Case-based MCQ

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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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A 55-year-old man comes to the office due to a hard lump on the palm of his right hand that has been present for several months.  It is painless and does not affect hand function.  Medical history is significant for type 2 diabetes mellitus and hypertension.  The patient works as a gardener.  Vital signs are normal.  On examination, a hard, fibrous, nodular band is present at the base of the ring finger.  He has full movement of his fingers.  What is the most likely cause of this patient’s current condition? A. Calcific peritendinitis B. Diabetic cheiroarthropathy C. Fibrosis of the palmar fascia D. Flexor tenosynovitis E. Median nerve injury

Correct Answer Is D This patient has a number of findings (eg, esophageal dysmotility, fibrotic lung disease, arthralgias) consistent with extradermal manifestations of systemic sclerosis (SSc).  Classic early skin manifestations of SSc include thickening or hardening, edema, and pruritus.  However, if skin symptoms are mild, patients may first seek attention due to gastrointestinal (GI), joint, or respiratory disease. GI complications are common in SSc and primarily affect the esophagus.  SSc causes smooth muscle atrophy and fibrosis in the lower esophagus; the upper third of the esophagus is made of striated muscle and seldom affected by SSc.  Common symptoms include dysphagia, choking, heartburn, and hoarseness.  Esophageal manometry in affected patients typically shows hypomotility and incompetence of the lower esophageal sphincter (LES). Dysfunction of inhibitory neurons causes diffuse esophageal spasm and presents with chest pain and dysphagia rather than heartburn.  Manometry is characterized by periodic, high-amplitude, non-peristaltic contractions. Eosinophilic esophagitis is characterized by heartburn that does not respond to standard medications for gastroesophageal reflux disease.  Manometry most often shows esophageal hypercontractility. Achalasia presents with dysphagia and regurgitation of undigested food.  As in SSc, manometry shows aperistalsis in the distal esophagus.  However, achalasia causes increased LES pressure and incomplete LES relaxation, whereas SSc causes decreased LES pressure. Esophageal involvement may occur in polymyositis.  It can involve both the upper and lower esophagus and is characterized by dysphagia, regurgitation, and aspiration.  Manometry results are often functionally similar to SSc, but most patients will have symmetric proximal muscle weakness, not distal arthralgias. Systemic sclerosis can cause atrophy and fibrosis of the smooth muscle in the lower esophagus.  This leads to decreased peristalsis and decreased tone in the lower esophageal sphincter.  Typical symptoms include heartburn and dysphagia.

A 42-year-old woman comes to the office with a 4-month history of heartburn.  She describes a periodic “sticking sensation” in her chest during meals.  In addition, the patient has recently been unable to participate in her normal exercise routine due to dyspnea on exertion and joint pain in her hands and feet.  She does not use tobacco, alcohol, or illicit drugs.  Lung examination reveals bilateral end-inspiratory crackles.  Endoscopic evaluation shows mild hyperemia in the distal esophagus.  Esophageal manometry shows lack of peristaltic waves in the lower two-thirds of the esophagus and a significant decrease in lower esophageal sphincter tone.  Which of the following is the most likely mechanism responsible for this patient’s manometric findings? A. Dysfunctional impairment of inhibitory neurons B. Eosinophilic infiltration of esophageal mucosa C. Loss of intramural neurons D. Smooth muscle atrophy and fibrosis E. Striated muscle inflammation

Correct Answer Is A The 2 most prevalent forms of arthritis are osteoarthritis (OA) and rheumatoid arthritis (RA), and individuals may have both conditions concurrently.  OA is much more common and characteristically involves the knees, hips, and distal finger joints.  RA, an inflammatory arthritis, typically involves the metacarpophalangeal, proximal interphalangeal, and wrist joints.  However, any joint may be affected.  This patient has multiple clinical and radiographic features suggestive of RA:  Her prolonged morning stiffness, systemic symptoms (ie, fatigue), and soft tissue swelling involving multiple joints are more consistent with RA than OA; she also has X-ray findings that favor a diagnosis of RA over OA, including periarticular erosions (seen here on hand x-rays), distal osteopenia, and soft tissue swelling. Additional evaluation of patients with suspected RA should include inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein), which are typically elevated in RA but normal in OA.  Cyclic citrullinated peptide antibodies are present in most patients with RA and can help confirm the diagnosis; rheumatoid factor should also be tested but has lower specificity. Initial management of RA includes nonsteroidal anti-inflammatory drugs and systemic glucocorticoids (eg, prednisone) to acutely reduce pain; however, these interventions do not alter the long-term prognosis and are inadequate for definitive therapy.  As soon as possible after the diagnosis is made, disease-modifying antirheumatic drugs (DMARDs) should be initiated to slow disease progression; first-line options include methotrexate, a folate antimetabolite that is cost-effective and well tolerated by most patients.  Alternate options include sulfasalazine, leflunomide, and hydroxychloroquine. Nonpharmacologic interventions for OA include regular exercise and weight loss; knee braces may reduce pain in some patients but are unlikely to alter the long-term course of the condition.  However, none of these interventions are adequate treatment for RA. Total knee arthroplasty is most commonly performed for patients with advanced OA.  It is occasionally needed for patients with severe deformity due to RA, but early initiation of DMARD therapy may eliminate the need for later joint replacement. Urate-lowering therapy is indicated for long-term treatment of gout.  Gout commonly affects the knee but typically causes episodic symptoms with brief but severe inflammatory changes (eg, redness, warmth, swelling).  X-rays in early gout are generally normal, although chronic findings include punched-out erosions with an overhanging rim of cortical bone (“rat bite” lesion). Clinical findings that favor the diagnosis of rheumatoid arthritis (RA) over osteoarthritis include prolonged morning stiffness, systemic symptoms, and soft tissue swelling.  Other characteristic findings in RA include periarticular erosions on x-ray, elevated inflammatory markers, and positive cyclic citrullinated peptide antibodies or rheumatoid factor.  Disease-modifying antirheumatic drugs (eg, methotrexate) slow disease progression and should be initiated on diagnosis.

A 56-year-old woman comes to the office with her daughter to discuss knee pain, which has been ongoing for several years.  The patient has a high tolerance for pain and has previously refused to see a doctor for her condition.  Lately, the pain has been affecting the patient’s daily activities, and she spends most of the day sitting in a chair.  The knee pain and stiffness are more pronounced on the right side and are worse in the morning but gradually improve by the afternoon.  She takes no medications.  Review of systems is positive for fatigue.  Vital signs are within normal limits.  BMI is 31 kg/m2.  Lower extremity examination shows that both knees are swollen and tender but more so on the right side.  The patient is unable to fully flex or extend the right knee.  There is mild, bilateral atrophy of the quadriceps.  Radiographs of the knees reveal osteopenia of the distal femur, multiple periarticular erosions, and soft tissue swelling.  Which of the following is the best long-term management for the most likely diagnosis in this patient? A. Antifolate immunosuppressant B. Knee braces and weight loss C. Systemic glucocorticoid D. Total knee replacement E. Urate-lowering therapy

Correct Answer Is C This patient’s low body weight (BMI <18.5 kg/m2), stress fracture, and distress in response to the recommendation to limit his physical activity are concerning for anorexia nervosa (AN).  Although AN is more common in female patients, male patients are also affected and at risk for bone loss.  Decreased bone mineral density, which is caused by a number of factors (eg, endocrine abnormalities, hypercortisolism, growth hormone resistance), results in an increased risk of bone fractures.  Other medical complications associated with AN include bradycardia, hypotension, and cardiac atrophy. The most important next step in management of this patient is to obtain a comprehensive dietary history.  Caloric intake and meal patterns, attitudes about food and weight, and history of bingeing and efforts to control weight with compensatory behaviors (eg, exercise, fasting, self-induced vomiting, misuse of laxatives, diuretics) should be assessed.  In addition, AN in male patients may present with a focus on muscularity rather than thinness.  In these cases, dietary history may reveal dietary restrictions aimed at muscle building and the use of protein supplements at the expense of balanced nutrition. Advising participation in another sport would not treat an underlying eating disorder. Although exogenous steroid use (eg, androgen) can predispose to decreased bone mineral density and fractures, it is typically associated with increased muscle strength and mass, and other typical signs of steroid use could be seen (eg, hypertension, acne, gynecomastia, testicular shrinkage).  Obtaining a dietary history would take priority in this patient with significantly low body weight and no other signs of steroid use. Hyperthyroidism can result in decreased bone mineral density and weight loss.  However, these symptoms are typically accompanied by increased appetite and signs of sympathetic hyperstimulation such as tachycardia, hypertension, heat intolerance, tremor, and hyperreflexia, which are not evident in this patient.  Hyperthyroidism would not explain this man’s distress at having to limit his physical activity. The initial management of small tibial stress fractures includes rest, analgesia, and stabilization with a splint or brace if necessary.  Surgical intervention could be considered for severe fractures or for lack of healing or severe pain despite conservative treatment. A dietary history to assess for anorexia nervosa should be obtained in any patient with a stress fracture, low body weight, and distress at having to limit physical activity.  Patients with anorexia nervosa are at risk for stress fractures due to decreased bone mineral density.

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A 20-year-old man comes to the emergency department due to worsening right leg pain.  The patient runs 10 km daily, but several weeks ago, he began having dull pain at the right lower shin during runs.  Now, the pain occurs even with light walking.  He has had no trauma, fever, chills, or redness in the affected area.  The patient has no prior medical conditions and takes no medications.  Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, pulse is 56/min, and respirations are 16/min.  BMI is 17 kg/m2.  Physical examination reveals tenderness of the right lower anterior tibia.  X-ray of the right lower extremity reveals a small tibial stress fracture.  When the findings are explained and treatment with analgesics and limited physical activity is discussed, the patient becomes distressed that he has to stop running.  Which of the following is the most appropriate next step in management of this patient? A. Advise participation in different sports B. Inquire about exogenous steroid use C. Obtain comprehensive dietary history D. Order thyroid function studies E. Refer for surgical intervention

Correct Answer Is A Septic bursitis This patient’s presentation is concerning for septic bursitis.  The prepatellar bursa is a fluid-filled synovial sac between the patella and the skin that alleviates friction.  Infection of the bursa can occur due to penetrating trauma, superficial abrasions (eg, from working while kneeling), or extension from local cellulitis.  Gram-positive skin floras (eg, Staphylococcus aureus) account for most cases, and the risk is greater in patients with immunocompromising conditions (eg, diabetes mellitus). Septic bursitis is characterized by boggy swelling of the bursa associated with erythema, warmth, pain, and fever, although fever may be less prominent in patients age ≥65.  Aspiration of bursal fluid is necessary to confirm the diagnosis; the fluid should be sent for cell count and differential, Gram stain, and culture.  Treatment includes systemic antibiotics; drainage is indicated when the bursitis fails to improve after 36-48 hours of antibiotic therapy or compressive symptoms (eg, neurovascular compromise) are present. Knee joint (rather than bursal fluid) aspiration is indicated for suspected septic arthritis, which presents with knee effusion and severely painful, reduced range of motion.  This patient has intact range of motion of the knee with little pain, indicating that the pathology is extraarticular. Gout can cause an inflammatory bursitis resembling septic bursitis, and bursa fluid is often sent for crystal microscopy.  However, gouty bursitis is significantly less common than septic bursitis, and infection should be ruled out before empirical treatment for gout (eg, colchicine) is initiated. A knee compression wrap and ice application are used to treat noninflammatory bursitis due to overuse.  This patient’s erythema and warmth are atypical for noninflammatory bursitis.  In some patients, it may be hard to differentiate septic from noninflammatory bursitis.  Therefore, aspiration should be performed to rule out infection. Knee x-ray may show nonspecific bursal swelling but does not rule out infection.  X-ray is most helpful if a concurrent fracture (eg, due to a fall) or foreign body is suspected. Septic prepatellar bursitis is characterized by acute erythema, warmth, and pain accompanying bursal swelling.  It is usually caused by skin breakage that allows entry of skin floras (eg, Staphylococcus).  Bursal fluid analysis is needed to confirm the diagnosis.  Treatment includes systemic antibiotics

A 68-year-old man comes to the office due to right knee pain and swelling.  Three days ago, the patient spent most of the day on his knees while replacing the kitchen floor.  The next day, the right knee started to become increasingly red and painful.  Medical history includes hypertension and type 2 diabetes mellitus.  Temperature is 37.8 C (100 F), blood pressure is 130/80 mm Hg, and pulse is 92/min.  On examination, erythema and warmth are present at the anterior right knee, as shown in the image below.  Palpation reveals a 5-cm, tender, fluctuant swelling just anterior to the patella.  Range of motion of the knee is intact but produces mild pain at the end-range of flexion and extension.  Pedal pulses are 2+, and sensation in the lower extremities is intact.  Gait is normal.  Which of the following is the most appropriate next step in management of this patient? A. Aspiration of the bursal fluid B. Aspiration of the knee joint C. Empiric colchicine therapy D. Knee compression wrap and ice application E. X-ray of the knee