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24 Cards in this Set
- Front
- Back
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– In the newborn nursery it is noted that a child has uneven gluteal folds. Physical exam of the hips reveals that one of them can be easily dislocated posteriorly with a jerk and a “click”, and returned to normal position with a “snapping:
Diagnosis Management |
Diagnosis: Dysplasia of the Hip
Management: Abduction splinting. (Don’t order X-Rays in a newborn. Calcification is still incomplete and you will not see anything). But U/S could be useful for imaging |
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A 6 year old boy has insidious development of limping with decreased hip motion. He complains occasionally of knee pain on that side. He walks into the office with an antalgic gait. Passive motion of the hip is guarded.
Diagnosis Management |
Diagnosis: Legg-Perthes syndrome (avascular necrosis of capital femoral epiphysis)
Management: AP and lateral X-Rays for diagnosis. Contain the femoral head within the acetabulum by casting and crutches. |
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A 13 year old boy complains of pain in the groin ( it could be the knee) and is noted by the family to be limping. He sits in the office with the foot on the affected side rotated towards the other foot. Physical examination is normal for the knee, but shows limited hip motion. As the hip is flexed, the leg goes into external rotation and it can not be rotated internally
Diagnosis Management |
Diagnosis: Forget the details, a bad hip at this age is always slipped capital femoral epiphysis
Management: AP and lateral X-Rays for diagnosis. The orthopedic surgeons will pin the femoral head in place |
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A little toddler has had the flu for several days, but he was walking around fine until about two days ago. He now absolutely refuses to move one of his legs. He is in pain, holds the leg with the hip flexed, in slight abduction and external rotation and you can not examine that hip he will not let you move it. He has elevated sedimentation rate.
Diagnosis Management |
Diagnosis: Septic Hip
Management: Aspiration for confirmation and open athrotomy for drainage |
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A child with a febrile illness but no history of trauma has persistent, severe localized pain in a bone.
Diagnosis Management |
Diagnosis: Acute Osteomyelitis
Management: Don't do X-ray! Won't show anything for weeks. Do a bone scan and then antibiotics |
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A 12 year old girl is referred by the school nurse because of potential scoliosis. The thoracic spine is curved toward the right, and when the girl bends forward a “hump” is noted over her right thorax. The patient has not yet started to menstruate
Management |
Too complicated for our purposes, but the point is that scoliosis may progress until skeletal maturity is reached. Baseline X-Rays are needed to monitor progression. At the onset of menses skeletal maturity is about 80%, so this patient still has a way to go. Bracing may be needed to arrest progression. Pulmonary function could be limited if there is large deformity
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– A 16 year old boy complains of low grade but constant pain in his distal femur present for several months. He has local tenderness in the area, but is otherwise asymptomatic. X-Rays show a large bone tumor, with “sunburst” pattern and periosteal “onion skinning”
Diagnosis Management |
Diagnosis: Osteosarcoma
Management: Do not attempt biopsy. Referral is needed, not just to an orthopedic surgeon (they see one of these every three years), but to a specialist on bone tumors. |
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A 66 year old lady picks up a bag of groceries and her arm snaps broken.
Diagnosis Management |
Diagnosis: Malignant spread of a primary tumor - a pathologic fracture for trivial reasons.
Management: X-rays to document the fracture, bone scan to look for other mets, and search for primary (women mcc breast, men mcc prostate) |
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A 58 year old lady has a soft tissue tumor in her thigh. It has been growing steadily for six months, it is located deep into the thigh, is firm, fixed to surrounding structures and measures about 8 cm. in diameter.
Diagnosis Management |
Diagnosis: Soft tissue sarcoma
Management: Get an MRI; leave biopsy and excision to experts |
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A middle aged homeless man is brought to the ER because of very severe pain in his forearm. The history is that he passes out after drinking a bottle of cheap wine and he slept on a park bench for an indeterminate time, probably more than 12 hours. There are no signs of trauma, but the muscles in his forearm are very firm and tender to palpation, and passive motion of his fingers and wrist elicit excruciating pain. Pulses at the wrist are normal.
Diagnosis Management |
Diagnosis: Compartment Syndrome - slept on the arm and swelled up the muscles
Management: Emergent fasciotomy |
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A patient presents to the ER complaining of moderate but persistent pain in his leg under a long leg plaster cast that was applied six hours earlier for an ankle fracture.
Management |
The only option is remove the cast. The cast might be on too tight, compressing the blood supply, or rubbing off skin. You don't give pain meds
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A young man involved in a motorcycle accident has an obvious open fracture of his right thigh. The femur is sticking out through a jagged skin laceration
Diagnosis Management |
Diagnosis: Open fracture, an orthopaedic emergency
Management: Orthopaedic emegencies that require reducation and cleaning within 6 hous |
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A 55 year old lady falls in the shower and hurts her right shoulder. She shows up in the ER with her arm held close to her body, but rotated outwards as if she were going to shake hands. She is in pain and will not move the arm from that position. There is numbness in a small area of her shoulder, over the deltoid muscle
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Diagnosis: Anterior dislocation of the shoulder, with axillary nerve damage.
Management: Get AP and lateral X-Rays for diagnosis. Reduce. |
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After a grand mal seizure, a 32 year old epileptic notices pain in her right shoulder and she can not move it. She goes to the near-by “Doc in a Box”, where she has X-Rays and is diagnosed as having a sprain and given pain medication. The next day she still has the same pain and inability to move the arm. She comes to the ER with the arm held close to her body, in a “normal” (i.e., not externally rotated, but internally rotated) position.
Diagnosis Management |
Diagnosis: Posterior Dislocation of the Shoulder
Management: X-rays |
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A front seat passenger in a car that had a head-on collision relates that he hit the dashboard with his knees, and complains of pain in the right hip. He lies in the stretcher in the ER with the right extremity shortened, adducted, and internally rotated
Diagnosis Management |
Diagnosis: Ortho Emergency - Posterior dislocation of hip; Could compromise blood supply leading to avascular necrosis
Management: X-rays and emergency reduction |
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A 77 year old man falls in the nursing home and hurts his hip. X-Rays show that he has a displaced femoral neck fracture.
Management |
The point of this vignette is that blood supply to the femoral head is compromised in this setting and the patient is better off with a metal prosthesis put in, rahter than an attempt at fixing the bone. With intertrochanteric fractures on the other hand, the broken bones can be pinned together and expected to heal.
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A football player is hit straight on his right leg and he suffers a posterior dislocation of his knee.
Management |
Posterior dislocation of knee can damage polpiteal artery and therefore bloodflow and pulses need to be assessed. Arteriogram and reduction needed
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A young recruit complains of localized pain in his tibia after a forced march at boot camp. He is tender to palpation over a very specific point on the bone, but X-Rays are normal.
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Stress fracture.
The lesson here is that stress fractures will not show up radiologically until 2 weeks later. Treat the guy as if he had a fracture (cast) and repeat the X-Ray in 2 weeks. |
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A man who fell from a second floor window has clinical evidence of fracture of his femur. The vignette gives you a choice of X-Rays to order.
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Always get x-rays 90 degrees from each other; AP and lateral; Always get x-rays above and below joints; And get x-rays of other bones that may be in the same line of force/impact
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A healthy 24 year old man steps on a rusty nail at the stables where he works as a horse breeder. Three days later he is brought to the ER moribund, with a swollen, dusky foot, in which one can feel gas crepitation
Diagnosis Management |
Diagnosis: Gas gangrene
Management: IV Penicilin, Surgical Debridement, Hyperbaric O2 |
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A 55 year old, obese man suddenly develops swelling, redness and exquisite pain at the first metatarsal-phalangeal joint.
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Diagnosis: Gout
Management: Diagnosis by serum uric acid determination and identification of uric acid crystals in fluid from the joint. Rx. with colchicine, allopurinol or probenicid. |
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A 67 year old diabetic has an indolent, unhealing ulcer at the heel of the foot.
Diagnosis Management |
Diagnosis: Neuropathic Ulcer due to poor circulation
Management: Control the diabetes, elevate the leg, keep the ulcer clean and be resigned to the idea you may need to amputate |
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A 67 year old smoker with high cholesterol and coronary disease has an indolent, unhealing ulcer at the tip of his toe. The toe is blue, and he has no peripheral pulses in that extremity.
Diagnosis Management |
Diagnosis: Ischemic Ulcer
Management: Doppler studies, arteriogram; Revascularization may be possible |
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A 44 year old, obese woman has an indolent, unhealing ulcer above her right maleolus. The skin around it is thick and hyperpigmented. She has frequent episodes of cellulitis, and has varicose veins.
Diagnosis Management |
Diagnosis: Venous stasis ulcer
Management: Unna boot; support stocking; varicose vein surgery |
