Musculoskeletal Disorders

A 33-year-old woman was referred to the endocrinology clinic because of osteoporosis. At age 6, she had fractured her right tibia with no history of trauma; at age 27, she fractured the third lumbar vertebra, and 3 years later she experienced a Colles' fracture of the left wrist. She gave birth to a healthy child 10 years ago.

A 10-year-old boy presented with a limp and occasional pain in the right knee of 2 years' duration. A roentgenogram of the pelvis revealed fragmentation of the right capital femoral epiphysis with an irregular acetabulum.

This 8-year-old girl presented with bilateral ptosis, down-slanting palpebral fissures, malar hypoplasia, mild micrognathia, and mild webbing of the neck. She also had marked lumbar lordosis and a dextroconvex thoracic scoliosis with scapular winging. There was a generalized reduction in muscle mass with proximal limb weakness, short stature, diminished deep tendon reflexes, and an awkward waddling gait.

A 55-year-old-man complained of joint stiffness and red, mildly tender plaques on his fingers. He had recently sustained a trauma to the hand while at his job as a fish handler. The condition was diagnosed as erysipeloid-a skin infection caused by the gram-positive bacillus Erysipelothrix rhusiopathiae.

For 7 days, a 10-year-old boy had had a headache and a fever (temperature, 38.8°C [102°F]); a viral upper respiratory tract infection had been diagnosed. His parents brought him to the emergency department when weakness in his right leg developed, which impaired walking.

The 83-year-old woman whose hands are shown in photograph A had a severe flare of arthritis in the metacarpophalangeal and proximal interphalangeal (PIP) joints after corticosteroid therapy for her asthma was stopped. The clue to the diagnosis of psoriatic arthritis is in her fingernails, which show both pitting and onycholysis.

Many disorders that scar the skin also affect the scalp. Systemic lupus erythematosus, when associated with high fever and extensive systemic involvement, can cause a diffuse anagen effluvium. Hair loss caused by localized discoid lupus erythematosus (DLE) is more common. DLE may affect the scalp, where it is seen as circumscribed areas of often irreversible hair loss.

Numerous plaques, some with yellow crusting and central scarring, had erupted primarily on the face and neck of a 46-year-old man. A single lesion had developed on his left elbow as well. The lesions were initially diagnosed as impetigo, but they failed to resolve after 2 courses of oral cephalexin.

A 6-year-old girl with mental retardation was seen for a physical examination. She was being followed by a neurologist for seizures that began in her first year of life. She had no acute health problems.

A 16-year-old African American boy complained of exertional pain below his left knee that severely limited his ability to participate in sports. The patient had had bilateral bowed legs until his early school years, when the right knee straightened. For the past year, exertional pain had been present below the left knee in the epiphyseal area.

Two years ago, Dr Alexander K. C. Leung reported on a case of pseudopseudohypoparathyroidism. The patient was a 13-year-old girl with short stature, short fourth metacarpals and metatarsals, mild mental retardation, and no identifiable biochemical abnormalities.

A 72-year-old woman was hospitalized after 8 years of pain and swelling of the right metatarsophalangeal joint. (In this film, the dark area over the distal joint of the large toe is an artifact.) Results of a purified protein derivative tuberculin test were positive, and a chest film revealed apical changes compatible with old tuberculosis (TB).

A 73-year-old man was admitted to the hospital with pain in his hands, feet, and elbows. The patient, an alcoholic, had a 20-year history of hypertension and diabetes. Deformities of the hands and feet had developed during the past 5 years. Tophi were present over both ear lobes. The serum uric acid level was 15 mg/dL.

The parents of a 2-year-old boy with a 3-day history of fever took him to the emergency department. The child's temperature fluctuated between 38°C (100.4°F) and 39°C (102.2°F). As part of the workup, chest films were taken.

Following an uneventful pregnancy, a 25-year-old woman was delivered of an infant girl by repeat cesarean birth with occiput anterior presentation at 39 weeks gestation. The deformity was readily evident at birth.

The mother of a 7-year-old boy with cardiofaciocutaneous syndrome sought treatment for the cutaneous aspects of her son's disease. Dry skin and keratosis pilaris of the upper outer arms were noted.

During his last routine pediatric visit, a 4-month-old boy with a large head circumference (98th percentile for his age) was referred for radiographic evaluation. The infant had been delivered by cesarean birth because of cephalopelvic disproportion; his head size had gradually increased since birth. There was a family history of this condition.

A 44-year-old woman was being seen regularly for skin manifestations of systemic lupus erythematosus (SLE). During a routine visit, blotchy erythema and hyperpigmentation were noted on the normally exposed areas of her neck and upper chest; the submental area was spared. Close examination revealed fine telangiectases and poorly marginated hyperpigmented and hypopigmented macules.

This neonate was born with an extra hypoplastic digit attached to the lateral aspect of the left little finger's middle phalanx. When informed of this anomaly on her daughter's hand, the mother registered neither shock nor surprise. Mother, grandmother, and other family members were similarly affected.

This 3-year-old child was brought to our ear, nose, and throat clinic for evaluation of the nasal mass that had developed over the previous few months, reports Dr Paul E. Lomeo of Muskegon, Mich. The youngster was known to have congenital problems, including cardiac, renal, and craniofacial anomalies. There was no identified syndrome associated with his health.

Concern about this flat, tan, atrophic, well-marginated, dime-sized lesion prompted a 44-year-old woman to seek medical advice. The lesion, which was mildly pruritic, had appeared 2 months earlier.

The wife of an 82-year-old man with Alzheimer's disease was concerned about her husband's poor posture. According to the woman, the patient had never sustained a back injury and had always maintained a sedentary lifestyle. He never smoked cigarettes and did not use alcohol. His history included multiple transient ischemic attacks (TIAs).

An area of mottled skin developed on the back of a 55-year-old woman who has had arthritis for several years. She often applied a heating pad to her middle and lower back for relief from arthritic pain.

A 6-cm midline tail-like soft tissue appendage was noted on the back of this newborn infant at the level of L5. An epithelialized mid-sacrum dimple was also present inferior to the appendage. The infant otherwise appeared to be normally developed.

A 65-year-old man had a 10-year history of deformity of the hands, pain, and nodules on the fingers. His serum uric acid level was 9 mg/dL. The suspected diagnosis of chronic tophaceous gout was confirmed by the finding of birefringent monosodium urate needle-shaped crystals in the joint fluid and the patient's significant response to colchicine within 12 to 24 hours of the start of therapy.

This 3-month-old boy has an untreated right clubfoot deformity. The foot is stiff and uncorrectable. The vertical midfoot crease indicates significant deformity. An anteroposterior (AP) simulated weight-bearing radiograph shows parallelism of the long axis of the talus and calcaneus; this indicates varus alignment of the hindfoot. There is also forefoot adduction.

Skull x-ray films were taken after this 62-year-old nursing home resident fell and hit his head. The radiographs revealed only a sharply demarcated radiolucent area, mainly over the right parietal bone. Osteoporosis circumscripta was diagnosed.

A 40-year-old woman presented for follow-up of a generalized skin condition that was most severe on her palms and soles. She had been born with a few lesions, which resolved in infancy. New lesions began to emerge and increase in number and severity when she was 2 years old; they have recurred intermittently for 38 years.

Gonococcal infection is the leading cause of bacterial arthritis in adults.

A 30-year-old man presented to the emergency department with new-onset seizures. His past medical history included loss of vision for 1 year, deafness, and osteomyelitis of the mandible.