Peds EOR - MSK conditions
Developmental dysplasia of the hip (DDH) is a disorder characterized by abnormal positioning of the ______________ in the acetabulum of the pelvis
femoral head
Legg-Calvé-Perthes disease is a childhood hip disorder involving idiopathic osteonecrosis in the _____________
femoral head
Long-term concerns with Legg-Calvé-Perthes disease include permanent __________ deformity and increased risk of osteoarthritis in adulthood.
femoral head
Lumbar lordosis may be treated by strengthening the hip extensors and by stretching the hip ____________.
flexors
Legg-Calvé-Perthes disease is most commonly found in children __________ years old.
four to ten
Genu varum in Blount's disease is caused by ________ deformities in the proximal tibia.
growth plate
Slipped capital femoral epiphysis involves a fracture through the _____________ which causes slippage of the overlying end of the femur (epiphysis).
growth plate
Slipped capital femoral epiphysis is most common in 7-16y obese male during:
growth spurt, jumping activities
Hip dysplasia is a congenital or developmental deformation or misalignment of the ___________.
hip joint
Treatment of congenital hip dysplasia depends on age of diagnosis 6-15 months old:
hip spica cast
Hip x-rays of a patient with slipped capital femoral epiphysis reveal the femoral head posterior and (superior/inferior) to the femoral neck within the hip capsule.
inferior
In osteochondritis dissecans, patients present with swelling and pain of the joint that worsens with physical activation; however, on physical exam, these patients have an ___________________.
intact full range of motion
Genu valgum is a condition in which the knees angle ________ and touch while the legs are straightened.
inward
Normal lordosis refers to ____________ curvature of the lumbar and cervical spine.
inward
Excessive curvature of the thoracic or sacral spine is known as ___________________.
kyphosis
Normal ______________ refers to outward curvature of the thoracic and sacral spine.
kyphosis
________________is a finding in the metabolic enzyme deficiency homocystinuria
kyphosis
What is the most common area of the knee to get Osteochondritis Disssecans (OCD)?
lateral aspect of the medial condyle
Osgood-Schlatter disease is diagnosed with ___________________.
lateral radiograph of the knee
Excessive lower back curvature is known as lumbar ___________________, which features significant forward pelvic tilt, resulting in the pelvis resting atop the thighs.
lordosis
Normal __________refers to inward curvature of the lumbar and cervical spine.
lordosis
Visual presentation of __________ appears as an abnormally large lower back arch with the patient appearing to puff out both stomach and buttocks.
lordosis
Osgood-Schlatter disease may present with pain on resisted knee extension with ___________ below the knee and prominent tibial tuberosity.
lump
Treatment of radial head subluxation involves ________________.
manual reduction.
Slipped capital femoral epiphysis is a hip disorder common in adolescents in which the head of the femur slips off the neck of the femur inferiorly and posteriorly, often due to_______________________.
mechanical overload
Osgood-Schlatter disease results from repetitive traction of the apophysis of the tibial tuberosity resulting in _____________ and micro-avulsion - the proximal patellar tendon insertion separates from the tibial tubercle.
microtrauma
Scheuermann's kyphosis appears to be of ______________ etiology with higher incidence in males.
multifactorial
An X-ray of nursemaid elbow will typically be (normal/abnormal).
normal
Slipped capital femoral epiphysis commonly presents with ipsilateral groin pain, but may also cause knee or thigh pain along the distribution of the ___________ nerve.
obturator
Treatment of congenital hip dysplasia depends on age of diagnosis 15-24 months old:
open reduction followed by hip spica cast
Long-term concerns with Legg-Calvé-Perthes disease include permanent femoral head deformity and increased risk of ___________ in adulthood.
osteoarthritis
Legg-Calvé-Perthes disease is a childhood hip disorder involving idiopathic ____________ in the femoral head.
osteonecrosis
Osteochondritis dissecans is ___________ of subchondral bone that occurs most frequently in patients between the ages of 10-20.
osteonecrosis
Slipped capital femoral epiphysis requires emergent stabilization and surgical intervention to avoid _____________ in the femoral head.
osteonecrosis
Genu varum. is a physical deformity marked by (____________) bowing of the lower leg in relation to the thigh.
outward
Normal kyphosis refers to ______________ curvature of the thoracic and sacral spine.
outward
Osgood-Schlatter disease is inflammation of the ________________ at the tibial tuberosity.
patellar ligament
Excessive lower back curvature is known as lumbar hyperlordosis, which features significant forward___________, resulting in the pelvis resting atop the thighs.
pelvic tilt
Hip x-rays of a patient with slipped capital femoral epiphysis reveal the femoral head (anterior/posterior) and inferior to the femoral neck within the hip capsule.
posterior
On physical exam, the forearm of a child with nursemaid elbow will be in incomplete extension with the forearm partially (pronated/supinated).
pronated
Common mechanisms for _______________ injuries include an adult tugging on an uncooperative child or swinging a child by the arms during play.
radial head subluxation
_____________ is a dislocated elbow joint caused by a sudden pull on an extended pronated forearm.
radial head subluxation
X-rays are (always/rarely) necessary for diagnosing genu varus or valgum.
rarely
Children with nursemaid elbow typically present with the complaint of _____________.
refusal to use an arm
A greater than 70-degree curvature of the spine is associated with poor ____________________ in adulthood.
respiratory function
Scoliosis is associated with (restrictive/obstructive) lung disease.
restrictive
Genu varum usually results from three causes: occupational conditions, __________, or trauma.
rickets
At routine screening, a patient is asked to flex forward and the scapula height is observed (known as Adam's test) if scoliosis is present: asymmetry in ___________ is noted.
scapular height
Somatropin (growth hormone) therapy can lead to ____________ due to rapid, uneven growth of the vertebrae.
scoliosis
The spinal curvature can be measured using the Cobb angle, which is typically greater than 10 degrees in patients with ____________.
scoliosis
In _________________, the femoral epiphysis remains in the acetabulum (hip socket), while the metaphysis moves anteriorly with external rotation.
slipped capital femoral epiphysis
__________________ is the most common hip disorder in adolescence.
slipped capital femoral epiphysis
Genu valgum is (never/sometimes) physiologically normal during childhood development.
sometimes
Osteochondritis dissecans is osteonecrosis of ______________ that occurs most frequently in patients between the ages of 10-20.
subchondral bone
In osteochondritis dissecans radiographs will show __________________ of the affected area though radiographs may be normal during the early stages of the disease.
subchondral radiolucency
The ________________ is the classic method of reducing a subluxed radial head. It has a success rate of 80-92%.
supination-flexion technique
Treat Slipped capital femoral epiphysis with _______________ for all patients
surgical fixation with screw
40 degrees and greater curvature of the spine is resistant to bracing and requires ________________, which is best done at special centers.
surgical fixation with spinal fusion
An exercise that is recommended during treatment of Legg-Calvé-Perthes disease is ___________, due to its effect on mobility with minimal impact on the joints.
swimming
Physiologic genu varum is an infantile condition that is usually self-correcting by ____________ years of age.
three to four
Genu varum in Blount disease is caused by growth plate deformities in the proximal _______ bone.
tibia
Osgood-Schlatter disease is inflammation of the patellar ligament at the __________________.
tibial tuberosity
Osgood-Schlatter disease may present with pain on resisted knee extension with lump below the knee and prominent ______________.
tibial tuberosity
One of the methods of treatment of Legg-Calvé-Perthes disease is __________, which involves moving the femur away from the pelvis to decrease the wear on the bone.
traction
Genu valgum is a normal condition in children (age range) ____________ years old, nearly always resolving with age.
two to five
In adolescents or adult patients, genu varum may require a _______________ for permanent correction.
valgus osteotomy
At birth, the normal knee position is (varus/valgus) _________.
varus
Slipped capital femoral epiphysis often presents with an antalgic or _____________ gait with externally rotated leg on the affected side.
waddling
Most cases of genu valgum resolve (with surgery/without intervention overtime).
without intervention overtime
Genu varum, also called ________________, is a physical deformity marked by (outward) bowing of the lower leg in relation to the thigh.
bow-leggedness
20 to 40 degrees curvature of the spine is an indication for ________ in an immature child
bracing
Idiopathic scoliosis can be treated with observation, _______________, or surgical intervention.
bracing
The spinal curvature can be measured using the Cobb angle, which is typically greater than ___ degrees in patients with scoliosis.
10
Curves of 10-15 degrees are treated by _______________________ with clinical evaluation and possible x-ray.
6-12 month follow-up
A test of dislocation applied to dislocatable (but not already dislocated) hips
Barlow's test
Hip dysplasia affects females over males at a(n) ____ ratio.
8:1
The major complication of slipped capital femoral epiphysis is: A. Avascular necrosis of the hip B. Osteochondritis dissecans C. Leg-length discrepancy D. Transient synovitis of the hip E. Intoeing
A (Avascular necrosis of the hip)
A 10-year-old girl comes to the clinic because her father noticed a curve in her spine. The patient denies shortness of breath or cardiac palpitations. Her temperature is 37.1°C (98.8°F), pulse is 90/min, respirations are 20/min, and blood pressure is 108/72 mm Hg. Physical examination shows a well appearing girl with a spinal curve that ranges laterally from T6-T10, with the convexity of the curve to the right, resulting in a dextroscoliosis. Which of the following is a correct component of measuring the Cobb angle? A. Draw a parallel line on the superior aspect of the most superior vertebrae B. Draw a parallel line from the apex vertebral segment of the curve C. Measuring the degree of curvature based on leg length discrepancy and sacral base unleveling D. Draw a parallel line on the inferior aspect of the most superior vertebrae E. Draw a parallel line on the superior aspect of the most inferior vertebrae
A (Draw a parallel line on the superior aspect of the most superior vertebrae) (The severity of scoliosis is based on the determination of the Cobb angle, which is found by measuring the intersection of parallel lines drawn from the superior endplate of the superior segment of the curve and the inferior endplate of the inferior segment of the curve) (Scoliosis is a deformity of the spine that is most often idiopathic, but can be associated with other musculoskeletal conditions. Idiopathic scoliosis is usually painless and adolescent girls tend to be most affected. A lateral curve is named according to the convexity of the curve. A left sided convexity is a "levoscoliosis," while a right sided convexity is a dextroscoliosis) (The Cobb angle is used to assess the severity of scoliosis. It is calculated by measuring the intersection of parallel lines drawn from the superior endplate of the superior segment of the curve and the inferior endplate of the inferior segment of the curve. A Cobb angle of between 5 and 15 degrees indicates mild scoliosis. Moderate disease is present if the Cobb angle is found to be between 20 and 45-50 degrees. Scoliosis is severe if the angle is greater than 45-50 degrees. Moderate to severe scoliosis can present with difficulty breathing or cardiac insufficiency secondary to compression. Most commonly, scoliosis presents due to an asymmetry noticed on clinical exam)
Abduction of the flexed hip of a 1-month-old elicits a "clunk." What test is this and what does it assess? A. Ortolani sign; developmental dysplasia of the hip B. Lachman test; slipped capital femoral epiphysis C. Galeazzi test; Legg-Calvé-Perthes disease D. Pavlik's sign; Osgood-Schlatter disease
A (Ortolani sign; developmental dysplasia of the hip)
Flex and adduct hips, apply light pressure on knees, directing force posteriorly. Test is positive if hip dislocates posteriorly
Barlow's test
Curves of 15-20 degrees need serial _________________ every 3-4 months for larger curves and every 6-8 months for small curves or for patients near the end of growth
AP radiographic follow-up
First-line treatment for Osgood-Schlatter disease is conservative: ______________________.
Analgesics, ice, and physical therapy
Which thoracic curvature is an indication for treatment with bracing in an adolescent with scoliosis? A. Less than 20 degrees B. 20 to 40 degrees C. 40 to 60 degrees D. 40 degrees with lumbar curvature of 30 degrees E. Greater than 70 degrees
B (20 to 40 degrees) (Scoliosis is defined by lateral curvature of the spine with rotation of vertebrae and is typically located in thethoracic or lumbar spine in the right or left directions. Idiopathic scoliosis most commonly presents as a right thoracic curve in females from 8 to 10 years of age. Scoliosis is typically asymptomatic unless curvatures are so severe that there is pulmonary dysfunction or there is an underlying disorder (bone or spinal tumor) that is causing the scoliosis. X-rays need to be taken of the entire spine to help determine the degree of curvature)
A 5-year-old boy comes to the office because of a limp for 3 weeks. History is unremarkable for trauma or recent illness. Past medical history includes attention deficit hyperactivity disorder, but no regular medications. Vital signs are within the normal ranges. Examination shows a painless limp of the left lower extremity with limited *internal rotation* and *abduction* of the left hip joint. A Pelvic X-ray shows some degree of collapse and deformity of the femoral head secondary changes to the shape of the hip socket. Which of the following is the most appropriate treatment in this patient? A. Antibiotics B. Bracing with partial weight bearing C. Observation D. Pavlik harness E. Surgery
B (Bracing with partial weight bearing) (Legg-Calve-Perthes disease patients who have lost range of motion and have a radiograph demonstrates moderate femoral head involvement,should be initially treated with bracing with partial weight bearing) (Legg-Calvé-Perthes disease is a childhood hip disorder initiated by a disruption of blood flow to the ball of the femur called the femoral head. Due to the lack of blood flow, the bone dies (osteonecrosis or avascular necrosis) and stops growing. Over time, healing occurs by new blood vessels infiltrating the dead bone and removing the necrotic bone which leads to a loss of bone mass and a weakening of the femoral head. The bone loss leads to some degree of collapse and deformity of the femoral head and sometimes secondary changes to the shape of the hip socket. It is also referred to as idiopathic avascular osteonecrosis of the capital femoral epiphysis of the femoral head since the cause of the interruption of the blood supply of the head of the femur in the hip joint is unknown) (Since this patient has lost range of motion (abduction and internal rotation), simply observing him is not enough. Bracing with the use of a Petrie cast keeps the hips in abduction and holds the femoral head in concentric alignment with the acetabulum. The patient is also placed on crutches to limit the amount of weight transferred through the hip. If the patient had limited femoral head involvement or full range of motion, observation with close follow-up would be appropriate)
A 1-month-old infant is brought to the pediatrics department by his parents for a routine examination. He is their first child, a result of a healthy pregnancy with no complications. His mother was properly immunized and was negative for Group B streptococcus colonization. On examination, the child is alert with positive Moro, Babinski, and grasp reflexes. Pulmonary, cardiac, and abdominal examinations are unremarkable. His left leg appears shorter than his right and a clunk is noted during Ortolani examination. Which of the following is a risk factor for the most likely diagnosis? A. Asian American ethnicity B. First-born C. Macrosomia D. Male gender E. Vaginal delivery
B (First-born) (Developmental dysplasia of the hip (DDH) is defined as the abnormal development of the hip joint. Remember the four F's to remember risk factors for developmental dysplasia of the hip: First (firstborn), Female, Family history, Feet first (Breech). (Developmental dysplasia of the hip (DDH) is defined as the abnormal development of the hip joint. The ball of the femur is loose in the socket, which poses a great risk to dislocation. Physical examination of developmental dysplasia of the hip can be characterized by gluteal fold asymmetry and/or leg length discrepancy. Physical examination maneuvers, such as Barlow and Ortolani techniques, can also help with the diagnosis of DDH. With the Ortolani maneuver, a clunk noise suggests the relocation of the head of the femur) (Risk factors for DDH include: firstborn infants, female (80% of all DDH), family history, and feet first (Breech presentation). For the first four months, you need ultrasound to confirm your exam findings as bones are not yet sufficiently ossified)
A 6-year-old comes to the clinic with a limp and left knee pain. He is notably short for his age. The pain is worse after soccer practice and exacerbated by internal rotation of his hip. At times the pain is severe enough that he refuses to walk. His temperature is 37.1°C (98.8°F), pulse is 102/min, respirations are 24/min, and blood pressure is 102/74 mm Hg. A hip radiograph is obtained and shows the left proximal femoral epiphysis to be misshapen and more horizontal compared to the unaffected right hip, the femoral head appears collapsed. Which of the following is the most appropriate next step in management? A. Magnetic resonance imaging of the knee B. Limit activity and start physical therapy C. Physical therapy and corticosteroids D. Reassurance that these are normal "growing pains" E. Start antibiotic therapy
B (Limit activity and start physical therapy) (Legg-Calve-Perthes disease is an avascular necrosis of the femoral head in children. It commonly presents as hip pain, but can be referred to the knee or groin, and is accompanied by a limp and limited range of motion at the hip joint) (Legg-Calve-Perthes disease is an idiopathic avascular necrosis of the capital femoral epiphysis in children, most commonly between 4 and 8 years old. It commonly presents as hip pain, but can be referred to the knee or groin, and is accompanied by a limp and limited range of motion at the hip joint. Risk factors include low birth weight and delayed skeletal maturity. It is diagnosed by pelvic X-ray, which shows collapse and fragmenting of the femoral head) (Treatment goals are to decrease pain and prevent femoral head deformity. Mechanical pressure on the joint should be reduced, which can be aided by bedrest, limitation of running and contact sports, overnight traction devices, physical therapy, and braces. Children older than 7 or 8 are at increased risk for a deformed hip joint, arthritis as adults and the need for surgical realignment with osteotomy or surgical contracture release. When possible, referral to an orthopedic specialist is indicated)
A 3-year-old boy is brought to the office because of pain in his left elbow. Father of the patient says that after picking up the boy from day care, he noticed his son was not moving his elbow and complained of pain. Patient is holding his left elbow flexed and pronated. Physical examination shows tenderness over the lateral aspect of the left elbow joint on palpation. Which of the following is the most appropriate next step in management? A. Recommend analgesics and rest B. Closed reduction via pronation and extension C. Closed reduction via supination and flexion D. Orthopedic cast E. Splint
C (Closed reduction via supination and flexion) (Closed reduction via supination and flexion is one of the two main methods for reduction in nursemaid's elbow, which is dislocation of the elbow joint caused by a sudden pull on the extended pronated forearm) (Nursemaid's elbow is dislocation of the elbow joint caused by a sudden pull on the extended pronated forearm. The technical term for the injury is radial head subluxation and it is a common pediatric presentation. The etiology is slippage of the head of the radius under the annular ligament. The classic mechanism of injury is longitudinal traction on the arm with the wrist in pronation. Nursemaid's elbow is characterized by significant pain, partial limitation of flexion/extension of the elbow, or total loss of pronation/supination in the affected arm. The diagnosis is made clinically and radiography is unnecessary, unless is needed to exclude fractures or other dislocation. Management involves reduction via either hyperpronation or a combination of supination and flexion. For the latter, support the child's arm at the elbow and exert moderate pressure over the radial head with one hand. With the other hand, hold the child's distal forearm and gently apply traction. While maintaining traction, fully supinate the forearm and flex the elbow in a single motion)
A 5-year-old boy comes to the clinic with his father because he has been limping for three weeks. Past medical history includes attention deficit hyperactivity disorder, but the boy does not take any medications. History is unremarkable for trauma or recent illness. His temperature is 37.1°C (98.8°F), pulse is 90/min, respirations are 22/min, and blood pressure is 100/70 mm Hg. Physical examination shows a painless limp of the right lower extremity with limited internal rotation and abduction of the right hip joint. A hip radiograph is obtained and shows the right proximal femoral epiphysis to be misshapen and more horizontal compared to the unaffected hip, the femoral head appears collapsed. Which of the following is the most likely diagnosis? A. Achondroplasia B. Developmental dysplasia of the hip C. Legg-Calve-Perthes disease D. Septic arthritis E. Slipped capital femoral epiphysis
C (Legg-Calve-Perthes disease) (Legg-Calve-Perthes disease is an idiopathic avascular necrosis of the proximal femoral epiphysis. A characteristic painless limp causes decreased internal rotation and abduction. Risk factors include ADHD and a positive family history. Hip radiograph demonstrates a misshapen, horizontal growth plate and a flattened femoral head) (Legg-Calve-Perthes disease is an idiopathic avascular necrosis of the proximal femoral epiphysis. It is believed to be the result of a disruption of the vascular supply to the femoral head. As the proximal femoral epiphysis undergoes necrosis, the morphology of the femoral head changes so that it loses its spherocity. This condition can lead to early degenerative hip joint disease, which can be catastrophic to a child's life. It occurs with a 5:1 ratio of boys to girls and is most commonly seen from 4-10 years of age. There is an increased incidence in patients with a positive family history, exposure to cigarette smoke, and low birth weight) (Patients typically present with a painless limp of an insidious onset, which may be accompanied by intermittent knee or thigh pain. They lose internal rotation and abduction as the femoral head undergoes morphologic changes.) (Radiographs of the pelvis are required to evaluate the morphology of the femoral head and to visualize the proximal femoral epiphysis. Characteristic signs on radiograph include a misshapen proximal femoral epiphysis that is horizontal compared to the unaffected hip, and an aspherous femoral head which appears collapsed (image))
A 11-year-old boy with obesity is brought to the emergency department because of antalgic gait and left knee pain for the past week. The patient rates the pain as an 8 on a 10-point scale. Medical history is noncontributory. Physical examination shows a painful left hip on palpation and a restricted range of motion on manipulation. Further examination of the knee shows no gross effusion or deformity. A pelvic x-ray is obtained and is shown below. Which of the following is the most appropriate next step in management? A. Antibiotic management B. Immobilization C. Open reduction internal fixation D. Pain management E. Weight loss
C (Open reduction internal fixation ) (Open reduction internal fixation is the most appropriate first step in management of patients with slipped capital femoral epiphysis, which is characterized by waddling gait, decreased range of motion, and bilateral groin pain in the thigh or knee) (Slipped capital femoral epiphysis (SCFE) is a Salter-Harris type 1 fracture through the proximal femoral physis, which results in slippage of the epiphysis. SCFE is the most common hip disorder in adolescence and is characterized by waddling gait, an acute or insidious onset of a limp, decreased range of motion, and bilateral groin pain in the thigh or knee. The diagnosis is a combination of clinical suspicion plus a pelvic radiography with anterior-posterior (AP) and "frog-leg" lateral views. SCFE is treated with external in-situ pinning, or open reduction and pinning. Consultation with an orthopaedic surgeon is necessary to repair this condition, which makes this the most appropriate first step in management. Pinning the unaffected side prophylactically is not recommended for most patients, but is appropriate if a second SCFE is very likely. Once SCFE is suspected, is recommended that the patient begins with non-weight bearing positions and remain on strict bed rest. Physical therapy is recommended once the initial symptoms have improved to prevent recurrence, to regain strength, and movement back to the leg)
A 13-year-old boy presents to the clinic for a complaint of right knee pain that he first noticed about a year ago. It started out as mild discomfort in the area just below the kneecap, but has been getting progressively worse. Now, it hurts anytime he uses his leg, even when walking. He does not remember any injury to his knee. On examination of his knee there is swelling and exquisite tenderness over the tibial tubercle. Radiographs are normal. What is the most likely diagnosis? A. Chondromalacia patellae B. Legg-Calvé-Perthes disease C. Osgood-Schlatter disease D. Patellar dislocation
C (Osgood-Schlatter disease) (Osgood-Schlatter disease is caused by microfractures of the patellar ligament where it inserts into the tibial tubercle. This condition usually occurs in the preteen and adolescent years, and is more common in males than females. The history of injury can be vague and the patient may not remember a specific injury that precipitated the pain. Often, the pain progresses to the point of interference of even routine physical activities. X-rays may or may not show any abnormalities. Upon x-ray, type I disease appears normal, but type II will reveal fragmentation of the tibial tubercle. Often, after healing there will be enlargement of the tibial tubercle. Generally, treatment consists of rest, limitation of activities, and isometric exercises. Chondromalacia patellae can only be diagnosed under an arthroscopic examination, not on the basis of clinical features. Patellofemoral overuse syndrome presents with medial knee pain and subpatellar pain. Additional signs are swelling and crepitus in the knee and it is more common in females than males. It is diagnosed by increased Q-angles (anterosuperior iliac spine through center of patella to tibial tubercle). Subluxation of the patella or dislocation is more common in adolescent girls and the patient presents with acute knee pain. The knee is in flexion with a mass lateral to the knee and with absence of the bony prominence of the patella (flat). X-ray confirms the dislocation. Legg-Calvé-Perthes disease is avascular necrosis of the proximal femur and usually presents between 4 and 8 years of age)
A 2-year-old girl is brought in to the emergency department because of immobility in her left arm for the past 3 hours.Three hours ago patient, and her father, were playing in the park where he held her by the hands and swung her around. During this, she momentarily let go with her right hand. Afterwards, she refused to use her left arm and cried at any attempt to move it. Patient is sitting in her father's lap, in no acute distress, and holding her left arm slightly flexed across her belly. Which of the following is the most appropriate next step in management? A. Analgesic B. Orthopedic cast C. Reduction D. Splint E. Vitamin K
C (Reduction) (Reduction is the most appropriate first step in managment of nursemaid's elbow, which is a dislocation of the elbow joint caused by a sudden pull on the extended pronated forearm. The two main methods for reduction are hyperpronation and a combination of supination/flexion) (Nursemaid's elbow is a dislocation of the elbow joint caused by a sudden pull on the extended pronated forearm. The technical term for the injury is radial head subluxation and is a common pediatric presentation, generally occurring between the ages of 1 and 3 years old. The etiology is slippage of the head of the radius under the annular ligament. The classic mechanism of injury is longitudinal traction on the arm with the wrist in pronation. Other mechanisms include falling onto the elbow, direct trauma to the elbow, or twisting of the arm, which leads to the radial head being pulled out of the annular ligament. Nursemaid's elbow is characterized by significant pain, partial limitation of flexion/extension of the elbow, or total loss of pronation/supination in the affected arm. In radial head subluxation, the child stops using the arm, which is held in flexion and pronated. There is minimal swelling and all the movements are permitted, except supination. The diagnosis is made clinically and radiography is unnecessary, unless is needed to exclude fractures or other dislocation. For management, reducion is made and the two main methods are hyperpronation and a combination of supination/flexion)
What condtition? Osteonecrosis or avascular necrosis of the subchondral bone caused by repetitive small stresses or trauma, disrupting blood supply thus bone death. Ultimately, bone separates from living bone via fibrous healing.
Osteochondritis Disssecans (OCD)
The spinal curvature can be measured using the ____________ , which is typically greater than 10 degrees in patients with scoliosis.
Cobb angle
A 4-month old female with asymmetric thigh creases during a routine checkup. Physical exam reveals that the left lower limb is shorter than the right and lay externally rotated. Hip abduction is limited to 30 degrees. Ortolani's test is positive producing a soft "clunk" with anterior relation of the femoral head into the acetabulum. Radiographs reveal a superiorly displaced left proximal femoral metaphysis and a shallow, hypoplastic left acetabulum. The infant is treated in a Pavlik abduction harness for congenital hip dislocation. What is the most likely diagnosis?
Congenital hip dysplasia
A 3-year-old boy is brought to the clinic because of left elbow pain. Father of the patient says that after picking up the boy from day care, he noticed his son was not moving his elbow and complained of pain. Patient is holding his left elbow flexed and pronated. Physical examination shows tenderness over the lateral aspect of the left elbow joint on palpation. Which of the following is the most likely diagnosis? A. Elbow dislocation B. Lateral condylar physeal fracture C. Medial condylar physeal fracture D. Radial head subluxation E. Supracondylar humeral fracture
D (Radial head subluxation)
_______________ is a congenital or developmental deformation or misalignment of the hip joint.
Hip dysplasia
_____________________ is the most appropriate first step in management of patients with slipped capital femoral epiphysis, which is characterized by waddling gait, decreased range of motion, and bilateral groin pain in the thigh or knee)
Open reduction internal fixation
Lay infant supine, flex hips and knees to 90 degrees, apply anterior pressure on the greater trochanters using index fingers, gently abduct the hips using thumbs.
Ortolani's test
Produces soft "clunk" with anterior relation of the femoral head into the acetabulum.
Ortolani's test
a test of reduction applied to an already dislocated hip
Ortolani's test
Which of the following statements about scoliosis is true? A. The most common form is congenital B. The patient has a normal Adam's test C. Patients with abnormalities > 5 degrees should be referred to an orthopaedist D. Most curvature is to the right in the thoracic spine, causing the right shoulder to be higher than the left E. Syringomyelia is not associated with scoliosis
D (Most curvature is to the right in the thoracic spine, causing the right shoulder to be higher than the left) (Scoliosis is defined as the presence of a lateral spinal curvature of 11 degrees or more. Its prevalence during adolescence is estimated to be between 2% and 3%. Curvatures > 100 degrees can contribute to restrictive pulmonary disease; however, deviations of this magnitude are extremely rare. Scoliosis is classified as idiopathic (80% of cases), congenital (5%), neuromuscular (10%), or miscellaneous (5%). Severe scoliosis is more common in female patients. Idiopathic scoliosis is an inherited autosomal-dominant condition that occurs with variable penetrance. Most patients are asymptomatic; however, they may report backaches. The child should be examined with his or her back facing the examiner. The patient is asked to flex forward, and the scapula height is observed (known as the Adam's test). If scoliosis is present, asymmetry in scapular height is noted. In most cases, the right shoulder is higher than the left because of a convex curve of the spine to the right in the thoracic area and to the left in the lumbar area. Hip height and symmetry may also be affected. Radiographs should only be considered when a patient has a curve that might require treatment or could progress to a stage requiring treatment (usually 40 to 100 degrees). Radiographs should include posteroanterior and lateral views of the spine with the patient standing. Magnetic resonance imaging should be obtained in patients with an onset of scoliosis before 8 years of age, rapid curve progression of more than 1 degree/ month, an unusual curve pattern such as left thoracic curve, neurologic deficit, or pain. Treatment depends on the degree of curvature. The primary goal of treating adolescent idiopathic scoliosis is preventing progression of the curve magnitude. Curves < 10 to 15 degrees require no active treatment and can be monitored unless the patient's bones are very immature and progression is likely. Moderate curves between 25 and 45 degrees in patients lacking skeletal maturity used to be treated with bracing, but this treatment has never been proven to prevent curve progression. Poor compliance with wearing a brace obviates any potential usefulness of the therapy. Much controversy surrounds brace indications, and trends since the mid-1980s have moved toward no bracing or bracing only the more significant curves (20 to 50 degrees). In more severe cases, braces (e.g., Milwaukee brace) or surgery may be indicated. Painful scoliosis may indicate underlying neurologic problems, such as syringomyelia or spinal cord lesion, and is less likely to be idiopathic)
A 13-year-old girl is evaluated by an orthopedic surgeon for knee pain. She thinks that the pain started after she fell while playing basketball during gym class 4 months ago. At the time she was evaluated and diagnosed with a muscle strain and told to rest and ice the joint. Since then the pain has gotten progressively worse and interferes with her ability to participate in gym. She has otherwise been healthy and does not take any medications. On physical exam, she is found to have mild swelling and erythema over the left knee. The joint is found to have an intact full range of motion as well as tenderness to palpation on both the medial and lateral femoral condyles. Radiograph shows a crescent-shaped radiolucency in the subchondral bone of the femur with the remainder of the radiograph being normal. Which of the following disorders is most likely responsible for this patient's symptoms? A. Anterior cruciate ligament injury B. Ewing sarcoma C. Osgood-Schlatter disease D. Osteochondritis dissecans E. Osteogenesis imperfecta
D (Osteochondritis dissecans) (This patient with knee pain, intact range of motion, tenderness to palpation, and subchondral lucency on radiograph most likely has osteochondritis dissecans)
A 40-year-old woman comes to the clinic because of an annual physical. She is up to date on all vaccinations and health care maintenance with no other complaints or significant findings on examination. At the conclusion of the visit, she states that she recently received notice that her daughter's school district will be starting routine screening for scoliosis. She asks what the recommendations are for screening asymptomatic scoliosis. Which of the following is the most appropriate response? A. All children at age 10 are screened and referred with cobb angle >5 B. All professional societies recommend against routine scoliosis screening. C.Girls and boys are screened at ages 15 and 16, respectively D. Girls are screened twice at age 10 and 12; boys once at age 13-14 E. Only children with a family history of scoliosis are screened
D (Girls are screened twice at age 10 and 12; boys once at age 13-14) (While controversially discussed, current recommendations suggest screening for scoliosis for boys at age 13 or 14 years, and for girls twice, at ages 10 and 12 years) (Adolescent idiopathic scoliosis (AIS) is the most common form of idiopathic scoliosis, accounting for 80 - 85% of cases. About 3% of adolescents has AIS with a Cobb angle ≥10º, but only 10% of cases require treatment) (Untreated scoliosis can either be stable or progressive. Curves progress in about two-thirds of patients before skeletal maturity. The magnitude of progression varies depending upon sex, curve magnitude at presentation, curve pattern, and remaining growth potential (younger > older). Progression is associated with cardiopulmonary dysfunction, early death, and/or pain) (There is much debate about the benefits and limitation of scoliosis screening. However, the American Academy of Orthopaedic Surgeons (AAOS), the Scoliosis Research Society (SRS), the Pediatric Orthopaedic Society of North America (POSNA), and the American Academy of Pediatrics (AAP) recognize that the potential benefits of early treatment of scoliosis can be substantial and support a common screening recommendation. They suggest that girls should be screened (twice) at ages 10 and 12 years and boys at age 13 or 14 years. The forward bend test should be included in screening, and screening personnel should be educated regarding the detection of spinal deformity)
A 12-year-old girl comes to the clinic because of back pain. History reveals the pain began during her physical education class and is persistent with activity and classroom sitting. Her temperature is 36.8°C (98.2°F), pulse is 90/min, respirations are 22/min, and blood pressure is 118/72 mm Hg. Physical examination shows the right shoulder is higher than the left and the Adams forward bending test reveals a rib hump measuring 7º with a scoliometer. Standing AP and lateral radiographs are performed and a Cobb angle is measured. Which of the following Cobb angle measurements would most appropriately indicate management with a brace? A. Fifty degrees B. Seventy-five degrees C. Ten degrees D. Thirty-five degrees E. Two degrees
D (Thirty-five degrees) (Adolescent idiopathic scoliosis is the most common form of scoliosis. For Cobb angles of 30° to 40°, determined by radiography, bracing is required. Treatment depends on Cobb angle, patient's age, patient's skeletal maturity, and socioeconomic and lifestyle factors) (Scoliosis is a curvature of the spine, typically accompanied by rotation of the spinal column. There are several types of scoliosis, including idiopathic, congenital, pathologic, and syndromic. Adolescent idiopathic scoliosis (AIS) is the most common type with females having a worse prognosis. Patients may complain of back pain or hip pain. The patient may also have leg-length discrepancies, uneven shoulder heights, midline skin defects, truncal shift or rib deformities) (One screening modality is performed using the Adam's bending test, which has the patient bend over slowly in the standing position. It accentuates any axial plane deformity and can be measured directly using a scoliometer, which measures the angle of trunk rotation (ATR). ATR greater than 7° and inability to perform Cobb angle requires referral to an orthopedist) (Radiographs are performed to assess the Cobb angle, which measures the coronal plane deformity. Angles of 10° or more define scoliosis. Curves with a Cobb angle between 30° and 40° are recommended to be managed with bracing. Treatment of AIS depends on Cobb angle, patient's age, patient's skeletal maturity, and socioeconomic and lifestyle factors)
A 14-year-old male basketball player presents to his pediatrician with right knee pain. He reports that he has experienced intermittent right knee pain localized to an area just inferior to his patella. He is fully ambulatory and has not experienced any knee instability. He recently increased the frequency of basketball practice from once per week to three times per week. On exam, his right tibial tubercle is visibly enlarged and tender to palpation. He has full range of motion of his knee. Resisted right knee extension elicits pain while resisted knee flexion is not painful. Lachman's test and the posterior drawer test are both negative. A lateral radiograph of the patient's right knee is shown (See Figure A). What is the most likely underlying cause of this patient's knee pain? A. Intraarticular ligamentous tear B. Fracture of the proximal tibial epiphysis C. Benign proliferation of bone with a cartilage cap D. Traction apophysitis by the patellar tendon E. Sesamoid bone fracture
D (Traction apophysitis by the patellar tendon) (The most likely diagnosis for this patient is Osgood-Schlatter disease (OSD), which results from traction of the patellar tendon on its insertion at the tibial tubercle. OSD typically affects adolescent athletes and presents with knee pain and swelling over the tibial tubercle)
A 3-year-old boy is brought to the clinic by his mother, who is concerned about the appearance of his legs. She has noticed that his knees tend to point outwards and that he is not meeting his age-related goals for height. He was breastfed up until 2 months ago, and did not take any dietary supplements throughout his infancy. On examination, he is in the 5th percentile for height and there is a marked varus deformity in the lower limbs. An X-ray of the legs is ordered and shown below. Which of the following is the most likely cause of this patient's condition? A. Anti-convulsant therapy B. Celiac disease C. Fanconi syndrome D. Vitamin D deficiency E. X-linked hypophosphatemic rickets
D (Vitamin D deficiency) (Rickets is a bone mineralization disorder which can lead to a varus deformity, short stature, and other bone abnormalities. The most common cause is Vitamin D deficiency, which can develop due to poor diet, prolonged breastfeeding, or reduced exposure to sunlight) (This patient is presenting with genu varum, or bow-leggedness. One of the most common conditions to consider when approaching a patient with a varus deformity is rickets. Rickets is caused by decreased mineralization of bone, leading to an increase in osteoid and cartilage, which allow bones to be more flexible. This leads to the characteristic bow-leggedness and short stature, and can also affect other areas with rapidly growing bones such as the wrist and chest) (The most common cause of rickets is Vitamin D deficiency. Vitamin D plays a key role in bone mineralization by ensuring adequate amounts of calcium and phosphate are present in the body. Vitamin D deficiency is usually secondary to inadequate intake or a lack of exposure to sunlight. Interestingly, children who are breastfed are at risk of developing Vitamin D deficiency unless they take daily supplements. To treat and prevent this condition from worsening, children should be given daily Vitamin D supplements) (The patient's age at presentation, short stature, and history of prolonged breastfeeding are all suggestive of rickets secondary to Vitamin D deficiency. Other causes of rickets include anti-convulsants, X-linked dominant hypophosphatemic rickets, and renal or hepatic disease)
While in the supine position, hip externally rotates and abducts with passive hip flexion. Seen in Slipped capital femoral epiphysis.
Drehmann sign
A 12-year-old girl comes to the clinic because of back pain for several months' duration. She denies night sweats, weight loss, or fatigue. Her temperature is 37.1°C (98.8°F), pulse is 90/min, respirations are 20/min, and blood pressure is 116/72 mm Hg. Physical examination shows a mild lateral curve of the thoracic spine, which increases with forward bending. Structural examination shows that the left leg is shorter than the right. Which of the following leg length discrepancies is appropriate to manage with a shoe lift? A. 2-5 cm B. 5-7 cm C. 7-10 cm D. Greater than 10 cm E. Less than 2 cm
E (Less than 2 cm) (Scoliosis can be a presentation of a short leg. Short leg syndrome occurs when there is a limb length discrepancy. Leg length discrepancies of less than 2 cm may be treated with a shoe lift) (Short leg syndrome occurs when there is a leg length discrepancy (LLD). LLDs occur when the growth plate is disrupted, whether from infection, tumors, or trauma. They may also occur from congenital disorders or paralytic disorders. Patients with LLD may be asymptomatic or they may experience back pain, inefficient gate, contractures of the ankles or postural scoliosis. Larger LLDs are associated with more severe symptoms. During the physical examination, a tape measure is used to measure from the anterior superior iliac spine to the medial malleolus, to evaluate the length of the leg. This is then compared it to the opposite side. LLDs of less than 2cm may be treated with a shoe lift or in some cases, observation alone)
A 2-year-old girl is brought to the emergency department because of an immobile left arm. She holds her arm in an adducted, semi-flexed, prone position. Physical examination shows discomfort of the left radial head on palpation, and attempts of pronation or supination of the patient's forearm are painful on manipulation. After a successful reduction, relief is immediate and the patient begins moving her left arm with full range of motion after 10 minutes. Which of the following is the most likely diagnosis? A. Bone infection B. Botulism C. Congenital syphilis D. Distal humerus fracture E. Nursemaid's Elbow
E (Nursemaid's Elbow) (Nursemaid's elbow is a dislocation of the elbow joint caused by a sudden pull on the extended pronated forearm. The technical term for the injury is radial head subluxation and is a common pediatric presentation, generally occurring between the ages of 1 and 3 years old) (Nursemaid's elbow is a dislocation of the elbow joint caused by a sudden pull on the extended pronated forearm. The technical term for the injury is radial head subluxation and is a common pediatric presentation, generally occurring between the ages of 1 and 3 years old. The etiology is slippage of the head of the radius under the annular ligament. The classic mechanism of injury is longitudinal traction on the arm with the wrist in pronation. Other mechanisms include falling onto the elbow, direct trauma to the elbow, or twisting of the arm, which leads to the radial head being pulled out of the annular ligament. Nursemaid's elbow is characterized by significant pain, partial limitation of flexion/extension of the elbow, or total loss of pronation/supination in the affected arm. In radial head subluxation the child stops using the arm, which is held in flexion and pronated. There is minimal swelling and all the movements are permitted, except supination. The diagnosis is made clinically and radiography is unnecessary, unless is needed to exclude fractures or other dislocation. For management, reducion is made and the two main methods are hyperpronation and a combination of supination/flexion)
A 2-year-old girl is brought in to the emergency department because of immobility in her left arm for the past 3 hours. She expresses pain at any attempts to move it. Patient is sitting in her father's lap in no acute distress, holding her left arm, and slightly flexed across her belly. Which of the following best explains this patient's condition? A. Botulism B. Disorder of cartilage calcification C. Juvenile rheumatoid arthritis D. Medullary carcinoma E. Nursemaid's elbow
E (Nursemaid's elbow)
A 14-year old boy comes to your office with complaints of gradual onset of pain just below his right kneecap over the past month. He has just started playing basketball for the junior varsity team at his school and he is very excited for the season to begin. Unfortunately, the pain in his knee is exacerbated by all the jumping he has to do during practice. He feels the same type of pain when he is going up and down the stairs. He denies any preceding injury to the knee. Physical examination shows full range of motion of his knee, but the pain is reproducible when he extends his knee against resistance. Which of the following is the most likely diagnosis? A. Patellofemoral syndrome B. Shearing injury of the anterior cruciate ligament C. Meniscal tear D. Pre-patellar bursitis E. Osgood-Schlatter disease
E (Osgood-Schlatter disease) (Osgood-Schlatter disease is a common cause of knee pain in physically active adolescents. Management involves reducing aggravating activities, icing the knee, analgesia and stretching) (Osgood-Schlatter disease is a common cause of knee pain in adolescents who are physically active. Repetitive contraction of the quadriceps muscle exerts excess traction on the tibial tuberosity via the patellar tendon. This causes pain in the anterior knee which is typically exacerbated by activities involving running or jumping, and climbing stairs. On physical examination there may be swelling, erythema and point tenderness of the tibial tuberosity with pain on resisted knee extension. It is a clinical diagnosis, however imaging may be useful to rule out other conditions such as tumor, osteomyelitis or avulsion fracture of the tibial tuberosity. Management typically involves refraining from activities that induce the pain, icing the knee at regular intervals, appropriate analgesia and stretching exercises)
A 1-month-old infant is brought in by her parents for a newborn examination. She was delivered vaginally with no complications. This was her mother's first pregnancy. Physical examination is otherwise normal, but her left leg appears shorter than her right and a clunk is noted during the Ortolani technique. Which of the following is the most likely treatment for her diagnosis? A. Closed surgical reduction B. Femoral shortening C. Monitoring D. Open hip reduction E. Pavlik harness
E (Pavlik harness) (Developmental dysplasia of the hip (DDH) is defined as the abnormal development of the hip joint. Infants with evidence of instability upon examination should be treated with a Pavlik harness) (Developmental dysplasia of the hip (DDH) is defined as the abnormal development of the hip joint. The ball of the femur is loose in the socket, which poses a great risk to dislocation. Physical examination of developmental dysplasia of the hip can be characterized by gluteal fold asymmetry and/or leg length discrepancy. Physical examination maneuvers, such as Barlow and Ortolani maneuvers, can also help with the diagnosis of developmental dysplasia of the hip. With the Ortolani maneuver, a clunk noise suggests the relocation of the head of the femur) (Children younger than 6 months with evidence of instability upon examination should be treated with a Pavlik harness. The patient must be carefully monitored to ensure that the harness fits and the hips are reduced. Ultrasonography is an excellent means of documenting the reduction of the hip in the Pavlik harness and should be performed early in the course of treatment. If instability is still noted after 6-8 weeks of the harness, surgical intervention may be required)
An 11-year-old girl comes to the clinic because of her annual well-child visit. She had the flu last winter but otherwise has been completely healthy and is doing well in school. She does not complain of back pain, motor or sensory abnormalities or problems controlling her bowel or bladder. Physical examination is within normal limits except a structural exam when she is asked to bend forward and reach toward her toes. There is a noticeable asymmetry of her posterior ribs on this movement. A thorough neurological examination reveals no abnormalities. Anteroposterior and lateral radiographs of the entire spine reveal a right thoracic curve with a Cobb angle of 15°. Which of the following is the most appropriate next step in management? A. Order MRI of the spine for further evaluation B. Referral for physiotherapy C. Referral to an orthopedic surgeon for bracing D. Referral to an orthopedic surgeon for spinal fusion E. Schedule follow-up in 4-6 months to monitor for progression
E (Schedule follow-up in 4-6 months to monitor for progression) (Scoliosis is the abnormal lateral curvature of the spine and by definition must have a Cobb's angle measurement of ≥ 10 degrees to be diagnosed. Management depends on the age of the patient, the remaining growth potential, and perceived risk of progression of the curve) (Scoliosis (image) is a complex deformity of the spine which can be classified according to the age of onset as infantile (<3yrs), juvenile (3-10yrs) or adolescent (>11yrs) scoliosis. It is most often idiopathic, but can be associated with other musculoskeletal conditions, or rarely, a tumor of the spine. Idiopathic scoliosis is usually painless. Adolescent girls tend to be most affected) (The Adams test is a common screening tool for scoliosis which involves examining the posterior chest wall for asymmetry on forward bending. A thorough physical exam should be performed with special emphasis on the neurological exam. Anteroposterior and lateral spine x-rays are necessary to assess the severity of the curve and to aid the management decision. A Cobb's angle (measure of spinal curvature) >10 degrees is necessary for the diagnosis of scoliosis. Management depends on the age of the patient, the remaining growth potential, and perceived risk of progression of the curve. Curves rarely progress after puberty when skeletal maturity is complete. Curves <20 degrees are managed by observation, with periodic follow-up to monitor for progression. Curves >30 degrees in adolescents, rapidly progressing curves, or curves >45 degrees may warrant more aggressive therapy)
A 14-year-old boy has left knee pain. He denies any trauma to the knee. The patient runs cross country for his high school team and attends practice regularly. On physical exam, the tibial tubercle is pronounced and there is tenderness to palpation over the affected area. The patient reports pain upon resisted knee extension. What is the most likely diagnosis?
Osgood-Schlatter disease
A 15-year-old girl with obesity comes to the clinic because of insidious limp. She says that she also has hip pain while running for the past two weeks. Her temperature is 37.8°C (100°F), pulse is 70/min, respirations are 22/min, and blood pressure is 125/90 mm Hg. Physical examination shows a painful hip on palpation and a restricted range of motion on manipulation. Which of the following is the most likely diagnosis? A. Legg-Calvé-Perthes disease B. Osgood-Schlatter disease C. Osteomyelitis D. Septic arthritis E. Slipped capital femoral epiphysis
E (Slipped capital femoral epiphysis) (Slipped capital femoral epiphysis is a Salter-Harris type 1 fracture through the proximal femoral physis and is characterized by waddling gait, an acute or insidious onset of a limp, decreased range of motion, and unilateral groin pain in the thigh or knee) (Slipped capital femoral epiphysis (SCFE) is a Salter-Harris type 1 fracture through the proximal femoral physis, which results in slippage of the epiphysis. SCFE is the most common hip disorder in adolescence and is characterized by waddling gait, an acute or insidious onset of a limp, decreased range of motion, and bilateral groin pain (as up to 40% of cases involve slippage on both sides and about 20% of all cases include a SCFE on both sides at the time of presentation) in the thigh or knee. The diagnosis is a combination of clinical suspicion plus a pelvic radiography with anterior-posterior (AP) and "frog-leg" lateral views. SCFE is treated with external in-situ pinning, or open reduction and pinning. Consultation with an orthopaedic surgeon is necessary to repair this condition, which makes this the most appropriate first step in management. Pinning the unaffected side prophylactically is not recommended for most patients, but is appropriate if a second SCFE is very likely. Once SCFE is suspected, is recommended that the patient begins with non-weight bearing positions and remain on strict bed rest. In severe cases, after enough rest, the patient requires physical therapy to regain strength and movement back to the leg)
A 14-year-old girl comes to the clinic because of a referral by a school nurse for a curve in her spine. The patient denies shortness of breath, cardiac palpitations, or other significant medical history. Her temperature is 37.1°C (98.8°F), pulse is 70/min, respirations are 16/min, and blood pressure is 114/72 mm Hg. Physical examination shows a spinal curve with an estimated Cobb angle to be approximately 12°. The spinal curve ranges laterally from T7-T12, with the convexity of the curve to the left, resulting in a levoscoliosis. Which of the following is the most appropriate imaging study to perform in this patient? A. CT of the spine B. Lateral radiograph of the spine during flexion C. MRI of the spine D. Oblique radiograph of the spine E. Standing AP and lateral radiographs of the spine
E (Standing AP and lateral radiographs of the spine ) (The most appropriate imaging study to order inpatients suspected of having scoliosis is a standing AP and lateral X-ray of the spine) (Scoliosis is a deformity of the spine that is most often idiopathic, but can be associated with other musculoskeletal conditions, or rarely, a tumor of the spine. Idiopathic scoliosis is usually painless and adolescent girls tend to be most affected. A lateral curve is named according to the convexity of the curve. A left sided convexity is a "levoscoliosis," while a right sided convexity is a dextroscoliosis) (The radiographic assessment of the scoliosis patient begins with erect anteroposterior and lateral views of the entire spine (occiput to sacrum). In addition, the examination should include a lateral view of the lumbar spine to look for the presence of spondylolysis or spondylolisthesis (prevalence in the general population is about 5 %). The scoliotic curve is then measured from the AP view. The most commonly used method is the Cobb method. If surgery is indicated, a set of lateral bending films is often taken to assess the rigidity or flexibility of the curves)
Classically presents with tenderness over the tibial tubercle in a 9-14-year-old male who has undergone a rapid growth spurt and doing sports that involve running.
Osgood-Schlatter disease
_____________ is inflammation of the patellar ligament at the tibial tuberosity.
Osgood-Schlatter disease
_______________ is characterized by a painful lump just below the knee.
Osgood-Schlatter disease
What condition has dead bone that causes the area to become weak...shear forces cause the articular cartilage to weaken and pull off surface of joint becoming a "loose body?"
Osteochondritis Disssecans (OCD)
The four F's to remember risk factors for developmental dysplasia of the hip:
First (firstborn) Female Family history Feet first (Breech).
The Q-angle is the angle between the functional longitudinal axises of the femur and the tibia, is normally between 10-12 degrees, and is increased in patients with genu (valgum/varus) .
Genu valgum
_______________ is a condition in which the knees angle inward and touch while the legs are straightened.
Genu valgum
_____________ is a physical deformity marked by outward bowing of the lower leg in relation to the thigh, giving the appearance of an archer's bow.
Genu varum
Tx for Osteochondritis Disssecans
Goal is for lesion to heal...thus decreasing shear forces and allowing new bone to form. -This may occur conservatively by creeping formation or by surgical intervention When overlying cartilage is intact may be treated non-operatively...commonly in skeletally immature. Activity modification...low-impact! Surgical intervention usually reserved for skeletally mature pt when disruption of the articular cartilage. Internal fixation Osteochondral allograft vs. autograft Microfracture REFER
________________ can be given to children with Osgood-Schlatter disease experiencing pain.
Ibuprofen
PE for Osteochondritis Disssecans
Pain over joint line + Wilson test effusion
Treatment of congenital hip dysplasia depends on age of diagnosis < 6 months old:
Pavlik harness
What health maintenance test should be performed on patients with scoliosis?
Pulmonary function tests t *to determine whether the scoliosis is affecting breathing.
_________________ is the most classic form of hyperkyphosis and results from wedged vertebrae that develop during adolescence.
Scheuermann's kyphosis
A positive Drehmann's sign is often seen in _______________________.
Slipped capital femoral epiphysis
An obese 16-year-old boy complains of pain in his left groin, hip, and thigh. His mother notices a limp when he walks. The patient denies any recent significant trauma to his left lower extremity. On physical exam, his gait is antalgic. With the patient in the supine position, there is external rotation and abduction of the thigh with passive flexion of the hip. A radiograph of the affected hip is performed, which demonstrates an inferior displacement of the left epiphysis. What is the most likely diagnosis?
Slipped capital femoral epiphysis,
_______________ is characterized by waddling gait, decreased range of motion, and bilateral groin pain in the thigh or knee.
Slipped capital femoral epiphysis,
________________ therapy can lead to scoliosis due to rapid, uneven vertebral growth.
Somatotropin (growth hormone)
Osgood-Schlatter disease usually affects (age group/gender)____________________.
adolescent males.
The etiology of nursemaid's elbow involves the radial head slipping under the _______ ligament.
annular
Slipped capital femoral epiphysis often presents with an _________ or waddling gait with externally rotated leg on the affected side.
antalgic
Patients with developmental dysplasia of the hip will present with ______________ and limited hip abduction on the affected side.
asymmetric skin folds
In children, Osgood-Schlatter disease may result in __________________ at the tibial tuberosity.
avascular necrosis
Osgood-Schlatter disease may result in a(n) ______________fracture, with the tibial tuberosity separating from the tibia.
avulsion
20 degrees or less curvature of the spine (does / does not) require treatment;
does not
In cases of age-related kyphosis, there is no standardized therapy but ________________ is a common modality.
exercise/physical therapy
On physical exam, the forearm of a child with nursemaid elbow will be in incomplete (extension/flexion) with the forearm pronated.
extension
Osgood-Schlatter disease may present with pain on resisted knee _____________ with lump below the knee and prominent tibial tuberosity.
extension
Lumbar lordosis may be treated by strengthening the hip ___________ and by stretching the hip flexors.
extensors
Slipped capital femoral epiphysis often presents with an antalgic or waddling gait with (internally / externally) rotated leg on the affected side.
externally
