Paeds

Question 1

Indication for serial casting in MTA?

Answer 1

Rigid deformity with medial crease

Question 2

How do you reduce a nursemaid’s elbow?

Answer 2

Supinate forearm and flex elbow to 90 deg

Question 3

2 options for tendon transfers of HMSN?

Answer 3

tib post to dorsum of foot

peroneus longus to brevis

Question 4

4 signs of AVN of femoral head following treatment for DDH (radiographic)?

Answer 4

1. failure of appearance or growth of the ossific nucleus 1 year after reduction
2. broadening of femoral neck
3. increased density and fragmentation of ossified femoral head
4. residual deformity of proximal femur after ossification

Question 5

Diagnosis and most common site/cause

Answer 5

Congenital pseudoarthrosis of the clavicle

Caused by extrinsic compression by the subclavian

Right middle 1/3 of clavicle 90%

Left only if situs inversus

Question 6

How do you differentiate CVT and oblique talus on x-ray

Answer 6

oblique talus:

navicular will reduce on plantarflexion latearl

Meary’s angle <35 degrees

Question 7

WHen i say Olecranon apophysis avulsion fracture, you say:

Answer 7

osteogenesis imperfecta

Question 8

What is Nail-Patella syndrome?

Answer 8

Hypoplastic Nails and Petallae

AD inheritance

Also includes:

Laxity

scoliosis

scapular hypoplasia

presence of cervical ribs

amongst other things

Question 9

Reduction Maneuver for displaced medial epicondyle fracture into joint?

Answer 9

Robert’s Technique

• Supination of the forearm - stretches flexor/pronator mass
• Valgus stress on the elbow - opens up ulnohumeral joint medially and stretch FP mass
• Extending the wrist and fingers - causes a pull on FP mass
• Early motion within 3-5 days minimizes risk of stiffness

Question 10

Most common cause of revision following early spica casting of a femur fracture in paeds?

Answer 10

Loss of reduction

Although rare

Question 11

Classification of Sprengel’s:

Answer 11

see chart

Question 12

What fracture type has the highest rate of growth arrest in the body?

Answer 12

SH4 of medial malleolus

Question 13

Describe the spectrum of myelodysplasia

Answer 13

Spina bifida oculta:

• Defect in vertebral arch with confined cord and meninges

Meningocoele:

• Protruding sac without neural elements

Myelomeningocoele:

• Protruding sac with neural elements

Rachischisis

• Neural elements exposed with no covering

Question 14

What zone of the growth plate does Little Leaguer’s shoulder occur?

Answer 14

Hypertrohpic zone

Question 15

4 factors predictive of physeal arrest in distal femur physeal fracture

Answer 15

SH classification

Presence of displacement

open fracture

Hardware penetration into physis from surgical management

Question 16

Valproic acid has what detrimental effect on surgery?

Answer 16

Increases bleeding time

Question 17

Complications of clubfoot correction (non op: 2, op: 6)

Answer 17

Nonop complications

• deformit relapse
• dynamic supination

Operative complications

• Residual cavus
• pes planus (due to overcorrection)
• undercorrection
• intoeing gait
• Osteonecrosis of talus
• dorsal bunion

Question 18

Should kids with MRSA attend school?

Play sports?

Answer 18

Yes, only if their wound/abscess/draining pus can be adequately covered up

They should not use pools or treatment pools

Question 19

What is normal thigh foot angle?

Answer 19

0-20 of ER

Question 20

Contraindications to Pavlik harness (4)?

Answer 20

1. Abnormal muscle function (i.e. spina bifida, spasticity)
2. Age over 6 months
3. Teratologic hip dislocation
4. Failure of Pavlik treatment for 3 weeks.

Question 21

Preferred surgical option for a large talocalcaneal coalition?

Answer 21

Triple fusion

Question 22

in osteo with community acquired MRSA, what should you consider doing?

Answer 22

Screen for DVT

Rapid CT-PE if any suggestive signs

Question 23

Why do you need a pre-op MRI in sprengels?

Answer 23

To identify omovertebral bar

Question 24

Three technical factors that can increase risk of compartment syndrome when using hip spica for femur fracture?

Answer 24

1. Rough cast edge at popliteal fossa
2. Excessive traction
3. Knee flexion > 90

Question 25

Cause and treamtent of stiff-knee gait in CP?

Answer 25

Cause: rectus femoris firing out of phase Treatment: transfer of distal rectus femoris tendon

Question 26

dDx for bilateral valgus (3)

Answer 26

Physiologic Renal osteodystrophy (Rickets) Skeletal dysplasia * Morquio * Spondyloepiphyseal dysplasia * Chondroctodermal dysplasia

Question 27

Treatment of hallux varus

Answer 27

Conservative: * most resolve with time Can do abductor hallucis release excsision of central epiphyseal bracket

Question 28

Workup of Arthrogryposis at 3 months? (3)

Answer 28

Perform at 3-4 months of age 1. neurologic studies 2. enzyme tests 3. muscle biopsies

Question 29

2 methods of percutaneous reduction of radial head fracture

Answer 29

1. K-wire joystick technique 2. Metaizeau technique involves retrograde insertion of a pin/nail across the fracture site fracture is reduced by rotating the pin/nail

Question 30

Anterolateral bowing: what's the chance this patient has NF? What is the chance an NF patient has anterolateral bowing?

Answer 30

what's the chance this patient has NF? 50% What is the chance an NF patient has anterolateral bowing? 10%

Question 31

Name 4 non-ortho manifestations of myelodysplasia

Answer 31

_Neurosurgical manifestations_ * Arnold-chiari manifestation (Type II); Most common associated congenital abnormality * Hydrocephalus * Tethered cord _Urological manifestations_ * Neurologic bladder _IgE mediated latex allergy_ * Results in profound anaphylaxis * Present in 20-70% of patients with this disorder

Question 32

What part of the acetabulum is deficient in a NON-neuromuscular hip dysplasia?

Answer 32

Anterior or anterolateral

Question 33

4 indications for surgery in infantile Blount's

Answer 33

Stage I and II in children \> 3 years Stage III, IV, V, VI in children \<3 years failure of brace treatment metaphyseal-diaphyseal angles \> 20 degrees

Question 34

Muscle imbalance in equinovalgus foot?

Answer 34

Opposite of equinovarus TA/TP weak PB/PL strong

Question 35

What is the Safe zone in DDH reduction? how do you increase it?

Answer 35

ROM at which hip stays reduced typically: 90-100 degrees flexion mild abduction of 20-45 degrees increase it with adductor tenotomy

Question 36

Paediatric trigger finger - waht must you release?

Answer 36

A1 pulley + 1 slip of FDS

Question 37

What is a reason why intra-thecal baclofen is preferred over PO for CP?

Answer 37

PO associated with cognitive impairment.

Question 38

What is contraindicated in the treatment of DMD scoliosis?

Answer 38

Bracing may interfere with already compromised respiraotry function

Question 39

What is angle A and how does it help evaluate DDH?

Answer 39

Acetabular Index varies with age (decreases) normal is less than 25 deg 2yo kid (remember 2yo is ~20deg)

Question 40

Name 5 reduction techniques of radial head reduction:

Answer 40

Elastic bandage Patterson Israeli Metaezeau (retrograde pin) K-wire joystock

Question 41

Indications for hemivertebrectomy in congenital scoli

Answer 41

Progressive curve \>40 degrees Patient \<5 lumbosacral vertebra best (but can be done in thoracic) (JAAOS 2004)

Question 42

BLocks to reduction in DDH

Answer 42

Labrum Inverted limbus capsule transverse acetabular ligament ligamentum teres pulvinar

Question 43

Give general principles of operative treatment for PFFD

Answer 43

_Limb Lengthening_ * if predicted LLD \<20cm * If femoral length \>50% of opposite side _Amputation ±prosthesis_ * If femoral length \<50% contralateral side or LLD \>20cm * If foot is proximal to level of contralateral knee * If prosthetic knee will not be below the level of the contralateral knee \*based on level of knee - must have it normal to walk normal _Hip Fusion_ * If absent acetabulum (Aitken D), fuse residual limb to pelvis and make knee into a hip

Question 44

5 Risks for CP

Answer 44

Prematurity (most common) Anoxic injury Prenatal intrauterine factors Perinatal infections (ToRCH, toxoplasmosis, rubella, CMV, Herpes) Meningitis Brain malformations

Question 45

Best predictor of success with tendon transfers in CP?

Answer 45

Patients with good voluntary control had the greatest improvement in functional use scores.

Question 46

Name this implant, procedure, and what its done for:

Answer 46

telescopic rod for Schofield-Miller realignment procedure for OI Can use telescoping or non-telescoping rods

Question 47

Pin configuration post CRPP of distal femoral physeal injury

Answer 47

antegrade avoids going intra-articular and avoids pin-tract infection into joint

Question 48

Kid with MPS comes in with burning in radial 3 digits, worse at night, some clumsiness of the hands. Top 2 dDx

Answer 48

Carpal tunnel syndrome: MPS is one of the most common causes of CTS in kids cervical myelopathy (unless its San Fillipo - no C-spine issues)

Question 49

What part of the physis does a SCFE occur in?

Answer 49

Hypertrophic

Question 50

4 non-orthopedic manifestations of Downs?

Answer 50

1. mental retardation 2. heart disease (50%) 3. endocrine disorders (hypothyroidism) 4. premature aging

Question 51

How do you screen for and diagnose MPS?

Answer 51

Screen: urine Diagnose: enzyme assay for activity in skin fibroblasts or WBC

Question 52

Orthopaedic Manifestations of Charcot Marie Tooth (HMSN)? (4)

Answer 52

pes cavus hammer toes hip dysplasia scoliosis

Question 53

Good prognostic signs of anterolateral bowing? (2)

Answer 53

Duplicated hallux Delta-shaped osseous segment in concavity of bow

Question 54

Indications for anterior approach in addition to posterior approach in scolisis

Answer 54

Large curve (\>75 degrees) Stiff curves Skeletally immature (Risser grade 0, boys

Question 55

Most common complication of lateral condyle fracture?

Answer 55

Lateral overgrowth/spurring

Question 56

Indications for contralateral pinning in SCFE

Answer 56

High risk patients: Endocrinopathy Obese Young age, indicated by: * Boys * Girls * Open Triradiate cartilage

Question 57

Genetic transmission of DMD

Answer 57

X linked recessive Important to counsel patients of risk of subsequent kids with the disease

Question 58

Non-ortho manifestations of Down (3)

Answer 58

Cardiac abnormaltieis (50%) Endocrine (hypothryoidism) mental retardation premature aging

Question 59

3 complications of radial head/neck fractures

Answer 59

AVN synostosis loss of ROM (pronation \> supination) radial head overgrowth

Question 60

What is the most common manifestation of child abuse?

Answer 60

Skin manifestations (bruises, burns) Fractures are the second most common

Question 61

When do you IMN a femur in paediatrics (age & weight)

Answer 61

\> 11 years \>49 kg Remember to use lateral start point

Question 62

Pediatric elbow dislocation - most common nerve injury

Answer 62

Ulnar nerve

Question 63

Kid with hemihypertrophy. What must you do?

Answer 63

serial ultrasounds q3 months until age 7, then physical exam q6 until skeletal maturity TO RULE OUT WILM'S TUMOUR

Question 64

Complications seen with too much flexion in Pavlik?

Answer 64

Femoral nerve palsy.

Question 65

2 complications of transphyseal distal humerus fracture?

Answer 65

Cubitus varus Medial condyle AVN

Question 66

Name 3 differences in the upper airway of a paediatric patient vs. adult

Answer 66

floppy epiglottis large tongue small larynx

Question 67

NIH Consensus Development Conference Statement diagnosis criteria for NF1?

Answer 67

**_Two or more of the following:_** * six or more café-au-lait macules over 5 mm in greatest diameter in prepubertal individuals and over 15 mm in postpubertal individuals. * two or more neurofibromas of any type or one plexiform neurofibroma. * freckling in the axillary or inguinal region. * optic glioma. * two or more Lisch nodules (iris hamartomas). * a distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with or without pseudarthrosis. * a first-degree relative (parent, sibling, or offspring) with NF-1 by the above criteria.is based on presence of both

Question 68

What are three ways to assess coronal deformity of the L/E on AP xrays?

Answer 68

1) mechanical axis 2) mLDFA 88 (range 85°-90°) and mMPTA (range 85°-90°) 3) Tibial Femoral Angle

Question 69

6 signs of preganglionic brachial plexus injury

Answer 69

Winged scapulae (long thoracic) Absent rhomboid function (dorsal scapular nerve) Absent RTC (suprascapular nerve) Absent Latissimus dorsi (thoracodorsal nerve) Horner's syndrome (sympathetic chain) Elevated hemidiaphragm (phrenic nerve)

Question 70

CP hip management based on Reimer's Migration Index

Answer 70

_Soft tissue release_ Children 40% _VDRO + ST release_ Kids \>4 OR Reimer's index \>60% _Abduction osteotomy or girdlestone procedure_ Chronic painful dislocation

Question 71

3 orthopaedic associations with tibial deficiency.

Answer 71

Ectrodactyly (cleft hand) preaxial polydactyly ulnar aplasia high rate of MSK anomalies (75%)

Question 72

How do you decide what size of nancy nail?

Answer 72

* nail size determined by multiplying width of narrowest portion of femoral canal by 0.4 * the goal is 80% canal fill

Question 73

Spinal manifestations of achondroplasia vs. pseudoachondroplasia

Answer 73

_Achondroplasia_ * foramen magnum stenosis * kyphosis * lumbar stenosis/decreased interpedicular distance _Pseudoachondroplasia_ * cervical instability

Question 74

Complications seen with too much abduction in Pavlik?

Answer 74

AVN

Question 75

What are two options to treat AVN following proximal femur fracture?

Answer 75

## Footnote ● Vascularised free fibula graft ● Core decompression

Question 76

By the time you transition from casting to boots and bars for Ponsetti, how much abduction should the foot be in?

Answer 76

70 degrees

Question 77

MPS with least spinal abnormalities?

Answer 77

San Filippo only has scoliosis, and even that is rare JAAS 2013

Question 78

2 factors prognostic of long term neurologic sequelae from paediatric trauma:

Answer 78

O2 sat at presentation GCS 72 hours post injury

Question 79

In surgical correction of blounts, what do you have to include in Langenskiold V, VI?

Answer 79

Epiphysiolysis (bar resection)

Question 80

First line treamtent in tarsal coalition?

Answer 80

trial of non-op with immobilization or orthotics - always

Question 81

2 indications for exploring the artery in a supercondylar fracture

Answer 81

Pulse is lost after reduction Persistance of pulseless hand after reduction

Question 82

3 nonorthopaedic conditions of marfans?

Answer 82

* cardiac abnormalities * aortic root dilatation * possible aortic dissection in future * mitral valve prolapse * superior lens dislocations (60%) * spontaneous pneumonthoraces

Question 83

AAOS guidelines for paediatric femoral shaft fractures

Answer 83

6 months - 5 years: spica 5 years - 11 years: TENS, IMN or submuscular plating \>11 years: submuscular plating or TENS They make NO reommendations on weight in the official criteria JAAOS 2011 states: We believe that regardless whether a patient has an unstable comminuted or oblique fracture, rigid nails are appropriate for **patients aged \>11 years who weigh \>49 kg**. We recommend the lateral trochanteric approach to avoid the risks associated with starting at or near the piriformis and near the tip of the trochanter

Question 84

Who gets Gower's sign? Describe it

Answer 84

Rises by walking hands up legs to compenate for gluteus maximum and quadriceps weakness

Question 85

2 life-threatening intra-operative complications in DMD:

Answer 85

intraoperative cardiac event malignant hyperthermia Consult anesthesia & cardio preop

Question 86

tarsal coalition Chance of it being bilateral? Patient with 1 coalition has what percentage of having another?

Answer 86

50% chance of being bilateral 20% chance of a second coalition if they have 1

Question 87

Complication with too mcuh abduction in DDH treatment?

Answer 87

AVN of femoral head via impingement of the posterior-superior retinacular artery

Question 88

What is the risk of AVN for Delbet Type 1B?

Answer 88

Nearly 100% (transphyseal proximal femur fecture with displacement of epiphysis out of acetabulum)

Question 89

MRSA infected kids have higher levels of what on admission?

Answer 89

ESR, CRP, WBC

Question 90

Indications for selective thoracic fusion:

Answer 90

Non-structural lumbar curve (Lenke 3 or above) Lower end vertebra touches CSVL Lenke 1C, 2C, 3C, 4C No significant sagittal imbalance Major Thoracic Curve Double thoracic Curve

Question 91

Risk factors for AVN post pinning of a SCFE. (5)

Answer 91

1. unstable SCFE 2. over-reduction of an acute slip 3. attempted reduction of a chronic slip 4. pins in the superolateral quadrant 5. femoral neck osteotomy

Question 92

7 options for interpositional graft after resection of physeal bar:

Answer 92

Fat PMMA Cranioplast (like PMMA: takes longer to set, less exothermic reaction, less chance of heat necrosis) Bone wax Cartilage Muscle Silicone

Question 93

Who gets Duchenne muscular dystrophy?

Answer 93

Males only X-linked recessive

Question 94

How does TA compare to PL in: a) Clubfoot b) Cavo - varus foot

Answer 94

a) TA stronger b) TA weaker

Question 95

BBFF: malrotation at what level has what effect?

Answer 95

Midshaft malrotations lead to decreased supination (vs distal malrotation)

Question 96

3 ways that Beckers differes from Duchennes?

Answer 96

1. dystrophin protein is decreased instead of absent 2. later onset with slower progression and longer life expectancy (average diagnosis occurs at age 8 compared to 2 years of age with Duchenne's) 3. more prone to cardiomyopathy

Question 97

4 radiographic signs of osteopetrosis?

Answer 97

"erlenmeyer flask" proximal humerus and distal femur "rugger jersey spine" with very dense bone loss of medullary canal "bone within a bone" appearance block femoral metaphysis

Question 98

Name 3 syndromes with abnormal ossification of secondary growth centers

Answer 98

Spondyloepiphyseal dysplasia Multiple epiphyseal dysplasia diastrophic dysplasia

Question 99

5 Orthopedic (non-spine) manifestations of Achondroplasia?

Answer 99

* facial features * frontal bossing * button noses * small nasal bridges * trident hands (inability to approximate extended middle and ring finger) * bowed legs * radial head subluxation * muscular hypotonia

Question 100

What percentage of LCP patients will eventually need THA?

Answer 100

50%

Question 101

What part of the growth plate does SCFE secondary to renal osteodystrophy occur?

Answer 101

Secondary spongiosa

Question 102

Torticollis: head tilt and rotation which direction?

Answer 102

Tilt: towards side of pathology Rotation: chin rotates away from pathology

Question 103

2 optioins for treating elbow flexion contractures

Answer 103

Clarke's pectoral transfer Steindler's flexorplasty

Question 104

What condition can be confirmed using fibroblast culturing to analyze type I collagen in equivocal cases?

Answer 104

OI (best for type 4)

Question 105

You plan a femoral derotational osteotomy on a child with femoral anteversion. Where do you make your osteotomy? How much correction do you need?

Answer 105

intertrochanteric osteotomy amount of correction = (IR-ER) / 2

Question 106

What is von Recklinghaussen disease?

Answer 106

NF1

Question 107

3 positive effects of bisphosphonates in OI (not the side effects)

Answer 107

Improves mobility decreases fracture rate improves vertebral bone density Improves vertebral height (not overall height)

Question 108

What is the Sofield-Miller procedure?

Answer 108

Realignment osteotomy with rod fixation for OI Fassier-Duval rods can be used.

Question 109

Age range for open reduction and hip spica +/- femoral osteotomy?

Answer 109

18 months - 4 years

Question 110

Describe the GMFCS scale.

Answer 110

Question 111

Most important thing to look for when examining tibal hemimelia?

Answer 111

Is the extensor mechanism intact and is there a flexion contracture of the knee.

Question 112

5 conditions associated with Cavovarus foot?

Answer 112

1. Charcot-Marie-Tooth 2. Freidreich's ataxia 3. Cerebral palsy 4. Polio 5. spinal cord lesions

Question 113

Never do what when ORIFing a lateral condyle fracture?

Answer 113

Never dissect posteriorly Blood supply comes from there and will cause AVN if you disrupt it

Question 114

You cant reduce a galleazzi fracture. What is most likely blocking reduction and which approach do you take to remove it?

Answer 114

ECU Dorsal

Question 115

Should Down syndrome kids avoid contact sports? If yes, what indication?

Answer 115

Avoid sports if progressive radiographic instability or signs of myelopathy

Question 116

INdications for hemiepiphysiodesis in congenital scoli

Answer 116

Failure of formation (hemivertebra) patient \<4 Curve \< 40 deg (only get about 15 degrees of correction. Contraindicated in failure of segmentation)

Question 117

How many ossification centers in the proximal humerus?

Answer 117

3: HH, GT, LT

Question 118

What 2 actions may help reduce AVN rates in femoral head/neck fractures in paediatric patients?

Answer 118

early reduction Joint decompression (hematoma aspiration or core decompression)

Question 119

Second most common nerve palsy in SCHF?

Answer 119

radial AIN most common

Question 120

Post tibial spine fracture, what is the factor most highly linked to arthrofibrosis?

Answer 120

Prolonged immobilization \> 4 weeks So start mobilizing before then

Question 121

Surgical treatment of hip dislocation in myelodysplasia is controversial b/c of high failure rates. What is the anatomic cause of failure? Be specific

Answer 121

Paralytic hip dislocation (not teratologic) B/c of paralysis of the hip abductors and extensors and unopposed pull of the hip adductors and flexors This leads to high relapse rates

Question 122

Foot muscular Imbalances in Hereditary Motor Sensory Neuropathy?

Answer 122

* plantar flexed 1st ray is initial deformity * cavus caused by peroneus longus (normal) overpower weak tibialis anterior * varus caused by tibialis posterior (normal) overpowering weak peroneus brevis

Question 123

When do you mobilize a medical epicondyle fracture in paediatric patients?

Answer 123

Early - after about a week if nondisplaced/displaced

Question 124

Phase 1 or 2 rib at an increased risk of progression?

Answer 124

Phase 2: rib overlap with apical vertebra

Question 125

Characteristic lesion in Fredrich's ataxia

Answer 125

Spinocerebellar degenerative disease, therefore, lesions in: * Dorsal root ganglia (peripheral) * Corticospinal tracts (central) * Dentate nuclei in the cerebellum * Sensory peripheral nerves

Question 126

Describe the Beighton-Horan scale.

Answer 126

**_5 or more on 9-point Beighton-Horan scale defines joint hypermobility_** * passive hyperextension of each small finger \>90° **(1 point each)** * passive abduction of each thumb to the surface of forearm **(1 point each)** * hyperextension of each knee \>10° **(1 point each)** * hyperextension of each elbow \>10° **(1 point each)** * forward flexion of trunk with palms on floor and knees fully extended **(1 point)**

Question 127

In LCP, when do you want to perform surgery (if indicated)

Answer 127

initial or fragmentation phase no positive effect has been found for containment surgery performed after initial or early fragmentation stage

Question 128

What is the best indicator of peak growth?

Answer 128

Risser 0 or closure of triradiate (occurs at same time)

Question 129

How does MRSA get its virulence and resistance?

Answer 129

_Virulence:_ * panton-valentine leukocidase (PVL) * It is released and kills WBC _Resistance:_ * mecA gene * Makes an altered penicillin-binding protein with less affinity for penicillin, giving it resistance. Normally, PBP binds penicillin into cell wall, inhibiting cell wall synthesis

Question 130

WHat joints are most commonly invovlved in JIA?

Answer 130

knee \> hand/wrist \> ankle \> hip \> C-spine

Question 131

Most common nerve palsy in SCHF?

Answer 131

AIN

Question 132

4 risk factors for DVt in pediatric psteomyelitis?

Answer 132

CRP \> 6 surgical treatment age \> 8-years-old MRSA

Question 133

7 donor options for nerve transfer in Brachial plexopathy?

Answer 133

sural intercostal spinal accessory phrenic cervical plexus contralateral C7 hypoglossal

Question 134

Name a contraindication to hemiepiphysiodesis in congenital scoliosis:

Answer 134

Segmentation defects (ie bars) b/c there is no chance for the concave side to catch-up i growth Therefore, part of the indication for hemiepeiphysiodesis is a failure of formation (hemi-vertebra - b/c when you epiphysiodese the wedged side, the concave side has the ability for catchup growth)

Question 135

Classification of tibial spine/eminence fractures

Answer 135

Meyers & McKeevers I: undisplaced II: displaced with posterior hinge III: completely displaced with no bony contact IV: comminuted

Question 136

Treatment of hip abduction contracture in myelodysplasia

Answer 136

Ober-Yount Procedure: proximal division of fascia lata and IT band release

Question 137

4 options for elbow release in arthrogryposis

Answer 137

Triceps to biceps Steindler flexorplasty Pec Major to biceps Triceps V-Y lengthening and posterior capsulectomy

Question 138

dDx of toe walking (4)

Answer 138

CP DMD Tethered Cord/spinal dysraphism Diastematomyelia CMT Unilateral Short limb causing unilateral toe walking **_Non-ortho_** Autism Schizophrenia

Question 139

DDH U/S: What is beta angle and what is normal?

Answer 139

* angle created by lines along the labrum and the ilium * normal is less than 55°

Question 140

Order of correction in ponsetti method

Answer 140

Cavus first (midfoot) Then adduction & Varus (hindfoot) Equinus last (CAVE)

Question 141

Indication for surgery in LCP?

Answer 141

Lateral pillar B, B/C, C in kids \>8 (bone age \>6) They do better with pelvic/femoral osteotomy

Question 142

Diagnosis?

Answer 142

CVT Clues: talus is vertical navicular dorsal dislocation

Question 143

You do an iliac crest biopsy to confirm diagnosis of OI. 3 positive findings?

Answer 143

decrease in cortical widths decreased cancellous bone volume increased bone remodeling

Question 144

In neuromsucular scoliosis that affects lungs, at what FVC can you safely perform surgery

Answer 144

30% and above

Question 145

You reduce a dislocated DDH hip. Development of what radiologic landmark in the next few months is considered a positive prognosticator?

Answer 145

Teardrop - not usually present in a dislocated hip.

Question 146

What is the most common type of child abuse?

Answer 146

Neglect Followed by physical \> sexual \> emotional maltreatment

Question 147

3 conditions that are commonly found with tibial hemimelia?

Answer 147

1. ectrodactyly 2. preaxial polydactyly 3. ulnar aplasia

Question 148

Risk factors for SMA syndrome in AIS surgery (7)

Answer 148

shorter (by a mean of 7.1 cm, p = 0.03) weighed less (by a mean of 11.5 kg, p = 0.001) had a lower body mass index (p = 0.003) had a greater minimal thoracic curve magnitude achieved by bending (a mean of 12 degrees greater [45 degrees for subjects with superior mesenteric artery syndrome and 33 degrees for controls], p = 0.015) had a lower percent correction of the thoracic curve on bending (a mean of 11% lower, p = 0.025) and had more lumbar lateralization (88%, compared with 61% in the control group, had a Lenke lumbar modifier of B or C instead of A, p = 0.008) _Multivariate logistic regression analysis identified:_ A staged procedure (odds ratio, 31.0) the lumbar modifier (odds ratio, 9.06) body mass index (odds ratio, 7.75) thoracic stiffness (odds ratio, 6.67) as the most predictive of the development of superior mesenteric artery syndrome (Braun et al. 2006 JBJS)

Question 149

How do you tell the difference between posteromedial bowing and calcaneovalgus foot?

Answer 149

Posteromedial bowing: apex is in distal tibia Calcaneovalgus foot: apex is at ankle joint

Question 150

Describe, in detail, the Ponseti method

Answer 150

* Corrects in order CAVE * All casts are LLC * weekly cast changes _1st cast:_ * Supinate the foot * elevate 1st ray (MT) * This will maintian all the MT heads in a row _2nd cast:_ * corrects MT adductus and hindfoot varus * abduct forefoot against counterpressure on the head of the talus (not CC joint or fibula) * This will correct MT adductus by reduction of the MT and navicular on head of talus and cuboid on calc * With further casting, the calc will evert and move under talus * Must perform abduction with the forefoot in supination and the foot in equinus so that the calc an evert and abunct under talus * Keep performing serial casts until full correction of "A" and "V" _TAL_ * In the office * Then cast for 2 more weeks * Then Denis-Brown brace (boots and bars) * These go on 24hrs a day for 3 months, then nighttime and naptime for 2-3 years

Question 151

Mainstay of treatment in duchenne muscular dystrophy? What effect does it have (3)

Answer 151

Corticosteroids * prolongs ambulation * slows scoliosis * slows deterioration of FVC

Question 152

4 indications for operative management of proximal humerus fracture (peads)?

Answer 152

Adolescent with severe deformity (\> 45 degrees or Vascular Injury Open fracture Intra-articular displacement

Question 153

Define Baumans Angle

Answer 153

Line down axis of Humerus Line through lateral condylar physis Angle between them SHould be 70-75

Question 154

Define Arthrogryposis

Answer 154

Non-progressive congenital disorder involving multiple rigid joints (usually symmetric), leading to severe limitation in motion

Question 155

What part of the growth plate does a SCFE occur in?

Answer 155

Hypertrophic zone caused by weakness in the perichondral ring

Question 156

What is the most common complication of proximal femur fracture?

Answer 156

AVN (Coxa vara and non-union also important)

Question 157

When do you brace congenital scoliosis?

Answer 157

To control supple compensatory curves

Question 158

Non-ortho associations of hemihypertrophy (2 major types)

Answer 158

_Malignant intra-abdominal tumours_ * Wilm's - most common * adrenal carcinoma * hepatoblastoma _GU abnormalities_ * medullary sponge kidney * polycystic kidney * inguinal hernia

Question 159

Best xray to ID a SCFE?

Answer 159

lateral

Question 160

Acceptable criteria for distal radius fractures

Answer 160

\<9 years old: 30 degrees dorsal angulation. Bayonette apposition \<1cm \>9 years old: 20 degrees dorsal angulation No rotational deformities

Question 161

What disorder is Botox contraindicated in?

Answer 161

Spinal muscular atrophy

Question 162

What is a Charnley WIlliams rod used for?

Answer 162

ORIF of NF tibial pseudoarthrosis

Question 163

Asymptomatic Paediatric Isthmic spondy, soccer player. Do you limit sports?

Answer 163

No Manage with close observation and no restrictions

Question 164

3 facets of first line treatment for JIA?

Answer 164

## Footnote 1. steroid injections 2. DMARDs - etanercept, rituximab, azathioprine 3. Opthamologic Exams

Question 165

Assume growth in males and females stop at what age?

Answer 165

Males: 16 Females: 14

Question 166

Treatment of dislocated hip in myelomeningocele?

Answer 166

Surgical reduction of hips in patients with spina bifida is associated with a high failure rate and therefore treatment indications are controversial. Reduction for patients with L4 level is most controversial and may be considered if unilateral. Dislocated hips in patients with L3 level and above are typically left alone.

Question 167

3 things affecting Proliferative Zone

Answer 167

Achondroplasia Multiple Hereditary Exostoses (MHE) Gigantism "A Giant Me"

Question 168

You treat a femur fracture with hip spica: 1) Where do you mould? 2) What is dreaded complication and how to prevent it? 3) What do parents need before leaving hospital?

Answer 168

1) Distal femur and buttocks 2) Compartment syndrome of the thigh, prevent by smoothing cast around politeal fossa, avoiding excessive traction and knee flexion 3) Special car seat

Question 169

8 risks for brachial plexus birth injury

Answer 169

Large of gestational age High birth weight Cephalopelvic disproportion Shoulder dystocia Forceps delivery Difficult presentation Breech position Prolonged labour

Question 170

DDH U/S: What is minimal age?

Answer 170

4-6 weeks.

Question 171

Name 3 conditions that can present with teratologic hip?

Answer 171

arthrogryposis myelomeningocele Larsen's syndrome

Question 172

3 surgical treatment options for Adolescent Blounts?

Answer 172

1. Transient lateral hemiepiphysiodesis 2. Permanent lateral hemiepiphysiodesis 3. Valgus HTO with ORIF or gradual corrrection (ilizarov or TSF)

Question 173

## Footnote 4 radiographic signs of hemophila on knee xray?

Answer 173

1. squaring of patella and femoral condyles (Jordan's sign) 2. ballooning of distal femur 3. widening of intercondylar notch 4. patella appear long and thin on lateral

Question 174

Indications for poor prognosis in bracing of AIS

Answer 174

poor in-brace correction hypokyphosis (relative contraindication) male obese noncompliant (effectiveness is dose related)

Question 175

Preferred treatment of congenital vertical talus

Answer 175

Reverse ponsetti casting + surgial reduction & pinning of talonavicular joint + TAL

Question 176

What are the stages of LCP?

Answer 176

_Initial:_ * infarction produces a smaller, sclerotic epiphysis with medial joint space widening _Fragmentation:_ * femoral head fragmentation (result of neovascular process) _Reossification:_ * Ossific nucleus undergoes reossification _Remodeling:_ * Femoral head remodels until skeletal maturity

Question 177

WHere does a Salter osteotomy hinge on?

Answer 177

Symphysis Pubis 1 cut from AIIS to sciatic notch

Question 178

How much bend do you want in a nancy nail?

Answer 178

3x canal size

Question 179

7 Physical or radiologic signs of child abuse?

Answer 179

1. long bone fxs in infant that is not yet walking 2. multiple bruises 3. multiple fxs in various stages of healing 4. corner fxs 5. posterior rib fractures 6. bucket handle fractures 7. transphyseal separation of the distal humerus 8. single transverse long bone fractures 9. skull fractures

Question 180

Manifestations of Gauchers (5)

Answer 180

_Systemic Manifestations_ * fatigue (anemia) * prolonged bleeding (thrombocytopenia) * fever, chills, sweats (infection) * seizure, developmental delay (CNS involvement) _Orthopaedic Manifestations_ * bone pain (fracture, osteomyelitis) * joint pain or contracture * bone crisis (osteonecrosis)

Question 181

3 keys to surgical treatment of CVT?

Answer 181

1. release of tight dorsal lateral structures 2. pinning of talonavicular joint 3. reconstruction of spring ligament

Question 182

What are the weak and spastic muscles in equinovarus foot?

Answer 182

Spastic: TP and TA Weak: PB, PL

Question 183

Sillence Type I and IV: a) What is the diesease? b) What is quickest way to differentiate on exam? c) Which has better prognosis? d) Inheritance patterns?

Answer 183

a) OI b) Type 1 has blue sclera c) Type 1 is milder d) Both AD Bonus: DIvided into A and B based on tooth invovlement. Type 1 more likely to lose hearing.

Question 184

3 blocks to reduction in proximal humerus reduction

Answer 184

long head biceps capsule periosteum

Question 185

DDH U/S: What is alpha angle and what is normal?

Answer 185

* angle created by lines along the bony acetabulum and the ilium * normal is greater than 60°

Question 186

4 ortho and 2 nonortho associations with Friedrich's ataxia

Answer 186

Ortho * cavovarus foot: often rigid * scoliosis * ataxia * areflexia (but with positive plantar response) Non-ortho * Cardiomyopathy * nystagmus

Question 187

paeds patient with femur fracture. \>100lbs. Result with flexible IM nail?

Answer 187

Increased risk of complications such as nonunion

Question 188

Indications for MRI in scoliosis case

Answer 188

atypical curve pattern * left thoracic curve * short angular curve * apical kyphosis rapid progression Any child excessive kyphosis structural abnormalities neurologic symptoms or pain foot deformities asymmetric abdominal reflexes a syrinx is associated with abnormal abdominal reflexes and a curve without significant rotation

Question 189

Othopaedic Manifestations of CMT?

Answer 189

Scoliosis Pes Cavus Hammertoes Hip dysplasia

Question 190

Explain how the Silfverskiöld test works!

Answer 190

1. Improved ankle dorsiflexion with knee flexed = gastrocnemius tightness 2. Equivalent ankle dorsiflexion with knee flexion and extension= achilles tightness

Question 191

newborn comes in with congenital dislocation of knee and DDH, which do you treat first and why?

Answer 191

Knee b/c you can't get a pavlik on with a dislocated knee

Question 192

DDH U/S: What is maximal age (for usefulness)?

Answer 192

4-6 months (i.e. use xray)

Question 193

Name (9) associated conditions with fibular deficiency

Answer 193

Anteromedial tibial bowing Ankle instability: ball & socket ankle Equinovalgus foot deformity Tarsal coalition (50%) Absent lateral rays Femoral abnormalities * PFFD * Coxa Vara Cruciate ligament deficiency Genu valgum: Due to lateral femoral condyle hypoplasia Significant leg shortening discrepancy * Shortening of femur and/or tibia

Question 194

How much does a leg grow in a year and where does the growth come from?

Answer 194

23 mm /year * proximal femur - 3 mm / yr (1/8 in) * distal femur - 9 mm / yr (3/8 in) * proximal tibia - 6 mm / yr (1/4 in) * distal tibia - 5 mm / yr (3/16 in)

Question 195

Conditions that may cause SCFE?

Answer 195

* obesity (most important) * hypothyroidism (labs show elevated TSH) * osteodystrophy of chronic renal failure * Rickets

Question 196

I say absent clavicles, you say:

Answer 196

Cleidocranial dysplasia failure of intramembranous ossifciation leads to failure of formation of midline structures ie failre of pubis to ossify

Question 197

2 techniques to reduce a radial head fracture

Answer 197

## Footnote **_Patterson maneuver_** 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 **_Israeli technique_** pronate the supinated forearm while the elbow is flexed to 90° and direct pressure stabilizes the radial head

Question 198

Best surgical appraoch to CP HV?

Answer 198

1st MTP fusion +/- Akin

Question 199

Risk factors for birth fractures

Answer 199

Vaginal deliveries breech presentation prolonged labor macrosomia (\>4.5 kg)

Question 200

3 types of CP gait

Answer 200

toe walking crouched stiff-knee

Question 201

in SCHF with median sensory symptoms, what is the major complication that is now at increased risk/most commonly to be missed?

Answer 201

Compartment syndrome They cannot give the regular symptoms (pain) of compartment syndrome so the risk goes up

Question 202

Why would you do a squatting skyline xray?

Answer 202

To diagnose symptomatic bipartate. Compare with static and if there is separation then there may be a fracture of the fibrocartlaginous connection.

Question 203

What pulleys need to be released in childresn' trigger finger?

Answer 203

A2 & A3

Question 204

Best x-ray view for lateral condyle fracture?

Answer 204

internal oblique

Question 205

List the normal progression of leg angulation:

Answer 205

Born: max varus 1.5 years: neutral (actually just under 2 years, but 1.5 easier to remember) 3 years: max valgus 7 years: physiologic valgus as per Selenius (0 --\> 1.5 --\> 3 --\> 6)

Question 206

Most common inheritance pattern of hereditary motor sensory neuropathy (HMSN). Name 2 other types

Answer 206

AD most most common So counsel parents and patients on risks of future generations can be AR and X-linked

Question 207

What percentage growth of the humerus comes from the proximal growth plate?

Answer 207

80%

Question 208

Principals for bladder extrophy repair?

Answer 208

Multidiosciplinary Gen surg + Urologist stage I: primary closure of bladder (newborn) stage II: epispadias repair in males (1-2 y/o) stage III: bladder neck reconstructions (4 y/o) pelvic osteotomies may be performed at any stage of process

Question 209

Contraindication to treatment of paediatric femur fracture (open physes)

Answer 209

Piriformis start femoral nail b/c of increased risk of AVN superior retinacular vessels of MFCA are at risk

Question 210

When evaluating function of CP kid, what are 6 areas to ask about?

Answer 210

1. nutritional status 2. respiratory function 3. sitting/standing posture 4. upper and lower extremities function 5. communication skills 6. acuity of hearing and vision

Question 211

What is the strongest independent risk factor for septic arthritis in paeds?

Answer 211

CRP \>20mg/L (even though it's not on the Kocher criteria)

Question 212

Physiologic Classification of CP

Answer 212

Spastic Athetoid Ataxic Mixed (Usually Spastic/Athetoid) Hypotonic

Question 213

4 technical considerations for fixation of pediatric distal femur fracture?

Answer 213

* avoid multiple attempts at reduction * avoid physis with hardware if possible * if physis must be crossed (SH I and SH II with small Thurston-Holland fragments), use smooth k-wires * SH II fracture, if possible, should be fixed with lag screws across the metaphyseal segment avoiding the physis * postoperatively follow closely to monitor for deformity

Question 214

Bado Classification

Answer 214

Monteggia Fractures Dislocation goes where the apex is (THINK the apex pushes the radial head out) I: apex anterior proximal ulnar fracutre with anterior dislocation of radial head II: Apex posterior ulna fracture with posterior dislocation of the radial head III: Apex lateral ulna fracture with lateral dislocatio nof the radial head IV: BBFF with anterior dislocation of radial head

Question 215

Most common cause of septic hip in neonates?

Answer 215

Group B Strep (one of the practice mcq's says that this is only for community kids, if they are aditted to nicu with multiple lines and stuff then it is Staph. Aureus)

Question 216

Two indications for endocrine workup in a SCFE?

Answer 216

* child is \< 10 years * weight is \< 50th percentile

Question 217

Stretching is a reccomendation for flexible flatfoot. If it is flexible wtf are you stretching?

Answer 217

Tight heel cord

Question 218

How do you immobilize a Galleazzi fracture?

Answer 218

In supination

Question 219

3 indications for CRPP of pediatric distal radius fracture.

Answer 219

1. Failure of cast management 2. SH 1 or 2 with NV compromise (reduces the need for constricting cast) 3. Fractures which required reduction under anesthesia (ie. failed ER reduction)

Question 220

What must you do for workup in patient with congenital scoliosis?

Answer 220

Echo: cardiac defects - 10% Renal ultrasound and GU workup - genitourinary defects - 25% MRI - spinal cord malformations

Question 221

What is normal range for IR and ER of hip?

Answer 221

IR = 20-60 ER = 30-60

Question 222

What protein is elevated in 75% of fetus in second trimester if they have spina bifida?

Answer 222

alpha-fetoprotein (AFP)

Question 223

What is the sudden cause of death in a patient with FGFR3 mutation

Answer 223

FOramen magnum stenosis

Question 224

4 radiographic findings in OI

Answer 224

thin cortices generalized osteopenia saber shins skull radiographs reveal wormian bones Metaphyseal bands (bisphosphonate use)

Question 225

Surgical treatment of flexible cavovarus foot? (4 elements)

Answer 225

1. plantar fascia release 2. Tib Post transfer 3. 1st ray dorsiflexion osteotomy 4. TAL (says orthobullets, but this is wrong as achilles is already loose in cavovarus - incr calc pitch - as in SPORC2016)

Question 226

What part of acetabulum is deficient in neuromuscular hip dysplasia?

Answer 226

posterior superior

Question 227

Describe an NF1 patient's risk of cancer

Answer 227

Increased risk of benign and maligant tumours, including: melanoma leukemia rhabdomyosarcoma pheochromococytoma carcinoma pancreatic endocrine tumours astrocytoma

Question 228

LLD Principals: a) b) 2-5 cm c) \> 5 cm

Answer 228

a) b) 2-5 cm = shorten long side c) \> 5 cm = lengthen short side +/- shorten long side

Question 229

What does Hilgenreiner's-Epipyseal angle predict? What are the values?

Answer 229

Predicts natural history of coxa vara Normal: Will resolve spontaneously if Will need surgery if \>60

Question 230

Most common long term sequelae of brachial plexus birth injuries

Answer 230

Glenoid retroversion Due to IR of shoulder due to Erb's palsy

Question 231

At what level of SPina Bifida is hip dislocation most common and why?

Answer 231

L3 - uopposed hip flexion and adduction

Question 232

8 injury patterns suspicious for child abuse

Answer 232

Long bone fractures in infant who is not walking Multiple bruises Multiple fractures in various stages of healing Corner fractures: High specificity for child abuse Posterior rib fractures Bucket handle fractures (Same as corner fractures, Avulsed bone fragment is seen en face as a bucket handle) Transphyseal separation of the distal humerus Skull fracture

Question 233

RIsk of AVN with paediatric hip factures

Answer 233

Type I: 80-100% Type II: 50% Type III: 30% Type IV: 10%

Question 234

PFFD: 4 indications for limb lengthening with the goal of ambulation without prosthesis.

Answer 234

1. predicated limb length discrepancy of \>20cm 2. stable hip and functional foot 3. femoral length \>50% of opposite side 4. femoral head present (Aiken classifications A & B)

Question 235

What is the primary treatment for Gauchers?

Answer 235

IV enzyme replacement therapy. Not effective in type 2. Medications end in -glucerase. Also consider bone marrow transplant

Question 236

4 conditions associated with CVT?

Answer 236

1. myelodysplasia (common) 2. arthrogryposis 3. diastematomyelia 4. chromosomal abnormalities High association with genetic or neuromuscular disorder (50%)

Question 237

Compare infantile and adolescent Blounts

Answer 237

_Infantile_ * pathologic genu varum in children 0-3 years of age * more common * deformity rarely from femur * typically bilateral _Adolescent Blount's_ * pathologic genu varum in children \> 10 years of age * more likely to have femoral deformity * less common * less severe * more likely to be unilateral

Question 238

dDx for anterolateral bowing (2)

Answer 238

NF tibial deficiency

Question 239

3 associated endocrine disorders with SCFE

Answer 239

Hypothyroidism Osteodystrohpy of CRF Growth HOrmone Treatment

Question 240

Where should pins be placed and why, for pediatirc femur ex-fix?

Answer 240

Laterally To reduce quads scarring.

Question 241

Treatment for lateral pillar A/B in kid less than 8 (bone age less than 6)

Answer 241

Nonoperative They do well regardless

Question 242

Start point for retrograde femoral nancy nails?

Answer 242

2-2.5 cm proximal to distal physsi

Question 243

What is the angle of Drennan and what is it used for?

Answer 243

**_Metaphyseal-diaphyseal angle (Drennan)_** * **Infantile Blounts** * angle between line connecting metaphyseal beaks and a line perpendicular to the longitudinal axis of the tibia * \>16 ° is considered abnormal and has a 95% chance of progression * Less than or equal to 10 has a 95% chance of self-resolution

Question 244

Name the syndrome associated with polyostotic fibrous dysplasia. Name the other associated abnormalities

Answer 244

McCune Albright * Polyostotic fibrous dysplasia * unilateral cafe-au-lait spots (Coast of Maine) * Endorcine pathlogies affecting hormone excess (precocious puberty, hyperthyroidism, cushings) * ± scoliosis Do testing to rule these things out

Question 245

Name 4 life-threatening perioperative complications with MPS

Answer 245

post-extubation stridor (may require emegent re-intubation, consider pre-procedure trach) cardiac death Stroke acute pulmonary edema \*Recommendation is to consult anesthesia, cardio and otolaryngology prior to surgery

Question 246

Diagnosis?

Answer 246

Sacral agenesis

Question 247

2 xray views to assess clubfoot?

Answer 247

dorsiflexion lateral (Turco view) AP Look for parallelism, low talocalcaneal angle, and negative talus-first metatarsal angle

Question 248

Treatment algorithm of femur fractures in paeds:

Answer 248

* pavlik or early spica casting _7m - 5 years:_ * * \>2-3cm shortening: traction with delayed spica casting or ORIF _6-11 years:_ * length stable: flexible IM nails * Length unstable: ORIF (plates) vs. ex-fix _Approaching skeletal maturity (\>11 years)_ * length stable or * Length unstable or \>100lbs: IM nail with lateral start point * Length unstable in proximal or distal end: ORIF plate/screws

Question 249

Plantarflexion lateral of two cases with rockerbottom sole deformity. What is the diagnosis in A and B?

Answer 249

A = Congenital oblique talus B = Congenital vertical talus (Difference is that Oblique talus corrects the talonavicular joint with stress plantarflexion lateral)

Question 250

Name the physeal zone associated with: Metaphyseal "corner fracture" in child abuse Scurvy

Answer 250

Primary Spongiosa

Question 251

What is the biggest risk factor for re-fracture after surgical treatment of pediatric femur fracture?

Answer 251

Use of ex-fix (Especially with transverse or short oblique fractures)

Question 252

4 manifestations of CMT?

Answer 252

1. pes cavus 2. hammer toes 3. hip dysplasia 4. scoliosis

Question 253

What operative intervention is contraindcated in CP patient with crouched gait

Answer 253

Isolated heel cored lengthening will *worsen* hip and knee flexion (you'll tip them over even more) Must do multiple releases at one (heel, knee, hip)

Question 254

Diagnosis?

Answer 254

**_Equinovalgus_** i.e. CP foot _Clues:_ Inferior tilt of talus Loss of medial arch

Question 255

When do lateral condyle pins come out after ORPP of lateral condyle fracture

Answer 255

6 weeks

Question 256

What are physical exam findings consistant with equinovarus foot?

Answer 256

1. intoed gait 2. inverted heel (tib post) 3. supinated forefoot (tib ant) 4. callous and pain along lateral border

Question 257

Treamtnet of CP hips

Answer 257

_Adductor and psoas release ± abduction bracing_ * Kids \< 4 & Reimer's index \>40% _Proximal femoral osteotmy & soft tissue release_ * kids \> 4 OR Reimer's index \> 60% _Abduction osteotomy or girdlestone_ * Chronic painful dislocation in GMFCS 5 _Salvage acetabular procedure (Chiari, shelf)_ * Skeletally mature with subluxation/dislocation

Question 258

DDX for Genu Valgum?

Answer 258

* bilateral genu valgum * physiologic * renal osteodystrophy (renal rickets) * skeletal dysplasia * Morquio syndrome * spondyloepiphyseal dysplasia * chondroctodermal dysplasia * unilateral genu valgum * physeal injury from trauma, infection, or vascular insult * proximal metaphyseal tibia fracture * benign tumors * fibrous dysplasia * osteochondromas * Ollier's disease

Question 259

3 poor prognostic indicators for subtalar coalition 1 contraindication to surgery

Answer 259

Coalitions \>50% the size of the posterior facet Hindfoot valgus \>16 degrees Narrowing of the posterior TC facet Contraindicaton: massive coalition: 100% of middle + 50% of posterior facet

Question 260

Risk factors for SCFE (7)

Answer 260

Obese (single greatest risk factor) Males (3 : 2) African Americans Pacific islanders Period of rapid growth Femoral retroversion History of previous radiation therapy to femoral head region

Question 261

5 Ortho manifestations of OI (there are many)

Answer 261

Bone fragility & fractures * Bone heals normally initially but does not remodel Genu varum Ligamentous laxity Short stature Scoliosis Codfish vertebrae (compression fracture) Basilar invagination Olecranon apophyseal avulsion fracture

Question 262

4 dDx for leg bowing in kids?

Answer 262

Physiologic Blount's disease Osteogenesis imperfecta Rickets/osteomalacia Syndromic

Question 263

Diagnosis

Answer 263

Bisphosphonates on OI Results in metaphyseal banding at each dosing

Question 264

Name 4 social risk factors for child abuse

Answer 264

recent job loss of parent children with disabilities (cerebral palsy, premature) step children Premature child

Question 265

3 indications for ORIF in pediatric distal femur fracture?

Answer 265

1. open fracture 2. failed closed reduction of SH1 or SH2 1. perisoteum usually infolded in these case 3. SH 3 - 4 in order to get anatomic reduction of joint surface

Question 266

dDx of knee or thigh pain paediatric patient:

Answer 266

Knee pathology Hip pathology * SCFE * LCP * Septic hip * Transient synovitis hip \*knee/thigh pain mandates a workup for SCFE

Question 267

What degree of scoliosis do pulmonary and cardiopulmonary complications happen in the immature and mature patient?

Answer 267

Pulmonary: 60 deg Cardiopulmonary: 90 deg Mature: 100 deg (Agabegi Jaaos 2015)

Question 268

Name 6 syndromes/diseases assocated with basilar invagination

Answer 268

Klippel-Feil Osteogenesis imperfecta Morquio syndrome achondroplasia spondyloepiphyseal dysplasia occipitocervical synostosis

Question 269

3 ultrasonographic measurements in DDH

Answer 269

Alpha angle (N: \>60) Beta angle (N: 55) Line extending from ilium should bisect femoral head Femoral head should be bisected by a line drawn down the ilium Pubofemoral distance * If there is asymmetry in pubofemoral distance \>1.5mm, then side with larger pubofemoral distance is dysplasic (JAAOS 2014)

Question 270

X-ray findings of clubfoot

Answer 270

Dorsiflexion lateral (Turco) * hindfoot parallelism between talus and calcaneus (talocalcaneal angle \<35 deg) AP: * Kite's talocalcaneal angle \<20 degrees (N = 20-40) * Talus - 1st MT angle \<5 degrees

Question 271

minimally invasive technique to treat congen. vertical talus: describe steps

Answer 271

1. reverse ponseti casting until TNJ reduced (LLC) 2. pin TNJ 3. perc TAL (like clubfoot) 4. LLC x 5 weeks (one cast change) 5. cast off, pin out, AFO until 2yo as per Dobbs et al. 2006 JBJS

Question 272

List 5 features associated with in-toeing that necessitate further workup:

Answer 272

Pain LLD Progressive deformity Family history of rickets, skeletal dysplasias, mucopolysaccharidoses Limb rotational profiles 2 standard deviations outside the normal

Question 273

dDx for global hypotonia (2). How do you tell the difference?

Answer 273

_SMA:_ * absent DTR * fasciculations (including tongue) _Duchnne muscular dystrophy_ * present DTRs Also: Emery-Dreifuss dystrophy limb girdle dystrohpy Guillain-Barre syndrome

Question 274

Management of unilateral pars defect at L4 that has failed conservative management.

Answer 274

Pars Repair Indiated at L4 and above L5: must fuse in-situ

Question 275

What x-ray is this? What is the diagnosis?

Answer 275

45 degree oblique Calcaneonavicular coalition

Question 276

What is the anatagonist of peroneus Longus?

Answer 276

Tibialis anterior

Question 277

Treatment algorithm for tibial deficiency What is is based on?

Answer 277

Based on function of knee extensor mechanism _No active knee extension:_ * knee disarticulation _active knee extension:_ * synostosis of fibula to remaining tibia + syme amputation _Ankle diastasis_ * Syme/boyd amputation DO NOT do a Brown's Centralization procedure. High failure rate

Question 278

What dysplasia has metaphyseal changes of the tubular bones with normal epiphysis?

Answer 278

metaphyseal chondrodysplasia

Question 279

A SCHF patient has an ulnar nerve palsy. What fracture type is it likely to be?

Answer 279

Flexion type Most common nerve palsy after flexion type injury is ulnar

Question 280

Best pin configuration for SCHF?

Answer 280

Lateral divergent pins (2 vs 3)

Question 281

How do you tell if the tib post or tib ant is the driving force in an equinovarus foot?

Answer 281

Confusion test in a seated position, get patient to perform resisted hip flexion If toes dorsiflex and supinate, then likely TA is the driving force

Question 282

4 indications for ORIF in BBFF?

Answer 282

Open fractures Refractures Failure of nonoperative management BBFF kids \>13

Question 283

3 non-ortho manifestations of Ehlors Danlos?

Answer 283

1. mitral valve prolapse 2. aortic root dilatation 3. gastroparesis

Question 284

5 associated conditions of external tibial torsion:

Answer 284

Miserable malalignment syndrome Osgood Schlatter disease Osteochondritis dessicans Early degenerative joint disease Neuromustular conditions

Question 285

6 Dural Ectasia associations

Answer 285

Marfan syndrome NF1 Ehlers-Danlos Achondroplasia Ank spond idiopathic

Question 286

Can a Klippel Feil patient play contact sports?

Answer 286

No if they have fusion of C3 and above

Question 287

Longitudinal traction in young kid. Arm held in elbow extension and forarm pronation. What is the injury pathomechanism?

Answer 287

Inteprosition of annular ligament in radiocapitellar joint (nursemaid's elbow)

Question 288

When do you need to excise a physeal bar in a growth arrest following distal femur fracture?

Answer 288

Indicated when deformity is present with a physeal bar of \<50% and at least 2 years or 2 cm of growth remaining

Question 289

Indications for pinning distal radius fracture in paeds (7)

Answer 289

- Ipsilateral distal humerus fracture - Excessive soft tissue swelling - Inability to obtain a reduction - SH I/II with NV compromise - SH III/IV fracture displaced - Inability to maintain an adequate reduction (i.e. loss of reduction) - Ones that need general anesthesia to reduce - After 2nd attempt at closed reduction

Question 290

2 spinal deformities with OI

Answer 290

Scoliosis basilar invagination (NOT AAI)

Question 291

What is Friedrichs Ataxia?

Answer 291

Neuronopathy in the dorsal root ganglia, accompanied by the loss of peripheral sensory nerve fibers and the degeneration of the posterior columns of the spinal cord.

Question 292

Kid with septic hip: what position will the hip be held in?

Answer 292

Flexion, abduction, ER

Question 293

Specifically for the distal radius, when do you want to operate to excise a distal radius physeal bar?

Answer 293

If \>2**mm** (not cm) of growth remains progressive deformity symptomatic

Question 294

3 advantages of nancy nailing over ORIF

Answer 294

1. shorter surgical time than ORIF 2. less blood loss than ORIF 3. equal union rates, radial bow and rotation as ORIF

Question 295

What aspect of deformity will not remodel in femoral mal-unions?

Answer 295

Rotation

Question 296

What two physical exam findings are most useful to guide maanagement in fibular hemimelia?

Answer 296

1. LLD 2. Is the foot stable and plantigrade?

Question 297

Where does congenital pseudoarthrosis of the clavicle almost always happen? What is the exception?

Answer 297

Right middle 1/3 situs inversus is the exception

Question 298

What is the major source of blood to the physis?

Answer 298

Perichondrial artery

Question 299

Criteria/algorithm for septic arthritis vs. transient synovitis

Answer 299

History of fever (T \> 38.5C) Non-weight-bearing ESR \> 40 mm/h WBC \> 12,000 cells/mm3. T _The probability of septic arthritis is_ * 0.2% with zero predictors * 3.0% with one predictor * 40.0% with two predictors * 93.1% with three predictors * 99.6% with four predictors.

Question 300

2 indications for CR and hip spica for DDH?

Answer 300

1. Age 6-18 months 2. Failed Pavlik

Question 301

6 Blocks to reduction in DDH:

Answer 301

ligamentum teres capsule transverse acetabular ligament inverted labrum Psoas Pulvinar

Question 302

3 associations with tarsal coalition:

Answer 302

Fibular hemimelia Apert's PFFD "People with tarsal coalition masturbate a lot: FAP FAP FAP"

Question 303

4 peri-operative considerations if operating on a Gauchers?

Answer 303

1. Pre-operative enzyme replacement 2. Hydration to reduce risk of bone crisis 3. Increased risk of infection 4. Increased bleeding risk

Question 304

Management of equinovarus foot

Answer 304

Flexible: AFO, casting, botox tendon transfer, either: TA/TP split transfer TA to cuboid TP to brevis depending on what's tight Rigid: lateral closing wedge calc ostetomy

Question 305

4 treatment options for fibular hemi-melia and their indications?

Answer 305

1. **Shoe lift** ( 2. **Contralateral epiphysiodesis** (LLD 3. **Limb lengthening** (projected LLD less than 30%, stable plantigrade foot, must remove fibular anlange) 4. **AMputation** (nonfunction foot or LLD \> 30%) - do at 1 year of age

Question 306

Diagnosis? Give 1 dDx

Answer 306

Multiple Epiphyseal Dysplasia Classic for MED to present as "bilateral" Legg-Calve-Perthes disease

Question 307

In a patient with Sprengel's, what is the most likely associated abnormality to expect?

Answer 307

1. Scoliosis 2. Klippel-Feil (JAAOS) see chart

Question 308

2 main surgical options for tibial hemimelia?

Answer 308

1) No ext mechanism/ absent tibia = knee disarticulation 2) Proximal tibia present with intact extensor emchanism = tibiofibular synostosis with modified Syme amputation

Question 309

Two MSK findings associated with bladder extrophy?

Answer 309

1. acetabuli are ~12 degrees externally rotated 1. without pubis to tether the anterior ring, the posterior elements externally rotate 2. gait shows an external foot progression

Question 310

Treatment for posteromedial bowing? What must you monitor for with your treatment plan?

Answer 310

Non-operative - will spontaneously resolve in 5-7 years Must watch for LLD (common complication)

Question 311

How is CP gait desribed/classificed

Answer 311

_Sagittal plane_ * Jump * Crouch * Stiff knee _Transverse plane_ * IR * ER * Neutral _Coronal plane:_ * Genu varum * Genu valgum * hip adduction

Question 312

4 operative indications for proximal humerus fracture in paeds

Answer 312

Severely displaced fracture in kid age \>11 (Neer-Horowitz 3/4) Open fracture at any age Vascular injury Intra-articular displacement

Question 313

Next step if Pavlik harness treatment fails?

Answer 313

Convert to abduction brace for 3-4 weeks.

Question 314

Zone of injury for proximal humerus fractures?

Answer 314

Zone of provisional calcification (part of hypertrophic) However may go through several Spares proliferative JAAOS 2015

Question 315

Indications (3) & Contraindications(3) for Centralization procedure in Radial clubhand. What age should it be done at?

Answer 315

Indications: * Good elbow ROM * Good biceps function * Young patient Contraindications: * Older patient with good function * Patients with elbow extension contracture who rely on radial deviation * proximate terminal condition Should be done at 6-2 months of age

Question 316

The patella vascular supply is composed of _____ branches which stem from which 3 larger arteries?

Answer 316

6 small branches ( the geniculates plus anertior tibial recurrant) Popliteal, Superficial femoral and Anterior Tibial

Question 317

What are the 2 cardinal manifestations of Marfan's syndrome?

Answer 317

Aortic root dilatation Superior lens dislocation If both are present, do not need genetic testing - therefore test for both **(Echo and optho consult)**

Question 318

5 things affecting Hypertrohpic Zone of growth plate

Answer 318

SCFE MED SED Schmids Fractures (SH1) Ricekts Enchondromas

Question 319

What are the 5 physeal zones?

Answer 319

1. Reserve 2. Proliferative 3. Hypertrophic 4. Primary Spongiosa 5. Secondary Spongiosa

Question 320

Risk factor for AVN of the hip

Answer 320

Trauma Steroid use Radiation

Question 321

Summarize treatment for COxa Vara in dwarves in one sentence.

Answer 321

Valgus intertrochanteric osteotomy for a neck shaft angle of less than 100 degrees.

Question 322

8 radiographic findings in Blount's disease and one physical finding

Answer 322

Varus focused at proximal tibia Severe deformity (\>16 degrees MDA of Drennan) Bilateral bowing (Can be asymmetric even though it's bilateral) Progressing deformity Sharp angular deformity Lateral thrust gait Lateral subluxation of tibia Metaphyseal beaking

Question 323

How long do you wear a Pavlik?

Answer 323

23 h/day for 6 weeks then ween over 6 weeks.

Question 324

Flat top talus is a complication of what casting method?

Answer 324

Ponseti

Question 325

Main vascular concern in tibial tibercle fracture?

Answer 325

Tear of recurrent anterior tibial artery May assess with CT-A if concerned Leads to compartment syndrome

Question 326

Spinal manifestations of diastrohpic dysplasia

Answer 326

AAI Cervical kyphosis TL kyphoscoliosis Rarely needs treatment

Question 327

What is the cuase of a fishtail deformity of the distal humerus?

Answer 327

lateral trochlear ossification center AVN

Question 328

Name the physeal zone associated with: Achondroplasia Gigantism MHE

Answer 328

Proliferative

Question 329

what are the orthopaedic issues in NF? (What type of music do NF patients listen to?)

Answer 329

**_Extreme SKA_** _**1. Extrem**ity deformities_ Hemihypertrophy Pseudoartrhosis AL Bowing **2. S**coliosis **3. K**yphosis **4. A**AI

Question 330

What is the role of enzyme replacement and bone marrow transplant in muccopolysaccharidosis?

Answer 330

Intravenous enzyme replacement therapy and hematopoetic stem cell transplantation (HSCT) improve cardiac, respiratory and somatic function, but they do not penetrate osteocartilaginous tissue and thus have no impact on skeletal abnormalities.

Question 331

Toronto score (Active Movement Scale) of what is an indication for surgery in brachial plexus injury?

Answer 331

\<4 \>4 = activity against gravty (Different UE functions are graded on a scale and added together)

Question 332

General order of closure of the distal tibial growth plate?

Answer 332

Central, then medial, then lateral This is why you get a Tillaux fracture, b/c it is the last part of fuse

Question 333

Most common cause of septic hip in adolescents? Treatment?

Answer 333

Neisseria gonorroeae High dose penicillin (does not need OR)

Question 334

Non-ortho manifestations of DMD

Answer 334

cardiomyopathy static encephalopathy Respiratory issues

Question 335

Surgical option in resistant vertical talus?

Answer 335

talectomy

Question 336

Radiographic classification of subacute paediatric OM:

Answer 336

types IA and IB show lucency type II is a metaphyseal lesion with cortical bone loss type III is a diaphyseal lesion type IV shows onion skinning type V is an epiphyseal lesion type VI is a spinal lesion

Question 337

Classification of lateral condyle fracture and treatment algorithm?

Answer 337

I: undisplaced (\<2mm) (nonop) II: 2-4mm displaced (CRPP vs ORPP) III: \>4mm displaced (ORIF or ORPP)

Question 338

4 surgical treatment options for congenital pseudoarthrosis of tibia (anterolateral bowing)

Answer 338

IM Nail with bone graft Free (vascularized) fibular graft Ilizarov frame Amputation

Question 339

dDx for septic hip? (3)

Answer 339

OM Psoas abscess Transient synovitis

Question 340

What 3 spinal deformity conditions are bracing CONTRAindicated in?

Answer 340

Spina Bifida SCI Muscular dystrophy

Question 341

4 joints with intra-articular metaphyseal cortex

Answer 341

hip, shoulder, elbow, and ankle

Question 342

3 exam findings consistant with tarsal coalition?

Answer 342

1. flattening of arch 2. valgus hindfoot 3. peroneal spasticity

Question 343

Congenital rib anomalies (ie fused ribs) have what association with congenital scoli?

Answer 343

occur on the concave side of the curve makes sense They (in and of themselves) have no effect on curve size or rate of progression (They are not talking about phase 2 ribs here, a la Mehta angle)

Question 344

Name the physeal zone associated with: Renal SCFE

Answer 344

Secondary Spongiosa

Question 345

Medical treatment of bone crisis for sickel cell?

Answer 345

hydroxyurea

Question 346

In congenital vertical talus what can you use as a proxy to the navicular (b/c it hasn't ossified yet) to determine diagnosis

Answer 346

1st MT

Question 347

3 causes of painful flatfoot.

Answer 347

1. tarsal coalition (sinus tarsi pain) 2. congenital vertical talus (rocker bottom foot) 3. accessory navicular (focal pain at navicular)

Question 348

Congenital knee dislocation Give 3 syndromic associations and 3 orthopaedic associations

Answer 348

_Syndromic:_ * Larsen's * Meningomyelocoele * Arthrogryposis _Orthopaedic_ * hip dysplasia * clubfoot * metatarsus adductus

Question 349

Three conditions associated with DDH to check for on physical exam?

Answer 349

congenital muscular torticollis (20%) metatarsus adductus (10%) congenital knee dislocation

Question 350

**_SMA treatment:_** 1. Hip Dislocations 2. Scoliosis 3. Hip Contractures

Answer 350

1. Leave dislocated - recurrance is high and usually asymptomatic 2. PSF to pelvis 3. Deal with hip contractures before scoiliosis correction in order to ensure they can sit in wheel chair. Otherwise leave them alone.

Question 351

What happens if the GT apophysis is prematurely arrested?

Answer 351

hip will go into valgus | (medial side keeps growing)

Question 352

What does the VilleFranche classification describe?

Answer 352

Ehlors Danlos **_Villefranche Classification (1998)_** Classical - **Type I** (gravis) and **Type II** (mitis) **COL5A1** or **COL5A2** mutation There are several other sub types

Question 353

Diagnosis What is their physical exam going to be like? What other test do you order?

Answer 353

Congenital radio-ulnar synostosis No pronation or supination on exam, with hand fixed in variable amounts of prosupination Order a chromosomal analysis as they commonly have duplicated sex chromosomes

Question 354

Flat top talus Almost pathognomonic for what?

Answer 354

Clubfoot treatment complication

Question 355

What is Little Leaguer's Shoulder?

Answer 355

SH 1 injury of the proximal humerus Overuse injury

Question 356

What is Arthroereisis. What is the fusion version of this?

Answer 356

Sinus tarsi pin/screw to jack up the hindfoot out of valgus Grice procedure involves doing this with ICBG

Question 357

4 signs of residual DDH in kid \> 3 months

Answer 357

Limited hip abduction Pelvic obliquity + galeazzi Trendelenburg gait

Question 358

BBFF - initial management?

Answer 358

SAC Found to have lower remanipulation rates Lower pain/swelling at 1 and 7 days post reduction

Question 359

Early investigations for Larsens?

Answer 359

1) Spine - AP/Lat - look for Carvical Hyphosis 2) Hip imaging - dislocation

Question 360

What is the natural history of OI fractures with age?

Answer 360

The symptoms improve with age

Question 361

Criteria for Septic Hip

Answer 361

Kocher: Fever \>38.5C WBC \>12,000mm^3 ESR \>40mm/h Refusal to weight bear on affected side 3/4 = 93% chance of septic arthritis

Question 362

4 complications of Lateral Condyle fracture (operative)

Answer 362

AVN Malunion/Non-union --\> cubitus valgus Tardy Ulnar Nerve Palsy Lateral spurring

Question 363

Why is ASF indicated in spina bifida related scoliosis?

Answer 363

dysplastic posterior elements that may impair posterior fusion

Question 364

Why do you wait to get x-rays in polydactyly patients (foot)

Answer 364

To allow full ossification of phalanges and plan surgery Surgical ablation typically done at 9-12 months of age

Question 365

What are the 4 deformities of clubfoot?

Answer 365

1. midfoot Cavus (tight intrinsics, FHL, FDL) 2. forefoot Adductus (tight tibialis posterior) 3. hindfoot Varus (tight tendoachilles, tibialis posterior, tibialis anterior) 4. hindfoot Equinus (tight tendoachilles)

Question 366

4 conditions associated with PFFD?

Answer 366

1. fibular hemimelia (50%) 2. ACL deficiency 3. coxa vara 4. knee contractures

Question 367

Predictors of poor outcome in paediatric septic hip (4)

Answer 367

Age Associated OM Hip joint (vs knee) Delay \> 4 days until treatment (JAAOS)

Question 368

What is contraindicated in the treatment of atlanto-occipital dissociation in paeds?

Answer 368

Halo + traction Risks displacement of injured occipitocervical joint (JAAOS 2014)

Question 369

3 options to treat IR contractures fo the shoulder

Answer 369

Lat dorsi and teres major tendon transfer Pec major and subscap lengthening proximal humerus ER osteotomy

Question 370

4 manifestations of osteopetrosis?

Answer 370

1. Appendicular fractures 2. Osteomyelitis 3. Cranial nerve palsies 4. Coxa vara

Question 371

What antibiotic should you avoid in paeds?

Answer 371

Cipro (fluorquinolone) b/c of risk of cartilage damage

Question 372

What level myelomeningocoele has a higher risk of hip dislcoation?

Answer 372

L3 + adductors, no abductors = higher risk of dislocation Marginal ambulators

Question 373

Risk of recurrence/refracture of pseudoarthrosis of tibia?

Answer 373

50%, even after initial union

Question 374

Treatment for calcaneovalgus foot?

Answer 374

observation and parental stretching

Question 375

RUNX2/CBFA1 mutation

Answer 375

cleidocranial dysplasia They have to RUNX2 b/c they can't use their arms (no clavicles)

Question 376

Signs of Dystrophic Curve (7)

Answer 376

Gibbous deformity: short segment kyphoscoliosis Rib penciling Intra-canal ribs Vertebral body scalloping Dystrophic pedicles Dural ectasia Intraspinal neurofibroma

Question 377

What is the weakest zone of the growth plate?

Answer 377

Hypertrophic zone

Question 378

Rib-Vertebral angle distance (RVAD/Mehta Angle) of what is at a higher risk of progression?

Answer 378

RVAD \>20

Question 379

What is the Pirani score?

Answer 379

Determines number of casts needed & likelhood of relapse Made up of 2 scores: Hind foot contracture score (HCFS): * Posterior crease * Empty heel * Rigid equinus Mid foot contracture score (MFCS): * Medial crease * Curvature of lateral border * Position of head of talus Each one scored 0, 0.5 or 1 Score \>4 = 4 or more casts Hindfoot score \>2.5 has a 72% chance of needing a tenotomy

Question 380

What is the most common cause of early death in Morquio?

Answer 380

Spinal cord stenosis JAAOS 2013

Question 381

What are some complications specific to operative treatment of club foot?

Answer 381

* **residual cavus** * result of placement of navicular in dorsally subluxed position * **pes planus** * results from overcorrection * **undercorrection** * **intoeing gait** * **osteonecrosis of talus** * results from vascular insult to talus resulting in osteonecrosis and collapse * **dorsal bunion** * caused by dorsiflexed first metatarsal (FHB and abductor hallucis overpull secondary to weak plantar flexion) and overactivity of anterior tibialis * treat with capsulotomy, FHL lengthening, and FHB flexor to extensor transfer at MTP joint

Question 382

Describe the deformity in congenital vertical talus

Answer 382

_Rockerbottom foot:_ Hindfoot: equinovalgus (everted & lateralized) Midfoot: rigid dorsiflexion Forefoot: abducted & dorsiflexed

Question 383

dDx for cavovarus foot (5)

Answer 383

Charcot-Marie-Tooth Freidreich's ataxia Cerebral palsy Polio spinal cord lesions

Question 384

4 indications for osteotomy in Infantile Blounts? What osteotomy would you do?

Answer 384

1. Stage I and II in children \> 3 years 2. Stage III, IV, V, VI in children 3. failure of brace treatment 4. metaphyseal-diaphyseal angles \> 20 degrees **_proximal tibia/fibula valgus osteotomy_**

Question 385

5 causes of hemihypertrophy

Answer 385

idiopathic neurofibromatosis beckwith-weidemann syndrome Klippel-trenauney syndrome proteus syndrome

Question 386

Major cause of death for patient with Friedrich's Ataxia

Answer 386

cardiomyopathy Must workup with Echo

Question 387

Defect in diastrophic dysplasia?

Answer 387

DTDST gene (SLC26A2) codes for diastrophic dysplasia sulfate transporter gene on chromosome 5

Question 388

How do you estimate blood volume in a kid?

Answer 388

75 - 80 mL/kg

Question 389

Most common complication after distal femoral physeal injury

Answer 389

LLD/growth arrest

Question 390

8 orthopedic manifestations of Downs?

Answer 390

1. generalized ligamentous laxity and hypotonia 2. C1-2 instability 3. hip subluxation and dislocation 4. patellofemoral instability and dislocation 5. scoliosis & spondylolithesis 6. pes planus 7. primus varus 8. SCFE

Question 391

In clubfoot release, what has the greatest influence on functional outcomes?

Answer 391

Extent of soft tissue release

Question 392

Surgical option for pathologic genu valgum: a) with significant growth remianing b) near the end or done growing

Answer 392

a) Medial hemiepiphysiodesis b) Distal femoral closing wedge osteotomy + release of peroneal nerve

Question 393

First surgical option for resistant Clubfoot?

Answer 393

posteromedial soft tissue release and tendon lengthening

Question 394

3 INDICATIONS for nerve repair/grafting in Brachial plexopathy?

Answer 394

complete flail arm at 1 month of age Horner's syndrome at 1 month of age lack of antigravity biceps function between 3-6 months of age

Question 395

Common injuries associated with TL spine trauma in paeds

Answer 395

Same as in adults: GI: Small bowel most common Lung contusion/pneumothorax Head injury

Question 396

Acceptable alignment distal radius fracture

Answer 396

\>9: 20 degrees dorsal angulation. No bayonet. No rotation in either case

Question 397

My **PAL** Adrian eats **HAM** on his **CPM** machine. How does this help you pass the exam?

Answer 397

PAL = **P**seudoarthrosis is **AL** bowing HAM = **H**emimelia is **AM** bowing CPM = **C**alcaneovalgus is **PM** bowing

Question 398

Last elbow ossification center fo FUSE?

Answer 398

Medial epicondyle age 17

Question 399

What is P and how does it help evaluate DDH?

Answer 399

Perkins Line Femoral head ossification should be medial to this line

Question 400

Paediatric proximal humerus fracture classification:

Answer 400

Neer-Horowitz Type I: nondisplaced (\<5mm) Type II: displaced \<1/3 of shaft width Type III: \>1/3 but less than 2/3 of width of shaft displaced Type IV: \>2/3 of width of shaft displaced

Question 401

Main blood supply to femoral head in kids \>4

Answer 401

Medial femoral circumflex artery via: posterosuperior lateral epiphyseal branch & posterior inferior retinacular branch

Question 402

Normal alpha angle (DDH)

Answer 402

\>60 deg angle of bony ilium and acetabulum

Question 403

3 factors (other than age) that differentiate adolescent Blounts from Infantile Blounts?

Answer 403

1. More likely to be unilateral 2. More association with LLD 3. Can have MCL laxity 4. No metaphyseal beaking

Question 404

Name 4 sources of blood supply to the femoral head:

Answer 404

MFCA (main after 4 years) via posterosuperior lateral epiphyseal branch & posterior inferior retinacular branch LFCA ( Artery of ligamentum teres ( Metaphyseal vessels

Question 405

Lateral Pillar Classifiation: (LCP)

Answer 405

Group A: lateral pillar maintains full height Group B: Lateral pillar maintains \>50% height Group B/C: Lateral pillar narrowed (2-3mm) or poorly ossified with ~50% height Group C: Lateral pillar maintains

Question 406

What type of SCHF is not associated with cubitus varus?

Answer 406

Flexion type It goes into cubitus valgus

Question 407

What is the pediatric equivalent of Lauge Hansen classification?

Answer 407

Diaz / Tachdjian SAD, SER, PER, SPF (Supination plantar flexion) (compare Lauge-Hansen which is SAD, SER, PER, PAB)

Question 408

What investigations must you do in a patient with Klippel Feil?

Answer 408

Echo (cardiac manifestations) Renal ultrasound (renal aplasia)

Question 409

Acceptable Alignment BBFF?

Answer 409

15 degrees, rotation \>45 degrees. bayonet apposition ok \>10: \>10 degrees, rotation \>30 degrees New idea says NO rotation can be tolerated both bone forearm fractures in children\> 13 is an indication for surgery

Question 410

What is a common block to reduction of tibial eminence fractures?

Answer 410

Medial meniscus

Question 411

Treatment of oblique talus?

Answer 411

Treatment typically consists of observation and shoe inserts Some require surgical pinning of the talonavicular joint and Achilles lengthening for persistent subluxation

Question 412

What single finding dictates how often slit lamp exams are necessary in JIA?

Answer 412

Presence of ANA If negative: Every 6 months If positive: Every 4 months

Question 413

Best test for looking at cross-sectional imaging of tarsal coalition Best test to look for fibrous coalition

Answer 413

CT best to look at cross-sectional imging MRI best to look at fibrous coalitions

Question 414

Non-ortho manifesataions of SMA

Answer 414

Resp - Major cause of morbidity and mortality. Consult them GI - Common: consult them (swallowing problems)

Question 415

In SCFE, the screw should be placed in what relationship to the intertrochanteric line to avoid what complication?

Answer 415

lateral to the intertrochanteric line To avoid screw impingement

Question 416

How does a patient with SCFE clinically present?

Answer 416

Pain Obligatory ER

Question 417

What motion is most limited in patient with Sprengel;s?

Answer 417

Abduction also Forward flexion

Question 418

7 indicators of poor prognosis with LCP

Answer 418

Age (bone age) \> 8 (bone age 6) years at presentation Female Decreased hip ROM (decreased abduction) Gage sign: radiolucency in the shape of a V in the lateral portion of the epiphysis Calcification lateral to the epiphysis Lateral subluxation of the femoral head Horizontal physis Metaphyseal cysts

Question 419

4 negative prognostic indicators of pediatirc spetic arthritis?

Answer 419

age associated osteomyelitis hip joint (versus knee) delay \>4 days until presentation

Question 420

What disease causes neuronopathy in the dorsal root ganglia, accompanied by the loss of peripheral sensory nerve fibers?

Answer 420

Frei**_d_**rich's Ataxia "d" is for dorsal root ganglia

Question 421

What is the managmeent algorithm of Fibular deficiency?

Answer 421

Based on Birch classification and stability and level of foot & ankle function Nonfunctional foot: amputation _Functional foot and:_ _LLD_ * Epiphysiodesis of contralateral leg _LLD 10-30%: lengthening or amputation_ * limb lengthening procedure ±epiphysiodesis of contralateral leg _LLD \> 30%: amputation_

Question 422

4 surgical indications for coxa-vara

Answer 422

Trendelenburg gait + Hilgenreiner-epiphyseal angle beween 45-59 degrees Progression of coxa vara on serial x-rays HE angle \> 60 femoral neck shaft angle

Question 423

What is the most important test a patient with JIA needs to have?

Answer 423

Regular slit-lamp examination by ophthalmologist. Iridoclyclitis (uveitis) can lead to rapid blindness

Question 424

Kid has \>40 deg of ER (\>3 SD) at age 12 and functionally limiting. ER due to external tibial torsion. Plan?

Answer 424

Supramalleolar derotational osteotomy \> proximal tibial osteotomy More complications with proximal

Question 425

Spinal manifestations of Achondroplasia:

Answer 425

Foramen magnum stenosis (NOT c-spine instability) Kyphosis Lumbar stenosis

Question 426

General treatment principle for Downs Spine

Answer 426

Nonoperative management if possible - high complication rates with surgery

Question 427

4 dDx for growth plate widening in kids:

Answer 427

Rickets Scurvy Schmid's metaphyseal chondrodysplasia Delayed maturation (illness) Endocrine pathology * Excess GH * Hyperparathyroidism * Hypothryoidism

Question 428

Outcomes of CRPP vs. ORIF in BBFF: (3)

Answer 428

Shorter OR time than ORIF Less blood loss than ORIF Equal union rates, radial bow and rotation as ORIF

Question 429

Acceptable reduction criteria required for femoral shaft fractures in peds?

Answer 429

* Less than 10 degrees varus/valgus * Less than 20 degrees AP * no more than 2cm of shortening or 10° of rotational malalignment

Question 430

What is is the predictable angular deformity with pediatric tibial fractures treated with LLC?

Answer 430

Varus if fibula intact. Valgus if fibula also broken.

Question 431

4 indications for open reduction of pediatric elbow dislocation?

Answer 431

1. open dislocation 2. inability to acheive closed reduction 3. incarcerated fragment - usually medial epicondyle or tip of coronoid 4. seves instability following closed reduction

Question 432

Differential for unilateral valgus (3)

Answer 432

_Proximal metaphyseal tibial fracture (Cozen's)_ _UnilateralPhyseal injury_ * Trauma * Infection * Vascular insult _Benign tumour_ * Fibrous dysplasia * Osteochondroma * Ollier's disease

Question 433

4 indications for open reduction of pediatric traumatic hip doslocation?

Answer 433

1. nonconcentric reduction 2. intra-articular fragment 3. unstable acetabular rim fracture 4. irreducible by closed means

Question 434

Indications for fusion in DMD scoliosis

Answer 434

FVC rapid progression poor response to steroid non-ambulatory status (b/c they progress quickly)

Question 435

When do SCHF pins come out?

Answer 435

3-4 weeks

Question 436

General Principals of Ilizarov technique?

Answer 436

Distraction osteogenesis (Ilizarov principles) * initiation * perform osteotomy and place fixator * metaphyseal corticotomy to preserve medullary canal and blood supply * distraction * wait 5-7 days then begin distraction * distract ~ 1 mm/day * following distraction keep fixator on for as many days as you lengthened

Question 437

What view is best for looking at accessory navicular?

Answer 437

**_External_** oblique

Question 438

Derotational femoral osteotomy for increased anteversion: 1) What are the 2 hard indications? 2) Where is it done? 3) How much do you de-rotate?

Answer 438

1) Less than 10° of external rotation on exam in an older child (\>8-10 yrs) 2) Intertrochanteric 3) (IR-ER)/2

Question 439

What are the American Academy of Pediatric's recommendations on kids and car safety (where they sit)?

Answer 439

(1) rear‐facing car safety seats for infants up to 2 years of age (2) forward‐facing car safety seats for children through 4 years of age (3) belt‐positioning booster seats for children through 8 years of age (4) lap‐and‐shoulder seat belts for all who have outgrown booster seats (5) the requirement that all children aged

Question 440

WHat is the spine deformity in multiple epiphyseal dysplasia

Answer 440

None

Question 441

Name the physeal zone associated with: * Gaucher's * diastrophic dysplasia

Answer 441

Reserve

Question 442

How do you clinically differentiate SMA vs. DMD

Answer 442

SMA has ABSENT deep tendon reflexes, while they are mantained in DMD SMA has fasciculations

Question 443

What is the best treatment for Sever's disease?

Answer 443

Calcaneal apophysitis Best is achilles stretching - may decrease recurrence No role for operative management

Question 444

What are "Thumb" and "Wrist" signs associated with?

Answer 444

_Marfans_ The characteristic Walker-Murdoch (wrist sign) is represented by full overlap of the distal phalanges of the thumb and fifth finger when wrapped around the contralateral wrist, whereas the Steinberg (thumb sign) is present when the distal phalanx of the thumb fully extends beyond the ulnar border of the hand when folded across the palm.

Question 445

3 treatments for a hemophilac knee? i.e. for * chronic synovitis * recurrent hemarthrosis * joint destruction

Answer 445

1. Surgical Synovectomy 2. Radioactive Synovectomy 3. TKR

Question 446

Name 3 tumours specific to NF1

Answer 446

Optic glioma Neurofibroma Neurofibrosarcoma (aka Malignent peripheral nerve sheath tumours)

Question 447

4 predictors of complications when doind a nancy nail?

Answer 447

1. \> 25 mm nail protruding from nail 2. Age \> 11 years 3. Weight \> 45 kg 4. Fracture is very proximal, distal or comminuted

Question 448

Describe the anatomy of CVT

Answer 448

Dorsal structures are tight (navicular dorsally dislocated) Rocketbottom foot * hindfoot equinovalgus * rigid midfoot dorsiflexion * forefoot abducted and dorsiflexed Tib post is tight

Question 449

What are the upper limits of normal for valgum and IM distance in a patient over the age of 7?

Answer 449

1. valgum \< 12 degrees 2. IM distance \< 8cm

Question 450

Name 3 general surgical intervnetions you can do for tibial hemimelia

Answer 450

* knee disarticulation followed by prosthestic fitting * tibiofibular synostosis with modified Syme amputation * Syme/Boyd amputation * Brown Procedure (centralization of fibula under femur) (no longer recommended due to high failure rate)

Question 451

radiographic definition of vertical vs. oblique talus

Answer 451

Forced plantarflexion lateral Meary's angle \>35 is congenital vertical talus

Question 452

What life-threatening allergy do most myelodysplastic patients have? What is the mechanism?

Answer 452

IgE mediate allergy to latex severe anaphylaxis Present in 20-70%

Question 453

Risk factors for congenital kyphosis progression (4)

Answer 453

Type I (failure of formation) Type III (mixed failure of formation and failure of segmentation) Immaturity Curve \> 40 deg

Question 454

What is the only lower limb deficiency with a defined inheritance pattern? What is the inheritance pattern and what must you do once diagnosis is made?

Answer 454

Tibial deficiency AD Must counsel parents of risk with further children

Question 455

What motion is most deficient in Sprengels?

Answer 455

Abduction

Question 456

List proportionate Dwarfism

Answer 456

Mucopolysaccharidosis * Hunter * Hurler * San Fillipo * Morquios' Cleidocranial dysplasia

Question 457

3 indications for operative percutaneous reduction of radial head fractures in peads?

Answer 457

\> 30° of residual angulation 3-4 mm of translation

Question 458

Principals of Proximal tibia/fibula valgus osteotomy for Blounts?

Answer 458

1. overcorrect into 10-15° of valgus because medial physeal growth abnormalities persist 2. distal segment is fixed in valgus, external rotation and lateral translation 3. temporary lateral physeal growth arrest with staples or plates can be used 4. include a bar resection (epiphysiolysis) when a physeal bar is present (Langenskiold V and VI) 5. consider hemiepiphysiodesis if bar \> 50% 6. medial tibial plateau elevation is required at time of osteotomy if significant depression is present 7. consider prophylactic anterior compartment fasciotomy

Question 459

Radial Longitudinal Deficiency/Radial CLubhand associated with what conditions (5)

Answer 459

TAR: thrombocytopenia absent radius - check plt Fanconi Anemia - check Hb VACTERL VATER Holt-Oram - congenital cardiac abnormalities

Question 460

Who a I? Multiple congenital joint dislocations ligamentous laxity abnormal facies:

Answer 460

Larsen Syndrome

Question 461

Ponsetti Method: be careful to avoid what during first cast?

Answer 461

pronation of forefoot must SUPINATE so that it lines up with the hindfoot

Question 462

5 Characteristics of trigger thumb

Answer 462

25% bilateral Associated with FPL nodule (Notta's nodule) Associated with thickening of FPL tendon sheath A1 pulley release has high recurrence rates Can resolve spontaneously, especially if dx early (before 3 years)

Question 463

In OI, fractures heal normally/abnormally?

Answer 463

Normally They *remodel* abnormally

Question 464

What is H and how does it help evaluate DDH?

Answer 464

Hilgenreiners Line A normal head should be below it.

Question 465

Highest cause of morbidity and mortality in paediatric fracutres overall and from MSK causes

Answer 465

Overall: CNS injuries (TBI) of MSK injuries: Spine

Question 466

3 radiographic signs not involving the fibula associated with fibular hemi-melia?

Answer 466

1. tibial spines are underdeveloped 2. intercondylar notch is shallow 3. ball and socket ankle joint

Question 467

dDx for abnormal dystrophin gene. How do you tell the difference?

Answer 467

DMD: complete absence Becker's: abnormal

Question 468

Treatment of tibial spine fractures by classification Name 2 blocks to reduction

Answer 468

Meyers & McKeevers I: nonp II: CR + Cast vs. operative III: operative IV: operative Blocks to reduction: meniscus intermeniscal ligament

Question 469

Why doe CMT pts get claw toes?

Answer 469

Increased toe extensor recruitment due to weak Tib Ant, this combined with weak foot intrisics result in claw toes.

Question 470

SCHF with cold, pulseless hand. Management?

Answer 470

Immediate CR & PP Open is not first step

Question 471

What is best position in Pavlik and what do the straps do?

Answer 471

1. **Flexion** 90-100° (controlled by **anterior** straps) 2. **Abduction** of 50° (controlled by **posterior** straps)

Question 472

Treatment for a GMFCS V CP patient with pain sitting in their wheelchair

Answer 472

Proximal femoral resection | (controversial)

Question 473

Describe Birch Classification for fibular hemimelia

Answer 473

_Type I: Functional foot_ try to save foot Ia: 0-5% inequality Ib: 6-10% Ic: 11-30% Id: \>30% _Type II: Nonfunctional_ IIa: functional UE: amputation IIb: nonfunctional UE: consider salvage

Question 474

Most common radiographic spinal finding in Down syndrome:

Answer 474

Atlanto-occipital instability (17%) AAI is second most common at 11%

Question 475

Classification of CP Hips & Treatment

Answer 475

_Hip at risk:_ * Hip abduction * Partial uncovering of femoral head * Remier's index * Treatment: Prevent dislocation: Adductor release ± psoas release, Avoid obturator neurectomy _Hip Subluxation_ * Reimer's index \>33% * Disrupted Shenton's line * Treatment: Adductor tenotomy if abduction tight, Proximal femur and pelvic osteotomy if significant dysplasia * Outcome: Reimer's \>60-70%, hips will dislocate _Spastic dislocation_ * Frankly dislocated hip * Reimer's index \>100% * Treatment: Open reduction with varus derotational osteotomy, ± femoral shortening & pelvic osteotomy _Windswept hips_ * Abduction of one hip with adduction of contralateral one * Treatment: Brace adducted hip ± tenotomy, Release abduction contracture of abducted hip

Question 476

dDx for torticollis

Answer 476

Congenital muscular torticollis AARD Grisel's disease Klippel-Feil

Question 477

4 Syndromes affecting Reserve Zone

Answer 477

Gaucher's Diastrophic dysplasia Pseudoachondroplasia Kniest "Kontio Panics with Dinner Gratuities"

Question 478

SMN gene association

Answer 478

SMN = Survival Motor Neuron = gene mutation for Spinal muscular atrophy

Question 479

4 complications of radial head fractures Which 2 are related to open reduction?

Answer 479

* Decreased range of motion * loss of pronation more common than supination * Radial head overgrowth * Osteonecrosis * up to 70% of cases occur with open reduction * Synostosis * occurs in cases of open reduction with extensive dissection or delayed treatment

Question 480

Manifestations of Achondroplasia

Answer 480

Rhizomelic dwarfism Affects Proliferative Zone of Growth plate frontal bossing Foramen magnum stenosis Kyphosis Lumbar stenosis Decreasing interpedicular distance from L1-L5 Champagne glass pelvis Genu Varum Trident Hands V-shaped Physis

Question 481

Best 2 tests for septic hip?

Answer 481

T \> 38.5 CRP \> 2

Question 482

Infetion of staph aureus with what gene encoding is associated what more complex infections?

Answer 482

PVL (Panton-Valentine leukocidin) +

Question 483

What are the normal values of Staheli Rotational Profile?

Answer 483

_femoral anteversion:_ * IR = ER = 30-60 degrees _tibial torsion:_ * TFA: 0 to -10 degrees ER * Transmalleolar: 0 to -10 degrees ER _Foot_ * Heel bisector between 2nd/3rd webspace _Foot Progression Angle_ * -5 to 20 degrees ER

Question 484

Kocher Criteria for Septic Hip

Answer 484

T \> 38.5C WBC \> 12 ESR \> 40 Refusal to weight bear 2/4: 40% chance 3/4: 93% chance 4/4: 99% chance of septic hip

Question 485

What is the radiographic definition of Blount's disease? Of Physiologic varus?

Answer 485

Metaphyseal-diaphyseal angle of Drennan Blounts \>16 degrees Physiologic

Question 486

Poor nutritional status (weight \< 5th percentile) is associated with what post-op complications in paediatrics?

Answer 486

Increased complications: * infections * length of intubation * longer hospital stays Make sure patient has adequate nutrition pre-op (albumin \> 3.5g/dL) and consider G-tube if not

Question 487

7 characteristics of Infantile Blounts on workup?

Answer 487

1. varus focused at proximal tibia 2. severe deformity 3. asymmetric bowing 4. progressing deformity 5. sharp angular deformity 6. lateral thrust during gait 7. metaphyseal beaking 8. different than physiologic bowing which shows a symmetric flaring of the tibia and femur

Question 488

Spine changes in NF1

Answer 488

Vertebral scalloping Rib penciling TP spindling Vertebral wedging Paravertebral soft-tissue mass Short curve with severe apical rotation intervertebral foraminal enlargement Wideened interpediculate distance Dysplastic pedicles

Question 489

Patient post-SCFE c/o functional limitations. He wants a femoral osteotomy. What kind will you do?

Answer 489

Proximal femoral derotational osteotomy Create: flexion, valgus, IR Imhauser osteotomy (intertrochanteric osteotomy)

Question 490

How does a positive coleman block test effect treatment of cavo-varus foot?

Answer 490

Rigid hindfoot varus. Do: **calcaneal valgus producing osteotomy**

Question 491

Name 5 non-ortho manifestations of OI

Answer 491

Blue sclera Hearing loss Brownish opalescent teeth (dentiogenesis imperfecta) Wormian skull bones (puzzle piece intrasutural skull bones) Increased risk of malignant hyperthermia

Question 492

3 yo presents with a 3 wk hx of back pain, fever and unable to ambulate. His CRP and WBC are elevated. You are consulted by his pediatrician. Radiographs reveal narrow disc space and endplate erosions. What should you do next?

Answer 492

Empiric Abx NOT MRI - b/c of risks of conscious sedation with MRI/biopsy, just start abx. This was an MCQ

Question 493

What is an Evans osteotomy and what deformity does it correct?

Answer 493

Corrects hindfoot valgus. (calcaneal lateral column lengthening osteotomy)

Question 494

Medical treatment for AD osteopetrosis?

Answer 494

interferon gamma-1 beta

Question 495

What differentiates the McClune Albright Cafe au Lait spots from those of NF1?

Answer 495

NF1 = smooth "coast of California" borders McCune-Albright syndrome = rough "coast of Maine" spots

Question 496

What are the main components of spondyloepophyseal dysplasia? (5)

Answer 496

_Cervical myelpathy_ * Due to AAI _Kyphoscoliosis_ _Respiratory difficulty_ * Due to respiratory insufficiency secondary to thoracic dysplasia _Problems with vision_ * Due to myopai or retinal detachment _Hip pain_ * Due to coxa vara _Decreased walking distance_ * Due to poor muscular endurance and skeletal defomrities

Question 497

What CP medication decreases acetylcholine levels in the synaptic cleft by blocking the presynaptic release of acetylcholine peripherally?

Answer 497

Botulinum toxin A

Question 498

Indication for physeal bridge resection? When would you do it with an osteotomy?

Answer 498

\>2 years or 2cm of growth remaining in a bar less than 50% of physis (except distal radius - less than 2mm of growth) +osteotomy if \>10-20 degress of angulation (as body will not remodel that)

Question 499

Treatment options for Delbet 1--4?

Answer 499

* Type 1 b is always ORIF * Types I-III can be treated with: **0-3yrs of age =** smooth wires +/- spica **4-10yrs of age =** 4.5-6.5 mm cannulated screws **\>10 yrs old =** 6.5-7.3mm cannulated screws * Type IV fractures are treated with pediatric or adult DHS depending on age. **\*\*\* Consider Capsular decompression to reduce pressure, usually for type 2s, however this is controversial**

Question 500

Indications for OR with medial epicondyle fracture? (4) Preferred fixation?

Answer 500

Intra-articular entrapment of medial epicondyle (absolute) _Relative_ * \>5-15mm displacement * fracture associated with elbow dislocation * ulnar nerve dysfunction * fracture of the dominant arm in a throwing athlete or weight bearing extremity of an athlete Preferred fixation: single cannulated screw via ORIF

Question 501

What are the primary surgical options for the three types of CP gait?

Answer 501

**_Toe walker_** - Gastrocs release vs. TAl dependant on Silverskiold test **_Crouch Walker_** - multiple simultaneous soft tissue releases (hip, knee, ankle) **_Stiff Knee_** - transfer of distal rectus femoris tendon

Question 502

DMD Scoliosis 1) 1 surgical indication that is unique compared to AIS 2) To pelvis?

Answer 502

1) respiratory function 2) Controversial

Question 503

What are Woodward and Green procedures used for and what is the difference?

Answer 503

Sprengels Woodward involves detachement of medial scapular muscles from their origin on the spinous process and re-attachemnt after inferior migration of the scapula. Green is similar except you detach the muscular insertions off of the medial border instead. \*\*\* Remember to consider clavicel osteotomy to reduce the chance of nerv einjury.

Question 504

**_Larsens Surgical Treatment:_** 1. Cervical Kyphosis 2. Hip Dislocation 3. Knee Dislocation

Answer 504

1. PSF (neuro intact) or P/ASF if neuor deficits 2. Open reduction - especially if unilateral (bilateral often fails/controversial) 3. open reduction with femoral shortening and collateral ligament excision

Question 505

3 spinal manifestations of Achondroplasia?

Answer 505

Thoracokyphosis Lumbar Stenosis Foramen Magnum/Upper Cervical Stenosis

Question 506

IN ponsetti method, when do you do an achilles tenotomy?

Answer 506

Prior to application of the final cast

Question 507

8 features of congenitally dislocated radial head

Answer 507

Bilateral Hypoplastic capitellum Convex radial head Associated with other congenital anomalies Lack of traumatic history Difficult to reduce Posteriorly dislocated Assicated with bowing and shortening of the radius

Question 508

3 radiograhpic findings of SCFE

Answer 508

Klein's line: will no intersect with femoral head Epiphysiolysis: growht plate widening or lucency Metaphyseal blanch sign of Steel: blurring of proximal femoral metaphysis

Question 509

7 reasons that in-toeing requires further investigations?

Answer 509

Developmental delay prematurity Pain LLD Progressive deformity Family history of rickets, skeletal dysplasias, mucopolysaccharidoses Limb rotational profiles 2 standard deviations outside the normal Abnormal physical exam (Dwarf, syndromic, abnormal neuro exam (ie reflexes) 1.

Question 510

Most commonly used meidcation for treatment of OI?

Answer 510

Bishphosphonates increase cortical thickness, fewer fracture.

Question 511

5 risk factors for LCP

Answer 511

Positive family history Low birth weight Abnormal birth presentation Second hand smoke exposure Asian, Inuit, central european descent

Question 512

# Define the types of dwarfism and give an example: Rhizomelic Mesomelic Acromelig Micromelic

Answer 512

Rhizomelic (roots): proximal bones are short (humerus, femur): achondroplasia Mesomelic (middle): middle bones short (forearm, tibia): Leri-Weill/Madelungs Acromelic (end): bones of hands and feet short: ?? Micromelic: entire lembs are short: Pituitary deficiency

Question 513

How much shortening is acceptable in femoral shaft fractures and why?

Answer 513

2cm b/c if accounts for anticipated overgrowth during healing of 1-2cm

Question 514

Managmenet and timing of treatment of congenital vertical talus?

Answer 514

Start with casting to stretch dorsal structures followed by surgery in almost all cases OR before 27 months for best results

Question 515

How do you immobilize Bado I, III fractures?

Answer 515

Immobilize in 110 degrees of flexion for Bado I, III to relax biceps and tighten IoM

Question 516

In what direction does the ankle physis close and what part closes last?

Answer 516

central (first) medial posterior anterolateral (last)

Question 517

Most common complication from tibial tubercle fracture?

Answer 517

Recurvatum physeal arrest anteriorly while posterior continues to grow --\> decreased tibial slope

Question 518

2 main presentations and gene association of multiple epiphyseal dysplasia?

Answer 518

COMP (cartilage oligometric matrix protein) causes mutation in COL9A1, A2 & A3 2 main presentations * dwarfism * Early OA

Question 519

Describe the boney deformities of clubfoot?

Answer 519

* talar neck is medially and plantarly deviated * calcaneus is in varus and rotated medially around talus * navicular and cuboid are displaced medially

Question 520

Surgical treatment for CMT claw toes?

Answer 520

Jones procedure (transfers the extensor tendons of the great and lesser toes through the bone into the metatarsal neck)

Question 521

What are ideal factor levels in a hemophiliac for : 1. acute hematomas 2. acute hemarthrosis and soft tissue surgery 3. skeletal surgery

Answer 521

* acute hematomas * increase blood factor levels to 30% * acute hemarthrosis and soft tissue surgery * increase blood factor levels to 40-50% * skeletal surgery * increase blood factor levels to 100% for first week following surgery then maintain at \> 50% for second week following surgery

Question 522

Most common 2 complications after fixation of femoral neck fracture in paeds:

Answer 522

1. AVN 2. coxa vara

Question 523

6 dDx for metaphyseal flaring:

Answer 523

Fibrous dysplasia Storage diseases Rickets Anemia Chronic lead posioning bone dysplasia

Question 524

When can you determine the Herring stage in LCP?

Answer 524

Fragmentation stage (~6 months after symptoms start)

Question 525

How can you be fooled into thinking someone doesnt have an achilles contracture? (I.e a false negative)

Answer 525

* the hindfoot valgus deformity must be manually corrected first before testing for achilles contracture * a valgus heel can mask an equinus contracture by allowing a shortened path for the achilles

Question 526

Presence of what is the main finding that differentiates NF2 from NF1?

Answer 526

bilateral vestibular schwannomas \*\* Also the DONT get scoliosis

Question 527

4 indications for OR in pediatric pelvis fracture? (radiographic)

Answer 527

Type 1 Avulsion Injuries with \> 2-3 cm displacement Type II Iliac Wing Fractures with \> 2-3 cm displacement Type III pelvic ring with displaced acetabular fractures \> 2mm Type IV pelvic ring with instability and \> 2 cm pelvic ring displacement

Question 528

is dynamic supination caused by operative or non-operative treatment of clubfoot? How do you treat it?

Answer 528

a) **NON-OPERATIVE** b) TA tendon transfer - full thickness

Question 529

When do children achieve 1/2 of the final leg length?

Answer 529

* girls at age 3 * boys at age 4

Question 530

MRSA infection have a (lower/higher) chance of needing surgery and (more/less) operations until cure?

Answer 530

Higher More

Question 531

Name 2 surgical options for treatment of Sprengel's

Answer 531

Woodward's Green Leibovic Bellman's Mears

Question 532

Delbet Classification

Answer 532

Paediatric femoral neck fractures Ia: transphyseal (epiphysis) no displacement Ib: transphyseal (epiphysis) displacement II: femoral neck (transcervical) III: Basicervical IV: Intertrochanteric

Question 533

How much fill of the femoral canal do you want with nancy nails?

Answer 533

80% (Therefore each nail should be diameter x 0.8 / 2) (i.e. canal is 1 cm, then use 2 x 4 mm nails)

Question 534

By definition, what three characteristics have to be present for JIA diagnosis?

Answer 534

1. Persistant inflammatory arthritis 2. \> 6 weeks 3. Patient \< 16 years

Question 535

Congenital hallux varus is associated with what?

Answer 535

Polydactyly

Question 536

What did Sillence classify?

Answer 536

OI

Question 537

Compared to closed reduction, open reduction of radial head/neck fractures has what 3 outcomes?

Answer 537

Greater loss of motion Increased rates of AVN Increased rates of synostosis

Question 538

Upper extremity contractures in CP

Answer 538

Shoulder IR Elbow flexion Forearm pronation Wrist flexion Thumb in palm deformity: * Flexed MCP * Extended IP Finger-flexion deformity Swan neck

Question 539

What is the consequence of lateral spurring post lateral condyle fracture?

Answer 539

None - it has no effect on outcomes

Question 540

Best radiographic way to follow CP hips

Answer 540

Reimer's Migration Index

Question 541

Name the physeal zone associated with: SCFE (not renal) Rickets (provisional calcification zone) Enchondromas Mucopolysacharide disease SED MED

Answer 541

hypertropic

Question 542

Classification for PFFD

Answer 542

Aiken A: * Femoral head: Present * Acetabulum: normal B: * Femoral head: Present * Acetabulum: Dysplastic C: * Femoral head: Absent * Acetabulum: severly dysplastic D: * Femoral head: Absent * Acetabulum: Absent

Question 543

General principle in treatment of gait disorders in CP with respect to contractures.

Answer 543

Flexible contracture: AFO Rigid contracture: OR

Question 544

WHat is Pavlik's disease?

Answer 544

erosion of pelvis or superior acetabulum and precention of the development of a posterior acetabular wall

Question 545

Classic presentation of diastrophic dysplasia?

Answer 545

Rhizomelic dwarfism Hitchiker's thumb cauliflower ears (80%) Cleft-palate (60%)

Question 546

What is the normal progression of coronal knee alignment in childhood?

Answer 546

Varum under 2 Neutral at 14 months Peak valgus at 3 years Physiologic valgus at 7 years

Question 547

What is the muscle imbalance in dynamic supination post Ponsetti Casting?

Answer 547

Tib ant overpull in relation to peroneal muscles

Question 548

Why do a Rhizotomy?

Answer 548

CP patients with ambulation inhibited by LE spacticity. Def'n: neurosurgical resection of dorsal rootlets that do not show a myographic or clinical response to stimulation

Question 549

Name 6 associated abnormalities with Sprengel's

Answer 549

**Scoliosis (most common)** **Klipper-Feil** **Spina bifida** **omovertebral bone** **rib anomalies** **clavicular abnormalities** humeral shortening foot abnormalities

Question 550

Goal for coxa vara correction in paeds

Answer 550

Valgus overcorrection of the femoral neck shaft angle to a Hilgenreiner-epiphyseal angle correct neck shaft angle correct leg length discrepancy correct hip anteversion/retroversion re-establish abductor muscle tensioning

Question 551

Name the 3 (Mehta) indicators of progression in congenital idiopathic scoliosis

Answer 551

Cobb \>20 degrees Phase 2 rib Rib-vertebral angle difference (RVAD) \>20 Thoracolumbar curve

Question 552

What Risser stage correspnds to the fastest growth spurt?

Answer 552

Risser 0

Question 553

In what condition is a full-length semi-rigid insole orthotic with a depression for the first ray and a lateral wedge useful?

Answer 553

Mild cavo-varus foot

Question 554

Risk of contralateral SCFE in otherwise healthy kid?

Answer 554

50% (10-60%) this is asking the risk of *contralateral* SCFE, not *bilateral* SCFE Bilateral is 20% in normal, 80% in endorinopathy

Question 555

Treatment for dynamic supination post clubfoot

Answer 555

Tib ant transfer to lateral cuneiform

Question 556

Three methods of predicting LLD?

Answer 556

1. Green-Anderson tables 1. uses extremity length for a given age 2. Moseley straight line graph 1. improves on Green-Anderson method by reformatting data in a graph form 2. accounts for differences between skeletal and chronologic age 3. minimizes error 3. Multiplier method

Question 557

3 favourable and 5 poor prognostic indicators for obstetric brachial plexus injury

Answer 557

_Favourable_: * Erb's palsy (Upper trunk C5-6) * Complete recovery possible if biceps and deltoids are M1 (contraction) by 2 months * Early twitch biceps activity suggests favourable outcome _Poor_ * Lack of biceps function by 3 months * Preganglionic injuries (worst prognosis) * Horner's syndrome: * Intermediate palsy: C5-7 involvement * Klumpke's palsy: C8-T1 lower root

Question 558

Approxiate amount of growth from each of the leg physes per year:

Answer 558

proximal femur - 3 mm / yr distal femur - 9 mm / yr proximal tibia - 6 mm / yr distal tibia - 5 mm / yr

Question 559

6 associated ortho conditions with arthrogryposis

Answer 559

Upper extremity deformity Hip subluxation and dislocation Knee contractures Foot conditions * Clubfoot * Vertical talus Neuromuscular C-shaped scoliosis (33%) Fractures (25%)

Question 560

Difference between bone infarct and osteomyelitis on imaging?

Answer 560

**osteomyelitis:** normal marrow uptake, abnormal bone scan **infarct:** decreased marrow uptake, abnormal bone scan

Question 561

Where will the conus medullaris lie in a tethered cord?

Answer 561

BELOW L23 - b/c it's tethered down

Question 562

Treatment if you malunite a femoral neck fracture into varus in paeds

Answer 562

Epiphysiodesis of the GT apophysis

Question 563

Name 3 copmlications of VEPTR

Answer 563

Thoracic outlet syndrome Rib fracture Skin breakdown (NOT clavicle fracture)

Question 564

What is the only muscular dystrophy with a positive upgoing Babinski?

Answer 564

Friedrich's ataxia

Question 565

OM in kids with what bug causes an increased risk of DVT?

Answer 565

MRSA

Question 566

Paediatric olecranon fractures are highly suspicious for:

Answer 566

Osteogenesis imperfecta

Question 567

Adequate reduction parameters for Delbet 2-4?

Answer 567

Type II * accept \<2mm cortical translation * \<5 deg angulation * no malrotation Type III and IV * accept \<10 degrees of angulation

Question 568

What are the only 2 recommendations with "moderate" or above strength in the AAOS CPG guidelines forDetection of DDH and management up to 6 months?

Answer 568

* No universal screening * performing an imaging study before 6 months of age in infants with one or more of the following risk factors: breech presentation, family history, or history of clinical instability.

Question 569

What condition is associated with MadeLungs?

Answer 569

Leri-weill dyschondrosteosis SHOX gene abnormality Causes mesomelic dwarfism

Question 570

According to AAOS AUS (2016), what is the best pin configuration for SCHF?

Answer 570

Lateral pins are safer Medial pins (cross pinning), can be used in highly unstable fractures that need more staiblity (crossed pinning biomechanically superior)

Question 571

Classic findings in Friedrich's ataxia

Answer 571

Ataxia areflexia positive plantar response

Question 572

What construct for SCHF pinning has the most biomechanical stability?

Answer 572

Medial and lateral crossed pins But we don't use them b/c of the risk of injury to the ulnar nerve

Question 573

4 maternal risk factors for congenital scoliosis

Answer 573

diabetes alcohol valproic acid hyperthermia

Question 574

Anatomic Classifiation of CP

Answer 574

Quadriplegic Diplegic (Legs \> arms, usually normal IQ as midline brain deficit) Hemiplegic

Question 575

5 general causes of LLD

Answer 575

_Hypoplasitc syndromes_ * PFFD * Fibular hemimelia * Tibial hemimelia _Hypertrophic syndromes_ * NF1 * Proteus * Klipper-trenaunay * Beckwidth-wiedemann _Idiopathic_ _Skeletal dysplasia_ * Ollier's disease * Fibrous dysplasia * MHE _Posteromedial bowing_ _Clubfoot_ _Traumatic_ _Acquired_

Question 576

Major complication of lateral closing wedge osteotomy for cubitus varus?

Answer 576

Lateral prominence

Question 577

5 poor prognostic indicators for physeal bar:

Answer 577

Cause: Infectious worse than traumatic Location: lateral worse than central Size: \>50% bad Type: bony vs. fibrous delay to presentation

Question 578

How do you reduce BADO I/III?

Answer 578

Flexion & supination

Question 579

Name 4 featuers of Acnohdroplasia (there are about 15)

Answer 579

_classic rhizomelic dwarfism_ * adult height ~ 50 inches * humerus shorter than forearm and femur shorter than tibia * normal trunk _facial features_ * frontal bossing * button noses * small nasal bridges _extremities_ * trident hands (inability to approximate extended middle and ring finger) * bowed legs (genu varum) * radial head subluxation * muscular hypotonia _spine_ * thoracolumbar kyphosis (often resolves at weight-bearing age) * excessive lordosis (due to short pedicles)

Question 580

There are 8 exam/lab findings other than inflamed joint that support JIA. At least one must be present for diagnosis. Name as many as possible.

Answer 580

1. rash 2. presence of RF 3. iridocyclitis (anterior uveitis) 4. C-spine involvement 5. pericarditis 6. tenosynovitis 7. intermittent fever 8. morning stiffness

Question 581

Pathology in SMA

Answer 581

Progressive loss of alpha motor neurons in anterior horn of spinal cord Muscle weakness LE \> UE (like anterior cord syndrome) Proximal \> distal

Question 582

Ulnohumeral dislocation in paeds: What fracture pattern are you worried about?

Answer 582

Medial epicondyle fracture make sure it's not incarcerated in the ulnohumeral joint. If it is, it's an indication for surgery

Question 583

What condition is characterized by autosomal recessive deficiency in B-glucocerebrosidase.

Answer 583

Gauchers disease

Question 584

What are the buzz words you need to say if you are proposing a closed reduction with hip spica for DDH?

Answer 584

1. Arthrogram to confirm reduction 2. Medial dye pool should be 5 mm or less with no interposed limbus 3. Immobilize in 100 flex, 45 abduction and neutral rotation (**SAFE ZONE**) 4. CT to confirm (with **SELECTIVE CUTS**) 5. Change after 6 weeks 6. 12 weeks total 7. Do adductor tenotomy if unstable safe zone (i.e. if too much abduction required to hold reduction)

Question 585

Three ways Pseudoachondroplasia differs from Achondroplasia?

Answer 585

* normal facies on physical exam * associated with cervical instability due to odontoid hypoplasia * absence of spinal stenosis

Question 586

SCHF patient comes with pulseless, cold hand. You operate. Still pulseless but now warm and pink. What do you do?

Answer 586

Close up and observe 24-72 hours Radial pulse will likely come back within that time frame Important thing is that the hadn is warm - perfused by collaterals

Question 587

What do you have to take into account when planning scoliosis correction in a myelodysplastic patient? (2)

Answer 587

_Anterior fusion_ * Posterior elementsare dysplastic and may impair fusion * Therefore have a high pseudoarthrosis rate _High infection rate_ * due to poor soft tissue coverage

Question 588

Flexion type SCHF results in cubitus \_\_\_\_\_\_\_\_\_\_\_\_?

Answer 588

Valgus It causes varus displacement, leading to cubitus valgus

Question 589

4 risk factors for thermal burns with casting

Answer 589

dipping water temperature is \> 24C (75F) more than 8 layers of plaster are used during cast setting, the arm is placed on a pillow. This decreases the dissipation of heat from the exothermic reaction fiberglass is overwrapped over plaster

Question 590

Associated ortho conditions for PFFD (4)

Answer 590

Fibular hemimelia (50%) ACL deficiency Coxa vara knee contractures

Question 591

Name 1 important surgical difference in treatment of infantile vs. adolescent Blount's:

Answer 591

Infantile: overcorrect into 10-15 degrees of valgus b/c medial growth abnormalities still exist Adolsecent: Do NOT overcorrect

Question 592

Foot polydactyly classification?

Answer 592

Venn-Watson classification _Postaxial_ * Y MT * T MT * Wide MT head * Complete duplication _Central:_ * duplication of 2nd, 3rd, 4th toe _Pre-axial_ * Short block 1st MT * wide MT head

Question 593

Treatment for physeal arrest:

Answer 593

_Bar resection with interposition Indications_ * Less than 50% growth plate involvement * \>2 years or 2cm growth remaining _Ipsilateral complesion of arrestIndications_ * \>50% physeal involvement * Can combined with contralateral epiphysiodesis and/or ipsilateral lengthening

Question 594

What disease causes progressive loss of alpha-motor neurons in the anterior horn of the spinal cord?

Answer 594

SM**_A_** "A" is for alpha motor neurons and anterior horn

Question 595

3 treatment options for NF related tibial bowing?

Answer 595

1. Total contact orthosis - bowing without fracture 2. ORIF with bone graft (Charnley Williams rod or Ilizarov) - pseudoarthrosis or fracture 3. Amputation - 3 failed ORIF attempts

Question 596

2 important complications of tibial tubercle fracture?

Answer 596

COmpartment syndrome - anterior, due to anterior recurrant tibial artery Recurvatum - anterior growth arrest, posterior keeps growing

Question 597

Preferred fixation of SHII distal femoral physeal fracture

Answer 597

Lag screw through the metaphyseal flare piece

Question 598

Describe the physical therapy regimen ideal for stiffness post supercondylar fracture?

Answer 598

None

Question 599

2 indications for surgical treatment of AAI in DOwns?

Answer 599

1. myelopathic patients 2. ADI \> 10 mm

Question 600

How does the acetabular deficiency is a **spastic child** differ from typical DDH?

Answer 600

**posterior-superior** instead of **anterior/anterolateral**

Question 601

Most important factors to rule out septic arthritis (2)

Answer 601

Patient weight bearing on affected limb CRP