Orthopedics/Rheumatology

Question 1

What are the characteristics of avascular necrosis of the proximal femur?

Answer 1

• insidious onset of a dull ache or throbbing localized to the groin, lateral hip, or buttocks
• usually, just one hip is affected
• think trauma, steroid use, or sickle cell
• in children AVN is known as Legg-Calve’ Perthes disease - will present with persistent pain and a limp
• ages 2-11 years old with a peak incidence of 4-8 years of age

Question 2

How is avascular necrosis of the proximal femur dx?

Answer 2

MRI is the study of choice for early detection

-Hip x-rays demonstrate necrosis effusion and joint ace widening with a negative aspirate

Question 3

What is the tx of avascular necrosis of the proximal femur?

Answer 3

treatment may be conservative or may eventually need a joint replacement

Question 4

What is congenital hip dysplasia?

Answer 4

or developmental dysplasia of the hip

• is a problem where the socket or acetabulum - and the femoral head are misaligned, resulting in an unstable hip joint
• typically, the problem is present at birth, but sometimes it appears later as the bones develop over time
• children with congenital hip dysplasia present with legs of unequal lengths and asymmetric skin folds around the groin, and they may develop limping and waddling gait when they start walking

Question 5

How is congenital hip dysplasia dx?

Answer 5

the diagnosis of congenital hip dysplasia is based on physical exam = hip exam at every well-child visit until 2 years

• there are several techniques for examining the hip
• barlow maneuver: adducting the hip while holding the knee straight, and when this pops the femoral head out of the socket, this raises suspicion of hip dysplasia
• to confirm the dislocation, the Ortolani maneuver is done and this consists of flexing the baby’s hip at 90 and then gently abducting it
• this causes a reduction of the hip dislocation (CLICK auscultated)
• ultrasound can be used to assess the position of the femoral head and the structure of the acetabulum
• radiographs are unreliable until the patient is at lest four months old because of radiolucency of femoral head

Question 6

What is the tx of congenital hip dysplasia?

Answer 6

below six months, congenital hip dysplasia is treated with a Pavlik harness and closed or open reduction for older kids, and in some cases, surgery might be necessary

• <6 months old: Pavlik harness (abduction bracing)
• 6-15 months old: hip spica cast
• 15-24 months old: open reduction followed by hip spica cast

Question 7

What is juvenile idiopathic arthritis?

Answer 7

a group of rheumatic disease that begins at or before age 16

Question 8

What is oligoarticular JIA?

Answer 8

most common form

• usually affects young girls
• it is characterized by the involvement of <4 joints during the first 6 months of disease

Question 9

What is polyarticular JIA?

Answer 9

second most common form

• it affects >5 joints at onset and is divided into 2 types: RF negative and RF positive
• typically, young girls are RF negative and have a better prognosis
• RF positive type typically occurs in adolescent girls and is often similar to adult RA
• in both types, arthritis tends to be symmetric and frequently involves the small joints

Question 10

What is systemic JIA?

Answer 10

(Still disease)

-is the least common form and involves fever and systemic manifestations

Question 11

What should JIA be suspected?

Answer 11

in children with symptoms of arthritis, signs of iridocyclitis, generalized adenopathy, splenomegaly, or unexplained rash or prolonged fever

• the diagnosis is primarily clinical
• patients with JIA should be tested for RF, ANA, and HLA-B27 because these tests may be helpful in distinguishing between forms

Question 12

What is the treatment of JIA?

Answer 12

involves NSAIDs, intra-articular corticosteroids, and disease-modifying anti rheumatic drugs - methotrexate

Question 13

What are the characteristics of osteosarcoma?

Answer 13

kids 10-14 years

• progressively worsening night pain, bone pain/joint swelling - may look similar to growing pains and can be easily missed
• X-rays: sun ray/burst or hair on end appearance followed by bone scan look for metastasis
• lung is most common site of metastasis, followed by bone
• treat with limb-sparing resection or radical amputation - 76% long-term survival with modern treatment

Question 14

What is Ewing’s sarcoma?

Answer 14

kids 5-25 years

• pain often accompanied by fever, often mimics an infection
• may have palpable mass, swelling, and local tenderness
• X-Ray: appears as a lytic lesion with an onion-skin appearance of periosteum
• treat with chemotherapy, surgery and radiation therapy

Question 15

What is Osteochondroma?

Answer 15

10-20 years

• benign chondrogenic lesion derived from aberrant cartilage - the most common benign bone tumor mostly in males ages 10-20 years old
• X-ray: sessile (broad base) or pedunuclated (narrow stalk) lesions found on the surface of bones
• treat with observation, resection if it becomes painful

Question 16

What is a nursemaid’s elbow?

Answer 16

a dislocation of the elbow joint caused by sudden pull on the extended pronated forearm, such as by an adults tugging on an uncooperative child or by swinging the child by the arms during play
-the technical term for the injury is radial head subluxation

Question 17

What are the signs and symptoms of a nursemaid’s elbow?

Answer 17

• common pediatric presentation, generally occurring between the ages of 1 and 3 years old
• generally, occurs with a pulling upward type of motion while the child has outstretched arm
• the child refuses to move the arm on presentation which is held in flexion and pronated, there is minimal swelling
• characterized by significant pain, partial limitation of flexion/extension of the elbow, or total loss of pronation/supination in the affected arm

Question 18

How is a nursemaid’s elbow dx?

Answer 18

the diagnosis is made clinically and radiography is unnecessary unless is needed to exclude fractures or other dislocation

Question 19

What is the tx of nursemaid’s elbow?

Answer 19

the supination-flexion technique is the classic method of reducing a sublimed radial head

• it has a success rate of 80-92%
• always ensure the child spontaneously uses the arm after reduction before discharging to confirm success

Question 20

What is Osgood-Schlatter disease?

Answer 20

is an inflammation of the patellar ligament, right at the point where it inserts on the tubular tuberosity, resulting in painful swelling just below the knee

Question 21

What is the presentation of Osgood-Schlatter disease?

Answer 21

tenderness over the tibial tuberosity results in micrograms and micro-avulsion - the proximal patellar tendon insertion separates from the tibial tubercle

• pain and swelling over the tibial tubercle at the point of insertion of patellar tendon
• pain on resisted knee extension with a lump below the knee and prominent tibial tuberosity

Question 22

How is Osgood-Schlatter disease dx?

Answer 22

clinical and based on inflammation of the tibial tuberosity, which worsens with activity

• diagnostic imaging is used only for atypical presentation (pain not related to activity, fever, rash, etc.) to exclude other conditions (osteomyelitis)
• ultrasound can should short tissue swelling around the tuberosity
• an x-ray might show fragmentation of tibial tuberosity in severe cases

Question 23

What is the tx of Osgood-Schlatter disease?

Answer 23

consists of reducing physical activity, applying ice to tuberosity to reduce swelling, physical therapy, as well as short term NSAIDs

• surgery (ossicle resection, excision of tibial tuberosity) is indicated if everything fails, for individuals with close growth plates
• might be necessary for persisting pain, especially if fragmented bones have avulsed off, and get trapped within the patella ligament

Question 24

What is scoliosis?

Answer 24

a lateral spine curvature with a Cobb angle of 10 degrees or more

Question 25

When does scoliosis most commonly begin?

Answer 25

8-10 years of age

Question 26

What is the routine screening of scoliosis?

Answer 26

at routine screening, a patent is asked to flex forward and the scapula height is observed (known as Adam’s test) if scoliosis is present, asymmetry in scapular height is noted

Question 27

Are boys and girls affected equally with scoliosis?

Answer 27

yes but it is 10 times more likely to progress and require treatment in girls

Question 28

How is scoliosis dx?

Answer 28

on Adams bending asymmetry in scapular height is noted

• radiographs standing PA and lateral
• Cobb angle >10 degrees as scoliosis - intra-interobserver error of 3-5 degrees
• MRI - to rule out intraspinal anomalies, should be performed if atypical curve pattern, rapid progression, neurologic symptoms of pain, reflex abnormalities, etc.
• pulmonary function tests to determine whether the scoliosis is affecting breathing
• will demonstrate a restrictive airway pattern

Question 29

What is the tx of scoliosis with curves of 10-15 degrees?

Answer 29

treated by 6-12 months follow-up with clinical evaluation and possible x-ray

Question 30

What is the tx of scoliosis with curves of 15-20 degrees?

Answer 30

need serial AP radiographic follow up every 3-4 months for larger curves and every 6-8 months for small curves or for patients near the end of growth

Question 31

What is the tx of scoliosis with curves of 20 or greater degrees?

Answer 31

need a referral to an orthopedist for continuous monitoring and management

Question 32

What is the tx of scoliosis with moderate curves of 20-40 degrees?

Answer 32

treated conservatively (physical therapy and bracing) to prevent further deformity

Question 33

What degrees of curves for scoliosis require surgery?

Answer 33

> 40 degrees

Question 34

What is slipped capital femoral epiphysis?

Answer 34

hip disorder in common in adolescents in which the head of the femur slips off the neck of the femur inferiorly and posteriorly, often due to mechanical overload

Question 35

What are the signs and symptoms of slipped capital femoral epiphysis?

Answer 35

• pain in the groin, hip, thigh, or ipsilateral knee without inciting trauma and painful limp in obese adolescent with painful limp
• antalgic or waddling gait with an externally rotated leg on the affected side
• drehmann sign: while in the supine position, hip externally rotates and abducts with passive hip flexion

Question 36

How is slipped capital femoral epiphysis most common in?

Answer 36

7 to 16 year obese male during a growth spurt, jumping activities

Question 37

How is slipped capital femoral epiphysis dx?

Answer 37

radiography for all patients to confirm diagnosis and grade severity

• AP and frog-leg lateral of right and left hip - lateral radiograph is the best way to identify a subtle slip
• widening of joint space, decrease in epiphyseal height and Steel sign - double density from the superimposition of epiphysis and metaphysis
• MRI can help diagnose a pre-slip condition when radiographs are negative

Question 38

What is the tx of slipped capital femoral epiphysis?

Answer 38

treat with surgical fixation with screw for all patients
-prophylactic screw fixation of the contralateral hip may be considered for patients, as there is a risk of disease in the contralateral hip later in life-usually for patients <10 or >16 years of age