Orthopedics 2

Question 0

Talipes equinovarus? A.k.a.? Management?

Answer 0

Fixed foot inversion with little ankle flexibility; clubfoot

Casting within the first week of life

Question 1

Metatarsus adductus? Difference from clubfoot? Age of onset? Caused by? Diagnosis? Management? Prognosis?

Answer 1

Medial curvature of the midfoot causing a C-shaped foot that can be straightened by gentle manipulation

Unlike clubfoot, Dorsiflexion is intact

Less than one

Intrauterine constraint

Physical examination (no imaging needed)

1. If foot overcorrects with passive motion – observation only
2. If the foot appropriately corrects with passive motion – stretching exercises
3. If foot cannot straightened – casting

Resolution and almost all patients

Question 2

Internal tibial torsion? Age of onset? Management? Prognosis?

Answer 2

Medial rotation of the tibia (Footpoint flexed inward when knee flexed to 90°)

Less than two years of age

Observation only

Resolution by five years age

Question 3

Femoral anteversion? Age? Clinical features? Management? Prognosis?

Answer 3

Inward angulation of the femur; less than 2 years of age

1. Feet/patella point medially
2. Hips are able to internally rotate more than normal
3. Child sits in “W” position on the floor

Observation only; excellent prognosis with resolution by 8

Question 4

Out-toeing – clinical features? major cause? Due to? Management? Prognosis?

Answer 4

1. Flexible foot with toes pointed outward
2. restricted plantar flexion
3. Excessive dorsiflexion (dorsum of foot can be placed into contact with shin)

Calcaneovalgus foot (flexible foot held in lateral position)

Stretching the foot; excellent prognosis

Question 5

Genu varum? Age? Clinical features? Diagnosis? Management? Prognosis?

Answer 5

Bowed legs; children younger than two (normal until two years of age)

1. Cowboys chance – when standing with together, knees laterally and the patella points forward
2. Normal gait (if not normal, consider Blount’s disease)

Diagnosis from physical exam

Observation; resolution by two years of age

Question 6

Blount’s disease – A.k.a.? Typical patient? Theorized pathogenesis? Clinical features? Suspect in any child with? Diagnosis? Management?

Answer 6

Tibia vara; Obese african-American boys who are early walkers

Overload Injury to the medial tibial complete (inhibits growth to medial side)

1. Angulation below knee
2. Lateral thrust with gait

Any child with

1. progressive bowing
2. unilateral bowing
3. persistent bowing after 2 years

Metaphysical-diaphyseal angle >11°

1. Bracing if M-D angle is greater than 16° or patient is 2-3 years of age
2. Surgery if child is older than four, recurrence, or no improvement with bracing

Question 7

Genu Valgrum – A.k.a.? Age? Clinical features? Most common cause? Diagnosis? Management? When to perform surgery?

Answer 7

Knock-knees ; 3-5; overcorrection of normal Genu varum

1. Separation of ankles when standing correct with these together
2. Swinging of legs laterally when walking

Physical exam

Observation; surgery if persists beyond 10 years or causes pain

Question 8

Osgood-Schlatter? Age? Typical patient? Clinical features? Pain worsens with? Management?

Answer 8

Inflammation/microfracture of tibial tuberosity due to overuse

10-17 years; athletes

1. Swelling of tibial tuberosity and the pain quick point tenderness over to be a typical
2. Pain occurs with extension of knee against resistance
3. Worsens with running, jumping, kneeling

Rest

Question 9

Patellofemoral syndrome? Typical patient? Clinical features? Radiograph may show? Management?

Answer 9

Slight malalignment of the patella that causes me pain

Adolescent girls

1. The pain directly under patella
2. Pain is worse with walking up and down stairs

Patellar in lateral position

Rest/stretching

Question 10

Growing pains – age? occur at what time of day? Does not interfere with? Physical exam findings?

Answer 10

Idiopathic bilateral leg pain; 4-12 years; pain in afternoon/evening (child may awaken at night in pain)

Does not interfere with play during the day

Physical exam is normal

Analgesics and reassurance

Question 11

Displaced fracture?

Angulated fracture?

Answer 11

Fractured ends are shifted

Fractured ends form an angle

Question 12

Greenstick fracture?

Answer 12

Only one side of the cortex is fractured

Question 13

Physeal fracture involves?

Salter-Harris Classification?

Answer 13

Growth plate

SALTR

1. Same – fracture within physis
2. Above – fracture is in physis and above into metaphysis
3. Low – fracture is in physis and below into Epiphysis
4. Through and through – fracture is in physis through the metaphysis and the epiphysis
5. cRush – crushing the physis

Question 14

Clavicular fracture – clinical features in infants? Older children? Diagnoses? Management?

Answer 14

1. Infants – asymmetric moral reflects for pseudoparalysis (refusal to move extremity because of pain). Crepitus
2. Children hold affected limb with opposite hand. Head tilted toward affected side

Radiographs

Sling for 4 to 6 weeks (neonates do not require treatment)

Question 15

Supracondylar fracture – type of fall? Emergency if? (Because?) Clinical features? Sign on radiograph? Management?

Answer 15

Child falls onto outstretched arm/elbow

Emergency fracture is displaced/angulated because of risk of neurovascular injury compartment syndrome

1. Point tenderness, swelling, deformity of the elbow
2. Possible neurovascular injury – can stretch radial or median nerves/brachial artery
3. Possible compartment syndrome – pain with passive extension of the fingers

Posterior fat pad sign on x-ray

Never passively move arm (further neurovascular injury)

If displaced or angulated – requires surgery. Otherwise cast

Question 16

Compartment syndrome? 5 P’s of late compartment syndrome? Most sensitive indication of impending compartment syndrome?

Answer 16

Pressure within anterior fascial compartment is greater than 30-45 mm Hg

Pallor, pulselessness, paralysis, pain, paresthesias

Pain with passive extension fingers

Question 17

Forearm fractures?

Answer 17

1. Colles fracture – fractured distal radius
2. Monteggia – Fracture of proximal ulna with dislocation of radial head
3. Galeazzi – Fracture of radius with distal radioulnar joint dislocation

Question 18

Toddlers fracture? Age? Clinical features?

Answer 18

Spiral fracture of the tibia

Nine months to 3 years

Child refuses to bear weight but is willing to crawl. Erythema, swelling and mild point tenderness

Question 19

Branches typical of child abuse?

Answer 19

1. Metaphyseal fractures
2. Posterior or first rib fractures
3. Multiple fractures at various ages
4. Complex skull fractures
5. Scapular, sternal, or the vertebral spinous process fractures