Orthopedic Flashcards
First newborn female, breech presentation, positive Barlow
Developmental dysplasia of the hip (DDH)
What is the imaging modality of choice in a 2-month-old girl with concern for DDH?
Ultrasound (US) of the hips (
What is the earliest time for US screening for DDH?
6weeks of age (before 6weeks, overly sensitive and can result in overtreatment)
A 1-month-old is diagnosed with DDH.What is the preferred treatment?
Pavlik harness
An 8-year-old boy presents with limping, pain in the right hip and knee, plain radiograph shows ossified and collapsed femoral epiphysis
Legg–Calve–Perthes disease
Adolescent with obesity presents with limping, pain in the right hip and knee, plain radiograph shows displacement of the femoral epiphysis
Slipped capital femoral epiphysis
A 5-year-old boy with upper respiratory symptoms, complaining of left leg pain and difficulty walking, decreases movement of the left hip. ESR and CRP are within normal ranges
Transient synovitis
A 5-year-old boy presents with left hip pain, fever and limping; he appears ill, grimaces with any left hip movement, limited range of motion, ESR and CRP are significantly elevated, hip US shows left hip effusion
Septic hip (pyogenic arthritis)
What is the next best step in cases of pyogenic arthritis?
Antimicrobial to cover against Staphylococcus aureus and streptococcal species, and in young children, Kingella kingae should also be covered Urgent orthopedic consultation
A 12-year-old male presents with left knee redness, pain, and swelling. There is a decreased range of motion along with elevated WBC, CRP, and ESR
Distal femur osteomyelitis
What is the most sensitive imaging modality to check for osteomyelitis?
MRI
Short umbilical cord, oligohydramnios, pulmonary hypoplasia, joint contractures, micrognathia, absent skin creases
Arthrogryposis
Indications for radiographic evaluation of bow leg “genu varum”
> 2years of age, unilateral, progressive after 1year, thigh leg angle >20°, suspected rickets or associated deformities
A 3-year-old African-American girl with obesity has severe progressive genu varum; plain radiograph shows proximal metaphyseal beaking
Blount disease
Basketball player presents with left knee pain, recurrent effusion, quadriceps atrophy, and pain with range of motion; plain radiograph shows subchondral fragment with a lucent line separating it from the condyle
Osteochondritis dissecans
A 13-year-old female with right knee pain; she feels that her knee cap is unstable, parapatellar tenderness, plain radiograph sunrise view shows lateral tilt of patella
Recurrent patellar subluxation and dislocation
A 5-year-old has cystic mass in the back of the left knee for 3months, it is painless, with no tenderness, normal range of motion
Popliteal cyst (Baker cyst)
The best management of Baker cyst
Observation for 12months
Knee pain with prolonged sitting, activity, and climbing or descending stairs, feeling of knee instability. Tenderness over the medial patellar facet, pain with patellar compression, and mild swelling
Patellofemoral pain syndrome (PFPS)
The best management of patellofemoral pain syndrome
Ice, rest, NSAID, quadriceps and hamstring strengthening
The most common cause of intoeing in children >3years
Femoral torsion
A 7-year-old girl, patellae are looking inward (kissing patellae), running like an egg-beater, always sitting in W position, internal rotation of the hip is more than external rotation
Femoral anteversion
Management of femoral anteversion
Reassurance (spontaneous resolution in more than 80% of the cases)
Are shoe wedges, twister cables, night splint, or discouraging W-sitting effective in cases of femoral anteversion?
Showed to be ineffective
The most common cause of intoeing in children between 18months and 3years
Tibial torsion
A 2-year-old with both feet pointing medially, especially when running, patellae in both legs are pointing anteriorly. The child trips frequently
Internal tibial torsion
Management of internal tibial torsion
Reassurance (almost all cases resolve spontaneously)
A 4-month-old with a curved foot; by drawing an imaginary line bisecting the foot, it passes laterally to the fourth toe
Metatarsus adductus
The best management of metatarsus adductus
Observation (if persists beyond 6months and deformity is rigid, a referral is necessary)
Newborn with a deformed foot; the foot can be everted and dorsiflexed (the foot touches the anterior tibia)
Postural or positional (calcaneovalgus foot) this is not a clubfoot
The best management of calcaneovalgus foot
Observation—condition due to the intrauterine position
Newborn male infant with turned inward right foot. The right foot can be passively stretched almost to the midline. The ankle is in equinus (downward), the foot is supinated (varus) and adducted, dorsiflexion beyond 90° is not possible
Clubfoot or congenital talipes equinovarus (TEV)
Best management of clubfoot
Serial casting (requires an immediate referral)
The most common neurological conditions associated with clubfoot
Myelomeningocele and cerebral palsy
The most common condition associated with cavus foot
Charcot–Marie–Tooth syndrome
A mother is concerned that her 6-month-old has a flat foot
Reassurance (medial arch of the foot does not develop until 4years of age and reaches adult value by 8years)
A 3-year-old child with tiptoe walking, normal neurological examination, the best course of action
Physical therapy for 6months for Achilles tendon stretching; if no improvement, orthopedic referral
A 15-year-old presents with progressive back deformity, plain radiographs of the thoracic spine shows 3 adjacent wedged vertebral bodies of at least 5°
Scheuermann kyphosis
A 12-year-old female has spinal scoliosis detected by school nurse; the scoliometer measures 7°
Adolescent idiopathic scoliosis (AIS)
Cases with AIS should be referred to orthopedic if
Scoliometer 7° or more, Cobb angle >20°
Management of female adolescent with AIS and Cobb angle >25°
Bracing (if skeletal growth remaining)
Management of female adolescent with AIS and Cobb angle >50°
Usually, surgery is required
The indication for MRI in cases with scoliosis
Pain, left thoracic curve, abnormal neurological exam, infantile and juvenile types
Adolescent with low-back pain for a few months. The pain is worse after physical activity or prolonged sitting. O/E: pain is exaggerated with lumbar flexion and bilateral rotation. Tenderness to palpation along the lumbar paraspinal muscles; tightness of the hamstring and calf muscles. Normal neurologic examination. No other symptoms. Normal spine radiograph
Mechanical low-back pain
What is the best management in the Mechanical low-back pain
Physical therapy (lumbar/core strength and stability exercises)
A 10-year-old female does gymnastics; presents with low-back pain that increases with the extension of the spine, plain radiograph shows defect in pars interarticularis, oblique view shows Scotty dog collar sign
Spondylolysis
A 10-year-old female does gymnastics; presents with low-back pain that increases with the extension of the spine, plain radiograph shows forward slippage in L5 over S1
Spondylolisthesis
Best initial management of spondylolysis
NSAID and rest
Management of spondylolisthesis
Referral to orthopedics
A 15-year-old boxer complaining of dull pain in radial aspect of the right wrist that is exacerbated by clenching, and tenderness in the anatomic snuffbox; plain radiograph on the right wrist is negative
Possible scaphoid fracture. (Radiograph is usually negative in the first 2weeks). Treat if highly suspected
The best management of scaphoid fracture
Thumb spica splint and repeat radiograph in 2weeks
The motor manifestation of posterior interosseous nerve injury
Finger drop (inability to extend the fingers at the metacarpophalangeal joint)
The motor manifestation of radial nerve injury
Wrist drop and finger drop
The motor manifestation of ulnar nerve injury
Partial claw hand
The motor manifestation of median nerve injury
Inability to flex the index finger
The most common sports injury in the knee, e.g., female playing soccer
Anterior cruciate ligament (ACL) injury
A 14-year-old complains of right shoulder pain after a fall, arm held in abduction, and externally rotated, the shoulder is boxlike. Patient resists adduction and internal rotation, plain radiograph shows a subcoracoid position of the humeral head in the AP view and humeral head lies anterior to the “Y” in an axillary view
Anterior shoulder dislocation
A 14-year-old complains of right shoulder pain after an electric shock, the arm is held in adduction and internal rotation, patient resists external rotation and abduction. Plain AP radiograph shows a humeral head that resembles an ice cream cone. The scapular “Y” view reveals the humeral head behind the glenoid (the center of the “Y”)
Posterior shoulder dislocation
Child with anterior shoulder dislocation loses the pinprick sensation in the deltoid
Axillary nerve injury (check axillary nerve sensation before and after reduction)
Right shoulder pain after a fall during basketball practice, prominent clavicle with loss of the normal contour of the shoulder, shoulder radiographs show separation between the clavicle and acromion
Acromioclavicular joint disruption
Right shoulder pain after a fall during basketball practice directly onto the lateral aspect of the right shoulder, pain when adducting the arm across the chest, there is mild swelling and tenderness at the distal end of the clavicle, shoulder radiographs are normal
Acromioclavicular joint sprain
The most common ligaments affected in ankle sprain
Lateral ligaments of the ankle (anterior talofibular most common, calcaneofibular, and posterior talofibular ligaments)
When can a patient with an ankle sprain go back to sports?
If no pain and painless range of motion
The best way to differentiate between an ankle sprain and fracture
Bony tenderness is usually a fracture
A 2-year-old boy fell 2h ago; now he is refusing to walk. He appears to have tenderness over the distal third of the left tibia. Radiographs of lower extremities are normal. What is the next best step?
Apply a cast on the left lower extremity and repeat radiography in 2weeks (possible toddler fracture)
A 12-year-old boy had a fracture of right tibia, fixed with an above-knee cast. He continues to have pain afterward, the pain keeps getting worse despite the maximum dose of prescribed pain medicine, any movement of the toes causes him excruciating pain, also he has numbness between the first 2 toes
Compartment syndrome. Presence of pain despite fracture immobilization and pain medication is a red flag for compartment syndrome
What is the next best step in the previous case of compartment syndrome?
Report immediately to the nearest ER (immediate removal of cast and orthopedic consultation)
The most common orthopedic complication of snake bite in the extremities
Compartment syndrome
A 12-year-old with right knee trauma. Knee radiograph showed no fracture but incidentally found a small, well-defined radiolucent cortical lesion with a surrounding rim of sclerosis in the upper tibia. The longitudinal axis of the lesion is parallel to the axis of the tibia
Osteoid osteoma
A 2-year-old child suddenly stops moving his right arm after his brother forcibly pulled his hand
Nursemaid elbow
Short, webbed neck decreased the range of motion in the cervical spine, low hairline. Fusion of cervical vertebrae on radiograph
Klippel–Feil syndrome
Common associations with Klippel–Feil syndrome
Sprengel’s deformity (elevation of the scapula), thoracolumbar anomalies, renal and cardiac anomalies
