Orthopaedic Flashcards
What does SCFE stand for?
SCFE= Slipped Capital Femoral Epiphysis
What is true about SCFE:
- sports related
- F > M
- associated w/ steroids
- subsequent bone necrosis
Complication: subsequent bone necrosis (avascular necrosis)
What is a SCFE?
Failure of physis + displacement of femoral head relative to neck.
Classic pop’n for SCFE?
Obese Black Boy 11-16 y.o. Left > Right
Classic SCFE ppt?
Black obese teen
Limp + EXTERNALLY rotated lower limb.
What do you see on XR for SCFE?
AP + Frog
- Blanch sign
- Klein’s Line (femoral neck does not intersect epiphysis)
How do you tx SCFE?
Admit to Hospital
Bed Rest
Ortho Consult
Immediate OR
What are two serious complications of SCFE?
- Osteonecrosis (avascular necrosis)
2. Chondrolysis (cartilage dissolution)
Picture of club foot. What do you do?
Ortho Ref within 1st month= Ponseti casting
Weekly casting
+/- tenotomy for hind foot equinus
Then bracing (boot + braces) x 3 mo. and then nightly
What is the mnemonic to describe Club Foot?
Congenital Talipes Equinovarus
= CAVE
- Cavus= arch
- Adductus= mid foot
- Varus = heel supinated
- Equinus= heel moved up back of leg
T or F: casting for club foot results in delayed motor milestones.
False
casting DOES NOT delay motor milestones
Child with achondroplasia. Which is true:
- decreased life expectancy
- despite small foramen magnum rarely get SC compression
- mental retardation
- spinal stenosis in childhood
Small foramen magnum, but few have cord compression
Other complications:
- OSA
- restrictive lung dx
How is achondroplasia inherited?
AD but most new mutation.
Normal torso but limbs short
List 5 features of achondroplasia:
- shortened long bones
- large head w/ frontal bossing
- short metacarpal
- Trident hand (tips of fingers can’t touch)
- spinal lordosis
T or F: achondroplasia typically have normal IQ.
True.
+/- delayed motor milestones but normal IQ.
T or F: achondroplasia have normal life span.
yes
- unless hydrocephalus or spine compression
Which feature is typical for achondroplasia:
- proximal limb shortening
- distal limb shortening
- short mid-portion of bone
- non-specific shortening
Proximal limb shortening (shortening of arms + leg)
Short limb with normal torso. Not walking till 18-24 due to large head. Normal IQ. Dx?
Achondroplasia
12 y.o. with L knee pain + swelling. Pain over R heel. FHX (+) for:
- psoriasis
- ankylosing spondylitis
- rheum arthritis
Ankylosing Spondylitis
Spondylosis Def’n
degeneration of spinal disc
= pain w/ extension
versus vertebral # or disc herniation is pain w/ flexion
Spondylolisthesis Def’n
forward slippage
What is legs-calve perthes dx?
- young kids (4-8)
- male
- idiopathic AVN of femoral epiphysis
- less ABduct + INTERNALLY rotate
- Tx: ROM w/ exercise
What is osgood-schlatter dx?
Tendonitis of tibial tubercle
(irritation of patellar tendon at point of insertion on tubercle)
- teen active boy
- anterior knee pain
- Clinical dx
- quad + hamstring stretch
- gradual activity
- knee mobilizer or crutches until pain resolve if severe
What are XR findings of osgood-schlater’s dx?
XR to R/O other dx
If finding= fragmentation of tibial tubercle and soft tissue swelling
All are done for Osgood-Schlater except:
- protective gear
- ice to reduce swelling
- stop activities that cause pain
- quadriceps strengthening once pain resolve
- cast x 3-4 week
NO casting needed
What findings on XR do you see in legg-calve-perthes dx?
Small capital femoral epiphysis
Sclerosis of head
Fragmented and collapsed head
Complex Regional Pain Syndrome Signs
- Teen
- F
- disproportionate pain
> allodynia= ht response to pain
> hyperalgesia= pain to normal stimuli
> swelling of limb, autonomic indicator like cyanosis, mottling - PT + CBT
6 wk ankle pain. Can’t wt bear. Foot swollen, red, warm. Likely cause:
- complex regional pain sun
- osteo
- manchaussen
Osteomyelitis
List two RF for SCFE (slipped capital femoral epiphysis)
- Male
- Puberty
- Hypothyroid, Hypo-Pit, Renal osteodystophy
- Obesity
List two steps for managing a SCFE?
- Admit + Bed rest
- BW if < 10 y.o. (to R/O endo like hypothyroid)
- OR for pinning
- Crutches x 4-6 wk
- Prophylactic pin fixation of contralateral side (high risk b/l 60%)
How do you tx Legg-Calves-Perthes?
ROM with exercise
+/- Casting x 6 week then orthosis
What determine poor prognosis for legg-calves-perthes?
> 9 y.o. (older you are the less you remodel)
1 y.o. with metaphyseal femur #. What is next:
- Ca2+ Phos and Alk-Phos level
- full skeletal survey
- Bone scan
Full skeletal survey
Reminder: skeletal survey if < 2 with suspicion of abuse or < 5 with suspicious fracture.
T or F: 1/2 of neonate with osteo do not show fever.
True
How is osteomyelitis primarily spread?
Hematogenous
Most common pathogen for osteomyelitis:
- Staph aureus, Strep pneumoniae, Strep pyogenes
- Common neo= GBS, E coli.
- Penetrating foot= Pseudomonas aeurginosa
- Sickle Cell= Salmonella
- Immunocompromised= Fungal, Bacteria
How early can you’d detect osteo changes on Bone scan versus XR?
Bone Scan: 2-3d
XR: 1-2 wk
Mom pulled arm during horseplay. 2 y.o. child now holding pronated. Next:
- XR
- Sling then ortho
- ortho
- skeletal survey
- manipulate until arm f’n resotred
Manipulate at elbow until arm function restored.
What is the most common childhood wrist fracture?
Colles Fracture
= # of distal radius
= wrist #
Flat feet w/ standing. Arch normal when sitting with feet in air. Dx? Intervention?
- Hypermobile Pes Planus
- No long term problems. Treat if pain, abN shoe wear or fatigue after long walk. Orthosis (support) help symp. Stretch if tight Achilles.
Child presents with ER with fever, sore hip, pain. Next?
- aspirate joint
- XR
- CBC
Aspirate joint
R/O septic hip
3 y.o. hip pain after URTI. Best way to R/O osteo:
- lack of fever
- normal WBC
- (-) BCX
- bone scan
Bone Scan
What is the position of septic hip in septic arthritis?
- ABduct + internal
- ABduct + external
- ADDuct + internal
- ADDuct + external
AB duct
EXTERNALLY rotated
Most common pathogen for Septic arthritis?
- Staph Aureus
Other:
- GAS
- Streptococcus pneumoniae
- N. gonorrhoea
- MRSA
Neo: GBS, Ecoli
Sickle cell: Salmonella
Tx: cefazolin x min. 2 wk
Hip pain. Fever. Leg flexed and externally rotated. Two most important condition. 3 test to differentiate
Septic arthritis versus Osteo
Joint aspirate
MRI
Bone scan
3 y.o. intoeing gait. Tibial torsion and flexible metatarsus adducts. FHX (+). Neuro exam normal. You advice:
- stop W sit
- ortho referral
- no tx as invariably resolve
- dennis split
- Xray limbs
No tx necessary as invariably resolves
2 y.o. flat feet. FHX (+). You suggest:
- no intervention
- shoes at all times
- orthotics
- foot exercise
- ortho referral
No intervention necessary
Flexible feet until 6 y.o. normal variant. Small will last till 10 y.o. If persistent to adulthood rarely cause issue.
18 mo. African immigrant. Not walking. BF only. Now eat fruit. Distal radius, ulna, proximal tibia prominence. Which lab support dx:
- low 25 OH vit D
- low ALP
- low PTH
- high ionized Ca
Low Vitamin D
High PTH
High ALKP for compensation
Features of Rickets
- FTT, muscle wasting, craniotabes, frontal bossing, delayed fontanel closure, rachitic rosary, scoliosis, enlargement of ankle + wrist
Name four causes of b/l toe walking
- Idiopathic (P/E normal and only seen with walking)
* * 2. Cerebral Palsy
* *3. Duchenne Muscular Dystrophy
* *4. Tethered Spinal Cord
* *5. Autism Spectrum Disorder
Best determinant of scoliosis on P/E:
- leg length
- asymmetric shoulder ht
- asymmetric rib cage on bending over
- asymmetry on lateral flexion
Asymmetric Rib Cage on bending over.
14 y.o. scoliosis. Cobb angle 50. Most appropriate management?
Posterior spinal surgery.
Recommended for skeletally immature pt w/ >45 OR skeletal mature > 50 degree.’
Remember Big Picture:
> 30= brace if skeletal immature (earlier if rapid progression)
> 40 think Sx; > 50 for sure.
Teen post-op scoliosis. Bilious vomiting. Wt loss. Abdo pain. Likely Complication
Superior mesenteric artery syndrome.
List aetiologies of scoliosis:
- Idiopathic (teen)
- Congenital
- Neuromuscular
> CP
>Charie Marie Tooth
> Spinal Tumour
> Spinal Muscular Atrophy
> Duchenne Muscular Dystrophy - Neurologic: tethered cord
Syndromes
> NF
> Marfan - Compensation for leg length discrepancy
How is scoliosis treated?
Big Picture:
30 degree = brace if will progress
>40-50 degree= Sx; 50 and mature= for sure!
Details: Brace
- immature but > 30
- progression beyond 25 degree
Details: Posterior Spinal Fusion
- immature but > 45 degree
- sekeltal mature with curve > 50 degree
Gymnast with lower back pain w/ extension. Normal exam.
- Spondyloarthropathy
- Spondylosis
- Posterior element overuse
- Vertebral avulsion #
Spondylosis
** gymnast, extension with hamstring tight
Tx: avoid painful activity, stretch, PT, +/- brace
vs. posterior overuse= extension pain
vs. vertebral avulsion #= flexion related pain
vs. sponadyloarthropathy= inflamed joint, enthesitis, psoriatic
What is most RELIABLE test of screen for DDH in 7 month old?
- shortening of thigh on affected side
- less hip aBduction of affected side
- hip slide out of acetabulum
- hip slip into socket
7 month old
= shortening of thigh on affected side
Barlow, Ortolani only helpful till 3 mo.
List positive predictors of septic arthritis:
- fever
- refusal to wt bear
- WBC > 12
- ESR > 40
3 of those= >90% chance septic hip.
Describe the classic population for legg calves perthes disease?
M
4-8 y.o.
Thin
Hyperactive
Why: physiologically younger than chronological age
What are DDH risk factors
First born F FHX frank breech left
Lecture: if (+) fhx screen with US at 6-8 wk.
other:
- postnatal positioning
- native Ca
- syndromes
What are the physical exam findings with DDH:
BB:
- Galeazzi
- Barlow (in popped out)
- Ortolani (take the out in)
- Leg Length Discrepancy
Late:
- Galeazzi (shortening of dislocated hip when both knee flexed and feet on table)
- Leg length discrepancy
- Trendelenberg gait
- Decreased ABduction
At what age are Barlow and Ortolani not helpful anymore
After 3 mon. old
Hips are stuck in whatever position they are in then.
Best screening tool for DDH in newborn period:
- serial P/E
- dynamic US
- MRI
- AP and frog XR
Serial P/E
Dynamic US have high false positive.
When should you do a screening US?
6-8 week old
OR once tx started
What is the use of AP and Frog leg pelvis in DDH?
Can use after 6 months as U/S less helpful.
14 y.o. Scoliosis. 38 degree from T4-T12 and 30 degree from T12-L4. 2 year post menarche. No pain. What do you do?
Observation.
Pre-menarche highest risk of progression.
Post menarche usually won’t progress.
