat foot:
- Normal longitudinal arch in non–weight-bearing position
- When standing arch disappears, midfoot sags, and hindfoot collapses into valgus
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What does the CPS say about orthotics in the treatment of flat feet?
Arch development in walking children <6 y.o.is not enhanced by shoes, inserts, heel-cups
157
List 2 physical exam features that distinguish rigid pes planus from flexible pes planus
1. Range of motion at the tarsal and subtalar joints is decreased
2. The arch does not increase with toe raising
3. NO change in appearance of flat foot when weight bearing or not weight bearing
158
What is the inheritance pattern for isolated polydactyly?
Usually AD
159
List 4 conditions associated with absent radius
Holt-Oram (cardiac defects)
TAR (thrombocytopenia, absent radius)
VACTERL
Fanconi anemia
160
List 2 ways of reducing a pulled elbow (radial head subluxation)
1. Hyperpronation method
| 2. Supination/flexion method
161
Ottawa ankle rules
X-ray ankle if pain in malleolar zone AND any of the following:
1. Bony tenderness at posterior edge/tip of lateral malleolus
2. Bony tenderness at posterior edge/tip of medial malleolus
3. Inability to weight bear both immediately and in ER
162
Ottawa foot rules
X-ray foot if pain in midfoot region AND any of the following:
- Bony tenderness at base of 5th metatarsal
- Bony tenderness at the navicular bone
- Inability to weight bear both immediately and in ER
163
What is the most common childhood wrist fracture? (past question)
Buckle fracture
164
What is the definition of complex regional pain syndrome (or reflex sympathetic dystrophy)?
Amplified musculoskeletal pain syndrome that is characterized by extreme pain in a limb out of proportion to the history and physical findings
Accompanied by one or more signs of autonomic dysfunction (coolness, sweating, edema, cyanosis)
165
What are the 5 classifications of JIA
1. Systemic
2. Polyarticular
- RF-negative
- RF positive
3. Oligoarticular
- Persistent
- Extended
4. Psoriatic arthritis
5. Enthesitis-related arthritis
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Differential diagnosis of monoarthritis
1. Trauma
2. Infection
- Acute-septic arthritis, osteomyelitis
- Chronic-TB and lyme
- Post-infectious
3. Inflammatory
- Transient synovitis
- JIA
4. Tumour
5. Hemarthrosis
6. Mechanical
- Osgood schlatter, AVN, SCFE
7. Pain syndrome (CRPS, conversion)
167
List 5 characteristics of growing pains
```
No relation to growth
Age 3-10 years
Bilatral leg pain (calf, thigh, shins)
Occurs at night
No interference with activities
Normal exam
Normal lab tests
```
168
Which antibiotic should be avoided in patients on methotrexate?
Cotrimoxazole
Septra can interfere with folic acid metabolism
169
List 3 manifestations of methorexate toxicity
1. Oral ulcers
2. Hepatotoxicity
3. Leukopenia
4. Nausea
5. Pneumonitis
6. Higher risk of infection
170
What two thing should you counsel an adolescent on methotrexate about?
```
No Alcohol (hepatoxicity)
Contraception
```
171
List 3 side effects of anti-TNF agents
1. Infection
2. Reactivation TB
3. Pancytopenia
4. MS-like syndrome
5. Autoimmunity
172
List 4 clinical features of antiphospholipid antibody syndrome
Venous thrombosis
Arterial thrombosis
Thrombocytopenia
Recurrent abortion
173
List 3 tests that can aid in the diagnosis of antiphospholipid antibody syndrome
Prolonged PTT
Anticardiolipin antibodies
Lupus anticoagulant
174
What bloodwork correlates with disease activity in SLE?
- Low C3/C4
- High titre ANA, anti-DNA antibodies
- Cytopenias
- ESR (note CRP usually normal)
175
List 5 risk factors for developing coronary aneurysms in KD
1. Prolonged fever
2. Male
3. <1 year of age and >9 years
4. Hypoalbuminemia
4. Prominent inflammatory markers
