Orthopedics

Question 1

What is the pneumonic for Salter Harris Fractures?

Answer 1

SALTR
S-straight across physis-type 1
Above physis involving metaphysis-type 2
Lower than physis involving epiphysis-type 3
Through both epiphysis and metaphysis-type 4
Rammed-physis crushed-type 5

Question 2

Which Salter Harris fractures warrant ortho consults?

Answer 2

type 3 and above

Question 3

How should you manage a suspected triplane ankle fracture?

Answer 3

• Get an ortho consult, as this is a combination of type 2 and 3 fractures it is technically a type 4 and warrants the consult
• Obtain a CT to determine level of angulation

Question 4

What are potential complications of a supracondylar fracture?

Answer 4

• brachial artery, median nerve, or ulnar nerve injuries

- Forearm compartment syndrome

Question 5

When ruling out a supracondylar fracture, what fat pads are concerning on x-ray?

Answer 5

posterior fat pads are never normal or a displaced anterior fat pad

Question 6

How do you diagnose a radial head subluxation/nursemaid’s elbow?

Answer 6

• Often no radiographic evidence so this is a clinical diagnosis, look for:
• arm dangling at side and unwilling to move
• pain with supination or palpation of radial head

Question 7

How should you reduce a radial head subluxation/nursemaid’s elbow?

Answer 7

-Hyperpronation at 90 degrees or supination with flexion at the elbow while applying pressure to the radial head

Question 8

What should be done for a bowing fracture?

Answer 8

• this is an occult fracture as the bone will be bowed but no actual fracture lines
• get orth to eval as they may need to break the bone to correct angulation

Question 9

How should you evaluate a suspected elbow fracture?

Answer 9

• There are 6 ossification centers of the elbow which ossify at differing ages, best thing to do is pull up a schematic
• Also consider obtaining films of the opposite elbow to eval what centers should be ossified for this patient and which shouldn’t

Question 10

What are Klein’s lines on a hip x ray?

Answer 10

• normally a line drawn on the superior margin of the femoral neck that should intersect the middle of the femoral physis
• If it doesn’t, indicates a SCFE

Question 11

Give a ddx for the limping child

Answer 11

discitis, septic hip, Osgood Schlatter, transient synovitis, avascular necrosis (Legg-Calve-Perthes), tumor, SCFE

Question 12

1) What is legg-Calve-Perthes disease?
2) How should you evaluate for it?
3) What is it’s complication?

Answer 12

1) osteonecrosis of the femoral head
2) obtain frog leg xrays
3) arthritis

Question 13

• What is Osgood Schlatter disease?
• How should it be evaluated?
• How should it be treated?

Answer 13

• Apophysitis at the insertion of the patellar tendon to the tibial tuberosity
• Clinical dx-knee pain/edema and point tenderness over the tibial tuberosity
• No need for immobilization, supportive care, if there is a hx of severe trauma have ortho see the patient to determine if pinning is needed

Question 14

What is Sever’s disease and how should it be treated?

Answer 14

• Apophysitis at the insertion of the Achilles tendon to the calcaneus
• Tx with NSAIDs and orthopedic shoe inserts

Question 15

-Differentiate between between benign and malignant bone lesions

Answer 15

• Benign bone lesions often appear on radiographic imaging as solitary, discrete lesions with sclerotic margins
• Malignant tumors often have ill-defined margins, periosteal reactions, or soft-tissue extension.

Question 16

• What is discitis?
• How does discitis present in children by age group-neonates, toddlers, older children?
• How will sxs differ by location affected?
• If you are suspicious for this entity, how should you go about evaluating for it?
• How will this be treated?

Answer 16

• Discitis = infection in the vertebral disc
• Presentation by age group:
  
  • Neonates and young infants-may present with sepsis or irritability.
  • Toddlers and young children: Back Pain, Refusal to ambulate, Limping, Need for support while standing, Pain with flexing thighs, Low-grade fever (although not common), RARELY will have neurologic symptoms or complaints
  • Older children-more systemic symptoms like fever, back pain, or ill-appearance
• Lumbar involvement is more common and can affect ambulation / gait. Cervical involvement can lead to torticollis or dysphagia.
• This is a hard diagnosis to make, delay in diagnosis is common (often 4-6mos!). Labwork may show elevation of inflammatory markers but are often not useful. Blood culture is important as 90% are pyogenic and most are caused by hematogenous spread as the pediatric spine is highly vascularized. If history is suspiscious for a specific cause (tuberculosis, cat scratch) consider serologies. Xray may show lesions but gold standard is MRI.
• Consult ortho/nsgy, this patient may need needle biopsy or surgery. Most common cause is S. aureus so providing staph coverage early on is a good bet until a definitive diagnosis is made

Question 17

• What are the 5 Ps of compartment syndrome?
• What are common causes of compartment syndrome?
• What is the main difference between acute and chronic compartment syndrome?

Answer 17

• 5 Ps:
  1) Pain out of proportion to exam-patient is requiring more analgesia than you would think per the injury
  2) Poikilothermia-area affected is cooler than the surrounding area
  3) Paresthesias-indicates nerve involvement, will progress to anesthesia
  4) Pulselessness/palor-late finding
  5) Paralysis-late finding
• Causes: Fracture, burns, crush injuries, vascular compromise (sickle cell, dvt), trauma, post-operative, infection (nec fasciitis)
• Chronic compartment syndrome is usually associated with repetitive motion (some form of exercise) and importantly patient will be asymptomatic at rest. They can typically describe when in their workout they will begin having sxs and the affected muscle group may be hypotrophied.

Question 18

• How common are scaphoid fractures?
• What physical exam findings are suggestive of a scaphoid fracture?
• How should these be managed?

Answer 18

• Scaphoid fractures are the most common wrist fractures but still only account for about 3% of all hand fractures
• Anatomical Snuffbox Tenderness, and Pain with Axial Loading of the 1st metacarpal, Tenderness of the Scaphoid Tubercle (on the volar aspect), Pain with radial deviation, Pain with active wrist range of motion
• Obtain x-rays of the hand (will still miss the injury up to 6% of the time), and immobilize in a thumb spica cast. If you are highly suspicious of this injury but xray is negative err on the side of immobilization with a removable splint and ortho FU in the outpatient setting so as not to miss this fracture.