Orthopaedics Flashcards by Paoyun Tang

What are the components of of the Kocher Criteria?

○ Refusal to weight bear
○ ESR > 40
○ WBC > 12
○ Fever >38.5 C

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What are the most common organisms in osteomyelitis?

○ Staphylococcus aureus (most common)
○ Group A streptococcus
○ Kingella kingae (higher in infants)
○ Streptococcus pneumoniae
○ Streptococcus pyogenes

In those with Sickle Cell - atypical Gram negatives and salmonella

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What antibiotics should be considered if osteomyelitis is suspected?

○ cefazolin IV q 8 hrs +/- vancomycin for MRSA coverage
○ cefuroxime IV q 8 hrs if <4 yoa or unimmunized

may transition to cloxacillin (MSSA) or cephalexin oral when appropriate
consult ID regarding transition to clindamycin or septra for MRSA

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What is the most common childhood fracture?

Fracture of distal radius (Torus being the most common pattern, buckle)

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At what age should physiological “in-turning” resolve?

Metatarsus adductus - 1 year
Tibial torsion - 5 years
Femoral anteversion - 8-10 years

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You are called to see a child with bowed legs. Weight is >97th %ile and height is at 50th %ile. They began walking at age 9 months of age. What is your main concern?

Blount disease (Idiopathic tibia vara)

may brace if <3 and less than stage 3. Otherwise will need to treat operatively

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What are the risk factors for blount disease?

African-Americans
Toddlers who are overweight
Those with an affected family member
Children who started walking early in life

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A child presents with unremitting and gradually increasing pain that is worst at night and relieved by aspirin. What is your suspicion?

Osteoid osteoma
- X-ray will show a round/oval metaphyseal or diaphyseal lucency

(any bone can be affected by proximal femur and tibia are most common)

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Features of osteochondroma

bony, nonpainful mass
irritated by pressure during athletic activity
distal femur, proximal humerus and proximal tibia are most common

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What is the difference between unicameral bone cysts and aneurysmal bone cysts?

ABC will have fluid levels
ABCs will have more rapid growth; concern for malignancy as ddx
UBCs are usually in the proximal humerus or femur, ABCs can be in any bone (usually the femur, tibia or spine)

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What is the bone condition expected in McCune Albright Syndrome?

Fibrous dysplasia

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What are the 4 components of a club foot?

CAVE

Cavus - plantarflexion
Adductus
Varus - of the hindfoot
Equinovarus - of the hindfoot

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Treatment for clubfoot

Serial casting (Ponseti method) with percutaneous tenotomy of heel cord, followed by abduction brace full-time x 3 months and night time abduction brace x 3-5 years

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What is Caffey’s Disease?

Cortical hyperostosis with inflammation of the fascia and muscle (mandible (75%), clavicle and ulna)

Think baby with swollen, puffy and painful cheeks with wood-like induration

Tx: indomethacin and prednisone

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What is the cause of a nursemaid’s elbow?

Subluxation of the radial head caused by longitudinal traction applied to an extended arm

This causes pain and the child will hold their arm pronated and flexed into their chest

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How is a Nursemaid’s elbow fixed?

1) full flexion past 90 degrees and supination of affected arm while keeping finger over the radial head to feel for ‘click’
2) hyperpronation of the forearm while in the flexed position

What is the recurrence rate of Nursemaid’s elbow?

5-40%

ceases after 5 years of age

What is a chance fracture?

Flexion-distraction injury of the spine caused by the creation of a flexion fulcrum anterior to the abdomen i.e. lab seatbelt with no shoulder strap

What is the proposed diagnostic criteria of Chronic Recurrent Multifocal Osteomyelitis (CRMO)?

Major criteria

- Osteolytic or sclerotic bone lesion on X-ray
- Multifocal bone lesions
- Pustulosis palmoplantaris or psoriasis
- Sterile bone biopsy with signs of inflammation and/or fibrosis, sclerosis

Minor criteria

- Normal CBC and good health
- CRP/ESR mildly to moderately elevated
- Course> 6 months
- Hyperostosis
- Association with other autoimmune diseases
- First or second degree relative with autoimmune or autoinflammatory disease

What are the risk factors for developmental dysplasia of the hip

Think of Fs

Family history
First baby
Female
Fat baby
Fit (oligohydramnios)
Foot first delivery (breech)

What is the best way to screen for DDH?

If <2-3 months of age, Barlow and Ortolani can be done (afterwards, unreliable)
Serial examinations looking for limited hip abduction
Look for apparent shortening of the thigh, asymmetry of the gluteal or thigh folds
Klisic/Galeazzi tests
If older, limp, waddling gait, leg-length discrepancy, positive trendelenburg, excessive lordosis

How is DDH treated?

<6 months: Pavlik harness
6 months - 2 years: Pavlik is only effective 50% of the time
> 2 years: open reduction with concomitant femoral shortening osteotomy

What are the complications of DDH?

Avascular necrosis of femoral epiphysis
Redislocation
Acectabular dysplasia
Infection

7 year old boy presents with a limp, pain in his groin and limited internal rotation and abduction of the hip. There is leg-length discrepancy. Name 3 conditions on your differential.

missed DDH
Legg-Calve-Perthes
(he is a little young) SCFE
Septic arthritis

Sinding-Larsen-Johansson Syndrome

Insertional periostitis at the inferior pole of the patella - active but younger pubescent children - resolves with rest, patellar strap, PT, time and warning not to "play through the pain"

Osgood-Schlatter Disease

Irritation of the patellar tendon at its insertion into the tibial tubercle - 10-15 years of age - anterior knee pain with running, jumping and kneeling - resolves with rest, patellar strap, PT, time and warning not to "play through the pain"

What are the features of the Sever Disease?

- Calcaneal apophysitis caused by repetitive stress leading to microfractures at the fibrocartilaginous insertion sites - most common cause of heel pain in children - Tx: activity modification, NSAIDS, heel cord stretching, heel cushions or arch supports

What is Iselin disease?

Apophysitis of the 5th metatarsal base

What is the diagnostic criteria for Fibromyalgia?

Diagnosis requires: ○ all 4 MAJOR criteria plus 3 of 10 minor criteria ○ OR may have first 3 MAJOR criteria plus 4 tender points and 5 minor criteria 1) MAJOR criteria: ○ Generalized MSK pain in at least 3 areas lasting >3 months ○ Absence of underlying condition or cause ○ Normal test results ○ At least 5 out of 18 typical tender points* ``` 2) Minor criteria (3/10 or 3M + 4 tender + 5/10) ○ Fatigue ○ Poor sleep ○ Headaches ○ Chronic anxiety or tension ○ Irritable bowel syndrome ○ Pain affected by weather ○ Subjective soft tissue swelling ○ Pain affected by anxiety and stress ○ Paresthesia ○ Pain affected by activities ```

Diagnostic criteria for Complex Regional Pain Syndrome Type 1

Regional pain and 2 symptoms from each of the following types of symptoms ``` 1) Neuropathic symptoms (2+) ○ Burning ○ Dysesthesia ○ Paresthesia ○ Allodynia (central pain sensitization) ○ Cold hyperalgesia ``` ``` 2) Autonomic dysfunction (2+) ○ Cyanosis ○ Mottling ○ Hyperhidrosis ○ Coolness (by at least 3 degrees Celsius) ○ Edema ```

Complex Regional Pain Syndrome Type 2

Like CRPS 1 but pain is caused by nerve injury rather than MSK injury

When should pes planus be treated?

When patients are symptomatic - Nonoperative: stretching, shoe wear modification, orthotics - Operative: achilles tendon or gastroscnemius fascia lengthening

What are the classic features of Patellofemoral Syndrome?

- pain with walking up and down the stairs, sitting in a flexed knee position for an extended period of time - no swelling - positive Grind test (extended knee, relaxed quadriceps, pressure on the patella so that it moves distally will cause pain) - response to physiotherapy, lower extremity stretching and strengthening, taping/braces/sleeves

What are the thresholds for treatment in scoliosis?

- skeletally immature + curve >30 degrees at first visit - brace - skeletally immature with progression of curve overtime past 25 degrees - skeletally immature > 45 degrees - surgery (brace is ineffective) - skeletally mature >50 degrees - surgery

Risk factors for slipped capital femoral epiphysis (SCFE)

"HOMED" - Hypothyroidism - Obesity - Male - Ethnicity: African Americans, Pacific Islanders, Latino - Down syndrome

Extension back injuries

Spondylolysis - stress fracture of pars interarticularis due to repetitive spinal extension - hyperlordosis, paraspinal muscle spasm, HAMSTRING tightness Posterior element overuse - focal tenderness of lumbar spine and paraspinal muscles - normal investigations

Flexion back injuries

Vertebral body apophyseal avulsion fracture - paraspinal muscle spasms - fractures posteriorly displace into the spinal canal Disc herniation - back muscle spasm, hamstring tightness, buttock pain