2025 – PAGE 417 – ORTHOPEDICS AND SPORTS MEDICINE

SPONDYLOLISTHESIS

In spondylolisthesis, a slipped vertebral body results in lower back pain. The problem and pain is usually around L5 or S1. Again, pain is worse with standing.

IMAGE: www.pbrlinks.com/SPONDYLOLISTHESIS1
IMAGE: www.pbrlinks.com/SPONDYLOLISTHESIS2 (copyright free)

MNEMONICS: Rename it spondyloSLIPthesis or spondyloLISPthesis.

SUBLUXED RADIAL HEAD (AKA NURSEMAID’S ELBOW)

A subluxed radial head (AKA nursemaid’s elbow) usually occurs in young children when a child is picked up or pulled by the arm. The forearm will be pronated, and the arm will be flexed and close to the body. It almost looks like the patient is wearing an invisible cast, and sometimes patients are noted to hold the affected elbow with the unaffected hand. Treat with forced supination and/or pronation.

PEARLS: Know that it involves the annular ligament (it slips over the radial head, allowing radial head dislocation). Also, it’s fine to look and feel for fractures, but there is NO NEED for imaging if the story fits.

IMAGE: www.pbrlinks.com/SUBLUXEDRADIAL1
IMAGE: www.pbrlinks.com/SUBLUXEDRADIAL2

DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)

Infants with developmental dysplasia of the hip (DDH) may be noted to have a leg-length discrepancy, extra creases at the thigh, “clunks” or “clicks” on exam. A majority of newborn “clunks” resolve by 2 weeks of age. So do NOT obtain any imaging at the time of birth. ALL patients with an unequivocal Barlow or Ortolani maneuver (meaning there’s no question in your mind on exam), limited hip abduction, or asymmetric hip abduction after 1 month should be referred to an orthopedist for evaluation. For children 6 weeks – 4 months of age, ultrasound should be used. After 4 months of age, hip x-rays should be used. Treatment of DDH requires a Pavlik harness.

• PEARL: Consider imaging before 6 months of age for any male or female infant with normal findings on physical exam, but any of the following risk factors.
  • Breech presentation in the third trimester
  • Positive family history
  • History of previous clinical instability
  • Parental concern
  • History of improper swaddling
  • Suspicious or inconclusive physical exam
• PEARL: Ultrasound can be used from 6 weeks to 6 months and radiographs are recommended > 4 months. Radiographs are preferred after 4 months due to the lower rate of false positives compared to ultrasound. NEVER image before 2 weeks of age. For a child with no clinical signs of DDH on exam but with a NEED for evaluation based on high-risk factors, you can ultrasound at 6 weeks or obtain radiographs at 4 months of age. When it comes to the Barlow and Ortolani signs, if EITHER of them is positive, send for imaging (after 2 weeks of age)! ALL children should be “screened” periodically at the well-child visits by EXAM! Meaning, if you’re asked if you should “screen” a child for DDH at the 2-month visit, the answer is always going to be YES. Lastly, if you encounter an asymptomatic child that was supposed to get imaging (e.g., breech, family history) but never did, and the patient is now 5 or 6 months old, GET IMAGING even if the exam is normal!
• IMAGE: www.pbrlinks.com/DDH1
• IMAGE: www.pbrlinks.com/DDH2