Ortho & MSK

Question 1

Factors that favor bone remodeling

Answer 1

Younger age
Closer to physics (growth plate)
Angulation in the plane of adjacent joint mobility (ex wrist can have dorsal or ventral angulation)

Question 2

Degrees of angulation that don’t require reduction

Answer 2

• 15 degrees at wrist
• 10 degrees mid arm
• no angulation more proximal
• no angulation in the plane that the joint does NOT move

Question 3

Salter Harris classification
(mnemonic)

Answer 3

1: S - separated growth plate
2: A - above growth plate
3: L - lower than growth plate
4: T - through the growth plate
5: ER - erased growth plate (squish - compression fracture)

Question 4

Ottawa knee rule

Answer 4

Knee X-ray series for knee injury only if any of the following:
- age 55 or older
- isolated tenderness of patella (no other bony tenderness at knee)
- tenderness of fibula head
- inability to flex to 90 degree
- inability to weight bear immediately after injury AND I’m the ED for 4 steps (2 weight transfers on affected limb) regardless of limp

Validated in kids with 100% sensitivity

Question 5

Ottawa ankle rules

Answer 5

Ankle X-ray series required if pain in the malleolar zone AND any of the following:
- bony tenderness at posterior edge 6 cm or tip of lateral malleolus
- bony tenderness at posterior edge 6cm or tip of medial malleolus
- inability to weight bear immediately AND in the ED

Foot X-ray series required if pain in midfoot and any of the following:
- bony tenderness at base of 5th metatarsal
- bony tenderness at navicular

• inability to weight bear immediately AND in the ED

Question 6

Ottawa ankle rules - is it at the anterior or posterior portion of the distal malleoli?

Answer 6

Posterior 6 cm
Must be posterior because the ATFL ligament is anterior to the malleoli and is most likely source of pain in an ankle sprain

Question 7

Kocher criteria for SA vs. transient synovitis?

Answer 7

• Temp >38.5
• Non weight-bearing
• ESR > 40
• WBC > 12

Score = 1 - likelihood 3%
Score = 2 - likelihood 40%
Score = 3 - likelihood 93%
Score = 4 - likelihood 99%

Question 8

which periodic fever syndrome is highly associated with developing amyloidosis and how do you treat it?

Answer 8

FMF

colchicine

Question 9

age cut off for ortolani and barlow

what maneuver can be used after the cut off?

Answer 9

3 mo

barlow: positive test is a clunk (click is normal)

Galeazzi can be used > 3 mo

Asymmetrical thigh and gluteal folds may be supportive
evidence of DDH in the context of other abnormal findings

Question 10

imaging in suspected DDH

Answer 10

For the first 3 months of life, ultrasonography is the
imaging modality of choice for evaluation of DDH because
ossification of the femoral head does not usually occur until
4 months of age

after 3-4mo, an anteroposterior plain radiograph can identify asymmetry, subluxation, or frank dislocation

Question 11

management of DDH:

1. abnormal examination with possible DDH
2. Risk factors for DDH but normal exam
3. Dislocated hip (positive Ortolani)

Answer 11

1. In infants with abnormal examination findings concerning for possible DDH, ultrasonography
   should be considered by 3 to 4 weeks of age.
2. For an infant with risk factors for DDH but normal hip examination
   findings, waiting until 6 weeks of age may reduce false positive ultrasonography results. Imaging should be obtained by 6 months of age.
3. A dislocated hip (positive
   Ortolani test result) requires referral but does not necessarily need imaging before treatment. Imaging may be obtained at the discretion of the provider with shared decision making with the parents

*from AAP peds in review

Question 12

timing for pavlik harness for DDH

Answer 12

Bracing should ideally be started in the first 9 weeks of life and no later than 5 months of age to increase
the likelihood of success

Question 13

complications of pavlik harness for DDH

Answer 13

femoral head avascular necrosis and
femoral nerve palsy