Rheum Flashcards
(128 cards)
1
Q
A 10 year old girl presents with 10 days of fever and a migratory arthritis. On exam she has a swollen left wrist. Her WBC is 18 and her ESR is 75. Diagnosis:
A. SLE
B. JRA
C. Rheumatic fever
D. Septic Arthritis
A
C. Rheumatic fever
2
Q
12 year old girl with 3 weeks of fever, malaise and polyarthralgias. No arthritis. Protein and blood in her urine, normal creatinine. Leukopenia, lymphopenia, normal platelets. ESR 75. What is the most likely diagnosis?
A. Systemic JIA
B. SLE
C. Rheumatic fever
D. Post strep GN
A
B) SLE
3
Q
Kid with Kawasaki disease. Got IVIG and high dose ASA. 24h later has gross hematuria 3+ blood and protein on urine dipstick. Elevated unconjugated bilirubin, transaminitis and LDH. (No mention of Hgb). What is the cause ?
A. Hemolytic IVIG reaction
B. Renal vein thrombosis
C. High dose ASA causing bleeding
A
A. Hemolytic IVIG reaction
4
Q
Girl plays soccer. Heel pain worse with running and jumping, but not with swimming. Tender Achilles on exam.
A. Calcaneal apophysitis
B. Calcaneal fracture
C. Achilles tendinitis
D. Plantar fasciitis
A
C. Achilles tendinitis
5
Q
You see a child with fever, arthralgoas and a rash on his lower limbs (see picture below). What test needs to be done now ?
A. Abdominal U/S
B. Urinalysis
C. IgA
A
B. Urinalysis
HSP
6
Q
A 10 year old twists his ankle playing soccer. He presents to the ER, where he is able to bear some weight but with +++ pain. What findings on physical exam would prompt you to order an X-ray ?
A. If he has pain on palpitation anterior to the medial malleolus
B. If he was unable to walk immediately after the injury
C. If he has pain in palpation posterior to medial malleolus
D. If there is swelling
A
C. If he has pain on palpation posterior to medial malleolus
7
Q
2 year old with mild metatarsus adductus and tibial torsion who has untiring since birth. There has been no improvement. They are presenting to your office today. The best advice is:
A. Reassurance
B. Hip, knee, tibia, foot xrays
C. Referral to Orthopedics
D. Advise them not to sit in W position
A
A. Reassurance
W- position more for femoral torsion
8
Q
You are treating a teenage boy with pericarditis. You suspect that his pericarditis might be secondary to SLE. Which of the following is most supportive of his diagnosis?
A. Positive RPR
B. Positive ANCA
C. Positive HLB27
D. Thrombocytosis
A
A. Positive RPR - SLE
B- ANCA - vasculitis
C- HLA B27 - ankylosing spondylythiasis
D. Thrombocytosis- SLE causes thrombocytopenia
9
Q
17 year old male with history of enthesitis related JIA comes to your office. Just had a new baby girl with his girlfriend and would like to quit smoking for her sake. What puts him Most at risk of not being able to quit ?
A. Chronic illness
B. Male gender
C. Older adolescent
D. Parenthood
A
A. Chronic illness
10
Q
Child in rhythmic gymnastics. Has back pain that is worse on extension. On exam has exaggerated lumbar lordosis, hamstring tightness. Bone scan is positive. What does she have ?
A. Spondylolysis
B. Posterior overuse syndrome
C. Herniated disk
D. Ring apophysis
A
A.spondylolysis
11
Q
6 y.o girl with diagnosis of JIA and pain in one knee. CRP 58. Sedimentation 25. ANA negative. No uveitis. What is the next step in management ?
A. NSAIDs
B. Methotrexate
C. Intra-articular corticosteroids
D. Oral steroids
A
A. NSAIDs
12
Q
Girl with systemic JIA well- controlled on methotrexate then re-presents with fever, unwell, rash, liver 3cm below costal margin. What is the most likely diagnosis ?
A. MAS
B. Sepsis
C. Methotrexate toxicity
D. Autoimmune hepatitis
A
A. MAS
13
Q
13 y.o girl presents with antalgic gait and pain for 2 weeks. She has difficulty with rotation and adduction of her leg. X-ray was similar to the one below. What is the diagnosis ?
A. Septic joint B. Calve-perthes C. SCFE D. Fracture E. Post infectious
A
C. SCEFE
14
Q
8 y.o boy had URTI 2 weeks ago; now presents with fever >40, unable to weight beat on right leg. WBC is 18, ESR 40 and CRP 80. What is the next step in management?
A. Admit and start IV abx
B. NSAIDs
C. Urgent Orthopedic consultation
A
C. Urgent orthopedic consult
Controversial = admit and start IV abx
15
Q
Description of a kid with Kawasaki disease. What is the most common lab finding ?
A. Neutropenia
B. Hypoalbuminemia
C. High IgA
D. ASOT
A
B. Hypoalbuminemia
16
Q
Toddler comes to the ED refusing to weight beat. X-ray if leg shows non-displaced spiral fracture of left tibia. Which is most likely ?
A. NAI
B. Rickett’s
C. Toddler’s fracture
D. Osteogenesis Imperfecta
A
C. Toddler’s fracture
17
Q
A kid has had 6 days of fever despite treatment with amoxicillin, with no response. He also has cracked lips, nonpurulent bilateral conjunctivitis, and a polymorphous rash. What would you expect to see on his labs ?
A. Neutropenia
B. Hypoalbuminemia
C. Elevated ASOT
D. Elevated EBV titres
A
B. Hypoalbuminemia
18
Q
Child with systemic JIA. Presents with fever, purpuric rash, hepatosplenomegaly and irritability. What is the MOST likely diagnosis ?
A. Methotrexate
B. Macrophage activation syndrome
C. Sepsis
A
B. Macrophage activation syndrome
19
Q
Which ECG change is characteristic of acute rheumatic fever ?
A. Peaked T waves
B. Prolonged PR interval
C. Sinus tachycardia
A
B. Prolonged PR interval
20
Q
14 y.o female gymnast presents with a 2 month history of lower back pain on extension. She has tight hamstrings, spasm of her paraspinal muscles, normal sensations and motor function. A bone scan lights up her lumbar vertebrae. What is the diagnosis ?
A. Spondylosis
B. Posterior element overuse syndrome
C. Disk germination
D. Vertebral body avulsion fracture
A
A. Spondylosis
21
Q
3 y.o girl presents with 7 day history of fever. She has bony pain but no arthritis on exam, but she has HSM and diffuse generalized lymphadenopathy. Her blood work shows WBC 18, PLT 110 and anemia. What is the next best step ?
A. Bone marrow aspirate
B. EBV serology
C. Work up for systemic JIA
A
A. Bone marrow aspirate
22
Q
5 y.o with intermittent abdominal pain and purpuric rash on thighs. He has joint pains and hematuria. Which of the following lab abnormalities would likely be present?
A. Thrombocytopenia
B. Schistocytes
C. Elevated IgA
A
C. Elevated IgA
HSP
23
Q
4 y.o F with one very inflamed joint for over 1 month, ANA negative, no uveitis. What is the first line treatment for her condition ?
A. Methotrexate
B. Systemic steroids
C. NSAIDS
D. IVIG
A
C. NSAIDs
Oligoarticular responds better to NSAIDs
24
Q
A teen girl presents with a 3 week history of arthritis, thrombocytopenia, hemolytic anemia, and decreased C3/C4 after attending camp. What test is most specific?
A. Borrelia burgdorferi serology
B. ANA
C. Anti- dsDNA
A
C. Anti dsDNA - SLE
ANA - highly sensitive
dsDNA - highly specific
25
If a child has a septic hip, what position do they normally hold their hip in ?
A. Abducted and internally rotated
B. Abducted and externally rotated
C. Adducted and internally rotated
D. Adducted and externally rotated
B. Abducted and externally rotated
26
A mother comes to you with her 2.5 year old son who she says is in-toeing. On exam, you find evidence of metatartus adductus. What do you suggest ?
A. Reassure
B. Avoid W sitting
C. Refer to orthopedics
A. Reassure (if flexible)
W sitting - femoral anteversion
Refer - if rigid flat feet or not correctable with passive exercise
27
A 6 year old Greek girl presents with high fever, tachypnea, and RUQ pain. On exam, there is no guarding in the abdomen. What is the most likely diagnosis ?
A. Bacterial pneumonia
B. Pleurodynia
C. FMF
A. Bacterial pneumonia
28
6 year old with clinical and laboratory evidence consistent with systemic JIA develops persistent fever, extensive and fixed rash, thrombocytopenia and hyponatremia. What is the most likely to decrease ?
A. Triglyceride
B. Fibrinogen
C. LDH
D. Ferritin
B. Fibrinogen - decreased
MAS
A- triglyceride - increased
C- LDH - increased
D - Ferritin - increased
29
Which is the most sensitive test for early detection of Legg-Calve-Perthes ?
A. Bone scan
B. Bone densitometry
C. Ultrasound
D. AP and frog leg xrays
A. Bone scan
30
You want to start an 11 year old boy with JIA on infliximab. Which is the most important prior to starting this medication ?
A. VZV vaccine
B. MMR vaccine
C. Checking for Mycobacterium Tuberculosis
C) checking for TB
31
Child with recurrent fever, cervical adenitis, aphthous ulcers, pharyngitis. Normal immune workup. Best treatment
A. Oral colchicine x 5 days
B. Oral prednisone x 1 day
B. Oral prednisone x 1 day
32
Girl walked and tripped on a curb now has cold extremity painful to touch
A. Complex regional pain syndrome (CRPS)
B. Osteomyelitis
A. CRPS
33
Kid with fevers, salmon rash, HSM (no joint pain).
A. Systemic JIA
B. ALL
A. Systemic JIA (arthritis can be delayed in onset)
34
Young girl with AOM and fever for 9 days, now with conjunctivitis, cracked lips etc....Kawasaki. Which is the most important to test before she leaves ?
A. Cardiac ultrasound
35
Septic joint next step?
A. Aspirate
B. Urgent consult to ortho
C. Admit and start IV antibiotics
A. Aspirate
B if hip, A if not hip
36
Hip XR, what do we do ??? SCFE
A. Pin it
37
Girl with JDM, what is the best diagnostic test ?
A. EMG
B. CK
A. EMG
38
Picture of a 7y.o boy with completely erythematous face. He’s on fluticasone and phenytoin. What is the most likely diagnosis ?
A. Drug hypersensitivity
B. SLE
C. JDM
A. Drug hypersensitivity
39
Kid with FMF, what to give ?
A. Colchicine
40
6 year old girl with arthritis of 3-4joints at a time. Her ANA is positive. Which is the most likely associated finding?
A. Eye pain
B. Photophobia
C. Unequal pupil
C. Unequal pupil
Uveitis with JIA - in JIA they don’t get red eye or pain.
41
14 year old with Duchenne’s, who is in a wheelchair, has recently seen his FVC fall from 30% to 21% predicted. What symptom will he MOST likely complain of ?
A. Headache early in the morning
B. Headaches in the afternoon
C. Tingling of his fingers
D. Dyspnea with exertion
A. Headaches in the morning
42
Boy with recurrent pharyngitis. Episodic jerking of shoulders and head over past 6 weeks. Most likely diagnosis ?
A. Rheumatic fever
B. Transient tic disorder
C. Tourettes
D. Some sort of seizure disorder
B. Transient tic disorder
43
Women with rash, arthritis, nephritis (SLE?). What associated ?
Lab wise
Pancytopenias
44
What is the most common childhood wrist fracture ?
A. Colles fracture
B. Greenstick
C. Buckle fracture
D. Salted Harris
C. Buckle fracture
45
A 7 y.o boy has a history of recurrent fevers, evanescence’s pink rash, lymphadenopathy, and hepatosplenomegaly. His MSK exam is normal. What’s the diagnosis ?
A. Leukaemia
B. Scarlet fever
C. Lyme disease
D. Systemic JIA
D. Systemic JIA - salmon coloured rash
46
14 year old who hasn’t been to see you in two years. She had scoliosis with Cobb angle of 50 degrees. What is the most appropriate management ?
A. Observe
B. Refer for brace/orthosis
C. Refer for posterior spinal fusion
D. Electrical muscle stimulation
C. Refer for posterior spinal fusion
Surgically correct if angle > 45
47
14 year old with fevers, polyarthritis, weight loss. Appears pale. No arthritis on exam. Urine positive for protein and blood. Decreased WBC and lymph’s. Normal PLTs. What is most likely diagnosis?
A. SLE
B. Systemic JIA
C. PSGN
D. RF
A. SLE
48
6 days post scoliosis surgery. Presents with bilious vomiting. Etiology?
A. SMA
B. Small bowel adhesions
C. Pancreatitis
A. Superior mesenteric artery syndrome
49
Boy with proximal muscle weakness, difficulty climbing stairs, easily fatigable and scaly rash on dorsum of hands. What is the diagnosis ?
A. JIA
B. SLE
C. JDM
D. Myasthenia gravis
C. JDM
50
3 year old with refusal to walk for 3 days. Temp 38.1C, mildly tachycardic, very irritable when you examine right leg which is held in slight abduction and external rotation. Right hip has decreased ROM and he is in pain when you move his hip. He refuses to walk. Bloodwork shows ESR 48, CRP 20, WBC 14, normal Hgb and PLTs. Most likely diagnosis ?
A. Transient sumo iris
B. Osteomyelitis
C. Septic arthritis
D. Legg- Calve- Perthes disease
C. Septic arthritis
51
5 year old fever of 38.5C had a recent URTI. Hip was externally rotated and child not weight bearing. ESR was 40. Diagnosis ?
A. Transient synovitis
B. JIA
C. Septic arthritis
C. Septic arthritis
Kocher criteria
1. WBC >12
2. ESR > 40
3. history of non- weight bearing
4. history of fever > 38C
This child has all four criteria fulfilled and therefore has a 99.6% chance of having septic arthritis
52
Picture of a kid with a malar rash. Has a fever, joint pain, diffuse rash. Only meds are fluticasone and phenytoin for a seizure disorder. What is the most likely ?
A. Drug hypersensitivity reaction
B. Juvenile dermatomyositis
C. Systemic Lupus erythematosus
D. Juvenile idiopathic arthritis
A. Drug hypersensitivity reaction vs C. SLE
Consider drug induced lupus erythematosus- culprits include procainamide, hydralazine, phenytoin is probable
Drug-induced lupus = is an autoimmune disorder caused by a reaction to certain medications. It differs from typical drug hypersensitivity reactions in that drug- specific T- cells or abs are not involved in induction of autoimmunity, it usually requires many months to years of drug exposure, is drug dose dependent and generally does not result in immune sensitization to the drug.
Drug hypersensitivity is an immune- mediated reaction to a drug.
53
8 year old girl tripped over a curb two weeks ago. She now complains of left leg pain. On exam the leg is cool and pale and she complains of pain even with light touch. Her X-ray is normal. What is likely diagnosis ?
A. Fracture
B. Conversion disorder
C. Reflex sympathetic dystrophy
C. Reflex sympathetic dystrophy- complex regional pain syndrome type 1
54
A 13 y.o boy presents with intermittent and recurrent hip and heel pain. What is likely to be found on review of family history ?
A. Psoriasis
B. Ankylosing Spondylitis
C. SCFE
B. Ankylosing spondylitis
AS= HLA B27 positive
Enthesitis related arthritis
55
12 year old athletic girl complains of knee pain that she notices when walking down the stairs. On exam you note pain on palpation behind her patella. What is her most likely diagnosis ?
A. Osgoode Schlatter
B. Patella fracture
C. Patellafemoral syndrome
C. Patellofemoral syndrome
56
A 2y.o boy with 2 days fever, now irritable, elevated inflammatory markers, and refusing to move right leg. Tender area over right tibia. Which of the following investigations will most likely make the diagnosis?
A. X ray of tibia
B. X ray of hip
C. Bone scan
D. Blood culture
C. Bone scan > Most not next step
Likely osteomyelitis
57
Boy comes into your office with left hip pain for 8 months, decreased and painful range of motion, with pain in the left heel. What disease is most likely in his family medical history:
A. Rheumatoid arthritis
B. Ankylosing spondylitis
C. Psoriasis
D. Inflammatory bowel disease
B. Ankylosing spondylitis
58
Teen boy with pain to the right knee, above the joint. No effusion. No trauma. X-ray shows mottling in bone and periosteal reaction. The likely diagnosis:
A. Osteosarcoma
B. Osteoid osteoma
C. Osteochondroma
D. Ewing’s sarcoma
A. Osteosarcoma - occurs in metaphysis of long bones with sunburst pattern
Controversial - with Ewing’s = diaphyses of long vines and onion skinning pattern
Going with osteosarcoma as other questions describe it as = mottling + periosteal reaction and location metaphysis is closer to the knee
59
14 year old female presents with pain above the right knee which is worse at night and with activity. On exam there is no fever, but there is tenderness to palpation above the knee. X-ray shows periosteal elevation and mottling of the distal femur. The most likely diagnosis is:
A. Osteomyelitis
B. Osteosarcoma
C. Osteoid osteoma
D. Aneurysmal bone cyst
B. Osteosarcoma
60
Child with 6 week history of severe ankle pain. Unable to weight beat. Unable to do physiotherapy. The foot is swollen, red, and warm. What is the most likely cause ?
A. Reflex sympathetic dystrophy
B. Osteomyelitis
C. Munchausen
B. Osteomyelitis
61
A 3 y.o child develops left hip pain following URTI. What is the best way to rule out osteomyelitis ?
A. Lack of fever
B. Normal WBC
C. Negative blood culture
D. Bone scan
D. Bone scan
62
Girl who is active. Heel pain worse with activity such as running and jumping. No concerns with swimming. Tender Achilles on exam. How to manage.
A. Avoid activity and rest
B. Something that sounds like an air cast
C. Use NSAIDs for the pain
D. Xrays
C. Use NSAIDs for the pain
Did not choose Avoid activity and rest because it should be avoid aggravating activities
63
What are TWO medication classes implicated in drug induced lupus ?
1. Anticonvulsants
2. Biological agents against TNF alpha
3 anti hypertensives - hydralazine
4 tetracyclines - minocycline
64
Other than medications what is one possible cause of exacerbation in systemic lupus erythematosus ?
1. Infections = parvovirus B19, EBV, CMV
| 2. Hormone dysregulation
65
2 year old has fever of 40C and is irritable. He refuses to move his left hip. What is the first thing you do ?
A. Aspirate the left hip with needle
B. X-ray
C. Bone scan
D. Admit, do blood culture and start antibiotics
A. Aspirate the left hip with needle
- might not see much on X-ray if it is septic joint. If U/S in choices it may be that
- don’t want to start abx until you have culture = from blood and ideally the synovial fluid
- US and MRI are best to detect joint effusion but can start with plain xrays - you can see capsular swelling and if there is anything like AVN or SCFE
Controversial - some chose xrays and others admit and blood culture and start abx
66
10 year old Lebanese girl with recurrent self limited abdominal pain and fever for one day. During an episode you do some labs and find increased ESR (60-80), AST and ALT slightly elevated, increased CRP and decreased albumin. What is a likely diagnosis ?
A. Paroxysmal nocturnal hemoglobinemia
B. Familial Mediterranean Fever
C. SLE
D. Cyclic neutropenia
B. Familial Mediterranean fever
Fever 1-3 days + abdo pain during attack
67
Best determinant of scoliosis on physical exam
A. Leg length discrepancy
B. Asymmetric shoulder height
C. Asymmetric rib cage on bending over
C. Asymmetric rib cage on bending over
Adam’s forward bend test
68
Kawasaki disease and parents refuse treatment with IVIG. Which of the following is an acceptable alternative treatment ?
A. ASA
B. ASA + steroids
C. ASA + cyclophosphamide
D. Steroids
B. ASA + steroids
ASA - no effect on subsequent CA aneurysms
Steroids - can alter rate of CA abnormalities in high risk KD
69
28 week baby currently ventilated for severe RDS. Also has associated anomaly (picture of club foot). What to do ?
A. Refer to ortho immediately for serial plastic (did not say plaster)
B. Refer to ortho once off ventilator
C. Refer to ortho at discharge
D. Refer to ortho at 3 months of age
B. Refer to ortho once off ventilator
Controversial - cheo chose refer to ortho immediately
70
3 y.o with monoarthritis for a few weeks. What is the most likely test result ?
```
A. Positive RF
B. Positive ANA
C. Increased WBC
D. Increased ESR
E. Decreased Hb
```
Controversial
B. Positive ANA (cheo answer)
D. Increased ESR - previous years
-likely oligoarthritis vs toxic synovitis
JIA
- ANA positive in 60-80 %
- ESR can be elevated but also can be norma
- microcytic anemia
- increased WBC
71
15 y.o with generalized malaise, violaceous rash on knuckles. You order ?
A. CK
B. ANA
C. U/A
D. ESR
A. CK
JDM - need muscle enzymes as part of diagnosis (CK, ALT, Aldolase, LDH)
Tx- steroids
72
Description of a child with Osgood schlatter. What is the management ?
A. Temporary restriction of physical activities
B. IcE
C. NSAIDs PRN
D. When feeling better, do quad strengthening exercises
E. Cylindrical casts for 3-4 weeks
B. Ice
C. NSAIDs PRN
D. When feeling better, do quad strengthening exercises
These are all right - maybe go with NSAIDs or ICE as you do these before quad strengthening
Up to date says No restriction in activity and NO casting so A and E are wrong
73
A 3 month old with tender swelling over the mandible bilaterally for one week, with fever and irritability. There is hyperostosis on X-ray. Diagnosis ?
A. Parotitis
B. Osteomyelitis
C. Hypervitaminosis A
D. Caffey’s disease
D. Caffey’s disease
Infantile cortical hyperostosis
74
What is correct about IVIG in Kawasaki disease ?
A. Decreases cytokines release
B. Interacts with antibodies causing vasculitis
C. Monthly IVIG regresses giant coronary artery aneurysm
A decrease cytokines release - decreases cytokines production but haven’t found source that says release
VS
B. Interacts with antibodies causing vasculitis - they aren’t even sure of etiology of kawasaki but this can be a proposed mechanism
:(.
75
3 y.o girl, well, has 3 weeks of right knee swelling, best initial treatment ?
A. Steroids
B. Methotrexate
C. NSAIDs
C. NSAIDs
76
14 year old with leg pain, radiograph shows a lesion in the distal femur with sunburst appearance. What is the likely cause ?
A. Osteoid osteoma
B. Ewing’s
C. Osteopenia sarcoma
D. Aneurysmal bone cyst
C. Osteopenia sarcoma
77
12 y.o female with 2 week history of fever, arthralgia and myalgia. She is pale but otherwise looks well. She has blood and protein in the urine. WBC 18 and platelets normal.
A. Acute rheumatic fever
B. Wegener’s Granulomatosis
C. SLE
D. JIA
C. SLE
78
In a child with myopathy, which of the following could help distinguish dermatomyositis from Duchenne’s MD ?
```
A. Proximal muscle weakness
B. Rash on face and knuckles
C. Abnormal muscle enzymes
D. Onset before age 5
E. More commonly affect girls than boys
```
B. Rash on face and knuckles
79
Which of the following statement is true about Kawasaki ?
A. Coronary artery thrombosis is a rare complication
B. Serologic tests are helpful
C. IV gamma globulin increase the acute phase of illness
D. Initial manifestation of KD shares many similarities with scarlet fever
A and D both correct :(.
Maybe D initial manifestations similar to scarlet fever
Unsure what they consider rare = the risk of MI from coronary artery thrombosis is greatest I. The first two years after illness onset
80
4 y.o male adolescent is referred for evaluation because of pain and swelling below his right knee. He is very active in sports. PE: reveals point tenderness over the anterior tubercle of the right knee. Diagnosis ?
A. Osgood -schlatter disease
B. Patellar tendonitis
C. Tear of collateral ligament
D. Tear of medial meniscus
A. Osgood Schlatter disease
81
Which of the following statements is true about osteomyelitis in children ?
A. The most common site is the proximal humerus
B. Most infections are caused by H. Flu
C. The epiphyseal growth plate limits the spread of metaphyseal infection
D. Radiologic examination is useful to confirm a diagnosis
D. Radiologic examination is useful to confirm a diagnosis - MRI best
A- the most common site is the femur not the humerus
B. Most infections caused by staph aureus - not H. Flu
C- can enter joint space in newborns and infants
82
A 2 y.o boy is brought in by mom not moving left arm. He is holding it pronates. Mom admits she pulled on left wrist during horseplay. Patient not cooperative with exam. Next test:
```
A. Sling with x-ray
B. Sling then orthopedics referral
C. Orthopedics referral
D. Skeletal survey
E. Manipulate at elbow until arm function restored
```
E. Manipulate at elbow until arm function restored
83
What is true in this child. Hip X-ray shown - SCFE
A. Sports related trauma
B. More frequent in females
C. Associated with steroid use
D. Subsequent bone necrosis
D. Subsequent bone necrosis
84
A child has been receiving IV penicillin for meningoccemia for the past 7 days. He has now developed a warm swollen right knee. What should be done ?
```
A. Provide NSAIDs
B. Add a second abx
C. Change to a different antibiotic
D. Aspirate and culture
E. Bone scan
```
A. Provide NSAIDs
Complications of meningitis during treatment = arthritis found in 10% of patients
- first few days of treatment and manifests as effusion of large joint, often the knee. Resolve without a change in treatment and occasionally repeated arthrocentesis is needed to control symptoms
- non- suppurative presumed immune complex arthritis
85
Features of Kawasaki disease include all EXCEPT:
A. Elevated WBC
B. ANA negative
C. Platelet count 75
D. Urine with 10-15 WBC/ Hpf
C. Platelet count 75 - thrombocytosis after 1st week
86
In an adolescent with pain below the knee after running, the X-ray shows changes compatible with Osgood schlatter last disease. All are done except:
```
A. Protective gear
B. Ice may be used to reduce swelling
C. Only stop activities which cause pain
D. Quadriceps strengthening exercises when pain resolves
E. Casting for 3-4 weeks
```
E. Casting for 3-4 weeks
87
12 y.o. boy with right anterior knee pain. No history of trauma. On exam, he has tenderness at the tibial tubercle.
What are 3 recommendations you would make for management of this patient ?
1. Control of pain and swelling
- ice
- NSAIDs
- protective pad
2. Continuation of activity
3. Physical therapy
- to strengthen quads and improve quad and hamstring flexibility
4. Education
- course
- residual swelling
88
Gymnast with back pain and hyperlordosis on exam.
A. What does she likely have?
B. What investigation would you do to confirm this ?
C. What are two ways you would treat this ?
A. Spondylolysis
B. Spine X-ray
C. Two ways to treat
1. Activity modification + physiotherapy therapy
2. Lumbosacral orthosis (brace)- which immobilized the spine in slight flexion to decompress the posterior elements, may lead to a faster resolution of symptoms.
3. Pain management - ice and NSAIDs
89
Girl with juvenile idiopathic arthritis.
A. What are two factors that predict an increased risk of developing uveitis ?
B. What are three long term complications of JIA other than uveitis ?
A. Two factors that predict increased risk of uveitis
1. ANA (+)
2. Oligoarticular JIA
B. What are three long term complications of JIA other than uveitis?
1. Growth disturbances = short stature
2. Osteoporosis = decreased activity + steroids
3. Muscle atrophy
4 joint destruction = avascular necrosis
5. Leg length discrepancy
6. Chronic pain
7. Pulmonary HTN and fibrosis
90
18 month old with missed developmental dysplasia of the hip:
A. Name two clinical features of this diagnosis
B. Name one physical exam finding
A. Name two clinical features
1. Limp or waddling gait
2. Kid toe walks on affected side
3. Excessive lordosis - develops secondary to altered hip mechanics
B. Name one physician exam finding
1. Limited hip aBduction inaffected side
2. Asymmetry of the gluteal or thigh folds
3. Galeazzi sign = knees are at different levels when hips are flexed
4. Tradelenburg sign
5. Klisic test = line drawn through the two fingertips runs below the umbilicus b/c the greater trochanter is abnormally high) first ginger on ASIS, third finger on greater trochanter
91
Photo of gottron’s papules and heliotrope rash. Child has recent difficulty walking up the stairs.
A. What is the diagnosis ?
B. What are two investigations required for diagnosis?
A. Diagnosis - Juvenile Dermatomyositis
B. Two investigations required for diagnosis ?
1. Muscle biopsy
2. Elevated muscle enzymes - CK, AST, ALT, aldolase, LDH
Diagnostic criteria:
1. Symmetrical proximal muscle weakness
2. Characteristic skin changes = including Gottron’s papules on the dorsal surface of the knuckles and heliotrope rash over the eyelids
3. Elevated muscle enzymes - including CK, AST, aldolase, LDH
4. Muscle biopsy = demonstrating necrosis and inflammation
92
A term baby is born to a mother with maternal lupus. He is noted to have congenital heart block.
A. Name the 2 most common antibodies in congenital heart block
B. Name 3 other manifestations of neonatal lupus
A. Two antibodies
- anti- Ro
- anti- La
B. Three manifestations
1. Neonatal lupus rash
2. Thrombocytopenia and neutropenia
3. Cholestatic hepatitis and hepatomegaly
4. CNS manifestations
93
A 12 year old boy has been having trouble playing soccer lately due to pain in his feet. You see him and diagnose flat feet.
A. What are three categories of flat feet ?
B. What are two indications for referral in flat feet ?
A. 3 categories of flat feet
1. Flexible flat foot = functional flat foot (calcaneovalgus)
2. Flexible flat foot with Achilles tendon shortening = hypermobile flat foot with associated ligamentous laxity and “tight heel cords “
3. Rigid flat foot = clinical Pes planus a/w tibialis posterior tendon dysfunction
B. 2 indications for referral
1. Rigid pes planus
2. Painful flexible pes planus
94
A 4 year old boy has swollen joints and is diagnosed with systemic onset JIA. Name the diagnostic criteria for systemic JIA.
Diagnostic criteria
1. Age at presentation less than 16 years old
2. Arthritis affecting 1 or more joints for at least 6 weeks
3. Fever for at least 2 weeks, with a minimum of 3 days of documented daily quotidian fevers
4. Accompanied by 1 or more of the following:
- evanescent erythematous rash - salmon colour rash
- generalized lymphadenopathy
- hepatomegaly or splenomegaly
- serositis
95
Kid comes into ED not using his arm after mom pulled hard to get his sweater off.
A. What is the diagnosis (be specific) ?
B. What is the anotomic abnormality/finding?
C. How will you reduce it ?
A. What is the diagnosis ?
- annular ligament subluxation (nursemaid’s elbow)
B. What is the anatomical abnormality?
- annular ligament subluxation - which anchors the radial head to the ulna
C. Reduce it
- flexion of elbow and supinate
- extension of elbow and hyperpronation
- supinate the forearm while holding pressure over the radial head. A palpable click or clunk can be felt
96
For DMD Duchenne’s muscular dystrophy, name four organ systems affected, aside from muscles. For each, name 1 related presentation specifically related to absence of dystrophin (4)
DMD 4 features aside from muscles
1. Cardiac = cardiomyopathy
2. Respiratory = nocturnal hypoventilatio, restrictive lung disease
3. GI = dysphagia + GERD
4. Joints = contractures and scoliosis
97
A 12 year old girl comes to your office with her mother. She has thoracic scoliosis (this was billed on real exam) and her mother is interested in surgical interventions. Name 4 indications for surgical management
4 indications for surgical management
1. Curves that process despite bracing, to Cobb angle > 50
2. Skeletally immature and prepubertal, progressive curve that is Cobb angle > 45
3. Skeletally mature patient with Cobb angle curve > 50
4. Lumbar curves with marked trunk shift
5. Other: infantile or juvenile
Adolescent idiopathic scoliosis
1. If other treatment has failed (progressive curvature despite bracing)
- change > 5 degrees between f/u visits
2. If progression likely to lead to unacceptable cosmesis or physiologic changes
- significant cosmetic concern, affecting quality of life
3. If curve > 45 in skeletally immature patient
4. If thoracic curve > 50-55 in skeletally mature patient
5. If lumbar curve > 35-40
98
4 y.o girl diagnosed with JIA.
A.Which type of JIA is most associated with uveitis ?
B. What blood test would we do to see if a patient is at increased risk ?
C. How often do we screen these patients with an eye appointment ?
A. Which type ? - oligoarticular JIA
B. What blood test ? - ANA
C. How often do we screen with eye appointments ?
- initially every 3 months for the first 4 years (patient is <6 y.o and it would be q6 months if ANA negative
Oligoarticular/polyarticular
ANA (+)
Duration age < 6y.o. > 6 y.o
<4 years = q3mo q6mo
4-7=. q 6 mo. Annually
> 7 =. Annually . Annually
ANA (-)
Duration Age <6y.0. > 6y.o
<4 =. q6mo Annually
4-7 = Annually Annually
>7 = Annually Annually
99
Description of teenage girl with MAS
A. 2 non-infectious acquired causes
B. Name 3 management
A. 2 non-infectious causes
1. Systemic JIA
2. SLE
3. Kawasaki
B 3 management
1. Supportive care
- close monitoring of VS + fluids + ins/outs + labs
- ABCs (resp support + fluids for hypotension + blood products
2. Consider transfer to PICU
3. Treat underlying cause
- abx if infection is suspected
4. Immunosuppressive treatment
- IVIG
- high dose corticosteroids
- step wise progression = cyclosporine - etoposide
5. BMT for primary HLH or refractory HLH
100
Name 5 risk factors for DDH
5 risk factors for developmental dysplasia of the hip
1. Female infant (more susceptible to maternal relaxin)
2. First born
3. Intrauterine: breech position, Oligohydramnios, fibroids
4. Family hx of DDH (12-33%)
5. LGA
6. Postnatal positioning (swaddling)
101
4 year old girl with sudden onset of inability to turn head to one side; no history of trauma, name 5 causes (5 causes of acquired torticollis)
5 causes of acquired torticollis
1. Infectious- 2nd mcc of acquired torticollis in children
- pharyngitis
- URTI
- osteomyelitis
- RUL pneumonia
- TB - pots disease
- cervical adenitis
- retropharyngeal abscess
- cervical neck discitis
2. Inflammatory
- injury/inflammation to SCM or trapezius is the mcc of acquired torticollis in children
- RA
3. Malignancy
- posterior fossa Tumor
- cervical spine tumors
- Soft tissue tumors
4. Neurological
- dystopia
- cranial nerve palsy
5. Muscular
- trauma/cervical spine injury
- spinal epidural hematoma - consider with mild trauma, hemophilia
6. Lemierre’s syndrome
- suppurative jugular thrombophlebitis (pharyngitis, septic pulmonary emboli, persistent fever despite abx and fusibacterium necrophorum)
7. Atlantoaxial rotary subluxation - rotational displacement of C1 and C2
102
Name 3 major criteria for skeletal manifestations of Marfans
3 major criteria for skeletal manifestations
1. Thumb sign
2. Wrist sign
3. Pectus carinatum or pectus excavatum
4. Dolichostenomelia = long limbs
5. Pes planus
6. Hindfoot deformity
7. Protrusio acetabuli (medial displacement of femoral head into pelvis)
8. Decreased US/LS ratio and increased arm span/ height ratio
9. Scoliosis or thoracolumbar kyphosis
10. Reduced elbow extension
11. Facial features 3/5 = dolichocephaly, enophthalmos, downslanting palpebral fissures, malar hypoplasia, retrognathia
103
Kid with rheum condition (JIA or SLE). Then develops pancytopenia, hepatosplenomegaly and is unwell. Associated condition ?
Macrophage activation syndrome
104
Picture seen below (congenital vertical talus). State what is most likely associated condition ?
Trisomy 13 and 18
105
Babe with clubfoot - name one part of the treatment
Serial casting with Ponseti technique
106
8 year old boy is referred to you for persistent hip and knee pain for 2 months duration. No history of trauma. Walks into office with an antalgic gait. You note decreased abduction and internal rotation on exam. X ray done (picture shows left hip with small femoral head, scalloped edges). Diagnosis ?
Legg- Calve-Perthes disease (avascular necrosis of femoral head)
107
Description of a young girl with weakness, clumsy. Has a rash on her body and over her hands and knuckles. Mom concerned. Likely diagnosis ?
Juvenile dermatomyositis
108
Baby fell off change table and not using arm. X-ray with corner fracture ? What is diagnosis ?
Non accidental injury
- classic metaphyseal lesion = metaphyseal chip or corner fractures
Common peds fractures secondary to no accidental trauma
1. Metaphyseal fracture (buckle handle/corner)
2. Spiral fracture Of long bones
3. Posterior rib fracture
4. Spinous process fracture
109
What are 4 diagnostic criteria for JDM ?
4 diagnostic criteria for JDM
1. Rash = heliotropic rash over eyelids and gottron papules- dorsal surface of knuckles
2. Proximal muscle weakness
3. Elevated CK, AST, LDH, Aldolase
4. Abnormal muscle biopsy- necrosis and inflammation
110
Picture of a child with purpuric lesions on the lower limbs.
A. What is the diagnosis ?
B. What long term complication would you monitor floor ?
A. What is the diagnosis ?
- Henoch- Scholein purpura
B. Long term complication ?
- renal disease occurs in 1-2% and can develop IO to 6 months after diagnosis, especially those who presented with HTN or urinary abnormalities
Monitor BP and U/A for 6-12 months after diagnosis
- first month = weekly
- month 2-3 = q2 weeks
- and after that monthly till 6 months
111
Picture of a girl with a butterfly rash. This is 15 year old girl presents with Hypertension
A. What do you think the diagnosis is ?
B. What are two other renal complications of the diagnosis ?
A. Diagnosis
- SLE
B. Renal complications
1. Glomerulonephritis
2. Chronic kidney disease
-can have HTN, proteinuria, hematuria, edema, nephrotic syndrome, renal failure
112
Young girl presenting with pain and widening of the wrist an bowing of the legs.
A. What is the diagnosis ?
B. What are three physical findings on exam ?
A. What is the diagnosis ?
- rickets
B. What are 3 physical findings on exam
1. Frontal bossing
2. Rachitic rosary = swelling of the costochondral junction
3. Delayed growth, FTT
4. Other = craniotabes, scolisis
113
Name 4 causes of persistent toe walking
Name 4 causes of persistent toe walking
Neuromuscular
- cerebral palsy
- Duchenne’s/ Becker muscular dystrophy
- spina bifida
Muscular
- Achilles’ tendon contracture
- leg length discrepancy
Behavioural
- autism
- idiopathic
```
Bilateral
1. Hypertonia like spastic diplegia
2. Autism
3. Tethered cord
4. Diastematomyelia = spinal cord is split at upper vertebrae
5. Muscular dystrophy
6. Neuromuscular disease
7 idiopathic
```
Unilateral
1. Short Achilles’ tendon
2. Shortened limb
3. Dislocated hip
4. Tibial bowing on the affected side
5. Spastic Hemiplegia
- variation of normal between 10-18 months as kids are learning to walk
114
Child with monoarticular JRA involving one knee. List 3 long- term orthopedic complications of arthritis
3 long term orthopedic complications of Monoarticular JRA
1. Leg length discrepancy = in acute phase pro inflammatory cytokines cause overgrowth, then once inflammation is settled, can have premature fusion of growth plates
2. Muscle atrophy/weakness
3. Fusion/joint flexion contractures - particularly the knees, hips, wrists
4. Short stature
5. Ulnar drift of hand
6. Popliteal cysts
115
Give 2 differential diagnosis for congenital torticollis other than sternocleidomastpid Tumor
Torticollis dx
1. Congenital hemivertebrae
2. klippel Feil syndrome
3. Unilateral absence of sternocleidomastpid muscle
4. Congenital muscular torticollis
5. Postural torticollis
6. Pterygium Colli = webbed neck deformity
7. Unilateral absence of of sternocleidomastoid
8. Sternocleidomastoid cysts ie;
- cystic hygroma,
- branchial cleft cyst
9. Vertebral anomalies
- C1-C2 articular joint lesions
- hemivertebra
- klippel- Feil syndrome = fusion of cervical vertebrae
10. Arnold Chiari malformation
11. Congenital scoliosis
12. Clavicle fracture
13. Cranial nerve palsy
14. Neonatal encephalopathy
15. Posterior fossa Tumor
116
Child with SLE presenting with hypertensive encephalopathy - list 3 medications and routes of administration
HTN management
- IV hydralazine
- IV labetalol
- IV nicardipine
PO nifedipine
PO amlodipine
117
List the diagnostic features of Kawasaki disease (6 lines)
Fever for > 5 days and 4/5 criteria
1. Non-purulent conjunctivitis
2. Polymorphous rash
3. Cervical adenopathy, at least one LN > 1.5cm
4. Oral mucosal changes
5. Swelling and skin changes in extremities
118
4 year old girl with arthritis of 2 months duration. On exam she has a swollen elbow and knee. Her ANA is positive.
A. What is her diagnosis?
B. What is one complication that she is at risk for ?
C. What would your initial treatment be ?
A. What is her diagnosis ?
- oligoarticular JIA
B. What complication is she at risk for ?
- Anterior uveitis
C. What would your initial treatment be ?
- NSAIDs
119
What is general diagnostic criteria for JIA (my question )
1. Age at onset < 16y.o
2. Arthritis (swelling or effusion, or the presence of 2 or more of the following signs: (limitation of ROM, tenderness or pain on motion, increased heat) in > 1 joint
3. Duration of disease > 6 weeks
4. Onset type defined by type of articular involvement in the 1st 6 months after onset
- polyarthritis: >5 inflamed joints
- oligoarthritis: < 4 inflamed joints
- systemic disease: arthritis with rash and a characteristic quotidian fever
5. Exclusion of other forms of juvenile arthritis
120
Young boy (? 6y.o) with history of 4 weeks of decreased energy. He has recently started to complain about leg pain. On exam, you find bilateral tenderness over his proximal tibia. There is no erythema and no warmth ? What are two diseases that could cause this ?
Bilateral bone pain
1. Leukaemia
2. Lymphoma
3. LCH
121
Young girl who has flat feet. Mum is concerned. When she stands the feet are flat and you note that they are valgus and that her forefoot is abducted. When she sits down with her feet in the air, her arches look normal.
A. What is her diagnosis ?
B. What kind of intervention is needed for her (1) ?
A. What is her diagnosis ?
- flexible flat feet
B. Intervention ?
- reassurance = most children will grow out of this and no orthopedic intervention is necessary
- investigations needed of persistent after 8 years
122
14 year old boy presents with groin discomfort. X-ray shows shows femoral neck and femoral head not aligned in the middle ?
A. What is the diagnosis ?
B. What are two steps in management?
C. What are two risk factors for this disease ?
A. Diagnosis
- slipped capita femoral epiphysis
B. Two management steps
1. Admit to hospital, complete non- weight bearing
2. Urgent orthopedic consultation for surgical pinning
C. 2 risk factors
1. Overweight/obese
2. Endocrinopathies = hypopituitarism, hypothyroidism, GH def, vit D def
3. Male
4. Renal osteodystrophy
5. Local trauma
6. Neglected inflammatory conditions ie: septic arthritis
7. Previous radiation of the pelvis, chemotherapy
123
Child recovered from recent reactive arthritis. Has residual 30 degree painless flexion contracture of the knee. Name 3 non- pharmacologic treatment modalities
1. Physiotherapy
2. Splitting
3. Serial casting
124
Child with mono arthritis. Name 3 medications from different classes of medications that are used for treatment
1. Analgesics = Tylenol
2. Anti inflammatories = ibuprofen, naproxen
3. Intra- articular steroids
4. DMARD- MTx
5. Biologics
125
Boy had recent illness - fx, dx, conjunctivitis, urethritis, now with sacroiliitis. You diagnose him with Reuter syndrome (Reactive arthritis). List 4 organisms that could cause Reiter syndrome
1. Campylobacter
2. Salmonella
3. Mycoplasma
4. Group A streptococcus
5. Neisseria Gonorrhea
6. Chlamydia trachomatis
126
Child with hip pain for 3 days. Today fever to 39, significant increase in pain. He is sitting with leg flexed and externally rotated.
A. What are 2 most important diseases on your differential diagnosis?
B. List 3 investigations you would do to differentiate
2 dx
1. Septic arthritis
2. Osteomyelitis
3 investigations
1. CBC and WBC count
2. ESR
3. Joint aspiration (u/S guided) and culture
4. MRI of hip
127
What are two surgical complications of HSP ?
1. Intussusception
2. Bowel perforation
3. GI hemorrhage
4. Bowel ischemia
128
Neonate with complete heart block. Echo normal. List 2 causes
- maternal SLE
- inherited/congenital heart block
1. Neonatal lupus due to maternal anti- ro amd anti-la antibodies = 60-90% of CHB
2. Myocarditis (may or may not been seen on EcHO)
3. Familial inheritance of conduction disease
4. Structural cardiac defects = congenital corrected TGA, AV discordance, polysplenia with AV canal defect (this would be seen on Echo)
5. Kearn’s Sayre’s can present with conduction defects, including complete heart block
