Case-based MCQ

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Correct Answer Is E This child with knee pain has limited hip mobility and bilateral hip effusions, consistent with transient synovitis (TS).  TS is a common, self-limiting, inflammatory hip condition that occurs in children age 3-8.  The aetiology is unclear but often involves postviral or, less commonly, posttraumatic (eg, gymnastics class) joint inflammation.  In some cases, no preceding trigger is identified. Presentation includes a well-appearing child with acute hip pain or referred knee pain.  Knee examination is normal (as in this case), and patients often hold the hip flexed, abducted, and externally rotated to relieve pressure in the joint space.  Limping is common, although patients can usually bear weight on the affected leg.  Fever is typically absent (or low-grade), and laboratory evaluation (eg, C-reactive protein, white blood cell count) is usually normal. Ultrasound reveals small unilateral or bilateral effusions (even when symptoms are confined to one hip).  Treatment of TS is conservative (eg, nonsteroidal anti-inflammatory medications), and symptoms generally resolve within days to weeks. Juvenile idiopathic arthritis presents with chronic joint pain and inflammation and may be associated with rash and fever.  The hips are rarely involved, and elevated inflammatory markers are expected. Osgood-Schlatter disease, or osteochondritis of the tibial tubercle, presents in active adolescents with chronic anterior knee pain that is worse with running and jumping.  Tenderness over the tibial tubercle is a characteristic finding not seen on this patient’s examination. Septic arthritis typically presents in ill-appearing, febrile children with acute joint pain and inflammation.  Patients classically refuse to bear weight on the affected extremity, unlike in this case.  In addition, leukocytosis and elevated inflammatory markers are typical, and ultrasound reveals a unilateral (not bilateral) effusion. Slipped capital femoral epiphysis occurs when the femoral diaphysis is displaced anteriorly along the growth plate relative to the femoral head.  Typical presentation involves an obese adolescent with chronic hip (or referred knee) pain, limp, and limited internal rotation of the hip.  Ultrasound may detect the slippage but would not show effusions, as seen in this patient. Transient synovitis is a self-limiting, inflammatory hip condition most common in children age 3-8.  Presentation may include limp (with ability to bear weight), hip pain, or pain referred to the knee.  Most patients are afebrile with normal laboratory studies (eg, white blood cell count, C-reactive protein) and small, bilateral hip effusions.

A 6-year-old girl is brought to the clinic for evaluation of knee pain.  The patient first had soreness in her right knee 4 days ago, after her first gymnastics class.  Her mother gave her acetaminophen and massaged her knee, but this did not help.  The patient also developed a limp over the past 2 days.  She has no chronic medical conditions and does not take daily medications.  Height is at the 50th percentile and weight is at the 75th percentile.  Temperature is 37.9 C (100.2 F).  When walking, she limits weight-bearing on her right side.  When supine, the right hip is held flexed with the knee pointed laterally.  There is limited internal rotation and extension of the right hip.  The right knee has full range of motion and there is no tenderness on palpation around the knee.  Laboratory evaluation shows leukocyte count of 11,500/mm3 and C-reactive protein of 8 mg/L (normal: <10).  Ultrasound of the hips shows small, bilateral effusions.  Which of the following is the most likely diagnosis in this patient? A. Juvenile idiopathic arthritis B. Osgood-Schlatter disease C. Septic arthritis D. Slipped capital femoral epiphysis E. Transient synovitis

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Explanation: Correct Answer Is A This elderly woman has an acutely shortened, externally rotated leg following a fall.  This presentation is most consistent with either a femoral neck or an intertrochanteric fracture, which are the most common hip fractures in older adults, typically occurring due to mechanical falls.  The classic pattern of shortening and external rotation of the leg compared with the contralateral side is primarily due to contraction of the psoas and iliacus without the normal acetabular counterforce.  This pattern is also seen in anterior hip dislocation, which is significantly less common than fracture and typically occurs following severe trauma (eg, industrial accident, motor vehicle collision).  An x-ray generally confirms the diagnosis of fracture. Hip fractures are classified as either intracapsular (femoral head and neck) or extracapsular (intertrochanteric or subtrochanteric).  Intracapsular fractures typically present without significant ecchymoses and have a higher risk of avascular necrosis.  Extracapsular fractures are at higher risk for displacement and usually have visible ecchymosis.  Both types generally require surgical correction (eg, open reduction with internal fixation).  In stable patients, surgery within 48 hours is associated with lower mortality and a lower risk of pressure ulcers and pneumonia. Femoral shaft fracture in elderly patients can present with shortening of the leg, often with angulation.  Pubic ramus fracture can occur from minor (or no) trauma in elderly patients and also can cause shortening of the ipsilateral leg.  However, external rotation is more typical of femoral neck fracture. Posterior hip dislocation typically presents with adduction and internal rotation at the hip.  It usually occurs from an axial force on the femur (eg, dashboard injury), and some patients have neurologic manifestations due to involvement of the sciatic nerve. Isolated fracture of the greater trochanter can occur due to a ground-level fall in older patients.  Typical features include pain with abduction and tenderness at the trochanter.  However, leg length is not affected. Femoral neck and intertrochanteric fractures are the most common hip fractures in older adults and most typically occur due to mechanical falls.  Examination findings include shortening and external rotation of the leg compared with the contralateral side.

An 84-year-old woman with Alzheimer dementia is brought to the emergency department for evaluation after refusing to get out of bed.  She has been known to wander the halls at her facility, and a nursing aide reported finding her on the floor next to her bed earlier that day.  Vital signs are within normal limits.  On examination, the patient is in pain.  Her right leg appears shorter than her left.  She is able to wiggle her toes but has significant external rotation of the right lower extremity compared with the left.  There is no evidence of head trauma and the lower leg compartments are soft.  Which of the following is the most likely diagnosis in this patient? A. Femoral neck fracture B. Femoral shaft fracture C. Posterior hip dislocation D. Pubic ramus fracture E. Trochanteric fracture

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Spiral fractures of the distal tibia can be seen in ambulatory children age ≤3 and are known as toddler’s fractures.  These fractures typically result from a twisting injury during a low-impact fall in the early walking years. A thorough history is essential during initial evaluation because nonaccidental trauma must be considered if the mechanism does not match the injury or if a spiral fracture occurs in a nonambulatory child.  However, this patient’s fall after tripping is typical for a toddler’s fracture, and the location of his bruising (eg, scattered bruises on the bilateral knees and lower legs) is common in early walkers as they stumble while walking (in contrast, bruises on the face, neck, torso, and buttocks are more commonly associated with physical abuse). Tibial fractures present with pain, limp, and/or refusal to bear weight.  Pain elicited with ankle dorsiflexion or twisting of the knee and ankle in opposite directions is characteristic.  Fracture site tenderness and leg swelling may also be present.  Anteroposterior and lateral radiographs may be normal initially but usually show a hairline fracture, as seen in this patient.  Treatment involves immobilization and pain control with no additional workup. Bone marrow evaluation is performed for suspected leukemia, which can present with bruising and bone pain.  However, this patient has acute symptoms after a fall and a fracture line on x-ray that is consistent with the mechanism of injury. Calcium, phosphorus, and parathyroid hormone levels are part of the evaluation for rickets.  Although fractures can occur with severe rickets, x-ray findings include bowing of the tibia and widening of the epiphyseal plates, which are not seen in this patient. Collagen type 1 mutation is seen in osteogenesis imperfecta, which often presents with easy bruising and multiple fractures after minimal or no injury.  In contrast, this patient’s fracture and bruising on the knees/shins are in an expected location for a toddler learning to walk. MRI can detect osteomyelitis in a patient with fever, as well as bony tenderness, warmth, and swelling.  This patient’s lack of fever and x-ray findings make infection unlikely. Toddler’s fractures, or spiral tibial fractures, are seen in children during the first few years of walking.  Injury typically occurs following a twisting motion during a minor fall.  Spiral fractures may be suspicious for nonaccidental trauma if the history is inconsistent or if the child is not yet ambulatory.

A 15-month-old boy is brought to the emergency department due to refusal to stand.  Earlier today, the patient fell from a standing height after tripping on toys.  The event was witnessed by several employees at the day care that he has been attending for a week.  He cried initially but was consoled and continued playing.  At home, however, he was unwilling to walk or bear weight on his right leg.  The patient has met appropriate growth parameters and developmental milestones.  Weight and height are at the 75th percentile.  Temperature is 37.7 C (99.9 F).  The patient is sitting comfortably in his mother’s lap.  The abdomen is soft with no organomegaly.  The right distal tibia is slightly edematous compared with the left.  Palpation over the right distal tibia elicits crying.  Skin examination shows scattered bruises on the bilateral knees and lower legs.  In addition to leg immobilization, which of the following is the best next step in evaluation of this patient? The radiograph is shown in the image below:   A. Bone marrow evaluation B. Calcium, phosphorus, and parathyroid hormone levels C. Collagen type 1 mutation testing D. MRI of the tibia E. No additional workup

Correct Answer Is C This patient has Dupuytren contracture (DC) at the base of the ring finger.  DC is characterized by progressive fibrosis of the palmar fascia due to fibroblast proliferation and disordered collagen deposition.  Although the etiology is unknown, risk factors include age >50, male sex, family history, and Northern European ancestry.  Manual work (eg, gardening) may also be a risk factor, and DC occurs more commonly in patients with a history of tobacco and alcohol use and diabetes mellitus. Initial fascial fibrosis results in painless puckering of the skin just proximal to the metacarpophalangeal joint.  As fibrosis continues, pathognomonic fascial nodules form along the flexor tendons and eventually progress to palpable fibrotic cords.  Although patients may initially have full movement in their fingers (as seen in this patient), formation of these cords eventually results in contractures that lead to decreased extension at the metacarpophalangeal and proximal interphalangeal joints.  The ring and little fingers are most commonly involved, with the middle finger involved to a lesser extent. The diagnosis is made clinically and does not require imaging.  Mild cases can usually be managed with modification of hand tools (eg, padded gloves, cushion tape).  Persistent or progressive disease may require needle disruption of cords (aponeurotomy) or intralesional glucocorticoid injections.  Surgery is occasionally required for advanced disease or contractures. Calcific peritendinitis is an inflammatory condition caused by calcium hydroxyapatite crystal deposition in the tendons.  Flexor tenosynovitis is inflammation of the tendons and their synovial sheaths, typically caused by bacterial infections.  Because of the inflammatory nature of both conditions, they present with pain, erythema, and swelling, features absent in DC. Diabetic cheiroarthropathy (“diabetic stiff hand syndrome”) occurs in patients with long-standing diabetes mellitus.  Decreased collagen degradation leads to thickened scleroderma-like skin, sclerosis of the tendon sheaths, and stiffness in the joints.  However, fibrotic nodules and cords, which are pathognomonic for DC, are not present. Diabetes mellitus is a risk factor for median nerve mononeuropathy at the wrist, which results in numbness in the palmar thumb and the index, middle, and ring (radial half) fingers, as well as weakness in the thenar muscles (eg, thumb abduction and opposition), akin to carpal tunnel syndrome. Dupuytren contracture results from progressive palmar fascia fibrosis, leading to puckering of the skin and fibrotic nodule and cord formation along the flexor tendons.  Patients develop contractures that limit extension at the metacarpophalangeal and proximal interphalangeal joints.  The diagnosis is made clinically; no imaging is needed

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