Rheumatology/Ortho

Question 1

What is the treatment of acute rheumatic fever (acute and chronic)?

Answer 1

• Treatment:
  
  • Bed rest, close monitoring for evidence of carditis
  • Antibiotics for GAS eradicationIM Pen G x 1 dose or PO Amoxicillin x 10 days (must be started before 9^th day of symptoms to prevent ARF)
  • Migratory polyarthritis or uncomplicated carditishigh-dose ASA for 4-8 weeks
  • Carditis with cardiomegaly or CHF Prednisone x 4-6 weeks (tapering at 2-3 weeks), then start ASA for 6 weeks
  • Chorea Phenobarbital > Haloperidol
• Prevention – Chemoprophylaxis for Recurrence of ARF:
  
  • Highest risk of recurrence within 5 years
  • Use Pen G IM q4weeks or Penicillin V PO BID
  • Treatment duration
    
    • ARF without carditis: 5 years or until 21 years of age (whichever is longer)
    • ARF with carditis: long-term antibiotic prophylaxis

Question 2

What are the biochemical changes seen in macrophage activation syndrome?

Answer 2

• Drop in cell lines, high ferritin (often >1000) and lipids
• Fibrinogen ↓, D-dimers ↑, ESR ↓, CRP ↑

Question 3

What are the autoantibodies implicated in SLE? What are their sensitivities?

Answer 3

• ANA (sens 97%, spec 50%)
• dsDNA (sens 70%)
• Sm (sens 32%)
• RoSSa/LaSSb (~20-30%)
• Antiphospholipid-Ab (35%)
  
  • In children 60% in the context of autoimmune disorders
  • Indications for testing: thrombosis, SLE yearly, unexplained prolonged PTT, clinical features (blood, CNS, renal, cardiac, derm)

False-positive rapid plasma reagin (RPR) test result, positive lupus anticoagulant test or elevated anticardiolipin IgG/IgM antibody

Question 4

What is the treatment for septic arthritis (including empiric, <4yo, MSSA, MRSA)?

Answer 4

• Antibiotics for 3-4 weeks (if hip → 4-6 weeks)
  
  • Empiric → Cefazolin q6h IV (covers MSSA and K kingae)
  • If <4 years of age + unimmunized → Cefuroxime q8h IV (for H.flu)
  • MSSA → continue Cefazolin or narrow to Cloxacillin IV
  • MRSA → Clindamycin, Vancomycin
  • Transition to PO based on clinical improvement and decrease in CRP (typically within 3-7 days)
• Consult with Orthopedic Surgery for consideration of urgent irrigation

Question 5

What is spondylolysis, how is it diagnosed and how is it managed?

Answer 5

• Definition: Stress fracture of the pars interarticularis caused by repetitive spinal extension and rotation
• Onset is insiduous
• Exacerbated by extension - Often due to sports with frequent mvt, e.g. dance, gymnastics
• Exam: Reduced hamstring flexibility, may see hyperlordosis, paraspinal muscle spasm, hamstring tightness
• Ix: x-rays, bone scan, possibly CT
• Tx: avoid painful activities, PT, rest +/- brace (return to play is 4-8wk w/ brace, 3-6mo without brace)

Question 6

What is posterior element overuse syndrome, how is it diagnosed and how is it managed?

Answer 6

• Exacerbated by extension, insiduous in onset
• Exam: focal tenderness over lumbar spine and paraspinal muscles
• Ix - negative
• Tx: NSAIDs, rice, +/- brace (return to play 4-8wk)

Question 7

What is vertebral avulsion fracture, how is it diagnosed and how is it managed?

Answer 7

• Definition: Repetitive spinal flexion and extension can injure the ring apophysis, resulting in fractures that may posteriorly displace into the spinal canal (e.g. volleyball, gymnastics, weight lifting)
• Exacerbated by flexion, acute in onset
• Exam: spinal flexion and extension limited, and paraspinal muscle spasm
• Lumbar lateral x-rays: ossified fragment in the canal
• CT preferred to identify the fracture (may be missed by MRI)
• Tx - PT & rest, if red flags may need surgery surgery
• Return to play: 3-6 months

Question 8

What is disc hernation, how is it diagnosed and how is it managed?

Answer 8

• Associated sx: back spasm, hamstring tightness, buttock pain
• Exacerbated by flexion, acute sometimes chronic
• Radicular symptoms are uncommon
• Exam: decreased flexion, positive straight elg raise, decreased reflexes and strength of lower extremities (less commonly)
• Ix
  
  • Lumbar x-rays - rule out fractures and tumours
  • MRI - clarifies extent of hernia, including nerve root impingement
• Tx - mostly conservative, consider surgical if cauda equina syndrome
• Return to play - 3-6 months

Question 9

What is the percentage that these food groups should make up (especially for athletes): carbohydrates, protein, fats, saturated fats

Answer 9

• Carbohydrates: 45-65%
• Protein 10-30%
• Fats: 25-35%
• Saturated fats: < 10%

Question 10

What is the recommended amounts of calcium, Vit D and iron per day for children and youth? What are example of good sources?

Answer 10

• Calcium: bone health, enzyme activity, muscle contraction
  
  • Daily recommended intake: 1000mg/day 4-8yo; 1300mg/day 9-18yo
  • Sources: milk, yogurt, cheese, broccoli, spinach
• Vit D: bone health, absorption of calcium
  
  • 600 IU/day for 4-18yo
  • Sources: fortified foods and sun exposure
• Iron: oxygen delivery
  
  • 9-13yo: 8mg/day
  • 14-18yo: 11mg/day males, 15mg/day females
  • Female athletes, vegetarians and distance runners should be periodically screened for iron status (losses through sweat, menstrual blood)
  • Soruces: eggs, leafy vegetables, fortified whole grains, lean meat

Question 11

What are the six ‘E’s in developing effective injury prevention programs for indigenous groups?

Answer 11

• Education —> anticipatory guidance for families (e.g. helmets, seat belts, PFDs), local media, school programs, CPR training, swimming lessons, emergency preparedness
• Empowerment → incorporate indigenous culture & language, ensure local participation in planning and implementation
• Enabling → provide easier access and affordability (e.g. smoke detectors, bike helmets, PFDs)
• Engineering → design safer products and environments
• Enforcement → involve board council members and community leaders to help with implementation and reinforcement
• Employment → enhance community participation and create revenue