PEM Source

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All posts with tag: "ortho"

PEM Questions

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You are seeing a 12 year old boy with pain in his lower back and right buttock for 2 weeks. He is an active soccer player. On exam, he has tenderness over his right sacroiliac joint. 

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You are seeing a 6 year old girl who comes in for right leg pain after a ground level fall at the park. She is currently being worked up by her pediatrician for precocious puberty, including vaginal spotting and breast buds. On exam, her temp is 37.5, HR 90, RR 22, pulse ox 100% on room air. Her face appears asymmetric. Heart and lung exam is normal. Abdomen is soft, and you do not palpate any masses. Her right leg shows no swelling, obvious deformity, or neurovascular compromise, but she is tender to palpation along her anterior tibia. She has a large light brown irregularly shaped macule on her back. 

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A father brings in his 11-year-old son for medial elbow pain. The boy is the star player (and often the starting pitcher) on his little league team, and Dad is the coach. The team is in second place and there are just a few more games until playoffs. At first, the boy had medial elbow pain only at the end of the game, but lately his elbow hurts after the first throws, and he is not pitching as accurately as he had been before. On physical exam, he is tender at the medial epicondyle. On your preliminary read of the xray, there is no fracture, dislocation, and the expected ossification centers are all present. 

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You are seeing a 17-year-old boy with one day of right calf pain and swelling. The day before onset of his symptoms, he was helping with a kitchen remodel and tried to remove a support beam by kicking it multiple times. He continued to help, and it wasn’t until the next morning that he noticed his symptoms. He has no significant PMH. He has taken no medications. He has had no recent travel, illness, or other trauma. On exam, he is afebrile, HR 65, RR 18, BP 140/80, weight 135 kg, BMI 42. His right calf circumference measures 1.5 inches more than his left. His calf is not particularly tender to palpation, and there is no redness or warmth. His leg is not swollen above the knee. He has normal sensation distally and normal color. He is able to walk without a limp but has pain with walking. He has no pitting edema. 

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You are seeing a 3 year old child with 3 weeks of gradually progressing low back pain, now impacting her ability or willingness to walk. There has been no trauma and no fever noted at home, although temperature is 37.8 in the ED. On exam she has loss of lumbar lordosis and tenderness to palpation of the lumbar spine. She has full passive range of motion without pain of the hips. She was seen by her PCP 3 days ago and CBC was normal, blood cultures negative to date. Today, CBC is still normal and ESR is 47. Plain radiograph shows narrowing of the L3/4 disc space. MRI is not available in your ED.

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You are seeing a 16 year old basketball player who presents with pain and swelling over his dorsal PIP joint, and inability to extend at the PIP joint. 

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A 20 month old boy is brought in by his mother for refusal to bear weight on the right leg. She was at work all day and the child went to the park with his father, but no known trauma occurred. He has had no fever, URI symptoms, or rash. He was born full-term and has no significant past medical history. Physical exam of his right leg is unremarkable. AP and lateral X-rays are as shown. 

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You are seeing a 17 year old boy who fell while skateboarding and sustained an axial loading force to his right thumb. He is exquisitely tender at the base of the thumb (carpometacarpal joint), and you note swelling as well. Which of the following injuries is least likely to be encountered based on this mechanism and exam?

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You are seeing an adolescent who slammed her finger in a door and has a subungual hematoma. 

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You are seeing a child who fell on an outstretched hand and sustained a radius fracture. 

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A teen who plays on the high school varsity basketball team comes in after jamming her finger during a game. She has a distal phalanx simple dislocation without fracture. 

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(Click the link to comment and to vote - voting not working through email, sorry!) An 11yo girl presents with 2 weeks of right knee pain and limp after falling off a bicycle. She has had no fever, rash, other trauma. Vital signs are: temperature 37.5, HR 80, RR 16, BP 110/60. Her exam is normal except for: a 1/6 musical systolic ejection murmur at the LLSB, acanthosis nigricans, and gait with a noticeable limp. Her right knee has no effusion, deformity, erythema, or warmth appreciable. [yop_poll id="165"]
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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 17 year old who was playing basketball for his high school team this evening when he felt a sudden pop and immediate pain in his right Achilles tendon area. He is able to bear weight, but with pain. On exam, there is a palpable gap in his Achilles tendon, and you suspect a ruptured tendon. [yop_poll id="119"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 11 year old left-hand dominant boy is brought in after accidentally sustaining an injury from a paint injection gun while helping his father on a project at home. The injury occurred 2 hours ago. On exam, he has a barely perceptible entrance puncture wound at the tip of his right index finger, no deformity or swelling, and a normal neurovascular exam. Radiographs are negative for fracture and his tetanus is up to date. [yop_poll id="117"]
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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 year old boy active in club soccer who comes in complaining of intermittent posterior heel pain, particularly after soccer games. He has pain at the posterior calcaneus, especially when the sides of the heel are squeezed. There is no history of trauma or fall. There are no other abnormal physical exam findings, and radiographs are normal. The patient is not limping and currently does not have pain at rest. [yop_poll id="99"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following elbow radiography findings can be normal in a 2 year old that fell on an outstretched arm and has decreased use of her elbow? [yop_poll id="89"]
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(Click the link to comment and to vote - voting not working through email, sorry!) A 16 year old football player is brought in with severe right knee pain after being hit from the front. He states that he thought his knee was displaced initially, but now it looks back in place. He has no obvious deformity or effusion on observation, and no ecchymosis. Instability testing is difficult due to the patient’s pain. Radiographs are negative for fracture or dislocation. Dorsalis pedis pulses are palpable and normal bilaterally. [yop_poll id="65"]
(Click the link to comment and to vote - voting not working through email, sorry!) 14yo boy presents with LLQ abdominal pain and left hip pain for 5 days. He has not had any fever. He is an active baseball player and skinned his right knee the week before. On exam, he prefers to keep his left hip flexed at 90 degrees, walks with a limp and lordosis, and is most comfortable laying on his right side with his hips flexed. He has LLQ abdominal tenderness and has maximal pain with any attempt to extend or internally rotate his left hip. Genitourinary exam is normal. [yop_poll id="61"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 9 month old baby is brought in with this problem, first noted a few hours prior. Hair tourniquet By James Heilman, MD [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], from Wikimedia Commons [yop_poll id="55"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 18 month old child has sustained an arm fracture. Per the parent, the 4 year old sibling was carrying the child and tripped. [yop_poll id="34"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 year old was bitten by the family cat superficially on his right index finger, 3 days ago. He presents now with redness, warmth, and pain over the volar aspect of his index finger. [yop_poll id="31"]
(Click the link to comment and to vote - voting not working through email, sorry!) Put these causes of pediatric limp in order of what age they typically present, from youngest to oldest:
  1. Legg-Calve-Perthes disease
  2. Developmental dysplasia of the hip
  3. Slipped capital femoral epiphysis
  4. Nondisplaced hairline oblique fracture of the tibia w/o history of trauma
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A 12yo girl presents to the ED in December with fever for 4 days, malaise, and pain in the right thigh gradually leading to her having difficulty walking. There is no history of trauma, although she did play a lot of basketball 1 week ago. She is alert and oriented. Physical exam of her leg is unremarkable except for diffuse pain. She has no rash nor joint swelling or erythema. Her vital signs are: temp 39.1, HR 165, RR 22, BP 85/44. Labs show an elevated WBC count with a bandemia, a BUN of 20 with a creatinine of 2.2, and mildly elevated transaminases with a bilirubin of 2.4. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="9"]
NEW! Vote your answer and see what others voted for. Correct answer will be in Comments in a few days. A 14yo female soccer player comes to the ED complaining of bilateral knee pain x 1 month, right greater than left. She does not recall a specific traumatic injury or fall, nor of any knee swelling, popping, or locking. The pain is worse after soccer practice or a game, and after getting up from sitting for a prolonged period such as her 2-hour block classes. The pain is described as behind the knee cap. There is no knee effusion, and there is full active range of motion. She has been afebrile throughout the course. [yop_poll id="1"]
Of the following fractures, which is most concerning for non-accidental trauma? A. 18 month old brought in for refusing to walk, no history of any trauma or fall. Toddlerfx (source medscape) B. 18 month old brought in for refusing to walk, history of falling from a jungle gym approximately 3 feet off the ground. Cornerfx (source http://www.meddean.luc.edu/) C. Both are concerning for non-accidental trauma D. Neither are concerning for non-accidental trauma Check back in a few days for my answer and others' comments

Tips and Tricks

Harbor-UCLA Emergency Medicine Residency grad and all around great educator Tom Fadial has made some highly useful apps that you absolutely need. The latest, Fractures, is a comprehensive library of fracture types along with radiograph images, pearls, a guide to choosing the appropriate splint, and recommended orthopedics follow-up. The Sutures app reviews the basics of suture materials and anesthetic dosing, and includes links to video walkthroughs of suture techniques from another one of our favorite sites, Closing the Gap. The apps are available on iOS and Android, and some also have web-based versions. Go to fadial.com to check them out!

PEM Infographics (linked here) has many helpful infographics. One of my all-time favorites is how to use rock-paper-scissors-OK sign to test children's peripheral nerves in the upper extremity / hand exam rock paper scissors ok
Busy ED and don't have time for procedural sedation or prolonged anterior shoulder dislocation reduction techniques? Set 'em up in the Stimson technique position and forget 'em - check back in 20-30 minutes. AliEM posted this great tip for using soft restraints to attach weights to the patient's wrist. If you don't have weights - each 1 Liter bag of NS including the bag is about 2.4 lbs; attach 2 to 4 bags for 5-10 lbs of weight. Stimson2017  Weight for Stimson (Stimson technique via Wikipedia)

Controversies

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Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!

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(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 9 year old with a knee laceration IMG_1416 [poll id="51"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 4 year old with 1 day of limp and now, refusal to bear weight. He is afebrile. On exam, his hip is irritable to passive external and internal rotation. He holds his hip slightly externally rotated. His CBC WBC is 8,400 with 50% neutrophils, and his ESR is 20. His plain films are normal. He has reliable parents and an assigned pediatrician who can see him the next day. [poll id="25"]

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