Case-based MCQ

Correct Answer Is E Adolescent idiopathic scoliosis (AIS) refers to lateral curvature (ie, Cobb angle >10 degrees) of the spine without a specified etiology.  The deformity typically presents in children age ≥10 during periods of rapid growth.  Although poor posture may be noted, AIS is usually asymptomatic and identified during school scoliosis screening or annual physical examination.  Inspection of the back may reveal asymmetry of the shoulders, scapulae, or iliac crest.  Forward bend test shows asymmetric thoracic or lumbar prominence. The first step in evaluating clinically evident spinal asymmetry is x-ray of the spine.  Full-back posteroanterior and lateral radiographs confirm the diagnosis, measure the severity of disease (ie, Cobb angle), and assess skeletal maturity. Management of AIS depends on risk of progression (eg, degree of skeletal maturity) and severity (ie, degree of curvature on x-ray).  Scoliosis typically progresses slower with increasing degrees of bone ossification.  Therefore, patients are at increased risk for progression in early puberty (eg, premenarche). Most curves are mild (ie, Cobb angle 10-30 degrees) and can be monitored clinically every 6 months.  A thoracolumbosacral spinal brace is indicated in a child with growth potential remaining and Cobb angle ≥30 degrees to help reduce curve progression.  Surgical fixation is considered for severe curvature (ie, Cobb angle ≥40-50 degrees) . Scoliosis due to pathologic causes (eg, mass, dysraphism) may present with neurologic symptoms, severe pain, rapid progression, or vertebral abnormalities on x-ray.  MRI of the spine should be performed in such cases but is not indicated in this asymptomatic patient. Adolescent idiopathic scoliosis is defined as lateral curvature of the spine without a known etiology in a child age ≥10.  Forward bend test reveals an asymmetric thoracic or lumbar prominence.  The first step in evaluation is x-ray of the spine to determine the degree of curvature and assess skeletal maturity

A 13-year-old girl is brought to the office by her mother for a preparticipation sports physical.  She is planning to play lacrosse, which she had played the previous school year.  The coach notified the mother that the girl’s posture seemed abnormal.  The patient has no chronic medical conditions and takes no daily medications.  She has not undergone menarche.  BMI is at the 50th percentile.  Physical examination shows a right-sided lumbar prominence during forward bend test, and there is no tenderness of the spine.  The remainder of the examination reveals no abnormalities with normal neurologic function.  Which of the following is the best next step in the management of this patient? A. MRI of the spine B. Reassurance and follow-up in 6 months C. Surgical fixation D. Thoracolumbosacral spinal brace E. X-ray of the spine

Correct Answer Is A This patient has lateral wrist pain consistent with de Quervain tendinopathy (DQT).  DQT is an overuse syndrome involving the tendons of the abductor pollicis longus and extensor pollicis brevis and occurs most prominently at the point where the tendons pass under the extensor retinaculum in the first dorsal compartment.  It most commonly occurs in women age 30-50 and is seen in higher frequencies 4-6 weeks postpartum, possibly because of repetitive thumb abduction and extension when lifting the infant. The diagnosis of DQT is based on clinical features.  Examination typically shows tenderness at the radial side of the wrist at the base of the hand.  In addition, the Finkelstein test (adduction of the wrist with the fingers closed over the thumb in a fist) causes passive stretching of the tendons over the radial styloid; reproduction of the pain in this maneuver is strongly suggestive of DQT.  Conservative management with nonsteroidal anti-inflammatory drugs (eg, ibuprofen) and thumb spica splinting is usually adequate. Flexor carpi radialis tenosynovitis is associated with excessive wrist flexion and characterized by pain and tenderness at the anterior aspect of the wrist.  It is relatively uncommon; overuse of this muscle more commonly causes symptoms at the proximal origin (ie, medial epicondylitis). Osteoarthritis of the first metacarpophalangeal joint causes pain over that joint, not at the carpometacarpal joint.  It would be uncommon in this young patient without a history of significant trauma. Scaphoid fractures typically occur during forceful hyperextension of the wrist (eg, fall on an outstretched hand).  Pain and tenderness typically localize to the anatomic snuffbox. Stenosing tenosynovitis (“trigger thumb”) results in pain over the palmar aspect of the first metacarpophalangeal joint; the pain is associated with a catching sensation during movement or locking of the thumb in flexion. De Quervain tendinopathy presents with lateral wrist pain over the tendons of the abductor pollicis longus and extensor pollicis brevis.  It is most common in women age 30-50, with an increased frequency during the postpartum period.  Examination shows tenderness at the radial side of the wrist and a positive Finkelstein test (reproduction of pain on adduction

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A 30-year-old woman comes to the office due to pain over the lateral side of the right wrist for the last 4 days.  She is 6 weeks postpartum from her first child, and the pain is most severe when she lifts the infant from the crib.  The patient has not had acute trauma to the wrist or hand.  Vital signs are normal.  Examination shows tenderness over the radial side of the wrist and first dorsal compartment.  With the hand in a fist and the fingers closed over the thumb, passive adduction of the wrist reproduces the pain.  Which of the following is the most likely diagnosis in this patient? A. De Quervain tendinopathy B. Flexor carpi radialis tenosynovitis C. Osteoarthritis of first metacarpophalangeal joint D. Scaphoid fracture E. Trigger thumb

Explanation: Correct Answer Is D This patient with Paget disease of bone now has a destructive femoral lesion, raising strong suspicion for osteosarcoma.  Most cases occur in a bimodal distribution, as follows: In children and adolescents, osteosarcoma usually develops at the metaphysis of long bones, where cellular turnover is high (primary osteosarcoma). In adults age >40, osteosarcoma usually develops at sites of damaged bone, particularly due to Paget disease of bone, irradiation, or prior benign bone tumor (secondary osteosarcoma). Paget disease of bone is associated with increased bone remodeling and bone overgrowth.  Although most cases are asymptomatic, the risk of osteogenic sarcomatous transformation (at sites of bone overgrowth) is several-thousand times greater than the general population.  Manifestations of malignant transformation generally include worsened localized pain and soft tissue swelling.  Imaging usually shows a destructive bone lesion with a mixture of radiodense and radiolucent areas, a sunburst periosteal pattern, and/or Codman triangle  (periosteal elevation).  Adults who develop osteosarcoma have a poor prognosis. Lyme arthritis is a manifestation of Borrelia burgdorferi infection usually characterized by monoarticular arthritis of the knee.  However, it typically develops months to years after tick exposure.  In addition, although erosion of the joint cartilage or bone can sometimes occur, cortical bone destruction with periosteal elevation would be atypical. Osteoarthritis, characterized by inflammatory destruction of articular cartilage, often involves several joints (eg, knees, hips).  Imaging generally shows thickening of subchondral bone, joint space narrowing, and formation of osteophytes. Stress fracture is an overuse injury to bone caused by repetitive stress (eg, running on pavement).  Although stress fracture can be associated with periosteal elevation, cortical thickening, and sclerosis, the presence of bone destruction with radiolucent areas suggests a neoplastic process.  In addition, stress fracture is rare in the femur; most cases occur in the tibia and fibula. Calcium pyrophosphate deposition disease is common in older patients.  Symptomatic disease often presents with acute arthritis in the knee (>50% of cases).  However, imaging shows cartilage calcification (eg, menisci) and degenerative changes in the joint that are similar to osteoarthritis (eg, subchondral cysts, osteophytes, bone/cartilage fragmentation). Paget disease of bone is associated with increased bone remodeling, which dramatically increases the risk of osteosarcoma.  Most cases present with pain, soft tissue swelling, and hallmark radiographic findings (eg, destructive bone lesion, sunburst periosteal reaction, Codman triangle).

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A 65-year-old man comes to the office for evaluation of new-onset pain in the right knee.  The patient first noticed the pain 3 weeks ago after a long hike in the mountains.  The pain has not improved with acetaminophen, and he is now unable to sleep because of it.  He has also had intermittent low-grade fevers.  The patient has Paget disease of bone, which was diagnosed 10 years ago, and type 2 diabetes mellitus.  He drinks alcohol socially but does not use tobacco or illicit drugs.  Temperature is 37.2 C, blood pressure is 120/70 mm Hg, and pulse is 80/min.  BMI is 23 kg/m2.  The right knee has diffuse soft tissue swelling and a small effusion with no surrounding erythema.  The distal aspect of the thigh is tender to palpation.  X-ray of the right knee reveals medullary and cortical bone destruction with lucent areas and a surrounding periosteal elevation along the distal femur.  Which of the following is the most likely cause of this patient’s knee pain? A. Borrelia burgdorferi–induced monoarticular arthritis B. Destruction and inflammation of articular cartilage C. Formation of stress-related microfractures D. Malignant proliferation of osteoid sarcomatous stroma E. Precipitation of calcium pyrophosphate dihydrate crystals

This young woman with constitutional symptoms (fatigue), thrombocytopenia, probable mitral regurgitation (holosystolic murmur to the apex), and a positive antinuclear antibody (ANA), suggestive of systemic lupus erythematosus (SLE), now likely has a cerebrovascular accident (CVA) (sudden-onset unilateral weakness, negative cerebrospinal fluid [CSF] findings).  Given these features, antiphospholipid syndrome (APS) in the setting of SLE is likely. APS presents with a thrombotic event (deep venous thrombus or arterial thrombus) or pregnancy morbidity (fetal loss, severe preeclampsia, placental insufficiency) plus a positive serology for 1 of 3 antiphospholipid antibodies: anticardiolipin antibody, anti-beta2-glycoprotein-I antibody, or lupus anticoagulant.  The biggest risk factor for APS is SLE; APS occurs in up to 40% of these patients. A minority of healthy individuals may develop transient antiphospholipid antibodies, so all positive serology for APS should be repeated at 12 weeks to confirm diagnosis.  Patients with APS often require anticoagulation for life (heparin product or warfarin) as the risk of recurrent thrombus is high.  For those with concomitant SLE, hydroxychloroquine is also added. Multiple sclerosis (MS) presents with neurologic symptoms, but transverse myelitis causing a paraplegia or paraparesis is much more common than hemiparesis.  As MS is inflammatory, symptoms tend to develop over hours or days, not suddenly.  MS also would not explain this patient’s hematologic abnormalities, positive ANA/rapid plasma reagin (RPR), or murmur. Neurosyphilis can occasionally present with an arteritis causing a cerebrovascular event in a young patient, but it is typically accompanied by abnormal CSF cell counts (lymphocytic pleocytosis, 10-100/mm3).  In patients with APS, a false positive RPR test is not uncommon as the syphilis antigen used in RPR testing contains cardiolipin. Polyarteritis nodosa can cause a CVA in a minority of patients, but mononeuritis and polyneuropathy are far more common.  In addition, other findings such as arthralgias, myalgias, and cutaneous, renal, and/or gastrointestinal disease are often also present. Rheumatic fever causes chorea-like movements (Sydenham chorea).  It commonly presents with carditis and migratory arthritis. Antiphospholipid syndrome is characterized by a thrombotic event or pregnancy morbidity in the setting of a positive autoantibody to 1 of 3 phospholipids – anticardiolipin antibody, anti-beta2-glycoprotein-I antibody, or lupus anticoagulant.  It is very common in patients with systemic lupus erythematosus.

A 32-year-old woman is brought to the hospital due to sudden-onset left-sided weakness.  According to the family, she has had fatigue, malaise, and decreased appetite over the last several weeks.  She attributed these symptoms to a “viral infection” and treated herself with over-the-counter acetaminophen.  Her temperature is 37.4 C (99.4 F), blood pressure is 140/86 mm Hg, and pulse is 82/min.  The patient appears confused and agitated.  Lungs are clear to auscultation.  A 2/6 holosystolic murmur is heard at the cardiac apex.  Extremity examination reveals left-sided muscle strength is 1/5 with hyperactive deep tendon reflexes.  Babinski sign is present on the left side.  Laboratory results are as follows: Hemoglobin 10.2 g/dL Platelets 64,000/mm3 Leukocytes 6,800/mm3 Blood urea nitrogen 18 mg/dL Creatinine 70 umol/L Antinuclear antibody (ANA) positive Rapid plasma reagin (RPR) positive Cerebrospinal fluid cell counts are normal, and cultures are negative.  Which of the following is the most likely diagnosis in this patient? A. Antiphospholipid syndrome B. Multiple sclerosis C. Neurosyphilis D. Polyarteritis nodosa E. Rheumatic fever

Supracondylar fractures of the humerus are the most common elbow fractures in children.  The mechanism typically involves a fall onto an outstretched hand with a hyperextended elbow.  The supracondylar area is relatively thin and weak due to physiologic remodeling during childhood, and a supracondylar fracture most commonly results in posterior displacement of the distal humerus fragment, as seen in this patient.  The anteriorly displaced proximal fragment can entrap the median nerve and brachial artery, which are located anterior to the humerus. Distal perfusion should be monitored closely because brachial artery injury results in diminished brachial and radial pulses.  Motor and sensory function should also be assessed due to the risk of median nerve injury that can present with a weak “OK” sign (ie, inability to approximate tip of thumb and index finger). Diagnosis is based on x-ray, which reveals a fracture line and often a posterior fat pad indicative of elbow effusion.  Treatment involves analgesia and immobilization.  Neurovascular injury often resolves after orthopedic alignment and immobilization.  Patients who are treated promptly have a good prognosis. The axillary artery and nerve can be injured during proximal humerus fractures but not with supracondylar fractures. Brachial plexus compression is a complication of neonatal clavicle fracture or high-impact trauma to the neck and shoulder area, not the elbow. Ulnar nerve injury is a complication of a rare type of supracondylar fracture that occurs upon impact of a flexed (rather than hyperextended) elbow.  This mechanism of injury causes anterior displacement of the distal humerus fragment, which can impinge on the ulnar nerve located posterior to the medial epicondyle of the humerus. Displaced supracondylar fractures of the humerus most commonly present after a fall onto an outstretched hand with posterior displacement of the distal humerus fragment.  The anteriorly displaced proximal humerus fragment can entrap the brachial artery and median nerve, which pass anterior to the humerus.