Orthopedics: Pediatric Primary Care
Which of the following factors most affects outcomes in patients with LCPD? a. Age of child b. Severity of pain and antalgic gait c. Family hx of LCPD d. Bilateral involvement
a. Age of child Age, because younger children have more time to remodel compared with older children.
A physical finding not usually associated with clubfoot is: a. Contracture of the IT bands b. Deep crease on medial border of foot c. Atrophy of calf muscles d. Small foot with limited dorsiflection
a. Contracture of the IT bands
In a diagnostic work-up and management plan for a child with osteomyelitis, which of the following is not accurate or recommended? a. Elevated ESR confirms diagnosis b. Aspiration is usually indicated c. Antibiotic treatment for identified pathogen for 4-6 weeks is recommended d. Surgery is recommended if abscess is present
a. Elevated ESR confirms diagnosis Lab investigations are helpful but lack specificity for osteomyelitis. Leukocytosis and increased ESR and CPR may be present.
The most definitive feature or features for a diagnosis of "growing pains" includes: a. Exclusion of other causes of lower extremity pain b. Pain, swelling, erythema c. Loss of ambulation d. Decreased ROM
a. Exclusion of other causes of lower extremity pain Growing pain is a diagnosis of exclusion for intermittent lower extremity pain. All diagnostic markers are normal.
Systemic-onset JIA is most commonly associated with: a. High, daily, intermittent spiking fevers and rash b. Single joint involvement c. Positive RF factor and iridocyclitis d. Painless joint involvement
a. High, daily, intermittent spiking fevers and rash Systemic manifestations include fever, erythematous rashes, leukocytosis, serositis, lymphadenopathy, and rheumatoid nodules.
Signs and symptoms associated with Duchenne muscular dystrophy are: a. History of delayed developmental milestones b. Visual-motor disturbance, calf hypertrophy c. Delayed motor development, positive Ortolani maneuver d. History of "clumsiness," visual-motor disturbance
a. History of delayed developmental milestones DMD is a progressive disorder that affects muscles in the lower extremities, chest wall, and heart. There are no visual abnormalities or hip dislocation involved in the disorder.
Sports injuries are commonly associated with: a. Improper training b. Higher frequency in females c. Scoliosis d. Low socioeconomic status
a. Improper training Poor body mechanics are a common cause of sports injuries that can be lessened by proper training. Sports injuries are more commonly found in males in sports such as football, soccer, and wrestling. Not affected by socioeconomic status or preexisting conditions such as scoliosis.
In LCPD, which of the following s/sx are seen? a. Insidious onset of limp with knee and groin pain b. Sudden onset of limp and pain in lateral hip c. Fever and sudden onset insidious limp d. Afebrile and sudden onset of limp
a. Insidious onset of limp with knee and groin pain The patient with LCPD is generally afebrile, and the disorder arises from avascular necrosis of the femoral head. The pain is referred to the knee or groin area.
Which of the following is true for idiopathic scoliosis, which occurs primarily in adolescents? a. Mild curves occur equally between the sexes b. Generally there is no family history c. Back pain is usually associated with curves of 35 degrees or greater d. Bracing is indicated for thoracic curves of 10-25 degrees
a. Mild curves occur equally between the sexes The female-to-male ratio increases with increasing curve magnitude. Small curves are equivalent between both sexes. For curves <20 degrees, the risk for progression of the curve is low; these curves generally just need to be observed. However, for curves 20-45 degrees, the risk for progression is high during growth, and early intervention is paramount.
Complications of SLE commonly include which of the following? a. Pericarditis, arthritis, nephritis b. Encephalitis, nephritis, pericarditis c. Nephritis, arthritis, rheumatic fever d. Nephritis, hemolytic anemia, contact dermatitis
a. Pericarditis, arthritis, nephritis Deposits of immune complexes trigger a generalized inflammatory response that can lead to tissue damage, such as vasculitis and ischemia, and numerous organ system abnormalities (commonly heart and renal system).
In a newborn, a diagnosis of hip dislocation is suspected when: a. Positive Galeazzi, Barlow, and Ortolani signs b. Wide hip abduction that is symmetric c. Flaccidity of the left leg following extension of both legs with return to flexion d. Tonic neck reflex in which the left leg is flexed
a. Positive Galeazzi, Barlow, and Ortolani signs The Galeazzi sign can signal conditions that cause leg length discrepancies. The Barlow maneuver dislocated an unstable hip, and Ortolani reduces a dislocated hip. All three will be positive in hip dysplasia.
A 3-year-old presents with a history of fever for the past several days, pain in his left leg, and refusal to bear weight on his left leg. 10 days ago, he fell from a slide and bruised his leg. His WBC count is slightly elevated. You suspect other toxic synovitis or osteomyelitis. Which finding supports a diagnosis of osteomyelitis more so than toxic synovitis? a. Recent injury b. Leg pain c. Non-weight-bearing d. Elevated WBCs
a. Recent injury Osteomyelitis is frequently associated with local trauma, whereas toxic synovitis is more commonly associated with a recent URI. The elevated WBCs, fever, and refusal to bear weight can occur in either condition.
Tracy, a 9-year-old female, complains that she does not like to wear shorts because her knees look funny. On exam, you note a genu valgum angle of greater than 15 degrees. You should: a. Reevaluate in 1 year if still present b. Consult with an orthopedic specialist c. Instruct her to avoid sitting in the "W" position d. Encourage exercise to strengthen her quads
a. Reevaluate in 1 year if still present Valgus up to 15 degrees is common up through the age of 8 or 9 years, but persistence beyond that may lead to problems and degenerative changes and warrants referral.
You have been treating a 14-month-old for torticollis since birth. The condition has not resolved and the child still has limited neck rotation. The appropriate management plan would be to: a. Refer for surgical consultation b. Continue with passive ROM exercises c. Provide environmental stimulation opposite the contracture d. Apply cervical collar at night
a. Refer for surgical consultation Most torticollis resolves by 1 year of age. When there is no response to more conservative tx interventions such as passive stretching and environmental stimulation, resulting in limited neck ROM and facial asymmetry, surgery may be the recommended course of action.
Initial treatment of a grade I sprain includes with of the following? a. Rest, ice, compression, elevation, NSAIDs b. Heat, ROM exercise, compression, elevation, NSAIDs c. Rest, heat, compression, elevation, NSAIDs d. Rest, ice, ibuprofen, compression, NSAIDs
a. Rest, ice, compression, elevation, NSAIDs RICE for the injured part. Apply ice immediately for 15-20 minutes and then repeat every 2-6 hours for the first 48-hours. Give NSAIDs for up to 7-10 days for pain.
Subluxation of the radial head is referred to as "nursemaid's elbow." If the risk for fracture is low or absent, which of the following is recommended? a. Supination and flexion of forearm maneuver b. Extension and supination c. Use of finger traps with weight on the humerus d. The hypopronation and extension maneuver
a. Supination and flexion of forearm maneuver Two techniques can be used to reduce the radial head: supination and flexion or pronation and flexion
A macular, salmon-colored rash with irregular borders and central clearing is characteristic of which of the following? a. Systemic JIA b. Lyme disease c. SLE d. Rheumatic fever
a. Systemic JIA This is the characteristic rash associated with systemic JIA that occurs in 25-50% of children. Lyme disease rash is characteristic of erythema at the site of the tick bite with central clearing like a bull's eye. SLE typically has a "butterfly rash" seen on the cheeks and bridge of nose and gets worse in sunlight. Rheumatic fever often is associated with erythema marginatum, a nonpruritic, light pink macular rash that is usually on the trunk
A characteristic feature of polyarticular JIA disease is: a. The involvement of five or more inflamed joints b. Confinement to lower extremity joints, knees, and ankles c. Asymmetric involvement d. High, daily intermittent spiking fevers
a. The involvement of five or more inflamed joints JIA is the most common rheumatologic disease with an autoimmune basis and represents a group of conditions with onset of sx in children at or younger than 16 years of age with chronic inflammation of at least one synovial joint for 6 weeks or more.
Growth in muscle length is related to growth in length of: a. Underlying bone b. Underlying ligament c. Underlying tendon d. Opposing muscle group
a. Underlying bone Growth in muscles is due to the ROM the muscle is asked to perform as the underlying bone lengthens
For a newborn, the correct management of hip dislocation should include: a. Use of a flexion-abduction device such as a Pavlik harness to stabilize the hip b. Following and observing closely for 3-4 weeks, and then referring to an orthopedist c. Surgical reduction d. Traction for 6 weeks
a. Use of a flexion-abduction device such as a Pavlik harness to stabilize the hip The tx of choice for subluxation and reducible dislocations in the early phase is a Pavlik harness. The harness is applied with hips having greater than 90 degrees of flexion and with adduction of the hip limited to a neutral position.
A 14-year-old diagnosed with JIA is not UTD on his immunizations and is currently on methotrexate. Which of the following vaccines would be cautioned in this case? a. Varicella b. Influenza c. Inactive polio d. Tdap
a. Varicella There is risk of developing serious complication from live vaccines. Make sure they are caught up on vaccines before starting the methotrexate.
The parents of a 5-year-old recently diagnosed with muscular dystrophy want an explanation about the hereditary nature of the disease. The best explanation is: a. X-linked recessive gene transmitted by unaffected female carriers b. Recessive gene that is known to skip generations between transmission c. Dominant sex-linked gene predominantly in white families from Europe d. Recessive gene that requires both mother and father to be carriers
a. X-linked recessive gene transmitted by unaffected female carriers The X-linked dystrophies are the most common, with the most common dystrophy being Duchenne.
ANA seropositivity for antibodies: a. is a valuable diagnostic marker for JIA b. is not positive in any childhood diseases c. is more commonly found in older boys d. has 100% sensitivity and specificity
a. is a valuable diagnostic marker for JIA ANA consists of immunoglobulins directed against structures within the cell. It is found in various autoimmune diseases.
Most children with Duchenne muscular dystrophy become wheelchair dependent by what age? a. 4-6 years b. 10-12 years c. 14-16 years d. Highly variable depending on response to treatment
b. 10-12 years Many children with DMD begin using a wheelchair sometime between ages 7-12 years. Transition to a wheelchair is usually a gradual process; at first, the chair may be required only to conserve the child's energy while covering long distances.
A child with growing pains is most likely to experience: a. A mild limp b. Bilateral lower extremity pain c. Lower extremity pain primarily during the day d. Lower extremity pain associated with decreased ROM
b. Bilateral lower extremity pain Growing pains tend to occur during rapid growth, increasing in prevalence after age 5. The pain is a muscular pain located bilaterally in the legs and thighs.
Which of the following is an appropriate goal for a child being treated for osteomyelitis? a. Prohibiting activities b. Complete course of abx therapy c. Encouraging a low-fat diet d. Restricting visitors
b. Complete course of abx therapy Osteomyelitis is an inflammation of the bone that requires long term abx therapy (4-6 weeks). Diet activity, and rest are supportive care as indicated.
The appropriate management of Osgood-Schlatter disease includes: a. Local injection of soluble corticosteroid b. Decreasing activity, applying ice, and taking prescribed NSAIDs c. Program of strengthening and stretching for quads d. Casting in adduction for 6 weeks
b. Decreasing activity, applying ice, and taking prescribed NSAIDs Osgood-Schlatter disease is a benign condition resulting from overuse and is best treated with rest and supportive therapy.
An injury at which of the following sites will most likely result in a bone length discrepancy? a. Diaphysis b. Epiphysis c. Medullary cavity d. Metaphysis
b. Epiphysis Bone length occurs at the epiphyseal plates, which is also where the blood supply enters. If the blood supply is compromised growth may be jeopardized.
Genu varum is considered an abnormal condition when: a. Extreme knock-knees continues after age 7 b. Extreme tibial bowing continues after age 2 c. Parents are concerned about their child's appearance d. Tibial bowing is evident before age 2
b. Extreme tibial bowing continues after age 2 The typical pattern of normal bowing seen in children is a symmetric lateral bowing of both tibias in the first year followed by bowlegs in the second year. Asymmetric tibial bowing after 18 months is often associated with Blount's or tibia vara.
Which of the following suggests internal tibial torsion rather than internal femoral torsion in a 2 year old child presenting with an in-toeing gait? a. Sitting in "W" position b. Knees face forward when walking c. Generalized ligament laxity d. Limited external rotation of hip
b. Knees face forward when walking Observing the patella can be very helpful in differentiating internal tibial torsion from internal femoral torsion. The patella will rotate inward if the problem is above the knees.
Which of the following statements about acute osteomylelitis is true? a. It occurs more frequently in females than in males b. Peak ages are infancy and preadolescents c. Most common sites are radius and ulna d. It is a self-limiting disorder
b. Peak ages are infancy and preadolescents Males are twice as likely to be affected. Any bone may be affected, but the femur and tibia are the most common sites. One in 5000 children younger than 13 will develop osteomyelitis, with 50% of those infections occurring in the first 5 years of life.
Which of the following disorders is usually associated with adduction of the forefoot? a. Internal femoral torsion b. Talipes equinovarus congenita c. Genu valgum d. Internal tibial torsion
b. Talipes equinovarus congenita (clubfoot)
Which of the following diagnoses is associated with contracture of one of the sternocleidomastoid muscles? a. Lordosis b. Torticollis c. Scoliosis d. Kyphosis
b. Torticollis Asymmetric shortening of the sternocleidomastoid muscle results in preferential turning of the head to one side.
Which of the following represents appropriate anticipatory guidance for a child diagnosed with SCFE? a. Avoid contact sports until pain has resolved b. Use crutches to facilitate mobility during acute phase c. Apply ice to affected area d. Perform ROM and strengthening exercises
b. Use crutches to facilitate mobility during acute phase Tx of SCFE is aimed at preventing further slippage. Since the goal is no weight bearing and avoiding flexion of the hip, no sports are recommended. Ice would not change the problem in the femoral head, and ROM and exercise are contraindicated.
Which of the following children need an orthopedic referral? a. A 6-year-old with mild bowing of the lower legs b. A 6-month-old with internal tibial torsion c. A 3-week-old with equinovarus of the feet d. A newborn with a positive Pavlik sign
c. A 3-week-old with equinovarus of the feet Refer to ortho as early as possible, ideally in the newborn nursery, because the joints are most flexible in the first hours and days of life
A 14-year-old has pain in the knee. The pain increases with activity and is relieved with rest. The PNP diagnoses Osgood-Schlatter disease and orders: a. An x-ray exam, application of hot packs to the knee, and rest b. Application of hot packs to the knee, aspirin, and rest c. A reduction in activity, application of ice to the knee, and ibuprofen d. Application of ice to the knee and continued participation in sports
c. A reduction in activity, application of ice to the knee, and ibuprofen Osgood-Schlatter disease is a self-limiting condition with symptom management that includes avoiding or modifying activities that cause pain until the inflammation subsides, ice, and NSAIDs to reduce pain and inflammation.
Duchenne muscular dystrophy is characterized by which of the following signs and symptoms? a. At birth, affected infants are notably hypotonic, "floppy" babies b. Earliest symptom is often refusal to bear weight c. Abnormalities of gait and posture become evident during preschool years and during gross motor development d. Children are unable to keep up with peers when running by school age
c. Abnormalities of gait and posture become evident during preschool years and during gross motor development DMD typically presents with delayed walking, slower movements, rolling gait, waddle, large calves, and a positive Gower sign
During examination of a 2-week-old, you note irritability when lifted, asymmetrical Moro reflex, and spasm along the right sternocleidomastoid. What does this suggest? a. Torticollis b. Sprengel deformity c. Fractured clavicle d. Klippel-Feil syndrome
c. Fractured clavicle A fractured clavicle is not uncommon following birth, especially in larger babies. The spasm of the sternocleidomastoid and asymmetrical moro are classic signs of the problem.
Tibial torsion is commonly associated and can be treated with: a. Pain, analgesics b. Restricted ROM, braces c. Internal rotation of lower extremities, observation d. In adolescents 13-16 years of age, increasing dietary calcium
c. Internal rotation of lower extremities, observation Tibial torsion involves the twisting of the long bone along its long axis, resulting in increased internal rotation. Tx of tibial version (the normal variation in tibial rotation) is observation and monitoring.
The most common rheumatoid disease of childhood is: a. SLE b. Kawasaki disease c. JIA d. Legg-Calve-Perthes disease
c. JIA
Radiographic findings of disease progression and sphericity of the femoral head is helpful in the diagnosis and follow-up of: a. Transient synovitis of the hip b. Osgood-Schlatter disease c. Legg-Calve-Perthes disease d. Slipped capital femoral epiphysis
c. Legg-Calve-Perthes disease LCPD develops from an infarction of the bony epiphysis of the femoral head and often presents as avascular necrosis of the femoral head. Radiograph depicts stages of progression and remodeling and is important in diagnosis and tx.
Antonio is a newborn, and the PNP notes on physical assessment that both feet turn in with the hind and midfoot in normal neutral position. When attempting ROM of the forefoot, the PNP finds that both feet move relatively freely past midline in all directions consistent with: a. Clubfoot b. Syndactyly c. Metatarsus adductus d. Fracture in his feet
c. Metatarsus adductus In flexible MA, the forefoot can be abducted past midlines.
Varus between the tibia and femur of up to 15 degrees followed by a progression to neutral angle, which then progresses to valgus between 7-9 degrees, is associated with which of the following? a. Blount disease b. Internal tibial torsion c. Normal developmental growth pattern d. Abnormal tibiofemoral growth pattern
c. Normal developmental growth pattern The normal growth pattern is one of slight varus, which progresses to a neutral angle, and then slight valgus. Persistence of any phase beyond what is expected warrants further investigation.
Which of the following would be the most appropriate initial management of a newborn diagnosed with developmental dysplasia of the hip? a. Observe and reexamine at 2-week well-child visit b. Triple diapering in nursery c. Pavlik harness d. Surgical reduction
c. Pavlik harness
Dislocation of the hip of a child 6 months or older may typically present with: a. Asymmetry of skin folds b. Atrophied hip muscles c. Positive Galeazzi sign d. Negative Trendelenburg sign
c. Positive Galeazzi sign The Galeazzi maneuver can depict a leg length discrepancy. The exam is reliable in children with dislocatable, but not dislocated, hips or in children with bilateral hip dislocation.
While completing the hip exam on a newborn infant, you are able to dislocate the infant's right hip. The appropriate management plan would be to: a. Triple diaper and reevaluate in 2 weeks b. Recommend positioning prone while awake c. Refer to ortho specialist d. Order tight swaddling of infant
c. Refer to ortho specialist Although still recommended in some sources, triple diapering is not thought to be effective because the musculoskeletal forces are greater than those exerted by diapers. Swaddling and the prone position are *contraindicated* and may increase the risk of dislocation. The appropriate tx would be an evaluation fo an ortho specialist and most likely a Pavlik harness.
A full-term infant in the newborn nursery is noted to have a deformity in her left foot consisting of a convex lateral border and forefoot, which can be abducted past an imaginary line extending from the middle of the heel through the second toe. Which of the following management strategies is most appropriate? a. Reverse-last shoes b. Out-flare shoes c. Stretching exercises d. Orthopedic referral
c. Stretching exercises Metatarsus adductus is a flexural deformity of the foot related most commonly to intrauterine positioning. Flexible deformities able to be moved past the midline can be managed with stretching exercises.
A baseball coach asks for advice on how to prevent Little League elbow in his 8 and 9 year old players. Which of the following would be incorrect advice? a. Have each child pitch only 3 innings b. Limit or eliminate curve balls c. Use ice massage before and after pitching d. Conduct slow warm ups
c. Use ice massage before and after pitching Little League elbow, or epicondylitis, is a result of repetitive forearm supination and pronation. Therefore, the goal is to prevent injury by reducing the repetitive motion. Ice falsely reassures parent or coach that the injury can be prevented by applying ice before and after pitching.
Which of the following statements is not true of SCFE? a. It is thought to be precipitated by hormone changes during puberty b. Unilateral involvement is more common than bilateral c. It is more common among males and African Americans d. It is thought to be caused by repetitive stresses in young athletes prior to growth spurt
d. It is thought to be caused by repetitive stresses in young athletes prior to growth spurt The etiology of SCFE is unknown but thought to be related to stresses on the physis from rapid growth.
A healthy 6-year-old child presents with a limp and knee pain. The pNP finds limited passive internal rotation and abduction of the hip joint on physical examination. The most likely diagnosis is: a. SCFE b. Osgood-Schlatter disease c. Transient synovitis of the hip b. LCPD
d. LCPD LCPD often presents with an intermittent limp especially after exertion, with mild or intermittent pain in the anterior part of the thigh. Some children may present with limited ROM of the affected extremity. The most common symptom is persistent pain that may be referred to the medial aspect of the ipsilateral knee or to the lateral thigh. SCFE often occurs after age 8 and predominantly in boys who are overweight. Osgood-Schlatter does not occur until early adolescence and is often associated with sports. Transient synovitis typically occurs between ages 3-8 years, and the child often refuses to bear weight and has a low-grade fever.
What is the appropriate treatment for genu varum in a 15-month-old child? a. Passive exercise with each diaper change b. Denis Browne splint at night c. Blount brace at night d. No treatment is warranted
d. No treatment is warranted Genu varu, or bowed leg, is normal until approximately 18 months.
Which of the following would not be an appropriate indicator for developmental dysplasia of the hip in a 6-month-old child? a. Allis sign b. Skinfold symmetry c. Galeazzi sign d. Ortolani maneuver
d. Ortolani maneuver After the age of 6 months, Ortolani maneuver is less reliable due to diminished laxity of the hip. After 2 months of age, soft tissue contractures may develop, making this test unreliable.
CW, a 20-month-old, presents in the ER with a greenstick fx of his left femur. Physical exam also reveals an enlarged anterior fontanelle and enlarged costochondral junction. What do these findings suggest? a. Child abuse b. Osteogenesis imperfecta c. Osteoporosis d. Rickets
d. Rickets Rickets develops after several months of vitamin D deficiency and is characterized by craniotabes and enlarged anterior fontanelle with delayed closing. The enlarged costochondral junction, or rachitic rosary, is a classic sign.
During physical exam of Jason, a 2.5-year-old, you note large, muscular-looking calves and observe his difficulty rising from a sitting position. The Denver A developmental screening exam reveals delays in gross motor area. Which of the following laboratory tests would be most beneficial? a. Serum calcium b. Serum magnesium c. Serum phosphorus d. Serum creatinine kinase
d. Serum creatinine kinase Creatinine is formed in healthy muscle tissue from creatinine at a steady rate. When muscle wasting occurs, as in muscular dystrophy, creatinine excretion is dramatically increased. Deficiencies in serum calcium, phosphorus, and magnesium may result in muscle cramping and spasms but do not represent the clinical picture described.
An obese 13-year-old male with 2 days of right knee pain without trauma or illness has an exam of significant pain upon right hip motion, and he maintains his leg in external rotation and adduction. Based on these findings, the most likely diagnosis is: a. Osgood-Schlatter disease b. Chondromalacia c. Spondylolysis d. Slipped capital femoral epiphysis
d. Slipped capital femoral epiphysis SCFE typically occurs just after the onset of puberty, often in overweight and slightly skeletally immature boys. Pain is typically reported in affected groin, hip, or knee, and there is often a limp.
Which of the following statements is true regarding SCFE? a. It is more common in females who are underweight b. It generally occurs following severe sudden trauma c. Incidence is more common in athletes d. The goal of tx is to stabilize or improve the position of the femoral head
d. The goal of tx is to stabilize or improve the position of the femoral head The goal of treatment of SCFE is to prevent further slippage and to stabilize the epiphysis via surgical intervention.
Management of scoliosis depends on the severity of curve as well as the age of the child. Which of the following would require surgical intervention? a. Curves of 15 degrees in a child who is still growing b. Thoracic and/or lumbar curve greater than 25 degrees, even if growth is complete c. Thoracic curve greater than 30 degrees or lumbar curve greater than 40 degrees that has not progressed while in brace. d. Thoracic curve greater than 50 degrees or lumbar curve greater than 40 degrees
d. Thoracic curve greater than 50 degrees or lumbar curve greater than 40 degrees Surgery may be required in children with structural problems that cause kyphosis and in adolescents with curvature of the back that exceeds 50-60 degrees. Surgery is indicated for children who have progressive spinal deformity that cannot be controlled by nonoperative means, such as bracing, where there is significant spinal growth remaining.
A 4-year-old boy is brought in by his mother, who is concerned about sudden onset of a painful limp in his right leg 2 days ago. Today he has a low-grade fever. Which of the following diagnoses is most likely? a. Osgood-Schlatter b. JIA c. Osteomyelitis d. Transient synovitis of the hip
d. Transient synovitis of the hip