Week 8: neuro, MSK, rheum, pain Flashcards
(78 cards)
1
Q
JIA
- must be diagnosed before ____ (age)?
- subtype is assigned after how many months of symptoms?
A
- must be diagnosed before age 16
- subtype assigned after 6 months
2
Q
Psoriatic arthritis
bimodal age distribution - what is the peak age of presentation?
A
age 3 and age 11
3
Q
Which type of JIA is associated with HLA-B27?
most common age and sex?
where is the pain?
A
enthesitis JIA
- boys 8 and older
- lower extremity at insertion of tendons/ligaments, fascia, joint capsule to bone
4
Q
what is the criteria for diagnosis of psoriatic arthritis?
A
Chronic arthritis and psoriasis OR meets 2 of following: -dactylitis (sausage-like digit) -nail pitting -onycholysis -first degree relative with psoriasis
5
Q
what is the most common form of JIA?
where is the arthritis?
A
50% of JIA is oligoarticular
4 or fewer joints
large joints (knee/hip), may be just one
6
Q
what form of JIA is often + for ANA?
where is the arthritis?
A
Often +ANA • increased risk anterior uveitis (compared to oligoarticular) • Mix of large and small joints • Asymmetric or symmetric Usually early childhoo
7
Q
which form of JIA commonly affects small joints and teenage girls?
A
Polyarticular RF positive JIA
8
Q
General characteristics of joint pain with JIA?
A
- persistent
- daily
- worse in AM
- not severe
- improves with activity
9
Q
What is the difference between oligoarticular and polyarticular JIA?
A
oligo: 4 or less joints (usually large joints)
slow onset
RF neg
polyarticular: 5+ joints in first 6 months, mix of large and small, symmetric/asymmetric, slow onset
RF positive
polyarticular: 5+ joints in first 6 months, symmetric, nodules, RAPID onset
10
Q
What are some features of systemic JIA?
A
• Fever, rash, lymphadenopathy, hepatosplenomegaly, serositis
• Fever (39+) daily with migratory rash: salmon colored macules to trunk and proximal limbs
• Pain worse during febrile period
• Arthritis may be mild or not present initially
Polyarticular arthritis within first 6 months of symptoms: large and small joints
11
Q
Common complication of JIA
-what increases risk?
A
anterior uveitis
highest risk of +ANA and young age (<6)
higher risk in oligo, polyarticular RF neg, psoriatic
12
Q
What is unique feature of anterior uveitis associated with enthesitis related JIA?
A
painful and acute
oligo and polyarticular often asymptomatic
13
Q
Physical exam of JIA
A
- full MSK including TMJ
- C-spine and L-spine
- leg length discrepancy
- joint hypermobility
- flexion contractures
14
Q
Workup of JIA
most important test?
A
- usually normal ESR/CRP
- if marked elevation in ESR/CRP –> workup for malignancy/infection
RF, anti-CCP Ab, ANA, HLA-B27
most important is ANA (helps stratify development of uveitis)
XR, US, MRI
15
Q
management of JIA
A
- refer to rheum and ophtho
- calcium and vit D
- PT and OT
- NSAIDs first line
16
Q
SNOOPPPY mnemonic for headache red flags for peds
A
Systemic Neurological symptoms/signs Onset: sudden (thunderclap) Occipital Pattern: precipitated by Valsalva (coughing, sneezing) Pattern: positional (worse in recumbent) Pattern: progressive Parents: no family history Younger than 6
also: wakes up from sleep and <6 months
17
Q
Chronic progressive headaches
Features
A
brain tumour/abscess
- crescendo hx
- <6 months duration
- increasing severity and frequency
- wakes up from sleep
- persistent vomiting without headache
- neuro and development change
18
Q
Cluster headaches
Features
A
short unilateral ice pick pain tearing nasal stuffiness Horner syndrome pacing
19
Q
What are some common side effects with triptan?
A
tingling, chest pressure, warming sensation, flushing, dizziness
*combined with naproxen is increased effectiveness
20
Q
Medication overuse headache
definition
A
occurs 15+ days in a month as a result of:
- using simple analgesics (NSAIDs, tylenol) for 15+ days/month for >3 months
- using triptans/ergotamine/opioids/combo for 10+ days/month
21
Q
GENU VARUM vs GENU VALGUM
what’s the diff?
A
genu varum: bow legs
-deformity distal to knee angled toward midline
genu valgum: knock knees
-deformity distal to knee angled away from knee
22
Q
Common causes of genu varum
A
- physiologic
- rickets (vit D deficiency - nutrition vs genetic)
- achondroplasia
- trauma, infection, tumour of PROXIMAL TIBIA
- excess prenatal fluoride
23
Q
Common causes of genu valgum
A
- physiologic
- rickets (renal)
- trauma, infection, tumour of DISTAL FEMUR or PROXIMAL TIBIA
- paralytic conditions (polio, CP)
- osteogenesis imperfecta
- RA
24
Q
how to measure limb length? intercondylar distance?
how often to measure?
A
limb length:
superior iliac spine to medial malleolus
intercondylar distance:
-lie on side with medial malleoli touching
measure intercondylar and intermalleolar distance q6 months
25
When would you expect physiologic varus to correct naturally?
18-24 months old
consider pathological process if not starting to correct or angulation is progressive
26
Risk factors for in-toeing
- intrauterine positioning
- club foot (bony abnormality)
- metatarsus adductus
- sleeping prone with legs internally rotated
- internal tibial torsion
- metatarsus primus varus
- internal femoral anteversion
27
Internal tibial torsion
- features?
- management?
- feet turn inward during walking, knees are straight
* deformity is distal to knee
- watch and wait
- usually corrects once walking
- refer if no improvement at 18 months or walking x 1 year
28
Medial femoral torsion
- features?
- management?
- sit in W position
- both knees and feet turn inward
* deformity is proximal to knee
- run in egg beater position
Resolves by age 8
29
most common cause of out-toeing?
- physiologic
- seen in infants
- resolves when child learns to walk
- usually by 18 months
normal to have 5 degrees toe-out in kids >3
30
Definitions
sprain
strain
tendinitis
sprain: ligament/connective attaching bone --> bone
strain: muscle/tendon attaching muscle --> bone
tendinitis: tendon
31
Examples of overuse syndromes
repetitive microtrauma
```
eg Osgood-Schlatter, shin splints (medial tibial stress)
patellofemoral syndrome (chondromalacia patellae)
```
32
Sprains:
-based on assessment of?
Strains:
-based on assessment of?
SPRAINS:
-assessment of joint instability (ROM, weight bearing)
STRAINS
-assessment of strength
33
Management of sports injuries in acute phase:
relative rest (as long as painfree)
ice limit to 20 min
compression
NSAIDs
34
Prevention of sports injuries
specifically what is AAP recommendation on weight training?
flexibility (stretching), hydration, warmup
training and conditioning
rehab
weight training: wait until tanner stage 5
35
Osgood-Schlatter disease
features?
diagnosis?
- most common in adolescent athletes (running and jumping)
- partial avulsion of patellar tendon at its insertion on the tibia
- pain, swelling, bony prominence and tenderness over the tibial tubercle at the insertion of the patellar tendon
- symptoms tend to resolve at approximately 14-15 yrs
- clinical dx, may use XR to rule out pathology
36
Patellofemoral syndrome
features?
diagnosis?
- pain around or behind the patella that is aggravated by load bearing activities on a flexed knee (eg climbing stairs, running, squatting)
- anterior patellar pain after sitting for long time
- runner's knee, jumper's knee
- clinical diagnosis, plain films not helpful
- physio to focus on strength of knee, hip, and core
- avoid prolonged NSAID use
- no evidence for surgical intervention
- rest!
37
Growing pains
- location?
- timing?
- common age?
- intermittent poorly localized pain b/l lower extremities
- at night, resolves in minutes and in the morning
- common to calves and anterior thighs
- NEVER to joints
common age 4-14
38
Growing pains
- diagnosis?
- management?
Physical exam
- generally normal
- CBC and ESR if symptoms don't resolve and presentation not typical
- requires normal blood results (dx of exclusion)
- reassure
- heat, massage, stretch
39
Nursemaid Elbow
- aka?
- signs and symptoms?
- common age
radial head subluxation
sudden onset elbow pain, refusal to use arm
- arm held in slight flexion, forearm pronated
* refusal to SUPINATE
- NO gross deformity
- NO swelling
common age 1-4
40
Nursemaid Elbow
suspect fracture if?
- obvious deformity
- lack of spontaneous movement
- swelling
- tenderness
41
Salter Harris fracture
What part is involved in:
type 1 and 2:
type 3 and 4:
type 5:
1 and 2: involve growth plate
3 and 4: involve epiphysis (intra-articular)
type 5: crush injury to growth plate
**growth arrest common because physis is injured
42
If toddler is refusing to bear weight, what type of fracture do you suspect?
toddler's fracture:
spiral fracture of distal tibia
typically 9 months to 3 months
43
What type of fractures raise concerns re: physical abuse?
- long bone in pre-ambulatory kids
- ribs
- metaphyseal lesions
- multiple and old fractures
44
Transient synovitis
- common age
- features
- diagnosis
- management
```
Transient synovitis
• Typical age 4-10 (can be younger or older)
• M>F (2:1)
• Acute unilateral hip pain
○ Referred pain to anterior thigh or knee
• Diagnosis of exclusion
○ CBC, CRP/ESR: WNL or mild elevation
○ XR: normal or effusion
○ US: effusion
○ Arthrocentesis: N WBC and neg gram stain
• Supportive care
○ F/U in 24-48 hours
○ Rest and NSAIDs
○ Recover in 3-10 days
69% recurrence rate
```
45
Septic arthritis
- common organism?
- features
- diagnosis
- complications
Septic arthritis
• Staph aureus most common
-gonorrhea if sexually active
• Fever, decreased use of affected leg, limp/refusal to walk or weight bear
• Hip most commonly affected: held in FABER
• Pain with passive ROM, diaper changes
• Diagnosis: hard to differentiate from transient synovitis
○ Temp >38.5
○ Elevated ESR/CRP and WBC
○ XR: effusion
○ US: effusion
○ Synovial aspirate: WBC and bacteria on gram stain
• Complications in 10-25%
Joint damage can occur within 6-8 hours
46
Osteomyelitis
- common age
- patho
- location
- organism
- features
- diagnostics
```
Osteomyelitis
-50% in kids <5
• Staph aureus most common
• Bacteremia deposits bacteria into bone marrow
• Femur, tibia, pelvis
• 50% fever. Pain, limp, reduced ROM, refusal to weight bear
○ If sub-periosteal spread: erythema, warmth, swelling
• Labwork may be non-specific
○ CRP elevated in 90%
○ Blood cultures positive in 40-55%
• Imaging
○ XR: normal, only soft tissue changes
MRI gold standard
```
47
DISKITIS
- common age
- features
- workup
• Kids under 5
• Lumbar back pain, progressive limp, refusal to walk. Afebrile
• Labwork nonspecific
• Imaging
○ XR: abnormal in 75%: decreased vertebral disc space, erosion of end plate
○ CT: not helpful
MRI: r/o vertebral osteomyelitis
48
Legge-Calve-Perthes disease
- definition
- common age
- symptoms
- workup
Legg-Calve-Perthe
• Avascular necrosis of femoral head
• 3-12 years old
• M>F
• Chronic intermittent limp, painful or painless
• Worse with internal rotation and abduction
• Labwork: normal
• XR: negative if early, widening of joint space
Later: increased density and decreased size of femoral head
REFER TO ORTHO
49
Slipped capital femoral epiphysis
- definition
- common age group
- features
- imaging
Slipped capital femoral epiphysis (SCFE)
-most common hip disorder in age group
-displacement of femoral epiphysis from femoral neck through growth plate
• Teens 9-16
• M>F
• Overweight, knee pain
• Knee exam normal despite report of knee pain
○ Passive hip flexion causes obligate external rotation
○ Pain with internal rotation
• Imaging: both hips (20% SCFE bilateral)
US or MRI
REFER TO ORTHO
50
Osgood Schlatter disease
- definition
- commonly seen in?
- symptoms
- imaging
- overuse injury
- commonly seen in adolescent athletes especially with jumping or running
- repetitive microtrauma causes avulsion of patellar tendon
- bony prominence, swelling, tenderness over tibial tubercle
- clinical diagnosis
- imaging to r/o other pathology
symptoms resolve at 14-15 years of age
51
Physical exam of a child with a limp should include:
- all joints and spine
- hips for all kids with knee pain
- supine and standing
- muscle strength
- leg length measurements
52
Henoch Schonlein Purpura (HSP)
- what type of vasculitis?
- symptoms
- workup
- management
- small vessel
- IgA vasculitis
lower extremity purpura/petechiae to legs and buttocks
- abdo pain
- arthritis of knees/ankles (50% of kids)
- renal: proteinuria and hematuria
Workup:
-U/A, CRP
Self limiting 1-3 months
supportive, NSAIDs
53
Kawasaki Disease
symptoms
CRASH and BURN
```
conjunctivitis
rash (any)
adenopathy (cervical, unilateral, >1.5 cm)
strawberry tongue
hands and feet (erythema and peeling)
```
Burn: fever x 5 days
54
Kawasaki Disease
- what type of vasculitis?
- what are some GI, MSK and CNS symptoms
- lab workup
- treatment
- complications
medium vessel arteritis
- abdo pain, vomiting
- arthritis
- irritable, headache
CBC (elevated WBC and platelets), elevated CRP and LFTs urinalysis
Echo and ECG
CXR
need high dose ASA and IVIG within first 10 days
complications: coronary artery aneurysm
55
juvenile dermatomyositis
- patho
- symptoms
autoimmune vasculopathy of muscles and skin
-necrosis of muscles causing inflammation and proximal muscle weakness
symptoms:
- symmetric proximal muscle weakness
- neck abdo muscles, limb girdle
- fever, malaise, fatigue
56
juvile dermatomyositis
skin manifestations
cardiac manifestations
- heliotrope discoloration (violaceous over eyelids)
- grotton papules (shiny red plaques ro flexural surfaces of fingers, elbows, knees)
- ulcerations
CVS: HTN in 25-50%
57
Absence (petit mal) seizures are type of ______ seizures
features
generalized
```
lasts 5-10 seconds
-looks like daydreaming (cannot be interrupted)
ABSENCE of aura and postictal confusion
-COMPLETE loss of consciousness
-clusters >20/day
-provoked by hyperventilation
```
58
Complex partial seizures are type of _______ seizures
features
focal
-lasts 1-2 min
-sudden onset
daydreaming
-automatism (lip smacking, rubbing hands)
-PARTIAL loss of consciousness
-frequent aura
-brief post-ictal
-not provoked by hyperventilation
59
Head injury
symptoms of basilar fracture
- racoon eyes (b/l periorbital ecchymosis)
- hemotympanum
- battle sign (post-auricular ecchymosis)
60
Majority of concussion symptoms resolve by ______ weeks
four weeks
if prolonged: refer to interdisciplinary concussion team
61
CT head required for any kid with minor head injury and any of these findings:
- GCS <15 at 2 hours after injury
- suspected open/depressed scalp fracture
- worsening h/a
- irritable
- basal skull fracture
- large boggy hematoma of scalp
- dangerous MoI
- 4+ episodes of vomiting
62
Concussion
initial rest is recommended for ______ (time)
first 24-48 hours
- limited physical and cognitive activity
- sleep (encourage)
- screen time (limit)
- drugs (avoid)
- driving (avoid)
63
Concussion
when should return to sport occur?
- when back to school FT at full academic load without accommodations
- seek care immediately if new concussion symptoms or new suspected consussion
64
Guillane Barre
-common triggers?
-viral infection
(URTI or gastro) 10-14 days before onset
EBV, CMV
65
Guillane Barre
symptoms
-ascending weakness and paresthesia
progressive weakness/tingling in legs
-crawling skin sensation in feet and hands
progresses to acute flaccid paralysis
66
Guillane Barre
prognosis and dtreatment
-remits spontaneously
can takes weeks to months to years
-can have lasting residual weakness
67
Myasthenia Gravis
symptoms
-variable
classic triad:
- droopy eyelids
- blurry vision
- sense of choking
also:
-slurred speech
worse in evening
68
Multiple sclerosis
early symptoms
triggers
MSK: paresthesia and weakness (face, trunk, limbs)
impaired gait
eyes: blurred vision, diplopia
fatigue, depression
triggers: exercise, heat, weather
69
Bells palsy
- patho
- symptoms
facial nerve (CN 7) neuritis
LOWER motor neuron
peripheral neuropathy
-viral vs autoimmune vs idiopathic trigger --> neural inflammation
unilateral facial weakness, inability to close one eye
- mouth drooping
- unilateral ptosis
- loss of nasolabial fold
- SMOOTH forehead
- sensitivity to sound
- facial paresthesia
70
Scoliosis
signs and symptoms
- shoulder height asymmetry
- scapular prominence
- rib prominence/hump
- leg length discrepancy
71
SLE
-patho
genetic predisposition activated by environmental factors
-self-antigens, autoimmune
- environmental trigger: UV radiation, viral infection (EBV)
- estrogen
72
SLE
symptoms
systemic: fever, fatigue, weight loss, lymphadenopathy, HSM
photosensitive butterfly malar rash
- discoid rash
- arthritis (symmetric)
- kidneys: lupus nephritis
- headache
- antiphospholipid antibody syndrome (prothrombotic) --> increased risk DVT
- pericarditis
- pleurisy, pulmonaryHTN
73
SLE
what to know about ANA testing?
90% of SLE cases will show ANA antibodies
| 20% of general population will have positive ANA with no SLE
74
Acute rheumatic fever
organism?
JONES criteria
GAS
2 major manifestations OR 1 major and 2 minor manifestations AND evidence of GAS
JONES criteria: (imagine heart shape in the place of O)
J = migratory polyarthritis (J for joints): 60-80%
O = carditis (O shaped like heart): 50-80%
N = subcutaneous nodules (N for nodules): 0-10%
E = erythema marginatum (E = erythema rash): <6%
S = Sydenham chorea (S = sydenham): 10-30%
Minor manifestations: fever, arthralgia, elevated ESR/CRP, prolonged PR interval
75
Acute rheumatic fever
timeline after GAS infection
2-3 weeks between GAS infection and manifestation of arthritis and carditis
chorea 1-8 months after GAS
**high rate of recurrence in first 5 years
76
Acute rheumatic fever
diagnostic test?
throat culture
ASO antibody titres
77
Acute rheumatic fever
describe the arthritis and carditis symptoms
arthritis: occurs in 70%
large joints (knees, ankles, wrists, elbows)
- migratory
- lasts 1-2 days to a week
carditis:
mitral and aortic murmur
78
Acute rheumatic fever
treatment
-penicillin to prevent recurrent ARF
for YEARS (if carditis present then will be on PCN until age 21 or 10 years after initial dx)
NSAIDs for arthritis
high dose ASA for carditis
