Free Orthopedics Review | Dr Hutaif General Orthopedics -...

Pectus carinatum has a high diagnostic value for Marfan syndrome.
Hyperextension of the knees is not common in patients with Marfan syndrome. This skeletal feature is seen in many other conditions; therefore, it has low diagnostic specificity.
Atlantoaxial subluxation is rare in Marfan syndrome, but is common in some of the skeletal dysplasias.
Although patients with Marfan syndrome are generally tall, height is too nonspecific to be a helpful diagnostic criterion. Kyphosis is not a skeletal diagnostic criterion.

The Milwaukee brace offers the best chance of controlling this curve.
C harleston bending braces are not effective for curves larger than 35°. Boston overlap braces are not effective for curves with an apex above T8. Lateral electrical spinal stimulation has been proven ineffective for scoliosis. This curve is not large enough to pose a recommend fusion.

Obesity is not any more common in patients with Scheuermann kyphosis than in the general population.
Vertebral wedging is a common feature of Scheuermann kyphosis. Endplate irregularity is a common feature of Scheuermann kyphosis.
Schmorl nodes are a manifestation of the disordered behavior of the vertebral endplates under load. Back pain is common in Scheuermann kyphosis.

Exercises must be the first treatment for this patient because he is too mature for brace treatment.
Brace treatment is not indicated for someone of this skeletal maturity. Surgery is not indicated unless the patient fails conservative treatment.

The talar head and neck are deviated medially. This deformity cannot be corrected surgically but may improve with growth.
The dome of the talus is not originally flattened, but it may become this way after repeated manipulation. The navicular is positioned more medially than normal and may touch the medial malleolus.
The foot has either a normal arch or a cavus deformity (the opposite of a rocker bottom). The rocker bottom foot may develop as a result of over-vigorous manipulation of a clubfoot against a tight heelcord.
The tendoachilles inserts are more medially positioned than normal on the calcaneus.

Plantarflexion of the first ray, especially if the first ray is not colinear with the talus on the lateral radiograph, should serve as an indication for a plantar release.
Anterior extrusion of the talus is common because of the tightness of the Achilles tendon and the posterior capsule. Inferior subluxation of the calcaneocuboid joint is not a feature of clubfoot.
Medial subluxation of the calcaneocuboid joint, in combination with the clinical appearance of a curved lateral border of the foot, should serve as an indication for a lateral release, not a plantar release.
Inability to dorsiflex the ankle is an indication for a posterior release.

Patients with total involvement have the highest degree of axial muscle imbalance; therefore, they have the highest risk of hip subluxation (greater than 50%).
Hip dysplasia is uncommon in athetoid cerebral palsy (C P).
Diplegic C P has the second highest incidence of neuromuscular hip dysplasia, but total involvement has the highest rate. Hip subluxation is not common in hemiplegic C P.
Monoplegia is a rare form of C P with a low rate of subluxation.

Spontaneous partial reduction will occur when the patient becomes upright, and there is good remodeling potential due to growth.
C losed reduction and abduction cast is not necessary because of the patientâs age, remodeling potential, and range of motion available in the joint.
A formal attempt at closed reduction is not necessary because there is no way of holding it without internal fixation. This process will occur naturally to a large degree when the patient becomes upright.
Open reduction and percutaneous pin fixation poses a risk of pin tract infection because of the large amount of muscle traversed. This procedure is not necessary because of the good results with conservative treatment.

Once the ulna is predictably reduced, the radial head has a good chance of staying reduced.
Repeat closed reduction and a long arm cast has a significant chance of redisplacement. If further time passes, radial head reduction will be difficult.
Annular ligament reconstruction is only indicated if there is late subluxation (after several weeks) that does not reduce with closed means.
Once the ulna is realigned and fixed, closed reduction of the radius must be tried next.
Pinning of the radial head should be a last resort because of the risk of breakage and stiffness.

The Hilgenreiner-epiphyseal angle is a measure of the shear stress on the femoral neck. A value greater than 60° is an indication for surgery.
The range of abduction does not directly reflect the mechanical stresses on the femoral neck that may need correction. The epiphyseal extrusion index is a parameter used in Perthes disease.
The acetabular index is used in developmental hip dysplasia. It is usually essentially within normal limits, even in severe coxa vara.

An exam under anesthesia and arthrogram should be performed. C losed reduction must be performed if the hip reduces with a medial dye pool less than 4 mm and a safe zone greater than 20°.
The Pavlik harness is not strong enough to hold an infant older than 4 to 6 months. Open reduction is reserved for hips that do not reduce by closed means.
A Salter osteotomy is only indicated if the hip is still unstable after an open reduction.

The young age is the overwhelmingly positive factor in this patient. None of the findings mandate a more vigorous approach than observation.
The Atlanta Scottish Rite orthosis has not been proven to have any effect on the disorder. Femoral osteotomy would only be possibly indicated, if there were subluxation greater than 25%.
Iliac osteotomy would only be indicated in this age group, if there were subluxation and/or other poor prognostic factors. Petrie cast is indicated only if the patient has subluxation.

In situ fixation has results superior to any of the other methods.
Besides being extremely cumbersome, spica cast treatment carries significant risk of redisplacement and chondrolysis. There is no indication for traction in this situation.
The amount of displacement can be accepted as long as it is stabilized.
Metaphyseal osteotomy carries a risk of avascular necrosis. It should only be undertaken in grade III slips.

Staphylococcal osteomyelitis is the presumptive diagnosis; therefore, intravenous oxacillin should be administered.
Infection is much more likely than tumor. The predicted organisms should be sensitive to oxacillin. A bone biopsy is not mandatory unless the patient fails to respond to intravenous antibiotics.
Debridement is not likely to be necessary given no evidence of a sequestrum.
Although acute hematogenous osteomyelitis is the likely diagnosis, it is standard practice to begin treatment with intravenous antibiotics and then switch to oral antibiotics when a clinical response is evident.
Gentamicin is not needed in this setting.

C alcaneovalgus foot has all of these findings and resolves spontaneously.
Fibular hemimelia typically has less calcaneus attitude and more valgus and shortening. Vertical talus entails loss of an arch and loss of cohesive movement of the foot as a whole. There is no evidence of muscle weakness.
There is no evidence of a neuropathic component.

C onservative therapy is predicted to bring a good result because biceps are returning at four months of age. However, stretching of the shoulder is indicated to maintain a range of external rotation and abduction.
Magnetic resonance imaging is only indicated if there is a need to consider microvascular repair.
Tendon transfers are performed later (at several years of age), if shoulder abduction and external rotation are significantly limited.
Microvascular repair is mainly considered in patients who do not have return of biceps function by five months.
Open reduction is indicated later (if the shoulder joint is subluxated or severely contracted) after motor recovery has reached a plateau.

The straight legs and circumduction suggest spasticity of the rectus femoris as the most likely cause.
Recurrent hamstring tightness (by itself) would cause the opposite combination of problems.
Overlengthening of the heelcords usually causes increased dorsiflexion at the ankles and would help to increase the flexion moment rather than the extension.
C ontracture of the tensor fascia lata is extremely rare in cerebral palsy. Spasticity in the psoas muscle would not lead to a stiff knee gait.

The tibial torsion described has an excellent chance of resolution over time. Observation is indicated.
This child has tibial torsion. The Denis Browne bar has not been proven to affect the natural history of tibial torsion. The knee-ankle-foot orthoses are used for genu varum, which is not the primary problem in this case.
A femoral osteotomy is rarely used to correct femoral anteversion in older children. A tibial osteotomy is rarely used to correct tibial torsion in older children.

The foot in a patient with tibial hemimelia does not resemble the other four conditions described; the foot is in equinus and varus.
C alcaneovalgus foot is dorsiflexed and everted through the axis of the ankle joint. A vertical talus has excessive forefoot dorsiflexion and valgus.
A patient with an L5 myelomeningocele may have this appearance due to activity of the dorsiflexors and evertors, with absent power in the plantarflexors and invertors.
Due to the posteromedial bow in the tibia, the foot may appear dorsiflexed and in valgus.

Telescoping or Bailey-Dubow rods are able to grow with the patient and maintain stabilization for a mean of 4 years between operations in growing children.
Without the addition of internal fixation, bowing is likely to resume.
Although a single rod is likely to provide current stability, bowing is likely to occur as the patient grows and the bone becomes longer than the rod.
Parallel rods do not interlock and are likely to splay and lose fixation.
There are no reports of large segment allograft replacement for diaphyses in osteogenesis imperfecta. In the absence of internal fixation, bowing is likely to resume as growth occurs.

The patient has enough joint contractures to make arthrogryposis a likely diagnosis.
Larsen syndrome is characterized by dislocation of multiple joints.
C erebral palsy is characterized by spasticity and flexors overpowering extensors. Ehlers-Danlos is characterized by hyperlaxity of the large joints.
Down syndrome does not present with stiffness.

Virtually all patients with metatarsus adductus will improve with time in the absence of active treatment.
C asts are not needed for the majority of cases because spontaneous improvement is by far the most common outcome. Reverse last shoes are not needed in the majority of patients with metatarsus adductus.
Most patients will not need surgery.
Equinus of the hindfoot is not part of the pathology in metatarsus adductus.

If followed by postoperative bracing, lengthening of the adductors is usually successful in children younger than 4 to 6 years of age.
Traction would not be appropriate because the muscles are spastic. The surgical plan does not include the most important component â weakening the overactive adductors.
Trochanteric transfer is not advisable in patients younger than 8 years old. Trochanteric transfer would not help decrease the overpull of the adductors which is the cause of the subluxation.
Nighttime abduction splinting should be a component of the care after surgery. Bracing alone would not be an adequate treatment.
Physical therapy in the absence of surgery does not seem to be enough to overcome the pull of the adductors.

There is a good chance that a satisfactory closed reduction may be achieved by correcting the valgus and external rotation.
The fracture should first be reduced. There is a good chance of a satisfactory reduction. The patient is old enough that a significant physeal growth disorder is not likely.
Magnetic resonance imaging is not indicated unless there is a question of physeal disorder after healing or an entrapped fragment.

In a historical cohort study, the risk was increased to 1.7 times the expected rate of breast cancer. The radiation dose is currently lower. The exposure to the breast may be lowered by taking posteroanterior rather than anteroposterior films, and eliminating lateral films in routine situations.

The mean growth is 0.7 mm per vertebra per year. This measurement is averaged across all of the thoracic and lumbar vertebrae.

In congenital scoliosis, the vertebrae are abnormally formed from birth. The vertebrae are normal at birth in infantile idiopathic scoliosis.
Age of onset is before age 3 in both types of scoliosis.
The thoracic curve may be convex to the left slide or the right side in either curve type. In infantile idiopathic scoliosis, it is most commonly convex to the left.
The rib-vertebral angle difference (angle between the apical vertebral endplate and the rib on the convexity minus the rib on the concavity) greater than 20° predicts an increased risk of worsening in infantile idiopathic scoliosis but not in congenital scoliosis.
Bracing has not been shown to affect infantile idiopathic scoliosis.

Because the odds are greatly in favor of a noninfectious process, it is appropriate to treat empirically with rehydration and analgesia.
Magnetic resonance imaging would not distinguish between infection and vaso-occlusive crisis. Bone scan would not distinguish between infection and vaso-occlusive crisis.
Needle biopsy is not necessary at this stage since the odds are high (greater than 95%) that the process is not infection. White blood cell scan is not able to distinguish between infection and vaso-occlusive crisis.

Open reduction and 2-level fusion is the simplest way of handling this injury.
Immobilization in a hyperextension cast is likely to exacerbate the abdominal injury. An orthosis is not likely to reduce the deformity.
Traction would not be a good mechanism to reduce the deformity. In situ fusion would be insufficient without instrumentation.

Secondary ossification is very imprtant in managing fractures. It begins at age 1-2 and is complete by 14 years girls and 16 years in boys.

Definitive diagnoisis of septic arthritis is made by needle asperation.

Osteomyelitis in the child requires 3-6 weeks of antiobiotics which may be administered parenterally or internally.C orrect Answer:
requires antibiotic therapy for 3 to 6 weeks.

By definition, patients with a lateral patellar compression syndrome do not have a subluxation or dislocation of the patella.C orrect
Answer: Subluxation of the patella

Osteochondral defects occur bilaterally in the distal femur for approximately 20% to 30% of patients. The fact that 20% to 30% of patients with an osteochondral lesion in the distal femur have bilateral involvement suggests that there is a predisposition to the development of a lesion at this location, either genetic or secondary to repetitive microtrauma.

The presence of a high signal intensity line at the interface between the lesion and the underlying bone suggests instability of an osteochondritis dissecans lesion.

The neonatal hand is proportionally different from the mature hand.

Pediatric bone has less mineral and more vascular channels than adult bone. This gives it a lower bending strength and lower modules of elasticity than adult bone.

C entral deficiencies allow a wide grasp, good release and pinch. These are also termed "cleft hand". The other conditions produce greater impairment.

Radial deficiencies are often seen in the later association. which may include cardiac,renal,anorectal and tracheoesphogeal abnormalities.

Arthrogryposis multiplex congenita is an idiopathic disorder that may be due to a primary deficiency of anterior horn cells. Arthrogryposis multiplex congenita results in lack of muscle development; the joint stiffness is secondary to this. It is usually reasonably symmetrical.

The percentage of the genome that represents the sequence of our genes is approximately 5%. The rest of the genome codes are for initiator and termination sequences, maintenance functions, and unknown functions.

Autosomal recessive conditions classically show âhorizontalâ inheritance. Ancestors do not display the gene because they would likely have only one copy of the mutant allele. Only when two carriers reproduce is the phenotype manifest in approximately one- fourth of their offspring.
Autosomal dominant inheritance is characterized by vertical transmission. Many generations manifest the trait because it takes only a single copy of a mutant allele to display the phenotype.
Sex-linked conditions are often traced back in a family. Normally the males are affected and the females are carriers. Multifactorial conditions are thought to result from the combination of different genes. Although the risk of recurrence in kindred is somewhat greater than the population as a whole, it is still quite low (only a few percent). It is rare for siblings to be affected.
Anticipation refers to the phenomenon in which successive generations are likely to display more severe forms of a given disorder. Myotonic dystrophy is a classic example of this phenomenon.

Two copies of a mutant allele are required to reduce enzyme function to levels that cause clinical impairment.
Enzyme defects are rarely inherited by an autosomal dominant pattern because even half of the normal activity of most enzymes is adequate to maintain normal function.
Enzyme defects are rarely inherited in an X-linked dominant pattern because one copy of a mutant allele is usually sufficient.
Multifactorial inheritance refers to the interaction of multiple, or different genes, to produce a disorder. Enzyme deficiencies are typically the result of a defect in a single gene.
Because enzymes are typically coded by a single gene, they follow mendelian patterns.

Morquio syndrome is a member of the family of mucopolysaccharidoses. Morquio syndrome is a deficiency in the enzyme galactose-6-sulfatase. A deficiency in galactose-6-sulfatase results in increased urinary excretion of keratosulfate.
Alpha-L-iduronidase is deficient in Hurler syndrome.
Beta-glucuronidase is deficient in some rare mucopolysaccharidoses. Fibroblast growth factor receptor protein is deficient in achondroplasia. Sulfate transport protein is deficient in diastrophic dysplasia.

Polymerase chain reaction refers to denaturing DNA, isolating a segment of interest with known primers, and reannealing the strands multiple times to produce exponential copies of a segment.

The term pleiotropy refers to a disease taking different shapes in various patients.
Variation in the severity of a given problem is better termed "variable expressivity." Target joints are not genetically determined.
Hurler syndrome usually not being present in prior generations of an affected patient is an example of autosomal recessive inheritance.
The term pleiotropy refers to a disease taking different shapes in different subjects, whereas the cause of patients with
Ollier disease having more involvement on one side of the body is unknown.

Stiffness and mandibular hypoplasia are fairly common in juvenile rheumatoid arthritis (JRA) due to inflammation of the temporomandibular joint that affects the growth plates of the mandibles.
Basilar invagination is rare in JRA.
Rotatory subluxation of C 1-C 2 is rare in JRA. Subaxial subluxation is rare in JRA.
C ervical stenosis is not a clinical problem in JRA.

Magnetic resonance imaging should be the next step to rule out pyogenic spondylitis.
Ultrasound has not been proven effective in evaluation of anterior spinal pathology.
C omputed tomograms do not have a greater sensitivity than plain films in early diagnosis of infection.
An indium labeled scan may yield diagnostic information but would not be the preferred test because of the time needed and inability to provide other diagnostic information.
Hip arthrogram would not be the next step because the hip range of motion is normal. Even if hip pathology were suspected, the next step would be a plain film and an ultrasound.

A retrospective comparison study has shown no increase of risks in delayed treatment of supracondylar fractures.