Musculoskeletal 1

Question 1

What to expect with musculoskeletal types of limp pain (7)

Answer 1

1. Acute and severe: trauma, infection, malignancy
2. Gradually worsening: inflammation or mechanical
3. Constant: tumor or infection
4. Morning or inactivity pain: inflammatory
5. Night time pain: growing pains or malignancy
6. After activity pain: mechanical
7. . Absence of pain: neuromuscular or metabolic

Question 2

Antalgic Gait (3)

Answer 2

Gait that develops as a way to avoid pain while walking (antalgic = anti- + alge, “against pain”). It is a form of gait abnormality where the stance phase of gait is abnormally shortened relative to the swing phase.
*Indicates pain with weight bearing

1. Directed by pain in affected limb
2. Single limb support – shortened stance phase in affected painful extremity
3. Cautious gait with diskitis

Question 3

Myopathic Gait

Answer 3

Weakness of proximal muscles of pelvic girdle (may have gluteal weakness)

Question 4

Circumduction gait (5)

Answer 4

1. Shortens limb for foot clearance
2. Excessive hip abduction
3. Pelvic rotation
4. Hiking
5. Leg length discrepancy

Question 5

Equinus Gait (4)

Answer 5

1. Limited ankle dorsiflexion
2. Gastroc soleus weakness
3. Shortened Achilles tendon
4. Should be in flat shoe with support

Question 6

Trendelenburg Gait (2)

Answer 6

1. Hip abductor weakness

2. Stance on involved side leans toward affected site as the contralateral pelvis drops

Question 7

Neuropathic Gait (3)

Answer 7

1. Ankle dorsiflexor weakness
2. Seen in charcot-marie tooth
3. Foot drop due to dorsiflexor weakness

Question 8

Cautious Gait (3)

Answer 8

1. To avoid jarring of back
2. Gait is slow
3. Due to painful spine or discitis

Question 9

Grotesque limp pattern (2)

Answer 9

1. Bizarre gait which is out of the normal range

2. Inconsistent with organic pathology

Question 10

Plain film

Answer 10

= first line for abnormal gait’ soft tissue changes can be seen in 50%

Question 11

What are bone scans good for? (7)

Answer 11

1. Increased flow and osteoblastic activity
2. Osteomyelitis
3. Stress fracture
4. Occult fracture
5. Neoplasm
6. Metastases
7. Early bone infection

Question 12

Musculoskeletal Ultrasounds (4)

Answer 12

a. Osteomyelitis
b. Inflammatory myositis
c. Hip effusions with 77-100% sensitivity
d. Not used if over 4 months or if very chubby; After 4 months can do frog leg or PA/later for hip dysplasia

Question 13

Musculoskeletal CT (3)

Answer 13

a. Imaging cortical bone
b. Osteoid osteoma
c. Tarsal coalition

Question 14

Musculoskeletal MRI (2)

Answer 14

a. Cartilage, joints, soft tissue, marrow

b. Will show infections

Question 15

When to do lab tests for musculoskeletal problem?

Answer 15

Acute non-traumatic limp with fever, malaise, night pain or localized areas of complaint

Question 16

Musculoskeletal ESR

Answer 16

If there is in issue, ESR will increase in 24-48 hours and persist for 3 weeks
*90% of osteomyelitis will have elevation

Question 17

Musculoskeletal CRP (2)

Answer 17

1. Acute phase protein synthesis
2. Increases in 6 hours but normalizes in 6-10 days
   * More sensitive because it goes up before ESR and it is more stable than ESR

Question 18

Musculoskeletal WBC

Answer 18

Can be normal in osteomyelitis

Question 19

Musculoskeletal CBC w/ Diff

Answer 19

65%-70% abnormal in osteomyelitis and septic arthritis

Question 20

Bone Cancer presentation and best test to do for it (5)

Answer 20

1. Increasing pain above area of tumor
2. Dull, achy pain
3. Insidious onset that gets worse
4. Febrile
5. Best test to do = CBC w/ diff and sedimentation rate

Question 21

Where does pain occur w/ Osgood Schlatter?

Answer 21

below the knee

Question 22

Toxic Synovitis (8)

Answer 22

1. Benign self-limiting
2. Usually less than 4 year
3. Boys 3-8 more common
4. Afebrile or very low grade very
5. Pain is mild
6. Restricts of movement with leg held in external rotation
7. WBC normal or very slight elevations of markers of inflammation; WBC > 12000, high sed. rate > 40, inability to bear weight
   (history of fever more likely to be septic arthritis)
8. Diagnosis of exclusion

Question 23

Osteomyelitis patho (2)

Answer 23

1. Hematogenous spread or by direct invasion of pathogens into bone; can be precipitated by trauma
2. Osteomyelitis in a baby most commonly spreads hematologically, but in teenage years it can occur from external trauma or cellulitis

Question 24

Osteomyelitis Presentation (5)

Answer 24

1. Fever and pain; usually occur together
2. Erythema
3. Swelling and pinpoint tenderness of affected bone
4. Decreased ROM due to muscle splinting
5. If lower extremities - can present with limp

Question 25

Osteomyelitis tests (3) and treatment (1)

Answer 25

1. MRI = more specific 2. Blood cultures may be positive 3. X-ray may be normal for one week 4. Treatment of 4-6 weeks of antibiotics

Question 26

Septic Arthritis Patho (3)

Answer 26

1. Infection in joint following puncture injury, hematogenous spread of bacteria into the joint space or continuous spread from cellulitis or osteomyelitis 2. Hematogenous spread is most common in neonates and infants due to a large network of blood vessels that cross from metaphysis to epiphysis. * More common in infants because of blood vessels that disappear at 1 year old * The vessels are obliterated by physis formation at one year. 3. Can accompany osteomyelitis

Question 27

Septic Arthritis Clinical Presentation (4)

Answer 27

1. Monoarticular arthritis with erythema and swelling * one hip may seem more swollen than the other 2. Fever 3. Limited motion due to pain 4. Intensive synovitis

Question 28

Septic Arthritis Common Pathogens (5)

Answer 28

1. Staphylococcus aureus #1 cause 2. Non group A strep 3. Haemophilus influenza type B 4. Salmonella is more common is sickle cell disease 5. Neisseria gonorrhoeae is possible in sexually active adolescent (purulent green discharge)

Question 29

Definitive Diagnosis of Septic Arthritis (6)

Answer 29

1. Joint aspiration 2. WBC elevated with shift to left 3. Markers of inflammation are elevation 4. Ultrasound detect joint effusions 5. X-ray lag for 10 days 6. MRI, CT and bone scan can be more helpful and demonstrate the abscess * MRI is more helpful in this case

Question 30

Septic Arthritis Tx (6)

Answer 30

1. Admission for IV antibiotics 2. Once improved, three weeks of oral antibiotics 3. Neonate: Cloxacillin and gentamicin 4. Infant 1-3 months of age: Cefuroxime; cefotaxime 5. Child: cefazolin 6. Adolescent: ceftriaxone or cefixime + azithromycin

Question 31

Lyme Disease (5)

Answer 31

1. Borrelia burgdorferi by tick bites 2. School age children 3. Arthritis is second most common presentation with erythema migrans as most common 4. Monoarticular arthritis months to years after infection 5. Swelling out of proportion to pain ********

Question 32

Growing Pains (8)

Answer 32

1. Intermittent nonarticular pain in childhood 2. Diagnosis of exclusion 3. 3-10 year old 4. Pain occurs at night 5. Bilateral ******* 6. Relieved with heat massage and mild analgesics 7. No limitation 8. Does not usually bother child during the day

Question 33

Rheumatic Fever required criteria for dx

Answer 33

Evidence of strep infection (ex: increased titer of ASO); positive throat culture for group A; recent scarlet fever

Question 34

Rheumatic Fever Major (5) and Minor (5) Diagnostic Criteria

Answer 34

Dx requires the required criteria, two major criteria and zero minor criteria OR the required criteria, one major criteria and two minor criteria Major: 1. Carditis 2. Polyarthritis 3. Chorea 4. Erythema marginatum 5. Subq nodules Minor: 1. Fever 2. Arthralgia 3. Previous rheumatic fever or heart disease 4. Acute phase reactions 5. Prolonged PR interval

Question 35

4 Types of Overuse Injuries

Answer 35

1. Stress fracture 2. Osgood Schlatter 3. Sinding-Larsen Johansson Disease 4. Severs Disease

Question 36

Stress fractures: most common location and cause

Answer 36

Most common location: lower extremities (tibia, metatarsals, fibula, navicular bones) but also can occur in upper extremities and ribs Cause: repetitive and submaximal loading of the bone, which eventually becomes fatigued and leads to a true fracture

Question 37

Stress fractures Clinical presentation (2)

Answer 37

1. Increasing pain in lower extremity during exercise | 2. Anything from knee down is usually where runners get it

Question 38

Stress fractures Patho (2) and Imaging (2)

Answer 38

Patho: 1. Bone is brittle and eventually breaks 2. Stress fracture of hip is rare but can disrupt blood supply leading to avascular necrosis of femoral head Imaging: 1. Bone scan detects early stress fractures; look for periosteal reaction around the bone 2. MRI is most sensitive, but is expensive