Orthopaedics Flashcards
Transient synovitis
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
Perthe’s disease
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
Slipped Upper Femoral Epiphysis
!orthopaedic emergency!
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
Spinal disorders
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
Osteoid Osteoma
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
Foot/ankle pain
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
Knee pain
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
Trendelenburg gait
definition: normal stance phase but excessive swaying of trunk
Antalgic gait
definition: painful limp with shortening of the stance phase and stride of the affected limb to decrease the pain of weight bearing
Buckle/torus fractures
mechanism: compression of bone
pathophysiology: cortex of bone does not break
site: metaphysis
management: stable fractures and heal within 4 weeks with immobilization
Greenstick fracture
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
Disc problems
disc prolapse: rare <10yrs, lumbar pain, poor straight leg raise
disc calcification: idiopathic/post inflammatory occuring post infancy with spontaneous resolution
Toddler’s fracture
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
Angular variations
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
Tibia vara
-Blount disease-
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
Osgood-Schlatter disease
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
Intoeing
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
Scoliosis
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
Kyphosis
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
Torticollis
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
Discitis
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
Sprengel deformity
definition: congenital elevation of the scapula usually unilateral
clinical:
- elevated scapula
- associated restriction of scapulothoracic motion
- hypoplasia of parascapular muscles
associations: Klippel-Feil
Proximal Humeral Epiphysiolysis
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
Panner disease
definition: osteochrondritis of the capitellum (lateral portion of distal humeral epiphysis) occuring spontaneously in childhood
XR: fragmentation of capitellum
treatment: activity restriction
Innervation forearm
Cavernous sinus
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
Congenital bone cyst
incidence: rare <3yrs
clinical: asymptomatic then diagnosed with pathological fracture
XR: solitary central lesion to proximal humerus/femur
Nerves upper arm
Waddling gait
definition: short steps that tilt the body side to side
cause: decreased function gluteus muscles
Toe walking
incidence: common complaint in early walkers but abnormal >3 yrs
cause: habit, NM disorder (CP, tethered cord), Achilles tendon contracture, leg-length discrepancy
Physeal fractures
incidence: 20% of paediatric fractures M>F
age: 13-14yrs boys, 11-12yrs girls
Salter-Harris classifications
type I: “Straight”- transverse through physis
type II (75%):“Above”- through physis and metaphysis
type III:“Lower”- through physis and epiphysis into the joint
type IV:“Through” - through the metaphysis, physis and epiphysis
type V:“cRush”- 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
Fractures
-internal fixation-
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
Metatarsus adductus
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
Patellofemoral Pain Syndrome
PFPS
pathophysiology: imbalance of ligaments controlling patella movements
clinical: anterior knee pain worse with activity/stairs and sitting for extended period
treatment: exercise program, antiinflammatories
Hypermobile Pes Planus
incidence: 15%
pathophysiology: generalised ligament laxity
risk factors: family hx
clinical: arch collapse with hindfoot valgus when weight bearing
treatment: reassure normal variant
Toe defects
curly toe: flexion PIP due to contractures flexor digitorum brevis
polydactyly: additional toes
syndactyly (more common): fusion of toes
Eosinophilic fibroma
incidence: 5-10yrs
site: skull, jaw, long bones
clinical: pain, pathological fracture
XR: small radiolucent without reactive bone
prognosis: good, may heal spontaneously
