NMS Q&A Family Medicine

172 NMS Q&A Family Medicinepresent. The sooner the diagnosis is made, the better theultimate outcome after correction, the best results occurringif the diagnosis is made no later than 6 weeks afterthe infant’s birth. The waddling gait seen in uncorrectedcases is associated with a broadened perineum because ofthe lateral displacement of the femoral head(s).8. The answer is D. The onset of fewer than four jointsinvolved in arthritis, within the first 6 months of arthriticpain, is called pauciarticular JRA and carries an increasedrisk for iritis. A positive antinuclear antibody titerincreases the risk. These patients are rheumatoid factornegative. This type of pauciarticular JRA is the foremostcause of blindness in children. These patients need periodicslit-lamp examination by an ophthalmologist. A secondtype of pauciarticular JRA affects boys between theages of 8 and 10 years. These boys are antinuclear antibodyand rheumatoid factor negative but manifest a highprevalence of human leukocyte antigen, type HLA-B27.9. The answer is E. The statement that “the majority ofcases require surgical correction if not resolved by time thechild reaches the age of 8 years” is not true in regard to intoeing,though 95% of intoeing cases resolve spontaneously bythat ages. The most common cause of intoeing is excessivefemoral anteversion, and it has its onset between the ages of2 and 3 years. It causes cosmetic and sometimes functionalgait changes and may lead to osteoarthritis. As its namewould indicate, the intoeing that is due to femoral anteversionis associated with a turning in of the patellae as well asthe feet, because the problem exists at the hips. Althoughmost cases will have resolved by the time the child reachesthe age of 8, those that do not usually accommodate, unlessthe condition is severe. Osteotomy, the only treatment available,is fraught with complications and thus is extended toonly a minority of cases that have persisted. Although threeother conditions listed may be causes of intoeing and eachhas its own pathophysiology and therapeutic approach, eachseldom requires surgery. Rarely, cases of developmental hipdislocation occur in association with metatarsus adductusand chances of surgery would depend on timeliness of diagnosis.Metatarsus adductus virtually always resolves by theage of 1 year or later in childhood, and internal tibial torsionresponds poorly to any surgical approach. Tibial torsion hasusually ceased to be noticeable by the time the child reachesthe age of 16 months. If it has not, it may be ameliorated bymechanical devices.10. The answer is D, long-arm cast for 3 weeks. The fracturedescribed is a torus or “green stick” fracture, seen inpreadolescent children. It is well named and refers to thefact that the bone is soft, not brittle, at these ages. Virtuallyby definition, reduction of any type is unnecessarybecause there is no separation of fragments and seldomangulation. The immobilization should be standard forthe fracture, generally following the rule to include a jointboth proximal and distal to the fracture within the cast.However, this immobilization need be only for 3 weeksinstead of the usual 6 weeks for most fractures.ReferencesEilert RE . Orthopedics . In: Hay WW , Levin MJ , Sondheimer JM ,et al., eds. Current Pediatric Diagnosis and Treatment , 17th ed .New York : McGraw-Hill ; 2005 : 810 – 828 .Family Medicine Board Review 2009 . Kansas City, Missouri ; May3–10, 2009 .Wenacur R , Tucker JB . Musculoskeletal problems in children . In:Rudy DR , Kurowski K , eds. Family Medicine: House Officer Series.Baltimore, MD : Williams & Wilkins ; 1997 :439–446.