Orthopedics Flashcards
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
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 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
What is the most common cause of back pain in children?
Back strain - muscular soreness from overuse or bad body mechanics
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 is transient synovitis?
A common self-limited postinfectious response of the hip joint
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
There is an initial ischemic episode of unknown etiology that interrupts vascular circulation to the capital femoral epiphysis. The articular cartilage hypertrophies, and the epiphyseal marrow becomes necrotic. The area revascularizes, and the necrotic bone is replaced by new bone. This process can take 18-24 months. There is a critical point in these dual processes when the subchondral area becomes weak enough that fractures of the epiphysis occurs. At this time the child becomes symptomatic. With fracturing, further reabsorption and replacement by fibrous bone occurs, and the shape of the femoral head is altered. Articulation of the head in the hip joint is interrupted. The bone reossifies with or without treatment, but without treatment the femoral head flattens and enlarges, causing joint deformity. These children need prompt referral to an orthopedist.
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?
general S&S
Pain may be referred to the knee and to the groin
insidious onset of a limp with knee pain, activity related and resolves with rest
- pain less acute and severe than transient synovitis or septic arthritis.
- afebrial
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
- follow disease progression and response to treatment.
Increased density in the affected femoral head or a subchondral fracture in the femoral head, termed the “crescent sign”
However, there may be no radiographic findings early in Legg-Calvé-Perthes disease. MRIs and bone scans are helpful in recognizing early disease but are of limited value for following disease progression.
What is the management for Legg-Calve-Perthes disease? When is surgery indicated?
Physical therapy and restriction of vigorous exercise
observation ONLY:
1- full ROM
2- less than 6 yrs
3- involvement in less than 1/2 of femoral head
Surgery/referal–> 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, child older an 6 yrs
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
- some have acute, severe pain and a inability to walk to move hip
- cant flex hip as femur abducts/ rotates externally
- Internal rotation, flexion, and abdubtion are usually decreased in the affected hip
- Bilateral in 30% of cases
What is the treatment for SCFE?
How do diagnose?
- immediate referal to ortho
- no ambulation allowed!
Treatment involves pinning the epiphysis to prevent further slippage
Dx: radiograph confirms; lab only to r/o infection
What are four possible complications of SCFE?
- Avascular necrosis
- Chondrolysis (degeneration of aurticular cartilage)
- Limb length discrepancy
- Osteoarthritis
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
What is metatarsus adductus?
Medial curvature of the mid-foot (metatarsals)
Metatarsus adductus occurs in children younger than ___
1 year of age
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
How is talipes equinovarus managed?
Treatment involves casting within the first week of life
In Femoral anteversion, feet point ______ and patella points _______
both point medially
Bowed legs (genu varum) are a normal variation until ___ years of age
2
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 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
referal is indicated only if genu valgum persists beyond ___ years of age or causes ______ pain
7 years of age; knee pain, or unilateral involvement
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, peak 10-14 yrs, associated with rapid growth spurt
What are the clinical features of Osgood-Schlatter disease?
Swelling of the tibial tuberosity
Point tenderness over tibial tubercle
Prominence/ enlargement compared to unaffected side
Unilateral, but may be bilateral (50%)
Tenderness over the tibial tubercle
Management of Osgood-Schlatter disease includes…
Rest, stretching of the quadriceps and hamstrings, and analgesics
Self-limiting, Rest with limited activity to control pain
Complete activity restriction not recommended
NSAIDS prn
- Ice prn
- Isometric exercise program
- Knee immobilizer may provide relief
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 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
What are the 5 Ps of compartment syndrome (late signs)
- Pallor
- Pulselessness
- Paralysis
- Pain
- Paresthesias
Duchenne MD
x- linked recessive
- defective X chrom. Mother carrier- usually few sxs
1: 3500 males affected
Protein- dystrophin missing –> Dystrophin protects muscle fibers –> degeneration and weakness of muscles
Symptoms-2-3 years of age (3-5 peak diagnosis)& Progresses rapidly
Weakness begins in truncal area –>LE –>UE
Difficulty running, walking up steps
+ gowers sign ( way of standing)
Dx for Duchennes MD
creatine kinase, EMG, ECG
muscle biopsy = diagnostic
