Ortho Flashcards
(120 cards)
1
Q
torticollis in infancy
A
wry (twisted) neck deformity
contracture of the sternocleidomastoid (forms an intramuscular fibroma)
2
Q
torticollis is caused in newborns by
A
uterine malposition (breech delivery) birth trauma
3
Q
DDx of torticollis in older CH
A
neurogenic/CNS mass inflammatory (local head & neck infxns) traumatic ocular strabismus hysterical & psychiatric
4
Q
Dx of torticollis often requires?
A
simple radiographs
consider CT of brain to uncover neurogenic causes
5
Q
tx of torticollis
A
ROM exercises
occasionally surgically released
6
Q
scoliosis is?
A
lateral curvature of the spine
often assoc. w/ rotation
idiopathic in 80% of cases
7
Q
historical factors suggesting a pathologic cause
A
pain
left thoracic curves are more often associated w/ spinal pathology (syrinx or tumor)
stifness
midline skin lesion
8
Q
screening exam for scoliosis should be performed when?
A
< 12 yrs
standing erect (plumb line) and toe-touch
leg length comparison (screeens for compensatory scoliosis)
9
Q
radiographs for scoliosis indicated for?
A
5 degrees or more
higher risk of progression
10
Q
DDx of pathologic scoliosis
A
secondary congenital neuromuscular constitutional traumatic neoplastic
11
Q
secondary scoliosis
A
muscle spasm
leg length discrepancy
12
Q
congenital scoliosis
A
d/o of spinal development
often w/ bone, renal, urogenital or neural abnormalities
13
Q
neuromuscular scoliosis
A
cerebral palsy
polio
muscular dystrophy
spinal muscular atrophy
14
Q
constitutional scoliosis
A
metabolic d/o’s
athritides
15
Q
scoliosis curve severity
A
0-15 degrees 15-25 25-45 45+ 60+
16
Q
mgnt of scoliosis
A
unlikely to progress monitor regularly bracing vs. operative operative intervention may cause pulmonary compromise
17
Q
CH & walking general info
A
infants bend their hips, knees & ankles more than adults to improve balance
their ft are externally rotated & widely spread
they walk at a faster cadence but a slower velocity b/c of shorter stride length
18
Q
on avg, infants begin to crawl when
A
9 months
19
Q
on avg kids begin to walk w/ assistance at
A
12-14 months
20
Q
on avg. kids begin to walk independently when
A
15 months
21
Q
on avg kids begin to run when?
A
@ 18 months
22
Q
ch develop a nml adult gait pattern around what age?
A
3 yo
23
Q
genu varum
A
tibial bowing
nml up to 6 mon-2yrs
24
Q
genu valgum
A
knock knees
nml at ages 3-8 yrs
25
concerning features of a limp
nocturnal pain/limp
pain at rest
systemic findings: fever, wt loss, lymphadenopathy, HSM
pain out of proportion to exam findings
26
PE for limping
```
general exam, inspect bilaterally
attention to contusions, erythema, edema, rashes & temp of affected area
ROM of affected & adjacent joints
neurovascular status & strength
gait: do your best
```
27
plain radiographs
fx, effusion, lytic lesions, osteoid osteoma
knee pain may be reflection of hip patho
in CH that lacks obvious focus of pain
limited in acute osteomylelits
28
why are plain radiographs limited in acute osteomyelitis?
appears on x-ray up to 1 wk after onset of pain
29
ULS for limping
effusion- esp. for hips
| developmental dysplasia of hip
30
bone scan for limping
useful for eval of acute osteomyelitis & suble fx's
31
MRI for limping
mores specific for osteomyelitis & neoplasm
32
labs for infxn & limping
```
CBC
blood cx
ESR
CRP
consider Lyme titers
```
33
labs for muscle tenderness & limping
CK
renal fx if CK elevated
return to exam to ensure no necrotizing fasciitis
34
joint aspiration & limping
include Gram stain, cx, cell count, glucose & protein of fluid
35
DDx of limping- causes localized to the limb
```
strain, sprain, contusion
fx
limp length inequality
transient (toxic) synovitis
septic arthritis
osteomyelitis
developmental dysplasia of hip (DDH)
slipped capital femoral epiphysis (SCFE)
Legg-Calve-Perthes dz (LCPD)
Osgood-Schlatter
patellofemoral syndrome
osteoid osteoma
neoplasm of bone, joint of soft tissue
```
36
DDx for limping trivial causes
```
hair tourniquets (may NOT be trivial)
blisters
nail trauma
ill-fitting shoes
subcutaneous FBs
plantar warts
```
37
DDx for limping & systemic causes of arthritis
```
Henoch-Schoenlein purpura (HSP)
rheumatologic dz
Kawasaki dz
serum sickness
Lyme dz
IBD
gonorrhea & meningococcemia
neoplasm
```
38
DDx limping and abdominal pathology
appendicitis
| psoas muscle abscess
39
DDx limping and pelvic pathology
PID or abscess
| ovarian torsion/cysts
40
DDx limping & genitourinary pathology
testicular torsion/ epididymitis
urolithiasis
inguinal hernia
41
DDx limping & back pathology
muscle strain
discitis, herniated disc
spondylysis/spondyloslisthesis
42
DDx limping & neurologic pathology
tumor: spinal/cerebral/cerebellar/retroperitoneal
| stroke
43
A 0-2 yr old comes into the office with hip pain. What's on your DDx?
DDH (developmental dysplasia of hip)
| septic arthritis
44
A 3-5 yr old comes into the office w/ hip pain. What is on your DDx?
transient synovitis
45
A 4-7 yr old comes into the office w/ hip pain. What is your DDx?
Legg-Calve-Perthes
46
A 10-15 yr old comes into office w/ hip pain. DDx?
SCFE
47
A 0-2 yr old w/ knee pain. DDx?
septic arthritis
48
A 10-15 yr old w/ knee pain. DDx?
subluxing patella chondromalacia
| Osgood Schlatter
49
Tibia pain in 0-2 yr old. DDx?
toddler fx
50
tibia pain in 3-5 yr old. DDx?
"growing pains"
51
tibia pain in 10-15 yr old. DDx?
stress fx
52
spine pain in a 3-5 yr old. DDx?
discitis
53
spine pain in 10-15 yr old. DDx?
spondylolisthesis
54
0-5 yr old with any limb pain. DDx?
JRA
Leukemia
Cerebral Palsy
Osteomyelitis
55
4-7 yr old with any limb pain. DDx?
osteomyelitis
56
10-15 yr old with any limb pain. DDx?
bone tumor
| osteomyelitis
57
what is the MCC of limp in children?
trauma
58
greenstick fxs reflect the unique ability of kids' bones to ?
bend
59
MC mechanism in toddler's fractures
twisting or tripping
60
what is more common? soft tissue or bone injury
soft tissue injury
61
MC ID'd fx in preschool children (ages 9mo to 3 yrs) presenting w/ a limp
toddler's fx
62
what is a toddler's fx
nondisplaced spiral or oblique fx of lower third of tibial shaft
63
the MC presentation of toddler's fx
child refuses to bear wt on affected leg
| hx of minimal or no trauma
64
what do you find on PE in toddler's fx
possibly warmth & pain w/ palpation
usually no swelling
pain w/ gentle torsion of the foot
65
pathophys of toddler's fx
sudden twisting of tibia
fx more obvious 10-14 days after injury (callus formation)
generally heals w/ subperiosteal new bone formation running entire length of tibia (indicates fx more extensive & likely extends up the shaft through middle & proximal 1/3)
66
tx of toddler's fx
long leg cast immobilization
67
what is developmental dysplasia of the hip
displacement of th efemoral head from its nml position in the acetabulum- affects nml development of both
68
dislocation in DDH
femoral head completely outside of the acetabulum
69
subluxable in DDH
femoral head can be displaced outside of acetabulum
70
dysplasia in DDH
radiographic abnormality
71
in DDH children often walk on what?
affected side's toes to compensate for short limb
72
risk factors in DDH
```
female gender
breech malposition
FH of DDH
limited fetal mobility
clinical evidence of joint instability
significant persistent hip asymmetry
```
73
hx in DDH
```
prenatal hx (breech, gestation, birthweight)
MS abnormalities
FH of DDH
ethnic background
postnatal risk factors
```
74
examination of DDH
screen on every well child visit
0-4 mo check hip instability via Ortolani maneuver, Barlow maneuver
4 mo leg length/abduction-Galeazzi sign
12 mo+- trendelenburg's sign
75
imaging of DDH
plain films- incrase inusefulness beyond 4 months of age; widened pelvic floor; decreased femoral head coverage; femoral ossific nucleus
ULS- requires static & dynamic images, trained
76
Dx DDH
reg. well child visit screening- follow clics for 1st 2 wks, refer clunks (subluxation, dislocation on exam)
work up- ULS < 5 months, plain films > 4months
77
tx of DDH < 6 mo old
Pavlik harness- prevent hip extension & abduction
78
tx of DDH > 6 mo old
open or closed reduction
79
what is Legg-Calve-Perthes dz
avascular necrosis of proximal femoral head
80
Legg-Calve-Perthes dz is predominately?
unilateral
both hips are involved in less than 10% of cases
hips are involved successively, not simultaneously
81
Legg-Calve-Perthes dz may have insidious onset or may occur after?
hip injury
| coagulation or endocrine abnormalities may also contribute to cause
82
pathophysiology of Legg-Calve-Perthes dz
- rapid growth relative to blood supply development of secondary ossification centers in epiphysis
- causes interruption of adequate blood flow & results in avascular necrosis (necrosis, removal of necrotic tissue, & replacement w/ new bone)
- bone replacement may result in nml bone
83
frequency of Legg-Calve-Perthes dz
4/100,00
usually bet 4-10 yr old (mean age 7 yo)
boys>girls 4:1
white children affected more
84
sx's of Legg-Calve-Perthes dz
antalgic limp, pain typically mild
pain often gradual onset, intermittent & referred to thigh or knee
pain usually worsens w/ activity
85
exam of Legg-Calve-Perthes dz
loss of medial rotation
| loss of abduction
86
acute radiographic signs in Legg-Calve-Perthes dz
- small femoral epiphysis (96%)
- sclerosis of femoral head w/ sequestration & collapse (82%)
- widening of joint space d/t thickening of cartilage, failure of epiphyseal growth, the presence of joint fluid, or joint laxity (60%)
- fx line between avascular center of the femoral head & the subchondral bone
87
what does a bone scan show in LCP dz
reduced uptake
88
what does an MRI show in LCP dz
marrow necrosis
irregularity of the femoral head
loss of signal from affected side
89
non-operative mgnt of LCP dz
prevent deformity & osteoarthritis
- restoration/maint of ROM
- prevention of subluxation
- attainment of a spherical femoral head at healing
- bed rest & NSAIDs
- abduction bracing until lateral portion of femoral head has regenerated (12-18 mo)
- surgery for sever dz
90
Slipped Capital Femoral Epiphysis (SCFE)
structural failure of the upper femoral physis that allows displacement of the femoral head on the neck
* frequently misdiagnosed
* early tx leads to better outcome but there are freq. delays in dx
91
what is the MC hip abnormality presenting in school age or adolescence (age 7-15)?
slipped capital femoral epiphysis
92
what is a primary cause of osteoarthritis?
SCFE
93
what is the key predisposing factor in SCFE?
obesity
94
almost exclusive incidence of SCFE during adolescent growth spurt suggest?
hormonal role
95
pathophysiology of SCFE
Salter-Harris type 1fx thru proximal femoral physis
- physeal cartilage weak
- hip stress-->shear force at growth plate-->epiphysis to move posteriorly & medially
- blood supply tenuous & frequently lost after fx
96
manipulation of SCFE frequently results in what?
osteonecrosis & chondrolysis d/t tenuous blood supply
97
frequency of SCFE
```
m>f
>AA
typically occurs after onset of puberty
freq. in overwt, skeletally immature boys
slippage is bilateral in 20-37%
```
98
sx's of SCFE
hip & knee pain
insidious onset
antalgic limp
out-toeing (to avoid internal rotation)
99
signs of SCFE
- thigh may be shortened, externally rotated, and abducted
- internal rotation & abduction limited by pain
- tenderness on palpation of hip w/ discomfort often referred to hip, groin, or thigh
100
early radiologic findings in SCFE
widening of growth plate & osteopenia of the involved femoral head & neck
101
late radiologic findings of SCFE
displacement of the femoral neck relative to the femoral head
"ice cream scoop falling off the cone"
102
acute signs of SCFE
widened physis
lateral frog leg readiograph- demonstrates slippage earliest, slippage begins w/ posterior displacement & prgresses w/ medial rotation
103
line of Klein
line drawn along lateral aspect of femoral neck on AP view
| line should intersect a portion of femoral head
104
tx of SCFE
fixation: using a screw
osteotomy-attempts to change head alignment may predispose to avascular necrosis
goal- avoid chondrolysis, AVN, degenerative arthritis
105
what is a common cause of knee pain in active adolescents?
osgood-schlatter dz
106
how do you dx osgood-schlatter dz
characteristic localized pain at tibial tuberosity
| *radiographs not needed for dx, but do confirm clinical suspicion & exclude other causes of knee pain
107
pathophysiology of Osgood-Schlatter dz
most cases caused by micro trauma in deep fibers of patellar tendon at insertion on tibial tuberosity (avulsion mya be present)
usually d/t quadriceps femoris
108
s/sx of Osgood-Schlatter dz
```
pain
heat
tenderness
soft-tissue edema at tibial tuberosity
thickening & indistinct margins of patellar tendon
```
109
cartilaginous tibial tuberosity in Osgood-Schlatter dz
no initial change
| after 3-4 wks, fragmented ossification visible w/in tendon
110
ossified tibial tuberosity in Osgood-Schlatter Dz
linear or nodular avulsed bony fragments
| bony defect at donor site
111
tx for Osgood-Schlatter Dz
conservative
- NSAIDs
- application of ice
- avoid stress on knee caused by quads loading
- possible brief period of inactivity
- stretching of quads & hamstrings to reduce stress on tubercle
- usually self-limited & resolves w/ skeletal maturity
112
osteoid osteoma
benign skeletal tumor
113
osteoid osteoma presents as?
severe pain, worse at night & with activity
114
osteoid osteoma dramatically improves w/ what?
NSAIDs
115
what will you see on x-ray in osteoid osteoma?
radiolucent nidus 2-3 mm diameter w/ large, dense reactive bone growth
CT can confirm
116
osteochondroma
benign focal neoplasm
| non-painful swelling, may be irritated by athletic activity
117
osteosarcoma
malignant focal neoplasm
typically painful
common at metaphysis of long bone
"sunburst" pattern on x-ray
118
Ewing's sarcoma
malignant focal neoplasm
| typically painful
119
name some systemic neoplasms
leukemias & lymphomas
| metastases from other sites
120
pain from leukemia is often described as?
a deep, boring pain that awakens a child from sleep
| *up to 25% of pts w/ leukemia present w/ limp, bone pain or refusal to walk as a primary complaint
