ORTHOPEDICS 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 (< 6 months)
What is the imaging modality of choice in a
7-month-old girl with concern for DDH?
Pelvis radiograph (> 6 months)
What is the earliest time for US screening for
DDH?
6 weeks of age (before 6 weeks, 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”
> 2 years of age, unilateral, progressive after
1 year, 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 3 months, it is painless, with no
tenderness, normal range of motion
Popliteal cyst (Baker cyst)
The best management of Baker cyst
Observation for 12 months
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
> 3 years
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)
The most common cause of intoeing in children
between 18 months and 3 years
Tibial torsion
Are shoe wedges, twister cables, night splint, or
discouraging W-sitting effective in cases of
femoral anteversion?
Showed to be ineffective
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 6 months 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
Best management of clubfoot
Serial casting (requires an immediate referral)
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)
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 4 years of age and reaches adult
value by 8 years)
A 3-year-old child with tiptoe walking, normal
neurological examination, the best course of action
Physical therapy for 6 months 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 previous case?
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
Management of spondylolisthesis
Referral to orthopedics
Best initial management of spondylolysis
NSAID and rest
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 2 weeks). Treat if
highly suspected
The motor manifestation of posterior interosseous nerve injury
Finger drop (inability to extend the fingers at the
metacarpophalangeal joint)
The best management of scaphoid fracture
Thumb spica splint and repeat radiograph in
2 weeks
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 2 h 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 2 weeks (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
Fibrous cortical defect (non-ossifying fibromas),
Most cases are accidentally discovered in
radiographs taken for other reasons. No
treatment is required in most cases
A 12-year-old with severe pain in the upper part of the right tibia at night improved dramatically with ibuprofen; radiograph showed 1.5 cm sharp round lesion (nidus) surrounded by a rim of radiodensity
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
