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RheumatologyMain121-130Q1A7-year-oldboywasbroughttotheemergencydepartmentafterfailingontohisoutstretchedarm.Hecomplainsofpaininhisleftarmandrefusestomovehisarmattheelbow.Onexamination:theleftarmisswollen,slightlypale,andedematous.Hisradialpulseisintact.Thepatient'sradiographisshownbelow.Whilethepatientiswaitingfortheorthopedicresidentoncalltoexaminehim,hecontinuestocomplainofincreasingpaindespitemultipledosesofpainmedication.Whichofthefollowingshouldyoubemostconcernedaboutinthispatient?A.DisplacementofthefractureB.TransientneuropraxiaC.BrachialarteryinjuryD.CompartmentsyndromeE.NarcoticabuseA1Correctanswer:DElbowfracturesaccountforoverhalfofallfracturesinchildren,andthemostcommontypeisasupracondylarhumerusfracture.Theseinjuriesoccurmostcommonlyinchildrenages2-12yearsold.Thetypicalhistoryusuallyconsistsofafallontoanoutstretchedarmwiththeelbowextended.Radiographsoftenshowalargeortriangularanteriorfatpad(lucency)andthepresenceofaposteriorfatpad(lucency)sign.Duetoitslocation,supracondylarhumerusfracturesmaybecomplicatedbyneurovascularinjuryorcompartmentsyndrome.Compartmentsyndromeischaracterizedbyseverepain,pallor,poikilothermia,paresthesias,andthelatefindingsofpulselessnessandparalysis.Patientswithpredisposinginjuriesshouldbecontinuallymonitoredforthedevelopmentofcompartmentsyndrome,particularlyasswellingfromtheinjuryincreases.Initialtreatmentincludesremovalofanybandages,measurementofcompartmentpressures,andemergentorthopedicevaluationforpossiblefasciotomy.(ChoiceA)Displacementofthefractureisanunlikelycauseofthispatient'sincreasedpainsincetheradiographshowsnodisplacementandthepatientisrefusingtomovetheextremity.(ChoiceB)Transientneuropraxiasareverycommoninpatientswithsupracondylarhumerusfractures,butwouldnotcauseincreasingpain.(ChoiceC)Brachialarteryinjuryisamajorconcerninpatientswithsupracondylarhumerusfracturesduetotheirlocation.Therefore,pulsesshouldbemonitoredfrequentlytodetermineifvascularinjuryhasoccurred.Manipulationofthefractureshouldonlybedonebyaspecialisttoavoidcausingvascularinjuryduringfracturereduction.Inthispatient,thepulsesareintactandheishavingincreasingpain,whichismoreconcerningforcompartmentsyndromethanvascularinjury.(ChoiceE)Narcoticabuseisunlikelyinachildthisage,andtheincreasingpainfromswellingduetocompartmentsyndromeisthemorelikelyreasonthatheisrequiringmultipledosesofpainmedication.Educationalobjective:Compartmentsyndromecanbeacomplicationofsupracondylarhumerusfractures.Itischaracterizedbyseverepain,pallor,poikilothermia,paresthesias,andthelatefindingsofpulselessnessandparalysis.Q2A2-month-oldgirlisbroughttotheofficebyherfatherforaweilchildvisit.Heisconcernedaboutright-sidedflatteningofthebackofhischild'sheadthathenoticed3weeksago.Thepatientalsoseemstopreferturningherheadtotherightwhiletiltingherheadtotheleft.Shewasbornfull-termviaCesareandeliveryforbreechpositioning.SheisbreastfedexclusivelyandreceivesvitaminDsupplementation.Sheisplacedtosleeponherbackasinstructed:andherparentshavenotyetstartedtummytime11sincetheyarenervousshemayfallasleep.Thepatientspitsupfrequentlyandappearsmostcomfortablewhenhelduprightafterfeeding.Physicalexaminationrevealsflatteningoftherightocciputwithanteriordisplacementoftherightearandforehead.Herheadisturnedtotheright,andthereisapalpable,firmmassthatdoesnottransiiluminateintheinferiorportionoftheleftsideoftheneck.Thepatient'shipsarestablewithnoclicksorclunks.Whichofthefollowingisthemostlikelyunderlyingcauseofthispatient'spresentation?A.CongenitallymphaticmalformationB.FractureoftheclavicleC.PrematureclosureofacranialsutureD.PosturaldeformityoftheneckE.TumorofposteriorfossaA2Correctanswer:DThisinfantpresentingwithaneckmassandheadtilttoonesidewithchindeviationtotheotherhascongenitalmusculartorticollis(CMT).CMTisaposturaldeformitythattypicallypresentsbetweenage1-6monthswithlimitedrangeofmotionoftheneck.Physicalexaminationmayrevealapalpable,well-circumscribedmassthatdoesnottransliluminateintheinferiorportionofsternocleidomastoidmuscle.RiskfactorsforCMTarerelatedtocrowdingintheuterus,suchasmultiplegestation,breechpositioning,andoligohydramnios.Associatedconditions,whicharealsolikelyrelatedtointrauterinepositioning,includedevelopmentaldysplasiaofthehip,metatarsusadductus,andclubfoot.Treatmentstrategiesincludepositioning(eg,increasedtummytime),passivestretching,andphysicaltherapy.Missedordelayeddiagnosismayleadtocraniofacialasymmetry.Flatteningoftheheadwithipsilateralanteriordisplacementoftheearandforehead,knownaspositionalplagiocephaly,IsalsoacommonconsequenceofCMT.(ChoiceA)Cystichygromasarecongenitalmalformationsofthelymphaticsystemandarelocatedintheposteriortriangleoftheneck.Theyareoftendetectedprenatallyandhaveahighassociationwithaneupioidy.Postnatalexaminationwouldrevealafluctuantmassthattransiiluminates,(ChoiceB)Claviclefracturesareassociatedwithdifficultvaginaldeliveries(eg，shoulderdystocia)andpresentswithcrepitus,swelling,anddecreasedrangeofmotionoftheipsilateralupperextremity.Claviclefracturesdonotaffecttheneck.(ChoiceC)Anormalnewbornskullhassuturesandfontanei