MEMORIZE PEDS Flashcards

Question

Technique hip arthrogram

Answer 1

1 Needle directed medial to lateral 45° to the thigh and 45° to the horizon aiming towards the ASIS 2 Inject 1:1 ratio of normal saline:radiopaque contrast dye

Answer 2

1 Improvement in the acetabular index 2 Sharp (not rounded) lateral border of the acetabulum 3 Narrow teardrop 4 Intact Shenton line

Answer 3

1 Failure of femoral head to ossify (or failure of an already present ossific nucleus to grow) within 1 year of reduction 2 Broadening of the femoral neck (coxa magna) 3 Increased density of the femoral head (followed by fragmentation) 4 Residual deformity after ossification is complete

Answer 4

**Age < 6 months** a Pavlik harness b Serial clinical exams and US looking for reduced hip, complications of pavlik c Continue treatment until alpha beta normal then discontinue brace, follow until minimum 2 years d Failed treatment discontinue brace wait until 6 months for closed reduction **Age 6-12 months** a Closed reduction b Arthrogram c Adductor tenotomy d Spica casting in ‘human position’ 100 flexion, abduction safe zone (<50), slight IR for 6 weeks e Post-spica abduction brace full time x 4 weeks, then part time x 4 weeks **Age 12-18 months** a Open reduction (bikini incision, remove blocks to reduction, capsulorrhaphy) b Adductor tenotomy c Spica casting in in 30 degrees flexion/abduction/IR for 6 weeks **Age 18 months - 3 years** a Open reduction (bikini incision, remove blocks to reduction, capsulorrhaphy) b Pelvic (Salter/Pemberton) or femoral osteotomy (shortening derotation subtroch osteotomy) c Adductor tenotomy d Possible psoas recession e Spica casting in 30 degrees flexion/abduction/IR for 6 weeks **Age >3 years** a Open reduction (bikini incision, remove blocks to reduction, capsulorrhaphy) b Pelvic osteotomy (Salter/Pemberton) c Femoral shortening derotation osteotomy (fixation 3.5mm LCDC) d Adductor tenotomy e Possible psoas recession f Spica casting in 30 degrees flexion/abduction/IR

Answer 5

I will need 2 assitants to help with positioning. My plan is for a closed reduction, arthrogram possible adductor tenotomy and spica casting. **1 Supine position** **2 EUA** **3 Clinically reduce the hip and examine for stability throughout range of flexion and abduction** **4 Perform arthrogram with 50:50 mix of NS and contast dye** a 45 degrees to shaft of femur under adductor longus aimed at ipsilateral ASIS b Confirm <5mm medial dye pool, concentrically reduced hip joint on orthogonal viws **5 Apply spica cast with posterior mold in ‘human position’100 flexion (+/- 10), abduction in safe zone (<50), IR (slight)** a If abduction required for stability is within 20 degrees of max abduction (safe zone of ramsey) then perform medial miniopen adductor tenotomy **6 Post-reduction CT/MR**

Answer 6

1 Supine position 2 anterior Smith-Peterson approach 3 Adductor tenotomy through separate mini-open medial incision a possible psoas recession through anterior appraoch 4 T capsulotomy and remove blocks to reduction 5 Reduce the joint using ligamentum teres as the guide to true acetabulum 6 Capsulorrhaphy bringing the lateral leaf medial 7 If femoral shortening is required (age > 3, tension on reduction) then a separate lateral incision, transverse subtrochanteric shortening osteotomy b amount of bone cut is based on proximal-distal segment overlap after reduction c fixation with 3.5mm LCDC plate 2 screws proximal and distal 8 Possible acetabular procedure (Salter/Pemberton acetabuloplasty) if >18 months 9 Spica cast with posterior mold is used for approximately 6 weeks in 30 degrees of abduction/flexion/IR

Answer 7

Advantages 1 Decreases contact pressure on head 2 Reduces AVN rate 3 Allows de-rotation to reduce excessive anteversion Disadvantages 1 Increased operative time 2 Increased blood loss 3 Separate incision required

Answer 8

1 Lateral subvastus approach 2 Cautery to mark a line in femur as a guide for rotation 3 Subtrochanteric osteotomy just below level of LT 4 Amount of shortening is determined by amount of overlap after femoral head reduced in the acetabulum 5 Amount of derotation is deteremined by matching the opposite limb 6 Fixation a DDH kids are just getting shortening so 4-5 hole LCDC plate with 2 screws proximal and distal

Answer 9

SCFE temporal classification 1 Pre-slip: Symptoms, no radiographic evidence of slip a may have physis widening / irregularity 2 Acute slip: <3 weeks of symptoms 3 Chronic slip: >3 weeks of symptoms a Most common type (85%) 4 Acute-on-chronic slip Loder SCFE Stable: Patient able to bear weight, with or without crutches a Nearly 0% AVN Unstable: Patient unable to walk even with crutches a 50% AVN

Answer 10

Mild <30 degree Moderate 30-50 degree Severe >50 degree **Epiphyseal-diaphyseal angle on frog leg lateral, normal 12 degrees

Answer 11

1 Widening physis 2 Irregular physis 4 Metaphyseal blanch sign of Steel a Radiographic double density created by the anteriorly displaced metaphysis overlapping the epiphysis 5 Kleins line does not bisect epiphysis (epiphysis is flush or below)

Answer 12

1 Contralateral symptoms 2 Radiographic evidence of contralateral slip 3 History of radiation 4 Endocrinopathy a hypothyroidism b GH treatment c Adiposogenital dystrophy ie decreased GnRH d panhypopituitarism 5 Young age a Controversial but < 8 b Open triradiates

Answer 13

Deformity a Extension (anterior displacement neck) b Varus c ER Southwick osteotomy (intertroch) a Flexion b Valgus c IR

Answer 14

* 1 Slip angle < 15 (southwick angle) a Arthroscopic femoral neck osteochondroplasty * 2 Slip angle 15-30 a Limited open anterior arthrotomy and femoral neck osteochondroplasty * 3 Slip angle 30-45 a Surgical hip dislocation and femoral neck osteochondroplasty * 4 Slip angle > 30 a Flexion intertrochanteric osteotomy * 5 Slip angle > 60 a Combined flexion intertrochanteric osteotomy and surgical hip dislocation (possibly staged)

Answer 15

Goal is to achieve flexion, valgus and IR and generally want to correct a high grade southwick angle (>50) to a low grade (<30). Preoperatively template correction with CT. Involve a senior colleague. 1 Supine approach 2 Lateral subvastus approach to the proximal femur 3 Mark a line in the femur with cautery as a guide to rotation 4 Chisel impacted in proximal segment 5 Blade plate is inserted proximally a Stabilized with a screw in the proximal fragment 6 Transverse osteotomy is made just proximal to the LT 7 The distal fragment is flexed and internally rotated to desired correction a Distal fragment is reduced to the plate and secured with screws 8 Confirm reduction and position on final fluoro 9 Tension free closure in layers with protected post-operative weight bearing

Answer 16

1 Males 2 Family history 3 Delayed bone age 4 Low birth weight 5 Second hand smoke 6 Low socioeconomic status

Answer 17

1 Lateral subluxation 2 Calcification lateral to the epiphysis 3 Horizontal growth plate 4 Gage sign (lateral V shaped epiphysis, pathogneumonic for LCP) cystic changes in metaphysis

Answer 18

1 Usually unilateral (12% bilateral), if bilateral usually radiographically asymmetric (differentiating it from MED) 2 Medial joint space widening measured from teardrop to ossification center (first sign) 3 Irregular ossification center 4 Epiphyseal sclerosis 5 Crescent sign (subchondral fracture) 6 Collapse of the femoral head 7 Metaphyseal cysts 8 Lateral epiphyseal subluxation (head at risk sign) or extrusion (uncovered head) 9 Lateral calcification (head at risk sign) 10 Diffuse metaphyseal reaction (head at risk sign) 11 Horizontal growth plate (head at risk sign) 12 Gage sign (lateral V shaped epiphysis, pathognomonic for LCP, head at risk) 13 MRI and bone scan can demonstrate phase (initial, fragmentation, reossification, remodeling) 14 +/- late signs of OA

Answer 19

Waldenstrom: Initial Fragmentation Re-ossification Remodel

Answer 20

Lateral Pillar (Herring): based on height of lateral pillar of capital epiphysis: Used at beginning of fragmentation stage – 6 months after onset of symptoms Group A – lateral pillar maintains full height without density changes Group B - >50% height maintained (poor outcome if bone age >6 yrs.) Group B/C – Lateral pillar -narrowed 2-3mm or poorly ossified, height loss 50% Group C - <50% height maintained – poorest outcome

Answer 21

Ideally the patient has the following characteristics 1 Herring B or BC boarder 2 Children over 8 3 Full hip ROM 4 Congruent joint 5 Initial or fragmentation stages (ie no deformity) Children will need containment (regardless of age, phase of disease, ROM, etc) if 1 Hip is uncovered or subluxed 2 Hinged abduction present on arthrogram

Answer 22

**1 Coxa magna** a Osteotomies of the neck to reduce neck width **2 Prominent and proximal GT** a Osteotomies of GT to distalize **3 Residual deformity in varus** a Osteotomies to correct varus **4 LLD**

Answer 23

**1 Preoperatively plan osteotomy for degree of correction** a For children with cerebral palsy anticipate shortening VDRO b For children with LCP non-shortening VDRO **2 Supine radiolucent table** **3 Lateral approach through ITB** a release vastus off tubercle **4 Fixation of bladeplate proximally** a Chisel in the neck followed by blade plate, screw in proximal fragment **5 Subtroch osteotomy at level of LT** a In cerebral palsy:shortening osteotomy based on bony overlap b In LCP: no shortening required **6 Reduce plate to shaft for deformity correction and secure plate distally** a Usually 2 screws distally is sufficient **7 Tension free closure in layers** **8 Post-operative** a Protected WB for LCP b Spica cast for CP for comfort If combined with acetabuloplasty then perform through separate anterior incision. Likely only need VDRO for LCP, if necessary perform VDRO + Salter/pemberton. For CP will need VDRO + Dega through dual approach.

Answer 24

1 Varus angle must not exceed a neck shaft angle < 110 degrees 2 Opening wedge osteotomy may reduce LLD 3 Add approximately 15 degrees of extension to the osteotomy to help contain the anterior femoral head 4 Perform a trochanteric apophysiodesis to reduce trochanteric prominence 5 Medially translate the distal fragment to avoid genu valgum

Answer 25

1 LLD <2cm a Observation b Shoe lift 2 LLD 2-5cm a Shoe lift b Contralateral epiphysiodesis c Contralateral skeletal shortening (usually for patients with inadequate growth remaining for epiphysiodesis) 3 LLD > 5-20cm a Limb lengthening +/- contralateral epiphysiodesis 4 LLD > 20cm a Multiple lengthening b Amputation and prosthetic fitting

Answer 26

Grade 1 = Recurvatum Grade 2 = Subluxation Grade 3 = Dislocation Treatment options – all of which lengthen the extensor mechanism relative to the femur 1 Manipulation and serial casting 2 Soft tissue release with quads snip and casting 3 VY lengthening quadriceps tendon 4 Femoral shortening osteotomy Indications for surgical treatment 1 Less than 30 degrees flexion after 3 months serial manipulation/casting a Surgery performed at 6 months of age.

Answer 27

Bilateral genu valgum a Physiologic b Renal osteodystrophy (renal rickets) c Skeletal dysplasia i Morquio syndrome ii Spondyloepiphyseal dysplasia iii Chondroctodermal dysplasia Unilateral genu valgum a Physeal injury from i Trauma ii Infection iii Vascular insult b Proximal metaphyseal tibia fracture (Cozen fracture) c Benign tumors i Fibrous dysplasia ii Osteochondromas iii Ollier's disease

Answer 28

1 History a Full history from pregnancy, perinatal, developmental, FHx b Full HPI of the deformity 2 Physical a Examine gait, lower extremities, LLD b Check hip rotation, knee deformities, foot deformities, stability of joints, etc c NV exam 3 Bloodwork a Thyroid hormones – TSH, T3, T4 b Parathyroid hormones 4 XR a Dedicated views hip knee ankle r/o infection, tumor, dysplasias b Full length views for alignment AP and lateral, possible CT scannogram 5 Referrals a General pediatrics referral to rule out rickets and other causes 6 Develop differential (above) 7 Decide on management a Bracing young children i AFO, KAFO, HKAFO b Hemiepiphysiodesis c Treat any infections/tumors/etc

Answer 29

At 3-4 years of age maximum 10 degrees valgus At 6-7 years of age reach the adult 5-7 degrees valgus Indications for OR: 1 Mechanical axis lies in lateral half of the joint line with pain (i.e. zone 2 with pain) 2 Mechanical axis lateral to the lateral joint line (i.e. zone 3) 3 15-20 degrees valgum Types of OR 1 Hemiepiphysiodesis femur or tibia 2 Hemiepiphysiodesis femur and tibia 3 Corrective osteotomies at maturity

Answer 30

1 Extensive lateral release a ITB b Capsule c Biceps femoris 2 VY lengthening of quadriceps 3 Medial capsule imbrication or MPFL reconstruction 4 Lateral patellar tendon insertion addressed with either a Roux-Goldthwait (medialize lateral slip patellar ligament) b Galeazzi (semi tendinosus through patellar bone tunnel) c Medialization of patellar tendon periosteal sleeve

Answer 31

1 Rickets a Nutritional vs Vitamin D–resistant rickets vs other types b Sort out with bloodwork and peds consult 2 Tumors a Fibrous dysplasia b Osteochondromas 3 Trauma a Physis b Malunion 4 Infection 5 Disorders of bone quality a Osteogenesis imperfecta b Adults (Paget’s disease, osteopetrosis) 6 Vascular a AVN 7 Iatrogenic a Varus producing osteotomy

Answer 32

1 Decreased femoral neck-shaft angle 2 Shortened femoral neck 3 Decrease in normal anteversion 4 Vertical position of physeal plate 5 Triangular Y shaped metaphyseal fragment in inferior femoral neck

Answer 33

Nonoperative a H-E angle <45 b H-E angle 45-59 and asymptomatic i Pain free ii No limp iii No progressive deformity Operative a H-E angle > 60 b H-E angle 45-59 and symptomatic c Neck shaft angle < 100 d Symptomatic limp, Trendelenburg gait, or progressive deformity Technique Valgus-producing proximal femoral osteotomy Goal for slight overcorrection 1 Neck shaft angle > 160 2 HE angle < 38

Answer 34

Foot and ankle: 1 Absent lateral rays 2 Tarsal coalition 3 Ball and socket ankle joint 4 Ankle instability 5 Equinovalgus 6 Equinovarus (less frequently) Lower extremity: 7 Fibular hemimelia/amelia 8 Anteromedial tibial bowing 9 Hypoplastic lateral femoral condyle 10 Genu valgum 11 ACL deficiency 12 PCL deficiency 13 Patella alta 14 Hypoplastic patella 15 PFFD 16 Varus or valgus femoral neck 17 Femoral retroversion 18 Acetabular dysplasia Upper extremity: 19 Ulnar hemimelia/amelia 20 Syndactyly Systemic: 21 Cardiorenal abnormalities

Answer 35

**2 Clinical assessment (6 questions)** **a Is foot reconstructable (3+ rays)** i Determines whether to amputate **b What is predicted LLD?** i Determines whether to amputate **c Stability ankle and knee** i Determines whether stabilize prior to lengthening procedure **d Concomittant genu valgum/knee deformity** i Determines whether patient needs femoral/tibial hemi-epiphysiodesis **e Are the upper extremities functional?** i Determines whether surgeon should attempt limb salvage in setting of indications for amputation **f Is there concomittant PFFD?** i Determines whether you need to consider PFFD treatments such as knee fusion foot ablation, van nes rotationalplasty or iliofemoral fusion **1 Foot preservable** 1A: LLD predicted < 6% a No treatment b Orthosis c Timed epiphysiodesis 1B: LLD predicted 6-10% a Epiphysiodesis +/- lengthening 1C: LLD predicted 11-30% a 1 or 2 lengthenings b +/- epiphysiodesis or extension orthosis 1D: LLD predicted >30% a >2+ lengthenings b Amputation **2 Foot not preservable** 2A: Upper extremity functional a amputate the leg 2B: Upper extremity non functional b consider leg salvage **Indications for amputation in fibular hemimelia** 1 5cm discrepancy at birth 2 >20cm or 30% predicted discrepancy 3 Non-functional foot deformity (<3rays) Amputation treatment pathway a Syme/Boyd and prosthetic fitting

Answer 36

1 Initiation: a Ensure stable joint above and below b Perform percutaneous metaphyseal corticotomy and place fixator c Fibular osteotomy performed mid-proximal third 2 Distraction a Wait 5-7 days to allow neovascularization of corticotomy b Distract 1 mm per day in 4 x 0.25mm increments made by the patient (one full turn usually 2mm, 0.25mm is one-eighth turn) c Maximum 20% lengthening Consolidation Fixator remains on for as many days as lengthening occurred i e.g. 3 months lengthening, distractor on for additional 3 months to mature i Alternatively, lengthening over a nail allows to reduced time in the frame i If lengthening over nail then when desired goal is reached, distally lock the nail and remove the frame

Answer 37

**1 Pin site infection** a Attempt to retain pins with pin care, antibiotics and daily cleanses. b If necessary remove or exchange nail. **2 Infected nail** a Remove any infected pin sites (possible exchange), and exchange nail b Remove nail and lengthen without, along with antibiotic therapy **3 Nerve symptoms** a Patient can undue last few turns acutely b If close to desired goal of correction then stop lengthening c Can consider temporarily stopping lengthening, CPN neurolysis, resume lengthening later date when symptoms resolved **4 Vascular symptoms** a Acutely undue last few turns b CTA

Answer 38

Class A a Femoral head ossifies but delayed b Short femur c Proximal femur is at or above level of acetabulum d Acetabulum well formed Class B a Femoral head ossifies but delayed b Proximal femur is above level of acetabulum c Proximal femoral pseudoarthrosis d Mild acetabular dysplasia Class C a Femoral head and proximal femur does not form b Severe acetabular dysplasia Class D a Femoral head does not form b Acetabulum does not form c Distal femoral condyles are at level of acetabulum

Answer 39

Nonoperative bridge therapy until 3 years of age Clinical and radiographic factors affecting treatment 1 Aitken class 2 Assess functionality of ankle (stability, ROM) 3 Projected LLD 4 If associated with fibular hemimelia then decide management of PFFD prior to distal management Type A and B: a Knee fusion foot ablation i Syme or Boyd ii Indications: >20cm of LLD at maturity, foot above level of contralateral knee, ankle has <60° arc of motion) b Van nes rotation plasty i >20cm of LLD at maturity, foot at level of contralateral knee, ankle has >60° arc of motion c Limb lengthening i <20cm of LLD at maturity, stable hip, good knee, ankle, foot function Type C and D: a Nonoperative treatment b Iliofemoral fusion

Answer 40

Type 1: Tib post sesamoid Type 2: Synchondrosis Type 3: Synostosis Treatment a conservative: i Acute casting, modified footwear, orthotics b Surgical: i Open medial approach over navicular ii Identify tib post and release off bone iii Excise accessory navicular iv Repair tib post through bone tunnels without advancement v Post-operatively splint and protected postoperative weight bearing for 12 weeks

Answer 41

Hindfoot (AP radiograph) Valgus: Increased talocalcaneal angle on AP Varus: Decreased talocalcaneal angle on AP Midfoot (Lateral radiograph) Cavus a Increased pitch b Decreased lateral talocalcaneal angle c Apex dorsal talofirst metatarsal angle Planus a Decreased pitch b Increased lateral talocancaleal angle c Apex plantar talofirst metatarsal angle Forefoot Abduction (AP radiograph) a TN coverage

Answer 42

Lateral 1 Lateral talo-firstmetatarsal/Meary angle a greater than 4 degrees apex plantar b Normally colinear, +4 to -4 degrees 2 Decreased calcaneal pitch a Normal 17-32 3 Increased talocalcaneal angle a Normal 25-40 (remember it moves opposite to the calcaneal pitch) AP 1 Increased talonavicular uncoverage a Normal < 7 degrees (?) 2 Increased talocalcaneal angle/Kite angle a Normal 15-30; increases as hindfoot falls into valgus Oblique 1 Assess for calcaneonavicular coalition

Answer 43

**1 Hereditary motor sensory neuropathies (CMT, autoimmune)** **2 CP** 3 CVA/closed head injury **4 Spinal cord lesions – diastematomyelia, tethered cord** 5 Huntington’s chorea 6 Friedreich’s ataxia **7 Spinal muscular atrophy** **8 Arthrogryposis** 9 Anterior horn cell disease (spinal root injury, polio) 10 Traumatic: compartment syndrome, talar neck malunion, peroneal nerve injury, residual club foot, knee dislocation with associated NV injury 11 Idiopathic

Answer 44

Lateral 1 Lateral talo-firstmetatarsal/Meary angle – greater than 4 degrees apex dorsal 2 Increased calcaneal pitch (Normal 17-32) 3 Decreased talocalcaneal angle (Normal 25-40) 4 Sinus tarsi see-through sign/ double talar dome sign 5 Bell shaped cuboid AP 1 Increased talonavicular uncoverage (Normal < 7 degrees) 2 Decreased talocalcaneal angle/Kite angle (Normal 15-30) 3 Metatarsal overlap with excessive forefoot pronation

Answer 45

1 Family history 2 Males 3 Race (highest in Hawaiians and Maoris) 4 Early amniocentesis (<13 weeks) 5 Oligohydramnios 6 Exposure to cigarette smoke in utero

Answer 46

The medial structures are tight and contracted a Tight long flexors (gastroc/soleus, tib post, FHL, FDL) b Tight posteromedial capsule and ligaments Bony displacement a Medial displacement and adduction of navicular, cuboid, calcaneus, and metatarsals Forefoot pronation

Answer 47

1 Loss of dorsiflexion is the earliest sign 2 Loss of abduction (midfoot/forefoot) 3 Return of deformity - CAVE 4 Increased lateral contact during stance phase 5 Dynamic supination during swing phase

Answer 48

Lateral a Increased lateral talo-firstmetatarsal/Meary angle i greater than 4 degrees apex dorsal b Decreased calcaneal pitch (Normal 17-32) i Hindfoot parallelism, calcaneus in equinis c Decrease talocalcaneal angle (normal 25-40) (because they’re parallel) 2 Forced dorsiflexion lateral (turco) a Hindfoot parallelism between talus and calcaneus 3 AP a Decreased talocalcaneal angle/Kite angle (Normal 15-30); i decreases as hindfoot falls into varus

Answer 49

1 Repeat casting (any age) to get as much correction as possible 2 Tenotomy if 15 degrees dorsiflexion not achieved 3 If > 2.5 years with dynamic supination in swing phase, tib ant transfer to third cuneiform 4 If > 4 years then consider closing wedge osteotomy through cuboid and medial opening wedge through medial cuneiform

Answer 50

1 Hyperdorsiflexion of the ankle 2 Eversion of the subtalar joint 3 Dorsal surface may rest on anterior tibia 4 Dorsal soft tissue contracture limiting plantarflexion and inversion 5 Associated posteromedial tibial bowing

Answer 51

Asymptomatic a No treatment Symptomatic Nonoperative a Orthotics b Achilles stretching Operative a Lateral column lengthening (Modified Evans) b Lateral column lengthening with plantar flexion osteotomy of the first ray c Triple C osteotomy (Calcaneocuboidcuneiform osteotomy)

Answer 52

Supine with bump and tourniquet 2 Sinus tarsi type approach a reflect EDB 3 Pin the CC joint 4 Lateral opening wedge osteotomy a 2cm from CC joint between anterior and middle facets 5 Trapezoidal allograft placed in osteotomy site 6 Secure the graft in compression with k wires 7 Assess forefoot supination and need for a first metatarsal plantarflexion osteotomy a If first metatarsal growth plate open i medial plantar incision ii plantar closing wedge of medial cuneiform iii fix with a staple b If first metatarsal growth plate is closed i dorsomedial incision ii dorsal opening wedge osteotomy of first metatarsal 8 Silverskold test with possible gastroc recession or TAL

Answer 53

1 Supine position with bump and tourniquet 2 Dual medial lateral incisions 3 Medial calcaneal slide osteotomy a From lateral to medial with oscillating saw, completed with osteotome in the calcaneal tuberosity b Osteotomy is parallel with peroneal tendons c Held with percutaneously placed screws through non-weight bearing calcaneal tuberosity 4 Lateral opening wedge osteotomy of the cuboid a Can use allograft or autograft from medial plantar closing wedge osteotomy b Held with K wires 5 Medial cuneiform plantar closing wedge osteotomy (correcting supination) a Held with K wires 6 Silverskold test with possible gastroc recession or TAL 7 Possible medial reefing of TN joint capsule

Answer 54

*Mild dominant forms (1, 4 and 5) *Severe recessive forms (2 and 3) *Sclera blue in 1 and 2 Type 1 mild nondeforming Type 2 severe fatal Type 3 severe progressively deforming Type 4 variable Type 5 calcification interosseous membranes, osteoporosis-pseudoglioma syndrome

Answer 55

1 General a Short stature b Hypermobility c Decreased bone mineral density with multiple fractures 2 Wormian skull bones 3 Skull base abnormalities a basilar impression b basilar invagination c platybasia 4 Codfish (biconcave) vertebrae 5 Kyphoscoliosis 6 Pectus deformity a carinatum b excavatum 7 Avulsion fractures a Classically olecranon b Tibial tubercle and others 8 Limb deformity & saber shins

Answer 56

**1 General** a Dysmorphic triangular shaped facies b Increased rates of malignant hyperthermia **2 Ocular** a Blue sclera b Glaucoma c Cataracts d Lens dislocation e Presbyopia 3 Dentogenesis imperfecta **4 Hearing loss** a Conductive b Sensorineural c Mixed **5 Cardiac** a Mitral valve insufficiency b Aortic valve insufficiency c Aortic root dilation 6 Renal a Hypercalcuria in 1/3 of patients b Increased risk for nephrolithiasis

Answer 57

1 Multidisciplinary a Pediatrics for optimization of calcium, vitamin D treatment with bisphosphonates b Anesthesia consultation for potential difficult airway, increased risk malignant hyperthermia, basilar invagination which may complicate airway management 2 Prior to age 2 the child is treated like other children with respect to fracture management a Casts/spicas/etc 3 IM telescoping rods with load sharing preferred over rigid plate fixation 4 Sofield miller procedure a Multiple osteotomy and telescoping rod placement b Indicated for fractures of deformed bones 5 PSF a curves > 45 degrees in type 1, 4, 5 b curves > 35 degrees in type 3

Answer 58

1 Fracture risk during transfer and positioning 2 Difficult airway due to large head, tongue and short neck, basilar invagination 3 Poor pulmonary function from chest wall anomalies 4 Malignant hyperthermia a avoid succinylcholine b clear lines preoperatively 5 Substantial blood loss anticipated a preoperative cross match, have blood ready

Answer 59

1 Obesity 2 Hispanic ethnicity 3 African american ethnicity 4 Early walkers 5 Vit D deficiency 6 Zinc deficiency

Answer 60

1 beak 2 wedge 3 metaphyseal saucer 4 epiphyseal step 5 secondary ossification centre below physis (2 physes) 6 bony bridge

Answer 61

1 Varus proximal tibial metaphysis 2 Wide medial growth plate 3 Irregular ossification of the epiphysis 4 Medial metaphyseal beaking 5 Femur usually normal a may be involved adolescent version

Answer 62

1 Varus 2 Flexion 3 IR 4 +/- shortening when unilateral

Answer 63

1 Metaphyseal diaphyseal angle (Drennan) ≥16 2 Langenskiöld’s radiographic classification (worse prognosis with increasing class) 3 Medial plateau depression/saucer (i.e. langenskold 3-4) 4 Separation of the medial epiphyseal ossification center (i.e. langenskold 5) 5 Medial bone bridge (i.e. langenskold 6)

Answer 64

<9 degrees represents physiological varus 9-16 degrees with varus thrust may progress >16 requires surgical treatment Nonsurgical a bracing controversial, can attempt up until age 3 **RAb osteotomy with fibular osteotomy and prophylaxtic partial fasciotomy.** Surgical 1 HTO with fibular osteotomy a medially based osteotomy b laterally based osteotomy c dome osteotomy 2 Growth modulation a lateral hemiepiphysiodesis 3 Physeal bar resection, fat interposition 4 Hemiplateau elevation (indicated for older children with severe plateau depression) 5 Angular deformity correction and lengthening (?)

Answer 65

1 History 2 Physical a Stability hip knee ankle b Deformity c NV exam d LLD 3 Plain films a Dedicated views of the knee 4 CT a Rule out physeal bar 5 Discuss surgical plan a Deformity meeting surgical criteria requires deformity correction; typically dome osteotomy is the preferred b Consider guided growth for deformities meeting surgical criteria, lower langenskold levels c Osseous bars should be resected with fat interposition d If high lengenskold with a severely depressed plateau then consider hemiplateau elevation

Answer 66

Nonsurgical a bracing not indicated Surgical a Hemiepiphysiodesis and guided growth i Generally considered ineffective with high rates of hardware failure ii There is no improvement in tibial rotation with guided growth iii Newer generation steel eight plates may be considered iv May be considered for distal femur varus > 10 degrees v Contraindications: Adolescent blounts with obesity, physeal bar, insufficient remaining growth b Acute corrective osteoteomy i Gold standard ii Best for deformities <15 degrees varus iii Likely requires fibular osteotomy iv Recommended to use rigid plate in adolescent blounts, not k wires c Gradual corrective osteotomy i Circular ring fixator ii Allows for larger corrections more safely d Gradual correction through physeal distraction i Circular frame with epiphyseal fixation that distracts across the physis ii Advantage is that it corrects through the CORA Note: Aim is for deformity correction rather than overcorrection Note: Just going to say HTO forget all the other stuff unless they ask for options

Answer 67

1 Macrosomia (>4,500g) 2 Difficult or prolonged labour 3 Shoulder dystocia 4 Multiparous pregnancy 5 Vacuum or forceps delivery 6 Prior BPBP

Answer 68

1 Loss of external rotation 2 Apparent humeral shortening 3 Asymmetrical axillary and proximal arm folds 4 Posterior shoulder fullness 5 Palpable click during shoulder manipulation 6 Deep axilla

Answer 69

1 Character of neurological injury a Preganglionic b Post ganglionic c Neuropraxia 2 Anatomic level a Erb (c5-6) b Klumpke (c8-t1) c Total (c5-t1) 3 Narakas groups a Group 1-4

Answer 70

Nonoperative 1 PT, OT, splinting, stretching Operative 1 Nerve grafting a Root rupture (postganglionic) b A disposiable nerve e.g. sural sensory nerve is grafted across the area of injury 2 Nerve transfer a Root avulsion (preganglionic) b Transfers a functioning, disposable, nerve fascicle from another muscle to the nerve supplying muscle which is not receiving innervation 3 Shoulder internal rotation contracture a L’Episcopo procedure 4 Glenohumeral dysplasia a Proximal humeral derotation osteotomy 5 Elbow flexion contracture a Serial splinting or casting

Answer 71

While there are many procedures for symptomatic internal rotation contractures of the shoulder related to brachial plexus birth palsy, my preference is the classic L’Episcopo procedure where lattisimus dorsi and teres major are mobilized by an osteoperiosteal flap from anteromedial to posterolateral aspect of the humerus in addition to releasing subscapularis, pectoralis major and joint capsule. Failing this I will perform a de-rotational humeral osteotomy with soft tissue balancing (releasing contracted anterior structures, capsulorrhaphy of lax posterior capsule. Components of the procedure 1 Lat dorsi and teres major transfer from anteromedial to posterolateral humerus 2 Subscapularis release 3 Pec major release/lengthening 4 Joint capsular release

Answer 72

Good Prognosis 1 Erb 2 Antigravity biceps by 3 months 3 Post-ganglionic injuries 4 Neurapraxias Poor Prognosis 1 Preganglionic injuries 2 Lack antigravity at 3-6 months 3 Klumpke 4 C7 involvement

Answer 73

1 Horner’s syndrome a Miosis (pupillary constriction) b Ptosis c Anhidrosis 2 Elevated hemidiaphragm a Phrenic n. 3 Scapular winging a Dorsal scapular n. 4 Lack of trapezius function

Answer 74

Vickers ligament from volar ulnar physis to lunate causing 1 Volar ulnar curvature 2 Increased radial inclination 3 Increased volar tilt 4 Positive ulnar variance 5 Proximal subsidence of the lunate

Answer 75

1 Physiolysis with Vicker’s ligament release, fat interposition +/- distal ulnar epiphysiodesis a Early, mild deformity, skeletally immature patient 2 Radial dome osteotomy, Vickers ligament resection +/- ulnar shortening osteotomy a More severe deformity 3 Radioscapholunate fusion with distal pole scaphoid excision 4 Total wrist fusion Treatment Algorhithm 1 Ulnar sided procedures a If ulna long shorten it b If ulna neutral stop it from growing further with epiphysiolysis 2 Radial sided procedures a If arthritic fuse it (total wrist fusion, scaphoradiolunate) b If the child very young and it’s caught early release deforming forces (vickers) c If the child older with severe deformity then correct the deformity with an osteotomy

Answer 76

1 Supine, arm board, tourniquet 2 Volar henry approach 3 Curved osteotome used to make dome osteotomy 4 Correct deformity a Radially deviate distal fragment b Dorsally displace distal fragment c Pronate hand 5 Fix with K wires

Answer 77

Statue of liberty position a Longitudinal traction b Abduction to 90° c External Rotation

Answer 78

Extension type a Anterior interosseous nerve followed by median, radial and ulnar Flexion type a Ulnar nerve Posterolateral displacement a Median and anterior interosseous nerve Posteromedial displacement a Radial nerve

Answer 79

1 Brachialis (muscle interposition or buttonhole) 2 Brachial artery 3 Nerve 4 Periosteum 5 Joint capsule

Answer 80

Humeral axis relative to lateral condylar physis on AP a Normal = 70-75 b Compare to contralateral side c Deviation >5-10 should not be accepted

Answer 81

Supine with armboard tourniquet 2 Transverse or ‘lazy S’ over flexion crease of antecubital fossa 3 The traumatic interval may be identified and followed anteriorly a If releasing blocks to reduction stay lateral to biceps tendon to avoid neurovascular structures b If exploring neurovascular bundle stay medial to biceps tendon and identify vessels just proximal to fracture site

Answer 82

Type I Fracture line remains lateral to the trochlea (therefore does not involve the ulnohumeral joint) Type II Fracture involves trochlea

Answer 83

1 Lateral spur 2 Nonunion 3 Cubitus varus (20%) 4 Cubitus valgus (10%) 5 Tardy ulnar nerve palsy 6 Fishtail deformity 7 Growth disturbance 8 Infection

Answer 84

1 Ulnar ostetomy a Subcutaneous approach to the ulna, FCU, ECU split b Transverse osteotomy at point of maximum angulation (CORA) c Re-establish length, restore PUDA and proximal varus 2 Radial head reduction a Closed reduction and check stability through pronation/supination b Possible open reduction through lateral approach, kocher interval 3 +/- annular ligament repair/reconstruction using Bell Tawse procedure a Distally based slip of lateral triceps fixed to supinator crest with suture anchor b Postoperative casting in supination

Answer 85

Type IA = transphyseal without dislocation of epiphysis (50% AVN) Type IB = transphyseal with dislocation of epiphysis (100% AVN) Type II = transcervical (30% AVN) Type III = cervicotrochanteric (20% AVN) Type IV = intertrochanteric (10% AVN)

Answer 86

1 Perform within 24 hours 2 Table a Age <10 perform on radiolucent operating table b Age ≥10 perform on fracture table 3 Reduction maneuver a Hip in extension, abduction, internal rotation, gentle traction b Avoid forceful manipulation 4 Anatomic reduction is preferred a Open through anterior smith pete if necessary for anatomic reduction b Closed reduction is preferred and usually successful Treatment options for pediatric hip fracture **1 Set-up** a Fracture table (>10) b Flat top (<10) **2 Reduction** a Closed b Open **3 Fixation Options** a None b K wires c Pediatric SHS **4 Construct** a K wires b Physeal sparing SHS i Patient under 10 years of age, fracture amenable to physeal sparing c Transphyseal SHS d +/- capsular decompression **5 Post op care** a Spica b Protected WB

Answer 87

1 Open hip fracture 2 Vascular injury requiring repair 3 Pathological hip fracture requiring bone culture, biopsy, or grafting 4 Failed closed reduction

Answer 88

1 Lag screw within 5mm subchondral bone 2 Avoid posterior perforation or screw placement in the anterolateral quadrant 3 Avoid transphyseal fixation in patients <10 if possible 4 Post-operative TTWB with crutches if stable pattern

Answer 89

1 Children <8 years 2 Pathological fractures that are not stable after fixation 3 Fractures treated with smooth K-wires 4 Fractures treated with physeal sparing technique

Answer 90

1 AVN 2 Coxa vara (NS angle < 120) 3 Premature physeal closure (coxa valga or vara and LLD) 4 Nonunion (10%) 5 Chondrolysis 6 Infection 7 Posttraumatic SCFE 8 Overgrowth of the femoral shaft

Answer 91

**1 Palvik harness** a <6 month **2 Early spica casting** a 6 month – 5 years b length stable **4 Flexible intramedullary nails** a 5-11yrs b < 110lbs/(~50kg) c length stable fracture pattern **5 Submuscular bridge plating** a 5-11 years b > 100lbs or length unstable fracture pattern **6 Ex-fix (DCO)** 7 Rigid IMN a Skeletally mature

Answer 92

1 Supine position radiolucent table 2 Fracture reduction a knee flexion b traction c F-tool 3 Use two nails with a combined diameter equal to 80% of the IM canal at its narrowest width 4 Retrograde start point is ~2.5cm from the distal femoral physis 5 Nails are rotated so the concavities face each other 6 For better rotational control, one nail is advanced to the femoral neck and the other to the greater trochanter 7 Only 1-1.5cm of the nail should remain outside the bone 8 A knee immobilizer is applied at completion of case with protec

Answer 93

Salter Harris 1 a Displaced i 2 crossing transphyseal pins from epiphysis to metaphysis b Non-displaced i Cast immobilization 3-4 weeks Salter Harris 2 a If Thurston Holland fragment large i Two partially threaded cannulated screws of metaphyseal fragment parallel to physis. b If TH fragment small i cross pin, treat as a displaced Salter Harris 1 Salter Harris 3 a Intraepiphyseal screw b Parallel with physis c Avoid the joint Salter Harris 4 a Metaphyseal lag screw in Thurston Holland fragment b Intra-epiphyseal screw parallel with the physis, avoiding the joint

Answer 94

Type I Intra-apophyseal a Partially threaded lag screw with washer from A to P Type II Apophyseal-epiphyseal a Partially threaded lag screw with washer from A to P Type III Intra-articular a Anterior approach, open arthrotomy, reduction, k wire fixation with multiple cross pins b Lag screws across the tubercle Type IV Transphyseal a Gentle manipulative reduction and medial/lateral k wire fixation from epiphysis to metaphysis b Lag screws across the tubercle Type V Transphyseal with intraarticular extension a Anterior approach, open arthrotomy, directly visualize and reduce the joint surface and fix with K wires b Then close the tibial tubercle with lag screws

Answer 95

1 Supine with tourniquet and bump 2 Anterior midline incision over patella, tibial tubercle a Full thickness flaps b Identify fracture site and carefully work up toward menisci c Visualize within the joint using a medial parapatellar arthrotomy d Irrigate fracture hematoma e Cauterize recurrent branch anterior tibial artery if identified 3 Inspect the joint for concomitant injuries a Chondral injuries b Meniscal tears, often coronary ligaments are torn and must be repaired with suture anchors or transosseous sutures 4 Reduce any joint fragments first a Under direct visualization with fluoroscopic guidance b Hold joint fragments with trans-physeal k wires 5 Reduce the tubercle with knee in full extension a Lag screw fixation 6 Ensure anatomic reduction of the joint, tubercle, mechanical axis of the limb, stability of the knee 7 Repair arthrotomy, retinaculum and torn periosteum with nonabsorbable sutures 8 Post-operative immobilization with cast 3-4 weeks then gentle ROM with protected weight bearing, followed by hinged knee immobilizer for an additional 4-6 weeks

Answer 96

1 Canmeds discussion with family 2 Challenging problem, involve a senior colleague 3 Goals are a correct proximal tibial alignment b restore global limb alignment in coronal and sagittal planes c maintain patellar height d maintain extensor mechanism tension to avoid extensor lag 4 Preoperative CT and scannogram bilateral limb 5 Obtain old OR note ensuring appropriate tools available for hardware removal including broken screw removal set Procedure 1 Supine position 2 Follow previous incisions 3 Hardware removal 4 Tibial tubercle osteotomy a Elevate tibialis anterior off anterior compartment b Predrill desired osteotomy and complete with osteotome from anteromedial to posterolateral c 5-6cm in length, 1-2 cm in depth depending on the size of the tubercle d Bevelled to facilitate repositioning 5 Opening wedge osteotomy using saw and osteotomes correcting mechanical axis of the tibia and tibial slope to contralateral values 6 Bone graft and plating a Allograft vs autograft b Small frag vs eight plates 7 Distalize tubercle and secure with partially threaded cannulated screws 8 Consider prophylactic anterior compartment fasciotomy

Answer 97

Type I: Minimally dispalced Type II: Anterior displacement with intact posterior hinge Type III: Complete fracture displacement Type IV: Comminuted Fixation Options 1 Approach a Arthroscopic b Open 2 Fixation a All intra-epiphyseal partially threaded cannulated screw b Transosseous bone tunnel, tied over endobutton c Suture anchor fixation 3 General approach a Supine with tourniquet and leg holder b Arthroscopic portals anteromedial, anterolateral c Diagnostic arthroscopy d Identify fragment i If the physis is open then intraepiphyseal screw if possible, otherwise suture anchor ii If the physis is closed then transosseous bone tunnel using ACL guide, tied over an endobutton with the leg in full extension

Answer 98

1 = Independent 2 = Uses aids for stairs and steps 3 = Assistive devices primarily 4 = Primarily wheelchair (may do transfer) 5 = Nonambulatory

Answer 99

Age <4 a MFCA b LFCA c Artery of ligamentum teres Age > 4 a predominantly MFCA

Answer 100

My goal is to assess and potentially correct coronal, sagittal and rotational deformity. Full History Physical a ROM hip knee b LLD c Stability of hip knee ankle d NV exam or foot e Clinically determine whether deformity is from the spine, hips, femur, knee, tibia, ankle a Dedicated view of affected joint/long bone b Scannogram for coronal and sagittal alignment c Bone age d Radiographically determine the location of the deformity/deformities Determine amount of growth remaining a Multiplier method b Moseley growth charts c Aps 1 Estimate mechanical axis clinically and radiographically 2 Determine whether the deformity is femoral, tibial or combined 3 Corrective osteotomies may be performed through the apex of the deformity a where the anatomical axis proximally meets the anatomical axis 4 Fixation a Gradual i ilizarov or taylor spatial circular frames b Acute i Osteotomy with plating/nailing

Answer 101

1 Wide and indistinct growth plates 2 Lateral expansion of growth plates 3 Cupped and splayed metaphysis 4 Short long bones for age 5 Angular deformity (coxa vara, genu varum/valgum) 6 Looser zones (aka milkman lines) a Transverse bands of unmineralised osteoid (‘Pseudofracture’) b Typically appear in the medial aspect of the proximal femur and at the posterior aspect of the ribs 7 Acetabular protrusio

Answer 102

1 Decreased longitudinal bone growth 2 Angular deformities → Genu varum, genu valgum, coxa vara 3 Osteomalacia 4 Costochondral enlargement (rachitic rosary) 5 Kyphoscoliosis 6 Skull → Delayed anterior fontanelle closure, parietal and frontal bossing, plagiocephaly (flat head) 7 Delayed primary dentition

Answer 103

1 May have general aspects of dysmorphism 2 May have signs of thyroid dysregulation (skin, hair, weight gain/loss, intolerance heat/cold) 3 May have signs of hypocalcemia (confusion, seizures) 4 May have renal failure 5 Nonspecific associations – anemia, hypocalcemic convulsions, hypotonia, cardiomyopathy, benign intracranial hypertension

Answer 104

1 Nutritional (Vit D deficiency (most common), calcium deficiency (rare), combined deficiency): Treatment = Vit D and calcium [Labs will show decreased Ca & PO4, Vit D, reactive hyperparathyroidism and ALP] 2 X-linked hypophosphatemic rickets (Aka. Familial hypophosphatemic rickets) Cause = renal phosphate wasting AND low or normal kidney production of 1,25- dihydroxyvitamin D3: Treatment = phosphate and Vit D (calcitriol) 3 Renal osteodystrophy: Causes = renal failure; Insufficient 1,25-dihydroxyvitamin D3 activation → Reduced phosphate excretion → hyperphosphatemia causes hypocalcemia which causes secondary hyperparathyroidism: Treatment = dietary phosphate restriction, phosphate binding agent, Vit D3 [Labs Calcium low, phosphate high, ALP and PTH high, vit D normal] 4 Hypophosphatasia: Causes = ALP deficiency (autosomal recessive): Treatment = no medical treatment [Labs calcium and phosphate high, decreased ALP, PTH likely low but says normal] 5 1-Alpha-Hydroxylase deficiency (‘Vitamin D dependent’): Causes = unable to convert 25-hydroxyvitamin D3 to its biologically active form of 1,25-dihydroxyvitamin D3: Treatment = 1,25 Vit D3 [Labs show Ca PO4 low, ALP and PTH high doubly hydroxylated vitamin D low] 6 End organ insensitivity (‘Vitamin D dependent’): Causes = lack receptor for 1,25 Vit D3: Treatment = high dose 1,25 Vit D3 and Calcium [Labs show Ca and PO4 low, ALP high and 1,25 OH vit D high]

Answer 105

Elbow extension, wrist extension, valgus

Answer 106

Closed (extension, pronation, varus, direct manipulation) → perc joystick → Metiziau → open Closed maneuvers 1 Patterson – hold the elbow in extension and apply distal traction with the forearm supinated and pull the forearm into varus while applying direct pressure over the radial head 2 Israeli – with elbow flexed 90 and forearm in supination apply thumb pressure to anterolateral radial head while forearm is gradually taken into pronation 3 Esmarch – wrap forearm distal to proximal while holding elbow in varus

Answer 107

Rockerbottom deformity → Hindfoot equinus valgus, midfoot & forefoot dorsiflexion abduction Navicular = dorsolateral dislocation Cuboid = dorsolateral Talus = vertical

Answer 108

1 Plantar convexity 2 Deep dorsal creases 3 Rigid rocker bottom deformity 4 Palpable gap over navicular dorsally

Answer 109

1 Talocalcaneal > 40 (20-40 Normal) on AP (indicates valgus) 2 Talo-first metatarsal (Meary > 20) – apex plantar = pes convexus 3 TAMBA > 35 4 Forced plantarflexion view r/o oblique talus

Answer 110

1 Serial manipulation and casting in reverse ponsetti technique for 6 weeks 2 Perc (possible open) TN pinning, pin removal at 6 weeks 3 Possible tib ant transfer to talar neck (*if you have to open*) 4 Achilles tenotomy 5 Boots and bars full time 2 months, qPM x 2 yrs

Answer 111

Rotational - Femoral anteversion (IR hip > 70, ER < 20) Internal tibial rotation (TFA < -10) Metatarsus adductus (heel bisector line passes lateral to second ray) Foot – Clubfoot, skewfoot, metatarsus primus varus (increased intermetatarsal angle), hallux varus

Answer 112

1 Femoral anteversion – usually nonop; surgery is a proximal femoral derotation osteotomy (subtroch fixed with locking plate) 2 Internal tibial torsion – usually nonop; surgery is a proximal or supramalleolar derotation osteotomy 3 Metatarsus adductus – usually nonop (spontaneous resolution, manipulation and serial casting); surgery can include medial opening wedge osteotomy of the medial cuneiform +/- lateral closing wedge osteotomy or osteotomies of the bases of metatarsals two through four

Answer 113

Central – CP, Friedrich’s ataxia, CVA Cord – SMA, myelomeningocele (L4), tethered cord, diastematomyelia Peripheral – CMT, polio, systemic (e.g. chemotherapy)

Answer 114

WEAK - tibialis anterior, peroneus brevis, intrinsics STRONG - peroneus longus (plantar flexes first ray, tibialis posterior (increases arch), long toe extensors and flexors (claws toes)

Answer 115

Goal to correct the deformity AND balance the deforming muscle forces 1 SOFT TISSUE RELEASES - Medial plantar release (abductor hallucis, tibialis posterior lengthening (don’t do this if you’re planning transfer), talonavicular joint capsulotomy, plantar fascia), TAL vs gastroc recession based on silverskold 2 OSTEOTOMIES - 1st metatarsal dorsiflexion osteotomy, lateral calcaneus closing wedge osteotomy (Dwyer) or lateral calcaneal slide 3 TENDON TRANSFERS: Peroneus longus to peroneus brevis, Tib post 4 incision technique, Jones for first toe clawing (EHL to 1st MT neck)

Answer 116

1 Parallel Park-Harris lines through the metaphysis of the distal radius 2 Presence of physeal bar 3 Positive ulnar variance 4 Angular deformity

Answer 117

Nonoperative - Minimal growth remaining Operative indications 1 >2mm growth remaining 2 Progressive deformity 3 Ulnar sided wrist pain 4 Limited ROM Options i. Physeal bar resection and interposition ii. Epiphysiodesis 1. Partial arrest = epiphysiodesis of remaining growth plate 2. Complete arrest = ulnar epiphysiodesis iii. Ulnar shortening osteotomy iv. Radial osteotomy v. Distraction osteogenesis

Answer 118

1 WBC > 12,000 cells/µl of serum 2 Inability to weight bear 3 Temperature > 101.3° F (38.5° C) 4 ESR > 40 mm/h

Answer 119

Physiologic CP (SHAAM) Spastic, hypotonic, athetoid, ataxic, mixed Anatomic CP: quadriplegic, diplegic (legs), hemiplegic (one side)

Answer 120

1 Femoral anteversion 2 Coxa valga 3 Focal head deformity from acetabular erosion of femoral head forming wedge shaped epiphysis with superolateral displacement

Answer 121

1 Abduction < 45 degrees 2 MI > 25%

Answer 122

1 Soft tissue lengthening - ‘preventative’ 2 Reconstruction - Soft tissue lengthening, shortening VDRO, acetabuloplasty (Dega), +/- capsulotomy 3 Salvage -Castle, McHale procedure, arthrodesis, arthroplasty

Answer 123

In general, children with migration index past critical (>50%), no arthritis Specific listed from JAAOS –(?) >4 years with MI >60% and no degeneration <8 years with failed soft tissue lengthening (MI >40% 1 year postoperative) >8 years with MI >40% and no degeneration

Answer 124

1 Medial transverse incision 1-3cm distal to inguinal crease 2 Adductor longus tenotomy 3 Gracilis myotomy 4 +/- adductor brevis lengthening 5 Iliopsoas tenotomy in nonambulators (psoas tenotomy in ambulators)

Answer 125

1 Child factors: First-born children, unplanned children, premature infants, stepchildren, and handicapped children 2 Home and family factors: Single-parent homes, drug abusing parents, parents who were themselves abused, unemployed parents, and families of lower socioeconomic status

Answer 126

1 Long bone fractures in nonambulatory child 2 Multiple fractures in various stages of healing 3 Rib fractures (posterior and posterolateral) 4 Transphyseal fracture of the distal humerus 5 Metaphyseal ‘corner fracture’ or ‘bucket handle fracture’ (violent shaking leads to avulsion of zone of provisional calcification) 6 Vertebral compression fractures 7 Spinous process avulsions

Answer 127

1 Bruises: perineum, buttock, genitalia, trunk, back of legs, back of head → Multiple and in different stages of healing 2 Skull fractures → Suggestive types include multiple, crossing suture lines, depressed, bilateral, skull base 3 Retinal hemorrhages 4 Subdural hematoma 5 Visceral injury

Answer 128

1 Cardiovascular a Aortic root dilatation, mitral valve prolapse, pulmonary artery enlargement, left ventricle enlargement b Requires serial clinical exams and ECHOs, Beta blockers 2 Ocular a Superiorly dislocated lenses, myopia, glaucoma, cataracts, and retinal detachment b Requires Annual ophthalmic exams 3 Scoliosis a Radiographically indistinguishable from AIS b Surgery considered at >45° c Unique features to consider - narrow pedicles, wide transverse processes, dural ectasia and vertebral scalloping 4 Protrusio acetabuli →May develop OA requiring THA (requires medial bone grafting)

Answer 129

Calcaneonavicular coalition →Anteater sign on oblique foot view Talocalcaneal coalition → C-sign (lateral), Dorsal talar beaking

Answer 130

Indications for resection: symptomatic & <50% posterior facet involvement Indications for subtalar fusion 1 >50% posterior facet involvement 2 Posterior facet joint degeneration 3 Hindfoot valgus >16-21 degrees

Answer 131

1 Posterior dislocation 2 Round radial head 3 Hypoplastic capitellum 4 Bilateral 5 No history of trauma Treatment →Nonoperative, consider operative in adulthood if symptomatic or restricts ROM (radial head resection)

Answer 132

Redirectional (volume stable) 1 Salter → Cuts both columns (requires internal fixation) improving anterior and lateral coverage, rotating through pubic symphysis. Allows for correction = 15° of lateral coverage, 25° of anterior coverage 2 Triple → Same as Salter but adds superior and inferior pubic rami osteotomies (No hinge, acetabulum free to rotate) 3 Ganz → Posterior column intact Reshaping (volume reducing) 1 Dega → No internal fixation required, Improves lateral coverage, rotates through the triradiate cartilage 2 Pemberton →No internal fixation required, improves anterior coverage, rotates through the triradiate Salvage 1 Shelf 2 Chiari (Medial displacement osteotomy vs Hinges on the pubic symphysis)

Answer 133

1 Midline cutaneous hemangioma (nevus flammeus) on the forehead 2 Limbs appear thin, atrophic 3 Absence of flexion creases 4 Limited ROM from weakness and contractures 5 Characteristic contractures

Answer 134

Upper extremity → Waiter’s tip (shoulder adduction, IR, elbow extension, forearm pronation, wrist flexed ulnar deviated, thumb opposed) Hip → flexion, abduction ER possible dislocation Knee → Flexion or extension contractures +/- CDK Foot → Rigid equinovarus & CVT Scoliosis → C shaped

Answer 135

1 Canmeds plus plus discussion with family regarding the nature of the condition, multidisciplinary approach to management, this is the start of a long relationship with multiple medical teams 2 Stretching and ROM exercizes, contracture taping, splinting from birth 3 Severe contractures can be treated with manipulations and serial castings or soft tissue release and casting 4 In the lower extremity proceed from distal to proximal (feet – knees – hips) (clubfoot or CVT then CDK then DDH treatment) 5 Surgery may be avoided if deficits can be overcome with adaptive equipment

Answer 136

Teratologic hip dislcocation – not responsive to Pavlik or closed reduction 1 Unilateral hip dislocation → open reduction 6-12 months VS observation (given high rate of failure and AVN) 2 Bilateral hip dislocations → Controversial – often observation Dislocated supple hips are often better than reduced stiff hips Open reduction of both will often not result in both being supple and reduced

Answer 137

Treat like standard CDK → Splinting, stretching, serial manipulation casting possible quads lengthening, femoral shortening and contracture release Congenital dislocation patella → standard lateral release, medial imbrication plus minus procedure on patellar ligament

Answer 138

Ponsetti method anticipating less correction than normal children, prepared to perform posteromedial release and casting after 6 weeks

Answer 139

1 Extension contracture → Stretching/splinting possible triceps lengthening and posterior capsular release 2 Internal rotation contracture → External humeral rotation osteotomy 3 Wrist flexion contracture → Stretching splinting, FCU transfer to dorsum of hand (FCU is often only functioning wrist flexor/extensor) → Carpal wedge osteotomy 4 Thumb in palm deformity →Soft tissue release

Answer 140

Associated conditions: arthrogryposis, digitotalar dysmorphism, friedman Sheldon, X linked MASA syndrome (wtf) Tsuyuguchi classification – Type 1 = supple, Type 2 = contracture, Type 3 = rigid Pathology = attenuation or deficiency EPB, EPL or both, first webspace contracture, adductor policis contracture, global instability first MTPJ Treatment Nonoperative – splinting stretching for all types for 3-6 months Operative - 1 Tendon transfer – EIP to EPL for type 1 and 2 deformity 2 Thumb reconstruction at age 3-5yrs (dorsal rotational advancement flap first webspace, four or 5 flap z plasty, deepening of first webspace with MCPJ contracture release, FPL lengthening 3 Arthrodesis – symptomatic, rigid deformity, residual deformity, type 3

Answer 141

My goal is to release the soft tissue contractures of the MCPJ to reduce it into a normal anatomical position, and balance deforming forces through soft tissue releases, tendon transfers and tenodeses. If unsuccessful then I will fuse the joint. Step 1: Soft tissue release → Z plasty incision over cleft first webspace releasing 1 dorsal fascia 2 first dorsal interosseous 3 adductor policis 4 FPB (in chronic type 2s) Step 2: Augment weak muscles of extension → Generally the specific tendons transferred depend on available viable muscles for which there is voluntary control, but typically one of PL/BR/FCR → APL/EPB/EPL →Side to side tenodesis effect can influence force vectors to help balance the joint (details too greasy to include) → for IP flexion consider FPL lengthening, or augmenting EPL tendon Step 3: Arthrodesis if unable to stabilize by balancing force vectors with tendon tranfers and releases →MCPJ usually sufficient in rare cases CMC fusion may be necessary

Answer 142

1 Physeal sparing (intra-articular): ADV (reduces growth plate arrest, subsequent LLD and angular deformities) DISADV (technically challenging, no consensus on best procedure, some procedures under and some over constrain the knee which may lead to delayed OA) Examples – multiple options, no consensus 1 Hamstring left attached to pes, transferred intermeniscal ligament and back down to periosteium of tibia 2 Combined intra/extra articular reconstruction with ITB 3 Graft may be passed through all epiphyseal tibial tunnel around a staple at femoral ACL footprint 2 Partial transphyseal (over the top) – transtibial, through joint, wraps around femur and secured back down to tibia 3 Partial transphyseal – transtibial, all epiphyseal femur 4 Physeal respecting transphyseal 5 Traditional transphyseal

Answer 143

While the guidelines depend on specific bone age, and vary based on gender and development of secondary sexual characterics as well as remaining growth, a general guideline Females (males add 1-2 yrs after puberty) [Note these numbers are not hard numbers, there is significant overlap in available options, patient by patient differences based on maturity and remaining growth left, and it’s a controversial topic.] < 8 years intraarticular extraphyseal 8-11 years all epiphyseal 11-14 years partial transphyseal (vs all epiphyseal) 15-16 years physeal respecting transphyseal < 16 years traditional adult transphyseal Recommendations from JAAOS 2018 1 Prepubescent or > 2 years growth remainig = intra-articular extraphyseal, all epiphyseal using ITB autograft 2 Adolescent approaching maturity = physeal respecting transphyseal ACL 3 Skeletally mature = adult-type transphyseal ACL

Answer 144

1 Vertical tunnel 2 Tunnel diameter ≤8mm 3 Central tunnels (avoid peripheral tunnels) 4 Avoid the perichondral ring 5 Hardware and bone should not be placed across the physes 6 Soft tissue grafts preferred 7 Heat necrosis should be avoided by hand drilling or slow drilling speeds **Note central less likely than peripheral to cause arrest, involvement > 5% of physis may lead to arrest, vertical tunnels better than oblique **Must use soft tissue autograft, avoid bone, if need to place bone don’t place it across the physis

Answer 145

1 Midsubstance slip of the iliotibial band looped posterolaterally over the lateral femoral condyle 2 Then passed through the intercondylar region, through the joint 3 Passed under the intermeniscal ligament to form a new ACL 4 A trough is placed under the intermeniscal ligament to allow for more anatomic graft placement without causing direct physeal injury. 5 Proximally, the graft is sutured to periosteum of the lateral femoral condyle at the insertion of the intermuscular septum. 6 Distal to the joint, the graft is sutured to periosteal flaps at the proximal anterior tibia with the use of heavy nonabsorbable sutures

Answer 146

1 Tunnels are drilled in femoral and tibial epiphysis under fluoroscopy visualization 2 Hamstring autograft is fixed on the femoral side with a cortical button or interference screw 3 Fixation on the tibial side can be with a cortical button or interference screw or distally over a post

Answer 147

1 Dual anterolateral posteromedial approaches protecting SPN, NV bundles 2 Arthrotomy 3 Reduce fracture under direct visualization 4 1-2 intraepiphyseal screws anterolateral to posteromedial 5 1-2 metaphyseal screws perpendicular to fracture line 6 Closure in layers with splint, NWB x 6 weeks

Answer 148

Benefits 1 Improve muscle strength 2 Delays loss of strength over time 3 Protect muscle from exercise induced damage 4 Increase the regenerative capacity of muscle 5 Prolongation of walking 6 Delayed decline of pulmonary function 7 Reduction in the need for scoliosis surgery Adverse effects 1 Acne 2 Personality changes 3 Hirsutism 4 Growth retardation 5 Weight gain 6 Osteoporosis

Answer 149

1 Preopeative work up a Bloodwork b Cultures c Imaging i Plain films ii MR r/o osteomyelitis/abscess 2 US guided aspirate a Send for culture, sensitivity, gram stain 3 Management a Open I&D, oval window capsule, drain b Sequestrectomy/ drilling of abscess Scenarios Neonatal multijoint sepsis a Options include open I&D of all joints, drains b Open I&D hip, needle washout of other joints If patient too sick to tolerate anesthesia then serial needle drainage

Answer 150

1 Soft tissue release 2 Femoral shortening varus derotation osteotomy (VDRO) 3 Dega acetabuloplasty (if skeletally mature then PAO) 4 Spica cast 1 Preoperatively template degree of bone loss with CT plan neck shaft angle correction with a goal of 120 degree neck shaft angle in ambulators and 100 degrees in nonambulators 2 Position: Supine 3 Approaches: Extended anterior Smith-Peterson approach over iliac crest for acetabuloplasty. a Lateral subvastus approach for shortening VDRO b Medial approach for soft tissue release 4 I will address soft tissue then femur then pelvis. 5 Soft tissue releases: Adductor longus tenotomy, gracilis myotomy, adductor brevis lengthening 6 Under fluoroscopic guidance place chisel in femoral neck and attach blade plate proximally 7 Using cautery longitudinally mark the bone as a reference for rotation 8 Transverse subtroch osteotomy 9 Reduction of the hip joint 10 Femoral shortening is based on overlap of the proximal and distal fragments with the hip concentrically reduced, and is roughly 5mm 10 Secure plate distally 11 Dega acetabuloplasty (if skeletally mature PAO) → using osteotome under direct visualization and if necessary fluoroscopic guidance, lever into supra-acetabular bone, providing coverage for posterosuperior deficit. Line of osteotomy is from AIIS to PIIS 12 Bone graft: If doing shortening osteotomy use femoral autograft otherwise, sub- apophyseal ASIS 13 Tension free closure in layers with drain placement 14 Postoperative casting is based on age and bone quality: If child over 10 no cast, if under 10 years spica applied for pain control for a minimum of 2 weeks, 6 weeks if osteopenic bone

Answer 151

Castle Procedure 1 Resection arthroplasty 2 Soft tissue interposition 3 Postoperative Skeletal 90 90 traction vs McHale procedure 1. Valgus support osteotomy

Answer 152

Consent 1 Closed (possible open) reduction 2 Adductor tenotomy 3 Arthrogram 4 Spica cast 5 CT/MR

Answer 153

Consent 1 Open reduction 2 Adductor tenotomy 3 Capsulorrhaphy 4 Spica cast 5 CT/MR

Answer 154

Consent 1 Open reduction 2 Adductor tenotomy 3 Proximal femoral shortening osteotomy 4 Dega acetabuloplasty for coverage (if AI > 20) 5 Capsulorrhaphy 6 Spica cast

Answer 155

1 VDRO +/- salter/pemberton +/- GT apophysis epiphysiodesis 1 Preoperatively template degree of angular and rotational correction with CT 2 Position: Supine 3 Approach: Anterior Smith Peterson approach over iliac crest for Dega acetabuloplasty Lateral for VDRO. 4 Femur addressed first - Chisel then attach blade plate proximally 5 Transverse subtroch osteotomy 6 Reduce head (if out) and valgus deformity (with slight overcorrection). Overlap between proximal and distal fragments is shortened. 7 Secure plate distally

Answer 156

The goals of the procedure are to obtain lateral/posterior/anterior coverage by performing an incomplete supraacetabular osteotomy preserving the inner shelf, from AIIS to sciatic notch following the contour of the acetabulum and maintaining correction with iliac crest autograft. 1 Supine on radiolucent table 2 Anterior approach, bikini incision following Smith Peterson intervals protecting LFCN 3 Subperiosteal exposure of the lateral iliac fossa 4 I will use a curved osteotome under fluoroscopic guidance to make an osteotomy from the AIIS to the greater sciatic notch remaining 1.5cm above the acetabulum. 5 At the most anterior AIIS and sciatic notch I will use a karrison rangeur to complete the osteotomy bicortically to facilitate correction 6 I will lever the lateral column using osteotomes and Meary retractors and place autograft harvested from the sub-apophyseal iliac crest 7 Preferential coverage (either anterior, posterior, lateral) is achieved by graft placement 8 Place a drain and perform a tension free closure in layers with post-operative hip spica cast ADV: Allows for greater degree of correction than Salter, and can be used for anterior deficiencies in DDH or posterior deficiencies in CP. Does not require exposure of the inner table or fixation. DISADV: Not appropriate for older children with closed tri-radiates

Answer 157

The goals are to provide anterior superior coverage by producing a bicortical osteotomy of the inner and outer tables from the greater sciatic notch to the AIIS. The deformity is corrected and maintained with iliac crest autograft and K wire fixation. 1 Supine on radiolucent table 2 Anterior approach, bikini incision following Smith Peterson intervals protecting LFCN 3 Release abdominal muscles from ASIS to mid third of the crest 4 The apophysis is split and left continuous with periosteum 5 Subperiosteal exposure of the medial and lateral tables 6 Using a new, waxed gigli saw with fluoroscopic guidance, I will make an osteotomy perpendicular to the iliac wing from the greater sciatic notch to the AIIS 7 Harvest ASIS autograft to desired size to support correction 8 I will mobilize the inferior/articular fragment downward, outward and forward using the Salter Maneuver (heel on contralateral knee) 9 Place graft anteriorly and fix with 2 or more K wires capturing both columns and the graft 10 Closure in layers including the cartilaginous apophysis with drain placement and postoperative spica cast ADV: Familiar approach and procedure, reliable correction DISADV: Requires fixation, limited to anterior correction, correction is limited to ~15-20 degrees

Answer 158

PAO contraindicated with open triradiate The PAO is an osteotomy that uses 4 bone cuts to reorienting the acetabulum for coverage. The posterior column is left intact which preserves blood supply. The cuts include an incomplete ischial cut, superior and inferior pubic rami and an ileal cut.

Answer 159

Supine position Anterior approach for salter procedure Split apophysis over the crest Expose the inner and outer tables Gigli saw to cut from sciatic notch to AIIS Second cut of the superior pubic ramus can be done by extending the anterior incision or making a separate incision. Subperiosteal release of the pectineus. The osteotomy is done with an osteotome or rangeur. Third cut ischial cut. Hip is flexed to 90 degrees, separate posterior incision, releasing adductor magnus origin exposing ischial tuberosity. Schantz screw in the ilium and ball spike pusher in the pubis will allow re-direction after the cuts are made. The gap can then be bone grafted and threaded Steinman pins used to hold the graft and maintain position of the acetabulum.

Answer 160

FGFR3 mutation (AD)