Part 31. Bone and Joint Disorders

Question 1

Normal full-term newborns can have up to 20-30 degree hip and knee flexion contractures. These contractures tend to resolve by?

Answer 1

4-6 mos of age

Question 2

The effects of in utero positioning resolve by?

Answer 2

3-4 mos of age

Question 3

By the age of ____ , the wide gait diminishes, reciprocal arm swings begins, and there is increased stride length and velocity.

Answer 3

2 yrs

Question 4

Adult fluid gait patterns usually noted by age ____

Answer 4

7 yrs

Question 5

What gait is produced by weak abnormal hip abductors?

Answer 5

Trendelenburg gait (trunk lists to the affected side with each step)

Question 6

Describe the Trendelenburg sign.

Answer 6

sagging rather than rising of the unsupported buttock

Question 7

Differentiate antalgic (painful) from painless gait.

Answer 7

In a painful gait, the stance phase is shortened as the child decreases the time spent on the painful extremity. In a painless gait, which indicates underlying proximal muscle weakness or hip instability, the stance phase is equal between the involved and uninvolved sides, but the child leans or shifts the center of gravity over the involved extremity for balance.

Question 8

What is imaging modality of choice for defining the exact anatomic extent of most musculoskeletal lesions?

Answer 8

MRI

Question 9

What imaging modality is superior for assessing bone involvement and cortical destruction (even subtle changes), including calcification or ossification and fracture?

Answer 9

CT Scan

Question 10

Best results are obtained when treatment for metatarsus adductus is started before what age?

Answer 10

8 mos

Question 11

Is surgical treatment for metatarsus adductus is opted, what procedure is most likely to result in permanent restoration of alignment?

Answer 11

Osteotomy (midfoot or multiple metatarsals)

Question 12

Which foot deformity has the highest association with developmental dysplasia of the hip (DDH)?

Answer 12

Calcaneovalgus Feet

Question 13

What is clubfoot also known as and what are its components?

Answer 13

Talipes Equinovarus
Components (CAVE):
Cavus - plantar flexion of the 1st ray
Adduction of the forefoot/midfoot on the hindfoot, with the hindfoot in…
Varus
Equinus

Question 14

What is the standard initial treatment for clubfoot deformity?

Answer 14

Ponseti method, involves a specific technique for manipulation and serial casting, and may be best described as minimally invasive rather than nonoperative. The order of correction follows the mnemonic CAVE.

Question 15

This is an uncommon foot deformity in which the midfoot is dorsally dislocated on the hindfoot and the ankle is in fixed equinus. The plantar surface of the foot is convex, and the talar head is prominent along the medial border of the midfoot.

Answer 15

Congenital vertical talus or rocker-bottom foot

Question 16

Patients with a flexible flatfoot and a tight tendo-Achilles should be treated with ?

Answer 16

stretching exercises

Question 17

This condition is characterized by a painful, rigid flatfoot deformity and peroneal (lateral calf) muscle spasm but without true spasticity.

Answer 17

Tarsal coalition (peroneal spastic flatfoot)
It represents a congenital fusion or failure of segmentation between two or more tarsal bones

Question 18

What is the imaging modality of choice when a coalition is suspected?

Answer 18

__CT scan.__ In addition to securing the diagnosis, this study helps define the degree of joint involvement in patients with a talocalcaneal coalition.

Question 19

These are idiopathic avascular necroses of bones, which may involve tarsal bones as well.

Answer 19

Osteochondroses

Question 20

This represents inflammation at the tendinous insertion of a muscle from repetitive tensile loading and is most commonly observed during periods of rapid growth.

Answer 20

Apophysitis.
These stresses result in microfractures at the fibrocartilaginous insertion site, associated with inflammation.
A period of rest (6-8 wk) and avoidance of sports will often resolve symptoms, although recurrence is common until maturity when the apophyses close

Question 21

What is the most common cause of heel pain in children?

Answer 21

Calcaneal apophysitis (Sever disease)
Treatment includes activity modification, nonsteroidal antiinflammatory medications, heel cord stretching exercises, and heel cushions or arch supports.

Question 22

A curly toe is caused by contracture of the ____ , and there is flexion at the MTP and the interphalangeal (IP) joints associated with medial deviation of the toe.

Answer 22

flexor digitorum longus.
Most cases resolve over time, and a subset will resolve completely.

Question 23

What is the most common congenital toe deformity ?

Answer 23

Polydactyly

Question 24

What comprise the female athlete triad?

Answer 24

1. disordered eating
2. amenorrhea
3. osteoporosis

Question 25

This is a localized pathologic process of the subchondral bone that secondarily affects the overlying articular cartilage and can progress to joint instability and cartilage separation and fragmentation.

Answer 25

**Osteochondritis dissecans (OCD)** Emerging evidence suggests that the cause of OCD is vascular insult to the developing knee that is unable to heal due to repetitive microtrauma.

Question 26

Anterior knee pain with localized soft tissue swelling along with an eventual firm and fixed increased prominence at the tibial tubercle, with no history of trauma is likely due to?

Answer 26

**Osgood-Schlatter disease** On PE, there is also point tenderness on the distal portion of the patellar tendon. Patients are treated with increasing levels of activity restriction or immobilization to get them to a pain-free state before advancing their activities.

Question 27

This typically presents as anterior knee pain very specifically localized to the inferior pole of the patella without prior history of a fracture.

Answer 27

**Sinding-Larsen-Johansson (SLJ) syndrome** Physical examination reveals point tenderness over the inferior pole of the patella. Treatment is activity restriction.

Question 28

A 16 y/o female complains of knee pain for the past few weeks especially when going up or down the stairs and running. There was no history of trauma. On PE, there is tenderness with palpation about the medial or lateral aspects of the patella. Grind test was positive. What is this condition and what is its mainstay treatment? ## Footnote Grind test: With the knee extended and the quadriceps relaxed, placing pressure on the patella and translating it distally into the top of the trochlear groove, causes pain.

Answer 28

**PAtellofemoral pain syndrome** The mainstay of treatment is **continued physiotherapy.** Orthoses, including patellar taping, knee sleeves, custom- ized knee braces, or even shoe inserts are often used in conjunction with physical therapy. However, evidence for long-term benefit from orthotic use is unclear.

Question 30

# True or False Females are known to have a lesser risk for ACL injury than males.

Answer 30

**FALSE** Females are known to have a *greater* risk for ACL injury than males. The gender-specific discrepancy appears to be caused mostly by insufficient neuromuscular activation patterns in females, resulting in increased dynamic genu valgum, or knock-knee, biased landing, and, therefore, a heightened tendency toward landing or stopping in an injury prone position.

Question 31

A 15 y/o volleyball player fell on her knees while playing a game, and complained of knee pain thereafter. On PE, there was noted limited ROM, and the Lachman test is positive. What is the gold standard for the diagnosis?

Answer 31

**Arthroscopic evaluation** is the gold standard for diagnosis and treatment. This is a case of Anterior cruciate ligament injury. The Lachman examination (anterior drawer test) is performed by applying an anteriorly directed force to the proximal tibia with the femur stabilized and the knee flexed 20-30 degrees. The amount of translation and the end point are assessed, with increased translation and an indistinct end point indicating a positive test.

Question 32

What are management options of ACL injuries?

Answer 32

Incomplete or partial ACL tears that still maintain a firm endpoint on examination may be treated nonoperatively, and the patient’s and family’s understanding and willingness to adhere to a protocol of bracing and activity restriction are important factors in optimizing outcomes. For complete tears of the ACL, due to the risk of ongoing knee damage if stabilization of the knee is delayed, surgical reconstruction is usually the preferred treatment for patients who are physically, mentally, and emotionally capable of maintaining precautions and complying with the long rehabilitation course after the procedure.

Question 33

More commonly affected hip in developmental dysplasia of the hip?

Answer 33

Left hip

Question 34

What is the most reliable sign of a dislocated hip in infants?

Answer 34

**Limitation of abduction** Other tests/signs are: Galeazzi sign (shortening of the thigh), Klisic test

Question 35

What is the diagnostic modality of choice for DDH before 4-6mos old (appearance of the femoral head ossific nucleus)?

Answer 35

**Ultrasonography** During the early newborn period (0-4 wk), however, physical examination is preferred over ultrasonography because there is a high incidence of false-positive sonograms in this age group. Therefore, waiting to obtain an ultrasound until the infant is at least 1 mo of age is preferred unless the child has a strongly positive physical exam.

Question 36

Management for DDH for newborns up to 6mos of age?

Answer 36

Pavlik harness on a full-time basis for 6 wk. If follow-up examinations and ultrasounds do not demonstrate concentric reduction of the hip after 3-4 wk of Pavlik harness treatment, the harness should be abandoned

Question 37

Management for DDH for children 6mos to 2 y/o?

Answer 37

Closed reduction (casting) followed by orthosis.

Question 38

Management for DDH for children older than 2 y/o?

Answer 38

A pelvic osteotomy is usually performed in conjunction with the open reduction. Postoperatively, patients are immobilized in a spica cast for 6-12 wk

Question 39

Most important complication of DDH?

Answer 39

Avascular necrosis

Question 40

A 6 y/o boy came in with complaint of right groin pain. He was also noted to seem to be walking with a limp. No other symptoms noted. Mother said that he had low grade fever with cough about 10 days ago which spontaneously resolved. CBC and ESR results were normal. What is the treatment of choice?

Answer 40

The treatment of transient monoarticular synovitis (Toxic synovitis) of the hip is symp- tomatic. Recommended therapies include activity limitation and relief of weight bearing until the pain subsides. Antiinflammatory agents and analgesics can shorten the duration of pain. Most children recover completely within 3-6 wk.

Question 41

An 8 y/o boy has been noted to have a limping gait for about 2 months with associated pain on the anteromedial thigh occuring after playing tag with his friends. On PE, there was note of limited hip motion particularly internal rotation and abduction. On hip radiograph, there was lateralization of the femoral head with widening of the medial joint space. What is your impression?

Answer 41

**Legg-Calve-Perthes Disease** is a hip disorder of unknown etiology that results from temporary interruption of the blood supply to the proximal femoral epiphysis, leading to osteonecrosis and femoral head deformity.