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Flashcards in Musculoskeletal + Rheumatology Deck (63)
1

Acquired toritcolis

Common causes:
- URI
- minor trauma
- cervical lymphadenitis

Serious:
- retropharyngeal abscess
- atlantoaxial subluxation

Get Cervical spine radiographs!

2

Legg Calve Perthes

Avascular necrosis of femoral head

Mostly boys

Limping painless --> pain in groin, hip, thigh, knee

Will persist for > 1 month if no tx

Dx - radiographs show wide articular space, then necrosis

Tx
- self healing
- maintain joint mobility via containment (maintain hip in acetabulum)

Complications - osteoarthritis

3

How long can developmental dysplasia of hip be considered

birth --> 3 yo

4

Slipped capital femoral epiphysis

Adolescents

Displacement of femoral head from neck because of stress fracture through femoral capital epiphyseal plate

Most pts obese, possible endocrine basis

Tx
- pinning
- external fixation
- bone grafts
- casting

5

Scoliosis

Abnormal curvature of spine caused by misalignment in frontal plane

Dx w/ Adams test (forward bending)

Tx
- bracing to slow down progression
- surgery if curve > 45 degrees

6

Primary neoplasms of bone in children

Osteosarcoma
Ewing sarcoma

7

Association with osteosarcoma

Retinoblastoma

8

Osteosarcoma

- Common in long bones at metaphysis
- Pain at tumor site
- Sites of mets - lung + bone
- pelvic tumors present worse prognosis

Radiographs - "sunburst" appearance

Dx - biopsy

Tx - surgery + chemo

9

Ewing sarcoma

Ages 10-20

- Mets to lung and LN
- worse prognosis if primary is in pelvis or if mets at time of dx

Radiograph - onion skin periosteal r
eaction

Dx - biopsy

Tx - surgery, radiation, chemo

10

Pes planus

Flat feet

Variant of normal

Usually in kids > 6 yo

11

Popliteal cyst

Arise from capsule or tendon sheaths

Painless
Nonpulsatile swelling
Posterior aspect of knee

More prominent on knee extension

Tx - none, will resolve spontaneously

12

Osgood Schlatter disease

Traction apophysitis of tibial tubercle caused by overuse

Localized tenderness
swelling over tibial tubercle

Pain exacerbated by running and jumping
relieved by rest

Radiograph - soft tissue swelling over tubercle

Tx - resolution in 12 - 24 mos; NSAIDs no help

13

Radial head subluxation

2/2 sudden traction on arm, usually in kids < 4 yo

Child cries immediately, won't move arm

Arm held partially flexed at elbow + supinated

Radiographs - normal

Tx - reduction by gentle supination with pressure overa radial head

14

Most common fx in pediatric population
- associated complication?

Supracondylar fractures

Complication = entrapment of brachial artery --> loss radial artery pulse


ALWAYS check radial pulse

15

Axillary N injured in..

proximal humerus fractures

16

Myotonic dystrophy

AD

Presents as teen

Skeletal muscle weakness
Myotonia (delayed muscle relaxation)
Cataracts
Cardiac conduction abnormalities

Most affected muscles:
- facial
- intrinsic hand
- ankle dorsiflexors

17

Juvenile dermatomyositis

Presents 5-10 yo

Symmetrical proximal muscle weakness
Gottron papules
heliotrope rash
arthralgias
dysphagia

18

Panner disease

osteochondrosis of capitellum

Adolescents, active in sports and throwing

Pain
Crepitation
Loss of motion of arm (pronation and supination, esp_

19

Most common elbow dislocation

posterior dislocation 2/2 falling backward on outstretched arm

20

Developmental dysplasia of hip
- charac
- tx

Developmental dysplasia of the hip encompasses both subluxation and dislocation of the newborn hip, as well as anatomic abnormalities.

It is more common in firstborns, females, breech presentations, oligohydramnios, and patients with a family history of developmental dysplasia.

1st step:
- refer to ortho

Tx: Closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age

21

Meniscal vs ligamentous presentation

Rupture of ligament = Rapid onset of effusion

Meniscal injury / ligament sprain = slower onset (24 to 36 hours) of a mild to moderate effusion

Meniscal injury = Recurrent knee effusion after activity

22

Anterior knee pain localized to tibial tuberosity

Young kid who recent went through growth spurt

Osgood-Schlatter lesion

- stress on patellar tendon --> microavulsions of growth plate on tibial tubercle where patellar tendon inserts

Pain reproduced by extending knee against resistance

Can see on xray lifting of tubercle from shaft of tibia

Tx w/ activity restrict, stretching, NSAIDs

23

When does anterior fontanelle close? What if it closes early?

13.5 months on average

Serial head measurement circumference

The patient needs to be monitored for craniosynostosis (premature closure of one or more sutures) and for abnormal brain development

When craniosynostosis is suspected, a skull radiograph is useful for initial evaluation. If craniosynostosis is seen on the film, a CT scan should be obtained

24

Patellofemoral pain syndrome

is a common overuse injury observed in adolescent girls.

The condition is characterized by anterior knee pain associated with activity.

The pain is exacerbated by going up or down stairs or running in hilly terrain. Can also c/o pain w/ sitting due to sustained flexion

It is associated with inadequate hip abductor and core strength;

Patients complain of popping, catching, stiffness, and giving way.
- EXAM: + J sign = patella moving from a medial to a lateral location when the knee is fully extended from the 90° position.


therefore, a prescription for a rehabilitation program is recommended

25

Causes of Reactive arthritis

Chlamydia
GI pathogens

NOT gonorrhea

26

Juvenile Rheumatoid arthritis
- What is it

Chronic
Nonsuppurative
Inflammation of joints

Joint effusions +
Destruction of joint cartilage +
bone deformity, destruction, fusion

Triggers:
- Borrelia
- Mycoplasma

27

Juvenile Rheumatoid arthritis
- presentation

AM stiffness
Joint pain
Swelling
Decreased ROM
Joint is warm

Polyarticular i
- knees
- ankles
- elbows
--> SPARES HIPS!
- small joints = bad prognosis

vs

Pauciarticular (oligoarthritis) in fewer but larger joints
- asymmetric distribution

vs

Systemic (extraarticular manifestations)

28

JRA - Polyarticular involvement

Subdivide into:

RF+
- older age onset
- assoc w/ nodules, erosions
- more in hands and wrists
- fem > males

ANA +
- females
- younger onset
- good prognosis
- higher risk of eye disease

Seronegative

29

JRA - Pauciarticular (oligoarthritis) involvement

Asymmetric

Subdivide into:

ANA+
- most common
- < 4 yo start
- knees, ankles, elbows
- girls > boys
- assoc w/ eye path like iridocyclitis

RF+
- erosions
- polyarthritis
- poor prognosis

HLA B27+
- males > females
- high risk for ankylosing spondylitis

Seronegative

30

JRA - systemic

Extraarticular manifestations

Fever
rash
HSM
pleuritis
pericarditis

31

Tx JRA

#1 - NSAIDs

#2 - Methotrexate

Antimalarials
PT
Ophtho f/u

Some: Steroids

32

Systemic lupus erythermatosus
- presentation

Great mimicker!

Fever
Malaise
Arthritis
Arthralgia
Butterfly rash
Photosensitive
Serositis
Libman Sacks endocarditis
Seizures
Stroke
Raynauds

33

SLE - dx

4 of the criteria must be present at some time:

MD SOAP N HAIR

Malar rash
Discoid rash

Serositis
Oral ulcers
Arthritis
Photosensitivity

Neuro - seizures

Heme - anemia, leukopenia, lymphopenia
ANA +
Immuno - LE prep, anti DNA ab
Renal - proteinuria, casts

34

Anti ds DNA

Very specific for SLE

poor prognosis

35

Anti-histone antibodies

More sensitive for drug induced lupus

36

What is death from SLE usually 2/2 to?

Nephritis

CNS complications

Infections

37

Neonatal lupus

Can occur in newborns w/ moms who have lupus

Transfer IgG anti-Ro at 12-16 wks gestation

All manifestations usually resolve except for congenital heart block

38

Albinism

Congenital deficiency of:
- tyrosinase (converts tyrosine --> melanin, Autosomal recessive)
- defective tyrosine transporters (dec amts of tyrosine, therfore melanin)

Can also result from lack of migration of neural crest cells

Variable inheritance due to locus heterogeneity (vs ocular albinism is X linked)

39

Acne vulgaris

2/2 to:
P. acnes infection
Abnormal keratinization of follicular epithelium
Increased production of sebum
Inflammation

Tx:
- no special diet
- benzoyl peroxide
- Retin A
- Adapalene
- topical abx (clinda, erythromycin)
- PO tetracycline
- hormonal therapy

40

Achondroplasia

AD

But 90% fresh mutations

Short stature
Large head
Lumbar lordosis
Short limbs

Normal intelligence

Hydrocephalus 2/2 narrow foramen magnum

41

most common reason for septic joint in kids

Staph aureus

42

Septic joint suspected in kids...what do you do first?

Arthrocentesis to dx and tx

DO NOT do empiric abx as can interfere w/ isolation of offending organism

43

Tx for septic arthritis
- birth-3 mo
- > 3mo

Birth-3 mo
- Staph, group B strep, Gm- bacilli, Kingella**
- Abx: Nafcillin or vanco for staph + gentamicin or cefotaxime

> 3 mo
- Staph, group A strep, Strep pneumo
- Abx: Nafcillin, clindamycin, cefazolin or vancomycin

44

Top causes of osteo in sickle cell kids

Salmonella

Staph aureus

45

+ limp

Following viral infection or mild trauma

Hip flexed, slightly abducted, externally rotated

What do you suspect?

Transient synovitis

#1 cause of hip pain in children

Usually in boys 3-10yo

Resolves in 1-4 weeks (at most 1 month!!!)

Synovial inflammation --> pain, decreased ROM, limping

Flex + abduct + externally rotate maximized joint space providing some relief

Will NOT have fever or significant lab abnormalities (vs septic arthritis having leukocytosis, increased ESR and CRP

If sx persist or worsen, consider legg calve perthes and may need MRI if xrays were normal

Tx:
- rest
- NSAIDs
- NOT REYE

46

#1 cause of osteomyelitis in infants an dchildren

Staph aureus

other common:
- group B strep + ecoli in infants
- strep pyogenes in children

47

greatest risk factors for cerebral palsy

Premature birth

Spastic diplegia is most commonly seen in preterms
- hypertonia
- hyperreflexia
- both feet pointing down and inward (equinovarus deformity)
- clasp knife rigidity

48

Tx impetigo

Topical mupirocin

Oral erythromycin

Usually caused by
- GABS
- S aureus

49

Eczema herpeticum

Form of primary herpes simplex virus infeciton assoc w/ atopic dermatitis

Usually superimposed on healing atopic dermatitis lesions after epxosure to herpes simplex virus

Numerous umbilicated vesicles over area of healing atopic dermatitis is typical

50

Complications of shoulder dystocia

Fx clavicle

Fx humerus

Erb-Duchenne palsy

Klumpke palsy

Perinatal asphyxia

51

Fractured clavicle 2/2 shoulder dystocia findings

Clavicular creipitus/bony irregularity

Dec MOro 2/2 pain on affected side

Intact biceps + grasp reflexes

52

Fx humerus 2/2 shoulder dystocia findings

Upper arm crepitus / bony irregularity

Decreased Moro 2/2 pain on affected side

Intact biceps + grasp reflexes

53

Erb Duchenne palsy

Decreased Moro + biceps reflex on affected side

Waiter's tip = extended elbow + pronated forear m+ flexed wrist and fingers

C4/C5-C6 affected

Results 2/2 increased distance between head and shoulder

Tx - usually spontaneously recover. Surgery if no improvement age 3-6 mo

54

Klumpke paralysis

"Claw Hand"
- extended wrist
- hyperextended MCP joints
- flexed IP joints
- No grasp reflex

Horner syndrome

Intact moro + biceps reflexes

C7-T1

Paralysis of hand

55

Vitamin D deficiency rickets
- risks
- clinical signs

Risks
- increased skin pigmentation
- only breastfeeding
- mom vit D def

Clinical
- Craniotabes
- delayed fontanel closure
- Enlarged skull, costochondral joints, long bone joints
- Genu varum

56

Vitamin D deficiency rickets
- Xray
- Labs

Xray
- osteopenia
- metaphyseal cupping + fraying
- epiphyseal widening

Labs
Decreased
- Ca
- PO4
- 25-OH vit D

Increased
- ALP
- PTH

57

Metatarsus adductus

Congenital foot deformity

More common in 1st born infants

2/2 molding effect of primigravid uterus

Type 1
- feet that OVERCORRECT passively and actively into abduction
- spontaneous resolution, no tx needed

Type 2
- feet that correct to neutral w/ passive and active mvmts
- tx w/ orthosis or corrective shoes

Type 3
- rigid feet that do not correct
- tx w/ serial casts

58

How do you tell if baby has hip dysplasia just by looking?

inguinal skin folds
- if they are asymmetric or extend beyond the anal aperture, this suggests developmental dysplasia of hip

59

If baby has asymmetric inguinal skin folds but negative Barlow and Ortolani, what do you do?

2wk - 6 mo --> Hip US

>4-6 mo --> Hip Xray

Xray is not helpful until age 4-6 mo because femoral head and acetabulum not yet ossified

60

When paralysis of upper extremity from injury to brachial plexus is found in a neonate injury, injury to what N should also be suspected?

Phrenic

The nerve roots are close together!

Will have impaired inspiration and the negative pressure from the OK diaphragm will pull mediastinum toward normal side impairing ventilation further

61

Fifth finger (postaxial polydactyly) more common in..

Blacks

If find in white child, careful exam of cardiac system is warranted

Assoc syndromes;
- trisomy 13
- rubinstein-taybi
- meckel gruber
- ellis van creveld

62

Harlequin syndrome

transient change in skin color of otherwise asymptomatic newborn

usually premies

dependent side of the body turns red while the upper side remains pale

63

Why is aseptic necrosis of femur head uncommon kids?

Femoral head has 2 main sources
- ascending A
- foveal A

Foveal A can become obliterated in older kids so increase risk of avascular necrosis