Orthopaedics

Question 1

Transient synovitis

Answer 1

incidence: 3/100, 3-8yrs, M:F 2:1

pathophysiology: unknown etiology, no clear precipitant, bilateral in 5%, URTI in last 7-14 days (70%)

clinical: acute onset of pain to groin/hip, anterior thigh or knee

• pain/restricted ROM of hip but usually able to weight bear with gradual spontaneous resolution

diagnosis: XR normal, US +/- effusion

management: minimal weight bearing, NSAIDs

Question 2

Perthe’s disease

Answer 2

incidence: 5-7yrs, M:F 4:1

pathophysiology: idiopathic avascular necrosis of the femoral head

causes: idiopathic or secondary to infection, steroids, SLE

• 10% familial

clinical:

• insidious onset of hip pain, limp and pain related to activity
• limping gait +/- pain to anteriomedial thigh/knee
• decreasd internal roation and abduction
• bilateral 10-20%

diagnosis:

XR: widened joint space, irregular physial plate, radiolucent metaphysis

treatment: usually self limiting disorder

• aim to prevent complications such as femoral head deformity/OA via containment using NWB, splint, surgery

Question 3

Slipped Upper Femoral Epiphysis

!orthopaedic emergency!

Answer 3

incidence: 1:10,000, 9-16yrs, M>F

risk factors: obesity, polynesian, renal issues, radiation tx

clinical:

• acute (<3 weeks), chronic (>3 weeks)
• stable (able to WB), unstable (unable to WB)
• usually chronic with acute slip causing rip in retinacular vessels and altering femoral blood supply
• hip, knee or thigh pain
• affected leg shorter with external rotation and trendelenberg gait
• bilateral 20%

XR: posterior displacement of femoral epiphysis with widening, lucency and irregularity of the physis

management: NWB, surgery for fixation

complications: chondrolysis. avascular necrosis

Question 4

Spinal disorders

Answer 4

spondylylosis: fracture within the pars interarticularis

• clinical: aching LBP worse on extension and relieved with rest
• RF: athletes

spondylolithesis: bilateral defect allows the vertebral disc to slip forward

scoliosis: abnormal lateral curvature of the spine

juvenille kyphosis (idiopathic thoracic kyphosis)

• early adolescence
• anterior wedging >5 degrees in at least 3 vertebral bodies of T-L spine

Question 5

Osteoid Osteoma

Answer 5

definition: benign bone forming tumour in lower extremities presents in second decade

incidence: M>F

clinical: unremitting and increasing pain

• worse at night
• relieved with steroids

XR: dense sclerotic lesions with a separate small lucent area

• 25% not seen on plain film

prognosis: resolves after years, may require excision

**Osteoblastomas (giant ostoid osteoma) are similar but more destructive

Question 6

Foot/ankle pain

Answer 6

plantar fasciitis: inferior heel pain assoc calcaneal spurs

• pain on 1st step in am

achilles tendonitis: postero-superior ankle pain

calcaneal aphophysitis (sever disease):

• pain to inferior aspect calcaneus caused by microtrauma calcaneal apophysis
• common in adolescence/athletes

Question 7

Knee pain

Answer 7

Sinding Larsen Johansson Disease (SLJ): tendonitis at the inferior attachment of the patella

Osteochrondritis dissecans: bone adjacent to the cartilage suffers a vascular insult and separates from adjacent bone

• knee pain with swelling, lesions on XR, surgery

Question 9

Trendelenburg gait

Answer 9

definition: normal stance phase but excessive swaying of trunk

Question 10

Antalgic gait

Answer 10

definition: painful limp with shortening of the stance phase and stride of the affected limb to decrease the pain of weight bearing

Question 13

Buckle/torus fractures

Answer 13

mechanism: compression of bone

pathophysiology: cortex of bone does not break

site: metaphysis

management: stable fractures and heal within 4 weeks with immobilization

Question 14

Greenstick fracture

Answer 14

mechanism: angulation of bone beyond limits but insufficient enough to cause complete fracture

pathophysiology: bend deformity of the compression side and break in cortex on the tension side

*bowing is similar mechanism with angulation deformity but with no obvious fracure on XR

Question 15

Disc problems

Answer 15

disc prolapse: rare <10yrs, lumbar pain, poor straight leg raise

disc calcification: idiopathic/post inflammatory occuring post infancy with spontaneous resolution

Question 18

Toddler’s fracture

Answer 18

definition: oblique fracture of the distal tibia without a fibula fracture

age: 1-3 yrs

mechanism: often no significant trauma

clinical: minimal pain and swelling

XR: do not always should fracture initially

Question 19

Angular variations

Answer 19

genu varum: birth to 18 months

• pathological causes: Blount disease (tibia vara)

genu valgum: age 3 to 8 years

• pathological causes: renal osteodystrophy, skeletal dysplasia

Question 20

Tibia vara

-Blount disease-

Answer 20

pathophysiology: abnormal growth of medial proximal tibia epiphysis causing progressive varus deformity

• 80% bilateral

classified according to age of onset:

• infantile: 1-3yrs
• juvenille: 4-10yrs
• adolescent: >11yrs

risk factors: females, obese

clinical: painless significant internal tibial torsion and leg length discrepancy

XR: fragmentation/wedging/beak deformity proximal medial tibia

treatment: orthotics, surgery

Question 21

Osgood-Schlatter disease

Answer 21

age: 11-14yrs, M>F

pathophysiology: stress of contracting quadriceps causes avulsion fracture in the tibial tubercle after a growth spurt

clinical: pain during and after activity

• tenderness/swelling over tibial tubercle

treatment: rest, activity modification

prognosis: resolves 1-2 yrs

Question 23

Intoeing

Answer 23

causes:

• metatarsus adductus
• internal tibial torsion (most common cause<2yrs)
• internal femoral torsion (most common cause>2yrs, F>M)

referral: unilateral/asymmetric suggestive of neuro dx

• children >7 with activity limiting or aesthetically obvious in-toeing secondary to tibial torsion
• children >10 with femoral anteversion

management: splinting is ineffective, 1% require surgery

Question 25

Scoliosis

Answer 25

incidence: most common cause of spinal deformity

causes: most idiopathic

• secondary: congenital, DMD, SMA, spina bifida, compensatory (leg length discrepancy)

risk factors: female, family hx (20%)

clinical:

• types: infantile (<3), juvenille (4-10), adolescent (>11)
• juvenille most common
• painless (70%), most right sided curve
• left sided curve and age<11 most associated high intraspinal pathology

treatment: depends on degree and progression

• <25 degrees: observed
• 20-50 degrees: bracing
• >50 degree: surgery

Question 26

Kyphosis

Answer 26

pathophysiology: increased angulation in the thoracic or thoracolumbar spine in the sagittal plane

causes

- postural: corrects in standing and prone

- Scheurmann kyphosis (2nd common): unknown etiology with narrow disc spaces, loss of anterior height of 3 or more vertebrae, irregular endplates

• congenital: severe deformities with rapid progression

Question 27

Torticollis

Answer 27

pathophysiology: head tilt usually secondary to short SCM

causes

congenital: in utero positioning, birth trauma

• associated plagiocephaly, DDH

acquired: cervical spine abnormality, CNS pathology, URTI

clinical: ear tilted towards clavicle of ipsilateral side and face looks up towards contralateral side

treatment: physio, surgical

Question 28

Discitis

Answer 28

incidence: more common < 6yrs

pathophysiology: infection of intevertebral space

organism: staph aureus

clinical:

• gradual irritability and back pain, limp, refusal to bend forward and loss of lumbar lordosis
• often no fever

XR: narrow joint space with irregular adjacent bony end plates

treatment: IVAB

Question 29

Sprengel deformity

Answer 29

definition: congenital elevation of the scapula usually unilateral

clinical:

• elevated scapula
• associated restriction of scapulothoracic motion
• hypoplasia of parascapular muscles

associations: Klippel-Feil

Question 30

Proximal Humeral Epiphysiolysis

Answer 30

incidence: 9-14yrs

cause: throwing sports

pathophysiology: fracture of the proximal humerus physis

clinical: pain after throwing

XR: widening of physis or normal

treatment: avoid throwing

Question 31

Panner disease

Answer 31

definition: osteochrondritis of the capitellum (lateral portion of distal humeral epiphysis) occuring spontaneously in childhood

XR: fragmentation of capitellum

treatment: activity restriction

Question 33

Innervation forearm

Answer 33

Question 34

Cavernous sinus

Answer 34

**definition:** bilaterally paired collections of venous plexuses on either side of the sphenoid bone **borders:** temporal bone, sphenoid bone, sella turcica **contents:** - CN III: oculomotor - CN IV: trochlear - CN V₁: opthalmic - CN V₂: maxillary - CN VI: abducens - internal carotid artery

Question 35

Congenital bone cyst

Answer 35

**incidence:** rare \<3yrs **clinical:** asymptomatic then diagnosed with pathological fracture **XR:** solitary central lesion to proximal humerus/femur

Question 36

Nerves upper arm

Answer 36

Question 37

Waddling gait

Answer 37

**definition:** short steps that tilt the body side to side **cause:** decreased function gluteus muscles

Question 38

Toe walking

Answer 38

**incidence:** common complaint in early walkers but abnormal \>3 yrs **cause:** habit, NM disorder (CP, tethered cord), Achilles tendon contracture, leg-length discrepancy

Question 41

Physeal fractures

Answer 41

**incidence:** 20% of paediatric fractures M\>F **age:** 13-14yrs boys, 11-12yrs girls **_Salter-Harris classifications_** **type I**: "**S**traight"- transverse through physis **type II (75%):**"**A**bove"- through physis and metaphysis **type III:**"**L**ower"- through physis and epiphysis into the joint **type IV:**"**T**hrough" - through the metaphysis, physis and epiphysis **type V:**"c**R**ush"- crush injury to the physis **management** - types I/II: closed reduction - types III/IV: require anatomical realignment - type V: rare and result in premature closure of growth plate

Question 42

Fractures -internal fixation-

Answer 42

**indications** - displaced epiphyseal fracture - displaced intra-articular fracture - fractures with multiple injuries - open fractures - unstable fractures **procedure:** Kirschner wires, Steinmann pins or cortical screws **benefit:** improves/maintains alignment

Question 43

Metatarsus adductus

Answer 43

**incidence:** most common foot disorder in infants **pathophysiology:** position in uterus **risk factors:** 1st child **associations:** 2% DDH **clinical:** forefoot adducted/supinated - position can be neutralised **treatment:** spontaneous 90%, referral if \>2yrs

Question 48

Patellofemoral Pain Syndrome PFPS

Answer 48

**pathophysiology:** imbalance of ligaments controlling patella movements **clinical:** anterior knee pain worse with activity/stairs and sitting for extended period **treatment:** exercise program, antiinflammatories

Question 49

Hypermobile Pes Planus

Answer 49

**incidence:** 15% **pathophysiology**: generalised ligament laxity **risk factors:** family hx **clinical:** arch collapse with hindfoot valgus when weight bearing **treatment:** reassure normal variant

Question 50

Toe defects

Answer 50

**curly toe:** flexion PIP due to contractures flexor digitorum brevis **polydactyly:** additional toes **syndactyly** (more common): fusion of toes

Question 58

Eosinophilic fibroma

Answer 58

**incidence:** 5-10yrs **site:** skull, jaw, long bones **clinical:** pain, pathological fracture **XR:** small radiolucent without reactive bone **prognosis:** good, may heal spontaneously