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OrthoBullets Study > Paeds > Flashcards

Paeds Flashcards

1
Q

What are the weak and spastic muscles in equinovarus foot?

A

Spastic: TP and TA

Weak: PB, PL

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2
Q

Treatment for physeal arrest:

A

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
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3
Q

Treamtnet of CP hips

A

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
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4
Q

7 indicators of poor prognosis with LCP

A

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

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5
Q

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

A

A2 & A3

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6
Q

Upper extremity contractures in CP

A

Shoulder IR

Elbow flexion

Forearm pronation

Wrist flexion

Thumb in palm deformity:

  • Flexed MCP
  • Extended IP

Finger-flexion deformity

Swan neck

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7
Q

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

A

> 11 years

>49 kg

Remember to use lateral start point

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8
Q

Classification for PFFD

A

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
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9
Q

What Risser stage correspnds to the fastest growth spurt?

A

Risser 0

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10
Q

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

A

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)

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11
Q

Treatment algorithm of femur fractures in paeds:

A
  • 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
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12
Q

dDx for anterolateral bowing (2)

A

NF

tibial deficiency

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13
Q

Indications for anterior approach in addition to posterior approach in scolisis

A

Large curve (>75 degrees)

Stiff curves

Skeletally immature (Risser grade 0, boys

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14
Q

Indications for hemivertebrectomy in congenital scoli

A

Progressive curve >40 degrees

Patient <5

lumbosacral vertebra best (but can be done in thoracic)

(JAAOS 2004)

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15
Q

dDx for septic hip? (3)

A

OM

Psoas abscess

Transient synovitis

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16
Q

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

A

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)
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17
Q

What is H and how does it help evaluate DDH?

A

Hilgenreiners Line

A normal head should be below it.

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18
Q

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

A

Knee

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

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19
Q

What x-ray is this?

What is the diagnosis?

A

45 degree oblique

Calcaneonavicular coalition

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20
Q

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

A

Avoid sports if progressive radiographic instability or signs of myelopathy

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21
Q

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

A
  • girls at age 3
  • boys at age 4
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22
Q

What is the weakest zone of the growth plate?

A

Hypertrophic zone

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23
Q

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

A

Indicated when deformity is present with a physeal bar of

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

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24
Q

Risk factors for birth fractures

A

Vaginal deliveries

breech presentation

prolonged labor

macrosomia (>4.5 kg)

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25
Q

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

A

Cobb >20 degrees

Phase 2 rib

Rib-vertebral angle difference (RVAD) >20

Thoracolumbar curve

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26
Q

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

A

Flexion, abduction, ER

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27
Q

5 associated conditions of external tibial torsion:

A

Miserable malalignment syndrome

Osgood Schlatter disease

Osteochondritis dessicans

Early degenerative joint disease

Neuromustular conditions

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28
Q

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

A

Varus if fibula intact.

Valgus if fibula also broken.

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29
Q

Flexion type SCHF results in cubitus ____________?

A

Valgus

It causes varus displacement, leading to cubitus valgus

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30
Q

BLocks to reduction in DDH

A

Labrum

Inverted limbus

capsule

transverse acetabular ligament

ligamentum teres

pulvinar

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31
Q

Common injuries associated with TL spine trauma in paeds

A

Same as in adults:

GI: Small bowel most common

Lung contusion/pneumothorax

Head injury

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32
Q

7 donor options for nerve transfer in Brachial plexopathy?

A

sural

intercostal

spinal accessory

phrenic

cervical plexus

contralateral C7

hypoglossal

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33
Q

Zone of injury for proximal humerus fractures?

A

Zone of provisional calcification (part of hypertrophic)

However may go through several

Spares proliferative

JAAOS 2015

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34
Q

2 life-threatening intra-operative complications in DMD:

A

intraoperative cardiac event

malignant hyperthermia

Consult anesthesia & cardio preop

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35
Q

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

A

OI

(best for type 4)

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36
Q

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

A

bilateral vestibular schwannomas

** Also the DONT get scoliosis

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37
Q

What is P and how does it help evaluate DDH?

A

Perkins Line

Femoral head ossification should be medial to this line

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38
Q

Kid with hemihypertrophy. What must you do?

A

serial ultrasounds q3 months until age 7,

then physical exam q6 until skeletal maturity

TO RULE OUT WILM’S TUMOUR

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39
Q

Criteria for Septic Hip

A

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

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40
Q

Risk factor for AVN of the hip

A

Trauma

Steroid use

Radiation

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41
Q

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

A

oblique talus:

navicular will reduce on plantarflexion latearl

Meary’s angle <35 degrees

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42
Q

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

A

lateral to the intertrochanteric line

To avoid screw impingement

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43
Q

Criteria/algorithm for septic arthritis vs. transient synovitis

A

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.
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44
Q

7 options for interpositional graft after resection of physeal bar:

A

Fat

PMMA

Cranioplast (like PMMA: takes longer to set, less exothermic reaction, less chance of heat necrosis)

Bone wax

Cartilage

Muscle

Silicone

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45
Q

3 indications for ORIF in pediatric distal femur fracture?

A
  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
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46
Q

Reduction Maneuver for displaced medial epicondyle fracture into joint?

A

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
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47
Q

Treatment for dynamic supination post clubfoot

A

Tib ant transfer to lateral cuneiform

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48
Q

When can you determine the Herring stage in LCP?

A

Fragmentation stage (~6 months after symptoms start)

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49
Q

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

A

Loss of reduction

Although rare

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50
Q

Classification of tibial spine/eminence fractures

A

Meyers & McKeevers

I: undisplaced

II: displaced with posterior hinge

III: completely displaced with no bony contact

IV: comminuted

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51
Q

Diagnosis

A

Bisphosphonates on OI

Results in metaphyseal banding at each dosing

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52
Q

How does TA compare to PL in:

a) Clubfoot
b) Cavo - varus foot

A

a) TA stronger
b) TA weaker

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53
Q

Name 3 conditions that can present with teratologic hip?

A

arthrogryposis

myelomeningocele

Larsen’s syndrome

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54
Q

What is the Sofield-Miller procedure?

A

Realignment osteotomy with rod fixation for OI

Fassier-Duval rods can be used.

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55
Q

Three methods of predicting LLD?

A
  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
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56
Q

DDH U/S:

What is minimal age?

A

4-6 weeks.

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57
Q

Treatment options for Delbet 1–4?

A
  • 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

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58
Q

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

A

80%

(Therefore each nail should be diameter x 0.8 / 2)

(i.e. canal is 1 cm, then use 2 x 4 mm nails)

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59
Q

X-ray findings of clubfoot

A

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
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60
Q

Most common complication after distal femoral physeal injury

A

LLD/growth arrest

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61
Q

Name 5 non-ortho manifestations of OI

A

Blue sclera

Hearing loss

Brownish opalescent teeth (dentiogenesis imperfecta)

Wormian skull bones (puzzle piece intrasutural skull bones)

Increased risk of malignant hyperthermia

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62
Q

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

A

No

Manage with close observation and no restrictions

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63
Q

Most important factors to rule out septic arthritis (2)

A

Patient weight bearing on affected limb

CRP

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64
Q

What motion is most deficient in Sprengels?

A

Abduction

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65
Q

4 technical considerations for fixation of pediatric distal femur fracture?

A
  • 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
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66
Q

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

A

6 small branches ( the geniculates plus anertior tibial recurrant)

Popliteal, Superficial femoral and Anterior Tibial

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67
Q

3 associations with tarsal coalition:

A

Fibular hemimelia

Apert’s

PFFD

“People with tarsal coalition masturbate a lot: FAP FAP FAP”

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68
Q

Main blood supply to femoral head in kids >4

A

Medial femoral circumflex artery

via: posterosuperior lateral epiphyseal branch

&

posterior inferior retinacular branch

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69
Q

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

A

If >2mm (not cm) of growth remains

progressive deformity

symptomatic

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70
Q

5 risk factors for LCP

A

Positive family history

Low birth weight

Abnormal birth presentation

Second hand smoke exposure

Asian, Inuit, central european descent

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71
Q

Manifestations of Achondroplasia

A

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

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72
Q

What happens if the GT apophysis is prematurely arrested?

A

hip will go into valgus

(medial side keeps growing)

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73
Q

Best pin configuration for SCHF?

A

Lateral divergent pins (2 vs 3)

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74
Q

Describe the deformity in congenital vertical talus

A

Rockerbottom foot:

Hindfoot: equinovalgus (everted & lateralized)

Midfoot: rigid dorsiflexion

Forefoot: abducted & dorsiflexed

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75
Q

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

A

Hypertrophic zone

caused by weakness in the perichondral ring

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76
Q

MPS with least spinal abnormalities?

A

San Filippo

only has scoliosis, and even that is rare

JAAS 2013

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77
Q

Lateral Pillar Classifiation: (LCP)

A

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

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78
Q

Cause and treamtent of stiff-knee gait in CP?

A

Cause: rectus femoris firing out of phase

Treatment: transfer of distal rectus femoris tendon

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79
Q

Characteristic lesion in Fredrich’s ataxia

A

Spinocerebellar degenerative disease, therefore, lesions in:

  • Dorsal root ganglia (peripheral)
  • Corticospinal tracts (central)
  • Dentate nuclei in the cerebellum
  • Sensory peripheral nerves
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80
Q

First line treamtent in tarsal coalition?

A

trial of non-op with immobilization or orthotics - always

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81
Q

What is the best treatment for Sever’s disease?

A

Calcaneal apophysitis

Best is achilles stretching - may decrease recurrence

No role for operative management

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82
Q

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

A

Echo: cardiac defects - 10%

Renal ultrasound and GU workup - genitourinary defects - 25%

MRI - spinal cord malformations

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83
Q

Surgical treatment for CMT claw toes?

A

Jones procedure

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

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84
Q

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

A

Acetabular Index

varies with age (decreases)

normal is less than 25 deg 2yo kid

(remember 2yo is ~20deg)

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85
Q

4 indications for surgery in infantile Blount’s

A

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

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86
Q

Can a Klippel Feil patient play contact sports?

A

No if they have fusion of C3 and above

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87
Q

WHat joints are most commonly invovlved in JIA?

A

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

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88
Q

What are ideal factor levels in a hemophiliac for :

  1. acute hematomas
  2. acute hemarthrosis and soft tissue surgery
  3. skeletal surgery
A
  • 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
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89
Q

Indications for contralateral pinning in SCFE

A

High risk patients:

Endocrinopathy

Obese

Young age, indicated by:

  • Boys
  • Girls
  • Open Triradiate cartilage
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90
Q

Adequate reduction parameters for Delbet 2-4?

A

Type II

  • accept <2mm cortical translation
  • <5 deg angulation
  • no malrotation

Type III and IV

  • accept <10 degrees of angulation
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91
Q

4 negative prognostic indicators of pediatirc spetic arthritis?

A

age

associated osteomyelitis

hip joint (versus knee)

delay >4 days until presentation

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92
Q

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

A

To identify omovertebral bar

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93
Q

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

A
  1. Persistant inflammatory arthritis
  2. > 6 weeks
  3. Patient < 16 years
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94
Q

Kocher Criteria for Septic Hip

A

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

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95
Q

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

A

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

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96
Q

What construct for SCHF pinning has the most biomechanical stability?

A

Medial and lateral crossed pins

But we don’t use them b/c of the risk of injury to the ulnar nerve

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97
Q

WHen i say Olecranon apophysis avulsion fracture, you say:

A

osteogenesis imperfecta

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98
Q

4 indications for open reduction of pediatric elbow dislocation?

A
  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
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99
Q

What is the pediatric equivalent of Lauge Hansen classification?

A

Diaz / Tachdjian

SAD, SER, PER, SPF (Supination plantar flexion)

(compare Lauge-Hansen which is SAD, SER, PER, PAB)

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100
Q

What is normal range for IR and ER of hip?

A

IR = 20-60

ER = 30-60

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101
Q

4 options for elbow release in arthrogryposis

A

Triceps to biceps

Steindler flexorplasty

Pec Major to biceps

Triceps V-Y lengthening and posterior capsulectomy

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102
Q

Describe the anatomy of CVT

A

Dorsal structures are tight (navicular dorsally dislocated)

Rocketbottom foot

  • hindfoot equinovalgus
  • rigid midfoot dorsiflexion
  • forefoot abducted and dorsiflexed

Tib post is tight

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103
Q

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

A

Aortic root dilatation

Superior lens dislocation

If both are present, do not need genetic testing - therefore test for both (Echo and optho consult)

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104
Q

Indication for surgery in LCP?

A

Lateral pillar B, B/C, C in kids >8 (bone age >6)

They do better with pelvic/femoral osteotomy

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105
Q

What did Sillence classify?

A

OI

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106
Q

How does a patient with SCFE clinically present?

A

Pain

Obligatory ER

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107
Q

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

A

L3 - uopposed hip flexion and adduction

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108
Q

Name 3 syndromes with abnormal ossification of secondary growth centers

A

Spondyloepiphyseal dysplasia

Multiple epiphyseal dysplasia

diastrophic dysplasia

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109
Q

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

A

Rigid hindfoot varus.

Do: calcaneal valgus producing osteotomy

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110
Q

What antibiotic should you avoid in paeds?

A

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

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111
Q

DMD Scoliosis

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

A

1) respiratory function
2) Controversial

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112
Q

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

A

Mild cavo-varus foot

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113
Q

LLD Principals:

a)

b) 2-5 cm
c) > 5 cm

A

a)

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

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114
Q

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?

A
  • 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.
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115
Q

Who gets Gower’s sign? Describe it

A

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

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116
Q

Conditions that may cause SCFE?

A
  • obesity (most important)
  • hypothyroidism (labs show elevated TSH)
  • osteodystrophy of chronic renal failure
  • Rickets
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117
Q

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

A

initial or fragmentation phase

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

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118
Q

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

A
  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)
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119
Q

Muscle imbalance in equinovalgus foot?

A

Opposite of equinovarus

TA/TP weak

PB/PL strong

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120
Q

Classification of CP Hips & Treatment

A

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
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121
Q

What is a Charnley WIlliams rod used for?

A

ORIF of NF tibial pseudoarthrosis

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122
Q

Principals for bladder extrophy repair?

A

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

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123
Q

2 methods of percutaneous reduction of radial head fracture

A
  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

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124
Q

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

A

PO associated with cognitive impairment.

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125
Q

Treatment of dislocated hip in myelomeningocele?

A

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.

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126
Q

dDx for cavovarus foot (5)

A

Charcot-Marie-Tooth

Freidreich’s ataxia

Cerebral palsy

Polio

spinal cord lesions

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127
Q

Anterolateral bowing:

what’s the chance this patient has NF?

What is the chance an NF patient has anterolateral bowing?

A

what’s the chance this patient has NF?

50%

What is the chance an NF patient has anterolateral bowing?

10%

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128
Q

3 INDICATIONS for nerve repair/grafting in Brachial plexopathy?

A

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

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129
Q

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

A

pes cavus

hammer toes

hip dysplasia

scoliosis

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130
Q

5 conditions associated with Cavovarus foot?

A
  1. Charcot-Marie-Tooth
  2. Freidreich’s ataxia
  3. Cerebral palsy
  4. Polio
  5. spinal cord lesions
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131
Q

4 dDx for leg bowing in kids?

A

Physiologic

Blount’s disease

Osteogenesis imperfecta

Rickets/osteomalacia

Syndromic

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132
Q

Describe Birch Classification for fibular hemimelia

A

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

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133
Q

Differential for unilateral valgus (3)

A

Proximal metaphyseal tibial fracture (Cozen’s)

UnilateralPhyseal injury

  • Trauma
  • Infection
  • Vascular insult

Benign tumour

  • Fibrous dysplasia
  • Osteochondroma
  • Ollier’s disease
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134
Q

2 optioins for treating elbow flexion contractures

A

Clarke’s pectoral transfer

Steindler’s flexorplasty

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135
Q

Treatment of hallux varus

A

Conservative:

  • most resolve with time

Can do abductor hallucis release

excsision of central epiphyseal bracket

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136
Q

Defect in diastrophic dysplasia?

A

DTDST gene (SLC26A2)

codes for diastrophic dysplasia sulfate transporter gene on chromosome 5

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137
Q

How do you estimate blood volume in a kid?

A

75 - 80 mL/kg

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138
Q

Principals of Proximal tibia/fibula valgus osteotomy for Blounts?

A
  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
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139
Q

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

A

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

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140
Q

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

A
  1. AVN
  2. coxa vara
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141
Q

4 conditions associated with CVT?

A
  1. myelodysplasia (common)
  2. arthrogryposis
  3. diastematomyelia
  4. chromosomal abnormalities

High association with genetic or neuromuscular disorder (50%)

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142
Q

3 nonorthopaedic conditions of marfans?

A
  • cardiac abnormalities
  • aortic root dilatation
  • possible aortic dissection in future
  • mitral valve prolapse
  • superior lens dislocations (60%)
  • spontaneous pneumonthoraces
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143
Q

NIH Consensus Development Conference Statement diagnosis criteria for NF1?

A

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
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144
Q

Bado Classification

A

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

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145
Q

Contraindications to Pavlik harness (4)?

A
  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.
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146
Q

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

A
  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
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147
Q

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

A
  1. valgum < 12 degrees
  2. IM distance < 8cm
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148
Q

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

A

Compartment syndrome

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

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149
Q

Give general principles of operative treatment for PFFD

A

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
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150
Q

4 indications for osteotomy in Infantile Blounts?

What osteotomy would you do?

A
  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

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151
Q

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

A

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

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152
Q

Non-ortho associations of hemihypertrophy (2 major types)

A

Malignant intra-abdominal tumours

  • Wilm’s - most common
  • adrenal carcinoma
  • hepatoblastoma

GU abnormalities

  • medullary sponge kidney
  • polycystic kidney
  • inguinal hernia
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153
Q

What is von Recklinghaussen disease?

A

NF1

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154
Q

Best x-ray view for lateral condyle fracture?

A

internal oblique

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155
Q

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

A

SMA

“A” is for alpha motor neurons and anterior horn

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156
Q

Management of equinovarus foot

A

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

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157
Q

Name the physeal zone associated with:

SCFE (not renal)

Rickets (provisional calcification zone)

Enchondromas

Mucopolysacharide disease

SED

MED

A

hypertropic

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158
Q

What are the 5 physeal zones?

A
  1. Reserve
  2. Proliferative
  3. Hypertrophic
  4. Primary Spongiosa
  5. Secondary Spongiosa
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159
Q

What is the best indicator of peak growth?

A

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

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160
Q

WHere does a Salter osteotomy hinge on?

A

Symphysis Pubis

1 cut from AIIS to sciatic notch

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161
Q

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

A

metaphyseal chondrodysplasia

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162
Q

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

A

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)

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163
Q

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?

A

Tibial deficiency

AD

Must counsel parents of risk with further children

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164
Q

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

A

early reduction

Joint decompression (hematoma aspiration or core decompression)

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165
Q

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

A

Nonoperative

They do well regardless

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166
Q

Treatment for calcaneovalgus foot?

A

observation and parental stretching

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167
Q

3 exam findings consistant with tarsal coalition?

A
  1. flattening of arch
  2. valgus hindfoot
  3. peroneal spasticity
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168
Q

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

A

Extent of soft tissue release

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169
Q

4 complications of radial head fractures

Which 2 are related to open reduction?

A
  • 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
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170
Q

Classification of Sprengel’s:

A

see chart

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171
Q

How long do you wear a Pavlik?

A

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

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172
Q

8 orthopedic manifestations of Downs?

A
  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
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173
Q

Surgical option in resistant vertical talus?

A

talectomy

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174
Q

Preferred fixation of SHII distal femoral physeal fracture

A

Lag screw through the metaphyseal flare piece

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175
Q

Valproic acid has what detrimental effect on surgery?

A

Increases bleeding time

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176
Q

Name the physeal zone associated with:

  • Gaucher’s
  • diastrophic dysplasia
A

Reserve

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177
Q

Spine changes in NF1

A

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

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178
Q

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

A

SH4 of medial malleolus

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179
Q

How is CP gait desribed/classificed

A

Sagittal plane

  • Jump
  • Crouch
  • Stiff knee

Transverse plane

  • IR
  • ER
  • Neutral

Coronal plane:

  • Genu varum
  • Genu valgum
  • hip adduction
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180
Q

4 indications for OR in pediatric pelvis fracture?

(radiographic)

A

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

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181
Q

Risk of contralateral SCFE in otherwise healthy kid?

A

50%

(10-60%)

this is asking the risk of contralateral SCFE, not bilateral SCFE

Bilateral is 20% in normal, 80% in endorinopathy

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182
Q

Acceptable Alignment BBFF?

A

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

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183
Q

Who gets Duchenne muscular dystrophy?

A

Males only

X-linked recessive

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184
Q

4 signs of residual DDH in kid > 3 months

A

Limited hip abduction

Pelvic obliquity

+ galeazzi

Trendelenburg gait

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185
Q

4 joints with intra-articular metaphyseal cortex

A

hip, shoulder, elbow, and ankle

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186
Q

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

A

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.

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187
Q

Spinal manifestations of Achondroplasia:

A

Foramen magnum stenosis (NOT c-spine instability)

Kyphosis

Lumbar stenosis

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188
Q

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

A

Medial epicondyle fracture

make sure it’s not incarcerated in the ulnohumeral joint. If it is, it’s an indication for surgery

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189
Q

What is Nail-Patella syndrome?

A

Hypoplastic Nails and Petallae

AD inheritance

Also includes:

Laxity

scoliosis

scapular hypoplasia

presence of cervical ribs

amongst other things

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190
Q

2 techniques to reduce a radial head fracture

A

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

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191
Q

AAOS guidelines for paediatric femoral shaft fractures

A

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

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192
Q

Indications for selective thoracic fusion:

A

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

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193
Q

What does the VilleFranche classification describe?

A

Ehlors Danlos

Villefranche Classification (1998)

Classical - Type I (gravis) and Type II (mitis)

COL5A1 or COL5A2 mutation

There are several other sub types

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194
Q

Best surgical appraoch to CP HV?

A

1st MTP fusion +/- Akin

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195
Q

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

Best test to look for fibrous coalition

A

CT best to look at cross-sectional imging

MRI best to look at fibrous coalitions

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196
Q

7 reasons that in-toeing requires further investigations?

A

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.

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197
Q

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

A

Nearly 100%

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

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198
Q

2 complications of transphyseal distal humerus fracture?

A

Cubitus varus

Medial condyle AVN

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199
Q

Complications seen with too much abduction in Pavlik?

A

AVN

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200
Q

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

A

Tib ant overpull in relation to peroneal muscles

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201
Q

tarsal coalition

Chance of it being bilateral?

Patient with 1 coalition has what percentage of having another?

A

50% chance of being bilateral

20% chance of a second coalition if they have 1

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202
Q

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

A

Spinal cord stenosis

JAAOS 2013

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203
Q

Name 4 featuers of Acnohdroplasia (there are about 15)

A

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)
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204
Q

Othopaedic Manifestations of CMT?

A

Scoliosis

Pes Cavus

Hammertoes

Hip dysplasia

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205
Q

What are the 4 deformities of clubfoot?

A
  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)
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206
Q

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

A
  1. Scoliosis
  2. Klippel-Feil

(JAAOS)

see chart

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207
Q

WHat is the spine deformity in multiple epiphyseal dysplasia

A

None

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208
Q

dDx of knee or thigh pain paediatric patient:

A

Knee pathology

Hip pathology

  • SCFE
  • LCP
  • Septic hip
  • Transient synovitis hip

*knee/thigh pain mandates a workup for SCFE

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209
Q

How can you be fooled into thinking someone doesnt have an achilles contracture?

(I.e a false negative)

A
  • 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
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210
Q

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

A

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

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211
Q

Describe the Beighton-Horan scale.

A

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)
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212
Q

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

A

Pain

LLD

Progressive deformity

Family history of rickets, skeletal dysplasias, mucopolysaccharidoses

Limb rotational profiles 2 standard deviations outside the normal

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213
Q

5 things affecting Hypertrohpic Zone of growth plate

A

SCFE

MED

SED

Schmids

Fractures (SH1)

Ricekts

Enchondromas

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214
Q

What is the natural history of OI fractures with age?

A

The symptoms improve with age

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215
Q

What are two options to treat AVN

following proximal femur fracture?

A

● Vascularised free fibula graft

● Core decompression

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216
Q

Preferred treatment of congenital vertical talus

A

Reverse ponsetti casting +

surgial reduction & pinning of talonavicular joint +

TAL

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217
Q

Paediatric olecranon fractures are highly suspicious for:

A

Osteogenesis imperfecta

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218
Q

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

A

> 30° of residual angulation

3-4 mm of translation

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219
Q

Order of correction in ponsetti method

A

Cavus first (midfoot)

Then adduction & Varus (hindfoot)

Equinus last

(CAVE)

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220
Q

5 causes of hemihypertrophy

A

idiopathic

neurofibromatosis

beckwith-weidemann syndrome

Klippel-trenauney syndrome

proteus syndrome

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221
Q

What part of the physis does a SCFE occur in?

A

Hypertrophic

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222
Q

What percentage of LCP patients will eventually need THA?

A

50%

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223
Q

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

A

Presence of ANA

If negative: Every 6 months

If positive: Every 4 months

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224
Q

Name 4 non-ortho manifestations of myelodysplasia

A

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
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225
Q

3 complications of radial head/neck fractures

A

AVN

synostosis

loss of ROM (pronation > supination)

radial head overgrowth

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226
Q

2 spinal deformities with OI

A

Scoliosis

basilar invagination

(NOT AAI)

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227
Q

4 ortho and 2 nonortho associations with Friedrich’s ataxia

A

Ortho

  • cavovarus foot: often rigid
  • scoliosis
  • ataxia
  • areflexia (but with positive plantar response)

Non-ortho

  • Cardiomyopathy
  • nystagmus
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228
Q

Never do what when ORIFing a lateral condyle fracture?

A

Never dissect posteriorly

Blood supply comes from there and will cause AVN if you disrupt it

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229
Q

Difference between bone infarct and osteomyelitis on imaging?

A

osteomyelitis: normal marrow uptake, abnormal bone scan

infarct: decreased marrow uptake, abnormal bone scan

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230
Q

What 3 spinal deformity conditions are bracing CONTRAindicated in?

A

Spina Bifida

SCI

Muscular dystrophy

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231
Q

Associated ortho conditions for PFFD (4)

A

Fibular hemimelia (50%)

ACL deficiency

Coxa vara

knee contractures

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232
Q

4 manifestations of CMT?

A
  1. pes cavus
  2. hammer toes
  3. hip dysplasia
  4. scoliosis
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233
Q

SMA treatment:

  1. Hip Dislocations
  2. Scoliosis
  3. Hip Contractures
A
  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.
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234
Q

4 radiographic findings in OI

A

thin cortices

generalized osteopenia

saber shins

skull radiographs reveal wormian bones

Metaphyseal bands (bisphosphonate use)

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235
Q

What part of acetabulum is deficient in neuromuscular hip dysplasia?

A

posterior superior

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236
Q

DDH U/S:

What is alpha angle and what is normal?

A
  • angle created by lines along the bony acetabulum and the ilium
  • normal is greater than 60°
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237
Q

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

A

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

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238
Q

6 Blocks to reduction in DDH:

A

ligamentum teres

capsule

transverse acetabular ligament

inverted labrum

Psoas

Pulvinar

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239
Q

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

A

O2 sat at presentation

GCS 72 hours post injury

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240
Q

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

A

TAR: thrombocytopenia absent radius - check plt

Fanconi Anemia - check Hb

VACTERL

VATER

Holt-Oram - congenital cardiac abnormalities

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241
Q

Complications seen with too much flexion in Pavlik?

A

Femoral nerve palsy.

242
Q

6 associated ortho conditions with arthrogryposis

A

Upper extremity deformity

Hip subluxation and dislocation

Knee contractures

Foot conditions

  • Clubfoot
  • Vertical talus

Neuromuscular C-shaped scoliosis (33%)

Fractures (25%)

243
Q

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

A

Prior to application of the final cast

244
Q

What view is best for looking at accessory navicular?

A

External oblique

245
Q

What are the normal values of Staheli Rotational Profile?

A

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
246
Q

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

A

Freidrich’s Ataxia

“d” is for dorsal root ganglia

247
Q

dDx for bilateral valgus (3)

A

Physiologic

Renal osteodystrophy (Rickets)

Skeletal dysplasia

  • Morquio
  • Spondyloepiphyseal dysplasia
  • Chondroctodermal dysplasia
248
Q

WHat is Pavlik’s disease?

A

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

249
Q

4 complications of Lateral Condyle fracture (operative)

A

AVN

Malunion/Non-union –> cubitus valgus

Tardy Ulnar Nerve Palsy

Lateral spurring

250
Q

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

A

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

251
Q

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

A

Overall: CNS injuries (TBI)

of MSK injuries: Spine

252
Q

List proportionate Dwarfism

A

Mucopolysaccharidosis

  • Hunter
  • Hurler
  • San Fillipo
  • Morquios’

Cleidocranial dysplasia

253
Q

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

A
  1. Rough cast edge at popliteal fossa
  2. Excessive traction
  3. Knee flexion > 90
254
Q

Indication for serial casting in MTA?

A

Rigid deformity with medial crease

255
Q

3 options to treat IR contractures fo the shoulder

A

Lat dorsi and teres major tendon transfer

Pec major and subscap lengthening

proximal humerus ER osteotomy

256
Q

Risk factors for congenital kyphosis progression (4)

A

Type I (failure of formation)

Type III (mixed failure of formation and failure of segmentation)

Immaturity

Curve > 40 deg

257
Q

Describe an NF1 patient’s risk of cancer

A

Increased risk of benign and maligant tumours, including:

melanoma

leukemia

rhabdomyosarcoma

pheochromococytoma

carcinoma

pancreatic endocrine tumours

astrocytoma

258
Q

Three ways Pseudoachondroplasia differs from Achondroplasia?

A
  • normal facies on physical exam
  • associated with cervical instability due to odontoid hypoplasia
  • absence of spinal stenosis
259
Q

Define Arthrogryposis

A

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

260
Q

Delbet Classification

A

Paediatric femoral neck fractures

Ia: transphyseal (epiphysis) no displacement

Ib: transphyseal (epiphysis) displacement

II: femoral neck (transcervical)

III: Basicervical

IV: Intertrochanteric

261
Q

Diagnosis?

A

Sacral agenesis

262
Q

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

A

Proximal femoral resection

(controversial)

263
Q

How do you clinically differentiate SMA vs. DMD

A

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

SMA has fasciculations

264
Q

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

A

proximal femur - 3 mm / yr

distal femur - 9 mm / yr

proximal tibia - 6 mm / yr

distal tibia - 5 mm / yr

265
Q

Indications for pinning distal radius fracture in paeds (7)

A
  • 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
266
Q

6 dDx for metaphyseal flaring:

A

Fibrous dysplasia

Storage diseases

Rickets

Anemia

Chronic lead posioning

bone dysplasia

267
Q

Name 6 syndromes/diseases assocated with basilar invagination

A

Klippel-Feil

Osteogenesis imperfecta

Morquio syndrome

achondroplasia

spondyloepiphyseal dysplasia

occipitocervical synostosis

268
Q

Paediatric proximal humerus fracture classification:

A

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

269
Q

What operative intervention is contraindcated in CP patient with crouched gait

A

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)

270
Q

Name 4 life-threatening perioperative complications with MPS

A

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

271
Q

Name the physeal zone associated with:

Achondroplasia

Gigantism

MHE

A

Proliferative

272
Q

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

A

Flexible contracture:

AFO

Rigid contracture:

OR

273
Q

3 things affecting Proliferative Zone

A

Achondroplasia

Multiple Hereditary Exostoses (MHE)

Gigantism

“A Giant Me”

274
Q

Who a I?

Multiple congenital joint dislocations

ligamentous laxity

abnormal facies:

A

Larsen Syndrome

275
Q

Medical treatment for AD osteopetrosis?

A

interferon gamma-1 beta

276
Q

4 predictors of complications when doind a nancy nail?

A
  1. > 25 mm nail protruding from nail
  2. Age > 11 years
  3. Weight > 45 kg
  4. Fracture is very proximal, distal or comminuted
277
Q

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

A
  1. LLD
  2. Is the foot stable and plantigrade?
278
Q

Describe the GMFCS scale.

A
279
Q

I say absent clavicles, you say:

A

Cleidocranial dysplasia

failure of intramembranous ossifciation

leads to failure of formation of midline structures

ie failre of pubis to ossify

280
Q

Good prognostic signs of anterolateral bowing? (2)

A

Duplicated hallux

Delta-shaped osseous segment in concavity of bow

281
Q

Acceptable criteria for distal radius fractures

A

<9 years old: 30 degrees dorsal angulation. Bayonette apposition <1cm

>9 years old: 20 degrees dorsal angulation

No rotational deformities

282
Q

Name 4 social risk factors for child abuse

A

recent job loss of parent

children with disabilities (cerebral palsy, premature)

step children

Premature child

283
Q

Name 4 sources of blood supply to the femoral head:

A

MFCA (main after 4 years)

via posterosuperior lateral epiphyseal branch & posterior inferior retinacular branch

LFCA (

Artery of ligamentum teres (

Metaphyseal vessels

284
Q

Non-ortho manifesataions of SMA

A

Resp - Major cause of morbidity and mortality. Consult them

GI - Common: consult them (swallowing problems)

285
Q

3 spinal manifestations of Achondroplasia?

A

Thoracokyphosis

Lumbar Stenosis

Foramen Magnum/Upper Cervical Stenosis

286
Q

Congenital hallux varus is associated with what?

A

Polydactyly

287
Q

Normal alpha angle (DDH)

A

>60 deg

angle of bony ilium and acetabulum

288
Q

is dynamic supination caused by operative or non-operative treatment of clubfoot?

How do you treat it?

A

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

289
Q

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

A

Improves mobility

decreases fracture rate

improves vertebral bone density

Improves vertebral height (not overall height)

290
Q

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

A

NF1 = smooth “coast of California” borders

McCune-Albright syndrome = rough “coast of Maine” spots

291
Q

When do you brace congenital scoliosis?

A

To control supple compensatory curves

292
Q

Workup of Arthrogryposis at 3 months? (3)

A

Perform at 3-4 months of age

  1. neurologic studies
  2. enzyme tests
  3. muscle biopsies
293
Q

Diagnosis?

A

CVT

Clues:

talus is vertical

navicular dorsal dislocation

294
Q

Name 3 tumours specific to NF1

A

Optic glioma

Neurofibroma

Neurofibrosarcoma (aka Malignent peripheral nerve sheath tumours)

295
Q

Name the physeal zone associated with:

Renal SCFE

A

Secondary Spongiosa

296
Q

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

A
  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
297
Q

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

A

Regular slit-lamp examination by ophthalmologist.

Iridoclyclitis (uveitis) can lead to rapid blindness

298
Q

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

A

Gauchers disease

299
Q

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

A

Friedrich’s ataxia

300
Q

Classic presentation of diastrophic dysplasia?

A

Rhizomelic dwarfism

Hitchiker’s thumb

cauliflower ears (80%)

Cleft-palate (60%)

301
Q

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

A

Proximal femoral derotational osteotomy

Create: flexion, valgus, IR

Imhauser osteotomy (intertrochanteric osteotomy)

302
Q

4 non-orthopedic manifestations of Downs?

A
  1. mental retardation
  2. heart disease (50%)
  3. endocrine disorders (hypothyroidism)
  4. premature aging
303
Q

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

A

Pulmonary: 60 deg

Cardiopulmonary: 90 deg

Mature: 100 deg (Agabegi Jaaos 2015)

304
Q

Larsens Surgical Treatment:

  1. Cervical Kyphosis
  2. Hip Dislocation
  3. Knee Dislocation
A
  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
305
Q

Diagnosis

What is their physical exam going to be like?

What other test do you order?

A

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

306
Q

Flat top talus

Almost pathognomonic for what?

A

Clubfoot treatment complication

307
Q

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

A

pronation of forefoot

must SUPINATE so that it lines up with the hindfoot

308
Q

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

A

Higher

More

309
Q

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

A

congenital muscular torticollis (20%)

metatarsus adductus (10%)

congenital knee dislocation

310
Q

Non-ortho manifestations of Down (3)

A

Cardiac abnormaltieis (50%)

Endocrine (hypothryoidism)

mental retardation

premature aging

311
Q

Next step if Pavlik harness treatment fails?

A

Convert to abduction brace for 3-4 weeks.

312
Q

What are “Thumb” and “Wrist” signs associated with?

A

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.

313
Q

What condition is associated with MadeLungs?

A

Leri-weill dyschondrosteosis

SHOX gene abnormality

Causes mesomelic dwarfism

314
Q

My PAL Adrian eats HAM on his CPM machine.

How does this help you pass the exam?

A

PAL = Pseudoarthrosis is AL bowing

HAM = Hemimelia is AM bowing

CPM = Calcaneovalgus is PM bowing

315
Q

What are physical exam findings consistant with equinovarus foot?

A
  1. intoed gait
  2. inverted heel (tib post)
  3. supinated forefoot (tib ant)
  4. callous and pain along lateral border
316
Q

Why would you do a squatting skyline xray?

A

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

317
Q

BBFF - initial management?

A

SAC

Found to have lower remanipulation rates

Lower pain/swelling at 1 and 7 days post reduction

318
Q

Most common complication of lateral condyle fracture?

A

Lateral overgrowth/spurring

319
Q

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

A

30% and above

320
Q

6 Dural Ectasia associations

A

Marfan syndrome

NF1

Ehlers-Danlos

Achondroplasia

Ank spond

idiopathic

321
Q

Two indications for endocrine workup in a SCFE?

A
  • child is < 10 years
  • weight is < 50th percentile
322
Q

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

A

Abduction

also Forward flexion

323
Q

Torticollis: head tilt and rotation which direction?

A

Tilt: towards side of pathology

Rotation: chin rotates away from pathology

324
Q

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

A

Supramalleolar derotational osteotomy > proximal tibial osteotomy

More complications with proximal

325
Q

Surgical option for pathologic genu valgum:

a) with significant growth remianing
b) near the end or done growing

A

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

326
Q

MRSA infected kids have higher levels of what on admission?

A

ESR, CRP, WBC

327
Q

Pathology in SMA

A

Progressive loss of alpha motor neurons in anterior horn of spinal cord

Muscle weakness LE > UE (like anterior cord syndrome)

Proximal > distal

328
Q

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

A

2cm

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

329
Q

Treatment for posteromedial bowing?

What must you monitor for with your treatment plan?

A

Non-operative - will spontaneously resolve in 5-7 years

Must watch for LLD (common complication)

330
Q

Risk factors for SMA syndrome in AIS surgery (7)

A

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)

331
Q

List the normal progression of leg angulation:

A

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)

332
Q

Diagnosis and most common site/cause

A

Congenital pseudoarthrosis of the clavicle

Caused by extrinsic compression by the subclavian

Right middle 1/3 of clavicle 90%

Left only if situs inversus

333
Q

Treatment of hip abduction contracture in myelodysplasia

A

Ober-Yount Procedure:

proximal division of fascia lata and IT band release

334
Q

3 orthopaedic associations with tibial deficiency.

A

Ectrodactyly (cleft hand)

preaxial polydactyly

ulnar aplasia

high rate of MSK anomalies (75%)

335
Q

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?

A

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

336
Q

3 treatment options for NF related tibial bowing?

A
  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
337
Q

Plantarflexion lateral of two cases with rockerbottom sole deformity.

What is the diagnosis in A and B?

A

A = Congenital oblique talus

B = Congenital vertical talus

(Difference is that Oblique talus corrects the talonavicular joint with stress plantarflexion lateral)

338
Q

Anatomic Classifiation of CP

A

Quadriplegic

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

Hemiplegic

339
Q

Signs of Dystrophic Curve (7)

A

Gibbous deformity: short segment kyphoscoliosis

Rib penciling

Intra-canal ribs

Vertebral body scalloping

Dystrophic pedicles

Dural ectasia

Intraspinal neurofibroma

340
Q

3 ultrasonographic measurements in DDH

A

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)

341
Q

Best 2 tests for septic hip?

A

T > 38.5

CRP > 2

342
Q

3 poor prognostic indicators for subtalar coalition

1 contraindication to surgery

A

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

343
Q

Name a contraindication to hemiepiphysiodesis in congenital scoliosis:

A

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)

344
Q

Compare infantile and adolescent Blounts

A

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
345
Q

What is the most common complication of proximal femur fracture?

A

AVN

(Coxa vara and non-union also important)

346
Q

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

A

alpha-fetoprotein (AFP)

347
Q

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

A

<4

>4 = activity against gravty

(Different UE functions are graded on a scale and added together)

348
Q

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

A

Use of ex-fix

(Especially with transverse or short oblique fractures)

349
Q

3 indications for CRPP of pediatric distal radius fracture.

A
  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)
350
Q

Indications for OR with medial epicondyle fracture? (4)

Preferred fixation?

A

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

351
Q

5 Characteristics of trigger thumb

A

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)

352
Q

Contraindication to treatment of paediatric femur fracture (open physes)

A

Piriformis start femoral nail

b/c of increased risk of AVN

superior retinacular vessels of MFCA are at risk

353
Q

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

A

Echo (cardiac manifestations)

Renal ultrasound (renal aplasia)

354
Q

4 surgical indications for coxa-vara

A

Trendelenburg gait + Hilgenreiner-epiphyseal angle beween 45-59 degrees

Progression of coxa vara on serial x-rays

HE angle > 60

femoral neck shaft angle

355
Q

Diagnosis?

A

Equinovalgus

i.e. CP foot

Clues:

Inferior tilt of talus

Loss of medial arch

356
Q

Predictors of poor outcome in paediatric septic hip (4)

A

Age

Associated OM

Hip joint (vs knee)

Delay > 4 days until treatment

(JAAOS)

357
Q

8 risks for brachial plexus birth injury

A

Large of gestational age

High birth weight

Cephalopelvic disproportion

Shoulder dystocia

Forceps delivery

Difficult presentation

Breech position

Prolonged labour

358
Q

3 surgical treatment options for Adolescent Blounts?

A
  1. Transient lateral hemiepiphysiodesis
  2. Permanent lateral hemiepiphysiodesis
  3. Valgus HTO with ORIF or gradual corrrection (ilizarov or TSF)
359
Q

Risk factors for SCFE (7)

A

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

360
Q

Name 3 general surgical intervnetions you can do for tibial hemimelia

A
  • 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)

361
Q

3 treatments for a hemophilac knee?

i.e. for

  • chronic synovitis
  • recurrent hemarthrosis
  • joint destruction
A
  1. Surgical Synovectomy
  2. Radioactive Synovectomy
  3. TKR
362
Q

Spinal manifestations of diastrohpic dysplasia

A

AAI

Cervical kyphosis

TL kyphoscoliosis

Rarely needs treatment

363
Q

Most common cause of septic hip in neonates?

A

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)

364
Q

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.

A
  1. rash
  2. presence of RF
  3. iridocyclitis (anterior uveitis)
  4. C-spine involvement
  5. pericarditis
  6. tenosynovitis
  7. intermittent fever
  8. morning stiffness
365
Q

You do an iliac crest biopsy to confirm diagnosis of OI.

3 positive findings?

A

decrease in cortical widths

decreased cancellous bone volume

increased bone remodeling

366
Q

Classification of lateral condyle fracture and treatment algorithm?

A

I: undisplaced (<2mm) (nonop)

II: 2-4mm displaced (CRPP vs ORPP)

III: >4mm displaced (ORIF or ORPP)

367
Q

3 advantages of nancy nailing over ORIF

A
  1. shorter surgical time than ORIF
  2. less blood loss than ORIF
  3. equal union rates, radial bow and rotation as ORIF
368
Q

4 maternal risk factors for congenital scoliosis

A

diabetes

alcohol

valproic acid

hyperthermia

369
Q

SCHF with cold, pulseless hand. Management?

A

Immediate CR & PP

Open is not first step

370
Q

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

A

CRP >20mg/L

(even though it’s not on the Kocher criteria)

371
Q

Main vascular concern in tibial tibercle fracture?

A

Tear of recurrent anterior tibial artery

May assess with CT-A if concerned

Leads to compartment syndrome

372
Q

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

A

ECU

Dorsal

373
Q

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

A

Flexion type

Most common nerve palsy after flexion type injury is ulnar

374
Q

Managmenet and timing of treatment of congenital vertical talus?

A

Start with casting to stretch dorsal structures

followed by surgery in almost all cases

OR before 27 months for best results

375
Q

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

A

Infantile: overcorrect into 10-15 degrees of valgus b/c medial growth abnormalities still exist

Adolsecent: Do NOT overcorrect

376
Q

Flat top talus is a complication of what casting method?

A

Ponseti

377
Q

What is the primary treatment for Gauchers?

A

IV enzyme replacement therapy.

Not effective in type 2.

Medications end in -glucerase.

Also consider bone marrow transplant

378
Q

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

A

Tight heel cord

379
Q

Physiologic Classification of CP

A

Spastic

Athetoid

Ataxic

Mixed (Usually Spastic/Athetoid)

Hypotonic

380
Q

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

A

None

381
Q

General treatment principle for Downs Spine

A

Nonoperative management if possible - high complication rates with surgery

382
Q

What is the managmeent algorithm of Fibular deficiency?

A

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

383
Q

8 radiographic findings in Blount’s disease

and one physical finding

A

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

384
Q

How do you screen for and diagnose MPS?

A

Screen: urine

Diagnose: enzyme assay for activity in skin fibroblasts or WBC

385
Q

What is the anatagonist of peroneus Longus?

A

Tibialis anterior

386
Q

How do you reduce BADO I/III?

A

Flexion & supination

387
Q

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

A

posterior-superior instead of anterior/anterolateral

388
Q

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

A

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.

389
Q

Diagnosis?

Give 1 dDx

A

Multiple Epiphyseal Dysplasia

Classic for MED to present as “bilateral” Legg-Calve-Perthes disease

390
Q

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

A

Corrects hindfoot valgus.

(calcaneal lateral column lengthening osteotomy)

391
Q

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

A

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

392
Q

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

A

PVL (Panton-Valentine leukocidin) +

393
Q

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

A

Nonop complications

  • deformit relapse
  • dynamic supination

Operative complications

  • Residual cavus
  • pes planus (due to overcorrection)
  • undercorrection
  • intoeing gait
  • Osteonecrosis of talus
  • dorsal bunion
394
Q

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

A

Pars Repair

Indiated at L4 and above

L5: must fuse in-situ

395
Q

Name the physeal zone associated with:

Metaphyseal “corner fracture” in child abuse

Scurvy

A

Primary Spongiosa

396
Q

4 factors predictive of physeal arrest in distal femur physeal fracture

A

SH classification

Presence of displacement

open fracture

Hardware penetration into physis from surgical management

397
Q

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

A

To allow full ossification of phalanges and plan surgery

Surgical ablation typically done at 9-12 months of age

398
Q

what are the orthopaedic issues in NF?

(What type of music do NF patients listen to?)

A

Extreme SKA

1. Extremity deformities

Hemihypertrophy

Pseudoartrhosis

AL Bowing

2. Scoliosis

3. Kyphosis

4. AAI

399
Q

4 radiographic signs of hemophila on knee xray?

A
  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
400
Q

Preferred surgical option for a large talocalcaneal coalition?

A

Triple fusion

401
Q

What is the most common type of child abuse?

A

Neglect

Followed by physical > sexual > emotional maltreatment

402
Q

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

A

Metaphyseal-diaphyseal angle of Drennan

Blounts >16 degrees

Physiologic

403
Q

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

A

central (first)

medial

posterior

anterolateral (last)

404
Q

Describe the boney deformities of clubfoot?

A
  • talar neck is medially and plantarly deviated
  • calcaneus is in varus and rotated medially around talus
  • navicular and cuboid are displaced medially
405
Q

What is Arthroereisis.

What is the fusion version of this?

A

Sinus tarsi pin/screw to jack up the hindfoot out of valgus

Grice procedure involves doing this with ICBG

406
Q

What is normal thigh foot angle?

A

0-20 of ER

407
Q

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

A

Prolonged immobilization > 4 weeks

So start mobilizing before then

408
Q

4 dDx for growth plate widening in kids:

A

Rickets

Scurvy

Schmid’s metaphyseal chondrodysplasia

Delayed maturation (illness)

Endocrine pathology

  • Excess GH
  • Hyperparathyroidism
  • Hypothryoidism
409
Q

Define Baumans Angle

A

Line down axis of Humerus

Line through lateral condylar physis

Angle between them

SHould be 70-75

410
Q

5 general causes of LLD

A

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

411
Q

8 injury patterns suspicious for child abuse

A

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

412
Q

Should kids with MRSA attend school?

Play sports?

A

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

They should not use pools or treatment pools

413
Q

Treatment algorithm for tibial deficiency

What is is based on?

A

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

414
Q

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

A

Epiphysiolysis (bar resection)

415
Q

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

A

Laterally

To reduce quads scarring.

416
Q

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

A

Rotation

417
Q

Surgical treatment of flexible cavovarus foot?

(4 elements)

A
  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)
418
Q

Foot polydactyly classification?

A

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
419
Q

What does Hilgenreiner’s-Epipyseal angle predict?

What are the values?

A

Predicts natural history of coxa vara

Normal:

Will resolve spontaneously if

Will need surgery if >60

420
Q

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

A

Early - after about a week if nondisplaced/displaced

421
Q

PFFD:

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

A
  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)
422
Q

INdications for hemiepiphysiodesis in congenital scoli

A

Failure of formation (hemivertebra)

patient <4

Curve < 40 deg

(only get about 15 degrees of correction. Contraindicated in failure of segmentation)

423
Q

RIsk of AVN with paediatric hip factures

A

Type I: 80-100%

Type II: 50%

Type III: 30%

Type IV: 10%

424
Q

Acceptable alignment distal radius fracture

A

>9: 20 degrees dorsal angulation. No bayonet.

No rotation in either case

425
Q

4 risk factors for thermal burns with casting

A

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

426
Q

How much bend do you want in a nancy nail?

A

3x canal size

427
Q

What is Friedrichs Ataxia?

A

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.

428
Q

Treatment of oblique talus?

A

Treatment typically consists of observation and shoe inserts

Some require surgical pinning of the talonavicular joint and Achilles lengthening for persistent subluxation

429
Q

Foot muscular Imbalances in Hereditary Motor Sensory Neuropathy?

A
  • 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
430
Q

How do you reduce a nursemaid’s elbow?

A

Supinate forearm and flex elbow to 90 deg

431
Q

dDx for torticollis

A

Congenital muscular torticollis

AARD

Grisel’s disease

Klippel-Feil

432
Q

Most common radiographic spinal finding in Down syndrome:

A

Atlanto-occipital instability (17%)

AAI is second most common at 11%

433
Q

4 risk factors for DVt in pediatric psteomyelitis?

A

CRP > 6

surgical treatment

age > 8-years-old

MRSA

434
Q

Name (9) associated conditions with fibular deficiency

A

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
435
Q

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

A

Hypertrohpic zone

436
Q

Pediatric elbow dislocation - most common nerve injury

A

Ulnar nerve

437
Q

Describe, in detail, the Ponseti method

A
  • 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
438
Q

What is the most common manifestation of child abuse?

A

Skin manifestations (bruises, burns)

Fractures are the second most common

439
Q

Summarize treatment for COxa Vara in dwarves in one sentence.

A

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

440
Q

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

A

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

441
Q

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

A

(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

442
Q

What is Little Leaguer’s Shoulder?

A

SH 1 injury of the proximal humerus

Overuse injury

443
Q

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

A

1st MT

444
Q

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

A

Lateral pins are safer

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

445
Q

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

A

Epiphysiodesis of the GT apophysis

446
Q

Goal for coxa vara correction in paeds

A

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

447
Q

3 ways that Beckers differes from Duchennes?

A
  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
448
Q

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

A

70 degrees

449
Q

Explain how the Silfverskiöld test works!

A
  1. Improved ankle dorsiflexion with knee flexed = gastrocnemius tightness
  2. Equivalent ankle dorsiflexion with knee flexion and extension= achilles tightness
450
Q

Describe the spectrum of myelodysplasia

A

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
451
Q

Paediatric trigger finger - waht must you release?

A

A1 pulley + 1 slip of FDS

452
Q

Best xray to ID a SCFE?

A

lateral

453
Q

3 radiograhpic findings of SCFE

A

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

454
Q

What type of SCHF is not associated with cubitus varus?

A

Flexion type

It goes into cubitus valgus

455
Q

Name 3 copmlications of VEPTR

A

Thoracic outlet syndrome

Rib fracture

Skin breakdown

(NOT clavicle fracture)

456
Q

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

A

IM Nail with bone graft

Free (vascularized) fibular graft

Ilizarov frame

Amputation

457
Q

Most common cause of septic hip in adolescents? Treatment?

A

Neisseria gonorroeae

High dose penicillin (does not need OR)

458
Q

Most important thing to look for when examining tibal hemimelia?

A

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

459
Q

2 main presentations and gene association of multiple epiphyseal dysplasia?

A

COMP (cartilage oligometric matrix protein)

causes mutation in COL9A1, A2 & A3

2 main presentations

  • dwarfism
  • Early OA
460
Q

5 Ortho manifestations of OI (there are many)

A

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

461
Q

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

A

Posteromedial bowing: apex is in distal tibia

Calcaneovalgus foot: apex is at ankle joint

462
Q

What is the Safe zone in DDH reduction?

how do you increase it?

A

ROM at which hip stays reduced

typically:

90-100 degrees flexion

mild abduction of 20-45 degrees

increase it with adductor tenotomy

463
Q

Where will the conus medullaris lie in a tethered cord?

A

BELOW L23 - b/c it’s tethered down

464
Q

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

A

Teardrop - not usually present in a dislocated hip.

465
Q

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

A
  1. tibial spines are underdeveloped
  2. intercondylar notch is shallow
  3. ball and socket ankle joint
466
Q

Indication for physeal bridge resection?

When would you do it with an osteotomy?

A

>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)

467
Q

dDx of toe walking (4)

A

CP

DMD

Tethered Cord/spinal dysraphism

Diastematomyelia

CMT

Unilateral Short limb causing unilateral toe walking

Non-ortho

Autism

Schizophrenia

468
Q

2 indications for exploring the artery in a supercondylar fracture

A

Pulse is lost after reduction

Persistance of pulseless hand after reduction

469
Q

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

A

MRSA

470
Q

Last elbow ossification center fo FUSE?

A

Medial epicondyle age 17

471
Q

7 characteristics of Infantile Blounts on workup?

A
  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
472
Q

How do you decide what size of nancy nail?

A
  • nail size determined by multiplying width of narrowest portion of femoral canal by 0.4
  • the goal is 80% canal fill
473
Q

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

A

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
474
Q

4 Syndromes affecting Reserve Zone

A

Gaucher’s

Diastrophic dysplasia

Pseudoachondroplasia

Kniest

“Kontio Panics with Dinner Gratuities”

475
Q

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

A
  1. Flexion 90-100° (controlled by anterior straps)
  2. Abduction of 50° (controlled by posterior straps)
476
Q

3 keys to surgical treatment of CVT?

A
  1. release of tight dorsal lateral structures
  2. pinning of talonavicular joint
  3. reconstruction of spring ligament
477
Q

What are the stages of LCP?

A

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
478
Q

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

A

Anterior or anterolateral

479
Q

Indications for poor prognosis in bracing of AIS

A

poor in-brace correction

hypokyphosis (relative contraindication)

male

obese

noncompliant (effectiveness is dose related)

480
Q

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

A

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
481
Q

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

A

None - it has no effect on outcomes

482
Q

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

A

FOramen magnum stenosis

483
Q

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

A

Phase 2: rib overlap with apical vertebra

484
Q

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

A

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
485
Q

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

A

telescopic rod for Schofield-Miller realignment procedure for OI

Can use telescoping or non-telescoping rods

486
Q

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

A
  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
487
Q

Best predictor of success with tendon transfers in CP?

A

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

488
Q

Radiographic classification of subacute paediatric OM:

A

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

489
Q

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

A

AD most most common

So counsel parents and patients on risks of future generations

can be AR and X-linked

490
Q

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

A

lateral trochlear ossification center AVN

491
Q

3 blocks to reduction in proximal humerus reduction

A

long head biceps

capsule

periosteum

492
Q

What disorder is Botox contraindicated in?

A

Spinal muscular atrophy

493
Q

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

A

Anterior fusion

  • Posterior elementsare dysplastic and may impair fusion
  • Therefore have a high pseudoarthrosis rate

High infection rate

  • due to poor soft tissue coverage
494
Q

2 xray views to assess clubfoot?

A

dorsiflexion lateral (Turco view)

AP

Look for parallelism, low talocalcaneal angle, and negative talus-first metatarsal angle

495
Q

SMN gene association

A

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

496
Q

In OI, fractures heal normally/abnormally?

A

Normally

They remodel abnormally

497
Q

Manifestations of Gauchers (5)

A

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)
498
Q

8 features of congenitally dislocated radial head

A

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

499
Q

Name 5 reduction techniques of radial head reduction:

A

Elastic bandage

Patterson

Israeli

Metaezeau (retrograde pin)

K-wire joystock

500
Q

Start point for retrograde femoral nancy nails?

A

2-2.5 cm proximal to distal physsi

501
Q

4 manifestations of osteopetrosis?

A
  1. Appendicular fractures
  2. Osteomyelitis
  3. Cranial nerve palsies
  4. Coxa vara
502
Q

Pin configuration post CRPP of distal femoral physeal injury

A

antegrade

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

503
Q

What is the Pirani score?

A

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

504
Q

4 indications for ORIF in BBFF?

A

Open fractures

Refractures

Failure of nonoperative management

BBFF kids >13

505
Q

Indications for MRI in scoliosis case

A

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

506
Q

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

A

Greater loss of motion

Increased rates of AVN

Increased rates of synostosis

507
Q

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

A

Secondary spongiosa

508
Q

Major cause of death for patient with Friedrich’s Ataxia

A

cardiomyopathy

Must workup with Echo

509
Q

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

A

Adolescent with severe deformity (> 45 degrees or

Vascular Injury

Open fracture

Intra-articular displacement

510
Q

3 non-ortho manifestations of Ehlors Danlos?

A
  1. mitral valve prolapse
  2. aortic root dilatation
  3. gastroparesis
511
Q

Define the types of dwarfism and give an example:

Rhizomelic

Mesomelic

Acromelig

Micromelic

A

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

512
Q

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

A

Medial meniscus

513
Q

Acceptable reduction criteria required for femoral shaft fractures in peds?

A
  • Less than 10 degrees varus/valgus
  • Less than 20 degrees AP
  • no more than 2cm of shortening or 10° of rotational malalignment
514
Q

Risk of recurrence/refracture of pseudoarthrosis of tibia?

A

50%, even after initial union

515
Q

How do you immobilize Bado I, III fractures?

A

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

516
Q

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

A
  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

517
Q

Genetic transmission of DMD

A

X linked recessive

Important to counsel patients of risk of subsequent kids with the disease

518
Q

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

A

Varum under 2

Neutral at 14 months

Peak valgus at 3 years

Physiologic valgus at 7 years

519
Q

3 types of CP gait

A

toe walking

crouched

stiff-knee

520
Q

4 radiographic signs of osteopetrosis?

A

“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

521
Q

2 indications for surgical treatment of AAI in DOwns?

A
  1. myelopathic patients
  2. ADI > 10 mm
522
Q

Indications for fusion in DMD scoliosis

A

FVC

rapid progression

poor response to steroid

non-ambulatory status (b/c they progress quickly)

523
Q

3 associated endocrine disorders with SCFE

A

Hypothyroidism

Osteodystrohpy of CRF

Growth HOrmone Treatment

524
Q

What is the major source of blood to the physis?

A

Perichondrial artery

525
Q

2 important complications of tibial tubercle fracture?

A

COmpartment syndrome - anterior, due to anterior recurrant tibial artery

Recurvatum - anterior growth arrest, posterior keeps growing

526
Q

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

A
  1. More likely to be unilateral
  2. More association with LLD
  3. Can have MCL laxity
  4. No metaphyseal beaking
527
Q

CP hip management based on Reimer’s Migration Index

A

Soft tissue release

Children 40%

VDRO + ST release

Kids >4 OR Reimer’s index >60%

Abduction osteotomy or girdlestone procedure

Chronic painful dislocation

528
Q

4 indications for open reduction of pediatric traumatic hip doslocation?

A
  1. nonconcentric reduction
  2. intra-articular fragment
  3. unstable acetabular rim fracture
  4. irreducible by closed means
529
Q

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

A

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

530
Q

Most commonly used meidcation for treatment of OI?

A

Bishphosphonates increase cortical thickness, fewer fracture.

531
Q

Early investigations for Larsens?

A

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

532
Q

How many ossification centers in the proximal humerus?

A

3: HH, GT, LT

533
Q

2 indications for CR and hip spica for DDH?

A
  1. Age 6-18 months
  2. Failed Pavlik
534
Q

Why is ASF indicated in spina bifida related scoliosis?

A

dysplastic posterior elements that may impair posterior fusion

535
Q

Medical treatment of bone crisis for sickel cell?

A

hydroxyurea

536
Q

2 options for tendon transfers of HMSN?

A

tib post to dorsum of foot

peroneus longus to brevis

537
Q

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

A

Right middle 1/3

situs inversus is the exception

538
Q

2 main surgical options for tibial hemimelia?

A

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

539
Q

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

A

Corticosteroids

  • prolongs ambulation
  • slows scoliosis
  • slows deterioration of FVC
540
Q

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?

A

Empiric Abx

NOT MRI - b/c of risks of conscious sedation with MRI/biopsy, just start abx.

This was an MCQ

541
Q

Why doe CMT pts get claw toes?

A

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

542
Q

BBFF: malrotation at what level has what effect?

A

Midshaft malrotations lead to decreased supination

(vs distal malrotation)

543
Q

Best radiographic way to follow CP hips

A

Reimer’s Migration Index

544
Q

DDH U/S:

What is beta angle and what is normal?

A
  • angle created by lines along the labrum and the ilium
  • normal is less than 55°
545
Q

radiographic definition of vertical vs. oblique talus

A

Forced plantarflexion lateral

Meary’s angle >35 is congenital vertical talus

546
Q

4 operative indications for proximal humerus fracture in paeds

A

Severely displaced fracture in kid age >11 (Neer-Horowitz 3/4)

Open fracture at any age

Vascular injury

Intra-articular displacement

547
Q

5 Risks for CP

A

Prematurity (most common)

Anoxic injury

Prenatal intrauterine factors

Perinatal infections (ToRCH, toxoplasmosis, rubella, CMV, Herpes)

Meningitis

Brain malformations

548
Q

7 Physical or radiologic signs of child abuse?

A
  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
549
Q

Spinal manifestations of achondroplasia vs. pseudoachondroplasia

A

Achondroplasia

  • foramen magnum stenosis
  • kyphosis
  • lumbar stenosis/decreased interpedicular distance

Pseudoachondroplasia

  • cervical instability
550
Q

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

A
  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
551
Q

Classic findings in Friedrich’s ataxia

A

Ataxia

areflexia

positive plantar response

552
Q

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

A

Halo + traction

Risks displacement of injured occipitocervical joint

(JAAOS 2014)

553
Q

Congenital knee dislocation

Give 3 syndromic associations and 3 orthopaedic associations

A

Syndromic:

  • Larsen’s
  • Meningomyelocoele
  • Arthrogryposis

Orthopaedic

  • hip dysplasia
  • clubfoot
  • metatarsus adductus
554
Q

Why do a Rhizotomy?

A

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

555
Q

Complication with too mcuh abduction in DDH treatment?

A

AVN of femoral head

via impingement of the posterior-superior retinacular artery

556
Q

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

A

SMA:

  • absent DTR
  • fasciculations (including tongue)

Duchnne muscular dystrophy

  • present DTRs

Also:

Emery-Dreifuss dystrophy

limb girdle dystrohpy

Guillain-Barre syndrome

557
Q

4 conditions associated with PFFD?

A
  1. fibular hemimelia (50%)
  2. ACL deficiency
  3. coxa vara
  4. knee contractures
558
Q

Second most common nerve palsy in SCHF?

A

radial

AIN most common

559
Q

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

A

80%

560
Q

You plan a femoral derotational osteotomy on a child with femoral anteversion.

Where do you make your osteotomy?

How much correction do you need?

A

intertrochanteric osteotomy

amount of correction = (IR-ER) / 2

561
Q

Two MSK findings associated with bladder extrophy?

A
  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
562
Q

What level myelomeningocoele has a higher risk of hip dislcoation?

A

L3

+ adductors, no abductors

= higher risk of dislocation

Marginal ambulators

563
Q

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

A

Increased risk of complications such as nonunion

564
Q

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

A

18 months - 4 years

565
Q

Name 2 surgical options for treatment of Sprengel’s

A

Woodward’s

Green

Leibovic

Bellman’s

Mears

566
Q

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

A

Shorter OR time than ORIF

Less blood loss than ORIF

Equal union rates, radial bow and rotation as ORIF

567
Q

3 causes of painful flatfoot.

A
  1. tarsal coalition (sinus tarsi pain)
  2. congenital vertical talus (rocker bottom foot)
  3. accessory navicular (focal pain at navicular)
568
Q

Most common complication from tibial tubercle fracture?

A

Recurvatum

physeal arrest anteriorly while posterior continues to grow –> decreased tibial slope

569
Q

5 Orthopedic (non-spine) manifestations of Achondroplasia?

A
  • 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
570
Q

How do you immobilize a Galleazzi fracture?

A

In supination

571
Q

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

A

IgE mediate allergy to latex

severe anaphylaxis

Present in 20-70%

572
Q

4 peri-operative considerations if operating on a Gauchers?

A
  1. Pre-operative enzyme replacement
  2. Hydration to reduce risk of bone crisis
  3. Increased risk of infection
  4. Increased bleeding risk
573
Q

3 facets of first line treatment for JIA?

A

  1. steroid injections
  2. DMARDs
    - etanercept, rituximab, azathioprine
  3. Opthamologic Exams
574
Q

Most common long term sequelae of brachial plexus birth injuries

A

Glenoid retroversion

Due to IR of shoulder due to Erb’s palsy

575
Q

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?

A

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

576
Q

Assume growth in males and females stop at what age?

A

Males: 16

Females: 14

577
Q

6 signs of preganglionic brachial plexus injury

A

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)

578
Q

Sillence Type I and IV:

a) What is the diesease?
b) What is quickest way to differentiate on exam?
c) Which has better prognosis?
d) Inheritance patterns?

A

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.

579
Q

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

A

Screen for DVT

Rapid CT-PE if any suggestive signs

580
Q

What is contraindicated in the treatment of DMD scoliosis?

A

Bracing

may interfere with already compromised respiraotry function

581
Q

RUNX2/CBFA1 mutation

A

cleidocranial dysplasia

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

582
Q

DDX for Genu Valgum?

A
  • 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
583
Q

Non-ortho manifestations of DMD

A

cardiomyopathy

static encephalopathy

Respiratory issues

584
Q

Treatment of tibial spine fractures by classification

Name 2 blocks to reduction

A

Meyers & McKeevers

I: nonp

II: CR + Cast vs. operative

III: operative

IV: operative

Blocks to reduction:

meniscus

intermeniscal ligament

585
Q

Name 6 associated abnormalities with Sprengel’s

A

Scoliosis (most common)

Klipper-Feil

Spina bifida

omovertebral bone

rib anomalies

clavicular abnormalities

humeral shortening

foot abnormalities

586
Q

General order of closure of the distal tibial growth plate?

A

Central, then medial, then lateral

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

587
Q

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

A

DMD: complete absence

Becker’s: abnormal

588
Q

How does MRSA get its virulence and resistance?

A

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
589
Q

First surgical option for resistant Clubfoot?

A

posteromedial soft tissue release and tendon lengthening

590
Q

DDH U/S:

What is maximal age (for usefulness)?

A

4-6 months

(i.e. use xray)

591
Q

General Principals of Ilizarov technique?

A

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
592
Q

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

A

Botulinum toxin A

593
Q

3 conditions that are commonly found with tibial hemimelia?

A
  1. ectrodactyly
  2. preaxial polydactyly
  3. ulnar aplasia
594
Q

Most common nerve palsy in SCHF?

A

AIN

595
Q

Major complication of lateral closing wedge osteotomy for cubitus varus?

A

Lateral prominence

596
Q

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

A

RVAD >20

597
Q

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

A
  • 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
598
Q

5 poor prognostic indicators for physeal bar:

A

Cause: Infectious worse than traumatic

Location: lateral worse than central

Size: >50% bad

Type: bony vs. fibrous

delay to presentation

599
Q

When do SCHF pins come out?

A

3-4 weeks

600
Q

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

A

6 weeks

601
Q

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

A

floppy epiglottis

large tongue

small larynx

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