Paeds

Question 1

What are the weak and spastic muscles in equinovarus foot?

Answer 1

Spastic: TP and TA

Weak: PB, PL

Question 2

Treatment for physeal arrest:

Answer 2

Bar resection with interposition Indications

• Less than 50% growth plate involvement
• >2 years or 2cm growth remaining

Ipsilateral complesion of arrestIndications

• >50% physeal involvement
• Can combined with contralateral epiphysiodesis and/or ipsilateral lengthening

Question 3

Treamtnet of CP hips

Answer 3

Adductor and psoas release ± abduction bracing

• Kids < 4 & Reimer’s index >40%

Proximal femoral osteotmy & soft tissue release

• kids > 4 OR Reimer’s index > 60%

Abduction osteotomy or girdlestone

• Chronic painful dislocation in GMFCS 5

Salvage acetabular procedure (Chiari, shelf)

• Skeletally mature with subluxation/dislocation

Question 4

7 indicators of poor prognosis with LCP

Answer 4

Age (bone age) > 8 (bone age 6) years at presentation

Female

Decreased hip ROM (decreased abduction)

Gage sign: radiolucency in the shape of a V in the lateral portion of the epiphysis

Calcification lateral to the epiphysis

Lateral subluxation of the femoral head

Horizontal physis

Metaphyseal cysts

Question 5

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

Answer 5

A2 & A3

Question 6

Upper extremity contractures in CP

Answer 6

Shoulder IR

Elbow flexion

Forearm pronation

Wrist flexion

Thumb in palm deformity:

• Flexed MCP
• Extended IP

Finger-flexion deformity

Swan neck

Question 7

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

Answer 7

> 11 years

>49 kg

Remember to use lateral start point

Question 8

Classification for PFFD

Answer 8

Aiken

A:

• Femoral head: Present
• Acetabulum: normal

B:

• Femoral head: Present
• Acetabulum: Dysplastic

C:

• Femoral head: Absent
• Acetabulum: severly dysplastic

D:

• Femoral head: Absent
• Acetabulum: Absent

Question 9

What Risser stage correspnds to the fastest growth spurt?

Answer 9

Risser 0

Question 10

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

Answer 10

occur on the concave side of the curve

makes sense

They (in and of themselves) have no effect on curve size or rate of progression

(They are not talking about phase 2 ribs here, a la Mehta angle)

Question 11

Treatment algorithm of femur fractures in paeds:

Answer 11

• pavlik or early spica casting

7m - 5 years:

• • >2-3cm shortening: traction with delayed spica casting or ORIF

6-11 years:

• length stable: flexible IM nails
• Length unstable: ORIF (plates) vs. ex-fix

Approaching skeletal maturity (>11 years)

• length stable or
• Length unstable or >100lbs: IM nail with lateral start point
• Length unstable in proximal or distal end: ORIF plate/screws

Question 12

dDx for anterolateral bowing (2)

Answer 12

NF

tibial deficiency

Question 13

Indications for anterior approach in addition to posterior approach in scolisis

Answer 13

Large curve (>75 degrees)

Stiff curves

Skeletally immature (Risser grade 0, boys

Question 14

Indications for hemivertebrectomy in congenital scoli

Answer 14

Progressive curve >40 degrees

Patient <5

lumbosacral vertebra best (but can be done in thoracic)

(JAAOS 2004)

Question 15

dDx for septic hip? (3)

Answer 15

OM

Psoas abscess

Transient synovitis

Question 16

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

Answer 16

23 mm /year

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

Question 17

What is H and how does it help evaluate DDH?

Answer 17

Hilgenreiners Line

A normal head should be below it.

Question 18

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

Answer 18

Knee

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

Question 19

What x-ray is this?

What is the diagnosis?

Answer 19

45 degree oblique

Calcaneonavicular coalition

Question 20

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

Answer 20

Avoid sports if progressive radiographic instability or signs of myelopathy

Question 21

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

Answer 21

• girls at age 3
• boys at age 4

Question 22

What is the weakest zone of the growth plate?

Answer 22

Hypertrophic zone

Question 23

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

Answer 23

Indicated when deformity is present with a physeal bar of

<50% and at least 2 years or 2 cm of growth remaining

Question 24

Risk factors for birth fractures

Answer 24

Vaginal deliveries

breech presentation

prolonged labor

macrosomia (>4.5 kg)

Question 25

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

Answer 25

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

Question 26

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

Answer 26

Flexion, abduction, ER

Question 27

5 associated conditions of external tibial torsion:

Answer 27

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

Question 28

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

Answer 28

Varus if fibula intact. Valgus if fibula also broken.

Question 29

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

Answer 29

Valgus It causes varus displacement, leading to cubitus valgus

Question 30

BLocks to reduction in DDH

Answer 30

Labrum Inverted limbus capsule transverse acetabular ligament ligamentum teres pulvinar

Question 31

Common injuries associated with TL spine trauma in paeds

Answer 31

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

Question 32

7 donor options for nerve transfer in Brachial plexopathy?

Answer 32

sural intercostal spinal accessory phrenic cervical plexus contralateral C7 hypoglossal

Question 33

Zone of injury for proximal humerus fractures?

Answer 33

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

Question 34

2 life-threatening intra-operative complications in DMD:

Answer 34

intraoperative cardiac event malignant hyperthermia Consult anesthesia & cardio preop

Question 35

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

Answer 35

OI (best for type 4)

Question 36

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

Answer 36

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

Question 37

What is P and how does it help evaluate DDH?

Answer 37

Perkins Line Femoral head ossification should be medial to this line

Question 38

Kid with hemihypertrophy. What must you do?

Answer 38

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

Question 39

Criteria for Septic Hip

Answer 39

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

Question 40

Risk factor for AVN of the hip

Answer 40

Trauma Steroid use Radiation

Question 41

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

Answer 41

oblique talus: navicular will reduce on plantarflexion latearl Meary's angle \<35 degrees

Question 42

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

Answer 42

lateral to the intertrochanteric line To avoid screw impingement

Question 43

Criteria/algorithm for septic arthritis vs. transient synovitis

Answer 43

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

Question 44

7 options for interpositional graft after resection of physeal bar:

Answer 44

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

Question 45

3 indications for ORIF in pediatric distal femur fracture?

Answer 45

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

Question 46

Reduction Maneuver for displaced medial epicondyle fracture into joint?

Answer 46

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

Question 47

Treatment for dynamic supination post clubfoot

Answer 47

Tib ant transfer to lateral cuneiform

Question 48

When can you determine the Herring stage in LCP?

Answer 48

Fragmentation stage (~6 months after symptoms start)

Question 49

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

Answer 49

Loss of reduction Although rare

Question 50

Classification of tibial spine/eminence fractures

Answer 50

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

Question 51

Diagnosis

Answer 51

Bisphosphonates on OI Results in metaphyseal banding at each dosing

Question 52

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

Answer 52

a) TA stronger b) TA weaker

Question 53

Name 3 conditions that can present with teratologic hip?

Answer 53

arthrogryposis myelomeningocele Larsen's syndrome

Question 54

What is the Sofield-Miller procedure?

Answer 54

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

Question 55

Three methods of predicting LLD?

Answer 55

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

Question 56

DDH U/S: What is minimal age?

Answer 56

4-6 weeks.

Question 57

Treatment options for Delbet 1--4?

Answer 57

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

Question 58

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

Answer 58

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

Question 59

X-ray findings of clubfoot

Answer 59

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

Question 60

Most common complication after distal femoral physeal injury

Answer 60

LLD/growth arrest

Question 61

Name 5 non-ortho manifestations of OI

Answer 61

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

Question 62

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

Answer 62

No Manage with close observation and no restrictions

Question 63

Most important factors to rule out septic arthritis (2)

Answer 63

Patient weight bearing on affected limb CRP

Question 64

What motion is most deficient in Sprengels?

Answer 64

Abduction

Question 65

4 technical considerations for fixation of pediatric distal femur fracture?

Answer 65

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

Question 66

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

Answer 66

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

Question 67

3 associations with tarsal coalition:

Answer 67

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

Question 68

Main blood supply to femoral head in kids \>4

Answer 68

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

Question 69

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

Answer 69

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

Question 70

5 risk factors for LCP

Answer 70

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

Question 71

Manifestations of Achondroplasia

Answer 71

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

Question 72

What happens if the GT apophysis is prematurely arrested?

Answer 72

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

Question 73

Best pin configuration for SCHF?

Answer 73

Lateral divergent pins (2 vs 3)

Question 74

Describe the deformity in congenital vertical talus

Answer 74

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

Question 75

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

Answer 75

Hypertrophic zone caused by weakness in the perichondral ring

Question 76

MPS with least spinal abnormalities?

Answer 76

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

Question 77

Lateral Pillar Classifiation: (LCP)

Answer 77

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

Question 78

Cause and treamtent of stiff-knee gait in CP?

Answer 78

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

Question 79

Characteristic lesion in Fredrich's ataxia

Answer 79

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

Question 80

First line treamtent in tarsal coalition?

Answer 80

trial of non-op with immobilization or orthotics - always

Question 81

What is the best treatment for Sever's disease?

Answer 81

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

Question 82

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

Answer 82

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

Question 83

Surgical treatment for CMT claw toes?

Answer 83

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

Question 84

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

Answer 84

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

Question 85

4 indications for surgery in infantile Blount's

Answer 85

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

Question 86

Can a Klippel Feil patient play contact sports?

Answer 86

No if they have fusion of C3 and above

Question 87

WHat joints are most commonly invovlved in JIA?

Answer 87

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

Question 88

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

Answer 88

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

Question 89

Indications for contralateral pinning in SCFE

Answer 89

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

Question 90

Adequate reduction parameters for Delbet 2-4?

Answer 90

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

Question 91

4 negative prognostic indicators of pediatirc spetic arthritis?

Answer 91

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

Question 92

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

Answer 92

To identify omovertebral bar

Question 93

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

Answer 93

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

Question 94

Kocher Criteria for Septic Hip

Answer 94

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

Question 95

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

Answer 95

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

Question 96

What construct for SCHF pinning has the most biomechanical stability?

Answer 96

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

Question 97

WHen i say Olecranon apophysis avulsion fracture, you say:

Answer 97

osteogenesis imperfecta

Question 98

4 indications for open reduction of pediatric elbow dislocation?

Answer 98

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

Question 99

What is the pediatric equivalent of Lauge Hansen classification?

Answer 99

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

Question 100

What is normal range for IR and ER of hip?

Answer 100

IR = 20-60 ER = 30-60

Question 101

4 options for elbow release in arthrogryposis

Answer 101

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

Question 102

Describe the anatomy of CVT

Answer 102

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

Question 103

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

Answer 103

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

Question 104

Indication for surgery in LCP?

Answer 104

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

Question 105

What did Sillence classify?

Answer 105

OI

Question 106

How does a patient with SCFE clinically present?

Answer 106

Pain Obligatory ER

Question 107

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

Answer 107

L3 - uopposed hip flexion and adduction

Question 108

Name 3 syndromes with abnormal ossification of secondary growth centers

Answer 108

Spondyloepiphyseal dysplasia Multiple epiphyseal dysplasia diastrophic dysplasia

Question 109

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

Answer 109

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

Question 110

What antibiotic should you avoid in paeds?

Answer 110

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

Question 111

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

Answer 111

1) respiratory function 2) Controversial

Question 112

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

Answer 112

Mild cavo-varus foot

Question 113

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

Answer 113

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

Question 114

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

Answer 114

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

Question 115

Who gets Gower's sign? Describe it

Answer 115

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

Question 116

Conditions that may cause SCFE?

Answer 116

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

Question 117

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

Answer 117

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

Question 118

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

Answer 118

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

Question 119

Muscle imbalance in equinovalgus foot?

Answer 119

Opposite of equinovarus TA/TP weak PB/PL strong

Question 120

Classification of CP Hips & Treatment

Answer 120

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

Question 121

What is a Charnley WIlliams rod used for?

Answer 121

ORIF of NF tibial pseudoarthrosis

Question 122

Principals for bladder extrophy repair?

Answer 122

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

Question 123

2 methods of percutaneous reduction of radial head fracture

Answer 123

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

Question 124

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

Answer 124

PO associated with cognitive impairment.

Question 125

Treatment of dislocated hip in myelomeningocele?

Answer 125

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

Question 126

dDx for cavovarus foot (5)

Answer 126

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

Question 127

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

Answer 127

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

Question 128

3 INDICATIONS for nerve repair/grafting in Brachial plexopathy?

Answer 128

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

Question 129

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

Answer 129

pes cavus hammer toes hip dysplasia scoliosis

Question 130

5 conditions associated with Cavovarus foot?

Answer 130

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

Question 131

4 dDx for leg bowing in kids?

Answer 131

Physiologic Blount's disease Osteogenesis imperfecta Rickets/osteomalacia Syndromic

Question 132

Describe Birch Classification for fibular hemimelia

Answer 132

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

Question 133

Differential for unilateral valgus (3)

Answer 133

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

Question 134

2 optioins for treating elbow flexion contractures

Answer 134

Clarke's pectoral transfer Steindler's flexorplasty

Question 135

Treatment of hallux varus

Answer 135

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

Question 136

Defect in diastrophic dysplasia?

Answer 136

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

Question 137

How do you estimate blood volume in a kid?

Answer 137

75 - 80 mL/kg

Question 138

Principals of Proximal tibia/fibula valgus osteotomy for Blounts?

Answer 138

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

Question 139

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

Answer 139

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

Question 140

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

Answer 140

1. AVN 2. coxa vara

Question 141

4 conditions associated with CVT?

Answer 141

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

Question 142

3 nonorthopaedic conditions of marfans?

Answer 142

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

Question 143

NIH Consensus Development Conference Statement diagnosis criteria for NF1?

Answer 143

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

Question 144

Bado Classification

Answer 144

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

Question 145

Contraindications to Pavlik harness (4)?

Answer 145

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

Question 146

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

Answer 146

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

Question 147

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

Answer 147

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

Question 148

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

Answer 148

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

Question 149

Give general principles of operative treatment for PFFD

Answer 149

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

Question 150

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

Answer 150

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

Question 151

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

Answer 151

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

Question 152

Non-ortho associations of hemihypertrophy (2 major types)

Answer 152

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

Question 153

What is von Recklinghaussen disease?

Answer 153

NF1

Question 154

Best x-ray view for lateral condyle fracture?

Answer 154

internal oblique

Question 155

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

Answer 155

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

Question 156

Management of equinovarus foot

Answer 156

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

Question 157

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

Answer 157

hypertropic

Question 158

What are the 5 physeal zones?

Answer 158

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

Question 159

What is the best indicator of peak growth?

Answer 159

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

Question 160

WHere does a Salter osteotomy hinge on?

Answer 160

Symphysis Pubis 1 cut from AIIS to sciatic notch

Question 161

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

Answer 161

metaphyseal chondrodysplasia

Question 162

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

Answer 162

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

Question 163

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

Answer 163

Tibial deficiency AD Must counsel parents of risk with further children

Question 164

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

Answer 164

early reduction Joint decompression (hematoma aspiration or core decompression)

Question 165

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

Answer 165

Nonoperative They do well regardless

Question 166

Treatment for calcaneovalgus foot?

Answer 166

observation and parental stretching

Question 167

3 exam findings consistant with tarsal coalition?

Answer 167

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

Question 168

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

Answer 168

Extent of soft tissue release

Question 169

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

Answer 169

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

Question 170

Classification of Sprengel's:

Answer 170

see chart

Question 171

How long do you wear a Pavlik?

Answer 171

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

Question 172

8 orthopedic manifestations of Downs?

Answer 172

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

Question 173

Surgical option in resistant vertical talus?

Answer 173

talectomy

Question 174

Preferred fixation of SHII distal femoral physeal fracture

Answer 174

Lag screw through the metaphyseal flare piece

Question 175

Valproic acid has what detrimental effect on surgery?

Answer 175

Increases bleeding time

Question 176

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

Answer 176

Reserve

Question 177

Spine changes in NF1

Answer 177

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

Question 178

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

Answer 178

SH4 of medial malleolus

Question 179

How is CP gait desribed/classificed

Answer 179

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

Question 180

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

Answer 180

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

Question 181

Risk of contralateral SCFE in otherwise healthy kid?

Answer 181

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

Question 182

Acceptable Alignment BBFF?

Answer 182

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

Question 183

Who gets Duchenne muscular dystrophy?

Answer 183

Males only X-linked recessive

Question 184

4 signs of residual DDH in kid \> 3 months

Answer 184

Limited hip abduction Pelvic obliquity + galeazzi Trendelenburg gait

Question 185

4 joints with intra-articular metaphyseal cortex

Answer 185

hip, shoulder, elbow, and ankle

Question 186

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

Answer 186

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

Question 187

Spinal manifestations of Achondroplasia:

Answer 187

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

Question 188

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

Answer 188

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

Question 189

What is Nail-Patella syndrome?

Answer 189

**_Hypoplastic_** Nails and Petallae **_AD_** inheritance **_Also includes:_** Laxity scoliosis scapular hypoplasia presence of cervical ribs amongst other things

Question 190

2 techniques to reduce a radial head fracture

Answer 190

## Footnote **_Patterson maneuver_** hold the elbow in extension and apply distal traction with the forearm supinated and pull the forearm into varus while applying direct pressure over the radial head **_Israeli technique_** pronate the supinated forearm while the elbow is flexed to 90° and direct pressure stabilizes the radial head

Question 191

AAOS guidelines for paediatric femoral shaft fractures

Answer 191

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

Question 192

Indications for selective thoracic fusion:

Answer 192

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

Question 193

What does the VilleFranche classification describe?

Answer 193

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

Question 194

Best surgical appraoch to CP HV?

Answer 194

1st MTP fusion +/- Akin

Question 195

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

Answer 195

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

Question 196

7 reasons that in-toeing requires further investigations?

Answer 196

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

Question 197

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

Answer 197

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

Question 198

2 complications of transphyseal distal humerus fracture?

Answer 198

Cubitus varus Medial condyle AVN

Question 199

Complications seen with too much abduction in Pavlik?

Answer 199

AVN

Question 200

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

Answer 200

Tib ant overpull in relation to peroneal muscles

Question 201

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

Answer 201

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

Question 202

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

Answer 202

Spinal cord stenosis JAAOS 2013

Question 203

Name 4 featuers of Acnohdroplasia (there are about 15)

Answer 203

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

Question 204

Othopaedic Manifestations of CMT?

Answer 204

Scoliosis Pes Cavus Hammertoes Hip dysplasia

Question 205

What are the 4 deformities of clubfoot?

Answer 205

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

Question 206

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

Answer 206

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

Question 207

WHat is the spine deformity in multiple epiphyseal dysplasia

Answer 207

None

Question 208

dDx of knee or thigh pain paediatric patient:

Answer 208

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

Question 209

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

Answer 209

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

Question 210

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

Answer 210

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

Question 211

Describe the Beighton-Horan scale.

Answer 211

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

Question 212

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

Answer 212

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

Question 213

5 things affecting Hypertrohpic Zone of growth plate

Answer 213

SCFE MED SED Schmids Fractures (SH1) Ricekts Enchondromas

Question 214

What is the natural history of OI fractures with age?

Answer 214

The symptoms improve with age

Question 215

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

Answer 215

## Footnote ● Vascularised free fibula graft ● Core decompression

Question 216

Preferred treatment of congenital vertical talus

Answer 216

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

Question 217

Paediatric olecranon fractures are highly suspicious for:

Answer 217

Osteogenesis imperfecta

Question 218

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

Answer 218

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

Question 219

Order of correction in ponsetti method

Answer 219

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

Question 220

5 causes of hemihypertrophy

Answer 220

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

Question 221

What part of the physis does a SCFE occur in?

Answer 221

Hypertrophic

Question 222

What percentage of LCP patients will eventually need THA?

Answer 222

50%

Question 223

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

Answer 223

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

Question 224

Name 4 non-ortho manifestations of myelodysplasia

Answer 224

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

Question 225

3 complications of radial head/neck fractures

Answer 225

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

Question 226

2 spinal deformities with OI

Answer 226

Scoliosis basilar invagination (NOT AAI)

Question 227

4 ortho and 2 nonortho associations with Friedrich's ataxia

Answer 227

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

Question 228

Never do what when ORIFing a lateral condyle fracture?

Answer 228

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

Question 229

Difference between bone infarct and osteomyelitis on imaging?

Answer 229

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

Question 230

What 3 spinal deformity conditions are bracing CONTRAindicated in?

Answer 230

Spina Bifida SCI Muscular dystrophy

Question 231

Associated ortho conditions for PFFD (4)

Answer 231

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

Question 232

4 manifestations of CMT?

Answer 232

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

Question 233

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

Answer 233

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

Question 234

4 radiographic findings in OI

Answer 234

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

Question 235

What part of acetabulum is deficient in neuromuscular hip dysplasia?

Answer 235

posterior superior

Question 236

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

Answer 236

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

Question 237

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

Answer 237

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

Question 238

6 Blocks to reduction in DDH:

Answer 238

ligamentum teres capsule transverse acetabular ligament inverted labrum Psoas Pulvinar

Question 239

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

Answer 239

O2 sat at presentation GCS 72 hours post injury

Question 240

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

Answer 240

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

Question 241

Complications seen with too much flexion in Pavlik?

Answer 241

Femoral nerve palsy.

Question 242

6 associated ortho conditions with arthrogryposis

Answer 242

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

Question 243

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

Answer 243

Prior to application of the final cast

Question 244

What view is best for looking at accessory navicular?

Answer 244

**_External_** oblique

Question 245

What are the normal values of Staheli Rotational Profile?

Answer 245

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

Question 246

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

Answer 246

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

Question 247

dDx for bilateral valgus (3)

Answer 247

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

Question 248

WHat is Pavlik's disease?

Answer 248

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

Question 249

4 complications of Lateral Condyle fracture (operative)

Answer 249

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

Question 250

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

Answer 250

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

Question 251

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

Answer 251

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

Question 252

List proportionate Dwarfism

Answer 252

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

Question 253

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

Answer 253

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

Question 254

Indication for serial casting in MTA?

Answer 254

Rigid deformity with medial crease

Question 255

3 options to treat IR contractures fo the shoulder

Answer 255

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

Question 256

Risk factors for congenital kyphosis progression (4)

Answer 256

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

Question 257

Describe an NF1 patient's risk of cancer

Answer 257

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

Question 258

Three ways Pseudoachondroplasia differs from Achondroplasia?

Answer 258

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

Question 259

Define Arthrogryposis

Answer 259

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

Question 260

Delbet Classification

Answer 260

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

Question 261

Diagnosis?

Answer 261

Sacral agenesis

Question 262

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

Answer 262

Proximal femoral resection | (controversial)

Question 263

How do you clinically differentiate SMA vs. DMD

Answer 263

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

Question 264

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

Answer 264

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

Question 265

Indications for pinning distal radius fracture in paeds (7)

Answer 265

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

Question 266

6 dDx for metaphyseal flaring:

Answer 266

Fibrous dysplasia Storage diseases Rickets Anemia Chronic lead posioning bone dysplasia

Question 267

Name 6 syndromes/diseases assocated with basilar invagination

Answer 267

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

Question 268

Paediatric proximal humerus fracture classification:

Answer 268

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

Question 269

What operative intervention is contraindcated in CP patient with crouched gait

Answer 269

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

Question 270

Name 4 life-threatening perioperative complications with MPS

Answer 270

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

Question 271

Name the physeal zone associated with: Achondroplasia Gigantism MHE

Answer 271

Proliferative

Question 272

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

Answer 272

Flexible contracture: AFO Rigid contracture: OR

Question 273

3 things affecting Proliferative Zone

Answer 273

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

Question 274

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

Answer 274

Larsen Syndrome

Question 275

Medical treatment for AD osteopetrosis?

Answer 275

interferon gamma-1 beta

Question 276

4 predictors of complications when doind a nancy nail?

Answer 276

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

Question 277

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

Answer 277

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

Question 278

Describe the GMFCS scale.

Answer 278

Question 279

I say absent clavicles, you say:

Answer 279

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

Question 280

Good prognostic signs of anterolateral bowing? (2)

Answer 280

Duplicated hallux Delta-shaped osseous segment in concavity of bow

Question 281

Acceptable criteria for distal radius fractures

Answer 281

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

Question 282

Name 4 social risk factors for child abuse

Answer 282

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

Question 283

Name 4 sources of blood supply to the femoral head:

Answer 283

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

Question 284

Non-ortho manifesataions of SMA

Answer 284

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

Question 285

3 spinal manifestations of Achondroplasia?

Answer 285

Thoracokyphosis Lumbar Stenosis Foramen Magnum/Upper Cervical Stenosis

Question 286

Congenital hallux varus is associated with what?

Answer 286

Polydactyly

Question 287

Normal alpha angle (DDH)

Answer 287

\>60 deg angle of bony ilium and acetabulum

Question 288

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

Answer 288

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

Question 289

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

Answer 289

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

Question 290

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

Answer 290

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

Question 291

When do you brace congenital scoliosis?

Answer 291

To control supple compensatory curves

Question 292

Workup of Arthrogryposis at 3 months? (3)

Answer 292

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

Question 293

Diagnosis?

Answer 293

CVT Clues: talus is vertical navicular dorsal dislocation

Question 294

Name 3 tumours specific to NF1

Answer 294

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

Question 295

Name the physeal zone associated with: Renal SCFE

Answer 295

Secondary Spongiosa

Question 296

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

Answer 296

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

Question 297

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

Answer 297

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

Question 298

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

Answer 298

Gauchers disease

Question 299

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

Answer 299

Friedrich's ataxia

Question 300

Classic presentation of diastrophic dysplasia?

Answer 300

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

Question 301

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

Answer 301

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

Question 302

4 non-orthopedic manifestations of Downs?

Answer 302

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

Question 303

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

Answer 303

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

Question 304

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

Answer 304

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

Question 305

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

Answer 305

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

Question 306

Flat top talus Almost pathognomonic for what?

Answer 306

Clubfoot treatment complication

Question 307

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

Answer 307

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

Question 308

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

Answer 308

Higher More

Question 309

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

Answer 309

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

Question 310

Non-ortho manifestations of Down (3)

Answer 310

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

Question 311

Next step if Pavlik harness treatment fails?

Answer 311

Convert to abduction brace for 3-4 weeks.

Question 312

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

Answer 312

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

Question 313

What condition is associated with MadeLungs?

Answer 313

Leri-weill dyschondrosteosis SHOX gene abnormality Causes mesomelic dwarfism

Question 314

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

Answer 314

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

Question 315

What are physical exam findings consistant with equinovarus foot?

Answer 315

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

Question 316

Why would you do a squatting skyline xray?

Answer 316

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

Question 317

BBFF - initial management?

Answer 317

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

Question 318

Most common complication of lateral condyle fracture?

Answer 318

Lateral overgrowth/spurring

Question 319

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

Answer 319

30% and above

Question 320

6 Dural Ectasia associations

Answer 320

Marfan syndrome NF1 Ehlers-Danlos Achondroplasia Ank spond idiopathic

Question 321

Two indications for endocrine workup in a SCFE?

Answer 321

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

Question 322

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

Answer 322

Abduction also Forward flexion

Question 323

Torticollis: head tilt and rotation which direction?

Answer 323

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

Question 324

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

Answer 324

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

Question 325

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

Answer 325

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

Question 326

MRSA infected kids have higher levels of what on admission?

Answer 326

ESR, CRP, WBC

Question 327

Pathology in SMA

Answer 327

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

Question 328

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

Answer 328

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

Question 329

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

Answer 329

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

Question 330

Risk factors for SMA syndrome in AIS surgery (7)

Answer 330

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

Question 331

List the normal progression of leg angulation:

Answer 331

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

Question 332

Diagnosis and most common site/cause

Answer 332

Congenital pseudoarthrosis of the clavicle Caused by extrinsic compression by the subclavian Right middle 1/3 of clavicle 90% Left only if situs inversus

Question 333

Treatment of hip abduction contracture in myelodysplasia

Answer 333

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

Question 334

3 orthopaedic associations with tibial deficiency.

Answer 334

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

Question 335

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

Answer 335

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

Question 336

3 treatment options for NF related tibial bowing?

Answer 336

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

Question 337

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

Answer 337

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

Question 338

Anatomic Classifiation of CP

Answer 338

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

Question 339

Signs of Dystrophic Curve (7)

Answer 339

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

Question 340

3 ultrasonographic measurements in DDH

Answer 340

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

Question 341

Best 2 tests for septic hip?

Answer 341

T \> 38.5 CRP \> 2

Question 342

3 poor prognostic indicators for subtalar coalition 1 contraindication to surgery

Answer 342

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

Question 343

Name a contraindication to hemiepiphysiodesis in congenital scoliosis:

Answer 343

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

Question 344

Compare infantile and adolescent Blounts

Answer 344

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

Question 345

What is the most common complication of proximal femur fracture?

Answer 345

AVN (Coxa vara and non-union also important)

Question 346

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

Answer 346

alpha-fetoprotein (AFP)

Question 347

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

Answer 347

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

Question 348

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

Answer 348

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

Question 349

3 indications for CRPP of pediatric distal radius fracture.

Answer 349

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

Question 350

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

Answer 350

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

Question 351

5 Characteristics of trigger thumb

Answer 351

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

Question 352

Contraindication to treatment of paediatric femur fracture (open physes)

Answer 352

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

Question 353

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

Answer 353

Echo (cardiac manifestations) Renal ultrasound (renal aplasia)

Question 354

4 surgical indications for coxa-vara

Answer 354

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

Question 355

Diagnosis?

Answer 355

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

Question 356

Predictors of poor outcome in paediatric septic hip (4)

Answer 356

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

Question 357

8 risks for brachial plexus birth injury

Answer 357

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

Question 358

3 surgical treatment options for Adolescent Blounts?

Answer 358

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

Question 359

Risk factors for SCFE (7)

Answer 359

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

Question 360

Name 3 general surgical intervnetions you can do for tibial hemimelia

Answer 360

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

Question 361

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

Answer 361

1. Surgical Synovectomy 2. Radioactive Synovectomy 3. TKR

Question 362

Spinal manifestations of diastrohpic dysplasia

Answer 362

AAI Cervical kyphosis TL kyphoscoliosis Rarely needs treatment

Question 363

Most common cause of septic hip in neonates?

Answer 363

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

Question 364

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

Answer 364

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

Question 365

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

Answer 365

decrease in cortical widths decreased cancellous bone volume increased bone remodeling

Question 366

Classification of lateral condyle fracture and treatment algorithm?

Answer 366

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

Question 367

3 advantages of nancy nailing over ORIF

Answer 367

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

Question 368

4 maternal risk factors for congenital scoliosis

Answer 368

diabetes alcohol valproic acid hyperthermia

Question 369

SCHF with cold, pulseless hand. Management?

Answer 369

Immediate CR & PP Open is not first step

Question 370

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

Answer 370

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

Question 371

Main vascular concern in tibial tibercle fracture?

Answer 371

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

Question 372

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

Answer 372

ECU Dorsal

Question 373

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

Answer 373

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

Question 374

Managmenet and timing of treatment of congenital vertical talus?

Answer 374

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

Question 375

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

Answer 375

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

Question 376

Flat top talus is a complication of what casting method?

Answer 376

Ponseti

Question 377

What is the primary treatment for Gauchers?

Answer 377

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

Question 378

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

Answer 378

Tight heel cord

Question 379

Physiologic Classification of CP

Answer 379

Spastic Athetoid Ataxic Mixed (Usually Spastic/Athetoid) Hypotonic

Question 380

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

Answer 380

None

Question 381

General treatment principle for Downs Spine

Answer 381

Nonoperative management if possible - high complication rates with surgery

Question 382

What is the managmeent algorithm of Fibular deficiency?

Answer 382

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

Question 383

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

Answer 383

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

Question 384

How do you screen for and diagnose MPS?

Answer 384

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

Question 385

What is the anatagonist of peroneus Longus?

Answer 385

Tibialis anterior

Question 386

How do you reduce BADO I/III?

Answer 386

Flexion & supination

Question 387

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

Answer 387

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

Question 388

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

Answer 388

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

Question 389

Diagnosis? Give 1 dDx

Answer 389

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

Question 390

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

Answer 390

Corrects hindfoot valgus. (calcaneal lateral column lengthening osteotomy)

Question 391

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

Answer 391

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

Question 392

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

Answer 392

PVL (Panton-Valentine leukocidin) +

Question 393

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

Answer 393

_Nonop complications_ * deformit relapse * dynamic supination _Operative complications_ * Residual cavus * pes planus (due to overcorrection) * undercorrection * intoeing gait * Osteonecrosis of talus * dorsal bunion

Question 394

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

Answer 394

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

Question 395

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

Answer 395

Primary Spongiosa

Question 396

4 factors predictive of physeal arrest in distal femur physeal fracture

Answer 396

SH classification Presence of displacement open fracture Hardware penetration into physis from surgical management

Question 397

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

Answer 397

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

Question 398

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

Answer 398

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

Question 399

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

Answer 399

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

Question 400

Preferred surgical option for a large talocalcaneal coalition?

Answer 400

Triple fusion

Question 401

What is the most common type of child abuse?

Answer 401

Neglect Followed by physical \> sexual \> emotional maltreatment

Question 402

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

Answer 402

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

Question 403

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

Answer 403

central (first) medial posterior anterolateral (last)

Question 404

Describe the boney deformities of clubfoot?

Answer 404

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

Question 405

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

Answer 405

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

Question 406

What is normal thigh foot angle?

Answer 406

0-20 of **_ER_**

Question 407

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

Answer 407

Prolonged immobilization \> 4 weeks So start mobilizing before then

Question 408

4 dDx for growth plate widening in kids:

Answer 408

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

Question 409

Define Baumans Angle

Answer 409

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

Question 410

5 general causes of LLD

Answer 410

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

Question 411

8 injury patterns suspicious for child abuse

Answer 411

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

Question 412

Should kids with MRSA attend school? Play sports?

Answer 412

Yes, only if their wound/abscess/draining pus can be adequately covered up They should not use pools or treatment pools

Question 413

Treatment algorithm for tibial deficiency What is is based on?

Answer 413

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

Question 414

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

Answer 414

Epiphysiolysis (bar resection)

Question 415

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

Answer 415

Laterally To reduce quads scarring.

Question 416

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

Answer 416

Rotation

Question 417

Surgical treatment of flexible cavovarus foot? (4 elements)

Answer 417

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

Question 418

Foot polydactyly classification?

Answer 418

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

Question 419

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

Answer 419

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

Question 420

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

Answer 420

Early - after about a week if nondisplaced/displaced

Question 421

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

Answer 421

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

Question 422

INdications for hemiepiphysiodesis in congenital scoli

Answer 422

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

Question 423

RIsk of AVN with paediatric hip factures

Answer 423

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

Question 424

Acceptable alignment distal radius fracture

Answer 424

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

Question 425

4 risk factors for thermal burns with casting

Answer 425

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

Question 426

How much bend do you want in a nancy nail?

Answer 426

3x canal size

Question 427

What is Friedrichs Ataxia?

Answer 427

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

Question 428

Treatment of oblique talus?

Answer 428

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

Question 429

Foot muscular Imbalances in Hereditary Motor Sensory Neuropathy?

Answer 429

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

Question 430

How do you reduce a nursemaid's elbow?

Answer 430

Supinate forearm and flex elbow to 90 deg

Question 431

dDx for torticollis

Answer 431

Congenital muscular torticollis AARD Grisel's disease Klippel-Feil

Question 432

Most common radiographic spinal finding in Down syndrome:

Answer 432

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

Question 433

4 risk factors for DVt in pediatric psteomyelitis?

Answer 433

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

Question 434

Name (9) associated conditions with fibular deficiency

Answer 434

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

Question 435

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

Answer 435

Hypertrohpic zone

Question 436

Pediatric elbow dislocation - most common nerve injury

Answer 436

Ulnar nerve

Question 437

Describe, in detail, the Ponseti method

Answer 437

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

Question 438

What is the most common manifestation of child abuse?

Answer 438

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

Question 439

Summarize treatment for COxa Vara in dwarves in one sentence.

Answer 439

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

Question 440

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

Answer 440

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

Question 441

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

Answer 441

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

Question 442

What is Little Leaguer's Shoulder?

Answer 442

SH 1 injury of the proximal humerus Overuse injury

Question 443

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

Answer 443

1st MT

Question 444

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

Answer 444

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

Question 445

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

Answer 445

Epiphysiodesis of the GT apophysis

Question 446

Goal for coxa vara correction in paeds

Answer 446

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

Question 447

3 ways that Beckers differes from Duchennes?

Answer 447

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

Question 448

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

Answer 448

70 degrees

Question 449

Explain how the Silfverskiöld test works!

Answer 449

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

Question 450

Describe the spectrum of myelodysplasia

Answer 450

_Spina bifida oculta:_ * Defect in vertebral arch with confined cord and meninges _Meningocoele:_ * Protruding sac without neural elements _Myelomeningocoele:_ * Protruding sac with neural elements _Rachischisis_ * Neural elements exposed with no covering

Question 451

Paediatric trigger finger - waht must you release?

Answer 451

A1 pulley + 1 slip of FDS

Question 452

Best xray to ID a SCFE?

Answer 452

lateral

Question 453

3 radiograhpic findings of SCFE

Answer 453

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

Question 454

What type of SCHF is not associated with cubitus varus?

Answer 454

Flexion type It goes into cubitus valgus

Question 455

Name 3 copmlications of VEPTR

Answer 455

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

Question 456

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

Answer 456

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

Question 457

Most common cause of septic hip in adolescents? Treatment?

Answer 457

Neisseria gonorroeae High dose penicillin (does not need OR)

Question 458

Most important thing to look for when examining tibal hemimelia?

Answer 458

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

Question 459

2 main presentations and gene association of multiple epiphyseal dysplasia?

Answer 459

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

Question 460

5 Ortho manifestations of OI (there are many)

Answer 460

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

Question 461

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

Answer 461

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

Question 462

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

Answer 462

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

Question 463

Where will the conus medullaris lie in a tethered cord?

Answer 463

BELOW L23 - b/c it's tethered down

Question 464

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

Answer 464

Teardrop - not usually present in a dislocated hip.

Question 465

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

Answer 465

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

Question 466

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

Answer 466

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

Question 467

dDx of toe walking (4)

Answer 467

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

Question 468

2 indications for exploring the artery in a supercondylar fracture

Answer 468

Pulse is lost after reduction Persistance of pulseless hand after reduction

Question 469

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

Answer 469

MRSA

Question 470

Last elbow ossification center fo FUSE?

Answer 470

Medial epicondyle age 17

Question 471

7 characteristics of Infantile Blounts on workup?

Answer 471

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

Question 472

How do you decide what size of nancy nail?

Answer 472

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

Question 473

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

Answer 473

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

Question 474

4 Syndromes affecting Reserve Zone

Answer 474

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

Question 475

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

Answer 475

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

Question 476

3 keys to surgical treatment of CVT?

Answer 476

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

Question 477

What are the stages of LCP?

Answer 477

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

Question 478

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

Answer 478

Anterior or anterolateral

Question 479

Indications for poor prognosis in bracing of AIS

Answer 479

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

Question 480

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

Answer 480

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

Question 481

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

Answer 481

None - it has no effect on outcomes

Question 482

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

Answer 482

FOramen magnum stenosis

Question 483

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

Answer 483

Phase 2: rib overlap with apical vertebra

Question 484

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

Answer 484

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

Question 485

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

Answer 485

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

Question 486

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

Answer 486

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

Question 487

Best predictor of success with tendon transfers in CP?

Answer 487

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

Question 488

Radiographic classification of subacute paediatric OM:

Answer 488

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

Question 489

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

Answer 489

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

Question 490

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

Answer 490

lateral trochlear ossification center AVN

Question 491

3 blocks to reduction in proximal humerus reduction

Answer 491

long head biceps capsule periosteum

Question 492

What disorder is Botox contraindicated in?

Answer 492

Spinal muscular atrophy

Question 493

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

Answer 493

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

Question 494

2 xray views to assess clubfoot?

Answer 494

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

Question 495

SMN gene association

Answer 495

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

Question 496

In OI, fractures heal normally/abnormally?

Answer 496

Normally They *remodel* abnormally

Question 497

Manifestations of Gauchers (5)

Answer 497

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

Question 498

8 features of congenitally dislocated radial head

Answer 498

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

Question 499

Name 5 reduction techniques of radial head reduction:

Answer 499

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

Question 500

Start point for retrograde femoral nancy nails?

Answer 500

2-2.5 cm proximal to distal physsi

Question 501

4 manifestations of osteopetrosis?

Answer 501

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

Question 502

Pin configuration post CRPP of distal femoral physeal injury

Answer 502

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

Question 503

What is the Pirani score?

Answer 503

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

Question 504

4 indications for ORIF in BBFF?

Answer 504

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

Question 505

Indications for MRI in scoliosis case

Answer 505

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

Question 506

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

Answer 506

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

Question 507

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

Answer 507

Secondary spongiosa

Question 508

Major cause of death for patient with Friedrich's Ataxia

Answer 508

cardiomyopathy Must workup with Echo

Question 509

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

Answer 509

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

Question 510

3 non-ortho manifestations of Ehlors Danlos?

Answer 510

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

Question 511

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

Answer 511

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

Question 512

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

Answer 512

Medial meniscus

Question 513

Acceptable reduction criteria required for femoral shaft fractures in peds?

Answer 513

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

Question 514

Risk of recurrence/refracture of pseudoarthrosis of tibia?

Answer 514

50%, even after initial union

Question 515

How do you immobilize Bado I, III fractures?

Answer 515

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

Question 516

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

Answer 516

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

Question 517

Genetic transmission of DMD

Answer 517

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

Question 518

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

Answer 518

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

Question 519

3 types of CP gait

Answer 519

toe walking crouched stiff-knee

Question 520

4 radiographic signs of osteopetrosis?

Answer 520

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

Question 521

2 indications for surgical treatment of AAI in DOwns?

Answer 521

1. myelopathic patients 2. ADI \> 10 mm

Question 522

Indications for fusion in DMD scoliosis

Answer 522

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

Question 523

3 associated endocrine disorders with SCFE

Answer 523

Hypothyroidism Osteodystrohpy of CRF Growth HOrmone Treatment

Question 524

What is the major source of blood to the physis?

Answer 524

Perichondrial artery

Question 525

2 important complications of tibial tubercle fracture?

Answer 525

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

Question 526

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

Answer 526

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

Question 527

CP hip management based on Reimer's Migration Index

Answer 527

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

Question 528

4 indications for open reduction of pediatric traumatic hip doslocation?

Answer 528

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

Question 529

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

Answer 529

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

Question 530

Most commonly used meidcation for treatment of OI?

Answer 530

Bishphosphonates increase cortical thickness, fewer fracture.

Question 531

Early investigations for Larsens?

Answer 531

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

Question 532

How many ossification centers in the proximal humerus?

Answer 532

3: HH, GT, LT

Question 533

2 indications for CR and hip spica for DDH?

Answer 533

1. Age 6-18 months 2. Failed Pavlik

Question 534

Why is ASF indicated in spina bifida related scoliosis?

Answer 534

dysplastic posterior elements that may impair posterior fusion

Question 535

Medical treatment of bone crisis for sickel cell?

Answer 535

hydroxyurea

Question 536

2 options for tendon transfers of HMSN?

Answer 536

tib post to dorsum of foot peroneus longus to brevis

Question 537

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

Answer 537

Right middle 1/3 situs inversus is the exception

Question 538

2 main surgical options for tibial hemimelia?

Answer 538

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

Question 539

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

Answer 539

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

Question 540

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

Answer 540

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

Question 541

Why doe CMT pts get claw toes?

Answer 541

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

Question 542

BBFF: malrotation at what level has what effect?

Answer 542

Midshaft malrotations lead to decreased supination (vs distal malrotation)

Question 543

Best radiographic way to follow CP hips

Answer 543

Reimer's Migration Index

Question 544

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

Answer 544

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

Question 545

radiographic definition of vertical vs. oblique talus

Answer 545

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

Question 546

4 operative indications for proximal humerus fracture in paeds

Answer 546

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

Question 547

5 Risks for CP

Answer 547

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

Question 548

7 Physical or radiologic signs of child abuse?

Answer 548

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

Question 549

Spinal manifestations of achondroplasia vs. pseudoachondroplasia

Answer 549

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

Question 550

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

Answer 550

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

Question 551

Classic findings in Friedrich's ataxia

Answer 551

Ataxia areflexia positive plantar response

Question 552

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

Answer 552

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

Question 553

Congenital knee dislocation Give 3 syndromic associations and 3 orthopaedic associations

Answer 553

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

Question 554

Why do a Rhizotomy?

Answer 554

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

Question 555

Complication with too mcuh abduction in DDH treatment?

Answer 555

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

Question 556

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

Answer 556

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

Question 557

4 conditions associated with PFFD?

Answer 557

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

Question 558

Second most common nerve palsy in SCHF?

Answer 558

radial AIN most common

Question 559

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

Answer 559

80%

Question 560

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

Answer 560

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

Question 561

Two MSK findings associated with bladder extrophy?

Answer 561

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

Question 562

What level myelomeningocoele has a higher risk of hip dislcoation?

Answer 562

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

Question 563

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

Answer 563

Increased risk of complications such as nonunion

Question 564

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

Answer 564

18 months - 4 years

Question 565

Name 2 surgical options for treatment of Sprengel's

Answer 565

Woodward's Green Leibovic Bellman's Mears

Question 566

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

Answer 566

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

Question 567

3 causes of painful flatfoot.

Answer 567

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

Question 568

Most common complication from tibial tubercle fracture?

Answer 568

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

Question 569

5 Orthopedic (non-spine) manifestations of Achondroplasia?

Answer 569

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

Question 570

How do you immobilize a Galleazzi fracture?

Answer 570

In supination

Question 571

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

Answer 571

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

Question 572

4 peri-operative considerations if operating on a Gauchers?

Answer 572

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

Question 573

3 facets of first line treatment for JIA?

Answer 573

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

Question 574

Most common long term sequelae of brachial plexus birth injuries

Answer 574

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

Question 575

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

Answer 575

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

Question 576

Assume growth in males and females stop at what age?

Answer 576

Males: 16 Females: 14

Question 577

6 signs of preganglionic brachial plexus injury

Answer 577

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

Question 578

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

Answer 578

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

Question 579

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

Answer 579

Screen for DVT Rapid CT-PE if any suggestive signs

Question 580

What is contraindicated in the treatment of DMD scoliosis?

Answer 580

Bracing may interfere with already compromised respiraotry function

Question 581

RUNX2/CBFA1 mutation

Answer 581

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

Question 582

DDX for Genu Valgum?

Answer 582

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

Question 583

Non-ortho manifestations of DMD

Answer 583

cardiomyopathy static encephalopathy Respiratory issues

Question 584

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

Answer 584

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

Question 585

Name 6 associated abnormalities with Sprengel's

Answer 585

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

Question 586

General order of closure of the distal tibial growth plate?

Answer 586

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

Question 587

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

Answer 587

DMD: complete absence Becker's: abnormal

Question 588

How does MRSA get its virulence and resistance?

Answer 588

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

Question 589

First surgical option for resistant Clubfoot?

Answer 589

posteromedial soft tissue release and tendon lengthening

Question 590

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

Answer 590

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

Question 591

General Principals of Ilizarov technique?

Answer 591

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

Question 592

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

Answer 592

Botulinum toxin A

Question 593

3 conditions that are commonly found with tibial hemimelia?

Answer 593

1. ectrodactyly 2. preaxial polydactyly 3. ulnar aplasia

Question 594

Most common nerve palsy in SCHF?

Answer 594

AIN

Question 595

Major complication of lateral closing wedge osteotomy for cubitus varus?

Answer 595

Lateral prominence

Question 596

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

Answer 596

RVAD \>20

Question 597

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

Answer 597

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

Question 598

5 poor prognostic indicators for physeal bar:

Answer 598

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

Question 599

When do SCHF pins come out?

Answer 599

3-4 weeks

Question 600

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

Answer 600

6 weeks

Question 601

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

Answer 601

floppy epiglottis large tongue small larynx