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Questions and Answers

What are the common treatment options for Pancoast tumour?

  • Physical therapy and lifestyle changes
  • Chemoradiation followed by surgical resection (correct)
  • Only surgical decompression
  • Activity modification and NSAIDs

    • Which condition is often characterized by symptoms such as shoulder/arm pain and paresthesias along the medial 4th and 5th fingers?

  • Rotator Cuff Tendinopathy
  • Thoracic Outlet Syndrome
  • Pancoast Syndrome (correct)
  • Subacromial Bursitis

    • What imaging study is best for initial investigation of a suspected Pancoast tumour?

  • Venous Doppler ultrasound
  • MRI of chest
  • CXR (correct)
  • CT guided core biopsy

    • What is the main cause of thoracic outlet syndrome?

    <p>Compression due to various structural abnormalities</p> Signup and view all the answers

    Which symptom is most consistent with neurogenic thoracic outlet syndrome?

    <p>Vague pain and atrophy of hand muscles</p> Signup and view all the answers

    Which conservative treatment is recommended for subacromial bursitis?

    <p>Physical therapy and NSAIDs</p> Signup and view all the answers

    What is a key presentation symptom of rotator cuff tendinopathy?

    <p>Pain during rest while sleeping</p> Signup and view all the answers

    Which test is commonly used to recreate radicular pain in patients suspected of having thoracic outlet syndrome?

    <p>Spurling test</p> Signup and view all the answers

    Which of the following is NOT a common presentation of Pancoast syndrome?

    <p>Severe low back pain</p> Signup and view all the answers

    What can cause Horner’s syndrome in Pancoast tumour cases?

    <p>Invasion of the sympathetic chain</p> Signup and view all the answers

    What is the primary disadvantage of enhanced first trimester screening (eFTS)?

    <p>It does not measure the risk of open neural tube defects (ONTD).</p> Signup and view all the answers

    Which of the following is a characteristic of Chorionic Villus Sampling (CVS)?

    <p>It is less invasive than amniocentesis.</p> Signup and view all the answers

    At what gestational age is the Nuchal translucency ultrasound typically performed?

    <p>11-13 weeks plus 6 days</p> Signup and view all the answers

    What is the purpose of the Maternal Serum Screen (MSS)?

    <p>To detect Down syndrome, trisomy 18, and ONTD.</p> Signup and view all the answers

    What is the false positive rate for the Invasive Prenatal Screening (IPS) Part 1?

    <p>2%</p> Signup and view all the answers

    Which risk factor is most commonly associated with dizygotic twins?

    <p>Undergoing fertility treatments</p> Signup and view all the answers

    How is a positive result from the eFTS generally handled?

    <p>CVS, amniocentesis, or NIPT are offered.</p> Signup and view all the answers

    What is the incidence of triplet pregnancies in North America?

    <p>1 in 6400</p> Signup and view all the answers

    What defines a dichorionic-diamniotic twin pregnancy?

    <p>Each twin has its own chorion and amniotic sac.</p> Signup and view all the answers

    What is commonly measured in the Maternal Serum Screen at 15-20 weeks?

    <p>MSAFP and unconjugated estrogen</p> Signup and view all the answers

    What is the most common presentation of talipes equinovarus?

    <p>Forefoot adduction and varus of the calcaneum</p> Signup and view all the answers

    What is the recommended initial management for a closed fracture in a child?

    <p>Splinting and control of swelling</p> Signup and view all the answers

    Which condition represents a defect in neural tube closure affecting the lumbar spine?

    <p>Spina bifida</p> Signup and view all the answers

    In the Salter Harris classification, which type is most commonly associated with long bone epiphyseal fractures?

    <p>Type II</p> Signup and view all the answers

    What complication is associated with testicular cancer in relation to surgical management?

    <p>Risk of testicular cancer is not eliminated by surgery</p> Signup and view all the answers

    What is the risk of miscarriage after having two prior miscarriages?

    <p>24-29%</p> Signup and view all the answers

    What defines a threatened miscarriage?

    <p>Vaginal bleeding and potentially reversible process.</p> Signup and view all the answers

    What management option is typically recommended for a complete miscarriage?

    <p>Expectant management.</p> Signup and view all the answers

    In the case of an inevitable miscarriage, what is usually observed?

    <p>Visible and palpable products of conception.</p> Signup and view all the answers

    Which medical intervention is indicated for Rh-negative mothers during a miscarriage?

    <p>WinRho.</p> Signup and view all the answers

    What is indicated for a medically induced abortion?

    <p>Failed pregnancy or maternal health concerns.</p> Signup and view all the answers

    After a complete miscarriage, when should a woman expect to resume menses?

    <p>4-6 weeks.</p> Signup and view all the answers

    What typically occurs during a complete miscarriage?

    <p>All products of conception are passed.</p> Signup and view all the answers

    What is a notable feature that indicates duodenal atresia on an abdominal X-ray?

    <p>Double bubble sign</p> Signup and view all the answers

    Which surgical treatment is considered the gold standard for appendicitis?

    <p>Open appendectomy</p> Signup and view all the answers

    What is the primary symptom of Meckel's diverticulum that arises due to ulcer formation?

    <p>Hematochezia</p> Signup and view all the answers

    What complication may arise from a humerus fracture due to direct trauma?

    <p>Wrist drop</p> Signup and view all the answers

    Which condition is characterized by an irreducible hernia without associated symptoms of bowel obstruction?

    <p>Incarcerated hernia</p> Signup and view all the answers

    In the context of severe dehydration, what is considered a late sign of cardiovascular decompensation in children?

    <p>Decreased blood pressure</p> Signup and view all the answers

    What defines the 'Rule of 2' related to Meckel’s diverticulum?

    <p>All of the above</p> Signup and view all the answers

    Which finding on an abdominal ultrasound indicates pyloric stenosis?

    <p>Wall enhancement and inflammatory changes</p> Signup and view all the answers

    What is the primary treatment for a scaphoid fracture?

    <p>Thump spica cast</p> Signup and view all the answers

    In cervical spine stenosis, which symptom is most commonly associated with nerve root compression?

    <p>Dull progressive neck pain</p> Signup and view all the answers

    What is the typical age range for the peak incidence of Ewing sarcoma?

    <p>10-20 years</p> Signup and view all the answers

    Which of the following is a common treatment option for osteosarcoma?

    <p>Chemotherapy and radiation</p> Signup and view all the answers

    What is the most common type of hernia that can become incarcerated?

    <p>Inguinal hernia</p> Signup and view all the answers

    Study Notes

    Duodenal atresia/stenosis

    • Diagnosed in neonates
    • Associated with Down Syndrome and polyhydramnios during pregnancy
    • Symptoms: bilious emesis, gastric distension
    • Most commonly affects the ileum and jejunum
    • X-ray: double bubble sign
    • Treatment: surgical excision of the undeveloped section of bowel, ampicillin & gentamycin prophylaxis

    Pyloric Stenosis

    • Normal abdominal ultrasound findings of the pylorus: 3.14 mm thick and 14 mm long, width 6mm, wall enhancement
    • Ultrasound accuracy: 94-100%, optimal investigation
    • Lifetime risk of fatal radiation for a 1-year-old child: 1.8%
    • Treatment: IV fluids, correct electrolyte abnormalities, NPO, analgesia, fever management, appendectomy (gold standard). Prophylactic antibiotics: Cefazolin + metronidazole
    • Reasonable treatment for uncomplicated appendicitis with delayed presentation (>5 days): antibiotics only
    • Recurrence rate: 10-20%

    Meckel’s Diverticulum

    • Displaced gastric mucosa in an abnormal portion of the bowel, leading to acid in an area not designed to withstand it
    • Rule of 2: 2% of the population have it (usually asymptomatic), 2% symptomatic, present around age 2, 2 males: 1 female, 2 inches long, 2 feet from terminal ileum, 2cm wide, 2 blood supplies, 2 types of ectopic mucosa
    • Symptoms: hematochezia (60%) - due to ulcer formation in the ileum from acid; bowel obstruction (25%); inflammation (15%)
    • Diagnostic Tool: 90%+ technetium 99m uptake
    • Treatment: IV hydration, acid blockade IV, surgical resection

    Incarcerated Inguinal Hernia

    • Incarcerated hernia: irreducible hernia, with normal overlying skin
    • Obstructed hernia: symptoms of mechanical bowel obstruction: Sudden onset abdominal pain, nausea, vomiting, abdominal distension, constipation, obstipation
    • Strangulated hernia: Sudden severe groin pain caused by ischemia of the hernial contents, signs of sepsis or shock, erythema and tenderness of the overlying skin
    • Management: emergency surgical reduction of the hernia

    Causes of Dehydration

    • Decreased intake: poor feeding, inability to convey thirst, lethargy, refusal, neglect
    • Increased losses: vomiting, diarrhea, increased insensible losses (fever, respiratory distress, burns), increased urine output (diabetes mellitus, diabetes insipidus, adrenal insufficiency), post-operative (NG tubes, drains, third spacing)

    Hydration Assessment

    • Level of consciousness, vital signs (increased heart rate is the first physical sign of dehydration)
    • Perfusion (capillary refill, mottling), mucous membranes, fontanelles (sunken), sunken eyes/tears, decreased skin turgor
    • Urine output (diapers)

    Investigations for Dehydration

    • Urine: specific gravity, ketones
    • Blood: urea, creatinine, electrolytes, venous gas (abnormal in respiratory distress and DKA), glucose

    Fluid Management for Dehydration

    • Total fluid intake = maintenance + deficits + ongoing losses
    • Normal saline (NS) is used in fluid bolus, then D5NS +20 mEq/L KCl is used in children as a maintenance fluid
    • Maintenance fluids: replace normal insensible and sensible losses, 4:2:1 rule (if >20kg → 60 + # kg over 20)
    • Deficits: Direct (exact, based on ins and outs & exact weight loss), Indirect (estimate, based on clinical assessment) - Mild: thirsty, increased losses, decreased intake, decreased urine output, decreased tearing, increased heart rate - Moderate: dry mucous membranes, sunken fontanelles/eyes, decreased urine output, delayed capillary refill, irritable - Severe: decreased blood pressure, decreased level of consciousness

    Fractures

    • Fractures in mobile joints (shoulder, elbow, finger, ankle): usually isolated injuries with few associated fractures
    • Fractures in stable joints (hip, knee): usually combined injuries, associated injuries
    • Most common fractured carpal bone: scaphoid (FOOSH)
    • Treatment for scaphoid fracture: thumb spica cast
    • Complication of scaphoid fracture: avascular necrosis of the proximal pole
    • Humerus Fractures: due to direct trauma, radial nerve injury may result in wrist drop and loss of thumb extension
    • Treatment of Humerus fracture: hanging arm cast, coaptation splint and sling, functional bracing
    • “Nightstick” Fracture: ulnar shaft fracture from direct trauma, often in self-defense
    • Treatment for “Nightstick” fracture: ORIF if significantly displaced
    • Galeazzi Fracture: diaphyseal fracture of the radius with dislocation of the distal radioulnar joint
    • Treatment for Galeazzi Fracture: ORIP of radius and casting of fractured forearm in supination to reduce the distal radioulnar joint
    • Boxer’s Fracture: Fracture of the 5th metacarpal neck from forward trauma of a closed fist
    • Treatment for Boxer’s Fracture: closed reduction and ulnar gutter splint, percutaneous pinning if excessively angulated

    Bone Neoplasms

    • Most common primary bone malignancy in children and teens: osteosarcoma
    • Osteosarcoma in adults: often a transformation of other benign tumors, including Paget’s disease
    • Osteosarcoma usually affects: metaphyseal distal femur, proximal tibia, and proximal humerus
    • Osteosarcoma often metastasizes to the lungs
    • Presentation of osteosarcoma: progressive pain that worsens at night, bone pain, erythema, and enlargement over the site of the tumor, limping, pathological fracture
    • Management of osteosarcoma: x-ray (sunburst appearance, Codman triangles), biopsy, neoadjuvant and adjuvant chemotherapy (methotrexate, doxorubicin, cisplatin, ifosfamide), surgical resection, usually resistant to radiation therapy
    • Prognosis of osteosarcoma: 5-year survival is 70% for primary osteosarcoma, poor for secondary osteosarcoma
    • Ewing Sarcoma: peak incidence between 10-20 years, affects mainly Caucasians, men more than women
    • Presentation of Ewing Sarcoma: localized progressive pain, worse at night, fever, swelling, tenderness on palpation, erythema
    • Ewing Sarcoma commonly affects: diaphysis of long bones, metastases: lung, skeletal system, bone marrow
    • Management of Ewing Sarcoma: x-ray (lytic lesion with classic onion skin appearance), biopsy, surgical resection, neoadjuvant and adjuvant polychemotherapy, radiation therapy
    • Prognosis of Ewing Sarcoma: 80% 5-year survival for localized disease
    • Chondrosarcoma: malignant tumor from mesenchymal cells that produce cartilage; etiology of secondary chondrosarcoma: osteochondroma, Paget disease of the bone, radiation
    • Presentation of Chondrosarcoma: insidious onset, dull, progressive pain, worse at night, local swelling, pathological fracture, neurovascular damage, limited range of motion
    • Management of Chondrosarcoma: x-ray (osteolysis with moth-eaten appearance, ring arc calcifications, popcorn calcification, endosteal scalloping and cortical breach with infiltration of soft tissue), biopsy, definitive surgical resection, chemo/radiation therapy as adjuvant or palliative treatment

    Bone Metastases

    • Lytic: lung, colon, thyroid, renal, breast
    • Blastic: prostate
    • General Management of Bone Metastases: Tx needed if:
      • Require fixation to prevent fracture if large (>1/3 diameter) or lytic
      • Produce pain on weight bearing in lower limb
      • If survival > 3 months, consider prophylactic fixation and radiation therapy 2 weeks after fixation
    • Treatment: protect, radiation, surgery

    Dislocations

    • Mobile joints (shoulder, elbow, finger, ankle): isolated injuries, few associated fractures
    • Stable joints (hip, knee): combined injuries, associated injuries
    • Shoulder dislocations: 95% anterior, 5% posterior
    • Mechanism of shoulder dislocation: abduction and external rotation
    • Treatment for shoulder dislocation: conscious sedation, reduction, traction, immobilization
    • Complications of shoulder dislocation: brachial plexus palsy, axillary artery injury, associated fracture, recurrent dislocation, frozen shoulder, rotator cuff tear
    • Elbow dislocations: posterolateral dislocation is most common
    • Associated injuries with elbow dislocations: median nerve, ulnar nerve, vascular injury
    • Knee dislocations: usually anterior
    • Common injuries with knee dislocations: vascular injury (especially popliteal artery), nerve injury, multiple ligament injuries
    • Treatment for knee dislocations: conscious sedation and immediate reduction (knee extension)
    • Posterior hip dislocations: hip flexion, adduction, internal rotation, limb shortening; mechanism: posteriorly directed force on internally rotated, adducted hip
    • Common injuries with posterior hip dislocations: Sciatic nerve injury, avascular necrosis, PCL tear, proximal tibia fracture, patella fracture, femur fracture
    • Treatment for posterior hip dislocations: immediate closed reduction, abduction pillow/bracing, CT evaluation after reduction

    Cervical Spine Stenosis

    • Narrowing of the cervical spinal canal and compression of the spinal cord (SC) and arterial/venous blood supply to the SC, most frequently due to aging
    • Often caused by cervical spondylosis: progressive degeneration of cervical vertebral bodies and intervertebral discs, leading to disc herniation, facet/uncovertebral/vertebral body osteophytes, ossification, and hypertrophy of the posterior longitudinal ligament/ligament flava
    • Symptoms: variable, due to compression and damage to spinal nerve roots and SC, pain in neck, subscapular region, shoulder, often radiation to arms
    • Symptoms: dermatomal parasthesias or numbness in arms, loss of sensation in lower limbs, symptoms exacerbated by neck flexion and extension, loss of fine motor control in hands, upper extremity weakness, spastic gait
    • Upper extremity lower motor neuron (LMN) in myotomal distribution: weakness, atrophy, decreased reflexes → C5-7 myotomes mostly affected
    • Workup: CT or MRI spine, EMG (usually not needed unless trying to rule out other diagnoses)
    • Treatment: non-surgical (activity modification, NSAIDs, muscle relaxants), surgical decompression (cervical discectomy and corpectomy, laminectomy, laminoplasty)

    Pancoast Tumor

    • Superior pulmonary sulcus tumor arising from the apical pleuro-pulmonary groove superior to the 1st rib
    • 3-5% of all lung cancers, almost all are non-small cell lung cancer (NSCLC)
    • Causes Pancoast syndrome when they invade surrounding structures: brachial plexus compression, parietal pleura/rib/vertebral invasion, sympathetic chain invasion
    • Presentation: brachial plexus palsy (compression of C8 and T1 nerve roots), shoulder/arm pain with paresthesias along the medial 4th and 5th fingers and medial side of the arm
    • Horner’s syndrome (miosis, anhidrosis, ptosis) and shortness of breath are late findings
    • Workup: CXR (initial investigation), CT for staging, CT-guided core biopsy, MRI check before surgery
    • Treatment: chemoradiation, then surgical resection

    Thoracic Outlet Syndrome

    • Nonspecific diagnosis that represents many conditions that involve compression of neurovascular structures passing through the thoracic outlet
    • Cause: space-occupying lesions (tumor, cyst), fibrous muscle bands, trauma, abnormal neck position
    • Secondary causes: clavicle fracture, trapezius muscle abnormalities
    • Common in: swimmers, tennis players, water polo athletes, baseball players
    • Symptomatic presentation: variable
    • Venous obstruction: upper extremity swelling, venous distension, pain in hand and/or forearm, DVT
    • Arterial obstruction: upper extremity color change, decreased pulses
    • Neurogenic: most common presentation; vague pain, atrophy of intrinsic muscles of the hands, sensory deficits
    • Workup: CXR, C-spine XR, venous dopplers
    • Treatment: conservative (lifestyle modifications - no overhead arm sleeping, posture correction, PT), surgical (rarely needed, indication = muscle atrophy of the hand)

    Subacromial Bursitis

    • Bursa: fluid-filled sac that lubricates joints
    • Common causes: subacromial impingement, repetitive overhead activities, direct trauma, crystal deposition, infection, autoimmune
    • Chronic bursitis often co-exists with tendonitis
    • Presentation: anterolateral shoulder pain, no radiation, pain on resisted arm abduction beyond ~75 degrees (painful arc)
    • Workup: x-ray shoulder (to rule out other pathologies), ultrasound shoulder
    • Treatment: rest, NSAIDs, PT, corticosteroid injections, surgery if not responsive to conservative treatment

    Rotator Cuff Tendinopathy

    • Most common cause of shoulder pain, a combination of tendonitis, tendinosis, and tendon rupture
    • Presentation: repetition/overuse, especially with overhead activity, occasionally due to a single event, may be associated with laxity or instability
    • Symptoms: pain with overhead activity, pain sleeping on, inability to lift arm in a complete tear
    • Subacromial Impingement: rotator cuff tendons (usually supraspinatus) are impinged when they pass through the subacromial space
      • The subacromial space is decreased if the lateral scapula is translated anteriorly or the humerus is internally rotated.

    Genetic Screening

    • Tests for T21, T12, Turner’s, DiGeorge, Cri Du Chat, Prader-Willi, Angelman, XY d/o are covered in Ontario and British Columbia, but not in other provinces.
    • Disadvantage: No screening for ONTD, need invasive tests to confirm diagnosis, not applicable to donor eggs
    • Enhanced First Trimester Screening (eFTS):
      • Offered at 11 weeks to 13 weeks + 6 days
      • Screens for DS, trisomy 18, placental growth factor, MSAFP, βhCG
      • Does not measure risk of ONTD and should be combined with MSAFP at 15-20 weeks
      • More accurate test for T21 than MSS
      • 5% false positive rate → if positive test, offer patient CVS, amniocentesis, or NIPT
    • Integrated Prenatal Screening (IPS) Part 1:
      • Offered at 11 weeks to 13 weeks + 6 days
      • Screens for DS, T18, βhCG, open neural tube defects
      • 2% false positive rate → if positive test, offer patient CVS, amniocentesis, or NIPT
    • Nuchal Translucency Ultrasound:
      • Part of the first trimester screening
      • Measures the thickness of the fluid-filled space at the back of the baby's neck
    • Integrated Prenatal Screening (IPS) Part 2:
      • Offered at 15 weeks to 20 weeks + 6 days
      • Screens for MSAFP, βhCG, unconjugated estrogen, Inhibin A
    • Maternal Serum Screen (MSS):
      • Offered at 15 weeks to 20 weeks + 6 days
      • Screens for MSAFP, βhCG, unconjugated estrogen, Inhibin A, detects DS, T18, open neural tube defects
      • Only offered alone if the patient missed the time window for IPS or eFTS
      • 8% false positive rate for T21, lower for NTD and T18 → if positive test, offer patient CVS, amniocentesis, or NIPT
    • Gestational Diabetes Screen:
      • Offered at 24-28 weeks
      • 50g OGTT
    • Laboratory tests:
      • CBC (Hb, PLT), ABO & Rh(D), repeat Ab, 1hr OGTT ± 2hr OGTT if positive 1 hour OGTT

    Invasive Diagnostic Tests

    • Amniocentesis:
      • US guided transabdominal extraction of amniotic fluid done ≥15 weeks GA
      • Indications: confirm positive eFTS/IPS/MSS/NIPT, assess fetal lung maturity in T3
      • Also screens for ONTD
      • In women >35, the risk of chromosomal anomaly is greater than the risk of miscarriage from the procedure
      • Disadvantage: 1/200-900 chance of pregnancy loss, results for QF-PCR or FISH can take 14-28 days
    • Chorionic Villus Sampling (CVS):
      • Biopsy of fetal-derived chorion using transabdominal needle or cervical catheter at 10-12 weeks
      • Enables pregnancy to be terminated earlier than with amniocentesis
      • Rapid karyotyping and biochemical assay within 48 hours, including FISH analysis
      • Disadvantage: 1% risk of procedure-related pregnancy loss, doesn’t screen for ONTD, 1-2% false negative results

    Multiple Gestation

    • Incidence of twins is 1/80 and triplets 1/6400 in North America
    • 2/3 of twins are dizygotic (fraternal)
    • Risk factors for dizygotic twins: IVF, increased maternal age, newly discontinued OCP, certain African regions
    • Ultrasound: ideally between 8-12 weeks GA, to determine if each fetus has its own chorion and amniotic sac
      • Dichorionic–diamniotic: twins who have their own chorions and amniotic sacs.
        • After 1 miscarriage, risk is 14-21%, after 2 = 24-29%, after 3 = 31-33%

    Miscarriage

    • Threatened miscarriage:
      • Process of miscarriage that has started
      • Potentially reversible before 20 weeks GA
      • Findings: Vaginal bleeding, Fetal activity, Closed cervical os
      • Management: Expectant treatment, bed rest, weekly pelvic ultrasound, rule out treatable causes of vaginal bleeding, WinRho for Rh-negative mothers
    • Inevitable miscarriage:
      • Vaginal bleeding and cervical dilation without expulsion of POC
      • Occurs before 20 weeks GA
      • Findings: Vaginal bleeding, visible/palpable POC, Fetal activity may be present, Closed cervical os
      • Management: Depends on patient preference, Expectant management (serial clinical monitoring; option for 12 weeks GA)
    • Complete miscarriage:
      • Complete passage of all products of conception (POC) before 20 weeks GA
      • Findings: Vaginal bleeding: POC outside uterus, Closed cervical os
      • Management: WinRho if Rh-, Should resume menses in 4-6 weeks, if not see MD
    • Missed miscarriage:
      • Fetal demise
      • Usually occurs at 500g if unknown gestational age (aka stillbirth)
      • Findings: Cervical os variable
      • Management: Vaginal delivery safer than c-section

    Club Foot

    • Background: Talipes equinovarus is a congenital deformity of the foot
    • Occurs in 2/1000 live births, 50% bilateral, 2 males:1 female
    • Presentation: Forefoot adduction, varus of the calcaneum, talus, and midfoot
      • Foot is not flexible
    • Management:
      • Serial corrective casts at birth
      • Surgery if resistant after 3-6 months
      • Early treatment needed.

    Spina Bifida

    • Background: Defect of neural tube closure, usually affects the lower lumbar spine, myelodysplasia
    • Occurs in 2/1000 births
    • Presentation:
      • Mild to complete paraplegia
      • Bladder and bowel dysfunction
      • Occulta, meningocele, myelomeningocele

    Fractures

    • Salter Harris Classification for long bone epiphyseal fractures:
      • Type II: Most Common
      • Types II-IV: Intra-articular requiring anatomic reduction
      • Type V: Diagnosed after growth arrest
    • Presentation:
      • Often associated with trauma
      • Pain, bleeding, anxiety
      • Open fracture: Infection risk (give Ancef), biologic compromise, higher soft tissue injury
      • Buckle fractures: In immature bone, bone fails in compression first
    • Management:
      • Initial: Look for open wounds, Neurovascular status
        • Closed fracture: Splint, X-Ray, Control swelling (ice, NSAIDs)
        • Open fracture: Eliminate gross contamination, Sterile dressing, Splint, X-Ray, Tetanus, Keflex (or another 1st gen cephalosporin), Add G-coverage for high risk wounds
      • If displaced and healing: Accept up to 20-30 degrees angulation in plane of joint in young child
    • Complications:
      • Testicular cancer (germ cell tumors): Risk of testicular cancer is not eliminated by surgery.

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