Ortho II

SUGGESTED READINGS ORTHO II

Read article - Arabella, LI, Skaggs, DL. “Evaluation of the Acutely Limping Child.”

OBJECTIVES ORTHO II

1. Describe the usual presentation and management of shoulder dislocation and rotator cuff injury.
2. Describe the mechanisms of injury, usual presentation and management of ligamentous injuries of the knee, including dislocation.
3. Discuss the usual clinical presentation and radiographic findings of osteoarthritis and the clinical indications for total joint replacement of shoulder, hip and knee. Discuss the pathophysiology of articular cartilage degeneration.
4. Discuss the common clinical presentations, diagnosis and management of the child with a painful limp.
5. Describe the usual clinical presentation, radiographic findings, and management of benign bone neoplasms versus malignant primary bone tumors.

CASE HISTORIES ORTHO II

1. A 2-year-old boy presents with refusal to bear weight. Mom says the day care noticed that he was crawling rather than walking when he woke up from his nap. It is unclear whether he had an injury on the playground. Mom denies any recent fever, cold, cough, flu, decreased appetite, or change in activity level prior to his refusal to walk this afternoon. He has full range of motion of the hip and knee, and he withdraws his foot when the leg is palpated above the ankle. There is no erythema, swelling, or gross deformity. X-rays of the entire lower extremity are normal.

2. A 5-year-old boy presents with limp for 2 months, which his parents first noticed when he was playing T-ball. Occasionally, he admits to some discomfort, so they give him Tylenol. On exam, his gait appears normal. He has decreased internal rotation and abduction of the left hip, with discomfort at the extremes of those motions. AP and frog pelvis x-rays show a little flattening of the left hip epiphysis.

3. A 4-year-old girl presents with refusal to bear weight. She was fussy last night and did not sleep well, and then she refused to walk this morning. She felt warm, but Mom did not take her temperature. In the E.R., her temp is 102.6. She has pain with “log rolling” of the right hip (internal and external rotation while it is extended) and cries with any attempt to do more range of motion of that hip. WBC is 16,000; ESR is 45 (normal < 20), and CRP is 18 (normal < 1.0). AP Pelvis x-rays are normal.

4. A 17-year-old boy presents with right ankle pain after twisting the ankle during baseball practice. He has tenderness on the lateral aspect of the ankle over the ATFL and CFL. He does not have tenderness medially. He does not have pain with squeezing of the syndesmosis or external rotation of the foot. He does not have limitation of subtalar motion, although inversion causes mild discomfort. Ankle X-rays show soft tissue swelling but no bony abnormalities.

5. A 9-year-old boy presents with right ankle pain after twisting his ankle during baseball practice. He has pain on the lateral aspect of the ankle over the distal fibula, rather than on the ligaments. Ankle X-rays show soft tissue swelling over the distal fibula and widening of the distal fibula physis.

6. A 17-year-old girl presents with right ankle pain after a car accident. There is circumferential swelling and pain. She has pain with squeezing of the syndesmosis proximally and pain with external rotation of the foot. Initial ankle x-rays are normal, but ankle mortise “stress view” x-rays (taken while externally rotating the foot) show a gap between the tibia and fibula at the distal tibia-fibula articulation.

7. An 11-year-old girl presents complaining of right ankle pain after twisting her ankle during soccer practice. This is the 3rd time she’s sprained her ankle. Exam shows mild tenderness over the ATFL. She has no subtalar motion. X-rays of the ankle are normal. X-rays of the foot show a bony bar between calcaneus and navicular on oblique view, with beaking of the talus on lateral view.

8. A 19-year-old female college basketball player presents with a swollen knee after a game. Another girl collided into her when she was landing, and her knee twisted and gave out. She was unable to finish the game. She has been on crutches. She has a large effusion. She can actively extend the knee. There is laxity with valgus stress, and she has laxity with Lachman and anterior drawer testing. X-rays of the knee are normal.

9. A 40-year-old man presents with a swollen knee after playing racquetball. He suddenly felt a pop, had pain, and could not finish the game. He cannot actively extend his knee against gravity, and the patella is palpable more superiorly than it should be. There is a soft tissue defect palpable inferior to the patella. X-rays of the knee show patella alta with no fracture.

10. A 14-year-old boy presents with knee pain for 3 months. He is morbidly obese with a BMI of 40. He walks with the foot externally rotated on that side compared to the other side. He has full knee flexion and extension with stable ligaments and no effusion. He points to the anterior thigh near the knee as the area of discomfort. Internal rotation of the hip is decreased on that side compared to the other side, and attempts at internally rotating further reproduces the thigh pain. X-rays of the knee are normal.

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