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PRCE > Rheumatology & Ortho q-bank > Flashcards

Rheumatology & Ortho q-bank Flashcards

1
Q 
What is the most common primary malignancy of bones in kids?
#2?
A

Osteosarcoma
Ewing’s sarcoma
M:F 1.5:1

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2
Q

How does osteosarcoma present and where?

A

Bone pain, limp, swelling. Rarely B-symptoms.

Located at epiphyses / metaphyses of maximum growth sites (distal femur, proximal tibia, humerus)

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3
Q

How to work up bone tumour?

A 
X-ray
CBC, chem (usually normal)
LDH and AlkP (elevated)
MRI
mets work-up: CT chest + bone scan
Ewing's requires BM bx x2
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4
Q

Osteosarcoma management?

A

Local resection VERY important + chemotherapy (doxo, MTX, ofosfamide, cisplatinum)
NO radiation.
5 year survival 75%
negative prognostic factors: pelvic tumours, widespread lung mets, bone mets (<20% survival)

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5
Q

Ewing’s presentation?

A

Systemic symptoms.
Pain, swelling, decreased ROM.
Femur and pelvis most common sites, equal distribution among extremities and central axis.
*primarily white people

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6
Q

Ewing’s treatment?

A

Radiation therapy
Chemo
Resection
Chemo
75% cure in small, nonmets, local tumours
<30% with mets to bone or bone marrow at dx

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7
Q

Syndromes / conditions predisposing to osteosarcoma?

A

Retinoblastoma
Li-Fraumeni
Paget disease
Radiotherapy

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8
Q

Presents with gradually increasing bone pain at femur or tibia, worse at night and relieved by aspirin/NSAIDs.

A

Osteoid osteoma.
25% not on xray, CT required
Treat by resection, some spontaneously resolve.

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9
Q

List 7 causes of intoeing gait

A

1) metatarsus adductus (types: flexible, bone, heel-cord)
2) talipes equinovarus (serial casting)
3) internal tibial torsion (reassure)
4) femoral anteversion (most common, clinical dx, no W sit)
5) spasticity
6) paralysis
7) maldirected acetabulum

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10
Q

Progression of treatment for JIA?

A
  • NSAIDs (4-6wks)
  • intra-articular steroid injection
  • Methotrexate
  • biologic DMARD ie: TNF-alpa antagonist (etanercept, adalimumab/humera, infliximab/remicaide)
  • systemic steroids for severe systemic illness, bridge therapy awaiting DMARD response, uvveitis control *may not prevent joint destruction in addition to many s/e’s
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11
Q

Who is at greatest risk of severe JIA uveitis and how to manage?

A

ANA + disease, < 6yo, oligoarticular

initial: mydriatics and steroids
then MTX or anti-TNF-alpha

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12
Q

Juvenile dermatomyositis diagnosis?

A
  • primarily clinical diagnosis based on characteristic rash (heliotrope, Gottron’s) with three signs of symmetric, proximal muscle weakness
  • supported by elevated muscle enzymes (CK, AST, ALT, LDH) and EMG (denervation & myopathy)
  • if in doubt or to grade disease: muscle biopsy (necrosis & inflammation)

*photosensitive, bulbar weakness= VFSS, PFTs

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13
Q

Which auto-antibodies are associated with dermatomyositis?

A

ANA +ve in 80%

anti-Jo1 and anti-Mi2 may indicate severe disease

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14
Q

Dermatomyositis treatment progression?

A 
Corticosteroids
Methotrexate
Hydroxychloroquine for rash
MMF
IVIG
cyclophosphamide 
PT 
OT
sun avoidance
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15
Q

HSP organs involved?

A

Palpable purpura… 15-60% develop recurrences! milder each time
MSK: arthritis/arthralgias (75%)
GI: pain, intussusception, bleeding
GU: HTN, hematuria, proteinuria (50%) with renal disease as long-term complication in 1-2%, ESRD in 8% of HSP nephritis. Can develop up to 6 months after diagnosis
CNS: ICH, sz, headache
rarely: orchitis, carditis, eye, testes torsion, pulmonary hemorrhage r

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16
Q

Lab evaluation for HSP?

A

leukocytosis, thrombocytosis, anemia
increased ESR, CRP
high IgA

LOOK CLOSELY AT:
blood pressure
urinanalysis
serum creatinine

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17
Q

Name examples of enthesitis-related arthritis

A

The spondyloarthritides except psoriasis:
ankylosing spondylitis
IBD-associated arthritis
reactive arthritis

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18
Q

If an older boy develops LE joint pain and back of the heel pain, what is his most likely diagnosis?

A

Spondyloarthritis
HLA-B27
oligoarthritis +/- enthesitis

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19
Q

What are features of inflammatory back pain?

A 
nighttime pain
morning stiffness
improved by activity 
worsened by rest
insiduous onset
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20
Q

Presentation of juvenile ankylosing spondylitis?

A

oligoarthritis + enthesitis (mainly LEs and hips)
rarely axial involvement before adulthood
uncommonly with fever and weight loss –> don’t miss IBD!

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21
Q

SCFE risk factors?

A

OBESITY
black, polynesian, male
hypothyroidism, hypopituitary, osteodystrophy
if thin patient, <10 presents with SCFE: screen for endocrinopathy (ie GH, cortisol)

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22
Q

SCFE or LCPD physical exam?

A

limp
shortened & externally rotated lower extremity
limited internal rotation, adduction and flexion

23
Q

SCFE vs LCPD treatment

A

SCFE: pin it
LCPD: cast it

24
Q

When to screen for scoliosis?

A

Examine AP & lateral, Adam’s forward bend test, superficial abdominal reflex

girls: at 10 and 12 years of age
boys: once at 13 or 14

25
Q

What are atypical findings on radiograph for scoliosis?

A 
left thoracic curve
double thoracic curve
high thoracic curves
widening of the spinal canal
erosive or dysplastic changes
26
Q

What features of scoliosis allow you to just observe?

A

Curve <20 and skeletally immature

Curves 20-45 in skeletally mature

27
Q

What features of scoliosis mandate bracing?

A

Curve >30 in skeletally immature patient
Curve 20-25 that has progressed >5 degrees in a skeletally immature patient
Ineffective in curves >45

28
Q

What features of scoliosis mandate surgery?

A

Curves >45 in skeletally immature patients
Curves >50 in skeletally mature patients
Curves >35 if significant shift of the trunk relative to the pelvis and LEs

29
Q

Mnemonic for features of clubfoot?

A 
CAVE
cavus (midfoot)
adductus (forefoot)
varus (hindfoot)
equinus (hindfoot)
order of correction also follows this order
30
Q

Name 4 ways that maternal SLE can affect the neonate

A

1) congenital heart block *** only permanent effect, <3% in Ro & La +ve mothers
2) photosensitive or discoid rash (3-4 mo, within first 6 weeks)
3) hematologic anemia, thrombocytopenia or neutropenia
4) hepatomegaly +/- splenomegaly, hepatitis

31
Q

What are long-term orthopedic complications of JIA?

A 
leg-length discrepancy
flexion contractures
popliteal cysts
short stature
osteoporosis
32
Q

What is the classic triad of osteogenesis imperfecta?

A

fragile bones
blue sclera
early deafness

Autosomal dominant!
Type 1 collagen, other connective tissue laxity, easy bruising, mild short stature.
FULL LIFESPAN. Easy fracturing decreases after puberty.

33
Q

How to confirm osteogenesis imperfecta?

A

collagen biochemical studies usig dermal fibroblasts

34
Q

What do kids with OI die from?

A

Cardiopulmonary complications!
- recurrent pneumonias, decreasing fxn, cor pulmonale
Neurological complications also common.

35
Q

What are the classification criteria for JIA?

A 
age <16 hrs
arthritis
>/= 6 weeks
-polyarthritis: >/= 5 joints
-oligoarthritis: = 4 joints
-systemic disease: arthritis with rash and characteristic quotidien fever  (***rarely ANA+ or RF+)
36
Q

What do you think of a patient with SoJIA and low white blood cell or platelet count?

A

Do they have MAS?

Ferritin values can peak in MAS too

37
Q

What do you think of a patient with SoJIA and super high ESR/CRP/WBC/Plts?

A

That’s totally normal.

Also, hemoglobin 70-100 is normal.

38
Q

What kind of cell counts make you suspicious for septic arthritis?

A

> 50-100 thousand cells / mm^3

39
Q

What are features of systemic onset JIA?

A

1) fever: >/=2 weeks, quotidien, >/=39C, documented daily for at least 3 days
2) arthritis in >/=1 joint for >/=6 weeks
3) at least one of the following:
evanescent erythematous rash
generalized LN enlargement
HSM
serositis (ie pericarditis)

40
Q

How to make SLE diagnosis?

A

4 of 11 criteria simultaneously

1) malar rash
2) photosensitivity
3) discoid rash
4) oral ulcers

5) arthritis
6) serositis
7) renal disorder
8) neurologic disorder
9) hematologic disorder

10) ANA
11) Anti-DNA/Sm/phospholipid Ab/VDRL

side note: women&raquo_space;> men (90%!)

41
Q

How often is ANA + in SLE patients?

In the healthy population?

A

95-99% + ANA in SLE patients

20% in general population

42
Q

What is the most specific Ab in SLE?

A

DsDNA

43
Q

What Ab correlates with disease activity in SLE?

A

Anti-Smith

44
Q

What Ab is present most often in drug-induced lupus?

A

Anti-histone antibodies

45
Q

What Ab is related to other connective tissue disorders and Raynauds?

A

Anti-ribonucleoprotein antibody

46
Q

How long do you treat rheumatic fever without carditis?

A

5 years or 21 years of age, whichever is longer

47
Q

How long do you treat rheumatic fever with carditis but without residual heart disease?

A

10 years or until 21 years of age, whichever is longer

48
Q

How long do you treat rheumatic fever with residual heart disease?

A

10 years or until 40 years of age- lifelong if they’ll take it!

49
Q

How long can it take for Osgood-Schlatter to heal?

A

12-24 months

-rest, ice, NSAIDs, limit exacerbating activity, consider protection, strengthen quads

50
Q

What are Jones criteria Major manifestations?

A 
Polyarthritis
Carditis
Nodules
Erythema marginatum
Chorea
51
Q

What are Jones criteria Minor manifestations?

A

Clinical:
arthralgia
fever

Laboratory:
elevated acute phase reactants
ESR
CRP
prolonged PR interval
52
Q

Name three causes of bilateral toe walking

A 
Idiopathic (habit)
Tight achilles tendon
Cerebral palsy
Muscular dystrophy
Duchennes
Autism spectrum disorder
Spinal dysraphism
53
Q

What position do patient’s hold with a septic hip?

A

flexed, abducted and externally rotated

54
Q

What is Reiter syndrome?

A

Reactive arthritis after an enteric infection
“can’t see, can’t pee, can’t climb a tree”
salmonella, shigella, yersinia, campy, CHLAMYDIA
usually HLAB27 positive

PRCE (8 decks)

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