orthopedics Flashcards
what causes buckle fracture, treatment
FOOSH
cast if symptomatic
what are greenstick fractures
incomplete fractures of long bones
typically children <10 yo
what is the salter Harris clasification
SALTR
type I
slipped
5-7%
fracture plane passes all the way through the growth plate, not involving bone
cannot occur if the growth plate is fused
good prognosis
type II above ~75% (by far the most common) fracture passes across most of the growth plate and up through the metaphysis good prognosis
type III
lower
7-10%
fracture plane passes some distance along with the growth plate and down through the epiphysis
poorer prognosis as the proliferative and reserve zones are interrupted
type IV
through or transverse or together
intra-articular
10%
fracture plane passes directly through the metaphysis, growth plate and down through the epiphysis
poor prognosis as the proliferative and reserve zones are interrupted
type V ruined or rammed uncommon <1% crushing type injury does not displace the growth plate but damages it by direct compression worst prognosis
Ossification centres about the elbow
ossification centers always appear in a specific sequence Capetellum- 1 Radius- 3 Internal (medial) epicondyle- 5 Trochlea- 7 Olecranon- 9 External (latreral) Epicondyle- 11
what is monteggia fracture
fracture of proximal 1/3 of ulna and radial head dislocation
A corner fracture is pathognomonic of what?
child abuse
what is the treatment for sever’s disease?
achilles stretching activity modifications and symptomatic treatment
nelsons: relative rest, ice, massage, stretching and strengthening the achilles tendon
symptoms frequently improve in 4- 8 weeks
name 3 overuse syndromes
osgood schlauer disease
sinding-larsen Johansson
sever’s disease
tx: symptomatic with NSAIDs, rest and and activity modification, physiotherapy
what is considered to be the threshold for scoliosis
10 degree curve is considered to be the threshold for scoliosis
congenital scoliosis is associated with what?
VACTERL
what are some red flags for scoliosis
history: pain gait changes weakness rapid progression bowel/bladder
physical: foot deformity hypnotic thoracic spine abnormal reflexes abnormal pattern signs of dysraphism (Myelomeningocele: Can cause incontinence, hydrocephalus, tethered cord, sensory loss, orthopedics deformities, leg weakness and/or or paralysis.)
what are some risk factors for progression for adolescent idiopathic scoliosis? (4)
larger curve (>30) thoracic curve (> lumbar) double primary curve physiologic age (based on menarche Risser grade)
curve <20
>20
risk of progressing?
<20- low risk of progressing
>20- higher risk of progressing therefore should refer to ortho
what degree for surgery for scoliosis? bracing?
surgery >40
bracing >25
who should you refer with scoliosis? (5)
atypical curve (left sided) skeletally immature, curve >/= 20 at presentation skeletally immature, progressive curve rapid progression/pain skeletally mature, curve >45
Clubfeet- CAVE
C- cavus
A- adductus
V- varus
E- equinus
what is the treatment for club feet
ponseti method
what type of intoning do we see for
infants
toddlers
child/adolescent
infants- metatarsus adductus
toddlers- internal tibial torsion
child/adolescent- increased femoral anteversion (internal hip rotation)
what is the treatment for intoeing
typically improves with growth and development
no evidence of significant long term effects
no imaging required
takes years to improve
would not operate until done growing (>12 anyways)
what are some warning signs of genu valgum
progressive deformity asymmetry persistence beyond expected age short stature beyond 2 standard deviations
what are some urgent causes of limp? (6)
septic arthritis hip SCFE osteomyelitis discitis fracture neoplasia
DDx limping child >10
Non-painful:
LLD
Painful: SCFE Juvenile arthritis overuse syndromes osteo/septic arthritis tumors discoid meniscus osteochondritis dissecans
osteochondritis dissecans
small segment of bone begins to separate from its surrounding region due to a lack of blood supply.
DDx limp 4-10
Non-painful DDH congenital limb deficiencies neuromuscular conditions LLD discoid meniscus
Painful septic arthritis Perthes transient synovitis osteomyelitis disci tis trauma tumors overuse apophysitis osteochondritis dissecans
Ddx limp <4
Non-painful
DDH
congenital limb deficiencies
neuromuscular conditions
Painful: toddlers fracture osteomyelitis septic arthritis transient synovitis reactive arthritis juvenile arthritis tumors trauma
what is the most common bug to cause pediatric septic arthritis?
staph aureus
what is the treatment for septic arthritis?
aspiration of the joint
what imaging should you do for SCFE
xray AP and frog leg pelvis
Ottawa ankle rules
An ankle X-Ray series is only required if there is any pain in the malleolar zone and…
Bone tenderness at the posterior edge or tip of the lateral malleolus (A)
OR
Bone tenderness at the posterior edge or tip of the medial malleolus (B)
OR
An inability to bear weight both immediately and in the emergency department for four steps
foot x ray rules
A foot X-Ray series is only required if there is any pain the midfoot zone and…
Bone tenderness at the base of the fifth metatarsal (C)
OR
Bone tenderness at the navicular (D)
OR
And inability to bear weight both immediately and in the emergency department for four steps
Risk factors for DDH (4)
Risk Factors: • First Born • Female • Family history • Frank breech
where does sever’s disease occur
at the insertion of the Achilles tendon into the calcaneus
- present with pain with squeezing the heel (positive squeeze test)
where do we see osteosarcoma
metaphysis of long bones
what 2 conditions predispose you to osteosarcoma
hereditary retinoblastoma
Li-Fraumeni syndrome
what is the classic X-ray finding for osteosarcoma? tx?
sunburst appearance
chemo, surgery
where do we see Ewings sarcoma? what is the classic xray finding
diaphysis of long bones, axial skeleton
onion skinning appearance
tx: chemo, surgery +/- radiation
what is spondylolysis
common cause of back pain in athletes
stress fracture of the pars interarticularis
most likely at L4/L5
acute hyperextension causes an acute fracture
what is spondylolethesis
with spondylolysis you get displacement of one vertebrae over another
what is the treatment for SCFE
admit to hospital
bed rest
percutaneous pinning
partial weight bearing with crutches for 4-6 weeks after surgery
2 complications of SCFE
avascular necrosis
chondrolysis (destruction of articular cartilage)
what are some risk factors for SCFE (5)
obese male African American history of radiation therapy endocrinopathies (GH and hypothyroid)
what is the natural history of untreated DDH
• Dysplasia: Inadequate development of femoral
head and/or acetabulum or both
– Maybe associated with degenerative arthritis
• Subluxation
– Associated with degenerative arthritis
• Dislocation – Early degenerative arthritis – Limb length inequality – Scoliosis – Ipsilateral knee pain – Gait abnormality – Low back pain
What are some complications of missed DDH (5)
Clinically disabling degenerative arthritis Limb length inequality (if unilateral) Scoliosis Ipsilateral knee deformity and pain gait abnormality
what are two treatment options for DDH
Pavlik (for 6 weeks)
closed reduction and spica cast(if older than 6 months of failed pavlik)
- A 14-year-old girl with spina bifida at the T12 level presents with a one-day history of a swollen leg and foot with erythema over the anterior tibia. Temp 37.8. WBC 16. ESR 22. Most likely:
a) fracture
b) cellulitis
c) osteomyelitis
d) deep venous thrombosis
e) erythema nodosum?
Fractures in children with myelomeningocele can present with marked swelling and redness, and may be mistaken for osteomyelitis. Physeal fractures in children with myelomeningocele can compromise bone growth.
A patient has a scoliosis Cobb angle of 50 degrees. What is the treatment ?
Spinal fusion
Repeat x-ray
Orthotic brace
spinal fushion
what is the kocher criteria? (4)
- fever >38.5
- wbc >12 000
- ESR >40, CRP >20
- unable to weight bear
In children suspected of having an anterior shoulder dislocation, which nerves should you check are intact?
Axillary nerve: deltoid contraction and sensory patch over deltoid
Musculocutaneous nerve: biceps contraction and sensory patch on lateral forearm
What are the indications for open reduction?
NO CAST
N - non-union O - open fracture C - compromise of neurovasculature A - intra-articular fracture S - Salter Harris type 3, 4, 5 T - polytrauma
In anterior shoulder dislocation, what tests can you perform to confirm the diagnosis?
- Apprehension test: abduct and externally rotate the arm and should see apprehension in the patient’s face since it re-creates a feeling of anterior dislocation
- Relocation test: posteriorly direct a force during the apprehension test to relieve apprehension
What are two conditions to rule out in a child with fever and limb pain?
- osteomyelitis
2. septic arthritis
Top common causes of septic arthritis? (3)
In neonates?
In sickle cell?
In teenagers?
- Staph aureus
- Strep pneumonia
- Non Group A strep
- Kingella Kingae
In neonates: GBS and gram negatives
Sickle cell: Salmonella
Teenagers: gonorrhea
What is the prognosis of transient synovitis?
More common in boys or girls?
typically resolves in 7-10 days
more common in boys
where is the most common site for metastasis for osteosarcoma?
the lungs
What are clinical features of osteogenesis imperfecta? (5)
-what is the diagnostic test for OI?
- Blue sclera
- Wormian sutures: extra bones in between sutures
- Cortical bone thinning
- Dentinogenesis imperfecta
- Triangular facies
- Late onset hearing loss in 50% of children
- diagnostic test: fibroblast testing or DNA testing
A patient presents to you with leg pain that occurs solely at night. What is your differential diagnosis? (3)
- Malignancy: osteosarcoma, Ewing sarcoma
- Osteoid osteoma (benign)
- Growing pains
McCune-Albright syndrome is associated with what skeletal abnormalities?
Polyostotic fibrous dysplasia
A 15-year-old with tibial pain (worse at night and relieved by nonsteroidal anti-inflammatory drugs) has a small lytic area surrounded by reactive bone formation on x-ray. What is the likely diagnosis?
Osteoid osteoma, a benign bone-forming tumor
How is metatarsus adductus treated?
passive stretching
How are clubfeet treated?
Most clubfeet respond well to serial casting using the Ponseti method.
What systemic conditions are associated with SCFE? (5)
hypothyroidism, panhypopituitarism, hypogonadism, rickets, and irradiation.
what are the three screening tests for DDH
barlow- clunk for dislocation (posterior force)
ortolani- clunk of reduction (abduction)
galeazzi- inequality in the height of the knees
what imaging do you do for DDH up to 6 months? after 6 months?
up to 6 months- ultrasound
after 6 months- x ray
when should you do an ultrasound for DDH
at 3-4 weeks of age
what are 4 consequences of inadequate treatment of septic hip?
- septic hip dislocation
- AVN
- arthritis
- growth arrest
at what age do we see perthes disease
4-12 yo
where do patients with SCFE feel their pain?
medial thigh or knee (referred pain from the hip)
Differential for painful knee (4)
Discoid Meniscus Osteochondritis Dissecans (Lateral portion of medial femoral condyle) Patellofemoral (Anterior) knee pain Osgood Schlatter’s Disease
calcaneovalgus foot deformity is sometimes associated with what? does it need treatment?
Sometimes associated with posteromedial bowing of tibia
due to a packaging problem resolves spontaneously
what is the cause of flexible flat feet? do they need orthotics?
due to ligamentous laxity
arch reconstitutes with standing on tiptoes
do not need orthotics or treatment
what causes rigid flat feet
tarsal coalition
need casting x 6 weeks then surgery
Valgum
gum makes your knees stick together
knock knees
Varum
rum makes your knees spread apart
Adolescent girl with scoliosis has undergone spinal surgery. She present with bilious vomiting for the last few days. What is the etiology?
a. bowel adhesions
b. superior mesenteric artery syndrome
c. malrotation with volvulus
d. Pancreatitis
superior mesenteric artery syndrome
In younger patients, superior mesenteric artery syndrome is most commonly described following corrective spinal surgery for scoliosis.
what are 4 causes of toe walking
- CP
- muscular dystrophy
- short achilles tendon
- Autism
