Musculskeletal

Inflammatory joint diseases

A

Amyloidosis

Behet disease

Familial Mediterranean fever

Juvenile dermatomyositis

Juvenile chronic arthritis, pauciarticular

Juvenile rheumatoid arthritis, polyarticular

Juvenile rheumatoid arthritis, systemic onset

Kawasaki disease

Reactive arthritis

Rheumatic fever

Sarcoidosis

Sjgren's syndrome

Systemic lupus erythematosus

Systemic scleroderma

Select the term that best matches each case.

A 13-year-old boy presents with acute painful swelling of the right ankle and knee, the left
hip, the right wrist and left elbow. Four years ago he had presented with recurrent painful
oral ulcer up to a centimetre across, which has healed without scarring. Two years ago
he had erythema nodosum.
Amyloidosis

Incorrect - The correct answer is Behet disease

This boy has Behet disease, where mouth ulcers,

genital ulcers, skin rashes, variable arthritis or
arthralgia can occur. Uveitis is found by
Ophthalmological examination.
An 11-year-old girl present with fatigue, low-grade fever and weight loss of 5 kg in the
past six months. She has a periorbital purplish rash, with telangiectasia over the eyelids.
She has a positive Gower's sign.
Amyloidosis

Incorrect - The correct answer is Juvenile dermatomyositis

This girl has juvenile dermatomyositis. Presentation

with systemic upset, heliotrope rash, telangiectasia
and proximal weakness are characteristic.
A 7-year-old girl presents with painful swelling of the right knee and left ankle. There is no
prodromal illness. On slit lamp examination she has an anterior uveitis.
Amyloidosis

Incorrect - The correct answer is Juvenile chronic arthritis, pauciarticular

Less than four joints are involved, and anterior uveitis

is strongly associated with pauciarticular juvenile
idiopathic arthritis.

-2

This 14-year-old boy presented with difficulty in

weight-bearing.
This image is from the static bone scan film at 24
hours.
What is the likely diagnosis?

(Please select 1 option)

Malignancy

Incorrect answer selected

Osteomyelitis

This is the correct answer

Reactive arthritis
Septic arthritis
Trauma

Technetium-99 accumulates in areas of increased

bone turnover, and is used for the three-phase bone
scan.
Osteomyelitis causes increased vascularity,
inflammation, and increased osteoblastic activity,
resulting in an increased concentration of 99mTc.
Any areas of increased blood flow or inflammation can
cause increased uptake of 99mTc in the first phase (5-

10 minutes) and second phase (2-4 hours), but

osteomyelitis causes increased uptake of 99mTc in the
third phase (24 hours).

-3
Radiological features of rheumatic disease
A

Bony destruction either side of an intervertebral disc

Chondrocalcinosis

Normal

Lytic changes in multiple vertebral bodies with normal discs

Pseudofractures

Sclerotic changes in multiple bones

Soft-tissue calcification

Syndesmophytes

Select the correct radiological finding typically

associated with each of the syndromes listed below:
Tuberculosis of the spine
Bony destruction either side of an intervertebral disc

Correct

Spinal infection begins in the disc and spreads to the

adjacent vertebral bodies.
Mechanical back pain
Bony destruction either side of an intervertebral disc

Incorrect - The correct answer is Normal

Plain radiographs hardly ever contribute to an understanding

of mechanical pain.
Osteomalacia
Bony destruction either side of an intervertebral disc

Incorrect - The correct answer is Pseudofractures

Radiological findings in osteomalacia include defective

mineralisation and transclucent bands (Loosers zones,
pseudofractures).

-4

A 12-year-old boy complains of pain in his arm after

falling at school.

What is the radiological diagnosis?

(Please select 1 option)
Fractured lunate

Incorrect answer selected

Fractured radius and ulna

This is the correct answer

Fractured scaphoid
Fractured ulna
Normal

There are fractures of the distal radius and ulna with

an abrupt kink in the contour of the bones.

-5

A 14-year-old boy is admitted after falling from a

swing and landing on his shoulder. Since then he has
not moved the shoulder and is in pain.

What is the radiological diagnosis?

(Please select 1 option)

Anterior dislocation of the humerus

Disruption of the acromio-clavicular joint
Fracture of the clavicle

Correct

Fracture of the scapula

Posterior dislocation of the humerus

There is a fracture of the mid body of the clavicle with

an abrupt angulation.

-6

This 17-year-old male complains of pain in the hand

following a fall.

What is the diagnosis?

(Please select 1 option)
Fractured capitate

Incorrect answer selected

Fractured lunate
Fractured radius
Fractured scaphoid

This is the correct answer

Fractured ulna

There is a fracture of the neck of the scaphoid.

There is a break in the cortex with a line crossing the
bone related to the fracture.
Scaphoid fractures may be difficult to demonstrate and
clinical review is required in seven to 10 days if there is

any concern regarding this possibility despite

apparently normal initial films.

A 1-year-old boy who has recently started walking -7

presents refusing to weight bear on his left leg. There
.is nothing specific to find on examination

What is the most likely diagnosis?

(Please select 1 option)
Non-accidental injury (NAI)

Incorrect answer selected

Osteosarcoma
Septic arthritis
Spiral fracture of the tibia

This is the correct answer

Transient synovitis

A spiral fracture of the tibia is known as the "toddler's

fracture" and is very common. It usually presents with
a limp or refusal to weight bear. It is common not to
recall a specific traumatic incident that caused the
fracture and there is often little to find on examination
although there may be warmth around the fracture site
and pain on dorsiflexion of the foot.
Transient synovitis usually affects children aged over 3
years.
Septic arthritis would leave a child systemically unwell
and pyrexial.
Osteosarcoma is very rare and most commonly
presents in adolescence.
Fractures suggestive of NAI are metaphyseal lesions
of the femur, tibia or humerus, posterior rib fractures,
scapula fractures and multiple fractures of different
ages .

-8

If hip instability is found on examination and a child of

less than 6 months is suspected of developmental
hip dysplasia (DDH), which of the following should be
the initial treatment?
(Please select 1 option)
Closed reduction and traction

Incorrect answer selected

Open reduction and splintage

Ortolani harness
Splintage in abduction

This is the correct answer

Splintage in adduction

Indications for treatment depend on the patient's age

and the success of the previous techniques.
Children younger than 6 months with instability upon
examination are treated with a form of bracing, usually
a Pavlik harness. If this is not effective or if the hip
instability or dislocation is noted when the child is older
than 6 months, closed reduction is typically
recommended, often with the administration of traction
before the reduction.
When the child is older than 2 years or with failure of
the previous treatment, open reduction is considered.
If the patient is older than 3 years, femoral shortening
is performed instead of traction, with additional varus
applied to the femur, if necessary.
A patient with residual acetabular dysplasia who is
older than 4 years should be treated with an acetabular
procedure.
Closed reduction and traction is incorrect in this case.
This is the treatment of choice if the DDH has been

missed initially and treatment is required once the child

has reached 6-months-old.
Open reduction and splintage is also incorrect here as
this treatment option is usually only considered if
previous treatment has failed; it is an invasive
treatment with associated risks.
Ortolani harness is incorrect; the name of the harness
is a Pavlik harness. Ortolani was an Italian
paediatrician in the early 1900s who evaluated,
diagnosed, and began treating hip dysplasia. The
Ortolani test is a physical examination for
developmental dysplasia of the hip and particularly
posterior dislocation of the hip, which was named after
him.
Splintage in abduction is the only correct answer in this
case. The Pavlik harness is fitted to the baby and
holds his or her hips in proper position (abduction). By
flexing up the legs, and allowing the knees to fall
outwards, the hips are held in proper position. By doing
so, the hip joint is properly reduced, and the hips will
form normally.
Splintage in adduction is incorrect. In order to treat the
hip dysplasia, splintage in abduction (Pavlik harness)
is required, to encourage the femoral head to stay in
the acetabulum.