AAOS Ch 3 Children Flashcards
Examination of a 6-year-old boy who sustained a displaced Salter-Harris type II fracture of the distal radius reveals 35° of volar angulation. A satisfactory reduction is obtained with the aid of a hematoma block. At the 10-day follow-up examination, radiographs show loss of reduction and 35° of volar angulation. Management should now consist of
1: acceptance of the malalignment and continued cast immobilization
2: repeat closed reduction with the aid of IV morphine and midazolam
3: repeat closed reduction with the aid of IV ketamine
4: repeat closed reduction with the patient under general anesthesia
5: gentle open reduction with smooth cross-pin fixation.
1: acceptance of the malalignment and continued cast immobilization
In a 6-year-old child with a physeal fracture, the healing response 10 days after injury is so advanced that manipulation would have to be very forceful to be successful. A forceful manipulation in a patient this age increases the risk of early growth arrest and a significant disability because 80% of the growth of the radius comes from the distal physis. Because of the large contribution of growth from the distal radial physis and the angulation being in the plane of wrist motion, the potential for remodeling of this fracture is great. It is highly probable that this fracture will completely remodel in 1 to 2 years of growth. In this patient, even a “gentle” open reduction would probably require enough force that the physis would be damaged.
A 12-year-old girl has had lower back pain for the past 6 months that interferes with her ability to participate in sports. She denies any history of radicular symptoms, sensory changes, or bowel or bladder dysfunction. Examination reveals a shuffling gait, restriction of forward bending, and tight hamstrings. Radiographs show a grade III spondylolisthesis of L5 on S1, with a slip angle of 20°. Management should consist of
1: brace treatment
2: laminectomy, nerve root decompression, and in situ fusion of L4 to the sacrum
3: in situ fusion of L4 to the sacrum
4: excision of the L5 lamina
5: physical therapy.
3: in situ fusion of L4 to the sacrum
Indications for surgical treatment of spondylolisthesis include pain and/or progression of deformity. Specifically, surgery is necessary when there is persistent pain or a neurologic deficit that fails to respond to nonsurgical therapy, there is significant slip progression, or the slip is greater than 50%. For patients with mild spondylolisthesis, in situ posterolateral L5-S1 fusion is adequate. In patients with more severe slips (greater than 50%), extension of the fusion to L4 offers better mechanical advantage. Postoperative immobilization may be achieved with instrumentation, casting, or both. In patients with a slip angle of greater than 45°, reduction of the lumbosacral kyphosis with instrumentation or casting is desirable to prevent slip progression. Laminectomy alone is contraindicated in a child. Nerve root decompression is indicated if radiculopathy is present clinically.
A 3-year-old patient with L3 myelomeningocele has bilateral dislocated hips. Management should consist of
1: observation
2: bilateral open reduction
3: bilateral open reduction and psoas transfers
4: bilateral open reduction and external oblique transfers
5: bilateral valgus osteotomies.
1: observation
In patients with myelomeningocele, the presence of bilateral hip dislocation does not affect ambulation, bracing requirements, sitting ability, degree of scoliosis, or level of comfort. There is little evidence to support active treatment of bilateral hip dislocations in patients with myelomeningocele proximal to L4.
A 7-year-old boy with a closed supracondylar fracture of the distal humerus is unable to flex the distal interphalangeal (DIP) joint of his index finger and the interphalangeal (IP) joint of his thumb. These findings are most likely due to a deficit involving fibers of which of the following nerves?
1: Ulnar
2: Radial
3: Musculocutaneous
4: Anterior interosseous
5: Posterior interosseous
4: Anterior interosseous
Inability to flex the DIP joint of the index finger and IP joint of the thumb indicates a motor deficit to the anterior interosseous nerve. The posterior interosseous, radial, ulnar, and musculocutaneous nerves do not innervate the profundus to the index finger nor the flexor pollicis longus.
In girls with idiopathic scoliosis, peak height velocity (PHV) typically occurs at what point?
1: Before Risser 1 and menarche
2: After Risser 1 and menarche
3: Between Risser 1 and menarche
4: After menarche but before Risser
5: At Risser 2
1: Before Risser 1 and menarche
PHV generally occurs while girls are still Risser 0; menarche typically occurs before Risser 1, which has a wide variation in its timing. The curve magnitude at the PHV is the best prognostic indicator available. Most untreated patients with curves greater than 30° at PHV require surgery, while patients with smaller curves at that stage typically do not require surgery.
Development of a valgus deformity in children after a fracture of the proximal tibial metaphysis most likely results from
1: lateral physeal arrest
2: tethering by the fibula
3: periosteal interposition
4: asymmetric physeal growth
5: anterior tibial artery stenosis.
4: asymmetric physeal growth
The incidence of proximal tibial metaphyseal fracture in children is estimated at 5 per 1,000 children per year. Of these, approximately 15% develop a valgus deformity. Closure of the physeal plates is rarely seen and typically there is overgrowth at both the proximal and distal ends of the tibia following the fracture. Studies of the “growth arrest lines” and bone scan analysis suggest that there is an asymmetric stimulation of the proximal tibial physeal plate with more medial than lateral growth, resulting in a valgus deformity. Lateral physeal arrest, tethering by the fibula, and periosteal interposition are suggested theories that attempt to explain the deformity, but they have not been proven.
During soft-tissue release for an idiopathic clubfoot, it is noted that the peroneus longus tendon has been transected in the midfoot. Failure to repair this structure may lead to
1: cavus
2: claw toes
3: a dorsal bunion
4: hindfoot valgus
5: forefoot pronation.
3: a dorsal bunion
While a dorsal bunion was commonly seen as a sequelae of poliomyelitis, direct injury to the peroneus longus is also one of the causes. Normally, the peroneus longus opposes the tibialis anterior dorsal pull on the first ray. As the flexor hallucis longus attempts to oppose the tibialis anterior, the metatarsophalangeal joint is pulled into flexion and a dorsal bunion results. Other combinations of muscle imbalance can produce a dorsal bunion. In long-standing deformity, correction typically involves release of the plantar capsule and flexors with dorsal reefing and a possible metatarsal osteotomy. The tibialis anterior is often transferred as well. Loss of function of the peroneus longus tendon would not result in cavus, claw toes, forefoot pronation, or hindfoot valgus.
A 6-year-old boy with spastic diplegic cerebral palsy has a crouched gait. Examination reveals hip flexion contractures of 15° and popliteal angles of 70°. Equinus contractures measure 10° with the knees >extended. Which of the following surgical procedures, if performed alone, will worsen the crouching?
1: Iliopsoas release from the lesser trochanter
2: Iliopsoas release at the pelvic brim
3: Hamstring lengthening
4: Heel cord lengthening
5: Split posterior tibial tendon transfer
4: Heel cord lengthening
Children with spastic diplegic cerebral palsy often have contractures of multiple joints. Because the gait abnormalities can be complex, isolated surgery is rarely indicated. To avoid compensatory deformities at other joints, it is preferable to correct all deformities in a single operation. Isolated heel cord lengthening in the presence of tight hamstrings and hip flexors will lead to progressive flexion at the hips and knees, thus worsening a crouched gait. Split posterior tibial tendon transfer is used for patients with hindfoot varus, which is not present in this patient.
Posterior spinal fusion for scoliosis should be performed on a patient with Duchenne muscular dystrophy when
1: he patient is still ambulatory
2: lordotic posture is present
3: the forced vital capacity (FVC) is less than 30% of the predicted value
4: curve magnitude measures 25° or greater
5: orthotic management fails.
4: curve magnitude measures 25° or greater
Progressive scoliosis develops in most patients with Duchenne muscular dystrophy. The onset of spinal deformity typically follows the cessation of walking, and curves can be expected to progress about 10° per year. Posterior spinal fusion with instrumentation should be performed as soon as a curve of 25° or greater is documented and before deterioration of pulmonary function (a FVC of less than 30%) precludes surgery. Patients with kyphotic posture tend to progress more rapidly than those with lordotic posture. Brace treatment is contraindicated because it is not definitive and it may mask curve progression while pulmonary function is concomitantly worsening.
An obese 4-year-old boy has infantile Blount disease. Radiographs reveal a metaphyseal-diaphyseal angle of 18° and a depression of the medial proximal tibial physis. Management should consist of
1: observation
2: varus prevention orthoses
3: physeal bar resection
4: proximal tibial osteotomy that produces a neutral mechanical axis
5: proximal tibial osteotomy that produces 10° of valgus.
5: proximal tibial osteotomy that produces 10° of valgus.
The deformity is too severe for observation, and, at age 4 years, the child is too old for orthotic treatment. To prevent recurrence, surgery should be performed before irreversible changes occur in the medial physis. A proximal tibial osteotomy should overcorrect the mechanical axis to 10° of valgus. Bar resection has not been shown to be as effective in this severe deformity, especially without a concomitant osteotomy.
Which of the following patients is considered the most appropriate candidate for selective dorsal rhizotomy?
1: Nonambulatory 2-year-old with spastic diplegia
2: Nonambulatory 2-year-old with spastic quadriplegia
3: Nonambulatory 12-year-old with spastic quadriplegia
4: Ambulatory 4-year-old with spastic diplegia
5: Ambulatory 9-year-old with hemiplegia and athetosis
4: Ambulatory 4-year-old with spastic diplegia
While other surgical and nonsurgical options exist for management of spasticity, the criteria originally laid out by Peacock and associates describe the most appropriate candidate for rhizotomy as a patient with spastic diplegia who is between the ages of 4 to 8 years and has a stable gait pattern that is limited by lower extremity spasticity. Rhizotomy is not recommended in patients with athetosis because of unpredictable results. In addition, rhizotomy should be avoided in nonambulatory patients with spastic quadriplegia because it is associated with significant spinal deformities.
Which of the following types of iliac osteotomy provides the greatest potential for increased coverage?
1: Ganz periacetabular
2: Pemberton innominate
3: Salter innominate
4: Sutherland double innominate
5: Steele triple innominate
1: Ganz periacetabular
The degree of acetabular dysplasia and the age of the child are important considerations when choosing what type of osteotomy to perform. The ability to obtain concentric reduction is a prerequisite of all osteotomies that redirect the acetabulum. Procedures that cut all three pelvic bones allow more displacement and, therefore, correction of acetabular dysplasia. The closer the osteotomy is to the acetabulum, the greater the coverage of the femoral head. Compared with the other acetabular osteotomies, the Ganz periacetabular osteotomy provides the greatest potential for correcting acetabular deficiency because there are no bone or ligamentous restraints to limit correction, but it has the disadvantage of being a technically demanding procedure. The amount of coverage provided by the Salter osteotomy is limited.
A newborn has a flflail right upper extremity after a difficult right occiput anterior vaginal delivery. Examination shows an obvious fracture of the right clavicle. Following stimulation, there is no movement of the arm or hand and there appears to be no sensation in the hand. Management should include
1: a CT scan arteriogram
2: an MRI scan of the brachial plexus
3: nerve conduction velocity studies and an electromyogram
4: surgical exploration and repair of the brachial plexus
5: observation for 60 days before obtaining further tests.
5: observation for 60 days before obtaining further tests.
The patient’s signs and symptoms suggest the clinical appearance of a brachial plexus palsy. Fractures of the clavicle can mimic this disorder, and sensory testing in infants can be difficult. Recovery of function in patients with obstetric palsy is common, even if the initial loss of function appears to be severe. Observation for 60 to 90 days frequently reveals substantial functional improvement, obviating the need for surgery or further diagnostic testing. Surgical repair of the lesion is advocated by some authors for severe loss of function that is still present after age 3 months. Early diagnostic studies have not been helpful in planning treatment, although an MRI scan obtained at a later time can assist with surgical planning. There is no indication for an arteriogram.
The most severe and rapidly progressive form of congenital scoliosis is
1: block vertebra
2: semisegmented hemivertebra
3: fully segmented hemivertebra
4: unilateral unsegmented bar
5: unilateral unsegmented bar with contralateral hemivertebra.
5: unilateral unsegmented bar with contralateral hemivertebra.
In the various types of congenital scoliosis, the combination of unilateral unsegmented bar with contralateral hemivertebra leads to the most rapid progression. The various types of congenital scoliosis in decreasing order of progression include unilateral unsegmented bar, fully segmented hemivertebra, semisegmented hemivertebra, and block vertebra.
Which of the following deformities is most likely associated with slight valgus of the femur, dimpling over the tibia, mild leg-length deficiency, increased heel valgus, and tarsal coalition?
1: Type 1 fibular hemimelia
2: Type 2 tibial hemimelia
3: Type 4 proximal femoral focal deficiency (PFFD
4: Posterior medial bowing of the tibia
5: Congenital pseudarthrosis of the tibia
1: Type 1 fibular hemimelia
Fibular hemimelia can exist in three forms; type 1 represents the milder form with a hypoplastic fibular present. An associated abnormality commonly found with fibular hypoplasia is anteromedial bowing of the tibia, with a skin dimple overlying the deformity. Abnormalities of the ankle joint (such as a ball-and-socket ankle and a valgus position of the hindfoot) are common, and tarsal coalition frequently exists. The patient almost always has some mild shortening of the femur, valgus of the distal femur, and anteroposterior knee instability. While tarsal coalition is present in some forms of PFFD, a type 4 deformity is associated with severe shortening, as is type 2 tibial hemimelia. Posterior medial bowing is associated with mild leg-length deficiency, although it is not associated with tarsal coalition. Congenital pseudarthrosis of the tibia is often seen in association with neurofibromatosis and frequently has a fracture that fails to heal.
When counseling a patient with hypophosphatemic rickets, which of the following scenarios will always result in a child with the same disorder?
1: Female patient who has a female child
2: Female patient who has a male child
3: Male patient who has a female child
4: Male patient who has a male child
5: Disorder not inherited
3: Male patient who has a female child
Hypophosphatemic rickets is an inherited disorder that is transmitted by a unique sex-linked dominant gene. Therefore, if a male patient has a female offspring, his affected X chromosome will be transmitted and all of his female children will have hypophosphatemic rickets. All male offspring of a male patient will be unaffected. All offspring of a female patient have a 50% chance of having the disorder. Understanding the inheritance of hypophosphatemic rickets facilitates early diagnosis and early treatment. Medical treatment with phosphorus and some types of vitamin D (most authors recommend calcitriol) improves, but does not fully correct, the mineralization defect in hypophosphatemic rickets. However, if medical treatment is begun before the child begins walking, the growth plate is then adequately protected and a bowleg deformity will most likely be prevented.
A 4-year-old child sustains a spiral fracture to the tibia in an unwitnessed fall. History reveals three other fractures to long bones, and the`parents are vague about the etiology of each. There is no family history of bone disease. The parents ask if the child has osteogenesis imperfecta (OI); however, there are no clinical or radiographic indications of this diagnosis. In addition to fracture care, management should include
1: notification of child protective services and hospital admission
2: a punch biopsy of skin for collagen analysis
3: DNA testing for OI
4: calcium, phosphate, and alkaline phosphatase studies
5: placement of intramedullary rods to prevent further fractures.
1: notification of child protective services and hospital admission
Child abuse and OI are frequently both in the differential diagnosis of a child with multiple fractures. If OI is suspected, testing is appropriate to confirm this diagnosis. This may include skull radiographs to look for wormian bones and/or fibroblast culturing and collagen analysis of a punch biopsy. Unfortunately, because of the large number of mutations that can yield the disease, DNA testing is not commercially available for OI. In this patient, however, the physician suspects nonaccidental trauma and is legally obligated in most states to notify child protective services. Because the child may be at considerable risk of further injury, hospitalization is indicated to protect the child until child protective services can complete a home investigation and assess the degree of risk. Work-up for both OI and child abuse can be done during the hospitalization.
Which of the following pathogens are most commonly associated with neonatal septic arthritis and osteomyelitis?
1: Staphylococcus aureus and Escherichia coli
2: Staphylococcus aureus and group A streptococci
3: Staphylococcus aureus and group B streptococci
4: Haemophilus influenzae and Escherichia coli
5: Haemophilus influenzae and group A streptococci
3: Staphylococcus aureus and group B streptococci
Staphylococcus aureus and group B streptococci have each been reported to be the most common pathogens in neonatal septic arthritis and osteomyelitis. Haemophilus influenzae is not seen in the neonatal period because of protective antibodies from the mother. Escherichia coli is an unusual pathogen, and, although seen in the neonatal period, it is still distinctly less common than Staphylococcus aureus or group B streptococci. Group A streptococci is an extremely uncommon pathogen in this age group.
Examination of a 6-year-old boy who sustained a displaced Salter-Harris type II fracture of the distal radius reveals 35° of volar angulation. A satisfactory reduction is obtained with the aid of a hematoma block. At the 10-day follow-up examination, radiographs show loss of reduction and 35° of volar angulation. Management should now consist of
1: acceptance of the malalignment and continued cast immobilization
2: repeat closed reduction with the aid of IV morphine and midazolam
3: repeat closed reduction with the aid of IV ketamine
4: repeat closed reduction with the patient under general anesthesia
5: gentle open reduction with smooth cross-pin fixation.
1: acceptance of the malalignment and continued cast immobilization
In a 6-year-old child with a physeal fracture, the healing response 10 days after injury is so advanced that manipulation would have to be very forceful to be successful. A forceful manipulation in a patient this age increases the risk of early growth arrest and a significant disability because 80% of the growth of the radius comes from the distal physis. Because of the large contribution of growth from the distal radial physis and the angulation being in the plane of wrist motion, the potential for remodeling of this fracture is great. It is highly probable that this fracture will completely remodel in 1 to 2 years of growth. In this patient, even a “gentle” open reduction would probably require enough force that the physis would be damaged.
Which of the following clinical scenarios represents an appropriate indication for convex hemiepiphysiodesis/hemiarthrodesis in the treatment of a child with a congenital spinal deformity?
1: A 3-year-old child with a hemivertebra opposite a contralateral bar and thoracic scoliosis that measures 53
2: A 4-year-old child with a fully segmented L1 hemivertebra and scoliosis that measures 80
3: A 4-year-old child with a fully segmented T10 hemivertebra and scoliosis that measures 50
4: A 4-year-old child with a posterolateral hemivertebra at the thoracolumbar junction and a kyphoscoliotic deformity that
measures 45
5: A 10-year-old child with a hemivertebra and scoliosis that measures 50°
3: A 4-year-old child with a fully segmented T10 hemivertebra and scoliosis that measures 50
Convex hemiarthrodesis and hemiepiphysiodesis are procedures designed to gradually reduce curve magnitude in congenital scoliosis because of hemivertebrae. They are used to surgically create an anterior and posterior bar to arrest growth on the convexity of the existing deformity. Success of the technique is predicated on continued growth on the concave side of the deformity. Prerequisites for this procedure include curves of limited length (less than or equal to five vertebrae), curves of reasonable magnitude (less than 70°), absence of kyphosis, concave growth potential, and appropriate age (younger than age 5 years).
A 2-week-old infant has been referred for evaluation of nonmovement of the left hip. History reveals that the patient was delivered 6 weeks premature by cesarean section. Examination reveals no fever, and there is mild swelling of the thigh. Passive movement of the hip appears to elicit tenderness and very limited hip motion. A radiograph of the pelvis shows mild subluxation of the left hip. The next step in evaluation should consist of
1: aspiration of the left hip
2: application of a Pavlik harness
3: a gallium scan
4: an MRI scan of the spine
5: modified Bryant traction.
1: aspiration of the left hip
The diagnosis of bone and joint sepsis in a newborn is difficult because of the relative lack of obvious signs and symptoms. Fever is usually absent. A study of 34 newborns with osteomyelitis identified prematurity and delivery by cesarean section as predisposing factors. In that study, the most common clinical findings were pseudoparalysis, local swelling, and pain on passive movement. Because early diagnosis is so important, any infant who exhibits these findings should be suspected as having bone or joint sepsis. Once the area of involvement is identified, aspiration is mandatory. In newborns who have an infection about the hip, radiographs may reveal subluxation. In this patient, septic arthritis must be ruled out by aspiration of the hip. Developmental dysplasia of the hip is not painful and is not accompanied by localized swelling. If no purulent material is obtained at the time of hip aspiration, an arthrogram should be obtained to rule out epiphysiolysis of the proximal femur. Because the area of involvement has been identified by clinical examination, a gallium scan or MRI scan of the spine is not
indicated.
In patients with neurofibromatosis, what is the most important sign of impending rapid >progression of a spinal deformity?
1: Apical curve rotation
2: Anterior vertebral body erosions
3: Cervical spine involvement
4: Penciling of three or more ribs
5: Curve magnitude of greater than 50°
4: Penciling of three or more ribs
Neurofibromatosis can progress very rapidly. Rib penciling is the only singular prognostic factor. Significant progression has been observed in 87% of the curves with three or more penciled ribs. The other factors are often present but do not have a high correlation with rapid, severe progression.
A 10-year-old girl has had a painful 40° left thoracic scoliosis for the past 16 months. A bone scan shows a localized area of uptake in the T10 vertebra, and a CT scan of this area is shown in Figure-25. Treatment for the lesion should include
1: observation
2: surgical excision
3: a thoracolumbosacral orthosis
4: posterior spinal fusion and instrumentation of T5-L3
5: administration of nonsteroidal anti-inflammatory medication for a prolonged period.
2: surgical excision
Painful left thoracic scoliosis is not considered idiopathic until proven otherwise; neurologic or other causes are the typical etiology. When pain is present, either central nervous system or bony tumors are frequently the cause. The CT scan shows an osteoid osteoma. Surgical excision of the lesion offers immediate pain relief, and, if performed early, return of full mobility of the spine is likely. Although osteoid osteomas of the long bones can be treated with prolonged use of nonsteroidal antiinflammatory medication, this treatment is not recommended for scoliosis of this magnitude, since the longer the scoliosis is present in a growing child, the more likely it will become structural and progressive. Use of orthotics alone or spinal fusion is not indicated when an underlying cause can be found.
Figure shows the radiograph of a 13-year-old girl who has scoliosis. She has long, slender fingers, and when she grasps her left wrist with her right hand, the index finger and thumb overlap by 3 cm. She wears glasses for myopia. A preoperative work-up should include
1: an echocardiogram
2: neurofibromin testing
3: a serum fibrillin level
4: an MRI scan of the spine
5: a urine mucopolysaccharide screen.
1: an echocardiogram
The patient has Marfan syndrome. In these patients, aortic dilation can be life-threatening and aortic rupture has been reported as a complication of spinal surgery. An ultrasound measurement of the diameter of the aorta should be done preoperatively and on a yearly basis thereafter, and treatment with beta blockers and avoidance of stressful activities should be prescribed prophylactically if dilation is present. An MRI scan of the spine is not indicated in the work-up of this disease. Urine mucopolysaccharide screening is used to rule out mucopolysaccharidoses, but this patient has no sign of these diseases. While fibrillin levels are abnormal in patients with Marfan syndrome, this is a structural protein and abnormality cannot be determined by serum measurement. Abnormalities of neurofibromin are associated with neurofibromatosis, not Marfan syndrome.
A 9-year-old boy who is small for his age has a painful limp and limited hip motion. Radiographs of the pelvis are shown. In addition to managing the problem with the hip, what laboratory studies should be obtained
1: Serum protein electrophoresis
2: Serum glucose and hemoglobin A1C
3: WBC and differential blood cell count
4: Thyroxin and thyroid-stimulating hormone
5: Transferrin and total iron-binding capacity
4: Thyroxin and thyroid-stimulating hormone
The child has bilateral slipped capital femoral epiphyses (SCFE). SCFE usually develops in early adolescence, but can occur in younger children with endocrine disorders such as panhypopituitarism and hypothyroidism. Any child younger than age 10 years or older than age 16 years who has SCFE should be carefully evaluated for an underlying endocrine problem. Unrecognized endocrine disorders can increase the risks of anesthesia.
Figure shows the clinical photograph of a 3-month-old infant with a foot deformity that has been nonprogressive since birth. Examination reveals that the deformity corrects actively and with passive manipulation. There is no associated equinus. Management should consist of
1: serial casting
2: UCBL orthoses
3: abductor hallucis lengthening
4: observation and parental reassurance
5: corrective shoes.
4: observation and parental reassurance
The patient has bilateral metatarsus adductus deformities. In a long-term follow-up study by Farsetti and associates, deformities that were passively correctable spontaneously resolved and no treatment was required. More rigid deformities were successfully treated with serial manipulation, with good results in 90%. There were no poor results. Therefore, observation is the management of choice for passively correctable deformities. In feet that are more rigid, serial manipulation and casting is the management of choice.
Figure shows the radiograph of a girl who has had a 3-month history of activity-related foot pain. She has had two previous ankle sprains on this side. Examination reveals that subtalar motion is limited and there is mild heel valgus. Which of the following studies will best confirm your diagnosis?
1: Comparison radiograph of the contralateral foot
2: Calcaneal radiograph
3: Electromyography (EMG) and a nerve conduction velocity study
4: CT scan
5: Rheumatoid factor
4: CT scan
The radiograph shows sclerosis in the midportion of the subtalar joint with no signs of degenerative joint disease present in any other joint. The diagnosis, based on the history and physical examination, is a tarsal coalition. Limited subtalar motion is the characteristic finding. A calcaneal view or an angled axial view parallel to the subtalar joint may show a talocalcaneal coalition. In younger children with fibrous or cartilaginous bars, radiographs may not reveal the problem. CT (or MRI) will best confirm that a coalition is present. EMG can rule out a neurologic problem causing foot deformity, but in a unilateral problem with limited subtalar motion and history of ankle sprains, a coalition is much more likely. A rheumatoid factor may be positive in isolated subtalar arthritis, but it is often negative even if arthritis is present and the history and physical examination are much more suggestive of a coalition.
Figure shows the radiograph of a 10-year-old girl who reports chronic shoulder pain after her gymnastics classes. Examination reveals pain on internal and external rotation but no instability. What is the most likely diagnosis?
1: Acromial fracture
2: Humeral stress fracture
3: Acromioclavicular joint separation
4: Fracture of the surgical neck of the scapula
5: Triceps avulsion fracture
2: Humeral stress fracture
The patient has a very wide humeral growth plate, indicating the presence of a proximal humeral stress fracture, an uncommon diagnosis in gymnasts. Gymnasts are prone to stress fractures of the scaphoid, distal radius, elbow, and clavicle. Proximal humeral stress fractures are more commonly seen in those participating in racket or throwing sports. Stress fractures can lead to growth arrest or inhibition, particularly in the distal radius. The radiograph shows normal findings for the acromion, acromioclavicular joint, scapula, and triceps origin.
The inheritance of the deformity shown in Figure is most commonly
1: autosomal-recessive
2: autosomal-dominant
3: X-linked dominant
4: mitochondrial
5: sporadic.
2: autosomal-dominant
Cleft hand and cleft foot malformations are commonly inherited as autosomal-dominant traits and are associated with a number of syndromes. An autosomal-recessive and an X-linked inheritance pattern have also been described, but these are much less common and are usually atypical. In the common autosomal-dominant condition, nearly one third of the known carriers of the gene show no hand or foot abnormalities. This is known as reduced penetrance. The disorder may be variably expressed; affected family members often exhibit a range from mild abnormalities in one limb only to severe anomalies in four limbs. Variable expressivity and reduced penetrance can cause difficulty in counseling families regarding future offspring in an affected family. Many patients have a cleft hand that may be caused by the split-hand, splitfoot gene (SHFM1) localized on chromosome 7q21.
Figure shows the hand deformities of a 3-year-old girl who has short stature. The most likely diagnosis is
1: achondroplasia
2: pseudoachondroplasia
3: diastrophic dysplasia
4: metaphyseal chondrodysplasia
5: multiple epiphyseal dysplasia.
3: diastrophic dysplasia
The thumb deformity shown in Figure is termed a “hitchhiker’s thumb” and is a distinctive feature of diastrophic dysplasia. Although achondroplasia, pseudoachondroplasia, multiple epiphyseal dysplasia, and metaphyseal chondrodysplasia are all associated with dwarfism, none of these disorders is associated with this distinctive abducted and hypermobile deformity of the thumb. Diastrophic dysplasia was described by Lamy and Maroteaux in 1960 and is inherited as an autosomal-recessive trait. Diastrophic dysplasia is caused by a mutation of a gene coding for a sulfate transport protein located on chromosome 5. The patient is severely dwarfed with the limbs being very short (micromelia) and will reach an eventual adult height of 80 cm to 140 cm. The shortening of the limbs is more severe in the proximal segment than the distal segment and is termed rhizomelic. Diastrophic dysplasia is associated with multiple anomalies including scoliosis, cervical kyphosis, thoracolumbar kyphosis, lumbar lordosis, and flexion contractures of the hips, knees, and elbows. The distinctive feature of diastrophic dysplasia is shortening of the first metacarpal and metatarsal, resulting in the “hitchhiker’s thumb” and bilateral clubfoot deformities. Another distinctive feature is a deformity of the external ears termed “cauliflower ears.” The ears become thickened and twisted with furrowed lobes and narrowing of the external auditory canal. The patient with diastrophic dysplasia usually has normal intelligence and no abnormalities of the heart or kidney.
Figure shows the radiograph of an 11-year-old boy with Duchenne muscular dystrophy who has been nonambulatory for the past 2 years. Management of the spinal deformity should consist of
1: wheelchair modifications and custom-molded inserts
2: posterior fusion with instrumentation
3: anterior and posterior fusion
4: observation and reexamination in 6 months
5: thoracolumbosacral orthosis bracing.
2: posterior fusion with instrumentation
The presence of any curve greater than 20° in a nonambulatory patient with Duchenne muscular dystrophy is an indication for posterior fusion with instrumentation. Because of progressive cardiomyopathy and pulmonary deficiency, waiting until the curve is larger can increase the risk of pulmonary or cardiac complications during or following surgery. There is some disagreement as to whether all such fusions must extend to the pelvis. Bracing or other nonsurgical management is ineffective and is not indicated in this situation.
Figure shows the current radiographs of a 13-year-old boy who was treated for an elbow fracture 1 year ago. He is neurovascularly intact. What is the most important component of treatment if reconstruction is being considered?
1: Construction of the annular ligament
2: Restoration of the radioulnar articulation
3: Restoration and maintenance of ulnar length and alignment
4: Adequate immobilization postoperatively in 120° of flexion
5: Placement of a Kirschner wire from the radial head to the capitellum
3: Restoration and maintenance of ulnar length and alignment
Restoration of ulnar length and alignment is usually sufficient to allow complete reduction of the radial head. Reconstruction of the annular ligament may be unnecessary, and while immobilization in 100° to 110° of flexion is helpful in maintaining reduction, 120° is excessive and risks vascular compromise. Pins across the radiocapitellar joint frequently break and should be avoided. Pinning from the proximal radius to the ulna is safer and can stabilize the radiocapitellar joint just as well.
Figure shows a newborn who has severe multiple symmetric joint contractures, including adduction/internal rotation of the shoulders, extended elbows, flexion-ulnar deviation of the wrists, thumbs in the palm of the hands, dislocated hips, knee flexion deformity, and clubfeet. The most likely diagnosis is
1: amyoplasia multiplex congenital
2: Friedreich ataxia
3: distal arthrogryposis
4: spinal muscle atrophy
5: thoracic-level myelomeningocele.
1: amyoplasia multiplex congenital
There are more than 150 different types of contracture syndromes included under the category of arthrogryposis, the most common of which some authors term amyoplasia multiplex congenital. Distal arthrogryposis is a much less severe form, affecting primarily the hands and feet. Spinal muscle atrophy is generally associated with hypotonia without contracture. Friedreich ataxia has a later onset and is usually not associated with significant contractures. While myelomeningocele can exhibit similar lower extremity deformities, the upper extremities rarely have fixed contractures.
Figure shows the radiograph of a 3-year-old child with progressive bowlegs. Laboratory studies show a calcium level of 9.5 mg/dL (normal 9.0 to-11.0 mg/dL), a phosphorus level of 4.2 mg/dL (normal 3 to 5.7 mg/dL), and an alkaline phosphatase level of 305 IU/L (normal 104 to 345 IU/L). What is the most likely diagnosis?
1: Blount disease
2: Hypophosphatemic rickets
3: Nutritional rickets
4: Schmid metaphyseal dysostosis
5: Jansen metaphyseal dysostosis
4: Schmid metaphyseal dysostosis
The patient has bowlegs associated with very wide physes, particularly noted at the hips. The widening of the growth plates is a classic sign of rickets; however, the normal levels of calcium, phosphorus, and alkaline phosphatase rule out both nutritional and hypophosphatemic rickets. Patients with nutritional rickets or hypophosphatemic rickets have hypophosphatemia and increased alkaline phosphatase levels. Jansen metaphyseal dysostosis has very severe radiographic findings that are not found in this patient; however, these radiographic findings are classic for Schmid metaphyseal dysostosis. This disorder is caused by a mutation in the gene for type X collagen, which is found only in the growth plates of growing children.
A 13-year-old boy sustains a closed injury to his knee after a fall. A radiograph is shown in Figure. Treatment should consist of which of the following?
1: Long leg cast in extension
2: Long leg cast in 45° of flexion
3: Percutaneous pinning with smooth wires and a cylinder cast
4: Anterior cruciate ligament reconstruction and early motion
5: Open reduction and internal fixation with lag screws and a cylinder cast
5: Open reduction and internal fixation with lag screws and a cylinder cast
The patient sustained a type III fracture of the tibial tubercle. This injury has been associated with Osgood-Schlatter disease. Treatment should consist of open reduction and internal fixation with lag screws, followed by casting for 6 weeks. Complications include meniscal tears, compartment syndrome, and leg length discrepancy.
Figure shows the pedigree of a family with an unusual type of muscular dystrophy. This pedigree is most consistent with what type of inheritance pattern?
1: Autosomal dominant
2: Autosomal recessive
3: X-linked dominant
4: X-linked recessive
5: Mitochondrial inheritance
4: X-linked recessive
The pedigree documents involvement of male offspring only, and it also shows transmission through an uninvolved female carrier. This inheritance pattern is most consistent with an X-linked recessive inheritance. It would be inconsistent with a dominant inheritance pattern unless there was incomplete penetrance. Autosomal-recessive inheritance would be possible only if the family member labeled II.F was also a carrier of the same gene; however, this is unlikely. Mitochondrial inheritance is possible, but as with autosomal patterns, mitochondrial inheritance normally affects both male and female offspring. It is transmitted only through the maternal line.
A 4-year-old boy is seen in the emergency department with a 2-day history of left groin pain and a limp. His parents deny any history of injury. Examination of the hip shows a 5° hip flexion position, 20° of abduction, internal rotation to 15°, and external rotation to 30°. His temperature is 100.9°F (38.3°C). Blood studies show a normal WBC count, and the erythrocyte sedimentation rate is 18 mm/h. The C-reactive protein is pending. A radiograph is shown in Figure. What is the most likely diagnosis?
1: Perthes disease
2: Transient synovitis
3: Slipped capital femoral epiphysis (SCFE
4: Septic arthritis
5: Juvenile arthritis
2: Transient synovitis
Transient synovitis is the most common cause of hip pain in children. Males are affected more often than females, and this a typical age for this problem. Normal radiographs rule out SCFE and Perthes disease. The normal WBC count, temperature, ability to walk, and normal ESR make septic arthritis unlikely. Both juvenile arthritis and transient synovitis are diagnoses of exclusion and the subsequent clinical course would differentiate. Transient synovitis usually lasts less than 4 or 5 days. With juvenile arthritis, the ESR usually is elevated.
A 7-year-old patient has had a painless limp for several months. Examination reveals pain and spasm with internal rotation, and abduction is limited to 10° on the involved side. Management consists of 1 week of bed rest and traction, followed by an arthrogram. A maximum abduction/internal rotation view is shown, and abduction and adduction views are shown in Figures. The studies are most consistent with
1: Catterall II involvement
2: tubercular synovitis
3: Herring type A involvement
4: hinge abduction
5: osteochondritis dissecans.
4: hinge abduction
The radiographs show classic hinge abduction. The diagnostic feature is the failure of the lateral epiphysis to slide under the acetabular edge with abduction, and the abduction view shows medial dye pooling because of distraction of the hip joint. Persistent hinge abduction has been shown to prevent femoral head remodeling by the acetabulum. Radiographic changes are characteristic of severe involvement with Legg-Calve-Perthes disease. The Catterall classification cannot be well applied without a lateral radiograph, but this degree of involvement would likely be considered a grade III or IV. Because the lateral pillar is involved, this condition would be classified as type C using the Herring lateral pillar classification scheme.
Figures show the radiographs of an 11-year-old boy who felt a pop and immediate pain in his right knee as he was driving off his right leg to jam a basketball. Examination reveals that the knee is flexed, and the patient is unable to actively extend it or bear weight on that side. There is also a large effusion. Management should include
1: ice and elevation, followed by graduated range-of-motion exercises
2: a long leg cast
3: excision of the fragment
4: open reduction and internal fixation
5: observation until maturity, followed by anterior cruciate ligament repair.
4: open reduction and internal fixation
Fractures through the cartilage on the inferior pole of the patella, the so-called sleeve fracture, are often difficult to diagnose because of the paucity of ossified bone visible on the radiographs. If the fracture is missed and the fragments are widely displaced, the patella may heal in an elongated configuration that may result in compromise of the extensor mechanism function. The treatment of choice is open reduction and internal fixation using a tension band wire technique to achieve close approximation of the fragments and restore full active knee extension.
A 2-day-old infant has the hyperextended knee deformity shown in Figure . No other deformities are found on examination. A radiograph shows that the ossified portion of the proximal tibia is slightly anterior to that of the distal femur. Management should consist of
1: gentle stretching and serial casting
2: Bryant traction for 1 to 2 weeks, followed by closed reduction
3: percutaneous quadriceps recession, followed by serial casting
4: delayed open reduction at age 6 months to avoid iatrogenic damage to either the distal femoral or proximal tibial physes
5: a renal ultrasound.
1: gentle stretching and serial casting
Congenital dislocation of the knee is an uncommon deformity that varies in presentation from simple hyperextension to complete anterior dislocation of the tibia on the femur. Treatment varies with the age at presentation and the severity of the deformity. Most authors recommend early nonsurgical management. A recent study of 24 congenital knee dislocations in 17 patients found that satisfactory results were obtained in most instances using closed treatment. Based on their findings, the authors concluded that immediate reduction or serial casting should be performed when the patient is seen early after birth. If the patient is seen late and correction cannot be achieved by serial casting, traction followed by closed or open reduction may be necessary. Early percutaneous quadriceps recession has been described for complex congenital knee dislocations associated with underlying disorders, such as arthrogryposis and Ehlers-Danlos syndrome. Ultrasound of the hip is required in all patients with congenital dislocation of the knee because 50% of these patients will have associated developmental dysplasia of the hip.
A 14-year-old girl with polyarticular juvenile rheumatoid arthritis (JRA) has severe neck pain and reports the onset of urinary incontinence. A lateral radiograph and lateral tomogram of the cervical spine are shown in Figures. An MRI scan of the upper cervical spine is shown in Figure. Management should consist of
1: a rigid cervical orthosis
2: a soft cervical collar
3: posterior C1-2 fusion with halo immobilization
4: administration of methotrexate
5: activity restrictions.
3: posterior C1-2 fusion with halo immobilization
The plain radiograph and tomogram show an abnormality of the upper cervical spine, with erosion of the dens. The MRI scan shows evidence of cord impingement. The cervical spine is frequently involved in polyarticular JRA. Stiffness and autofusion are commonly seen, but C1-2 instability can also occur secondary to synovitis and bony erosion. Basilar invagination is rare in JRA. There is no consensus regarding fusion in the asymptomatic patient. In patients with symptoms and neurologic signs, posterior C1-2 fusion is indicated.
A 2-year-old girl has had lethargy, fever, and abdominal pain for the past 6 months. In addition to multiple lytic lesions in the long bones and calvaria shown on the skeletal survey, the radiograph of the spine shown in Figure reveals a vertebral lesion. A biopsy specimen is shown in Figure. The most likely diagnosis is
1: leukemia
2: tuberculosis
3: Langerhans cell histiocytosis
4: metastatic neuroblastoma
5: multifocal osteomyelitis.
3: Langerhans cell histiocytosis
Leukemia, Langerhans cell histiocytosis, and metastatic neuroblastoma typically present with constitutional symptoms, bone pain, and multiple lytic lesions in young children. The radiographic appearance of the spinal lesion is a typical vertebra plana caused by eosinophilic granuloma (Langerhans cell histiocytosis). The biopsy specimen shows histiocytes with leukocytic infiltration, predominantly eosinophils. The clinical and other radiographic findings are also consistent with disseminated histiocytosis. Spinal tuberculosis is not usually associated with multiple osseous lesions, especially in the skull. The histology is not consistent with osteomyelitis.
Figure shows the clinical photograph of a 2-year-old boy who has a deformity of the left leg. Examination reveals eight cutaneous markings similar to those shown in Figure. Radiographs are shown in Figure. Management should consist of
1: fragmentation, realignment, and intramedullary nailing of the tibia
2: resection of the dysplastic region of the tibia and insertion of a vascularized fibula
3: supplemental vitamin D and phosphate
4: a clamshell orthosis
5: observation for spontaneous remodeling.
4: a clamshell orthosis
The diagnosis of neurofibromatosis may be based on the presence of at least six café-au-lait spots larger than 5 mm in diameter and the osseous lesion shown in Figure. Neurofibromatosis occurs in 50% of patients who have an anterolateral bowing deformity of the tibia, and this bowing may be the first clinical manifestation of this disorder. The patient has anterolateral bowing of the tibia and fibula that warrants concern for a possible fracture and pseudarthrosis; therefore, the limb should be protected in a total contact orthosis to prevent fracture. In contradistinction to posteromedial bowing of the tibia and fibula, spontaneous remodeling of an anterolateral bowing deformity is not expected. Intramedullary nailing or the use of a vascularized fibula is reserved for the treatment of a congenital pseudarthrosis of the tibia.
Figure shows the radiograph of a 13-year-old boy who has low back pain and tight hamstrings. There are no sensory or motor deficits. What is the recommended treatment for this condition?
1: Gill procedure
2: Thoracolumbosacral orthosis
3: Direct repair of the pars defect
4: Posterolateral fusion from L4 to the sacrum
5: Combined anteroposterior fusion from L5 to the sacrum
4: Posterolateral fusion from L4 to the sacrum
The standard treatment of spondylolisthesis in skeletally immature patients with greater than 50% slippage is a posterolateral fusion from L4 to the sacrum. An orthosis will not prevent progression of the slip. Isolated decompression (Gill procedure) is contraindicated in adolescents as it increases the likelihood of progressive slippage. Direct repair of pars defects is appropriate for L3 or L4 spondylolysis without spondylolisthesis. Anterior procedures are not generally indicated in adolescents with grade III spondylolistheses.
Figure shows the radiograph of a 7-year-old patient who has a bilateral Trendelenburg limp and limited range of hip motion but no pain. His work-up should include
1: a skeletal survey
2: genetic evaluation
3: cardiac evaluation
4: coagulation studies
5: an MRI scan of the hips.
1: a skeletal survey
The radiograph shows bilateral flattening of the femoral heads with mottling and “fragmentation” suggestive of Legg-Calvé-Perthes disease. However, when these changes occur bilaterally and are symmetric, multiple epiphyseal dysplasia or spondyloepiphyseal dysplasia should be suspected. Skeletal survey will show irregularity of the secondary ossification centers. With these conditions, there is no true osteonecrosis and no evidence that orthotic or surgical “containment” will alter the outcome of progressive degenerative arthritis. Cardiac anomalies and coagulopathies are not associated with the epiphyseal dysplasias.
Figure shows the radiograph of an 18-year-old patient who has severe knee pain. Treatment consisting of osteotomy should be performed
1: above the tibial tubercle
2: at or just below the tibial tubercle
3: in the tibial diaphysis
4: on both the femur and tibia
5: on the femur alone.
2: at or just below the tibial tubercle
Very large corrections of tibial deformity can be achieved at or just below the tibial tubercle. This level of osteotomy maintains the relationship between the tubercle and the rest of the joint, does not alter patellofemoral mechanics, and avoids complicating possible future conversion to total knee arthroplasty. High tibial osteotomy is contraindicated for large corrections because of excessive elevation of the tibial tubercle and overhang of the lateral plateau. Correction in the tibial diaphysis creates a zigzag pattern in the tibia by correcting below the deformity and risks nonunion in cortical bone. There is no evidence that the femur is deformed; therefore, femoral osteotomy is not indicated.
An 11-year-old boy has had a fever and pain and swelling over the lateral aspect of his right ankle for the past 3 days. Examination reveals warmth, swelling, and tenderness over the lateral malleolus, and he has a temperature of-103.2° F (39.5° C). Laboratory studies show a WBC count of 13,200/mm3 with 61% neutrophils, an erythocyte sedimentation rate of 112 mm/h, and a C-reactive protein of 15.7. Radiographs and a T2-weighted MRI scan are shown in Figures. Aspiration yields 1 mL of purulent fluid. Management should now consist of
1: oral antibiotics and a follow-up office appointment the next day
2: incision and drainage of the distal fifibular metaphysis
3: indium-labeled WBC scan
4: antituberculous medication for 6 months
5: three-phase technetium Tc 99m bone scan.
2: incision and drainage of the distal fifibular metaphysis
The initial signs and symptoms of acute hematogenous osteomyelitis vary widely but usually include fever, bone pain, and impaired use of the
involved extremity. In lower extremity infections, the child may limp or refuse to walk. Examination often reveals bone tenderness. In moreadvanced cases, erythema, warmth, and swelling may be present. The WBC and neutrophil counts are not always elevated, but the erythocyte sedimentation rate will be abnormal in more than 90% of patients. When the infection is diagnosed early, before a subperiosteal abscess has formed, antibiotics alone may be adequate to treat the infection. This patient has a more advanced infection, however, with the MRI scan revealing a subperiosteal abscess that was confirmed by aspiration. When an abscess is present, surgical drainage is generally indicated to remove devitalized tissue and to enhance the efficacy of the antibiotics. Further studies, such as bone or indium scans, are not necessary and will delay definitive treatment.
Figure shows the lateral cervical radiograph of a 2-year-old girl who was an unrestrained passenger in a motor vehicle accident. She is able to move her neck freely without pain, and her neurologic examination is normal. Management should include
1: observation
2: anterior decompression
3: upper cervical arthrodesis
4: application of a soft collar
5: immobilization in a halo vest.
1: observation
In children, injuries to the upper cervical spine are more common than injuries to the lower cervical spine. Radiographic findings that would indicate significant trauma in adults, such as anterior soft-tissue widening, may be normal variants in the cervical spine of a child. This child has pseudosubluxation of C2 on C3. Pseudosubluxation occurs because children have less slope to their articular facet joints and increased ligamentous laxity. It is possible to differentiate pseudosubluxation from more serious spinal problems by drawing a line along the front of the posterior elements of C1, C2, and C3, as described by Swischuk. Pseudosubluxation of C2 on C3 is a normal finding, so treatment is not indicated.
A 10-year-old boy has activity-related knee pain that is poorly localized. He denies locking, swelling, or giving way. Examination shows mild tenderness at the medial femoral condyle and painless full >range of motion without ligamentous instability. Radiographs are shown in Figures. What is the best course of action?
1: Knee arthroscopy with drilling of the lesion
2: Limited activity for 6 to 12 weeks
3: Removal of the loose body
4: Biopsy of the lesion
5: Open reduction and internal fixation
2: Limited activity for 6 to 12 weeks
The radiographs show an osteochondritis dissecans (OCD) lesion in the medial femoral condyle of a skeletally immature patient. The lesion is not displaced from its bed. Nonsurgical management of a stable OCD lesion in a patient with open physes consists of a period of activity limitation and occasional immobilization. Unstable lesions, loose bodies, and patients with closed physes require more aggressive treatment. Most of the surgical procedures can be done arthroscopically. Because the radiographic appearance is typical, biopsy is unnecessary. The radiographs do not show an osteocartilaginous loose body, and the patient reports no catching or locking; therefore, removal of the loose body is not indicated.
