Orthopedics

Question 1

Common causes diminished arm use in Newborn/infants

Answer 1

clavicle fracture, brachial plexus injury, septic arthritis/OM

Question 2

Common causes diminished arm use in children

Answer 2

nursemaid elbow, fracture, soft tissue injury

Question 3

Life and limb threatening causes diminished arm use

Answer 3

Septic arthritis
Osteomyelitis
Necrotizing cellulitis or fasciitis
Leukemia or bone malignancy
Fracture with neurovascular compromise
Child abuse 
Stroke

Question 4

Work-up for back pain

Answer 4

Urinalysis and urine culture
Infection or arthritis: CBC, CRP, ESR, blood culture (fever)
Neoplastic: CBC, liver function, CRP, LDH, uric acid
Plain film xray: AP and later views of spine, chest xray if pneumonia
CT scan if acute, high force trauma to back
MRI study of choice to evaluate back pathology (sensitive for spinal cord lesions, bone infections, discitis, vertebral fractures)

Question 5

How does osteoid osteoma present?

Answer 5

back pain - not worse with activity, may wake at night, better with NSAIDs

Question 6

Red flags for back pain

Answer 6

constant pain, at night, severe, morning pain (suggest CVD), radiation down leg, fever

Question 7

List 4 causes of back pain in a female patient with no history of trauma.

Answer 7

Infectious: Spinal and Non Spinal: Osteomyelitis, Spinal Epid Abscess, Pyelonephritis, Pneumonia, Appendicitis, Viral myalgia, Pancreatitis
Reactive Arthritis: Ankylosing Spondylitis, Arthritis of IBD
Neoplastic: Osteoid osteoma, Leuk/Lymphoma, Osteogenic sarcoma
Other: Sickle cell, Nephrolithiasis

Question 8

5 causes of acquired torticollis

Answer 8

Infections: cervical adenitis, RPA, discitis/vertebral osteomyelitis, strep pharyngitis, lemierres syndrome (pharyngitis, septic pulm. Emboli, persistent fever despite abx, fusobacterium necrophorum

Trauma: muscular injury (injury to SCM/trap most common cause of acquired tort in children), fracture, spinal epidural hematoma

Cervical spine injury or alantoaxial rotary subluxation
CNS tumour
Dystonia

Question 9

Give 2 differential diagnoses for congenital torticollis other than sternocleidomastoid tumor.

Answer 9

• congenital muscular torticollis
• postural torticollis
• hemivertebrae, congenital scoliosis, Klippel-Feil syndrome
• Clavicle #
• Cystic hygroma, branchial cleft cyst
• C1-C2 rotary displacement

Question 10

What is Spondylolysis? How does it present?

Answer 10

Stress fracture of the pars interarticularis caused by repetitive spinal extension and rotation (scotty dog)

Insidious onset of extension-related back pain, Hamstring flexibility is reduced, can be pain with impact activities (running, jumping).

Question 11

2 common organisms in Discitis? Best test for diagnosis?

Answer 11

S. aureus and kingella. 
MRI spine (xrays often normal)

Question 12

Treatment of an open fracture

Answer 12

Urgent ortho consult, clean open wounds, sterile dressing applied, antibiotics given, tetanus prophylaxis (ex. ancef with addition of gentamicin for large open fractures)

Question 13

Common pediatric injuries that cause compartment syndrome

Answer 13

displaced type III SCF (Volkmann contracture), forearm fractures, fracture tibia/fibula, open fracture, crush injuries, soft tissue trauma, burns, poisonous snakebites (pit vipers), deep tissue infection (myositis or fascitis)

Question 14

5 symptoms of compartment syndrome?

Answer 14

5 P’s: pain out of proportion to injury (exacerbated by full extension), paresthesia, pallor, paralysis, pulselesness

Question 15

Tx of compartment syndrome

Answer 15

Remove cast and place extremity at level of heart (neither elevated or dependent)
Consult ortho for fasciotomy
Analgesia
Supplemental O2
Avoid hypotension

Question 16

Volkmann’s contracture - what common injury causes it?

Answer 16

Supracondylar humeral # (ischemia of flexor muscles) –> claw-like hand

Question 17

Indication for fasciotomy for compartment syndrome?

Answer 17

• High clinical suspicion (ie. symptoms of compartment syndrome)
• Compartment pressure within 30 mmHg of diastolic pressure.

Usual compartment pressure 0-8.

Question 18

For each of the following categories, name two etiologies of a pathologic fracture: Non-malignant tumor, malignant tumor, hereditary disorders, metabolic, neuromuscular, infectious. oncology

Answer 18

Non-malignant tumor - Non-ossifying fibroma, Osteochondroma, UBC, ABC

Malignant tumor - Ewing’s Sarcoma, Osteosarcoma (ALL, NB)

Hereditary disorder - OI, NF

Metabolic- Rickets, Hyperparathyroidism

Neuromuscular - Cerebral palsy, Traumatic paraplegia or quadriplegia

Infectious - Osteomyelitis, Septic arthritis

Question 19

Indication for ortho referral for clavicle fracture

Answer 19

open #, severe skin tenting, medial or lateral #, shortening > 1.5 cm, displacement > 2 cm, floating shoulder, comminuted, NV compromise

Question 20

Most common nerve injury in shoulder dislocation?

Answer 20

Axillary nerve injury (deltoid weakness - loss of ABduction from 15-90 degrees, and numbness over shoulder cap)

Question 21

List 3 complications of shoulder dislocation?

Answer 21

• Hills-Sachs lesion (# of humeral head due to compression during dislocation)
• Bankart lesion
• axillar nerve injury

Question 22

List 5 techniques for reduction of shoulder dislocation

Answer 22

• External rotation
• Milch (added to ext rotation with arm overhead)
• Scapular manipulation
• Traction- countertraction
• Stimson (prone on bed with weight hanging off)
• Cunningham (massage)

Question 23

What is Roos’ test?

Answer 23

As patient to signal for a touchdown, if develops paresthesia/pain - positive test - suggestive of thoracic outlet syndrome

Question 24

Most common nerve injury with distal humerus #? Clinical findings of this nerve injury?

Answer 24

radial nerve (wraps around the humerus) -> wrist drop, loss of thumb extension, dec sensation on 1st webspace dorsum of hand

Question 25

Complications of supracondylar fracture?

Answer 25

vascular injury, nerve injury, compartment syndrome cause Volkmann’s ischemic contracture (claw hand), cubitus varus deformity, infection of pins, post operative stiffness, pin migration

Question 26

Most common nerve injury in Supracondylar fracture? Findings?

Answer 26

AIN (branch of median nerve) - can't do OK sign (flexion distal phalanx index finger and thumb), hand of benediction

Question 27

Nerve injury associated with medial epicondyle fractures?

Answer 27

Ulnar nerve

Question 28

Which non-wrist # can cause referred wrist pain?

Answer 28

radial head/neck fracture - referred wrist pain but localized tenderness at the elbow.

Question 29

Monteggia vs Galeazzi?

Answer 29

MUGR Monteggia = ulnar shaft fracture and radial head dislocation (proximal) Galleazi = radial fracture and radio-ulnar dislocation (distal)

Question 30

How to reduce nursemaid's elbow (2)?

Answer 30

Radial head subluxation - supinate + flex - hyperpronate

Question 31

Distal radius and ulna fractures accetable angulation?

Answer 31

0-5 years old: < 20 degrees 5-10: < 15 degrees >10: < 10 degrees

Question 32

4 signs of tenosynovitis

Answer 32

``` Tenderness to palpation of the joint or tendon sheath and with passive extension Swelling around joint + tendon sheath Erythema around joint + tendon sheath Reduced ROM (slightly flexed at rest) “Locking” or “catching” of the tendon during ROM ```

Question 33

3 common pelvic avulsion fractures?

Answer 33

Anterior superior iliac spine = Sartorius Anterior inferior iliac spine = rectus femoris (long head) Ischial tuberosity = hamstring

Question 34

Treatment of pelvic avulsion fracture?

Answer 34

Crutches with partial or no weight bearing for 4-6 weeks then gradual return to activity; ortho referal should be made If displacement greater 2-3 mm - consult ortho

Question 35

Young Burgess Classification - 3 types of pelvic fractures?

Answer 35

- lateral compression - AP compression - vertical shear

Question 36

Significant pelvic fracture - 4 potential injuries | - Anatomical landmark for pelvic binder

Answer 36

- vascular injury - hemorrhagic shock - urethral injury, bladder - spinal injury - intraabdominal - bowel, liver spleen Greater trochanters

Question 37

What is a Malgaigne fracture?

Answer 37

Malgaigne fracture: unstable fractures occur when fracture of pubic rami or symphysis are associated with displaced sacroiliac joint dislocation or sacral fracture = risk pelvic vein injury and severe hemorrhage

Question 38

How to reduce a patellar dislocation?

Answer 38

give benzo + analgesia, leg starts out flexed, then extend knee with medially upward force on lateral patella - Imaging post reduction including patellar view (look for osteochondral fragment in 25%, especially if trauma) - After reduction, immobilize in above knee posterior splint or knee immobilizer for 4 weeks; outpatient ortho for follow up

Question 39

NV injury that can occur with fractures around the knee?

Answer 39

popliteal vessel and peroneal nerve (ankle dorsiflexion, sesation superior/lateral aspect of foot)

Question 40

Features of patellofemoral syndrome?

Answer 40

Anterior knee pain Pain worse with squatting, running, knee can "give away or buckle" Patellar stress test (place hand just superior to patella and tell patient to contract quads while you apply pressure. Positive if elicits pain)

Question 41

Gymnast hyperextends knee. By the time she is in the ED she is better. Prominent tibial tubercle. What nerve is at risk of injury and what vessel?

Answer 41

Infrapatellar branch of the Saphenous Nerve | Recurrent Anterior Tibial Artery

Question 42

Ottawa ankle rules?

Answer 42

Ottawa ankle rules for obtaining foot and ankle xray for children over 5 Xray ankle:if pain in malleolar zone and bone tenderness at posterior edge or tip of lateral malleolus, bone tenderness at the posterior edge or tip of medial malleolus or inability to weight bear immediately and in ED Xray foot: pain midfoot and bone tenderness at base of fifth metatarsal, bone tenderness over the navicular bone, or inability to weight bear both immediately an in ED

Question 43

What is a Tillaux fracture? What is the management?

Answer 43

tillaux fractures are a traumatic condition characterized by a Salter-Harris III fracture of the anterolateral distal tibia epiphysis management is posterior splint with ortho f/u vs ORIF (if > 2mm displacement)

Question 44

What age is at risk for a Tillaux fracture?

Answer 44

more common in girls seen in children nearing skeletal maturity (12-14 years old) typically occur within one year of complete distal tibia physeal closure due to pattern of progression of physeal closure older than triplane fracture age group

Question 45

Management of a Triplane fracture?

Answer 45

Emergency orthopedic consultation CT scan to assess fracture (esp if > 2mm displacement) Likely will need ORIF

Question 46

How are ankle sprains classified? Management for each class?

Answer 46

Grade I: stretching of ligaments = air splint or elastic wrap along with ice for 72 hours; crutches with partial weight bearing until not limping Grade II: partial ligament tears without loss stability= walking cast/boot or posterior splint for up to three weeks with crutches ambulation Grade III: complete tears with loss of stability = walking cast/boot or posterior splint for up to three weeks with crutches ambulation

Question 47

Most common ligament sprained in the ankle?

Answer 47

ATFL (anterior talofibular ligament - pain distal fibula from foot inversion

Question 48

What is the low-risk ankle rule?

Answer 48

The injury is acute (<3 days old) The child is not at risk for pathological fractures (eg, osteogenesis imperfecta or known focal bone lesion such as an osteoid osteoma) The child has no congenital anomaly of the feet or ankle The child can reliably express pain or tenderness Physical examination demonstrates tenderness or swelling confined to the distal fibula and/or adjacent lateral ligaments distal to the anterior tibial joint line No gross deformity, neurovascular compromise, or other serious and potentially distracting injury are present

Question 49

Which fractures are considered low-risk by the LRAR?

Answer 49

Distal fibular avulsion # Non-displaced SH 1-2 fractures ankle sprains (tx with supportive splinting, crutches PRN, return to activities as tolerated)

Question 50

What is a Jones' fracture?

Answer 50

5th metatarsal fracture (risk of poor healing, risk or malunion, need immobilization)

Question 51

What is a Maisonneuve fracture?

Answer 51

Ankle fracture + proximal fibular fracture with tear of interosseus membrane

Question 52

What is a pseudo-Jones fracture?

Answer 52

Pseudo-Jones or Dancer’s fracture = tuberosity avulsion fracture of proximal tubercle of 5th metatarsal (non-union is NOT common)

Question 53

Brace vs. cast for low-risk ankle injuries?

Answer 53

Boutis (Pediatrics 2007): for isolated fibular injuries, SH 1 and 2, avulsion fractures: ankle brace was more effective than casting

Question 54

What is a Lisfranc injury? Complications?

Answer 54

Tarsometatarsal dislocation Always consider this with fractures of the 2nd metatarsal esp at the base Complications: compartment syndrome, injury to dorsalis pedis artery, injury to deep peroneal nerve, post-traumatic arthritis

Question 55

What is a Chance fracture?

Answer 55

Chance fracture results from flexion-distraction mechanism resulting in anterior wedge fracture of vertebral body and horizontal split through and posterior element of a vertebra + associated intra-abdominal injury, *seat-belt sign

Question 56

Imaging choices for suspected SCFE?

Answer 56

Step 1: X-rays 2 views (AP and frog leg) | Step 2: MRI (may pick up “pre-slip” SCFE that are not yet seen on X-rays)

Question 57

4 xray findings in SCFE?

Answer 57

- widening of the physis (epiphysiolysis) - Klein Line - Steel Sign: metaphyseal blanch sign - Southwick Angle: head-shaft angle of the affected side is subtracted from the head-shaft angle of the normal side - Chondrolysis of femoral head/acetabulum - osteonecrosis

Question 58

4 classic risk factors for SCFE?

Answer 58

Male Early adolescent (growth spurt) African American Obese

Question 59

4 RF for SCFE in a younger kid?

Answer 59

Atypical SCFE: - hypothyroidism - GH deficiency - hypopit - steroid use - renal failure

Question 60

4 complications of SCFE?

Answer 60

- AVN of femoral head - leg length discrepancy - chondrolysis - osteoarthritis

Question 61

Tapping a knee - 2 indications.

Answer 61

Remove effusion causing severe pain/ limiting function. Obtain fluid to dx suspected arthritis

Question 62

2 labs to r/o endocrine cause of SCFE?

Answer 62

TSH, free T4

Question 63

Common organisms for septic arthritis?

Answer 63

S. Aureus/Strep pneumo (most common), GAS, Kingella, Neisseria in sexually active teens Salmonella in sickle cell GBS in neonate

Question 64

Work-up of possible septic arthritis?

Answer 64

CBC, diff, blood culture, ESR, CRP, joint aspirate (WBC > 100,000, positive gram stain), +/- Lyme serologies xray, US to detect effusion

Question 65

What is the Kocher criteria?

Answer 65

fever, inability to weight bear, ESR > 40, WBC > 12 ``` 1/4 = 3% 3/4 = 93% 4/4 = 99% ```

Question 66

3 mechanisms for osteomyelitis?

Answer 66

- Hematogenous (most common – bacteria enter at metaphysis) -Direct spread from adjacent infection - Inoculation through penetrating wound Trauma may be a pre-disposing factor

Question 67

Xray findings in osteomyelitis

Answer 67

xrays normal in 1st 10 days deep soft-tissue swelling, elevation of muscle planes from bone, lytic lesions (10-14 days into course), periosteal elevation (day 10-21)

Question 68

Abx choice for osteomyelitis?

Answer 68

Cefazolin (or clindamycin)

Question 69

DDx of polyarthritis?

Answer 69

serum sickness, collagen vascular disease, rheumatic fever and HSP

Question 70

4 complications of septic arthritis?

Answer 70

Acute: osteomyelitis, bacteremia, sepsis Chronic: Growth arrest, joint destruction

Question 71

Why are neonates more at risk for osteomyelitis?

Answer 71

due to thin cortex and transphyseal vessels

Question 72

What are four complications of casting/ splinting?

Answer 72

``` Joint stiffness Muscle atrophy Skin breakdown Tight cast = acute compartment syndrome, pain, compression neuropathy, vascular compromise Pressure ulcers/sores Loss of reduction ```

Question 73

How to handle amputated limb en route to hospital?

Answer 73

Handle the amputated part with care, do not debride it, irrigate with normal saline and pack loosely with sterile saline soaked gauze. Place in a water-tight plastic bag and store in an ice water slurry. Ensure ice does not directly contact the amputated part.

Question 74

What is Osgood Schlatter? How does it present?

Answer 74

apophysitis of the tibial tubercle Localized tenderness at tibial tubercle, pain worse when jumping, squatting, going up stairs. Can develop callus and prominent tibial tubercle

Question 75

What is Sinding-Larsen-Johansson disease

Answer 75

similar to Osgood Schlatter but affecting inferior pole of patella instead. Xray can show fragmentation or small avulsion at distal pole of patella - differentiate from acute sleeve fracture of patella or bipartite patella

Question 76

What is Little league elbow?

Answer 76

medical epicondylitis or apophysitis from repeat valgus stress on elbow (from repeat pitching).

Question 77

What is Thoracic outlet syndrome?

Answer 77

compression of lower roots of brachial plexus (C8 to T1), or axillary vein or artery. Occurs in pitchers, swimmers, weight lifters (repetitive overhead use of arms). Can develop thrombosis of vein +/- embolus .

Question 78

What is a "burner" or a stinger"

Answer 78

Acute brachial plexus injury - from high-impact sports (ie. football), stretching of the brachial plexus. Immediate arm weakness/paralysis, paresthesias or numbness along a dermatome (usually C5 or C6), sx may resolve quickly before ED assessment. R/O c-spine injury.