Lecture 6: Rheum & MSK

Question 1

3 Requirements for Dx of Juvenile Arthritis (JIA)?

Answer 1

1. Evid of joint inflammation
2. CHRONIC arthritis (> 6 wks)
3. Sxs must have been present at < 16 yrs old

Question 2

4 signs on PE indicating chronicity of Juvenile Arthritis

Answer 2

1. Synovial thickening
2. Contracture
3. Bony proliferation
4. Limb length discrepancy

Question 3

Definition of Systemic Juvenile Arthritis/Still’s Dz
(subset of JIA)

What is the typical fever pattern in this dz?

Answer 3

Systemic inflammation BEFORE onset of arthritis

daily fever spike of > 39 C –> quickly goes below baseline
- feel fine b/t spikes

Question 4

4 characteristics of the rash a/w Systemic Juvenile Arthritis/Still’s Dz?

Answer 4

1. at peak of fever
2. Erythematous maculopapular rash on trunk/extremities
3. Migrates + fades quickly
4. Dermatographia

Question 5

1. Main thing seen on labs a/w Juvenile Arthritis?
2. What other lab results a/w JIA?
3. What is NOT seen in kids in JIA labs?

Answer 5

1. ANA (anti-nuclear Abs)
2. Evid of systemic inflam (C reactive protein, WBCs, etc)
3. Rheumatoid factor NOT seen in kids w/JIA

Question 6

Which type of JIA has the highest prevalence of ANAs
- what is only prob w/ANAs for Dx?

When is Rheumatoid factor positive?

Answer 6

Oligoarticular JIA = most ANAs

Rheumatoid factor is positive in adol + adults w/ RA

Question 7

What is lst line Tx for JIA?

• when should you switch pts to something else?
• what are the other 3 Tx options?

Answer 7

1st line = NSAIDs
- switch if not working in 1-2 wks

other Tx options

1. Hydroxychloroquine
2. Methotrexate
3. Biologics (-mabs, etc)

Question 8

What is the main complication of JIA?

Therefore kids w/what dz are required to be screen for this?

Answer 8

Uveitis
- note: MC cause of blindness in kids and often Asx

screening required for ALL kids w/chronic arthritis

Question 9

3 cutaneous manif a/w Juvenile Dermatomyositis (JDM)?

Answer 9

1. Heliotrope rash –> rash around eyes
2. Gattron’s papules (fingers)
3. Periungual erythema

Question 10

Main sign a/w Juvenile Dermatomyositis?
What it is/what is it d/t?

Other signs

1. Calcinosis/calcif of muscles
2. Lipotrophy

Answer 10

Gower’s sign = child must must hands to “walk own body up from lying prone position to stand
- d/t lack of strength of in hips/thighs (proximal muscle weakness)

Question 11

What 3 things provide evid of inflammatory myositis in JDM?

Answer 11

1. Muscle enzymes elevated
2. Muscle Bx
3. MRI

Question 12

What is the initial Tx for JDM?

- other tx options?

Answer 12

start w/prednisone

• other: Methotrexate, Cyclophosamide

Question 13

2 Cutaneous manifestations of Henoch-Schonlein Purpura (HSP)?

note: dz peaks in winter

Answer 13

1. Palpable purpura = MC

2. Edema (hands, feet, face, scrotum)

Question 14

MC areas and appearance of Palpable Purpura in HSP?

Answer 14

MC in dependent areas –> bac of legs/butt

appearance = petechia/macules/urticaria –> ecchymosis

Question 15

4 things a/w Arthralgia/arthritis see in Henoch-Schonlein Purpura?

Answer 15

1. in large LE joints
2. v. painful–> refuse to bear wt
3. joint swelling but usu no erythema
4. Transient

Question 16

3 signs a/w GI involvement in Henoch-Schonlein Purpura?

Note: onset = w/in 1wk -1 mo of rash

Answer 16

1. colicky abd pain
2. heme (+) stools
3. intestinal perforation

Question 17

What is the renal involvement in Henoch-Schonlein Purpura (HSP) d/t? 3 things seen w/it?

Note: onset = w/in 1-3 mo of rash

Answer 17

d/t acute glomerular nephritis

1. hematuria/proteinuria
2. HTN
3. +/- renal failure

Question 18

2 things seen on labs a/w Henoch-Schonlein Purpura
- what cannot be present?

Results on pathology?

Answer 18

1. Elevated inflam markers
2. Normocytic, normochromic anemia
   - CANT HAVE THROMBOCYTOPENIA

Pathology –> IgA deposition w/Leukocytoclastic vasculitis

Question 19

Classic palpable, non-thrombocytopenic purpuric rash + 1 of following:

• arthritis or arthralgia
• abd pain and/or GI blood loss
• Bx w/IgA deposition

What name of this/dz a/w?

Answer 19

EULAR consensus criteria for HSP

Question 20

What is given for Tx of arthritis in HSP?

Tx for severe GI dz or active renal dz?

Answer 20

Tx for arthritis = NSAIDs

Tx for severe GI dz or active renal dz = CCS

Question 21

1 y/o pt in February present w/fever for last 5 days, non-exudative bilateral conjuctivitis, swollen/red/cracked lips and tongue and LAD of single cervical node. What is Dx?\

What is name for lip/tongue sign?
Peak months?

Answer 21

Dx = Kawasaki Dz

Strawberry lips + tongue

Peak = February - May

Question 22

Nemonic for Dx criteria for Kawasaki Dz and what each stands for?

What if pts present w/4+ ?

Answer 22

“FEBRILE”

1. Fever
2. Exanthem
3. Bulbar conjunctivitis
4. Rash
5. Internal organ involvement (not part of it)
6. LAD
7. Extremity changes

4+ present –> can Dx on day 4 of fever

Question 23

What is the mainstay of Tx for Kawasaki Dz?
- when given and why?

Other medication given in this dz?

Answer 23

IVIG
- given w/ 7-10 days of onset of rash –> prevent cardiac complications (HIGH RISK OF CORONARY ARTERY ANEURYSM)

ASA –> once instance where given in kids
(Reye’s Syn)

Question 24

5 y/o comes in complaining of deep aching pain for 6 months that occurs MC in her legs. Her mother said the pain usu occurs after playing or later in day/night. PE was normal. What is Dx and how to Tx?

Answer 24

Dx = growing pains
Note: MC in 3-7 y/o & legs, chronic pain

Tx = stretching and reassurance

Question 25

5 y/o pt comes in non-articular bone pain, back pain, bone tenderness, severe wt loss + fever, night sweats and bruising... What is most likely cause?

Answer 25

Cancer

Question 26

What in newborns put them at risk for developing Developmental Dyplasia of Hip (DDH)? Other RFs: female, breech, FHx What are the 2 main presentations of baby w/DDH?

Answer 26

newborns = ligamentous laxity --> spontaneous hip dislocation 1. Asymmetrial Creases 2. Galeazzi's Sign --> asymmetric knee heights

Question 27

Name of the two screening tests for Developmental Dyplasia of Hip/what they are for?

Answer 27

1. Barlow Test = dislocation | 2. Orotolani Test = reduction

Question 28

Tx of DDH for younger kids < 6 mo vs older kids?

Answer 28

young kids < 6 mo --> Pavlik harness --> put hip back in place (usu in 2 wks) older kids --> surgery

Question 29

Why does Avascular Necrosis of the Femoral Head occur? what is it a common complication of? Note: aka Legg-Calve-Perthes Dz

Answer 29

Femoral Head lacks collateral blood supply complication of SCD

Question 30

3 common S/s of Avascular Necrosis of the Femoral Head? What is late sign of dz seen on XR? Tx for kids > 6 y/o?

Answer 30

1. painless limp 2. +/- intermittent LE pain 3. decr internal rotation + abduction of hip Late sign on XR = flattening of femoral head Tx = braces/surgery

Question 31

What d/o is an orthopedic emergency, mainly occurring in adolescents?

Answer 31

Slipped Capital Femoral Epiphysis

Question 32

12 y/o pt presents w/limp, decr ROM and atalgic gait. You notice she is holding her R leg externally rotated position. When you hip her R hip her leg externally rotates and there is limited internal rotation + loss of flexion/extension. Dx? Tx?

Answer 32

Dx = Slipped Capital Femoral Epiphysis - note: if unstable pts cant ambulate at all Tx: NWB status, ortho referral for surgery

Question 33

2 complcations of Slipped Capital Femoral Epiphysis?

Answer 33

1. Chondrolysis | 2. Avascular necrosis

Question 34

What is Osgood-Schlatter Dz? When does it typically occur and boys vs girls?

Answer 34

Microfracture or partial avulsion involving tibial tubercle (TT) Typically after growth spurt - earlier in girls than guys

Question 35

3 s/s of Osgood-Schlatter Dz? Tx = rest, modify activity, ICE, NSAIDs, stretch/exercises

Answer 35

1. knee pain (during/after activ) 2. tender + local swelling (TT) 3. bony enlargement (TT)

Question 36

How to distinguish in-toeing vs out-toeing? How position the child?

Answer 36

Thigh-Foot-Angle Measurements w/child lying prone | - look at angle of foot compared to thigh

Question 37

Other names for Bowleg and Knock Knees only 2 reasons surgery needed?

Answer 37

Bowleg = Genu Varum Knock Knees = Genu Valgum surgery if severe disformities or gait dysfxn

Question 38

What is torticollis? 2 common findings in infants?

Answer 38

shortening of sternocleidomastoid muscle 1. tilt ear towards affected side 2. look up toward contralateral side

Question 39

How does Polydactyly affect Af Am vs Caucasians?

Answer 39

Af Am --> pinky affected (AD inheritance) | Caucasians --> thumb affects

Question 40

3 types of Polydactyly? What type is the only one that doesnt need surg? what is Tx?

Answer 40

Type 1 = soft tissue only --> dont need surg - Tx = ligation or electrocautery Type 2 = duplicate finger +bone/joints Type 3 = duplicate finger + metacarpal

Question 41

What is scoliosis? How detect? When is least likely idiopathic? 2 non-idiopathic causes? How to measure angle of curve? Who more likely to have bigger curve?

Answer 41

Lateral curvature of spine (truncal asymmetry) - w/"forward bend test" Least likely idiopathic in infants (birth - 3 yrs) Non-idiopathic causes: 1. Cerebral Palsy 2. Muscular Dystrophy Cobb angle on Xray bigger curve more likely in females

Question 42

When is bracing considered for scoliosis? Other option/considered when?

Answer 42

bracing: curve 20-40 degrees Other option = surgery - curve > 40 degrees

Question 43

Mechanism for Nursemaid's Elbow why common in < 5

Answer 43

1. Axial traction on pronated forearm + extended elbow --> annular ligament -->trapped in radiohumeral joint "Swinging kids by arm" at age 5 annular ligament strengthened

Question 44

3 y/o boy presents w/arm pain w/active supination. He is holding his arm close to his w/elbow fully extended and forearm protonated. What should you do to Tx his condition?

Answer 44

Tx = Radial Head Subluxation | for Nursemaid's Elbow

Question 45

Steps of Radial Head Subluxation for Tx of Nursemaid's Elbow

Answer 45

1. thumb on radial head 2. apply longitudinal traction 3. supinate forearm 4. flex elbow