Orthopedics

Question 1

A previously healthy 4-year-old boy has been limping on his left leg for 4 days. The parents report no fevers, The boy had an upper respiratory infection about 2 weeks ago. His white blood cell count is 8 109/L (reference range [rr], 4.5-11 109/L), erythrocyte sedimentation rate is 30 mm/h (rr, 0-20 mm/h), and his C-reactive protein level is within normal limits. Pelvic radiographs are unremarkable. What is the best next step?

1. Spica cast
2. MR image of the pelvis
3. Nonsteroidal anti-inflammatory drugs (NSAIDs) and observation
4. Irrigation and debridement of the left hip
5. Broad-spectrum antibiotics and observation

Answer 1

3. Nonsteroidal anti-inflammatory drugs (NSAIDs) and observation

Question 2

Which bacterial organism most commonly causes pediatric septic arthritis?

1. Kingella kingae (K. kingae)
2. Escherichia coli (E. coli)
3. Staphylococcus aureus (S. aureus)
4. Haemophilus influenzae (H. influenzae)
5. Borrelia burgdorferi (B. burgdorferi)

Answer 2

3. Staphylococcus aureus (S. aureus)

Question 3

A 6-year-old boy who has been refusing to bear weight on his left leg. He has no history of injury; however, he had a recent ear infection and was prescribed amoxicillin. His temperature is 38.8°C. In the emergency department, the child has pain and guarding with range of motion of his left hip. Plain radiographs of the hip are unremarkable. Laboratory studies reveal a white blood cell count of 18.5, erythrocyte sedimentation rate of 45 mm/h (reference range [rr], 0-20 mm/h), and a C-reactive protein level of 6.5 mg/L (rr, 0.08-3.1 mg/L). What is the best next step?

1. Aspiration of the left hip
2. Surgical drainage of the left hip
3. MR image to assess for myositis
4. Bone scan to assess for osteomyelitis
5. Administration of intravenous antibiotics

Answer 3

1. Aspiration of the left hip

Question 4

The pelvic and knee radiographs of an 11-year-old girl are consistent with SCFE. She has pain on the inner aspect of her right thigh. She walks with a limp and has decreased range of motion of the right hip and knee secondary to her pain. Her right knee is stable, and there is no joint line tenderness. What is the best next step?

1. 1. Obtain CBC, ESR, CRP, RF, ANA
2. 2. Rest, ice, and elevation of the right limb
3. 3. Nsaids, Physiotherapy, activity modification
4. 4. Surgery on the right hip
5. 5. Ultrasound of hip and knee

Answer 4

4. 4. Surgery on the right hip

Question 5

A radiograph shows Perthes disease in a 4-year-old girl who has minimal pain, slight restriction in range of motion and does walk with a slight limp. Appropriate treatment at this time would include:

1. 1. Surgical intervention.
2. 2. Abduction bracing.
3. 3. Laboratory investigations including TSH.
4. 4. Hyperbaric oxygen treatment.
5. 5. Restricted activity, range of motion physical therapy.

Answer 5

5. 5. Restricted activity, range of motion physical therapy.

Question 6

A 2-year-old girl has a painless limp on her left side. Her left leg is shorter than her right leg, and her left hip has less range of motion than her right hip. Treatment should consist of:

1. 1. Observation
2. 2. Hip abduction bracing
3. 3. Abdominal ultrasound
4. 4. Observation with a shoe lift as needed
5. 5. Surgical reduction of the hip.

Answer 6

5. 5. Surgical reduction of the hip.

Question 7

A 12 year old boy presents with a 6 month history of foot pain. This is especially painful when he participates in baseball. He describes the pain as dull and achy and his mother says that she has kept him out of participating and that has eased the symptoms somewhat. On physical examination, he is directly tender to palpation over his heel at insertion of the Achilles tendon. What is the next step in your management?

1. MRI of foot
2. 2. Plain X-ray of foot (AP and Lateral)
3. 3. Achilles stretching, activity modifications, and symptomatic treatment
4. 4. Short leg walking cast
5. 5. Long leg casting

Answer 7

3. 3. Achilles stretching, activity modifications, and symptomatic treatment

Question 8

A 13 year old girl is evaluated for scoliosis. She has a slightly elevated right shoulder, a moderate rib prominence of forward bend test, and normal strength and reflexes in her lower extremities. She is 2 years postmenarchal. The radiograph reveals a 30-degree right thoracic and 25-degree left lumbar scoliosis. What is the most appropriate treatment?

1. Observe, repeat spine radiographs in 6 months
2. Obtain a total spine MRI scan
3. Night time bracing
4. Surgical intervention
5. Use of a custom thoracolumbar orthosis for 23 hours per day

Answer 8

1. Observe, repeat spine radiographs in 6 months

Question 9

An anterior-posterior radiograph of a newborn baby girl with rib hump is obtained. It shows congenital scoliosis. The following organ(s) is unlikely to be concurrently affected:

1. 1. Spinal Cord
2. 2. Ovaries
3. 3. Kidney
4. 4. Heart
5. 5. Trachea and Esophagus

Answer 9

2. 2. Ovaries