Orthopedics Flashcards
Newborn child with uneven gluteal folds, easy posterior dislocation of one hip (with a jerk and a “click”) and return to position with a “snap”, +/- family history. Diagnosis and management?
Developmental dysplasia of the hip, diagnosed by physical exam or sonogram (not x-ray, as calcification is not complete in newborn). Management by abduction splinting in Pavlik harness.
Child with insidious development of limping with decreased hip motion, complains occasionally of knee pain on same side, walking with an antalgic gait. Passive motion of the hip is guarded. Diagnosis and management?
Legg-Perthes disease (avascular necrosis of the capital femoral epiphysis), diagnosed by x-rays. Management by casting and crutches to contain the femoral head within the acetabulum.
Adolescent with pain in groin or knee noted to be limping, sits with sole of foot on affected side pointing toward the other foot. Normal knee exam, but limited hip motion and when hip is flexed the leg goes into external rotation and cannot be rotated internally. Diagnosis and management?
In this age group, a bad hip is always slipped capital femoral epiphysis, which is an orthopedic emergency. Diagnosis is by x-ray, management is with surgical pinning of the femoral head.
Toddler with flu for several days, walking fine until 2 days ago. Now in pain and refuses to move one leg, holding it with the hip flexed in slight abduction and external rotation. Elevated ESR. Diagnosis and management?
Septic hip, an orthopedic emergency. Aspirate under general anesthesia to confirm diagnosis, then perform open arthrotomy for drainage.
Child with febrile illness, no history of trauma, and severe localized bone pain. Diagnosis and management?
Acute hematogenous osteomyelitis. Diagnosis is first with bone scan (not x-ray, which will not show anything for 2 weeks). Managed with antibiotics.
Age ranges in which genu varum (bow-legs) and genu valgus (knock-knees) are considered normal?
Bow-legs normal up to age of 3, knock-knees normal between ages 4-8.
Persistence of bow-leggedness (genu varum) beyond normal age range (>age 3)?
Most commonly Blount disease (disturbance of medial proximal tibial growth plate), requiring surgical management.
Adolescent with an athletic knee injury. No swelling but persistently painful over tibial tubercle, tender to palpation, aggravated by contraction of quadriceps. Diagnosis and management?
Osgood-Schlatter disease (osteochondrosis of the tibial tubercle), managed with immobilization of the knee in an extension or cylinder cast for 4-6 weeks.
Baby born with both feet turned inward. On exam, plantar flexion of ankle, inversion of foot, adduction of forefoot, and internal rotation of tibia. Diagnosis and management?
Club foot (talipes equinovarus), requiring serial plaster casts starting from neonate period. Forefoot adduction corrected first, then hindfoot varus, then ankle equinus. About half need surgery.
Adolescent with potential scoliosis: curved thoracic spine and thoracic “hump” when bending forward. Management?
Skeletal maturity is 80% complete at onset of puberty and scoliosis may progress until maturity. Need baseline x-rays, possible bracing, monitoring of pulmonary function.
Young child with a humeral fracture, placed in a cast, later x-rays show significant angulation of the broken bone. Management?
Nothing. Children are able to remodel any reasonable alignment very well. Fractures are usually no big deal.
Child falls on hand with extended arm, breaking elbow by hyperextension. X-rays show supracondylar fracture of humerus with posterior displacement of distal fragment. Management?
May produce vascular or nerve injuries resulting in Volkmann’s ischemic contracture (wrist flexion, MCP extension, IP flexion). Can probably be treated with casting/traction, but monitor carefully for vascular and nerve integrity and development of compartment syndrome.
When is ORIF required in long bone fractures in children?
When the growth plate is divided by a fracture (displacement of epiphyses and growth plate without division can be treated with closed reduction)
Teenager with constant low-grade pain in distal femur for several months, with local tenderness but no other symptoms. X-rays show large bone tumor breaking through cortex into soft tissues with “sunburst” pattern. Diagnosis and management?
Osteogenic sarcoma (usually seen in 10-25 year olds, around the knee). Do not attempt biopsy, refer to bone tumor specialist.
10-year-old with persistent pain deep in the middle of the thigh. X-rays show large, fusiform bone tumor pushing the cortex out and producing periosteal “onion skinning”. Diagnosis and management?
Ewing sarcoma (usually seen in 5-15 year olds, in diaphyses of long bones). Do not attempt biopsy, refer to bone tumor specialist.
66-year-old woman breaks her arm while picking up a bag of groceries. Next steps?
Pathologic fracture indicates a bone tumor, probably metastatic. X-rays for broken bone, whole body bone scan for other metastases, other exams to look for primary tumor (breast in women, lung in men).
60-year-old man with fatigue and pain at specific places on several bones. Found to be anemic, and x-rays show multiple “punched out” lytic lesions throughout the skeleton. Diagnosis and management?
Multiple myeloma, the only tumor in which x-rays are better than bone scan. Look for Bence-Jones protein in urine and abnormal immunoglobulins in blood by electrophoresis. Managed with chemotherapy.
58-year-old woman with a soft tissue tumor in her thigh, growing steadily for 6 months, located deep in thigh, firm, fixed to surrounding structures, about 8 cm in diameter. Concern and management?
Concerning for soft tissue sarcoma. Start with MRI and leave biopsy and further management to specialists.
Adult with a fall from second floor window and clinical evidence for fractured femur. What x-rays to order?
Always get x-rays at 90 degrees to each other, always include joints above and below, always check other bones in the same line of force (lumbar spine in this case)
Clavicle fracture with tenderness at junction of middle and distal thirds of the clavicle. Treatment?
Figure-of-eight device for 4-6 weeks
55-year-old woman falls in shower and hurts her right shoulder. Presents with arm held close to body, rotated outwards like she is about to shake hands. Will not move the arm, has numbness over the deltoid muscle. Diagnosis and management?
Anterior dislocation of the shoulder, with axillary nerve damage, diagnosed by AP/lateral x-rays, managed with reduction.
What kind of shoulder injury is easy to miss on x-rays? When should you look for it and how is it seen?
Posterior dislocation of the shoulder. Can be seen after seizure, presenting as pain and inability to move the arm, held close to body with internal rotation. Axillary or scapular lateral x-rays can visulaize it.
Appearance, diagnosis, and treatment of Colles fracture?
Patient with fall on outstretched hand, presenting with deformed and painful wrist which looks like a “dinner fork”. X-rays show dorsally displaced, dorsally angulated fracture of distal radius and small non-displaced fracture of ulnar stylus. Treated with closed reduction and long arm cast.
Appearance, diagnosis, and treatment of Monteggia fracture?
Trauma to outer forearm raised in protection, resulting in diaphyseal fracture of proximal ulna with anterior dislocation of radial head. Needs closed reduction of radial head, ORIF of ulnar fracture.
Appearance, diagnosis, and treatment of Galeazzi fracture?
Fracture of the distal third of the radius and dorsal dislocation of the distal radioulnar joint. Needs ORIF of radius and casting of the forearm in supination to reduce the dislocated joint.
Young adult falls on outstretched hand and presents with wrist pain with tenderness to palpation over anatomic snuffbox. X-rays negative. Diagnosis and management?
Scaphoid fracture, not seen on x-rays for 2-3 weeks, with a high rate of non-union. Needs thumb spica cast with repeat x-rays in 3 weeks.
Management of displaced and angulated scaphoid fracture?
Needs ORIF
Patient punches a wall, comes in with swollen and tender hand, x-rays show fracture of fourth and fifth metacarpal necks. Next steps?
Depends on degree of angulation, displacement, or rotary malalignment. Closed reduction and gutter splint for mild ones, Kirschner-wire or plate fixation for bad ones.
