EMQs in Clinical Medicine.pdf - Peshawar Medical College

Back pain – answers 127
males. The younger the patient on presentation, the better the prognosis.
In many cases, rest is sufficient treatment. In severe disease, surgery may
be indicated.
C
J
E
A 3-year-old girl presents to the orthopaedic clinic with a waddling
gait. Her mother says that there has been a delay in walking. On
examination there is an extra crease on the left thigh.
Congenital dislocation of the hip (CDH) is around six times more common
in females and is more common after breech delivery. Ortolani’s test
and the Barlow manoeuvre are performed to identify this condition,
which is bilateral in about a third of cases. In Ortolani’s test the examiner
holds the baby’s thighs with the thumbs placed medially and the
fingers resting on the greater trochanters. The examiner flexes the hips to
90° and gently abducts to almost 90°. In CDH this movement is difficult
and, if pressure is applied to the greater trochanter, there is an audible
click as the dislocation reduces. Barlow’s test involves the examiner
grasping the upper thigh with the thumb placed in the groin and
attempting to lever the femoral head in and out of the acetabulum as he
or she abducts and adducts the thigh.
An 80-year-old woman presents to A&E after a fall. On examination
the left hip is adducted, externally rotated and excruciatingly painful.
Remember that the hip is adducted, externally rotated and shortened
after a fractured neck of femur.
An 8-year-old boy presents to A&E with marked limping and pain in
the right hip, which resolves within 48 h. His radiographs show no
abnormality at the hip or other joint involvement. Bone scan 2 weeks
later is also normal. The patient’s mother suffers from osteoarthritis.
The patient must have a normal radiograph for the diagnosis to be made.
This condition is also known as ‘irritable hip.’ Transient synovitis is a
diagnosis of exclusion, i.e. the diagnosis is made only when all other
possible diagnoses have been eliminated.
45 Back pain
Answers: K G J C D
K
A 22-year-old man complains of stiffness in the lower back and buttock
pain that is relieved by exercise. He also suffers from bouts of
painful red eye. His ESR is raised. His radiograph shows blurring of
the upper vertebral rims of the lumbar spine.
Buttock pain is caused by sacroiliitis. Blurring of the vertebral rims is an
early sign on a radiograph resulting from enthesitis at the insertion of
intervertebral ligaments. Later, persistent enthesitis leads to the formation
of bony spurs called syndesmophytes.