Cases

Cases

The following section contains 100 cases followed by the answers. For each case we have listed the relevant chapters that you may want to review before or after you look at the case or answer.

Case 1

A 12-year-old boy presents with a painful right knee and a limp. His mother says he strained his knee playing football a few weeks before, and he has been struggling to run since. His family has noticed a swelling over the inner aspect of his shin below the knee. He is not sleeping well.

His knee X-ray is shown.

1. What are the critical features in the history and examination?

2. What do the X-rays show?

3. What is the treatment?

Case 2

An 82-year-old man had a right hip replacement performed 17 years earlier. He now complains that his right hip feels unreliable and has started to click when he gets up out of a chair.

When he walks you notice that he hesitates slightly to put full weight on the right foot. He has a negative Trendelenburg test and has excellent movement in the right hip and no pain. He has about 1 cm of true shortening in the right femur. There are no signs of inflammation or infection clinically.

His hip X-ray is shown.

1. What is the likely cause of his symptoms?

2. What other investigations might be helpful?

3. How should he be managed?

Case 3

A 13-year-old girl noticed that one of her shoulders seemed a bit higher than the other. When she was swimming with her family, her mother thought that her daughter had a twisted back. There was no history of back pain or spinal trauma.

Her back X-ray is shown.

1. What does the X-ray show?

2. How should this be managed?

Case 4

A 7-year-old boy is brought to his general practitioner because his mother has observed that he has developed a limp. There is no history of trauma and he is a healthy boy who is active. He has complained recently of some pain in the left knee. When you observe him walking you notice that he has a left-sided limp and the left leg seems a bit stiff when he walks. You examine his left knee and find that it is normal. You correctly think you should examine his left hip because you have remembered about referred pain. You find that there is a restriction of internal rotation and extension. Leg lengths appear equal.

The boy’s X-ray is shown.

1. What is the likely diagnosis?

2. What factors affect the prognosis?

Case 5

A 13-year-old boy complains of intermittent pain in the right knee which has been troubling him for 3 months. He is not particularly sporty but recalls a knock on the knee whilst playing football around the time the problem began. His general health is otherwise normal. You observe that when he walks he has a slight limp on the affected side and his right foot is more externally rotated than the left. There is no abnormality in the knee when you examine the joint. You examine the hip and find that as it flexes it goes into external rotation.

1. What is the diagnosis?

2. What is the next step?

3. What is the likelihood of him developing the same condition on the opposite side?

Case 6

The parents of an 18-month-old toddler are concerned that she has bow legs. She has a normal birth history and subsequent milestones. Her parents say she eats a balanced diet and there is no history of skeletal dysplasia. Her clinical photograph is shown.

1. What should you examine?

2. What is the diagnosis?

3. What is the prognosis?

4. What do you advise the parents?

Case 7

A 4-year-old boy is brought to you because he walks on tiptoe. His parents report that he has always done so since he started to walk at 24 months of age. They say his shoes are wearing out quickly and they find this expensive. He was born at 32 weeks of gestation by normal delivery. Parents feel that he is a bright lad but seems a bit unsteady on his feet and they say his upper limb function is fine. You observe him walking and he walks on tiptoe when in shoe-wear and when walking barefoot. You look at his shoes and they are worn out at the toes. When you examine him you find that his feet are a normal shape but his legs seem a bit stiff, although you do not find any restriction of movement at the hips, knees or ankles. He has brisk but symmetrical knee and ankle reflexes.

1. What is the differential diagnosis?

2. Which parts of the brain control movement?

3. What is the most likely cause for his tiptoe walking pattern?

Case 8

The parents of a 3-year-old boy have noticed that he has become a bit clumsy when standing up and walking. He has started to walk on tiptoe. His general health is normal; he was born at term and walked at 15 months. There is no family history of walking difficulties.

1. What is the likely cause of this boy’s walking difficulty?

2. How can this be diagnosed?

3. What is the likely outcome?

Case 9

You are called to the neonatal unit because the midwife who delivered this newborn baby is concerned about the shape of the baby’s feet. The baby was born at term and the delivery was uncomplicated.

1. How would you describe the shape of the left foot?

2. Suggest two causes for the appearance of the baby’s left foot.

3. What else should you examine?

Case 10

This is the clinical photograph of a neonate. There are bilateral foot deformities.

1. What is this condition?

2. What else in the child should you examine?

3. What is the next step?

4. In a unilateral case will the child have symmetrical calf muscle bulk and foot size?

Case 11

The mother and grandmother of a healthy 3-year-old boy report that he wakes up at night about once a week crying and pointing to his legs saying that they are sore. His mother says that she has to console him, rub his legs and occasionally give him some paracetamol elixir before he settles down. You enquire further and his mother says that as far as she is concerned he is a healthy but very active boy who is ‘on the go’ all the time. The boy’s grandmother states that she thinks that he has growing pains because her daughter, the boy’s mother, had them when she was his age. You order some blood tests and the report is shown in the accompanying table.

1. What is the problem?

2. What should be considered when examining the child?

3. What is the outcome?

Case 12

A 3-year-old girl is brought to the accident and emergency department because she has suddenly stopped walking and will not take weight on her right leg. The parents say that she has not been unwell and, as far as they know, she has not fallen over. You examine her and find that she seems well but holds her right thigh slightly flexed at the hip and dislikes her hip being rotated or abducted. She has normal movements in the right knee and the left hip and knee. She does not appear to have a fracture in the lower limb clinically.

1. What else should you examine?

2. What is the differential diagnosis?

3. What investigations should be done?

Case 13

A 6-year-old girl has been noted to have a short left leg. The illustration shows a 2.5 cm discrepancy between her legs.

1. What is true and apparent leg length discrepancy?

2. What other investigations are helpful?

3. The child has a predicted 3.5 cm discrepancy at skeletal maturity. How should this be managed?

Case 14

This man has a right-sided hemiplegia. He has a flexed wrist that cannot be straightened.

1. What functional difficulties might this cause the patient?

2. How might the wrist posture be improved?

Case 15

A 60-year-old woman has increasing pain in her left forefoot (see picture below). She cannot get into high-heeled shoes.

1. What is the diagnosis?

2. What are the treatment options?

Case 16

1, 2, 7–8, 15

This 70-year-old farmer has difficulty getting his left Wellington boot on. He is slower around the farm and his wife says he wakes often during the night with leg pain. He denies much discomfort.

1. What are the cardinal features shown in the X-ray?

2. How should a walking stick be held to aid mobility?

3. Is the lack of pain critical to decision-making about treatment?

Case 17

A 47-year-old builder’s labourer presents with chronic back pain, which has prevented him from working for 3 years. Repeated investigations have all proven negative. He has recently attended a medical examination at the request of the Department for Work and Pensions and has been told that his Incapacity Benefit is to be withdrawn because he is thought to be fit and capable of work. He is distressed and states that his pain is as bad as it has ever been and that there is no way he can possibly return to work. He requests stronger analgesics and an MRI to determine the cause of his symptoms. There are no ‘red flags’ on taking a full history. You examine him and find that when he sits up to have his chest examined (chest is examined on the couch) he can do a full ‘long sit’ but that his straight leg raising is only 20° on the right and 30° on the left. There are no neurological signs.

1. What other ‘inappropriate’ back pain signs might you find?

2. What investigations would you order?

3. What treatment might be considered?

Case 18

A 70-year-old man has great difficulty walking about outside his house. He experiences pain in his right leg after a few yards, and this is relieved by rest. He has intermittent back pain. He is a moderate smoker (10 cigarettes per day), but his foot pulses are normal. The scan below shows a cross-section of one of his lumbar vertebrae.

1. What is abnormal about this?

2. How does this abnormality cause his symptoms?

3. How can the diagnosis be confirmed?

4. What are the treatment options?

Case 19

A woman cleaner attends the clinic with a painful elbow. Examination confirms tenderness over the lateral epicondyle of the humerus (see photograph).

1. What is the likely diagnosis?

2. What muscles attach to the common extensor origin?

Case 20

A 52-year-old secretary complains of a sore wrist after using a computer keyboard, particularly when pressing the spacebar. She can accurately locate the pain to the lateral aspect of the distal radius and thinks the wrist is more swollen.

1. What is the most likely diagnosis?

2. Is there a test for this condition?

3. What is the differential diagnosis?

4. What are the options for treatment?

Case 21

1, 7, 14, 16, 21

A 23-year-old pregnant woman is regularly woken at night with discomfort and numbness in both hands, which she relieves by getting up and walking about, shaking the hands.

1. What is the most likely diagnosis?

2. Why does it occur?

3. What is the likely prognosis?

4. What is the best form of treatment?

Case 22

A 60-year-old gravedigger with a known high alcohol intake has developed gradually progressive contractures of the fingers (see photograph below) that are now interfering with his ability to grip a spade.

1. What is the condition?

2. What is the significance of the high alcohol intake?

3. What other conditions are associated with this disorder?

4. What treatments are available?

Case 23

A 14-year-old boy complains of pain, redness and swelling of his left great toe (see photograph below). He says that the toe has been discharging from one of the nail-folds. There is no history of injury and he feels well.

1. What is this condition?

2. What should be done?

Case 24

A 55-year-old woman had a breast carcinoma treated by lumpectomy and radiotherapy, but 10 years later presented with thoracic back pain, a nagging discomfort that interfered with her sleep. She had cutaneous discoloration from prolonged use of a hot water bottle to relieve her back pain (erythema ab igne).

Initially she tried chiropractic treatment, but had increasing back pain and then numbness in her lower limbs with a feeling of ‘heavy legs’ and walking difficulty. She had Medical Research Council (MRC) grade 4 power in all muscle groups of the lower limbs and a sensory level detectable at T9. She had slight impairment of proprioception, brisk reflexes and an extensor plantar response on the right side. She could walk with a frame, but her impaired proprioception and weakness prevented her from walking unaided. She had control of her bladder and bowel function.

1. How many red flag signs did she manifest?

2. What is the most likely diagnosis?

3. Was it safe for her to have chiropractic treatment?

4. What tests are required to reach a diagnosis?

5. What treatment is required for pain and for her spinal cord dysfunction?

Case 25

A 16-year-old boy has discovered a swelling on the inside of his right knee. He is well and there is no pain; there is no history of significant injury. You examine the knee and there seems to be a bony lump at the medial side of the distal end of the femur. It is not tender. An X-ray is shown.

1. What is the diagnosis?

2. What other assessment is necessary?

3. What is the treatment?

Case 26

An 85-year-old man complains of increasing pain in his left thigh and reduced walking distance 15 years after a left total hip replacement.

An X-ray of a Charnley total hip replacement is shown.

1. What does this X-ray show?

2. What is the natural history of this problem?

3. How can this problem be managed?

Case 27

A patient who received a total knee replacement 6 months ago says her knee has ‘never been right’ since. It took several weeks to heal and has produced increased pain and a red hot swelling adjacent to the knee recently (see photograph below).

1. What is the likely diagnosis?

2. How can the diagnosis be confirmed?

3. What is the treatment?

Case 28

A patient who underwent a spinal decompression for neurogenic claudication 12 hours previously has experienced increased back and leg pain in the recovery ward with progressive weakness of the legs.

A copy of the nursing observation chart is shown.

1. What is the purpose of the nursing chart?

2. At what point should the doctor be informed of a significant change?

3. What is the likely diagnosis and management?

Case 29

A 75-year-old man with type 2 diabetes mellitus had been in good general health, but presented with a history of falls and unsteadiness that had come on over a period of 8 months and seemed to be increasing in severity. He had no pain anywhere. Until 8 months earlier he had been able to walk distances of several miles, but by the time of presentation he could manage only 20 yards with an awkward, scissoring gait. He had strong upper limbs, but had noticed some loss of fine hand control with difficulty fastening buttons. He described his hands as feeling slightly numb – ‘a woolly feeling’.

Examination revealed normal blood pressure and pulse and normal cranial nerve function. The patient had normal sensation in his upper limbs apart from slight numbness in the middle, ring and little fingers. Power seemed normal in all muscle groups of the upper limbs. Jaw, deltoid, biceps and brachioradialis reflexes were normal, but both triceps reflexes were brisk.

Lower limb sensation was altered in a stocking distribution, tone was increased and power seemed only slightly reduced in all four limbs. Knee reflexes were brisk but ankle reflexes were absent and plantar responses were equivocal. He had ankle clonus bilaterally. He walked with a scissoring gait and had a positive Romberg’s test result.

1. What is the reason for his gait disturbance and falling?

2. What is the significance of his tendon reflex findings and at what level of his nervous system would you expect to find any pathology?

3. The sagittal MRI is shown. What is the pathology and does it explain his neurological picture?

4. What is the natural history of his condition and can it be modified? How?

Case 30

A 50-year-old man presented with pain in the neck and left arm with paraesthesiae and numbness in the thumb and index finger. He had lost 7 kg of weight in the previous 4 months and had a general malaise. He was unaware of any leg problems, but neurological assessment revealed a brisk set of reflexes in the left lower limb. Routine blood tests yielded a mild anaemia (Hb 10.1 g/dl) and a very high erythrocyte sedimentation rate (ESR) (110 mm/h). Plasma proteins were raised and immuno-electrophoresis showed a monoclonal gammopathy with a raised IgM concentration.

1. What is the likely diagnosis?

2. Why does he have evidence of a radiculopathy of C6 and also a mild myelopathy of the upper limbs?

3. What tests are indicated to clarify the diagnosis?

4. What treatment is required:

a. for the neurological condition?

b. for the underlying condition?

Case 31

A 70-year-old man presented with a 1-year history of central neck pain associated with pain radiating down the lateral aspect of his right shoulder and upper arm. The pain intensified on lateral cervical rotation to the right and was worse on vertical compression of the head. The pain had also been disturbing his sleep at night.

There was some loss of perception to light touch over the lateral aspect of his shoulder, weakness of deltoid and his right biceps reflex was sluggish. The lower-limb neurological examination was normal. Gait was normal. Plain radiographs of the neck showed multi-level cervical spondylosis (see image below).

Physiotherapy, cervical traction and acupuncture had been tried, but without any improvement in pain levels.

1. At which level is the pertinent pathology and how can you best determine this?

2. What treatment is indicated?

3. Is surgery ever required?

Case 32

A 19-month-old girl was noted by her mother to be unwilling to walk and apparently unable to take her weight on her left leg. She became miserable and refused to eat. Her mother took her to a paediatric emergency department where it was established that she had previously been healthy apart from a cough and runny nose 2 days before.

Examination at that time showed a listless girl with a fever of 38.5°C and tachycardia. She lay still, held her left hip abducted and externally rotated, and resented attempts to move her leg.

Radiographs of her hip and lower limb were normal. Her white cell count was 18.9 × 10⁹/l, ESR 32 mm/h and C-reactive protein (CRP) 94 mg/l.

1. What is the differential diagnosis?

2. What further investigations may help to determine the diagnosis?

3. What is the appropriate management?

Case 33

A 34-year-old Asian man presented with a long history of low back pain and a 3-week history of severe sciatica and dysaesthesia in the right leg. He looked ill and had lost weight over a 6-month period. He had a productive cough and night sweats. His pain was relentless in all positions except in extreme flexion of hip and knee on the right side. He had an absent right ankle reflex, hyperaesthesia of the right foot and was reluctant to move his back. He had severe sciatica during attempted raising of the straight leg.

1. What baseline investigations help to differentiate between mechanical causes of sciatica and more serious pathology?

2. What spinal investigations are indicated?

3. What treatment is indicated?

Case 34

A 15-year-old girl presented with back pain of 1 year’s duration associated with a 3-month history of pain radiating from her back via the buttock to the upper thigh into the lateral aspect of the right leg and dorsum of the right foot. She also complained of occasional tingling in the sole of the right foot. Symptoms were made worse by any vigorous activity and relieved by lying down on her back. There were no sphincter disturbances. She was a very keen gymnast and ballet dancer but had had to stop this because of her symptoms. On examination she was of slim build and in excellent health. There was no scoliosis, forward flexion of the lumbar spine was restricted, and she was tender over the lower lumbar spine and sacrum. There were no root irritation or compression signs in the legs, but straight-leg raising was limited by short hamstrings. A lateral radiograph of the lumbar spine is shown.

1. What is the abnormality shown on the lateral radiograph?

2. What is the underlying cause of the abnormality in this patient?

3. What treatment is required?

Case 35

A 35-year-old cyclist commuting to work was knocked off his bicycle and landed heavily on to his right shoulder. His presenting radiograph is shown in figure A.

1. What fracture is visible and what is the treatment of choice?

2. A radiograph taken 12 weeks later is shown in figure B. What complication has occurred?

3. What is the treatment?

Case 36

A 22-year-old man falls on his extended outstretched hand during a football match. He presented with a painful swollen left shoulder. On physical examination the humeral head was palpable in a subcoracoid position.

The radiograph is shown.

1. In what directions can the shoulder dislocate?

2. What are the most well recognized associated injuries?

3. What is the appropriate treatment for this injury?

Case 37

1, 2, 9, 12, 19

A 61-year-old woman fell down two steps and landed heavily on to her left arm. She sustained a shoulder injury.

1. What injury has she sustained?

2. Where is the humeral head situated?

3. What aspects of clinical examination are important?

4. What are the options for treatment?

Case 38

A 21-year-old man crashed his motorcycle and sustained a fracture of the humerus, shown in the figure. He was unable to dorsiflex his wrist actively.

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Tags: Textbook of Orthopaedics Trauma and Rheumatology

Jul 12, 2016 | Posted by admin in RHEUMATOLOGY | Comments Off

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