Orthopedics

Question 0

Klumpke’s palsy – nerve roots? Clinical features? Associated finding?

Answer 0

C7 and C8.

1. Clawhand – unopposed finger flexion and inability to extend elbow/flex wrist
2. Horners

Question 1

Patient with flaccid arm and asymmetric Moro reflex – palsy? Nerve roots?

Answer 1

Erbs palsy a.k.a. Waiter’s tip. C5 and C6

Question 2

Management of brachioplexus injuries?

Answer 2

Observation for improvement. Surgery if no improvement within 18 months

Question 3

Child pulled to a stand – orthopedic injury? Features? Diagnosis? Treatment?

Answer 3

Nursemaids elbow – subluxation of Radial head (Radius slips out of annular ligament)

Child holds elbow flexed and is unwilling to use arm. No swelling, normal hand function

Simultaneously flexing elbow and supinating hand – Will start to use arm within 15 minutes

Question 4

Most common type shoulder dislocation? Seen in which activities? Treatment?

Answer 4

Anterior shoulder dislocation (gymnastics, wrestling); immobilization

Question 5

Torticollis? Name of genetic disorder with congenital torticollis? Causes of acquired Torticollis? Management?

Answer 5

Tilting the head to one side. Klippel-Feil syndrome

Cervical adenitis, abscess, diskitis, osteomyelitis, strabismus

Stretching exercises

Question 6

Atlantiaxial Instability seen in what syndromes? Management?

Answer 6

Down syndrome, Klippel-Feil

Fusion of C1 and C2 vertebra

Question 7

Klipple-Feil syndrome? Sprengel’s deformity?

Answer 7

Relative fusion of vertebra

Scapular rotated laterally leading to shoulder asymmetry and decreased ROM

Question 8

Adams forward bending test?

Cobb angle?

Answer 8

Test for scoliosis – bending over causes posterior displacement of the curved spine (unilateral hump)

Measures the degree of scoliosis

Question 9

Cobb angle that is concerning for respiratory/cardiovascular compromise?

Answer 9

60-65

Question 10

Common causes of pediatric back pain?

Answer 10

1. Back strain – pain without neurological deficits
2. Spondylolysis – stress fracture in pars interarticularis
3. Spondylolisthesis – body of vertebra moves anterior to spine
4. Diskitis – inflammation/infection of intravertebral disc
5. Herniated intravertebral disc – usually lumbar region

Question 11

Spondylolysis – usually secondary to (general movement)? from which activities? Usually which vertebra? Pain Aggravated with?

Answer 11

Repetitive hyper extension of the spine

Gymnastics, tennis, diving

L5; pain increases with hyperextension

Question 12

Discitis – causal organism? Typically presents with? Lab finding?

Answer 12

Staph aureus;

1. URI symptoms followed by back pain and tenderness of involved disc
2. Children may refuse to flex spine or ambulate

elevated ESR

Question 13

movements to test for developmental dysplasia of hip?

Answer 13

Barlow - posteriolateral pressure

Ortolani - replacing femur back into acetabulum after Barlow

Galeazzi - assesses asymmetry of femur position

Question 14

Patient diagnosed with developmental dysplasia of the hip – management?

Compilations if not treated?

Answer 14

1. Pavlik harness if diagnosed within six weeks of age
2. Otherwise surgery

Avascular necrosis, limb length discrepancy, painful gait, osteoarthritis

Question 15

Differential diagnosis for painful limp?

Answer 15

STARTSS HOTT
Septic arthritis
Transient synovitis
Acute rheumatic fever
Rheumatoid arthritis
Trauma/fracture/sprain
Sickle cell crisis
Slipped capital femoral epiphysis
HSP
Osteomyelitis
Tuberculosis
Tumor

Question 16

Septic arthritis – age of onset? Joint most affected? Causal organisms in pediatric patients? Preferred position of hip in affected children? Management?

Answer 16

1-3 years; hip; staph aureus and strip pyogenies

Flexed, abducted, and externally rotated

Surgical decompression by joint aspiration and empiric IV antibiotics

Question 17

Transient synovitis – also called? Diagnosis? Age of onset? Position of hip? Other symptoms? Management? Prognosis?

Answer 17

Toxic synovitis; diagnosis of exclusion; 2-7 years

Hip flexed, abducted, and externally rotated; low-grade fever, limp

NSAIDs and rest

Pain improves within three days and complete resolution by three weeks

Question 18

Legg-Calve-Perthes– Age of onset? Hip finding? Pain may be referred where? Sign suggestive of diagnosis? Prognosis?

Answer 18

4-9 years; Decreased internal rotation and abduction of hip; referred to knee and groin

Crescent sign on frog-leg lateral radiographs

If under 9 - Complete resolution within two years
If over 9 – osteoarthritis as adults

Question 19

Slipped capital femoral epiphysis – Age of onset? Typical patient? Disease which predisposes to bilateral involvement? Suggested sign on the imaging? Management? Do not manage by? Complications?

Answer 19

Adolescence; obese male; hypothyroidism

Klein line (line drawn flanking the superior edge of femoral neck) will not cross epiphysis

Pinning the epiphysis

Do not push Femoral head back into normal position – may cause avascular necrosis

Avascular necrosis, chondrolysis, limb length discrepancy, osteoarthritis

Question 20

Osteomyelitis – peak ages? Causal organisms? Mechanism of inoculation? Preferred imaging study? Treatment? Way to confirm response to treatment? Surgery necessary if?

Answer 20

<One year and between 9-11 years

1. Staph aureus and strep Pyogenes most common
2. Salmonella if sickle cell
3. Pseudomonas if child steps on nail

Hematogenous spread

Bone scan/MRI (detects within a few days)

Six weeks of antibiotics; decreasing ESR denotes response to antibiotics

Surgery if the fever/swelling persists after 48 hours of IV antibiotics

Question 21

Complications of osteomyelitis?

Answer 21

1. Spread of infection
2. Chronic osteomyelitis from nidus of residual infection
3. Pathologic fracture
4. Angular deformity/Limb length discrepancy