Module 5 - ortho Flashcards
A 13-year-old boy presents with right anterior knee pain. He plays on his school basketball team and the pain is worse at the end of practice. His physical examination demonstrates full range of motion of his knee with soft tissue swelling and point-tenderness about the tibial tubercle. Plain X-rays of his knee show well-maintained joint spaces with no fractures or tumors. Which of the following is most likely responsible for the patient’s condition?
- Malignancy
- Avascular necrosis
- Traction apophysitis
- Malingering
- Traction apophysitis
POINTS
- Osgood-Schlatter disease (traction apophysitis of the tibial tubercle) is a common cause of anterior knee pain in young, active individuals.
- The most common presentation is the insidious onset of localized pain about the tibial tubercle that improves with rest.
- This is primarily a clinical diagnosis. Plain radiographs may show irregular ossification or calcification of the patellar tendon, but more importantly, rule out other possible causes of anterior knee pain.
- Although this condition is usually self-limiting, the first line of treatment involves activity modification, the use of NSAIDs, and the local application of ice.
A 6-year-old boy is brought in by his parents with a two-week history of right hip pain and a limp. He has a past medical history of obesity. All his vital signs are within normal limits. On examination, there is no joint swelling or erythema. Internal rotation is limited and causes pain. An x-ray shows the widening of joint space, crescent sign, and the epiphysis appearing smaller and denser. Blood tests are unremarkable. What is the most appropriate treatment for this patient’s condition?
- Corticosteroids
- Rest and physical therapy
- Shelf osteotomy
- Hip arthroscopy
- Rest and physical therapy
POINTS
- Legg-Calve-Perthes disease is idiopathic necrosis of the femoral head.
- The treatment is aimed at pain and symptom management, containment of the femoral head in the acetabulum, and restoration of hip range of motion.
- Non-operative treatment is indicated for children with bone age less than six or lateral pillar A involvement.
- Activity restriction and protective weight-bearing are recommended until ossification is complete, and the patient may still take part in physical therapy.
A 14-year-old male comes to the office with his father for right hip pain for the past three weeks. He is a sports enthusiast and has been training for his sumo wrestling tournament finale for the past three months. Four days ago, his right hip pain was exacerbated during one of the training sessions, after which he started walking with a limp. He has not been able to practice secondary to the pain since then. His vital signs are within normal limits, and his body mass index is calculated as 34 kg/m^2. A physical exam shows a loss of internal rotation at the right hip, which is worsened when the hip is flexed to 90 degrees. X-rays are ordered, and the patient is counseled regarding the disease. What is the most appropriate definitive treatment for this diagnosis?
- NSAIDs and bed rest
- Application of leg cast
- Surgical pinning of the femoral head
- Physical therapy and stretching exercises
- Surgical pinning of the femoral head
POINTS
- This is a classic presentation of slipped capital femoral epiphysis (SCFE).
- Slipped capital femoral epiphysis is caused by shearing forces across the weak epiphysis, resulting in displacement. Obesity is a major risk factor for developing this disease.
- Slipped capital femoral epiphysis requires surgical intervention, often pinning in situ.
- The other hip may become involved later as well.
A basketball player falls and twists his right ankle. It is believed that he has suffered an ankle sprain. Which of the following ligaments is most commonly damaged in this type of injury?
- Anterior talofibular ligament
- Deltoid ligament
- Calcaneofibular ligament
- Posterior talofibular ligament
- Anterior talofibular ligament
POINTS
- The ankle joint is stabilized by three ligamentous systems: the lateral ligament complex, the medial deltoid ligament, and the syndesmotic ligaments.
- Most ankle sprains involve the lateral ankle and the anterior talofibular ligament is the most commonly injured ligament. This ligament originates from the lateral malleolus and attaches to the talus.
- A positive anterior drawer test in an injured ankle is evidence of an anterior talofibular ankle ligament sprain.
- The posterior talofibular ligament is the least commonly injured ligament of the lateral ankle ligaments.
A 2-week-old baby girl is presented to the clinic by a worried mother. She was born at 39 weeks gestation through a spontaneous vaginal delivery. Her post-natal evaluation was unremarkable, and she is exclusively breastfed and is gaining weight appropriately. Her maternal uncle suffered from Duchenne muscular dystrophy and died at a young age. Physical examination at rest shows the medial deviation of both forefeet, which deviates laterally on passive movement. The range of motion is normal in both feet. The rest of the examination is unremarkable. What is the most appropriate management?
- Genetic analysis
- X-ray feet
- Serial manipulation and casting
- Reassurance
- Reassurance
POINTS
- Metatarsus adductus is the most common cause of the medial deviation of the forefoot with a normal neutral position of the hindfoot in children under 2 years of age. This usually occurs bilaterally and in firstborns due to the smaller, primigravid uterus. Important to note is that the feet are flexible and overcorrect both passively and actively into lateral deviation.
- It is a clinical diagnosis that does not require imaging.
- It usually corrects spontaneously; therefore, only reassurance is required.
- It is not associated with an underlying syndrome; therefore, genetic analysis is not required. Clubfoot, characterized by rigid medial and upward deviation of both forefoot and hindfoot, requires serial manipulation and casting as primary treatment
A 7-year-old male presented with progressive muscle weakness. His mother notes that he was always a clumsy child and prone to frequent falls. At age 3, he walks on his toes a lot and has to push on his knees to be able to stand. He now complains of difficulty in going up the stairs, easy fatiguability, and increased falls. On examination, the muscles of the tongue, forearm, and calves are enlarged. He cannot get up from the floor by himself. Which of the following is expected on a muscle biopsy?
- Muscular degeneration and replacement with fatty tissue
- Irregular and hypertrophied muscle bundles
- Normal findings
- Increased mitochondria and presence of muscle inclusions
- Muscular degeneration and replacement with fatty tissue
POINTS
- The patient is most likely suffering from Duchenne muscular dystrophy (DMD).
- Progressive muscle weakness due to mutation in the dystrophin gene is seen.
- Muscle biopsy shows fatty replacement and muscle degeneration.
- As DMD is inherited as an X-linked recessive manner, boys are more frequently affected than girls.
A 7-year-old boy presents with short stature, bowing of legs, swelling of wrist, knee, and ankle. Which of the following skeletal x-rays is best suitable for the assessment of bone age?
- Right foot and ankle
- Left hand and wrist
- Right hand and wrist
- Left foot and ankle
- Left hand and wrist
POINTS
- The child is diagnosed as rickets. Rickets is a disease related to vitamin D deficiency. The child presents with short stature, bowing of legs, swelling of wrist, knee, and ankle. Vitamin D helps in the mineralization of cartilage. Radiographic screening is performed by frontal radiographs of the wrist and knees. Physis is widened, and metaphysis shows fraying cupping and irregularity. Epiphysis shows stunted growth. A radiograph of the left hand and wrist is widely used to assess bone age. Areas of ossification over the left hand and wrist correlate well with bone age. The left hand and wrist radiograph are preferred over the right side because most individuals are right-handed, and therefore the right side has a greater chance to be deformed.
- At birth, there is no ossification of any carpal bone. Although there is significant individual variability, the approximate ossification times of the carpal bones follow a predictable sequence, starting with the capitate and ending with the pisiform.
- The approximate ossification times for the carpal bones include capitate 1-3 months, hamate 2-4 months, triquetrum 2-3 years, lunate 2-4 years, scaphoid 4-6 years, trapezium 4-6 years, trapezoid 4-6 years, and pisiform, and 8-12 years. An easy way to remember is to start with the capitate and move in a counterclockwise direction on the palmar surface of the right wrist, excluding the pisiform.
- The ossification centers of the distal radius and distal ulna develop around one year and 5-6 years, respectively.
An 11-year-old boy presents with complaints of insidious onset of left knee pain that is getting progressively worse for the past three days. History reveals that the patient is a tennis player and says that the pain exacerbates while playing while gets better when rests. The rest of history is unremarkable. On physical examination, tenderness over the tibial tuberosity is noted, and the pain is induced by active flexion and passive extension of the knee joint. What would his radiographs most likely show that would confirm the diagnosis?
- Patellar tendon edema and a sliver-like osseous density posterior to the apophysis of the tibial tuberosity
- Patellar tendon edema and a disc-like osseous density posterior to the apophysis of the tibial tuberosity
- Patellar tendon edema and a sliver-like osseous density anterior to the apophysis of the tibial tuberosity
- Patellar tendon edema and a disc-like osseous density anterior to the apophysis of the tibial tuberosity
- Patellar tendon edema and a sliver-like osseous density anterior to the apophysis of the tibial tuberosity
POINTS
- Osgood-Schlatter disease is a common cause of knee pain in young people. It is a benign self-limited condition.
- Osgood-Schlatter disease occurs because the bone growth is faster than soft tissue growth resulting in muscle-tendon tension across the joint.
- Osgood-Schlatter disease is typically seen in younger children, and the diagnosis is made clinically. The pain may be reproduced by extending the knee against resistance. Visible soft tissue edema may be present over the tibial tuberosity.
- Radiographs usually confirm the diagnosis and show patellar tendon edema and a sliver-like osseous density anterior to the apophysis of the tibial tuberosity.
A 12-year-old male presents to the clinic with a three-week history of right knee pain and a one-day history of a limp. His past medical history is significant for iodine deficiency hypothyroidism, treated with iodine-supplemented salt. His vital signs are blood pressure 120/80 mmHg, pulse 88/min, temperature 37 C (98.6 F), and respiratory rate 14/min. His body mass index is 32 kg/m2. On examination, he has limited internal rotation of the right hip joint because of pain. No joint swelling or erythema is present. What is the pathophysiological basis of this patient’s condition?
- Osteonecrosis of the femoral head
- Slipping of the femoral epiphysis
- Intertrochanteric hairline fracture
- Growing pains
- Slipping of the femoral epiphysis
POINTS
- This patient’s presenting signs and symptoms are most consistent with slipped capital femoral epiphysis (SCFE).
- Slipped capital femoral epiphysis is a common condition in obese adolescents.
- Clinically, the patient may complain of a sudden onset limp. Examination shows limited internal rotation of the affected thigh.
- Osteonecrosis of the femoral head is seen in the presentation of Legg-calve Perthes disease. However, in SCFE, it can be a complication of missed diagnosis or after treatment.
A 17-year-old wheelchair bound male presents to the emergency department with complaints of shortness of breath. On exam, he is tachycardic and tachypneic. Physical exam shows severe scoliosis, diffuse rales on auscultation of the lung, and hypertrophy of the calf muscles. What is the most common mode of inheritance of this disorder?
- Autosomal dominant
- Autosomal recessive
- X-linked dominant
- X-linked recessive
- X-linked recessive
POINTS
- The patient has Duchenne muscular dystrophy (DMD). X-linked Mendelian inheritance is the most common mode of inheritance, however, up to 30 percent of cases may be due to a new mutation.
- DMD is more common in males than in females.
- Symptomatic carrier females have been described in which the normal X chromosome has been inactivated or in patients with Turners syndrome (45XO).
= The dystrophin gene is located on chromosome Xp21 and is codes for one of the largest proteins.
A 6-year-old girl presents to the emergency department with right arm pain and deformity after a fall from the trampoline. On physical exam, there is a right arm deformity just above the elbow. The arm appears well-perfused and pink. There is a break in the skin (approx 0.5xm) on the posterior upper arm above the elbow joint. Brachial and radial pulses, as well as sensations in the arm, are intact. There is a limited range of movement of the involved extremity due to pain. Intravenous access is established, and a morphine dose is given for pain. An x-ray of the elbow joint shows a displaced supracondylar fracture. What should be the next step in management?
- Orthopedic consult and intravenous antibiotics
- Orthopedic consult, intravenous antibiotics, and tetanus immunization confirmation
- Orthopedic consult, tetanus immunization confirmation
- Orthopedic consult, splinting under sedation
- Orthopedic consult, intravenous antibiotics, and tetanus immunization confirmation
POINTS
- Open fractures have a high risk of infection due to bone and deep tissue exposure to the environmental pathogen.
- Antibiotic prophylaxis is indicated in any open fracture.
- The duration and type of antibiotic prophylaxis should be discussed with the orthopedic service. It varies with the type of fracture and level of contamination ranging from 24 hrs for a simple fracture and clean wound to 48 hrs or more for a complicated fracture and grossly contaminated wound.
- Tetanus immunization is recommended for any open fracture or wound. Prior tetanus immunization status needs to be assessed. For those who have completed tetanus immunization (at least three doses) and received the last dose 5 years or more years previously, an age-appropriate booster dose of tetanus toxoid vaccine should be administered. The unimmunized patient should start and complete a primary series of vaccine.
An orthopedic physician is seeing a 4-year-old girl sent for a referral after being seen in an ER 2 days prior. The mom was told that the patient did not need to wear a splint because the fracture was only through one side of the bone. After looking at the image, the physician tells the mother that the patient requires 4-6 weeks of immobilization and that it is good she is only 2 days out from the fracture. Why does this type of fracture require early immobilization?
- There is a high rate of refracture
- The worry of vascular damage
- The concern about compartment syndrome
- For patient comfort
- There is a high rate of refracture
POINTS
- There is up to a 100% fracture recurrence rate in greenstick fractures if not immobilized adequately for the appropriate length of time.
- Even when properly immobilized, there is a high rate of recurrent fractures due to the weak bent portion of the fracture.
- There is a concern for deformity of the fracture site if not correctly and quickly immobilized.
- Even when properly immobilized, there should be follow-up with orthopedics for casting and a continued follow of injury.
A 3-year-old child is brought to the outpatient clinic with a history of difficulty in walking for the past 3 days. He does not have a history of trauma or fever. On examination, there is no neurological motor deficit, other than the restriction due to pain. He is having an antalgic gait. What investigation should be ordered to evaluate him further?
- Plain radiography
- Computed tomography
- Magnetic resonance imaging
- No imaging is indicated
- Plain radiography
POINTS
- The decision to image in the evaluation of a child with an antalgic gait will depend on the history and physical examination of the child. If imaging is obtained, plain radiography is the initial modality of choice. It is readily available, rapid, and does not require sedation. Plain radiography is useful to screen for injury and can detect bone lesions suggestive of an oncologic process as well as findings that may suggest infection. However, plain radiography can miss subtle fractures and is not specific for infection. When imaging children, one must practice ALARA (as low as reasonably achievable) principles.
- Computed tomography (CT) can be useful in the setting of trauma, but plain radiography is the initial imaging study of choice. CT can be useful for detecting subtle fractures or better delineating complex fractures initially detected by plain radiography.
- Magnetic resonance imaging is useful for detecting a variety of infectious and oncologic processes. However, due to limited availability and commonly the need for sedation in pediatric patients, this imaging modality is not a first-line study.
- Sometimes imaging may not be indicated in pediatric patients with an antalgic gait. A child with an acute trauma that is ambulatory and shows no overt signs of fracture may be observed with conservative treatment and no immobilization. Some fractures in children may not be apparent; therefore, if in doubt, immobilization and pediatric orthopedic followup are advised.
A 12-year-old boy presents with pain in his right knee after being involved in a motor vehicle accident. On physical examination, he has point tenderness over the distal femur and is having difficulty bearing weight on the leg. Initial X-ray imaging demonstrates slight physeal widening but is otherwise normal. The child is placed in an ace wrap and provided crutches for assistance with walking. Which of the following is the next best step in managing this patient?
- Discharge with no follow-up as X-ray is interpreted as normal
- Discharge with orthopedic or pediatric follow-up for repeat imaging in one month
- Admit for pain control
- Consult orthopedic service and obtain MRI
- Consult orthopedic service and obtain MRI
POINTS
- Although the x-ray findings are interpreted as normal, due to the severe mechanism of injury, the severe point tenderness, and the physeal widening on X-ray, there is high suspicion for a Salter-Harris fracture type 5 (SH-5).
- When there is a high suspicion of an SH fracture, as evidenced by the physical exam findings, the severe mechanism of injury, and the X-ray findings, orthopedics should be immediately consulted with follow-up imaging of some sort.
- This patient requires further workup, as this injury may lead to long bone growth arrest if not properly evaluated and treated.
- While the initial fracture of an SH-5 may not be identified on the initial evaluation, repeat imaging should be obtained within 1 week, not 1 month. While pain control is an important part of trauma and injury treatment, this is not the primary goal.
A 4-year-old boy is brought in by his parents due to worsening bilateral leg deformity. The patient denies any pain. The parents say they have not noticed any limitations to his activities and deny any history of fractures or infections. On examination, he meets all his developmental milestones for his age group and is well-nourished. He has a full and symmetric range of motion of his bilateral hip, knee, and ankle joints. He has a non-antalgic gait with symmetrical stride lengths and foot progression angles. When he stands upright with his patellae facing forward, the medial aspects of his knees touch each other, and he has an intermalleolar distance of 5 cm. What is the most appropriate next step in the management of this patient?
- Obtain full-length x-rays of bilateral lower extremity
- Obtain serum parathyroid hormone, calcium and vitamin D levels
- Reassurance and routine follow-up
- Obtain a buccal smear for chromosome analysis
- Reassurance and routine follow-up
POINTS
- This patient has genu valgum. Given the patient’s history, the etiology of their lower extremity deformity is physiological.
- At birth, there are between 15 to 20 degrees of varus tibiofemoral angulation. The angulation corrects to neutral at about the age of two and between 10 to 15 degrees of valgus tibiofemoral angulation between the ages of 3 and 4.
- At this point, the limb’s valgus angulation then starts to gradually decrease to approximately 3 to 5 degrees of valgus by the age of 7. This is the residual normal coronal plane angulation of the lower extremity that will be carried to adulthood and should not increase.
- Physiologic genu valgum or tibiofemoral angle will improve as part of the natural course of the deformity. No limitations to activities and sports participation can be expected.
