Orthopedics Cases (Pestana) Flashcards
In the newborn nursery it is noted that a child has uneven gluteal folds. Physical exam of the hips reveals that one of them can be easily dislocated posteriorly with a jerk and a “click”, and returned to normal position with a “snapping”.
What is it? – Developmental dysplasia of the hip
Management: Abduction splinting. (Don’t order X-Rays in a newborn. Calcification is still incomplete and you will not see anything).
A 6 year old boy has insidious development of limping with decreased hip motion. He complains occasionally of knee pain on that side. He walks into the office with an antalgic gait. Passive motion of the hip is guarded.
What is it? - In this age group, Legg-Perthes disease (avascular necrosis of the capital femoral epiphysis). Remember that hip pathology can show up with knee pain.
Management: AP and lateral X-Rays for diagnosis. Contain the femoral head within the acetabulum by casting and crutches.
A 13 year old boy complains of pain in the groin ( it could be the knee) and is noted by the family to be limping. He sits in the office with the foot on the affected side rotated towards the other foot. Physical examination is normal for the knee, but shows limited hip motion. As the hip is flexed, the leg goes into external rotation and it can not be rotated internally.
What is it? - Forget the details: a bad hip in this age group is slipped capital femoral epiphysis, an orthopedic emergency.
Management: AP and lateral X-Rays for diagnosis. The orthopedic surgeons will pin the femoral head in place.
A little toddler has had the flu for several days, but he was walking around fine until about two days ago. He now absolutely refuses to move one of his legs. He is in pain, holds the leg with the hip flexed, in slight abduction and external rotation and you can not examine that hip because he will not let you move it. He has elevated sedimentation rate.
What is it? - Another orthopedic emergency: septic hip.
Management: Under general anesthesia the hip is aspirated to confirm the diagnosis, and open arthrotomy is done for drainage.
A child with a febrile illness but no history of trauma has persistent, severe localized pain in a bone.
What is it? - Acute hematogenous osteomyelitis
Management: don’t fall for the X-Ray option. X-Ray will not show anything for two weeks. Do bone scan.
A 12 year old girl is referred by the school nurse because of potential scoliosis. The thoracic spine is curved toward the right, and when the girl bends forward a “hump” is noted over her right thorax. The patient has not yet started to menstruate.
Management: Too complicated for our purposes, but the point is that scoliosis may progress until skeletal maturity is reached. Baseline X-Rays are needed to monitor progression. At the onset of menses skeletal maturity is about 80%, so this patient still has a way to go. Bracing may be needed to arrest progression. Pulmonary function could be limited if there is large deformity.
A 16 year old boy complains of low grade but constant pain in his distal femur present for several months. He has local tenderness in the area, but is otherwise asymptomatic. X-Rays show a large bone tumor, with “sunburst” pattern and periosteal “onion skinning”.
What is it? - Malignant bone tumor. Either osteogenic sarcoma or Ewing’s sarcoma.
Management: The point of the vignette is that you do not mess with these. Do not attempt biopsy. Referral is needed, not just to an orthopedic surgeon (they see one of these every three years), but to a specialist on bone tumors.
A 66 year old lady picks up a bag of groceries and her arm snaps broken.
What is it? - A pathologic fracture (i.e: for trivial reasons) means bone tumor, which in the vast majority of cases will be metastatic. Get X-Rays to diagnose this particular broken bone, whole body bone scans to identify other mets, and start looking for the primary. In women, breast. In men, prostate. In heavy smokers, lung…and so on.
A 58 year old lady has a soft tissue tumor in her thigh. It has been growing steadily for six months, it is located deep into the thigh, is firm, fixed to surrounding structures and measures about 8 cm. in diameter.
What is it? - Soft tissue sarcoma is the concern.
Diagnosis: start with MRI. Leave biopsy and further management to the experts.
A middle aged homeless man is brought to the ER because of very severe pain in his forearm. The history is that he passes out after drinking a bottle of cheap wine and he slept on a park bench for an indeterminate time, probably more than 12 hours. There are no signs of trauma, but the muscles in his forearm are very firm and tender to palpation, and passive motion of his fingers and wrist elicit excruciating pain. Pulses at the wrist are normal.
What is it? - Compartment syndrome.
Management; Emergency fasciotomy.
A patient presents to the ER complaining of moderate but persistent pain in his leg under a long leg plaster cast that was applied six hours earlier for an ankle fracture.
The point of this vignette is that you never give pain medication and do nothing else for pain under a cast. The cast has to come off right away. It may be too tight, it may be compromising blood supply, it may have rubbed off a piece of skin…whatever. Your only acceptable option here is to remove the cast.
A young man involved in a motorcycle accident has an obvious open fracture of his right thigh. The femur is sticking out through a jagged skin laceration.
The point of this one is that open fractures are orthopedic emergencies. This fellow may need to have other problems treated first (abdominal bleeding, intracranial hematomas, chest tubes, etc), but the open fracture should be in the OR getting cleaned and reduced within six hours of the injury.
A 55 year old lady falls in the shower and hurts her right shoulder. She shows up in the ER with her arm held close to her body, but rotated outwards as if she were going to shake hands. She is in pain and will not move the arm from that position. There is numbness in a small area of her shoulder, over the deltoid muscle.
What is it? - Anterior dislocation of the shoulder, with axillary nerve damage.
Management: Get AP and lateral X-Rays for diagnosis. Reduce.
After a grand mal seizure, a 32 year old epileptic notices pain in her right shoulder and she can not move it. She goes to the near-by “Doc in a Box”, where she has X-Rays and is diagnosed as having a sprain and given pain medication. The next day she still has the same pain and inability to move the arm. She comes to the ER with the arm held close to her body, in a “normal” (i.e., not externally rotated, but internally rotated) position.
What is it? - Posterior dislocation of the shoulder. Very easy to miss on regular X-Rays.
Management: Get X-Rays again but order axillary view or scapular lateral.
A front seat passenger in a car that had a head-on collision relates that he hit the dashboard with his knees, and complains of pain in the right hip. He lies in the stretcher in the ER with the right extremity shortened, adducted, and internally rotated.
What is it? - Another orthopedic emergency: posterior dislocation of the hip. The blood supply of the femoral head is tenuous, and delay in reduction could lead to avascular necrosis.
Management: X-Rays and emergency reduction.
