ORTHOPEDICS Flashcards

Question

What is the mortise? On a mortise view, what suggests mortise instability?

Answer 1

Joint between distal tibia and talus On a mortise view: entire joint space should be 3-4 mm at all aspects and the joint space should not differ by more than 2 mm at any area within the mortise

Answer 2

Talar tilt test: only positive if both anterior talofibular ligament and calcaneofibular ligament are ruptured -stablize the distal tibia and fibular with one hand and with other hand, attempt inversion and check for laxity compared with the other side

Answer 3

Remember that in prepubertal chidlren, fractures are way more common than sprains! -SALTER HARRIS TYPE I fracture (only if they have a growth plate still!)--\> immobilize and ortho to see Exam: -Ankle sprain: tends to be more tender at the distal and posterior fibula where the ligaments attach to the talus -apply medial force to the ankle (will hurt laterally if there is a fracture)

Answer 4

A bone injury that results in more than 2 bone fragments

Answer 5

Distal fibular physis: fuses at 20 years old but takes several years to strengthen Distal tibial physis: fuses at 18 years old

Answer 6

1. Anterior fat pad (can be normal) 2. Posterior fat pad (always abnormal if present) 3. Radiocapitellar line 4. Anterior humeral line

Answer 7

Dislocation of radial head (subluxation)

Answer 8

1. Xray 2. BW: CBC, ESR, CRP 3. Ultrasound

Answer 9

Splint or brace and see family dr/ortho in 2 weeks -for all kids who have tenderness at the growth plate and a N xray, must classify as SH-1

Answer 10

Tibia/fibula joint with navicular/calcaneus

Answer 11

Acute onset knee pain Feeling a "pop" when landing from a jump Knee swelling after injury Most do not have tenderness on examination

Answer 12

Most result from noncontact injury mechanism such as a pivot or twisting motion or landing from a jump

Answer 13

Salter Harris I fracture: sufficient indication for splinting even without radiographic evidence of fracture. -"sprains" are relatively rare in children and are treated as SH type I until f/u assessment in 1 week by ortho.

Answer 14

1. Injured limb should be elevated and iced x 48 hrs 2. Splint should be kept dry 3. RTMD if increased pain or decreased sensation 4. F/U with ortho

Answer 15

Fracture of distal radius with dorsal displacement

Answer 16

Metacarpal and/or proximal phalangeal fractures -ulnar gutter: immobilizes ulna to the 4th and 5th digits -radial gutter: immobilizes radius to the 2nd and 3rd digits with a hole cut for the thumb

Answer 17

1. 1st metacarpal bone fracture 2. Proximal phalynx fracture of thumb 3. Scaphoid fracture

Answer 18

Fracture of distal tibia (usually undisplaced and spiral pattern due to rotation)

Answer 19

1. Stable forearm and wrist fractures 2. Humerus injuries

Answer 20

Elbow injuries

Answer 21

1. Distal tibia and fibula fractures 2. Ankle fractures/sprains 3. Foot fractures \*\*Can add an ankle stirrup for additional support/immobilization to prevent inversion/eversion

Answer 22

Fracture in the proximal diaphysis of the 5th metatarsal (very uncommon in children)

Answer 23

1. Avulsion fractures of the base of the 5th metatarsal (common in peds) 2. Shaft fracture (common in peds) 3. Jones fracture: fracture of the proximal diaphysis of the 5th metatarsal (rare in peds) Treatment: short-leg splint +/- closed reduction if displaced

Answer 24

1. Femoral anteversion 2. Metatarsus adductus 3. Internal tibial torsion

Answer 25

Increased anteversion of the femoral neck relative to the femur with compensatory internal rotation of the femur -age group: 3-6 yo -F:M 2:1 -natural course: most spontaneously resolve by age 10 -potential complications: NONE! This is a benign condition with no increased risk of arthritis/back issues/etc -treatment: observation and parental reassurance (most resolve spontaneously by age 10) -NO BENEFIT with braces/inserts/PT/sitting restrictions -operative treatment (derotational femoral osteotomy) may be considered if

Answer 26

History: -parents complain of intoeing gait in early childhood -child classically sits in W position -awkward running style, sometimes trips and falls Physical exam: -place child prone and flex knees. Then check internal rotation by rotating hips outwards and check the angle relative to the thigh -will see increased internal rotation of \> 70 degrees (normal = 20-60) -then check external rotation by rotating hips inwards to make an X and check the angle relative to the thigh -will see decreased external rotation of \< 20 degrees (normal 30-60)

Answer 27

1. R/O metatarsus adductus: have pt lie prone and straighten out feet. Look for adducted forefoot deformity, a curved lateral border, medial soft-tissue crease -overall: HEEL-BISECTOR ANGLE 2. R/O tibial torsion: have pt lie prone and look at thigh-foot angle. clock position normally; if they are not, this is tibial torsion -look at foot progression angle as they walk (normal for feet to be turned outward slightly) -overall: FOOT PROGRESSION ANGLE, TRANSMALLEOLAR AXIS, THIGH-FOOT AXIS 3. R/O femoral anteversion -Internal and external hip rotation

Answer 28

Internal tibial torsion -internal rotation of the tibia at the knee joint -age group: 1-3 yo (toddlers) -can be associated with DDH (15-20% of cases) -prognosis: resolves by age 6 usually

Answer 29

1. Pain 2. Limb length discrepancy 3. Progressive defmority 4. Family history positive for rickets/skeletal dysplasias/mucopolysaccharidoses

Answer 30

Treatment: observation and parental education -usually spontaneously resolve by age 6 -braces/PT does not change natural history of condition -operate only if child \> 6 yo with \> 10 degrees of internal rotation or severe cases with functional problems

Answer 31

Adduction of forefoot at tarsometatarsal joint with normal hindfoot alignment (thought to be due to intrauterine positioning)

Answer 32

1. Late pregnancy 2. First pregnancy 3. Twin pregnancy 4. Oligohydramnios \*\*\*Think of conditions that will cause squishing of baby Prognosis: no complications! Most resolves spontaneously in 90% of children by 4 yo Treatment: -if flexible deformity that can ACTIVELY be corrected to midline (tickle the foot to see if the child corrects themselves) = no treatment -if flexible deformity that can be PASSIVELY corrected to midline = serial stretching by parent -if rigid deformity with a medial crease = serial casting with the lateral border of foot -if resistant metatarsus adductus that persists \> 5 yo with severe deformity = surgery

Answer 33

Branch of median nerve -flexors of fingers and thumbs -pronator quadratus \*\*On exam: check AIN by asking patient to make "A-OK" sign (flexion of interphalangeal joint of thumb and distal interphalangeal joint of index finger)

Answer 34

Type I: nondisplaced Type II: displaced with posterior cortex intact Type III: Completely displaced

Answer 35

-Type I: posterior backslab splint to allow for swelling, then long arm casting at 90 degrees or less x 3 weeks -Type II: same as treatment for Type I only if anterior humeral line intersects capitellum and minimal swelling. If not, need to have closed reduction and pinning in OR -Type III: closed reduction and pinning in OR \*\*\*majority of supracondylar fractures are treated with closed reduction and pinning

Answer 36

Displacement of anterior humeral line = normally, anterior humeral line should intersect the middle third of the capitellum -in supracondylar fractures, capitellum moves posteriorly

Answer 37

Extension type supracondylar fracture: anterior interosseous nerve -flexion type supracondylar fracture: ulnar nerve

Answer 38

Displaced fractures of both the elbow (ie supracondylar fracture) and the wrist so that the elbow is not stabilized by anything! -treatment: prompt closed reduction and pinning in OR -never cast elbow injuries right away since they swell ALOT and have increased risk of compartment syndrome

Answer 39

Supracondylar fractures (ie. elbow fractures) = high risk of compartment syndrome due to increased swelling

Answer 40

On xray: -extension type: will see the anterior humeral line IN FRONT of the capitellum (capitellum will be posterior to the humerus) -flexion type: will see the anterior humeral line BEHIND the capitellum (capitellum will be anterior to the humerus)

Answer 41

Ulnar nerve

Answer 42

Gunstock deformity = cubitus varus = the extended forearm is deviated medially -caused by malunion due to failure of reduction -see this in kids who got reduced and casted instead of closed reduction/pinning in displaced supracondylar fractures -does not affect ROM/growth or cause pain but there are cosmetic concerns

Answer 43

Closed reduction and immobilization -most forearm fractures can be treated without surgery -short-arm cast if distal forearm fractures -long arm cast if mid-shaft or proximal forearm fractures -need weekly xrays for first 3-4 weeks following reduction -casting x 6-12 wks total -indications for open reduction: 1. children \< 10 yo: angulation \> 15 degrees, rotation \> 45 degrees post closed reduction 2. Children \> 10 yo: angulation \>10 degrees, rotation \> 30 degrees post closed reduction 3. Both bone forearm fractures in children \> 13

Answer 44

Increased risk of cubitus valgus (gunstock deformity)

Answer 45

1. Osteoblastoma (benign) 2. Infection

Answer 46

If you push in the anatomical snuff box, people will always complain of pain even if there is no fracture. SO push instead on the volar aspect at the base of the scaphoid to try to elicit tenderness

Answer 47

The arm needs to be in 30 degrees extension, hand in neutral position, and the splint needs to go all the way up to the armpit in order to fully stabilize the elbow (ie. not stop midway up the humerus)

Answer 48

Slipped Capital Femoral Epiphysis = failure of the physis and displacement of the femoral head relative to the neck -clinical presentation: can be acute, chronic or acute-on-chronic -acute: symptoms \< 3 weeks and usually has groin, thigh or knee pain -chronic: few month history of groin, thigh or knee pain with limp -most worrisome complication: osteonecrosis of the femoral head due to vascular injury from displacement of the femoral head (ie . avascular necrosis of femoral head) -present with knee pain due to referred pain along obturator nerve \*\*\*Most commonly seen in adolescents, obese and African-American

Answer 49

Pathophysiology of SCFE: -mechanical + endocrine factors = during puberty, physis becomes more vertical and thus, mechanical forces needed to shear the femoral head is less. Also, physis becomes more elongated and widened with increased circulating hormones, thus making it weaker 1. Obesity: affects mechanical load on the physis and level of circulating hormones 2. Hypothyroidism 3. Hypopituitarism 4. Renal osteodystrophy: decreased vitamin D and calcium thus weaker physis 5. Growth hormone therapy

Answer 50

Flexed, abducted, externally rotated hip with limp or refusal to weight bear -diagnosis: AP and frog leg views of both hips is the only imaging study needed to make the diagnosis -50% of patients have contralateral slip too so look at both hips! -on XRAY: 1. Widening and irregularity of physis 2. Klein line abnormality = draw a line from the superior femoral neck on the AP radiograph and the line should intersect the femoral head. If it doesn't, then this is diagnostic

Answer 51

Admit to hospital immediately and place on bed rest with no weight bearing!!!! -Ortho consult asap for pinning with one screw with partial weight bearing x 4-6 wks

Answer 52

1. Admit to hospital immediately and place on bed rest 2. Need to send screening labs to rule out underlying endocrinopathy (ie. hypothyroidism, hypopituitarism, vitamin D or calcium deficiency) because this is ATYPICAL for a child who is thin and not a teenager

Answer 53

1. Assymetrical level of pelvis = put thumbs on ASIS and compare 2. Leg length discrepancy 3. Adam's forward bend test: asymmetrical ribcage 4. Shoulder asymmetry 5. Abdominal reflex = tells you if there is a spinal abnormality

Answer 54

Clinical criteria for clubfeet: 1. Extreme plantarflexion (equino) 2. Medial angulation of hindfoot (varus) 3. Adduction and supination of forefoot (metatarsus adductus)

Answer 55

Thoracic curve = normally points right Thoracolumbar curve = normally points left \*\*\*Important because if you have a spine that points to the left, should order an MRI because more likely to be associated with neurological issues

Answer 56

Peroneal brevis tendonitis

Answer 57

Aircast x 4-6 weeks with gradual return to activities

Answer 58

10-15 yo -more common in boys -pathophysiology: repetitive injury with point tenderness at tibial tubercle, worse with activity. Thought to be caused by tight quads pulling on tibial tubercle -treatment: 1. Rest and activity modification x 2-3 months 2. Restriction of activities 3. Knee immobilizer (protective gear, NOT cast) 4. Ice 5. Physio with quadriceps strengthening and loosening exercises -resolution time: 12-24 months -complication: patellar tendon rupture

Answer 59

1. Bone malignancy: Ewing, osteosarcoma 2. Osteoid osteoma

Answer 60

1. Increased BMI 2. Laxity of ligaments 3. Wearing shoes too early Rigid flat feet: 1. Tarsal coalition 2. Inflammatory arthritis 3. Congenital vertical talus 4. Neuromuscular cause (CP)

Answer 61

-Bone scan: good for ribs, bad for skull and metaphyses (because they light up anyway due to area of growth), bad for acute fractures since there has not been enough time for increased bone intake -skeletal survey: bad for ribs, bad for metaphyses, good for everything else

Answer 62

1. Tight heel cord (isolated congenital shortening of the achilles tendon) 2. Idiopathic (variation of normal development) 3. Hereditary or acquired polyneuropathy 4. Behavioural (autism) 5. Intraspinal tumor 6. Spinal dysraphism 7. Spastic CP 8. Talipes equinovarus (clubfoot)

Answer 63

1. Pain and refusal to weight bear 2. Active movement usually worse than passive = usually will let you move their hip and can still get full ROM

Answer 64

1. History of fever 2. History of non weight bearing 3. ESR \> 40 4. WBC \> 12 \*\*\*If you don't have ANY of these, then your risk of having septic arthritis is \<0.2%. If you have all 4, then your risk is 99.6%.

Answer 65

1. Subluxation: head not centered in joint 2. Dislocation: head not located in joint 3. Hip dislocatable: head can be pushed out of joint 4. Hip dysplastic: steep acetabulum but head within joint

Answer 66

1. First born 2. Female 3. Foot first (breech) 4. Family history 1. Barlows: dislocate a reduced hip 2. Ortolani: reduce a dislocated hip 3. Galleazi: hips and knees flexed at 90 degrees and see different knee heights (can be falsely negative if both hips are dislocated) -these become reliable when baby \> 3 mo = then must rely on leg length discrepancy, extra groin fold, delayed running, limp, tredelenburg gait (painless limp)

Answer 67

Most spontaneously resolve within 4 wks

Answer 68

Positive barlow: high chance of sponanteous resolution = repeat exam at 4 wks and ultrasound if still positive. If not improved, then TREAT with Pavlik Harness Positive ortolani: this means the hip is already dislocated and you don't know how long it's been dislocated for so you need to treat asap with pavlik harness and then follow treatment with US If baby is high risk with equivocal exam: ultrasound right away If baby is not high risk with equivocal exam: repeat exam in 3 wks and ultrasound then if still equivocal or positive findings

Answer 69

For babies \< 6 mo: Pavlik Harness x 3 mo For babies \> 6 mo: closed reduction and casting babies (hip spica x 3 mo) because when they are this old, they can overcome the Pavlik Harness since they're stronger

Answer 70

Bowlegs: 1. Physiological bowing (99% of cases) 2. Pathological Tibia varum (Blounts disease) 3. Skeletal Dysplasia 4. Rickets Physiological bowing usually present at age 12-18 mo -natural history: gradual normalization by 2 years of age!!! -if still present OR worsening by 2 yo, need full length weight bearing xrays to rule out pathological causes

Answer 71

Knocked knees: 1. Physiologic valgus 2. Apparent valgus (seen in overweight teenagers because of thigh girth) 3. Rickets 4. Post trauma valgus overgrowth 5. Skeletal dysplasias

Answer 72

1. Infantile (\<10 yo) 3. Adolescent

Answer 73

1. Menarchal status??? Tells you how much more pubertal growth potential they have which tells you how much progression can be expected with the scoliosis 2. Painful?? = painful curve usually indicates other causes (intraspinal tumor) 3. Neurological symptoms? 4. Family history?

Answer 74

1. Neurological abnormalities 2. Rapid progression with severe deformity (ie. over 6-12 mo) 3. Left sided curve 4. Early onset age \< 10 5. Significant pain

Answer 75

This really all depends on the sexual maturity rating of the child (ie. what is their Risser score and have they reached menarche?) -ie. how much skeletal growth do they have remaining at presentation? -if growth spurt hasn't started yet, then the scoliosis can worsen 1-2 degrees/month during puberty Overall: 40: consider surgery IF risk for further progression

Answer 76

Baby \< 6 mo: ultrasound (since femoral heads have not ossified yet) Baby \> 6 mo: pelvic xray

Answer 77

Metatarsus adductus (medial deviation of the forefoot)

Answer 78

- most common congenital foot deformity - medial deviation (adduction) of the forefoot while the hindfoot remains in a normal position - often bilateral; when unilateral left \> than on the right - most common cause of in-toeing gait in the infant - 3 percent of term newborns, more in girls than boys and -appears to run in families - more commonly in first-born children due to the increased - higher in twin compared with singleton births - similar in preterm and term infants - outcome for patients without intervention or with nonsurgical treatment for metatarsus adductus is excellent.

Answer 79

Talipes equinovarus

Answer 80

1. **Positional clubfoot** - intrauterine crowding or breech position. It is not a true club foot. It is a normal foot that has been held in a deformed position in utero. The positional clubfoot easily corrects to a normal position with manipulation. 2**. Congenital clubfoot** is the _most common_ type. isolated idiopathic anomaly. manipulation - includes casting and bracing (Ponseti method) 3. **Pathological:** a. _Syndromic clubfoot_-trisomy 18, chromosome 22q11 deletion syndrome b. _MSK_- arthrogryphosis, skeletal dysplasia c- _Neuromuscular_ _-Neuro: SMA, NTD_ _- Muscular; myopathy, myotonic dystrophy_

Answer 81

**Malalignment of the calcaneotalar-navicular complex.** *(predominantly a hindfoot deformity)* **_CAVE_** **Mnemonic** **_(_**cavus, adductus, varus, equinus) **Cavus**-plantarflexion of the first ray **Adductus**- adduction of the forefoot/midfoot on the hindfoot **Varus** and **Equinus -** The hindfoot is in varus and equinus.