Paeds Flashcards
What are the weak and spastic muscles in equinovarus foot?
Spastic: TP and TA
Weak: PB, PL
Treatment for physeal arrest:
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
Treamtnet of CP hips
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
7 indicators of poor prognosis with LCP
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
What pulleys need to be released in childresn’ trigger finger?
A2 & A3
Upper extremity contractures in CP
Shoulder IR
Elbow flexion
Forearm pronation
Wrist flexion
Thumb in palm deformity:
- Flexed MCP
- Extended IP
Finger-flexion deformity
Swan neck
When do you IMN a femur in paediatrics (age & weight)
> 11 years
>49 kg
Remember to use lateral start point
Classification for PFFD
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
What Risser stage correspnds to the fastest growth spurt?
Risser 0
Congenital rib anomalies (ie fused ribs) have what association with congenital scoli?
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)
Treatment algorithm of femur fractures in paeds:
- 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
dDx for anterolateral bowing (2)
NF
tibial deficiency
Indications for anterior approach in addition to posterior approach in scolisis
Large curve (>75 degrees)
Stiff curves
Skeletally immature (Risser grade 0, boys
Indications for hemivertebrectomy in congenital scoli
Progressive curve >40 degrees
Patient <5
lumbosacral vertebra best (but can be done in thoracic)
(JAAOS 2004)
dDx for septic hip? (3)
OM
Psoas abscess
Transient synovitis
How much does a leg grow in a year and where does the growth come from?
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)
What is H and how does it help evaluate DDH?
Hilgenreiners Line
A normal head should be below it.
newborn comes in with congenital dislocation of knee and DDH, which do you treat first and why?
Knee
b/c you can’t get a pavlik on with a dislocated knee
What x-ray is this?
What is the diagnosis?
45 degree oblique
Calcaneonavicular coalition
Should Down syndrome kids avoid contact sports? If yes, what indication?
Avoid sports if progressive radiographic instability or signs of myelopathy
When do children achieve 1/2 of the final leg length?
- girls at age 3
- boys at age 4
What is the weakest zone of the growth plate?
Hypertrophic zone
When do you need to excise a physeal bar in a growth arrest following distal femur fracture?
Indicated when deformity is present with a physeal bar of
<50% and at least 2 years or 2 cm of growth remaining
Risk factors for birth fractures
Vaginal deliveries
breech presentation
prolonged labor
macrosomia (>4.5 kg)
Name the 3 (Mehta) indicators of progression in congenital idiopathic scoliosis
Cobb >20 degrees
Phase 2 rib
Rib-vertebral angle difference (RVAD) >20
Thoracolumbar curve
Kid with septic hip: what position will the hip be held in?
Flexion, abduction, ER
5 associated conditions of external tibial torsion:
Miserable malalignment syndrome
Osgood Schlatter disease
Osteochondritis dessicans
Early degenerative joint disease
Neuromustular conditions
What is is the predictable angular deformity with pediatric tibial fractures treated with LLC?
Varus if fibula intact.
Valgus if fibula also broken.
Flexion type SCHF results in cubitus ____________?
Valgus
It causes varus displacement, leading to cubitus valgus
BLocks to reduction in DDH
Labrum
Inverted limbus
capsule
transverse acetabular ligament
ligamentum teres
pulvinar
Common injuries associated with TL spine trauma in paeds
Same as in adults:
GI: Small bowel most common
Lung contusion/pneumothorax
Head injury
7 donor options for nerve transfer in Brachial plexopathy?
sural
intercostal
spinal accessory
phrenic
cervical plexus
contralateral C7
hypoglossal
Zone of injury for proximal humerus fractures?
Zone of provisional calcification (part of hypertrophic)
However may go through several
Spares proliferative
JAAOS 2015
2 life-threatening intra-operative complications in DMD:
intraoperative cardiac event
malignant hyperthermia
Consult anesthesia & cardio preop
What condition can be confirmed using fibroblast culturing to analyze type I collagen in equivocal cases?
OI
(best for type 4)
Presence of what is the main finding that differentiates NF2 from NF1?
bilateral vestibular schwannomas
** Also the DONT get scoliosis
What is P and how does it help evaluate DDH?
Perkins Line
Femoral head ossification should be medial to this line
Kid with hemihypertrophy. What must you do?
serial ultrasounds q3 months until age 7,
then physical exam q6 until skeletal maturity
TO RULE OUT WILM’S TUMOUR
Criteria for Septic Hip
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
Risk factor for AVN of the hip
Trauma
Steroid use
Radiation
How do you differentiate CVT and oblique talus on x-ray
oblique talus:
navicular will reduce on plantarflexion latearl
Meary’s angle <35 degrees
In SCFE, the screw should be placed in what relationship to the intertrochanteric line to avoid what complication?
lateral to the intertrochanteric line
To avoid screw impingement
Criteria/algorithm for septic arthritis vs. transient synovitis
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.
7 options for interpositional graft after resection of physeal bar:
Fat
PMMA
Cranioplast (like PMMA: takes longer to set, less exothermic reaction, less chance of heat necrosis)
Bone wax
Cartilage
Muscle
Silicone
3 indications for ORIF in pediatric distal femur fracture?
- open fracture
- failed closed reduction of SH1 or SH2
- perisoteum usually infolded in these case
- SH 3 - 4 in order to get anatomic reduction of joint surface
Reduction Maneuver for displaced medial epicondyle fracture into joint?
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
Treatment for dynamic supination post clubfoot
Tib ant transfer to lateral cuneiform
When can you determine the Herring stage in LCP?
Fragmentation stage (~6 months after symptoms start)
Most common cause of revision following early spica casting of a femur fracture in paeds?
Loss of reduction
Although rare
Classification of tibial spine/eminence fractures
Meyers & McKeevers
I: undisplaced
II: displaced with posterior hinge
III: completely displaced with no bony contact
IV: comminuted
Diagnosis
Bisphosphonates on OI
Results in metaphyseal banding at each dosing
How does TA compare to PL in:
a) Clubfoot
b) Cavo - varus foot
a) TA stronger
b) TA weaker
Name 3 conditions that can present with teratologic hip?
arthrogryposis
myelomeningocele
Larsen’s syndrome
What is the Sofield-Miller procedure?
Realignment osteotomy with rod fixation for OI
Fassier-Duval rods can be used.
Three methods of predicting LLD?
- Green-Anderson tables
- uses extremity length for a given age
- Moseley straight line graph
- improves on Green-Anderson method by reformatting data in a graph form
- accounts for differences between skeletal and chronologic age
- minimizes error
- Multiplier method
DDH U/S:
What is minimal age?
4-6 weeks.
Treatment options for Delbet 1–4?
- 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
How much fill of the femoral canal do you want with nancy nails?
80%
(Therefore each nail should be diameter x 0.8 / 2)
(i.e. canal is 1 cm, then use 2 x 4 mm nails)
X-ray findings of clubfoot
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
Most common complication after distal femoral physeal injury
LLD/growth arrest
Name 5 non-ortho manifestations of OI
Blue sclera
Hearing loss
Brownish opalescent teeth (dentiogenesis imperfecta)
Wormian skull bones (puzzle piece intrasutural skull bones)
Increased risk of malignant hyperthermia
Asymptomatic Paediatric Isthmic spondy, soccer player. Do you limit sports?
No
Manage with close observation and no restrictions
Most important factors to rule out septic arthritis (2)
Patient weight bearing on affected limb
CRP
What motion is most deficient in Sprengels?
Abduction
4 technical considerations for fixation of pediatric distal femur fracture?
- 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
The patella vascular supply is composed of _____ branches which stem from which 3 larger arteries?
6 small branches ( the geniculates plus anertior tibial recurrant)
Popliteal, Superficial femoral and Anterior Tibial
3 associations with tarsal coalition:
Fibular hemimelia
Apert’s
PFFD
“People with tarsal coalition masturbate a lot: FAP FAP FAP”
Main blood supply to femoral head in kids >4
Medial femoral circumflex artery
via: posterosuperior lateral epiphyseal branch
&
posterior inferior retinacular branch
Specifically for the distal radius, when do you want to operate to excise a distal radius physeal bar?
If >2mm (not cm) of growth remains
progressive deformity
symptomatic
5 risk factors for LCP
Positive family history
Low birth weight
Abnormal birth presentation
Second hand smoke exposure
Asian, Inuit, central european descent
Manifestations of Achondroplasia
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
What happens if the GT apophysis is prematurely arrested?
hip will go into valgus
(medial side keeps growing)
Best pin configuration for SCHF?
Lateral divergent pins (2 vs 3)
Describe the deformity in congenital vertical talus
Rockerbottom foot:
Hindfoot: equinovalgus (everted & lateralized)
Midfoot: rigid dorsiflexion
Forefoot: abducted & dorsiflexed
What part of the growth plate does a SCFE occur in?
Hypertrophic zone
caused by weakness in the perichondral ring
MPS with least spinal abnormalities?
San Filippo
only has scoliosis, and even that is rare
JAAS 2013
Lateral Pillar Classifiation: (LCP)
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
Cause and treamtent of stiff-knee gait in CP?
Cause: rectus femoris firing out of phase
Treatment: transfer of distal rectus femoris tendon
Characteristic lesion in Fredrich’s ataxia
Spinocerebellar degenerative disease, therefore, lesions in:
- Dorsal root ganglia (peripheral)
- Corticospinal tracts (central)
- Dentate nuclei in the cerebellum
- Sensory peripheral nerves
First line treamtent in tarsal coalition?
trial of non-op with immobilization or orthotics - always
What is the best treatment for Sever’s disease?
Calcaneal apophysitis
Best is achilles stretching - may decrease recurrence
No role for operative management
What must you do for workup in patient with congenital scoliosis?
Echo: cardiac defects - 10%
Renal ultrasound and GU workup - genitourinary defects - 25%
MRI - spinal cord malformations
Surgical treatment for CMT claw toes?
Jones procedure
(transfers the extensor tendons of the great and lesser toes through the bone into the metatarsal neck)
What is angle A and how does it help evaluate DDH?
Acetabular Index
varies with age (decreases)
normal is less than 25 deg 2yo kid
(remember 2yo is ~20deg)
4 indications for surgery in infantile Blount’s
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
Can a Klippel Feil patient play contact sports?
No if they have fusion of C3 and above
WHat joints are most commonly invovlved in JIA?
knee > hand/wrist > ankle > hip > C-spine
What are ideal factor levels in a hemophiliac for :
- acute hematomas
- acute hemarthrosis and soft tissue surgery
- skeletal surgery
- 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
Indications for contralateral pinning in SCFE
High risk patients:
Endocrinopathy
Obese
Young age, indicated by:
- Boys
- Girls
- Open Triradiate cartilage
Adequate reduction parameters for Delbet 2-4?
Type II
- accept <2mm cortical translation
- <5 deg angulation
- no malrotation
Type III and IV
- accept <10 degrees of angulation
4 negative prognostic indicators of pediatirc spetic arthritis?
age
associated osteomyelitis
hip joint (versus knee)
delay >4 days until presentation
Why do you need a pre-op MRI in sprengels?
To identify omovertebral bar
By definition, what three characteristics have to be present for JIA diagnosis?
- Persistant inflammatory arthritis
- > 6 weeks
- Patient < 16 years
Kocher Criteria for Septic Hip
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
What are the primary surgical options for the three types of CP gait?
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
What construct for SCHF pinning has the most biomechanical stability?
Medial and lateral crossed pins
But we don’t use them b/c of the risk of injury to the ulnar nerve
WHen i say Olecranon apophysis avulsion fracture, you say:
osteogenesis imperfecta
4 indications for open reduction of pediatric elbow dislocation?
- open dislocation
- inability to acheive closed reduction
- incarcerated fragment - usually medial epicondyle or tip of coronoid
- seves instability following closed reduction
What is the pediatric equivalent of Lauge Hansen classification?
Diaz / Tachdjian
SAD, SER, PER, SPF (Supination plantar flexion)
(compare Lauge-Hansen which is SAD, SER, PER, PAB)
What is normal range for IR and ER of hip?
IR = 20-60
ER = 30-60
4 options for elbow release in arthrogryposis
Triceps to biceps
Steindler flexorplasty
Pec Major to biceps
Triceps V-Y lengthening and posterior capsulectomy
Describe the anatomy of CVT
Dorsal structures are tight (navicular dorsally dislocated)
Rocketbottom foot
- hindfoot equinovalgus
- rigid midfoot dorsiflexion
- forefoot abducted and dorsiflexed
Tib post is tight
What are the 2 cardinal manifestations of Marfan’s syndrome?
Aortic root dilatation
Superior lens dislocation
If both are present, do not need genetic testing - therefore test for both (Echo and optho consult)
Indication for surgery in LCP?
Lateral pillar B, B/C, C in kids >8 (bone age >6)
They do better with pelvic/femoral osteotomy
What did Sillence classify?
OI
How does a patient with SCFE clinically present?
Pain
Obligatory ER
At what level of SPina Bifida is hip dislocation most common and why?
L3 - uopposed hip flexion and adduction
Name 3 syndromes with abnormal ossification of secondary growth centers
Spondyloepiphyseal dysplasia
Multiple epiphyseal dysplasia
diastrophic dysplasia
How does a positive coleman block test effect treatment of cavo-varus foot?
Rigid hindfoot varus.
Do: calcaneal valgus producing osteotomy
What antibiotic should you avoid in paeds?
Cipro (fluorquinolone) b/c of risk of cartilage damage
DMD Scoliosis
1) 1 surgical indication that is unique compared to AIS
2) To pelvis?
1) respiratory function
2) Controversial
In what condition is a full-length semi-rigid insole orthotic with a depression for the first ray and a lateral wedge useful?
Mild cavo-varus foot
LLD Principals:
a)
b) 2-5 cm
c) > 5 cm
a)
b) 2-5 cm = shorten long side
c) > 5 cm = lengthen short side +/- shorten long side
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?
- 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.
Who gets Gower’s sign? Describe it
Rises by walking hands up legs to compenate for gluteus maximum and quadriceps weakness
Conditions that may cause SCFE?
- obesity (most important)
- hypothyroidism (labs show elevated TSH)
- osteodystrophy of chronic renal failure
- Rickets
In LCP, when do you want to perform surgery (if indicated)
initial or fragmentation phase
no positive effect has been found for containment surgery performed after initial or early fragmentation stage
What are the buzz words you need to say if you are proposing a closed reduction with hip spica for DDH?
- Arthrogram to confirm reduction
- Medial dye pool should be 5 mm or less with no interposed limbus
- Immobilize in 100 flex, 45 abduction and neutral rotation (SAFE ZONE)
- CT to confirm (with SELECTIVE CUTS)
- Change after 6 weeks
- 12 weeks total
- Do adductor tenotomy if unstable safe zone (i.e. if too much abduction required to hold reduction)
Muscle imbalance in equinovalgus foot?
Opposite of equinovarus
TA/TP weak
PB/PL strong
Classification of CP Hips & Treatment
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
What is a Charnley WIlliams rod used for?
ORIF of NF tibial pseudoarthrosis
Principals for bladder extrophy repair?
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
2 methods of percutaneous reduction of radial head fracture
- K-wire joystick technique
- Metaizeau technique
involves retrograde insertion of a pin/nail across the fracture site
fracture is reduced by rotating the pin/nail
What is a reason why intra-thecal baclofen is preferred over PO for CP?
PO associated with cognitive impairment.
Treatment of dislocated hip in myelomeningocele?
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.
dDx for cavovarus foot (5)
Charcot-Marie-Tooth
Freidreich’s ataxia
Cerebral palsy
Polio
spinal cord lesions
Anterolateral bowing:
what’s the chance this patient has NF?
What is the chance an NF patient has anterolateral bowing?
what’s the chance this patient has NF?
50%
What is the chance an NF patient has anterolateral bowing?
10%
3 INDICATIONS for nerve repair/grafting in Brachial plexopathy?
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
Orthopaedic Manifestations of Charcot Marie Tooth (HMSN)? (4)
pes cavus
hammer toes
hip dysplasia
scoliosis
5 conditions associated with Cavovarus foot?
- Charcot-Marie-Tooth
- Freidreich’s ataxia
- Cerebral palsy
- Polio
- spinal cord lesions
4 dDx for leg bowing in kids?
Physiologic
Blount’s disease
Osteogenesis imperfecta
Rickets/osteomalacia
Syndromic
Describe Birch Classification for fibular hemimelia
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
Differential for unilateral valgus (3)
Proximal metaphyseal tibial fracture (Cozen’s)
UnilateralPhyseal injury
- Trauma
- Infection
- Vascular insult
Benign tumour
- Fibrous dysplasia
- Osteochondroma
- Ollier’s disease
2 optioins for treating elbow flexion contractures
Clarke’s pectoral transfer
Steindler’s flexorplasty
Treatment of hallux varus
Conservative:
- most resolve with time
Can do abductor hallucis release
excsision of central epiphyseal bracket
Defect in diastrophic dysplasia?
DTDST gene (SLC26A2)
codes for diastrophic dysplasia sulfate transporter gene on chromosome 5
How do you estimate blood volume in a kid?
75 - 80 mL/kg
Principals of Proximal tibia/fibula valgus osteotomy for Blounts?
- overcorrect into 10-15° of valgus because medial physeal growth abnormalities persist
- distal segment is fixed in valgus, external rotation and lateral translation
- temporary lateral physeal growth arrest with staples or plates can be used
- include a bar resection (epiphysiolysis) when a physeal bar is present (Langenskiold V and VI)
- consider hemiepiphysiodesis if bar > 50%
- medial tibial plateau elevation is required at time of osteotomy if significant depression is present
- consider prophylactic anterior compartment fasciotomy
How do you tell if the tib post or tib ant is the driving force in an equinovarus foot?
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
Most common 2 complications after fixation of femoral neck fracture in paeds:
- AVN
- coxa vara
4 conditions associated with CVT?
- myelodysplasia (common)
- arthrogryposis
- diastematomyelia
- chromosomal abnormalities
High association with genetic or neuromuscular disorder (50%)
3 nonorthopaedic conditions of marfans?
- cardiac abnormalities
- aortic root dilatation
- possible aortic dissection in future
- mitral valve prolapse
- superior lens dislocations (60%)
- spontaneous pneumonthoraces
NIH Consensus Development Conference Statement diagnosis criteria for NF1?
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
Bado Classification
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
Contraindications to Pavlik harness (4)?
- Abnormal muscle function (i.e. spina bifida, spasticity)
- Age over 6 months
- Teratologic hip dislocation
- Failure of Pavlik treatment for 3 weeks.
When evaluating function of CP kid, what are 6 areas to ask about?
- nutritional status
- respiratory function
- sitting/standing posture
- upper and lower extremities function
- communication skills
- acuity of hearing and vision
What are the upper limits of normal for valgum and IM distance in a patient over the age of 7?
- valgum < 12 degrees
- IM distance < 8cm
in SCHF with median sensory symptoms, what is the major complication that is now at increased risk/most commonly to be missed?
Compartment syndrome
They cannot give the regular symptoms (pain) of compartment syndrome so the risk goes up
Give general principles of operative treatment for PFFD
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
4 indications for osteotomy in Infantile Blounts?
What osteotomy would you do?
- Stage I and II in children > 3 years
- Stage III, IV, V, VI in children
- failure of brace treatment
- metaphyseal-diaphyseal angles > 20 degrees
proximal tibia/fibula valgus osteotomy
Surgical treatment of hip dislocation in myelodysplasia is controversial b/c of high failure rates. What is the anatomic cause of failure? Be specific
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
Non-ortho associations of hemihypertrophy (2 major types)
Malignant intra-abdominal tumours
- Wilm’s - most common
- adrenal carcinoma
- hepatoblastoma
GU abnormalities
- medullary sponge kidney
- polycystic kidney
- inguinal hernia
What is von Recklinghaussen disease?
NF1
Best x-ray view for lateral condyle fracture?
internal oblique
What disease causes progressive loss of alpha-motor neurons in the anterior horn of the spinal cord?
SMA
“A” is for alpha motor neurons and anterior horn
Management of equinovarus foot
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
Name the physeal zone associated with:
SCFE (not renal)
Rickets (provisional calcification zone)
Enchondromas
Mucopolysacharide disease
SED
MED
hypertropic
What are the 5 physeal zones?
- Reserve
- Proliferative
- Hypertrophic
- Primary Spongiosa
- Secondary Spongiosa
What is the best indicator of peak growth?
Risser 0 or closure of triradiate (occurs at same time)
WHere does a Salter osteotomy hinge on?
Symphysis Pubis
1 cut from AIIS to sciatic notch
What dysplasia has metaphyseal changes of the tubular bones with normal epiphysis?
metaphyseal chondrodysplasia
Kid with MPS comes in with burning in radial 3 digits, worse at night, some clumsiness of the hands. Top 2 dDx
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)
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?
Tibial deficiency
AD
Must counsel parents of risk with further children
What 2 actions may help reduce AVN rates in femoral head/neck fractures in paediatric patients?
early reduction
Joint decompression (hematoma aspiration or core decompression)
Treatment for lateral pillar A/B in kid less than 8 (bone age less than 6)
Nonoperative
They do well regardless
Treatment for calcaneovalgus foot?
observation and parental stretching
3 exam findings consistant with tarsal coalition?
- flattening of arch
- valgus hindfoot
- peroneal spasticity
In clubfoot release, what has the greatest influence on functional outcomes?
Extent of soft tissue release
4 complications of radial head fractures
Which 2 are related to open reduction?
- 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
Classification of Sprengel’s:
see chart
How long do you wear a Pavlik?
23 h/day for 6 weeks then ween over 6 weeks.
8 orthopedic manifestations of Downs?
- generalized ligamentous laxity and hypotonia
- C1-2 instability
- hip subluxation and dislocation
- patellofemoral instability and dislocation
- scoliosis & spondylolithesis
- pes planus
- primus varus
- SCFE
Surgical option in resistant vertical talus?
talectomy
Preferred fixation of SHII distal femoral physeal fracture
Lag screw through the metaphyseal flare piece
Valproic acid has what detrimental effect on surgery?
Increases bleeding time
Name the physeal zone associated with:
- Gaucher’s
- diastrophic dysplasia
Reserve
Spine changes in NF1
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
What fracture type has the highest rate of growth arrest in the body?
SH4 of medial malleolus
How is CP gait desribed/classificed
Sagittal plane
- Jump
- Crouch
- Stiff knee
Transverse plane
- IR
- ER
- Neutral
Coronal plane:
- Genu varum
- Genu valgum
- hip adduction
4 indications for OR in pediatric pelvis fracture?
(radiographic)
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
Risk of contralateral SCFE in otherwise healthy kid?
50%
(10-60%)
this is asking the risk of contralateral SCFE, not bilateral SCFE
Bilateral is 20% in normal, 80% in endorinopathy
Acceptable Alignment BBFF?
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
Who gets Duchenne muscular dystrophy?
Males only
X-linked recessive
4 signs of residual DDH in kid > 3 months
Limited hip abduction
Pelvic obliquity
+ galeazzi
Trendelenburg gait
4 joints with intra-articular metaphyseal cortex
hip, shoulder, elbow, and ankle
What are Woodward and Green procedures used for and what is the difference?
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.
Spinal manifestations of Achondroplasia:
Foramen magnum stenosis (NOT c-spine instability)
Kyphosis
Lumbar stenosis
Ulnohumeral dislocation in paeds: What fracture pattern are you worried about?
Medial epicondyle fracture
make sure it’s not incarcerated in the ulnohumeral joint. If it is, it’s an indication for surgery
What is Nail-Patella syndrome?
Hypoplastic Nails and Petallae
AD inheritance
Also includes:
Laxity
scoliosis
scapular hypoplasia
presence of cervical ribs
amongst other things
2 techniques to reduce a radial head fracture
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
AAOS guidelines for paediatric femoral shaft fractures
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
Indications for selective thoracic fusion:
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
What does the VilleFranche classification describe?
Ehlors Danlos
Villefranche Classification (1998)
Classical - Type I (gravis) and Type II (mitis)
COL5A1 or COL5A2 mutation
There are several other sub types
Best surgical appraoch to CP HV?
1st MTP fusion +/- Akin
Best test for looking at cross-sectional imaging of tarsal coalition
Best test to look for fibrous coalition
CT best to look at cross-sectional imging
MRI best to look at fibrous coalitions
7 reasons that in-toeing requires further investigations?
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.
What is the risk of AVN for Delbet Type 1B?
Nearly 100%
(transphyseal proximal femur fecture with displacement of epiphysis out of acetabulum)
2 complications of transphyseal distal humerus fracture?
Cubitus varus
Medial condyle AVN
Complications seen with too much abduction in Pavlik?
AVN
What is the muscle imbalance in dynamic supination post Ponsetti Casting?
Tib ant overpull in relation to peroneal muscles
tarsal coalition
Chance of it being bilateral?
Patient with 1 coalition has what percentage of having another?
50% chance of being bilateral
20% chance of a second coalition if they have 1
What is the most common cause of early death in Morquio?
Spinal cord stenosis
JAAOS 2013
Name 4 featuers of Acnohdroplasia (there are about 15)
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)
Othopaedic Manifestations of CMT?
Scoliosis
Pes Cavus
Hammertoes
Hip dysplasia
What are the 4 deformities of clubfoot?
- midfoot Cavus (tight intrinsics, FHL, FDL)
- forefoot Adductus (tight tibialis posterior)
- hindfoot Varus (tight tendoachilles, tibialis posterior, tibialis anterior)
- hindfoot Equinus (tight tendoachilles)
In a patient with Sprengel’s, what is the most likely associated abnormality to expect?
- Scoliosis
- Klippel-Feil
(JAAOS)
see chart
WHat is the spine deformity in multiple epiphyseal dysplasia
None
dDx of knee or thigh pain paediatric patient:
Knee pathology
Hip pathology
- SCFE
- LCP
- Septic hip
- Transient synovitis hip
*knee/thigh pain mandates a workup for SCFE
How can you be fooled into thinking someone doesnt have an achilles contracture?
(I.e a false negative)
- 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
What are three ways to assess coronal deformity of the L/E on AP xrays?
1) mechanical axis
2) mLDFA 88 (range 85°-90°) and mMPTA (range 85°-90°)
3) Tibial Femoral Angle
Describe the Beighton-Horan scale.
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)
List 5 features associated with in-toeing that necessitate further workup:
Pain
LLD
Progressive deformity
Family history of rickets, skeletal dysplasias, mucopolysaccharidoses
Limb rotational profiles 2 standard deviations outside the normal
5 things affecting Hypertrohpic Zone of growth plate
SCFE
MED
SED
Schmids
Fractures (SH1)
Ricekts
Enchondromas
What is the natural history of OI fractures with age?
The symptoms improve with age
What are two options to treat AVN
following proximal femur fracture?
● Vascularised free fibula graft
● Core decompression
Preferred treatment of congenital vertical talus
Reverse ponsetti casting +
surgial reduction & pinning of talonavicular joint +
TAL
Paediatric olecranon fractures are highly suspicious for:
Osteogenesis imperfecta
3 indications for operative percutaneous reduction of radial head fractures in peads?
> 30° of residual angulation
3-4 mm of translation
Order of correction in ponsetti method
Cavus first (midfoot)
Then adduction & Varus (hindfoot)
Equinus last
(CAVE)
5 causes of hemihypertrophy
idiopathic
neurofibromatosis
beckwith-weidemann syndrome
Klippel-trenauney syndrome
proteus syndrome
What part of the physis does a SCFE occur in?
Hypertrophic
What percentage of LCP patients will eventually need THA?
50%
What single finding dictates how often slit lamp exams are necessary in JIA?
Presence of ANA
If negative: Every 6 months
If positive: Every 4 months
Name 4 non-ortho manifestations of myelodysplasia
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
3 complications of radial head/neck fractures
AVN
synostosis
loss of ROM (pronation > supination)
radial head overgrowth
2 spinal deformities with OI
Scoliosis
basilar invagination
(NOT AAI)
4 ortho and 2 nonortho associations with Friedrich’s ataxia
Ortho
- cavovarus foot: often rigid
- scoliosis
- ataxia
- areflexia (but with positive plantar response)
Non-ortho
- Cardiomyopathy
- nystagmus
Never do what when ORIFing a lateral condyle fracture?
Never dissect posteriorly
Blood supply comes from there and will cause AVN if you disrupt it
Difference between bone infarct and osteomyelitis on imaging?
osteomyelitis: normal marrow uptake, abnormal bone scan
infarct: decreased marrow uptake, abnormal bone scan
What 3 spinal deformity conditions are bracing CONTRAindicated in?
Spina Bifida
SCI
Muscular dystrophy
Associated ortho conditions for PFFD (4)
Fibular hemimelia (50%)
ACL deficiency
Coxa vara
knee contractures
4 manifestations of CMT?
- pes cavus
- hammer toes
- hip dysplasia
- scoliosis
SMA treatment:
- Hip Dislocations
- Scoliosis
- Hip Contractures
- Leave dislocated - recurrance is high and usually asymptomatic
- PSF to pelvis
- Deal with hip contractures before scoiliosis correction in order to ensure they can sit in wheel chair. Otherwise leave them alone.
4 radiographic findings in OI
thin cortices
generalized osteopenia
saber shins
skull radiographs reveal wormian bones
Metaphyseal bands (bisphosphonate use)
What part of acetabulum is deficient in neuromuscular hip dysplasia?
posterior superior
DDH U/S:
What is alpha angle and what is normal?
- angle created by lines along the bony acetabulum and the ilium
- normal is greater than 60°
Longitudinal traction in young kid. Arm held in elbow extension and forarm pronation. What is the injury pathomechanism?
Inteprosition of annular ligament in radiocapitellar joint (nursemaid’s elbow)
6 Blocks to reduction in DDH:
ligamentum teres
capsule
transverse acetabular ligament
inverted labrum
Psoas
Pulvinar
2 factors prognostic of long term neurologic sequelae from paediatric trauma:
O2 sat at presentation
GCS 72 hours post injury
Radial Longitudinal Deficiency/Radial CLubhand associated with what conditions (5)
TAR: thrombocytopenia absent radius - check plt
Fanconi Anemia - check Hb
VACTERL
VATER
Holt-Oram - congenital cardiac abnormalities
Complications seen with too much flexion in Pavlik?
Femoral nerve palsy.
6 associated ortho conditions with arthrogryposis
Upper extremity deformity
Hip subluxation and dislocation
Knee contractures
Foot conditions
- Clubfoot
- Vertical talus
Neuromuscular C-shaped scoliosis (33%)
Fractures (25%)
IN ponsetti method, when do you do an achilles tenotomy?
Prior to application of the final cast
What view is best for looking at accessory navicular?
External oblique
What are the normal values of Staheli Rotational Profile?
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
What disease causes neuronopathy in the dorsal root ganglia, accompanied by the loss of peripheral sensory nerve fibers?
Freidrich’s Ataxia
“d” is for dorsal root ganglia
dDx for bilateral valgus (3)
Physiologic
Renal osteodystrophy (Rickets)
Skeletal dysplasia
- Morquio
- Spondyloepiphyseal dysplasia
- Chondroctodermal dysplasia
WHat is Pavlik’s disease?
erosion of pelvis or superior acetabulum and precention of the development of a posterior acetabular wall
4 complications of Lateral Condyle fracture (operative)
AVN
Malunion/Non-union –> cubitus valgus
Tardy Ulnar Nerve Palsy
Lateral spurring
SCHF patient comes with pulseless, cold hand. You operate. Still pulseless but now warm and pink. What do you do?
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
Highest cause of morbidity and mortality in paediatric fracutres overall and from MSK causes
Overall: CNS injuries (TBI)
of MSK injuries: Spine
List proportionate Dwarfism
Mucopolysaccharidosis
- Hunter
- Hurler
- San Fillipo
- Morquios’
Cleidocranial dysplasia
Three technical factors that can increase risk of compartment syndrome when using hip spica for femur fracture?
- Rough cast edge at popliteal fossa
- Excessive traction
- Knee flexion > 90
Indication for serial casting in MTA?
Rigid deformity with medial crease
3 options to treat IR contractures fo the shoulder
Lat dorsi and teres major tendon transfer
Pec major and subscap lengthening
proximal humerus ER osteotomy
Risk factors for congenital kyphosis progression (4)
Type I (failure of formation)
Type III (mixed failure of formation and failure of segmentation)
Immaturity
Curve > 40 deg
Describe an NF1 patient’s risk of cancer
Increased risk of benign and maligant tumours, including:
melanoma
leukemia
rhabdomyosarcoma
pheochromococytoma
carcinoma
pancreatic endocrine tumours
astrocytoma
Three ways Pseudoachondroplasia differs from Achondroplasia?
- normal facies on physical exam
- associated with cervical instability due to odontoid hypoplasia
- absence of spinal stenosis
Define Arthrogryposis
Non-progressive congenital disorder involving multiple rigid joints (usually symmetric), leading to severe limitation in motion
Delbet Classification
Paediatric femoral neck fractures
Ia: transphyseal (epiphysis) no displacement
Ib: transphyseal (epiphysis) displacement
II: femoral neck (transcervical)
III: Basicervical
IV: Intertrochanteric
Diagnosis?
Sacral agenesis
Treatment for a GMFCS V CP patient with pain sitting in their wheelchair
Proximal femoral resection
(controversial)
How do you clinically differentiate SMA vs. DMD
SMA has ABSENT deep tendon reflexes, while they are mantained in DMD
SMA has fasciculations
Approxiate amount of growth from each of the leg physes per year:
proximal femur - 3 mm / yr
distal femur - 9 mm / yr
proximal tibia - 6 mm / yr
distal tibia - 5 mm / yr
Indications for pinning distal radius fracture in paeds (7)
- 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
6 dDx for metaphyseal flaring:
Fibrous dysplasia
Storage diseases
Rickets
Anemia
Chronic lead posioning
bone dysplasia
Name 6 syndromes/diseases assocated with basilar invagination
Klippel-Feil
Osteogenesis imperfecta
Morquio syndrome
achondroplasia
spondyloepiphyseal dysplasia
occipitocervical synostosis
Paediatric proximal humerus fracture classification:
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
What operative intervention is contraindcated in CP patient with crouched gait
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)
Name 4 life-threatening perioperative complications with MPS
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
Name the physeal zone associated with:
Achondroplasia
Gigantism
MHE
Proliferative
General principle in treatment of gait disorders in CP with respect to contractures.
Flexible contracture:
AFO
Rigid contracture:
OR
3 things affecting Proliferative Zone
Achondroplasia
Multiple Hereditary Exostoses (MHE)
Gigantism
“A Giant Me”
Who a I?
Multiple congenital joint dislocations
ligamentous laxity
abnormal facies:
Larsen Syndrome
Medical treatment for AD osteopetrosis?
interferon gamma-1 beta
4 predictors of complications when doind a nancy nail?
- > 25 mm nail protruding from nail
- Age > 11 years
- Weight > 45 kg
- Fracture is very proximal, distal or comminuted
What two physical exam findings are most useful to guide maanagement in fibular hemimelia?
- LLD
- Is the foot stable and plantigrade?
Describe the GMFCS scale.
I say absent clavicles, you say:
Cleidocranial dysplasia
failure of intramembranous ossifciation
leads to failure of formation of midline structures
ie failre of pubis to ossify
Good prognostic signs of anterolateral bowing? (2)
Duplicated hallux
Delta-shaped osseous segment in concavity of bow
Acceptable criteria for distal radius fractures
<9 years old: 30 degrees dorsal angulation. Bayonette apposition <1cm
>9 years old: 20 degrees dorsal angulation
No rotational deformities
Name 4 social risk factors for child abuse
recent job loss of parent
children with disabilities (cerebral palsy, premature)
step children
Premature child
Name 4 sources of blood supply to the femoral head:
MFCA (main after 4 years)
via posterosuperior lateral epiphyseal branch & posterior inferior retinacular branch
LFCA (
Artery of ligamentum teres (
Metaphyseal vessels
Non-ortho manifesataions of SMA
Resp - Major cause of morbidity and mortality. Consult them
GI - Common: consult them (swallowing problems)
3 spinal manifestations of Achondroplasia?
Thoracokyphosis
Lumbar Stenosis
Foramen Magnum/Upper Cervical Stenosis
Congenital hallux varus is associated with what?
Polydactyly
Normal alpha angle (DDH)
>60 deg
angle of bony ilium and acetabulum
is dynamic supination caused by operative or non-operative treatment of clubfoot?
How do you treat it?
a) NON-OPERATIVE
b) TA tendon transfer - full thickness
3 positive effects of bisphosphonates in OI (not the side effects)
Improves mobility
decreases fracture rate
improves vertebral bone density
Improves vertebral height (not overall height)
What differentiates the McClune Albright Cafe au Lait spots from those of NF1?
NF1 = smooth “coast of California” borders
McCune-Albright syndrome = rough “coast of Maine” spots
When do you brace congenital scoliosis?
To control supple compensatory curves
Workup of Arthrogryposis at 3 months? (3)
Perform at 3-4 months of age
- neurologic studies
- enzyme tests
- muscle biopsies
Diagnosis?
CVT
Clues:
talus is vertical
navicular dorsal dislocation
Name 3 tumours specific to NF1
Optic glioma
Neurofibroma
Neurofibrosarcoma (aka Malignent peripheral nerve sheath tumours)
Name the physeal zone associated with:
Renal SCFE
Secondary Spongiosa
4 signs of AVN of femoral head following treatment for DDH (radiographic)?
- failure of appearance or growth of the ossific nucleus 1 year after reduction
- broadening of femoral neck
- increased density and fragmentation of ossified femoral head
- residual deformity of proximal femur after ossification
What is the most important test a patient with JIA needs to have?
Regular slit-lamp examination by ophthalmologist.
Iridoclyclitis (uveitis) can lead to rapid blindness
What condition is characterized by autosomal recessive deficiency in B-glucocerebrosidase.
Gauchers disease
What is the only muscular dystrophy with a positive upgoing Babinski?
Friedrich’s ataxia
Classic presentation of diastrophic dysplasia?
Rhizomelic dwarfism
Hitchiker’s thumb
cauliflower ears (80%)
Cleft-palate (60%)
Patient post-SCFE c/o functional limitations. He wants a femoral osteotomy. What kind will you do?
Proximal femoral derotational osteotomy
Create: flexion, valgus, IR
Imhauser osteotomy (intertrochanteric osteotomy)
4 non-orthopedic manifestations of Downs?
- mental retardation
- heart disease (50%)
- endocrine disorders (hypothyroidism)
- premature aging
What degree of scoliosis do pulmonary and cardiopulmonary complications happen in the immature and mature patient?
Pulmonary: 60 deg
Cardiopulmonary: 90 deg
Mature: 100 deg (Agabegi Jaaos 2015)
Larsens Surgical Treatment:
- Cervical Kyphosis
- Hip Dislocation
- Knee Dislocation
- PSF (neuro intact) or P/ASF if neuor deficits
- Open reduction - especially if unilateral (bilateral often fails/controversial)
- open reduction with femoral shortening and collateral ligament excision
Diagnosis
What is their physical exam going to be like?
What other test do you order?
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
Flat top talus
Almost pathognomonic for what?
Clubfoot treatment complication
Ponsetti Method: be careful to avoid what during first cast?
pronation of forefoot
must SUPINATE so that it lines up with the hindfoot
MRSA infection have a (lower/higher) chance of needing surgery and (more/less) operations until cure?
Higher
More
Three conditions associated with DDH to check for on physical exam?
congenital muscular torticollis (20%)
metatarsus adductus (10%)
congenital knee dislocation
Non-ortho manifestations of Down (3)
Cardiac abnormaltieis (50%)
Endocrine (hypothryoidism)
mental retardation
premature aging
Next step if Pavlik harness treatment fails?
Convert to abduction brace for 3-4 weeks.
What are “Thumb” and “Wrist” signs associated with?
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.
What condition is associated with MadeLungs?
Leri-weill dyschondrosteosis
SHOX gene abnormality
Causes mesomelic dwarfism
My PAL Adrian eats HAM on his CPM machine.
How does this help you pass the exam?
PAL = Pseudoarthrosis is AL bowing
HAM = Hemimelia is AM bowing
CPM = Calcaneovalgus is PM bowing
What are physical exam findings consistant with equinovarus foot?
- intoed gait
- inverted heel (tib post)
- supinated forefoot (tib ant)
- callous and pain along lateral border
Why would you do a squatting skyline xray?
To diagnose symptomatic bipartate. Compare with static and if there is separation then there may be a fracture of the fibrocartlaginous connection.
BBFF - initial management?
SAC
Found to have lower remanipulation rates
Lower pain/swelling at 1 and 7 days post reduction
Most common complication of lateral condyle fracture?
Lateral overgrowth/spurring
In neuromsucular scoliosis that affects lungs, at what FVC can you safely perform surgery
30% and above
6 Dural Ectasia associations
Marfan syndrome
NF1
Ehlers-Danlos
Achondroplasia
Ank spond
idiopathic
Two indications for endocrine workup in a SCFE?
- child is < 10 years
- weight is < 50th percentile
What motion is most limited in patient with Sprengel;s?
Abduction
also Forward flexion
Torticollis: head tilt and rotation which direction?
Tilt: towards side of pathology
Rotation: chin rotates away from pathology
Kid has >40 deg of ER (>3 SD) at age 12 and functionally limiting. ER due to external tibial torsion. Plan?
Supramalleolar derotational osteotomy > proximal tibial osteotomy
More complications with proximal
Surgical option for pathologic genu valgum:
a) with significant growth remianing
b) near the end or done growing
a) Medial hemiepiphysiodesis
b) Distal femoral closing wedge osteotomy + release of peroneal nerve
MRSA infected kids have higher levels of what on admission?
ESR, CRP, WBC
Pathology in SMA
Progressive loss of alpha motor neurons in anterior horn of spinal cord
Muscle weakness LE > UE (like anterior cord syndrome)
Proximal > distal
How much shortening is acceptable in femoral shaft fractures and why?
2cm
b/c if accounts for anticipated overgrowth during healing of 1-2cm
Treatment for posteromedial bowing?
What must you monitor for with your treatment plan?
Non-operative - will spontaneously resolve in 5-7 years
Must watch for LLD (common complication)
Risk factors for SMA syndrome in AIS surgery (7)
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)
List the normal progression of leg angulation:
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)
Diagnosis and most common site/cause
Congenital pseudoarthrosis of the clavicle
Caused by extrinsic compression by the subclavian
Right middle 1/3 of clavicle 90%
Left only if situs inversus
Treatment of hip abduction contracture in myelodysplasia
Ober-Yount Procedure:
proximal division of fascia lata and IT band release
3 orthopaedic associations with tibial deficiency.
Ectrodactyly (cleft hand)
preaxial polydactyly
ulnar aplasia
high rate of MSK anomalies (75%)
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?
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
3 treatment options for NF related tibial bowing?
- Total contact orthosis - bowing without fracture
- ORIF with bone graft (Charnley Williams rod or Ilizarov) - pseudoarthrosis or fracture
- Amputation - 3 failed ORIF attempts
Plantarflexion lateral of two cases with rockerbottom sole deformity.
What is the diagnosis in A and B?
A = Congenital oblique talus
B = Congenital vertical talus
(Difference is that Oblique talus corrects the talonavicular joint with stress plantarflexion lateral)
Anatomic Classifiation of CP
Quadriplegic
Diplegic (Legs > arms, usually normal IQ as midline brain deficit)
Hemiplegic
Signs of Dystrophic Curve (7)
Gibbous deformity: short segment kyphoscoliosis
Rib penciling
Intra-canal ribs
Vertebral body scalloping
Dystrophic pedicles
Dural ectasia
Intraspinal neurofibroma
3 ultrasonographic measurements in DDH
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)
Best 2 tests for septic hip?
T > 38.5
CRP > 2
3 poor prognostic indicators for subtalar coalition
1 contraindication to surgery
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
Name a contraindication to hemiepiphysiodesis in congenital scoliosis:
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)
Compare infantile and adolescent Blounts
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
What is the most common complication of proximal femur fracture?
AVN
(Coxa vara and non-union also important)
What protein is elevated in 75% of fetus in second trimester if they have spina bifida?
alpha-fetoprotein (AFP)
Toronto score (Active Movement Scale) of what is an indication for surgery in brachial plexus injury?
<4
>4 = activity against gravty
(Different UE functions are graded on a scale and added together)
What is the biggest risk factor for re-fracture after surgical treatment of pediatric femur fracture?
Use of ex-fix
(Especially with transverse or short oblique fractures)
3 indications for CRPP of pediatric distal radius fracture.
- Failure of cast management
- SH 1 or 2 with NV compromise (reduces the need for constricting cast)
- Fractures which required reduction under anesthesia (ie. failed ER reduction)
Indications for OR with medial epicondyle fracture? (4)
Preferred fixation?
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
5 Characteristics of trigger thumb
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)
Contraindication to treatment of paediatric femur fracture (open physes)
Piriformis start femoral nail
b/c of increased risk of AVN
superior retinacular vessels of MFCA are at risk
What investigations must you do in a patient with Klippel Feil?
Echo (cardiac manifestations)
Renal ultrasound (renal aplasia)
4 surgical indications for coxa-vara
Trendelenburg gait + Hilgenreiner-epiphyseal angle beween 45-59 degrees
Progression of coxa vara on serial x-rays
HE angle > 60
femoral neck shaft angle
Diagnosis?
Equinovalgus
i.e. CP foot
Clues:
Inferior tilt of talus
Loss of medial arch
Predictors of poor outcome in paediatric septic hip (4)
Age
Associated OM
Hip joint (vs knee)
Delay > 4 days until treatment
(JAAOS)
8 risks for brachial plexus birth injury
Large of gestational age
High birth weight
Cephalopelvic disproportion
Shoulder dystocia
Forceps delivery
Difficult presentation
Breech position
Prolonged labour
3 surgical treatment options for Adolescent Blounts?
- Transient lateral hemiepiphysiodesis
- Permanent lateral hemiepiphysiodesis
- Valgus HTO with ORIF or gradual corrrection (ilizarov or TSF)
Risk factors for SCFE (7)
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
Name 3 general surgical intervnetions you can do for tibial hemimelia
- 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)
3 treatments for a hemophilac knee?
i.e. for
- chronic synovitis
- recurrent hemarthrosis
- joint destruction
- Surgical Synovectomy
- Radioactive Synovectomy
- TKR
Spinal manifestations of diastrohpic dysplasia
AAI
Cervical kyphosis
TL kyphoscoliosis
Rarely needs treatment
Most common cause of septic hip in neonates?
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)
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.
- rash
- presence of RF
- iridocyclitis (anterior uveitis)
- C-spine involvement
- pericarditis
- tenosynovitis
- intermittent fever
- morning stiffness
You do an iliac crest biopsy to confirm diagnosis of OI.
3 positive findings?
decrease in cortical widths
decreased cancellous bone volume
increased bone remodeling
Classification of lateral condyle fracture and treatment algorithm?
I: undisplaced (<2mm) (nonop)
II: 2-4mm displaced (CRPP vs ORPP)
III: >4mm displaced (ORIF or ORPP)
3 advantages of nancy nailing over ORIF
- shorter surgical time than ORIF
- less blood loss than ORIF
- equal union rates, radial bow and rotation as ORIF
4 maternal risk factors for congenital scoliosis
diabetes
alcohol
valproic acid
hyperthermia
SCHF with cold, pulseless hand. Management?
Immediate CR & PP
Open is not first step
What is the strongest independent risk factor for septic arthritis in paeds?
CRP >20mg/L
(even though it’s not on the Kocher criteria)
Main vascular concern in tibial tibercle fracture?
Tear of recurrent anterior tibial artery
May assess with CT-A if concerned
Leads to compartment syndrome
You cant reduce a galleazzi fracture. What is most likely blocking reduction and which approach do you take to remove it?
ECU
Dorsal
A SCHF patient has an ulnar nerve palsy. What fracture type is it likely to be?
Flexion type
Most common nerve palsy after flexion type injury is ulnar
Managmenet and timing of treatment of congenital vertical talus?
Start with casting to stretch dorsal structures
followed by surgery in almost all cases
OR before 27 months for best results
Name 1 important surgical difference in treatment of infantile vs. adolescent Blount’s:
Infantile: overcorrect into 10-15 degrees of valgus b/c medial growth abnormalities still exist
Adolsecent: Do NOT overcorrect
Flat top talus is a complication of what casting method?
Ponseti
What is the primary treatment for Gauchers?
IV enzyme replacement therapy.
Not effective in type 2.
Medications end in -glucerase.
Also consider bone marrow transplant
Stretching is a reccomendation for flexible flatfoot. If it is flexible wtf are you stretching?
Tight heel cord
Physiologic Classification of CP
Spastic
Athetoid
Ataxic
Mixed (Usually Spastic/Athetoid)
Hypotonic
Describe the physical therapy regimen ideal for stiffness post supercondylar fracture?
None
General treatment principle for Downs Spine
Nonoperative management if possible - high complication rates with surgery
What is the managmeent algorithm of Fibular deficiency?
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
8 radiographic findings in Blount’s disease
and one physical finding
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
How do you screen for and diagnose MPS?
Screen: urine
Diagnose: enzyme assay for activity in skin fibroblasts or WBC
What is the anatagonist of peroneus Longus?
Tibialis anterior
How do you reduce BADO I/III?
Flexion & supination
How does the acetabular deficiency is a spastic child differ from typical DDH?
posterior-superior instead of anterior/anterolateral
What is the role of enzyme replacement and bone marrow transplant in muccopolysaccharidosis?
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.
Diagnosis?
Give 1 dDx
Multiple Epiphyseal Dysplasia
Classic for MED to present as “bilateral” Legg-Calve-Perthes disease
What is an Evans osteotomy and what deformity does it correct?
Corrects hindfoot valgus.
(calcaneal lateral column lengthening osteotomy)
Poor nutritional status (weight < 5th percentile) is associated with what post-op complications in paediatrics?
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
Infetion of staph aureus with what gene encoding is associated what more complex infections?
PVL (Panton-Valentine leukocidin) +
Complications of clubfoot correction (non op: 2, op: 6)
Nonop complications
- deformit relapse
- dynamic supination
Operative complications
- Residual cavus
- pes planus (due to overcorrection)
- undercorrection
- intoeing gait
- Osteonecrosis of talus
- dorsal bunion
Management of unilateral pars defect at L4 that has failed conservative management.
Pars Repair
Indiated at L4 and above
L5: must fuse in-situ
Name the physeal zone associated with:
Metaphyseal “corner fracture” in child abuse
Scurvy
Primary Spongiosa
4 factors predictive of physeal arrest in distal femur physeal fracture
SH classification
Presence of displacement
open fracture
Hardware penetration into physis from surgical management
Why do you wait to get x-rays in polydactyly patients (foot)
To allow full ossification of phalanges and plan surgery
Surgical ablation typically done at 9-12 months of age
what are the orthopaedic issues in NF?
(What type of music do NF patients listen to?)
Extreme SKA
1. Extremity deformities
Hemihypertrophy
Pseudoartrhosis
AL Bowing
2. Scoliosis
3. Kyphosis
4. AAI
4 radiographic signs of hemophila on knee xray?
- squaring of patella and femoral condyles (Jordan’s sign)
- ballooning of distal femur
- widening of intercondylar notch
- patella appear long and thin on lateral
Preferred surgical option for a large talocalcaneal coalition?
Triple fusion
What is the most common type of child abuse?
Neglect
Followed by physical > sexual > emotional maltreatment
What is the radiographic definition of Blount’s disease? Of Physiologic varus?
Metaphyseal-diaphyseal angle of Drennan
Blounts >16 degrees
Physiologic
In what direction does the ankle physis close and what part closes last?
central (first)
medial
posterior
anterolateral (last)
Describe the boney deformities of clubfoot?
- talar neck is medially and plantarly deviated
- calcaneus is in varus and rotated medially around talus
- navicular and cuboid are displaced medially
What is Arthroereisis.
What is the fusion version of this?
Sinus tarsi pin/screw to jack up the hindfoot out of valgus
Grice procedure involves doing this with ICBG
What is normal thigh foot angle?
0-20 of ER
Post tibial spine fracture, what is the factor most highly linked to arthrofibrosis?
Prolonged immobilization > 4 weeks
So start mobilizing before then
4 dDx for growth plate widening in kids:
Rickets
Scurvy
Schmid’s metaphyseal chondrodysplasia
Delayed maturation (illness)
Endocrine pathology
- Excess GH
- Hyperparathyroidism
- Hypothryoidism
Define Baumans Angle
Line down axis of Humerus
Line through lateral condylar physis
Angle between them
SHould be 70-75
5 general causes of LLD
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
8 injury patterns suspicious for child abuse
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
Should kids with MRSA attend school?
Play sports?
Yes, only if their wound/abscess/draining pus can be adequately covered up
They should not use pools or treatment pools
Treatment algorithm for tibial deficiency
What is is based on?
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
In surgical correction of blounts, what do you have to include in Langenskiold V, VI?
Epiphysiolysis (bar resection)
Where should pins be placed and why, for pediatirc femur ex-fix?
Laterally
To reduce quads scarring.
What aspect of deformity will not remodel in femoral mal-unions?
Rotation
Surgical treatment of flexible cavovarus foot?
(4 elements)
- plantar fascia release
- Tib Post transfer
- 1st ray dorsiflexion osteotomy
- TAL (says orthobullets, but this is wrong as achilles is already loose in cavovarus - incr calc pitch - as in SPORC2016)
Foot polydactyly classification?
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
What does Hilgenreiner’s-Epipyseal angle predict?
What are the values?
Predicts natural history of coxa vara
Normal:
Will resolve spontaneously if
Will need surgery if >60
When do you mobilize a medical epicondyle fracture in paediatric patients?
Early - after about a week if nondisplaced/displaced
PFFD:
4 indications for limb lengthening with the goal of ambulation without prosthesis.
- predicated limb length discrepancy of >20cm
- stable hip and functional foot
- femoral length >50% of opposite side
- femoral head present (Aiken classifications A & B)
INdications for hemiepiphysiodesis in congenital scoli
Failure of formation (hemivertebra)
patient <4
Curve < 40 deg
(only get about 15 degrees of correction. Contraindicated in failure of segmentation)
RIsk of AVN with paediatric hip factures
Type I: 80-100%
Type II: 50%
Type III: 30%
Type IV: 10%
Acceptable alignment distal radius fracture
>9: 20 degrees dorsal angulation. No bayonet.
No rotation in either case
4 risk factors for thermal burns with casting
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
How much bend do you want in a nancy nail?
3x canal size
What is Friedrichs Ataxia?
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.
Treatment of oblique talus?
Treatment typically consists of observation and shoe inserts
Some require surgical pinning of the talonavicular joint and Achilles lengthening for persistent subluxation
Foot muscular Imbalances in Hereditary Motor Sensory Neuropathy?
- 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
How do you reduce a nursemaid’s elbow?
Supinate forearm and flex elbow to 90 deg
dDx for torticollis
Congenital muscular torticollis
AARD
Grisel’s disease
Klippel-Feil
Most common radiographic spinal finding in Down syndrome:
Atlanto-occipital instability (17%)
AAI is second most common at 11%
4 risk factors for DVt in pediatric psteomyelitis?
CRP > 6
surgical treatment
age > 8-years-old
MRSA
Name (9) associated conditions with fibular deficiency
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
What zone of the growth plate does Little Leaguer’s shoulder occur?
Hypertrohpic zone
Pediatric elbow dislocation - most common nerve injury
Ulnar nerve
Describe, in detail, the Ponseti method
- 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
What is the most common manifestation of child abuse?
Skin manifestations (bruises, burns)
Fractures are the second most common
Summarize treatment for COxa Vara in dwarves in one sentence.
Valgus intertrochanteric osteotomy for a neck shaft angle of less than 100 degrees.
Name the syndrome associated with polyostotic fibrous dysplasia. Name the other associated abnormalities
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
What are the American Academy of Pediatric’s recommendations on kids and car safety (where they sit)?
(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
What is Little Leaguer’s Shoulder?
SH 1 injury of the proximal humerus
Overuse injury
In congenital vertical talus what can you use as a proxy to the navicular (b/c it hasn’t ossified yet) to determine diagnosis
1st MT
According to AAOS AUS (2016), what is the best pin configuration for SCHF?
Lateral pins are safer
Medial pins (cross pinning), can be used in highly unstable fractures that need more staiblity (crossed pinning biomechanically superior)
Treatment if you malunite a femoral neck fracture into varus in paeds
Epiphysiodesis of the GT apophysis
Goal for coxa vara correction in paeds
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
3 ways that Beckers differes from Duchennes?
- dystrophin protein is decreased instead of absent
- later onset with slower progression and longer life expectancy (average diagnosis occurs at age 8 compared to 2 years of age with Duchenne’s)
- more prone to cardiomyopathy
By the time you transition from casting to boots and bars for Ponsetti, how much abduction should the foot be in?
70 degrees
Explain how the Silfverskiöld test works!
- Improved ankle dorsiflexion with knee flexed = gastrocnemius tightness
- Equivalent ankle dorsiflexion with knee flexion and extension= achilles tightness
Describe the spectrum of myelodysplasia
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
Paediatric trigger finger - waht must you release?
A1 pulley + 1 slip of FDS
Best xray to ID a SCFE?
lateral
3 radiograhpic findings of SCFE
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
What type of SCHF is not associated with cubitus varus?
Flexion type
It goes into cubitus valgus
Name 3 copmlications of VEPTR
Thoracic outlet syndrome
Rib fracture
Skin breakdown
(NOT clavicle fracture)
4 surgical treatment options for congenital pseudoarthrosis of tibia (anterolateral bowing)
IM Nail with bone graft
Free (vascularized) fibular graft
Ilizarov frame
Amputation
Most common cause of septic hip in adolescents? Treatment?
Neisseria gonorroeae
High dose penicillin (does not need OR)
Most important thing to look for when examining tibal hemimelia?
Is the extensor mechanism intact and is there a flexion contracture of the knee.
2 main presentations and gene association of multiple epiphyseal dysplasia?
COMP (cartilage oligometric matrix protein)
causes mutation in COL9A1, A2 & A3
2 main presentations
- dwarfism
- Early OA
5 Ortho manifestations of OI (there are many)
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
How do you tell the difference between posteromedial bowing and calcaneovalgus foot?
Posteromedial bowing: apex is in distal tibia
Calcaneovalgus foot: apex is at ankle joint
What is the Safe zone in DDH reduction?
how do you increase it?
ROM at which hip stays reduced
typically:
90-100 degrees flexion
mild abduction of 20-45 degrees
increase it with adductor tenotomy
Where will the conus medullaris lie in a tethered cord?
BELOW L23 - b/c it’s tethered down
You reduce a dislocated DDH hip. Development of what radiologic landmark in the next few months is considered a positive prognosticator?
Teardrop - not usually present in a dislocated hip.
3 radiographic signs not involving the fibula associated with fibular hemi-melia?
- tibial spines are underdeveloped
- intercondylar notch is shallow
- ball and socket ankle joint
Indication for physeal bridge resection?
When would you do it with an osteotomy?
>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)
dDx of toe walking (4)
CP
DMD
Tethered Cord/spinal dysraphism
Diastematomyelia
CMT
Unilateral Short limb causing unilateral toe walking
Non-ortho
Autism
Schizophrenia
2 indications for exploring the artery in a supercondylar fracture
Pulse is lost after reduction
Persistance of pulseless hand after reduction
OM in kids with what bug causes an increased risk of DVT?
MRSA
Last elbow ossification center fo FUSE?
Medial epicondyle age 17
7 characteristics of Infantile Blounts on workup?
- varus focused at proximal tibia
- severe deformity
- asymmetric bowing
- progressing deformity
- sharp angular deformity
- lateral thrust during gait
- metaphyseal beaking
- different than physiologic bowing which shows a symmetric flaring of the tibia and femur
How do you decide what size of nancy nail?
- nail size determined by multiplying width of narrowest portion of femoral canal by 0.4
- the goal is 80% canal fill
3 favourable and 5 poor prognostic indicators for obstetric brachial plexus injury
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
4 Syndromes affecting Reserve Zone
Gaucher’s
Diastrophic dysplasia
Pseudoachondroplasia
Kniest
“Kontio Panics with Dinner Gratuities”
What is best position in Pavlik and what do the straps do?
- Flexion 90-100° (controlled by anterior straps)
- Abduction of 50° (controlled by posterior straps)
3 keys to surgical treatment of CVT?
- release of tight dorsal lateral structures
- pinning of talonavicular joint
- reconstruction of spring ligament
What are the stages of LCP?
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
What part of the acetabulum is deficient in a NON-neuromuscular hip dysplasia?
Anterior or anterolateral
Indications for poor prognosis in bracing of AIS
poor in-brace correction
hypokyphosis (relative contraindication)
male
obese
noncompliant (effectiveness is dose related)
What is the angle of Drennan and what is it used for?
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
What is the consequence of lateral spurring post lateral condyle fracture?
None - it has no effect on outcomes
What is the sudden cause of death in a patient with FGFR3 mutation
FOramen magnum stenosis
Phase 1 or 2 rib at an increased risk of progression?
Phase 2: rib overlap with apical vertebra
What are the main components of spondyloepophyseal dysplasia? (5)
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
Name this implant, procedure, and what its done for:
telescopic rod for Schofield-Miller realignment procedure for OI
Can use telescoping or non-telescoping rods
4 treatment options for fibular hemi-melia and their indications?
- Shoe lift (
- Contralateral epiphysiodesis (LLD
- Limb lengthening (projected LLD less than 30%, stable plantigrade foot, must remove fibular anlange)
- AMputation (nonfunction foot or LLD > 30%) - do at 1 year of age
Best predictor of success with tendon transfers in CP?
Patients with good voluntary control had the greatest improvement in functional use scores.
Radiographic classification of subacute paediatric OM:
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
Most common inheritance pattern of hereditary motor sensory neuropathy (HMSN). Name 2 other types
AD most most common
So counsel parents and patients on risks of future generations
can be AR and X-linked
What is the cuase of a fishtail deformity of the distal humerus?
lateral trochlear ossification center AVN
3 blocks to reduction in proximal humerus reduction
long head biceps
capsule
periosteum
What disorder is Botox contraindicated in?
Spinal muscular atrophy
What do you have to take into account when planning scoliosis correction in a myelodysplastic patient? (2)
Anterior fusion
- Posterior elementsare dysplastic and may impair fusion
- Therefore have a high pseudoarthrosis rate
High infection rate
- due to poor soft tissue coverage
2 xray views to assess clubfoot?
dorsiflexion lateral (Turco view)
AP
Look for parallelism, low talocalcaneal angle, and negative talus-first metatarsal angle
SMN gene association
SMN = Survival Motor Neuron = gene mutation for Spinal muscular atrophy
In OI, fractures heal normally/abnormally?
Normally
They remodel abnormally
Manifestations of Gauchers (5)
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)
8 features of congenitally dislocated radial head
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
Name 5 reduction techniques of radial head reduction:
Elastic bandage
Patterson
Israeli
Metaezeau (retrograde pin)
K-wire joystock
Start point for retrograde femoral nancy nails?
2-2.5 cm proximal to distal physsi
4 manifestations of osteopetrosis?
- Appendicular fractures
- Osteomyelitis
- Cranial nerve palsies
- Coxa vara
Pin configuration post CRPP of distal femoral physeal injury
antegrade
avoids going intra-articular and avoids pin-tract infection into joint
What is the Pirani score?
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
4 indications for ORIF in BBFF?
Open fractures
Refractures
Failure of nonoperative management
BBFF kids >13
Indications for MRI in scoliosis case
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
Compared to closed reduction, open reduction of radial head/neck fractures has what 3 outcomes?
Greater loss of motion
Increased rates of AVN
Increased rates of synostosis
What part of the growth plate does SCFE secondary to renal osteodystrophy occur?
Secondary spongiosa
Major cause of death for patient with Friedrich’s Ataxia
cardiomyopathy
Must workup with Echo
4 indications for operative management of proximal humerus fracture (peads)?
Adolescent with severe deformity (> 45 degrees or
Vascular Injury
Open fracture
Intra-articular displacement
3 non-ortho manifestations of Ehlors Danlos?
- mitral valve prolapse
- aortic root dilatation
- gastroparesis
Define the types of dwarfism and give an example:
Rhizomelic
Mesomelic
Acromelig
Micromelic
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
What is a common block to reduction of tibial eminence fractures?
Medial meniscus
Acceptable reduction criteria required for femoral shaft fractures in peds?
- Less than 10 degrees varus/valgus
- Less than 20 degrees AP
- no more than 2cm of shortening or 10° of rotational malalignment
Risk of recurrence/refracture of pseudoarthrosis of tibia?
50%, even after initial union
How do you immobilize Bado I, III fractures?
Immobilize in 110 degrees of flexion for Bado I, III to relax biceps and tighten IoM
minimally invasive technique to treat congen. vertical talus: describe steps
- reverse ponseti casting until TNJ reduced (LLC)
- pin TNJ
- perc TAL (like clubfoot)
- LLC x 5 weeks (one cast change)
- cast off, pin out, AFO until 2yo
as per Dobbs et al. 2006 JBJS
Genetic transmission of DMD
X linked recessive
Important to counsel patients of risk of subsequent kids with the disease
What is the normal progression of coronal knee alignment in childhood?
Varum under 2
Neutral at 14 months
Peak valgus at 3 years
Physiologic valgus at 7 years
3 types of CP gait
toe walking
crouched
stiff-knee
4 radiographic signs of osteopetrosis?
“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
2 indications for surgical treatment of AAI in DOwns?
- myelopathic patients
- ADI > 10 mm
Indications for fusion in DMD scoliosis
FVC
rapid progression
poor response to steroid
non-ambulatory status (b/c they progress quickly)
3 associated endocrine disorders with SCFE
Hypothyroidism
Osteodystrohpy of CRF
Growth HOrmone Treatment
What is the major source of blood to the physis?
Perichondrial artery
2 important complications of tibial tubercle fracture?
COmpartment syndrome - anterior, due to anterior recurrant tibial artery
Recurvatum - anterior growth arrest, posterior keeps growing
3 factors (other than age) that differentiate adolescent Blounts from Infantile Blounts?
- More likely to be unilateral
- More association with LLD
- Can have MCL laxity
- No metaphyseal beaking
CP hip management based on Reimer’s Migration Index
Soft tissue release
Children 40%
VDRO + ST release
Kids >4 OR Reimer’s index >60%
Abduction osteotomy or girdlestone procedure
Chronic painful dislocation
4 indications for open reduction of pediatric traumatic hip doslocation?
- nonconcentric reduction
- intra-articular fragment
- unstable acetabular rim fracture
- irreducible by closed means
Indications (3) & Contraindications(3) for Centralization procedure in Radial clubhand. What age should it be done at?
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
Most commonly used meidcation for treatment of OI?
Bishphosphonates increase cortical thickness, fewer fracture.
Early investigations for Larsens?
1) Spine - AP/Lat - look for Carvical Hyphosis
2) Hip imaging - dislocation
How many ossification centers in the proximal humerus?
3: HH, GT, LT
2 indications for CR and hip spica for DDH?
- Age 6-18 months
- Failed Pavlik
Why is ASF indicated in spina bifida related scoliosis?
dysplastic posterior elements that may impair posterior fusion
Medical treatment of bone crisis for sickel cell?
hydroxyurea
2 options for tendon transfers of HMSN?
tib post to dorsum of foot
peroneus longus to brevis
Where does congenital pseudoarthrosis of the clavicle almost always happen? What is the exception?
Right middle 1/3
situs inversus is the exception
2 main surgical options for tibial hemimelia?
1) No ext mechanism/ absent tibia = knee disarticulation
2) Proximal tibia present with intact extensor emchanism = tibiofibular synostosis with modified Syme amputation
Mainstay of treatment in duchenne muscular dystrophy? What effect does it have (3)
Corticosteroids
- prolongs ambulation
- slows scoliosis
- slows deterioration of FVC
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?
Empiric Abx
NOT MRI - b/c of risks of conscious sedation with MRI/biopsy, just start abx.
This was an MCQ
Why doe CMT pts get claw toes?
Increased toe extensor recruitment due to weak Tib Ant, this combined with weak foot intrisics result in claw toes.
BBFF: malrotation at what level has what effect?
Midshaft malrotations lead to decreased supination
(vs distal malrotation)
Best radiographic way to follow CP hips
Reimer’s Migration Index
DDH U/S:
What is beta angle and what is normal?
- angle created by lines along the labrum and the ilium
- normal is less than 55°
radiographic definition of vertical vs. oblique talus
Forced plantarflexion lateral
Meary’s angle >35 is congenital vertical talus
4 operative indications for proximal humerus fracture in paeds
Severely displaced fracture in kid age >11 (Neer-Horowitz 3/4)
Open fracture at any age
Vascular injury
Intra-articular displacement
5 Risks for CP
Prematurity (most common)
Anoxic injury
Prenatal intrauterine factors
Perinatal infections (ToRCH, toxoplasmosis, rubella, CMV, Herpes)
Meningitis
Brain malformations
7 Physical or radiologic signs of child abuse?
- long bone fxs in infant that is not yet walking
- multiple bruises
- multiple fxs in various stages of healing
- corner fxs
- posterior rib fractures
- bucket handle fractures
- transphyseal separation of the distal humerus
- single transverse long bone fractures
- skull fractures
Spinal manifestations of achondroplasia vs. pseudoachondroplasia
Achondroplasia
- foramen magnum stenosis
- kyphosis
- lumbar stenosis/decreased interpedicular distance
Pseudoachondroplasia
- cervical instability
Risk factors for AVN post pinning of a SCFE. (5)
- unstable SCFE
- over-reduction of an acute slip
- attempted reduction of a chronic slip
- pins in the superolateral quadrant
- femoral neck osteotomy
Classic findings in Friedrich’s ataxia
Ataxia
areflexia
positive plantar response
What is contraindicated in the treatment of atlanto-occipital dissociation in paeds?
Halo + traction
Risks displacement of injured occipitocervical joint
(JAAOS 2014)
Congenital knee dislocation
Give 3 syndromic associations and 3 orthopaedic associations
Syndromic:
- Larsen’s
- Meningomyelocoele
- Arthrogryposis
Orthopaedic
- hip dysplasia
- clubfoot
- metatarsus adductus
Why do a Rhizotomy?
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
Complication with too mcuh abduction in DDH treatment?
AVN of femoral head
via impingement of the posterior-superior retinacular artery
dDx for global hypotonia (2). How do you tell the difference?
SMA:
- absent DTR
- fasciculations (including tongue)
Duchnne muscular dystrophy
- present DTRs
Also:
Emery-Dreifuss dystrophy
limb girdle dystrohpy
Guillain-Barre syndrome
4 conditions associated with PFFD?
- fibular hemimelia (50%)
- ACL deficiency
- coxa vara
- knee contractures
Second most common nerve palsy in SCHF?
radial
AIN most common
What percentage growth of the humerus comes from the proximal growth plate?
80%
You plan a femoral derotational osteotomy on a child with femoral anteversion.
Where do you make your osteotomy?
How much correction do you need?
intertrochanteric osteotomy
amount of correction = (IR-ER) / 2
Two MSK findings associated with bladder extrophy?
- acetabuli are ~12 degrees externally rotated
- without pubis to tether the anterior ring, the posterior elements externally rotate
- gait shows an external foot progression
What level myelomeningocoele has a higher risk of hip dislcoation?
L3
+ adductors, no abductors
= higher risk of dislocation
Marginal ambulators
paeds patient with femur fracture. >100lbs. Result with flexible IM nail?
Increased risk of complications such as nonunion
Age range for open reduction and hip spica +/- femoral osteotomy?
18 months - 4 years
Name 2 surgical options for treatment of Sprengel’s
Woodward’s
Green
Leibovic
Bellman’s
Mears
Outcomes of CRPP vs. ORIF in BBFF: (3)
Shorter OR time than ORIF
Less blood loss than ORIF
Equal union rates, radial bow and rotation as ORIF
3 causes of painful flatfoot.
- tarsal coalition (sinus tarsi pain)
- congenital vertical talus (rocker bottom foot)
- accessory navicular (focal pain at navicular)
Most common complication from tibial tubercle fracture?
Recurvatum
physeal arrest anteriorly while posterior continues to grow –> decreased tibial slope
5 Orthopedic (non-spine) manifestations of Achondroplasia?
- 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
How do you immobilize a Galleazzi fracture?
In supination
What life-threatening allergy do most myelodysplastic patients have? What is the mechanism?
IgE mediate allergy to latex
severe anaphylaxis
Present in 20-70%
4 peri-operative considerations if operating on a Gauchers?
- Pre-operative enzyme replacement
- Hydration to reduce risk of bone crisis
- Increased risk of infection
- Increased bleeding risk
3 facets of first line treatment for JIA?
- steroid injections
- DMARDs
- etanercept, rituximab, azathioprine - Opthamologic Exams
Most common long term sequelae of brachial plexus birth injuries
Glenoid retroversion
Due to IR of shoulder due to Erb’s palsy
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?
1) Less than 10° of external rotation on exam in an older child (>8-10 yrs)
2) Intertrochanteric
3) (IR-ER)/2
Assume growth in males and females stop at what age?
Males: 16
Females: 14
6 signs of preganglionic brachial plexus injury
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)
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?
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.
in osteo with community acquired MRSA, what should you consider doing?
Screen for DVT
Rapid CT-PE if any suggestive signs
What is contraindicated in the treatment of DMD scoliosis?
Bracing
may interfere with already compromised respiraotry function
RUNX2/CBFA1 mutation
cleidocranial dysplasia
They have to RUNX2 b/c they can’t use their arms (no clavicles)
DDX for Genu Valgum?
- 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
Non-ortho manifestations of DMD
cardiomyopathy
static encephalopathy
Respiratory issues
Treatment of tibial spine fractures by classification
Name 2 blocks to reduction
Meyers & McKeevers
I: nonp
II: CR + Cast vs. operative
III: operative
IV: operative
Blocks to reduction:
meniscus
intermeniscal ligament
Name 6 associated abnormalities with Sprengel’s
Scoliosis (most common)
Klipper-Feil
Spina bifida
omovertebral bone
rib anomalies
clavicular abnormalities
humeral shortening
foot abnormalities
General order of closure of the distal tibial growth plate?
Central, then medial, then lateral
This is why you get a Tillaux fracture, b/c it is the last part of fuse
dDx for abnormal dystrophin gene. How do you tell the difference?
DMD: complete absence
Becker’s: abnormal
How does MRSA get its virulence and resistance?
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
First surgical option for resistant Clubfoot?
posteromedial soft tissue release and tendon lengthening
DDH U/S:
What is maximal age (for usefulness)?
4-6 months
(i.e. use xray)
General Principals of Ilizarov technique?
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
What CP medication decreases acetylcholine levels in the synaptic cleft by blocking the presynaptic release of acetylcholine peripherally?
Botulinum toxin A
3 conditions that are commonly found with tibial hemimelia?
- ectrodactyly
- preaxial polydactyly
- ulnar aplasia
Most common nerve palsy in SCHF?
AIN
Major complication of lateral closing wedge osteotomy for cubitus varus?
Lateral prominence
Rib-Vertebral angle distance (RVAD/Mehta Angle) of what is at a higher risk of progression?
RVAD >20
What are some complications specific to operative treatment of club foot?
-
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
5 poor prognostic indicators for physeal bar:
Cause: Infectious worse than traumatic
Location: lateral worse than central
Size: >50% bad
Type: bony vs. fibrous
delay to presentation
When do SCHF pins come out?
3-4 weeks
When do lateral condyle pins come out after ORPP of lateral condyle fracture
6 weeks
Name 3 differences in the upper airway of a paediatric patient vs. adult
floppy epiglottis
large tongue
small larynx
