Rheumatology & Ortho q-bank Flashcards Preview

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Flashcards in Rheumatology & Ortho q-bank Deck (54):
1

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

Osteosarcoma
Ewing's sarcoma
M:F 1.5:1

2

How does osteosarcoma present and where?

Bone pain, limp, swelling. Rarely B-symptoms.
Located at epiphyses / metaphyses of maximum growth sites (distal femur, proximal tibia, humerus)

3

How to work up bone tumour?

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

4

Osteosarcoma management?

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)

5

Ewing's presentation?

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

6

Ewing's treatment?

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

7

Syndromes / conditions predisposing to osteosarcoma?

Retinoblastoma
Li-Fraumeni
Paget disease
Radiotherapy

8

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

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

9

List 7 causes of intoeing gait

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

10

Progression of treatment for JIA?

-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

11

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

ANA + disease, < 6yo, oligoarticular

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

12

Juvenile dermatomyositis diagnosis?

- 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

13

Which auto-antibodies are associated with dermatomyositis?

ANA +ve in 80%
anti-Jo1 and anti-Mi2 may indicate severe disease

14

Dermatomyositis treatment progression?

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

15

HSP organs involved?

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

16

Lab evaluation for HSP?

leukocytosis, thrombocytosis, anemia
increased ESR, CRP
high IgA

LOOK CLOSELY AT:
blood pressure
urinanalysis
serum creatinine

17

Name examples of enthesitis-related arthritis

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

18

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

Spondyloarthritis
HLA-B27
oligoarthritis +/- enthesitis

19

What are features of inflammatory back pain?

nighttime pain
morning stiffness
improved by activity
worsened by rest
insiduous onset

20

Presentation of juvenile ankylosing spondylitis?

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

21

SCFE risk factors?

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

22

SCFE or LCPD physical exam?

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

23

SCFE vs LCPD treatment

SCFE: pin it
LCPD: cast it

24

When to screen for scoliosis?

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

What are atypical findings on radiograph for scoliosis?

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

26

What features of scoliosis allow you to just observe?

Curve <20 and skeletally immature
Curves 20-45 in skeletally mature

27

What features of scoliosis mandate bracing?

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

28

What features of scoliosis mandate surgery?

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

Mnemonic for features of clubfoot?

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

30

Name 4 ways that maternal SLE can affect the neonate

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

What are long-term orthopedic complications of JIA?

leg-length discrepancy
flexion contractures
popliteal cysts
short stature
osteoporosis

32

What is the classic triad of osteogenesis imperfecta?

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

How to confirm osteogenesis imperfecta?

collagen biochemical studies usig dermal fibroblasts

34

What do kids with OI die from?

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

35

What are the classification criteria for JIA?

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

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

Do they have MAS?
Ferritin values can peak in MAS too

37

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

That's totally normal.
Also, hemoglobin 70-100 is normal.

38

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

>50-100 thousand cells / mm^3

39

What are features of systemic onset JIA?

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

How to make SLE diagnosis?

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 >>> men (90%!)

41

How often is ANA + in SLE patients?
In the healthy population?

95-99% + ANA in SLE patients
20% in general population

42

What is the most specific Ab in SLE?

DsDNA

43

What Ab correlates with disease activity in SLE?

Anti-Smith

44

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

Anti-histone antibodies

45

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

Anti-ribonucleoprotein antibody

46

How long do you treat rheumatic fever without carditis?

5 years or 21 years of age, whichever is longer

47

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

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

48

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

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

49

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

12-24 months
-rest, ice, NSAIDs, limit exacerbating activity, consider protection, strengthen quads

50

What are Jones criteria Major manifestations?

Polyarthritis
Carditis
Nodules
Erythema marginatum
Chorea

51

What are Jones criteria Minor manifestations?

Clinical:
arthralgia
fever

Laboratory:
elevated acute phase reactants
ESR
CRP
prolonged PR interval

52

Name three causes of bilateral toe walking

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

53

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

flexed, abducted and externally rotated

54

What is Reiter syndrome?

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