Orthopaedics

Question 1

Developmental dysplasia of hip (congenital hip dislocation)

Answer 1

Path: newborn, find on 6 week check. click hip (4 weeks - still click and no laxity) , due to hip socket to shallow and ball pops out . Can result in subluxed or dislocated femoral heads leading to early degenerative joint disease.
Cause: poor hip development due to lax musculature and excessive uterine packing (breech presentation) leading to excessive stretching of posterior hip capsule and contractures.
Dx: US at 6months, early detection to allow proper hip development
xray 4-6 months
Tx: harness (hip socket)

Barlows maneuver (femoral head dislocated posteriorly) and ortolani maneuver (soft click - reduction of femoral head into acetabulum - pops it back in)
galeazzi sign - knees are unequal heights when hips and knees are felxed.
Asymmetric inguinal skin folds

Complications - joint contractures an AVN of femoral head, without treatment - significant defect is likely

Question 2

Leg calve perthe disease

Answer 2

4-10 year old, idiopathic avascular necrosis - decreased blood supply to hip
Pt: slow onset, antalgic gait, painless limb, thigh muscle atrophy.
Usually self limiting but can last up to 18months
-pain can be in groin or anterior thigh and can go to knee.
-limited abduction and internal rotation of hip, atrophy of affected leg.

Dx: radiographs - flattened and fragmented femoral head

Tx: observation if limited femoral head invovlemnt or full ROM present.

• bracing, hip abduction with a petrie cast or osteotomy
• progress good if patient is <6 years age and has FOM and decrease femoral head involvement and stable joint.

Question 3

Slipped capital femoral epiphysis

Answer 3

Path: kids going through large growth spurt, displaced femoral epiphysis from femoral neck through the growth plate. metaphysis moves anteriorly and superiorly
Pt: non-traumatic joint pain in teenager, obese, 10-16 years. associated w hypothyroidsim and other endocrinologies

Hist/PE: insidious onset of dull hip pain, referred knee pain and a painful limp
-Restricted ROM, inability to bar weight. limited internal rotation and abduction of hip. patients hold hip in passive external rotation.

Dx: frog leg Xray. AP, lateral views. (can see posterior and inferior displacement of femoral head)
-in patients under 10th percentile of height, rule out hypothyroidism with TSH.

Tx: surgery

• surgical screw fixation to reduce risk of AVN
• no weight bearing allowed until defect is surgically stabilised.

Complications - chondrolsis, AVN of femoral head, premature hip osteoarthritis

Question 4

Septic joint

Answer 4

fever, leukocytosis, elevated CRP, esr
-inability to weight bear
DxL athroplasty >WCC
Tx: drain, abx

Question 5

Transient synovitis

Answer 5

-any age
-hip pain
-inability to bear weight
-Post viral illness
Tx: supportive and inflammatories

(KOCHER CRITERIA) –> more likely transient synovitis than septic joint

Question 6

Knee - Osgood schaltters

Answer 6

Teenage athlets, knee pain, tibial swelling
Dx. Clinical
Tx: - stop sports, if continue - will get a lump on leg.

Question 7

Scoliosis

Answer 7

Path: deformity of spine (side to side) 
teenage girl, severe - SOB
Dx - adams test - touch knees, one shoulder higher than the other 
Tx: - brace to slow progression
surg - reversal

Question 8

Ewings scarcoma

Answer 8

mid shaft ling bone, onion skin appearnce
-Local pain and swelling, systemic symptoms present (fever, anorexia, fatigue)

Dx - leukoycosis, increase ESR, lytic bone lesion w onion skin - on xray (periosteal reaction)
Tx: local excision, chemo, readiation

Question 9

Osteosarcoma

Answer 9

End of bone (metaphyses) - sunburnt pattern , can mets to lung
Osteoblasts
Local pain and swelling, systemic symptoms negative
Dx: Increase ALP. sunburst lytic bone lesion, CT chest to rule out pulmonary mets
Treatment - local excision, chemo

Question 10

Duchenne muscular dystropy

Answer 10

X linked recessive disorder - deficiencey of dystrophin (cytoskeletal preotin)
3-5 years
-female characters - symptomatic depending on severity

Hist/PE: axial and proxoimal muscles more than digital
-clumbsiness, fatigability, difficutling standing maneuvers, waddling gait
Psydoypertrophy of gastrocenmius muscle
intellectual disabilites comon.
Dx - muscle biospy - necrotic mscle fibers with absence of dystrophin preotn.
negative dystrophimn immunostatin. (increase CK)
emg - polypahsic potential and recrutiment

Tx; Physcial thearpy, maintain ambulation and prevent contractures. Libreral use of tendon release surger may prolong

Complciaton - high mortaltiy due to high output cardiac facilrue.