Tricky Orthopedics

That being said, let’s go through some commonly tested and easily confused orthopedic entities…

Salter-Harris Classification

• Type 1 – Slipped (Physis)
• Type 2 – Above (metaphysis)
• Type 3 – Lower (Epiphysis)
• Type 4 – Transverse all 3
• Type 5 – Rammed (crush)

Hand/Wrist injuries

Scapholunate vs. Perilunate vs. Lunate Dislocation

• Mechanism for all 3: forceful extension of the wrist
• Scapholunate dislocation
  • Space between the lunate and scaphoid widened >3mm
  • Tx: Thumb Spica, refer to hand surgeon
• Perilunate dislocation
  • Capitate is dislocated dorsally in relation to the lunate
    • Lunate (teacup) is aligned with the distal radius
  • Risk: Median nerve injury, avascular necrosis, compartment syndrome
  • Tx: Hand surgeon consult and prompt reduction
• Lunate dislocation
  • Lunate displaced and rotated volarly (“Spilled teacup”)
  • Risk: Median nerve injury, avascular necrosis, compartment syndrome
  • Tx: Hand surgeon consult and prompt reduction

Scaphoid fracture: See Nusbaum’s tribute to Egan’s wrist (http://sinaiem.org/the-matt-egans-wrist-memorial-radiology-pearl/)

Galeazzi

• Middle distal 3^rd of radius fracture
• Associated with dislocation/subluxation of distal radioulnar joint
• Mechanism: fall on outstretched hand (FOOSH) or direct wrist trauma
• Risk: AIN (branch of median) injury
• Tx: ORIF

Monteggia

• Proximal 1/3 ulna fracture
• Associated with radial head dislocation
• More common in pediatrics (peak 4- 10 years)
• Risk: PIN (branch of radial) injury
• Tx: Closed reduction vs. ORIF

Pediatric leg pain

SCFE (Slipped Capital Femoral Epiphysis)

• M>F
• Adolescent males
• Risk factors: Obesity
• Symptoms: Groin, thigh or knee pain; may be for weeks to months
• Findings: Abnormal gait, decreased hip motion, abnormal leg alignment
• X-ray: Obtain Frog leg view
• Tx: Percutaneous fixation (at times bilateral)

Legg-Calve-Perthes Disease

• Idiopathic avascular necrosis of the proximal femur
• M>F
• 4 – 8 years
• Symptoms: Insidious onset; may cause painless limp; intermittent knee, hip, groin, or thigh pain
• Findings: Decreased ROM particularly internal rotation and abduction, gait disturbance, limb length discrepancy
• Tx: Orthopedic consult for nonoperative vs. operative

Osgood Schlatter’s Disease (Tibial Tubercle Apophysitis)

• M>F
• Boys 12-15 years, Girls 8-12 years
• Risk factors: jumpers or sprinters
• Symptoms: anterior knee pain, bilateral 20-30%
• Findings: Tenderness at anterior knee, enlarged tibial tubercle
• Tx: RICE, Self-limited
• Similar to Sinding-Larsen-Johansson Syndrome which is inferior pole of the patella apophysitis found more often in jumpers

References (Accessed 1/2/17)

1. Gaillard, Frank. Salter-Harris Classification. Radiopaedia.org. https://radiopaedia.org/articles/salter-harris-classification
2. Watts, Evan. Scapholunate Ligament Injury & DISI. http://www.orthobullets.com/hand/6041/scapholunate-ligament-injury-and-disi
3. Karadsheh, Mark. Lunate Dislocaton (Perilunate Dissociation). http://www.orthobullets.com/hand/6045/lunate-dislocation-perilunate-dissociation
4. Jones, Tracy. Monteggia Fractures. http://www.orthobullets.com/trauma/1024/monteggia-fractures
5. Allen, Deborah. Galeazzi Fractures. http://www.orthobullets.com/trauma/1029/galeazzi-fractures
6. Souder, Chris. Slipped Capital Femoral Epiphysis. http://www.orthobullets.com/pediatrics/4040/slipped-capital-femoral-epiphysis
7. Souder, Chris. Legg-Calve-Perthes Disease. http://www.orthobullets.com/pediatrics/4119/legg-calve-perthes-disease-coxa-plana
8. Woon, Colin. Osgood Schlatter’s Disease (Tibial Tubercle Apophysitis). http://www.orthobullets.com/sports/3029/osgood-schlatters-disease-tibial-tubercle-apophysitis
9. McKean, Jason. Sinding-Larsen-Johansson Syndrome. http://www.orthobullets.com/sports/3030/sinding-larsen-johansson-syndrome?expandLeftMenu=true