Orthopaedics

Question 1

What is the most common cause of hip pain in children 3-10 years?

Answer 1

Transient toxic synovitis (often follows viral respiratory infection)

Question 2

What is the appropriate work-up for toxic synovitis?

Answer 2

CBC, CRP/ESR, radiographs, joint aspiration (diagnosis of exclusion and MUST rule out septic arthritis with aspiration)

Question 3

What is Legg-Calve-Perthes Disease?

Answer 3

Idiopathic osteonecrosis of the femoral head

Question 4

What is a significant predictor of poor outcome with LCPD?

Answer 4

Older age at onset

Question 5

What is the initial treatment for LCPD?

Answer 5

Rest and PT

Question 6

What is patellofemoral pain syndrome?

Answer 6

Overuse syndrome in runners due to maltracking of the patellofemoral joint. Pain is anterior in the patellar region and exacerbated by running, squatting, stair climbing and prolonged sitting with the knee bent.

Question 7

What is the treatment for PFPS?

Answer 7

PT with quad and hip strengthening

Question 8

What is Osgood-Schlatter disease?

Answer 8

Overuse syndrome in jumping sports. Pain is over tibial tubercle

Question 9

What is Plica syndrome?

Answer 9

Irritated synovial remnants (plicae) that did not resorb properly during development due to repeated flexion of the knee. Symptoms are pain and popping/snapping with knee flexion.

Question 10

What is internal tibial torsion?

Answer 10

Excessive in-toeing with flexible, normal foot and patellae in neutral position.

Question 11

How is internal tibial torsion diagnosed?

Answer 11

Place the child on his knees and assess for inward-pointing toes (rather than normal 30d of external rotation)

Question 12

How is internal tibial torsion treated?

Answer 12

Watchful waiting until resolution by age 6 (unless always falling, then may need surgery)

Question 13

What is SCFE?

Answer 13

Displacement of the femoral epiphysis in obese adolescents.

Question 14

How is SCFE diagnosed?

Answer 14

AP and frog-leg lateral radiographs of the hip

Question 15

How is SCFE treated?

Answer 15

Surgical fixation

Question 16

At what Cobb angle should bracing be considered?

Answer 16

25-45d (only effective if child is still growing and < 1 year past menarche if female)

Question 17

What is a nursemaid’s elbow?

Answer 17

Subluxation of the annular ligament over the radial head

Question 18

How do you reduce a nursemaid’s elbow?

Answer 18

Supinate the forearm and flex the elbow while applying pressure over the radial head

Question 19

What is a toddler’s fracture?

Answer 19

Spiral fracture over the tibia from insignificant rotational trauma (running and falling with a twisting motion)

Question 20

How do you treat a toddler’s fracture?

Answer 20

Refer to orthopaedics for casting

Question 21

What is the next step for a child with non-accidental trauma?

Answer 21

Skeletal survey

Question 22

What types of fractures are highly specific for non-accidental trauma?

Answer 22

Metaphyseal corner fractures (due to high-energy tension/shearing forces)
Posterior rib fractures

Question 23

What is meralgia paresthetica?

Answer 23

Burning pain in the anterior-lateral thigh caused by compression of the lateral femoral cutaneous nerve

Question 24

What is the treatment for metatarsus adductus?

Answer 24

Watchful waiting unless the deformity is rigid in a child > 3 months or residual in a child > 6 months (serial casting/surgery)

Question 25

What is the most common pathogen involved in osteomyelitis?

Answer 25

Staph aureus

Question 26

How is the pathogen involved in osteomyelitis most typically identified?

Answer 26

Blood culture in 40-50% of cases (otherwise need aspiration at site of bony destruction with pathology)

Question 27

What is the only sufficient test to definitely rule out septic arthritis?

Answer 27

Arthrocentesis

Question 28

When should you start IV antibiotics for suspected septic arthritis?

Answer 28

Any time there is > 90% PMNs (WBC cut-offs vary), even if there are other fluid findings suggestive of alternative diagnosis

Question 29

Where is the pes anserine bursa located?

Answer 29

Medial, proximal aspect of the tibia

Question 30

What is a treatment option for pes anserine bursitis?

Answer 30

Corticosteroid injection

Question 31

What is the most common organism causing septic arthritis in teenagers?

Answer 31

Gonococcus

Question 32

What is considered a positive straight leg test?

Answer 32

When radicular symptoms occur (pain and paresthesias) below the level of the knee (not thigh) between 25-75 degrees of hip flexion while lying or with knee extension while seated and with passive ankle dorsiflexion. “Crossover” pain with radicular symptoms in the leg not lifted is very specific for disk disease but not very sensitive.

Question 33

What exam sign should raise suspicion of spondylolisthesis?

Answer 33

Any adolescent athlete who has back pain worse with hyperextension.

Question 34

At what time is surgical consultation recommended for spondylolisthesis?

Answer 34

Teen/young adult with > 50% slip or older adult with 100% slip

Question 35

How does discitis usually present?

Answer 35

Children in infancy to age three, often without fever or elevated WBC and with sterile blood cultures, but with elevated ESR. Child has low back pain and limp. Treat with anti-staph antibiotic.