Orthopedics Flashcards
Brachial Plexus injury most commonly occurs as a result of ______ ______
birth trauma
Where is the injury in Erb’s palsy? What are the clinical features?
Upper brachial plexus injury involving the C5 and C6 nerve roots
Clinical features includ a flaccid arm and an asymmetric Moro reflex; Arm held in internal rotation with the elbow extended and forearm pronated (waiters tip)
Where is the injury in Klumpke’s palsy? What are the clinical features?
Lower brachial plexus injury involving C7 and C8 nerve roots
Clinical features include a claw hand owing to the unopposed finger flexion and decreased ability to extend the elbow and flex the wrist
How is congenital aplasia of the brachial plexus (Erb’s and Klumpke’s) diagnosed?
Diagnosis is on basis of history and physical examination
May include a plain radiograph of the shoulder to evaluate for associated clavicular fracture
EMG and nerve conduction studies to assess for neuropathy or myopathy
For congeital brachial plexus aplasias, improvement is often noted within ______ hours
48
What is nursemaid’s elbow? What is the mechanism of injury?
Subluxation of the radial head; Upward force on the arm causes the radial head to slip out of the annular ligament which normally keeps it in place
What are the clinical features of Nursemaid’s elbow?
- Sudden onset of pain which is difficult to localize
- Elbow is held flexed and no swelling is present; hand function is normal
What is the management for nursemaids elbow? Why is radiograph not needed?
Management: Treatment of the subluxation is to reduce it by simultaneously flexing the elbow and supinating the hand
Diagnosis is on the basis of clinical presenation; if a film is ordered, the technologist may accidentally reduce the subluxation in the process of positioning the arm for the radiograph
How are anterior shoulder dislocations diagnosed?
Diagnosis is based on radiographs (axillary view) of the glenohumeral joint to visualize the dislocation
What is the treatment of anterior shoulder dislocation? What is the recurrence rate in adolescents?
Treatment is immobilzation after closed reduction
Recurrence of dislocation approaches 90% in the adolescent population
What is torticollis?
Tilting of the head to one side; either congenital or acquired
What causes congenital torticollis?
Usually the result of uterine constraint or birth trauma, either of which causes conracture of the sternocleidomastoid muscle
Can also be caused by Klippel-Feil syndrome, a cervical spine deformity
What are the clinical features of torticollis?
- Head is tilted toward the affected side with the chin pointed away from the contracture
- Decreased range of motion and stiffness are noted when stretching the head to the opposite side
What is the management for Torticollis?
Treatment includes stretching exercises to relieve the muscle contracture; if head asymmetry is noted, helmet therapy must be initiated by 4-6 months of age to correct head shape as the head grows
What can cause acquired torticollis?
Causes may include cervical adenitis, peritonsillar or retropharyngeal abscess, cervical diskitis or osteomyelitis….
What is atlantoaxial instability?
Caused by an unstable joint between the occiput and the first cervical vertebrae or between the first and second cervical vertebrae
What are the clinical features of atlantoaxial instability?
Physical exam is usually normal and patients are usually asymptomatic
Spinal cord injury may occur if a patient with instability sustains injury
How is atlantoaxial instability diagnosed?
How is it managed when severe?
Diagnosis is made on the basis of lateral flexion-extension radiographs of the cervical spine
Mangement includes fusion of C1 and C2
What is Klippel-Feil syndrome?
Failure of normal vertebral segmentation that results in relative fusion of the involved vertebrae
What is Sprengel’s deformity (associated with Klippel-Feil syndrome)?
Congenital abnormality of the scapula in which the scapula is rotated laterally leading to should asymmetry and diminished shoulder motion
What are the clinical features of scoliosis?
Asymmetry of the shoulder height, scapular position and the waistline may be present; Pain is absent
What positional should radiographs be taken to diagnose scoliosis? What is calculated to measure the degree of scoliosis?
Standing posterior-anterior (PA) and lateral radiographs of the spine
Cobb angle
Describe the management for the following levels of scoliosis
- 10-20° of scoliosis:
- 20-40° of scoliosis:
- >40° of scoliosis:
- 10-20° of scoliosis: Follow up scoliosis film is obtained 4-6 months later; 5° of progression is considered significant
- 20-40° of scoliosis: Bracing is indicated
- >40° of scoliosis: Surgery is indicated
After growth has concluded, surgery is considered if scoliosis is > __°
50°
What is kyphosis?
Anterior-posterior (AP) curvature of the thoracic spine
Most adolescents with kyphosis have _______ _______ in which they can voluntarily correct the rounded area
flexible kyphosis
What is Scheuermann’s kyphosis?
A stiff idiopathic kyphosis in which three consecutive vertebrae are wedged; develops in previously normal adolescents
What is the most common cause of back pain in children?
Back strain - muscular soreness from overuse or bad body mechanics
What is spondylolysis? In what region is it located?
A stress fracture in the pars interarticularis secondary to repetitive hyperextension of the spine; typically involves the lumbar region, particularly L5
In spondylolysis, pain increases with ______
hyperextension
How is spondylolysis diagnosed when the fracture is acute? Why?
Because it is a stress fracture, plain films may not detect the fracture
Bone scan or single photon-emission computed tomographic (SPECT) scan may be used for diagnosis
What causes spondylolysis to progress to spondylolisthesis?
When the body of the vertebra involved in spondylolysis slips anteriorly; the subluxed vertebra can impinge on nerve roots
What is the most common infectious agent in diskitis? Where is the inflammation?
Staphylococcus aureus is the most commonly identified causeal organism
Inflammation of the intervertebral disk
What are the clinical features of diskitis?
Typically begins with signs and symptoms of an upper respiratory illness or minor trauma - followed by back pain with tenderness over the involved disk
What lab finding is elevated in diskitis? What imaging can confirm the diagnosis?
ESR is elevated
MRI and bone scan can confirm the diagnosis
What is the management of diskitis?
Treatment includes bed rest; may use antistaphylococcal antibiotics
What is the most commonly affected region for a herniated intervertebral disk?
The lumbar region is most commonly affected
What anatomic abnormality leads to developmental dysplasia of the hip?
Occurs when the acetabulum is abnormally flat, leading to the easy dislocation of the head of the femur
Developmental dysplasia of the hip (DDH) is more common in ____ (6:1 ratio)
girls
What are the risk factors for DDH?
Female sex, first born, breech presentation, family history and oligohydramnios
What two maneuvers are positive in physical examination of DDH?
- Positive Barlow maneuver: with the hips at 90° flexion, place thumb on medial side of thigh and middle finger on the greater trochanter and apply gentle pressure posteriorly and laterally - “clunk” is positive
- Positive Ortolani manuever: Abduct the hip, applying gentle pressure upward with the middle finger to slide the head of the femur back into the acetabulm - feeling the hip slipping into the acetabulum is positive
What is the Galeazzi sign in DDH?
Assesses the asymmetry of femur position; place hips in 90° flexion and if the hip is dislocated the affected femur is shifted posteriorly compared with the normal limb
How is DDH diagnosed if the physical exam is equivocal?
Ultrasound is used to assess DDH in young infants because the femoral head does not ossify until 4-6 months of age
AP radiographs of the pelvis may be used to assess for DDH if the infant is older than 6 months
What are the two methods of treating DDH? When is each used?
- Pavlik harness: typically used for 2-3 months if the diagnosis is made by 6 weeks of age
- Surgery may be required if the diagnosis is made beyond 6 weeks of age, the hips are bilaterally dislocated, irreducible on exam or the Pavlik harness fails to stabilize the hip
What are some possible complications of DDH
- Avascular necrosis of the femoral head
- Limb length discrepancy
- Painful abnormal gait
- Osteoarthritis
What cause of limping in a child is considered an orthopedic emergency?
Septic arthritis of the hip
What is the differential diagnosis for a painful limp?
Mnemonic: the joint STARTSS HOTT
- Septic arthritis
- Transient synovitis
- Acute rheumatic fever
- Rheumatoid arthritis
- Trauma (fracture, strain, sprain)
- Sickle cell disease
- Slipped capital femoral epiphysis
- Henoch-Schonlein purpura
- Osteomyelitis
- Tuberculosis
- Tumor (osteosarcoma, leukemia)
What are the most common organisms associated with septic arthritis of the hip?
Staphylococcus aureus and Streptococcus pyogenes; Neisseria gonrrhoeae may cause septic arthritis in adolescents
What are the clinical features of septic hip?
- Fever and irritability
- Limp, refusal to walk and pain with movement of joint
- Erythema, welling, asymmetry of soft tissue folds
What lab findings are there with Septic arthritis of the hip?
- Elevated WBC count
- Elevated ESR
- Elevated C-reactive protein
- Blood culture positive in 30-50% of all cases
What is the best imaging for septic arthritis of the hip?
Ultrasound (demonstrates fluid in the joint capsule)
What is the management for septic hip?
- Surgical decompression by joint aspiration
- Empiric intravenous antibiotics for 4-6 weeks
What is transient synovitis?
A common self-limited postinfectious response of the hip joint
What is the most common cause of painful limp in toddlers?
Transient synovitis
When is the peak age range of presentation for transient synovitis?
2-7 years
What are the clinical features of transient synovitis?
- Low grade fever
- Limp
- Hip pain (may be acute or insidious in onset)
What is the management for transient synovitis? What happens to WBC count and ESR?
Treatment includes NSAIDs, bed rest, and observation
WBC count and ESR are normal or only slightly elevated
What is Legg-Calve-Perthes disease?
Idiopathic avascular necrosis fo the femoral head
What is the age of onset for Legg-Calve-Perthes? Who is the typical patient?
Age of onset is 4-9 years
Patients are typically active, thin boys who are small for their age
Children with Legg-Calve-Perthes havve decreased ________ rotation and ______ of the hip
internal; abduction
In Legg-Calve-Perthes, where can the pain be referred?
Pain may be referred to the knee and to the groin
What type of radiographs are used to see Legg-Calve-Perthes disease? What is seen on imaging?
AP and frog-leg lateral radiographs of the pelvis
Increased density in the affected femoral head or a subchondral fracture in the femoral head, termed the “crescent sign”
What is the management for Legg-Calve-Perthes disease? When is surgery indicated?
Physical therapy and restriction of vigorous exercise
Surgery is indicated if there is more than 50% damage to the femoral head or if there is movement of the femoral head out of the acetabulum
Who is the typical patient with a slipped capital femoral epiphysis?
Obese adolescent boy
What are the clinical features of slipped capital femoral epiphyssis (SCFE)? How often is it bilateral?
- Patients have a painful limp with pain in the groin, hip or knee
- Internal rotation, flexion, and abdubtion are usually decreased in the affected hip
- Bilateral in 30% of cases
What is the significance of the klein line in patients with SCFE?
A line drawn flanking the superior edge of the femoral neck (Klein line) crosses 10-20% of the epiphysis in a normal hip; In SCFE, the Klein line will not cross the epiphysis at all
What is the treatment for SCFE?
Treatment involves pinning the epiphysis to prevent further slippage
What are four possible complications of SCFE?
- Avascular necrosis
- Chondrolysis (degeneration of aurticular cartilage)
- Limb length discrepancy
- Osteoarthritis
What are the most common organisms responsible for osteomyelitis?
When should salmonella be considered?
When should pseudomonas aeruginosa be considered?
S. Aureus and S. pyogenes are the most common organisms
Salmonella should be considered in patients with sickle cell anemia
Pseudomonas aeruginosa infection can occur if a child steps on a nail
Children most commonly acquire osteomylitis by _______ ________
hematogenous seeding
What are the clinical features of osteomyelitis?
- Fever and irritability
- Bone pain, erythema, swelling, and induration
- Painful limp
What is elevated in laboratory studies of osteomyelitis?
Elevated WBC count, ESR, and C-reactive protein
What imaging technique is used to detect osteomyelitis a few days after the onset of symptoms?
When is a plain radiograph used?
Bone scan or MRI detects osteomyelitis a few days after the onset of symptoms
Plain radiograph begins to reveal elevation of the periosteum suggesting osteomylitis, after 10-14 days
How long should antibiotics be used for osteomyelitis?
When should IV antibiotics be switched to oral antibiotics during management?
Antibiotics should be given for 6 weeks
Decreasing ESR indicates a response to IV antibiotics at which time oral antibiotics usually can be use to complete the antibiotic course
What can cause chronic osteomyelitis?
A nidus of residual infection, such as a sequestrum (focus of necrotic bone) or an involucrum (formation of new bone or fibrosis surrounding the necrotic, infected bone)
What is metatarsus adductus?
Medial curvature of the mid-foot (metatarsals)
Metatarsus adductus occurs in children younger than ___
1 year of age
What causes metatarsus adductus?
Intrauterine constraint
What are the clinical features of metatarsus adductus?
When should clubfoot be considered?
Clinical features include a C-shaped foot that can be straightened to varying degrees by gentle manipulation
If the ankle cannot dorsiflex, clubfoot should be considered
What is the management for metatarsus adductus where….
- Flexible foot that can overcorrect with passive motion:
- Flexible foot that can correct with passive motion, but not overcorrect:
- Stiff foot that cannot be straightened:
- Flexible foot that can overcorrect with passive motion: observation only
- Flexible foot that can correct with passive motion, but not overcorrect: exercises to stretch the foot
- Stiff foot that cannot be straightened: Evaluation by pediatric orthopedic specialist; casting may be necessary
What is talipes equinovarus?
Clubfoot; fixed foot in inversion with no flexibility
What other disorders are associated with talipes equinovarus?
DDH, myelomeningocele, myotonic dystrophy, some skeletal dysplasias
How is talipes equinovarus managed?
Treatment involves casting within the first week of life
What is the most common cause of in-toeing in children younger than 2 years of age?
Internal tibial torsion
In Internal tibial torsion, the patella faces _______ and the foot points ______ when the knee is flexed to 90º
forward; medially
Management of internal tibial torsion is…
observation only
What is the most common cause of in-toeing in children older than 2 years of age?
Femoral anteversion
In Femoral anteversion, feet point ______ and patella points _______
both point medially
Children with Femoral anteversion sit in a ____ position
“W” (opposite of sitting cross legged on the floor)
Managment of Femoral anteversion is….
observation
What is the major cause of out-toeing?
Calcaneovalgus foot - which is a flexible foot held in a lateral position
Clinical features of cacaneovalgus foot are a flexible foot with toes pointed ______; plantar ______ is restricted
Outward; flexion
Management of a calcaneovalgus foot includes….
stretching the foot (rarely casting may be needed)
Bowed legs (genu varum) are a normal variation until ___ years of age
2
What is the “cowboy” stance associated with genu varum?
When child stands erect with the feet together, the knees bow laterally and the patella point forward
When is a standing AP radiograph indicated with genu varum?
Indicated only if bowing is unilateral, is severe, or persists after 2 years of age to assess for pathologic bowing
What is Blount’s disease?
What causes it?
A progressive angulation of the proximal tibia
It is thought to be a result of overload injury to the medial tibial growth plate
When is Blount’s disease suspected?
In any child with progressive bowing, unilateral bowing, or persistent bowing after 2 years of age
A metaphyseal-diaphyseal (M-D) angle > __º is consistent with Blount’s disease
11º
What is the management for Blount’s disease and when is it indicated?
Bracing for 1 year if the M-D angle is greater than 16º or if the patient is 2-3 years of age
Surgical osteotomy if there is no improvement with bracing, if the patient is older than 4 years of age, if there is recurrence or angulation
When is recurrence of blount’s disease common?
Common in obese children if treatment is started after 4 years of age or if the epiphysis is fragmented from injury
What are the clinical features of knock-knees (genu valgum)?
- Separation of the ankles when standing erect with knees together
- Swinging legs laterally with walking or running
Surgery is indicated only if genu valgum persists beyond ___ years of age or causes ______ pain
10 years of age; knee pain
What is Osgood-Schlatter disease?
Inflammation or microfacture of the tibial tuberosity caused by overuse injury
Age of onset of Osgood-Schlatter disease is commonly _ -_ years
10-17 years
What are the clinical features of Osgood-Schlatter disease?
Swelling of the tibial tuberosity
Tenderness over the tibial tubercle
Management of Osgood-Schlatter disease includes…
Rest, stretching of the quadriceps and hamstrings, and analgesics
Patellofemoral syndrome is common in ______ _____
adolescent girls
What are the clincal features of patellofemoral syndrome?
- Knee pain directly under or around patella
- Pain is worse with activity or with walking up and down stairs; relieved with rest
- Physical examination of the knee may show the patella in a lateral position
What is the management of patellofemoral syndrome?
Includes stretch, stretching, and strengthening of the medial quadriceps
What are growin pains?
Idiopathic bilateral leg pains that occur in the late afternoon or evening but do not interfere with play during the day
Treatment of growing pains is…
analgesics and reassurance
What is the difference between an open fracture and a closed fracture?
In a closed fracture, the skin is intact; In an open fracture, the skin is broken and antibiotics are required because of the risks of infection
What terms are used to describe the spatial relationship of the fractured ends of a broken bone?
- Nondisplaced or nonangulated (well approximated)
- Displaced (Fractured ends that are shifted)
Angulated (Fractured ends that form an agnle) - Overriding (fracture whose ends override without cortical contact)
What is compression fracture? Where does it usually occur and how is it treated?
Occurs if the soft bony cortex buckles under compressive force; Commonly occurs in the metaphysis; Requires only splinting for 3-4 weeks
What is an incomplete fracture?
Occurs if only one side of the cortex is fractured with the other side intact
What are the four types of complete fractures?
- Transverse: horizontal across the bone
- Oblique: Diagnoal fracture across the bone
- Spiral: Oblique fracture encircling the bone (may be associated with child abuse)
- Comminuted: Fracture that is composed of multiple fracture fragments
What are different locations where fractures can occur in the bone?
- Epihyseal: end of the bone
- Metaphyseal: Ends of the central shaft
- Diaphyseal: Central shaft of the bone
- Physeal: Involves the growth plate
What grade Salter-Harris fracture may affect subsequent bone growth
Some grade 2-3 fractures and all grade 4-5 fractures
What are the clinical features of a clavicular fracture?
- Infants may be asymptomatic or may present with asymmetric moro reflex or pseudoparalysis
- Crepitus felt over the fracture
- Children typically hold the affected limb with the opposite hand
What is the treatment for a clavicular fracture?
Treatment includes placement in a sling for 4-6 weeks to assist immobilization of the limb; A firgure of eight bandage can be used to draw the shoulder back but is combersome
What causes supracondylar fracture
Occurs when a child falls onto an outstretched arm or elbow
When is a supracondylar fracture an emergency?
Orthopedic emergency if the fracture is displaced and angulated because of the risk of neurovascular injury and comparment syndrome
What are some clinical features of supracondylar fractures?
Point tenderness, swelling, and deformity of the elbow may be seen
Pain with passive extension of the fingers after a supracondylar fracture is suggestive of ________ ______
comparment syndrome
What sign on AP and lateral radiographs may be observed if a supracondylar fracture is present?
Posterior fat pad sign: a triangular fat pad shadow posterior to the humerus
Compartment syndrome occurs when the pressure within the anterior fascial comparment is greater than __-__ mm Hg
30-45 mmHg
What are the 5 Ps of compartment syndrome (late signs)
- Pallor
- Pulselessness
- Paralysis
- Pain
- Paresthesias
What is cubitus varus (associated with supracondylar fracture)?
Decreased or absent carrying angle as a result of poor positioning of the distal fragment
What are the three common types of forearm fractures?
- Colles fracture: distal radius
- Monteggia fracture: Proximal ulna with dislocation of the radial head
- Galeazzi fracture: Radius with distal radioulnar joint
Forearm fractures heal within __ - __ weeks
6-8
Why must radiographs of femur fractures include the joint above and below the area of injury?
Femur fractures require a great deal of mechanical force
What is the management of femur fractures?
Treatment includes casting for 8 weeks
Some femur fractures require traction for callus formation before casting
What is a toddler’s fracture?
A spiral fracture of the tibia (fibula remains intact)
Toddler’s fractures usually occur between __ and __ of age
9 months and 3 years
What are the clinical features of a toddler’s fracture?
How long is casting done?
Child refuses to bear weight but is willing to crawl; erythema, swelling, and mild point tenderness may be found over the distal tibia on examination
Long leg cast for 3-4 weeks
What types of fractures should make the clinician suspect abuse?
- Metaphyseal fractures
- Posterior or first rib fractures
- Multiple fractures at various ages of healing
- Complex skull fractures
- Scapular, sternal, and vertebral spinous process fractures
