Paeds Trauma Flashcards

Question

In the absence of a distal radial pulse, what are clinical indicators of sufficient perfusion? [JAAOS 2012;20:69-77]

Answer 1

* Normal capillary refill * Temperature * Color (typically described as pink)

Answer 2

1. Normal 2. Pulseless with a pink hand (perfused) 3. Dysvascular (pulseless with a white hand)

Answer 3

Posterior fat pad

Answer 4

1. \>4 years of age = middle 1/3 2. \<4 years of age = may lie in anterior 1/3

Answer 5

Gartland classification (describes extension type) * .Type I - nondisplaced * Type II - displaced with intact posterior hinge * Type IIA – no rotation or translation * .Type IIB – rotation or translation * Type III - complete displacement * Type IV - unstable in flexion and extension (complete disruption of periosteal hinge) * Medial comminution – collapse of medial column with resulting loss of Baumann’s angle

Answer 6

1. Angle formed between a line parallel to the longitudinal axis of the humeral shaft and a line along the lateral condylar physis as viewed on the AP image 2. Normal = 70-75 (compare to contralateral side) 3. Deviation \>5-10 should not be accepted

Answer 7

1. Type I * Nonoperative * Long arm cast 90° elbow flexion for 3-4 weeks 2. Type II * Nonoperative * Type IIA – controversial, some authors treat these nonoperative with closed reduction, casting and close followup (consider if minimal swelling) * Operative * Type IIB – CRPP 3. Type III * Operative * CRPP, long arm splinting with elbow at 60-80°, pins removed at 3-4 weeks 4. Type IV * Operative * CRPP

Answer 8

1. Brachialis muscle interposition 2. Button-holing of metaphyseal spike through brachialis 3. Brachial artery 4. Nerve 5. Periosteum 6. Joint capsule

Answer 9

1. Elbow extension, longitudinal traction, correct varus/valgus and medial/lateral translation and rotation, flex elbow with thumb pressure over olecranon to correct sagittal alignment 2. Consider milking brachialis if distal humerus buttonholed through

Answer 10

1. “push-pull technique” [Journal of Pediatric Orthopaedics B 2016, 25:412–416] * With elbow at 45 correct coronal plane deformity (varus/valgus/translation), flex elbow to 90 with towel under apex of deformity apply a posterior directed force along the axis of the forearm, slight over correction can be corrected with a pull along the axis of the forearm 2. Traditionally done in extension

Answer 11

1. Pin migration 2. Pin tract infection 3. Osteomyelitis/septic arthritis 4. Malunion 5. Compartment syndrome 6. Ulnar nerve injury

Answer 12

1. Open fracture 2. Dysvascular limb 3. Skin puckering 4. Floating elbow 5. Median nerve palsy 6. Evolving compartment syndrome 7. Young age (unreliable exam) 8. Cognitive disability (unreliable exam)

Answer 13

1. Safe to delay 12-18 hours 2. Arm is splinted in 20-40° of flexion, neurovascular checks 3. Nurse q2h, no sedating analgesics

Answer 14

1. Adequate number of lateral pins * In general, Type II – 2 pins, Type III – 3 pins 2. As far apart as possible 3. Pins should be divergent 4. Pins should not converge or cross at fracture site 5. Pins should engage both the medial and lateral columns 6. Consider a medial pin if fracture remains unstable or in presence of comminution

Answer 15

1. Small incision over medial epicondyle 2. Elbow in extension (prevents ulnar nerve from subluxing anterior) 3. Identify and protect ulnar nerve

Answer 16

* Reverse obliquity * Very distal fractures * Very young

Answer 17

1. Failure to engage both fragments with at least two pins 2. Failure to achieve bicortical fixation with at least two pins 3. Failure to achieve ≥2 mm of pin separation at the fracture site

Answer 18

1. In the presence of adequate perfusion (pink) * Reduce fracture and pin * If adequate perfusion remains – admit for observation with elbow in approx. 45° flexion 2. In the presence of pulseless extremity and inadequate perfusion (white) * Reduce the fracture and pin * If remains dysvascular – explore artery and monitor for compartment syndrome (consider fasciotomy) * If adequate perfusion - admit for observation with elbow in approx. 45° flexion

Answer 19

Median nerve

Answer 20

1. Increase ambient temperature 2. Apply topical lidocaine or papaverine 3. Stellate ganglion block

Answer 21

1. Failed closed reduction 2. Open fracture 3. Compartment syndrome 4. Neurologic and/or vascular injury requiring open exploration

Answer 22

“go to the metaphyseal spike”- [CORR course] 1. Anterior approach = extension type * Transverse or ‘lazy S’ over flexion crease of antecubital fossa * If releasing blocks to reduction – stay lateral to biceps tendon to avoid neurovascular structures * If exploring neurovascular bundle – identify proximal to fracture site 2. Lateral approach = posteromedial displacement * Plane between BR and triceps 3. Medial approach = posterolateral displacement and flexion type

Answer 23

1. Increased elbow stiffness 2. Difficult access to interposed anterior structures 3. Risk of trochlear osteonecrosis 4. Less cosmetic

Answer 24

1. Cubitus varus * Can lead to cosmetic concerns and tardy posterolateral rotatory instability b * No effect on elbow ROM * Correctional osteotomy should be considered if significant varus present * Performed at \>1 year * Lateral closing wedge osteotomy with pin fixation * What is the Skaggs osteotomy? [J Child Orthop. 2011 Aug; 5(4): 305–312] * Interlocking lateral wedge osteotomy with lateral pin fixation * Corrects cubitus varus and extension * Enhanced stability and less lateral prominence than closing wedge 2. Compartment syndrome

Answer 25

Typically 6 years of age

Answer 26

Internal oblique view (fragment often lies posterolateral)

Answer 27

1. Limited diagnostic value as it is performed in the OR with patient under sedation 2. Useful for intra-operative assessment

Answer 28

Traditionally performed via the lateral soft spot, which is a triangle formed by the radial head, olecranon, and lateral column of the humerus. * This area may be distorted in patients with lateral condylar fracture * Alternatively, the needle may be placed directly into the posterior surface of the olecranon fossa.

Answer 29

1. Milch classification (historical) * Type I – fracture line that courses lateral to the trochlea and into the capitulotrochlear groove * Elbow is stable as the trochlea is intact * Type II – fracture line that extends into the apex of the trochlea * Elbow is unstable as the trochlea is disrupted 2. Jakob classification (based on fracture fragment displacement) * Type I – nondisplaced, intact articular surface * Type II – fracture is complete extending through the articular surface, may be moderately displaced * Type III – complete displacement and fragment rotation, loss of relationship between capitellum and radius 3. WEISS Classification (based on displacement and articular cartilage) * Based on fracture displacement and articular congruity * TYPE I * Fracture is displaced \< 2 mm * TYPE II * Fracture displaced ≥2mm with intact articular cartilage, as demonstrated by arthrogram (i.e. articular hinge) * TYPE III * Fracture displaced ≥2mm and the articular surface is not intact (i.e. no hinge)

Answer 30

1. Nonoperative indications * Type I, nondisplaced * Fractures with an intact cartilage hinge that has been confirmed on MRI * ≤2 mm displacement on all radiographic views 2. Operative indications * \>2mm displacement * 2-4mm = CRPP * \>4mm = ORIF * Nonunion

Answer 31

1. CRPP * Weiss Type II (2-4mm displacement, intact articular cartilage) * Technique * Closed reduction performed with forearm supinated, elbow extended, varus stress to elbow followed by fragment manipulation anteromedially * Two parallel or slightly divergent K-wires plus a transverse pin to control rotation 2. Open reduction * Weiss and Jakob Type III (articular cartilage disruption, displaced \>4mm, fragment malrotation) * Technique * Kocher interval (anconeus and ECU) * Avoid posterior and distal dissection (risk of fragment AVN) * Anatomic reduction under direct visualization with fluoro confirmation * Fixation * K-wire OR Partially threaded screw

Answer 32

1. Lateral spur 2. Nonunion (due to synovial fluid, pull of common extensor origin, poor metaphyseal circulation to distal fragment) * More common with nonoperative treatment 3. Cubitus varus (20%) * More common in nondisplaced and minimally displaced fractures 4. Cubitus valgus (10%) 5. Tardy ulnar nerve palsy * Progressive ulnar nerve paralysis developing late (average 22 years post injury) * Manage with anterior ulnar nerve transposition 6. Fishtail deformity * Deepening of the trochlear groove, no clinical significance 7. Growth disturbance * Minimal and involved medial aspect of the condyle (little effect on length or deviation)

Answer 33

Medial epicondyle

Answer 34

1. Direct trauma 2. FOOSH – elbow extension, wrist extension, forearm supination and elbow valgus * Flexor pronator avulsion 3. Elbow dislocation (usually posterolateral) * UCL avulsion

Answer 35

1. Acute * Non-displaced * Minimally displaced * Significantly displaced (\>5mm) * Entrapment of fragment in joint * Fracture through epicondylar apophysis 2. Chronic * Little League elbow syndrome

Answer 36

Anterior and distal

Answer 37

1. Block to elbow extension 2. Fragment at level of joint radiographically * A significantly displaced (\>5mm) epicondyle remains proximal to the joint 3. Malreduction of joint radiographically

Answer 38

Roberts maneuver * Elbow valgus * Forearm supination * Elbow extension * Wrist extension

Answer 39

1. Open fractures 2. Failed closed reduction of an incarcerated medial epicondyle 3. Ulnar nerve dysfunction (relative) 4. Valgus elbow instability (relative) 5. High demand upper extremity function (relative) 6. Displacement \>5mm (relative)

Answer 40

1. Supine 2. Tourniquet and Esmarch 3. Medial incision just anterior to the medial epicondyle 4. Identify fragment and ulnar nerve * Ulnar nerve does not need to be released – protect throughout with blunt retractor 5. Reduction with “milking” technique * Flex wrist, supinate forearm, flex elbow and apply Esmarch from distal to proximal 6. Place wire through medial epicondyle fragment from inside out 7. Use wire to reduce fracture to distal humerus site and hold with additional small wire or 18 gauge needle 8. Drill and advance a 4.0mm partially threaded cannulated screw with washer up the medial column * Avoid bicortical fixation * Avoid olecranon fossa * Usual length is 35-40mm

Answer 41

1. Radial nerve injury 2. Stress riser in lateral cortex (fracture risk)

Answer 42

1. Loss of motion 2. Cubitus valgus 3. Nonunion * Nonoperative (49.2% union) * Operative (92.5% union) 4. Ulnar nerve symptoms * No difference in operative vs. nonoperative 5. Operative * Septic arthritis * Myositis ossificans * Pin tract infections * Radial nerve injury

Answer 43

1. \<30 = acceptable 2. 30-60 = no consensus * More angulation tolerated better in younger patients with remodeling potential 3. \>60 = unacceptable

Answer 44

1. Nonoperative * 2-3 weeks in cast followed by progressive ROM * Indications * \<30° angulation and \<2mm translation * Full pronation and supination 2. Closed reduction * Indications * Unacceptable angulation * Block to supination or pronation * Techniques * Patterson – hold the elbow in extension and apply distal traction with the forearm supinated and pull the forearm into varus while applying direct pressure over the radial head * Israeli – with elbow flexed 90 and forearm in supination apply thumb pressure to anterolateral radial head while forearm is gradually taken into pronation * Esmarch – wrap forearm distal to proximal while holding elbow in varus 3. Percutaneous reduction * Indications * Failed closed reduction after limited number of attempts * Techniques * K-wire joystick technique * Leverage technique – pin is inserted into the fracture site and levered into position * Push technique – blunt end of large K-wire is pushed against the posterolateral aspect of the radial head * Metaizeau technique * A thin flexible nail or smooth wire with a curved tip is inserted from the distal radius into the intramedullary canal of the radius. The tip of the flexible nail is advanced to the fracture site and into the radial head. The nail is then rotated to rotate the radial head onto the shaft 4. Open reduction * Indications * Failed closed and percutaneous reduction attempts * Gap at fracture site after reduction (indicates soft tissue interposition) * Technique * Lateral approach * 1-2 K-wires from radial head (non-articular zone) to radial metaphysis

Answer 45

1. Proximal ulna fracture OR plastic deformation of the ulna 2. Radial head dislocation

Answer 46

Bado * Type 1: Apex anterior proximal ulna fracture with anterior dislocation of the radial head * Type 2: Apex posterior proximal ulna fracture with posterior dislocation of the radial head * Type 3: Apex lateral proximal ulna fracture with lateral dislocation of the radial head * Type 4: Fractures of both the radius and ulna at the same level with an anterior dislocation of the radial head (1-11% of cases)

Answer 47

1. Nonoperative * Bado I, II and III * Technique * Closed reduction * Successful when ulnar length is restored, pattern is length stable and radial head reduces spontaneously 2. Operative * Bado I, II, and III with failed closed reduction * Length unstable ulnar fracture * Bado IV * Technique * Intramedullary nail for length stable patterns * Plate fixation for length unstable/comminuted patterns * Note – annular ligament reconstruction is rarely indicated with restoration of ulnar length

Answer 48

1. Ulnar osteotomy * Osteotomy at point of maximum angulation * Gains length * Redirects radial head to capitellum (apex of ulnar osteotomy correction should point to the direction you want the radial head to go) * fixed with plate and screw 2. Radial head reduction * initially, attempt to reduce radial head into intact annular ligament * if unsuccessful, pie-crust annular ligament and attempt second reduction * if unsuccessful, incise annular ligament and repair around radial neck following reduction 3. +/- annular ligament repair/reconstruction * indicated after ulnar osteotomy reassessed and determined to be adequate or optimized and radial head still unstable * Bell Tawse technique – lateral triceps tendon

Answer 49

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

Answer 50

1. Early loss of reduction 2. Midshaft and distal shaft fractures displaced 5-10° above acceptable limits

Answer 51

1. Unacceptable reduction 2. Loss of reduction 3. Fractures with ≤1 to 2 years of remaining growth 4. Open fractures 5. Pathological 6. Floating elbow 7. Associated neurovascular injury

Answer 52

1. Small incisions (cosmetic) * 30-75% require small incision at fracture site to assist reduction and passage of nail 2. Little to no periosteal stripping 3. Minimal fracture hematoma disruption 4. Less expensive 5. Less tourniquet time 6. Can take less time to insert

Answer 53

1. Implant prominence 2. Second procedure for implant removal 3. Less rigid than plates which often requires period of immobilization

Answer 54

Prominent implants, delayed union, nonunion, implant migration, bursitis, hypertrophic scars, neuropathy, refracture, tendon laceration, synostosis, infection

Answer 55

1. Start with ulna (easier nail passage) 2. Ulna start point either olecranon or lateral to olecranon through anconeus split 3. Radius start point is just proximal to the distal radial physis between the 1st and 2nd compartments 4. Nails are cut as close to bone to minimize irritation but long enough to allow retrieval 5. Tourniquet is not routinely used

Answer 56

1. Rigid fixation 2. Anatomic reduction 3. Early range of motion 4. Complete correction of malrotation and restoration of radial bow

Answer 57

1. Large incisions 2. More expensive 3. Increased tourniquet time

Answer 58

Painful implants, nonunion, malunion, neuropathy, hypertrophic scars, refracture, weakness, implant failure, infection, synostosis, carpal tunnel

Answer 59

1. \<10 = IM nail 2. \>10 with growth remaining = IM nail or plate (surgeon or patient preference) 3. \>10 with \<1 year of growth = plate

Answer 60

1. Fracture (most common) 2. Repetitive stress (Eg. gymnasts) 3. Infection, irradiation, tumor, ischemia, iatrogenic

Answer 61

Resting/reserve zone (contains the pluripotent chondrocytes) OR proliferative zone

Answer 62

Zone of provisional calcification (component of the hypertrophic zone)

Answer 63

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

Answer 64

1. Limit gentle closed reduction attempts to 1-2 in ED 2. Limit gentle closed reduction attempts to 1-2 in OR (after failed ED attempt) 3. Do not reattempt closed reduction after 7-10 days following injury

Answer 65

1. Nonoperative * Indications * Minimal growth remaining 2. Operative * Indications * \>2mm growth remaining * Progressive deformity * Ulnar sided wrist pain * Limited ROM * Options * Physeal bar resection and interposition * Epiphysiodesis * Partial arrest = epiphysiodesis of remaining growth plate * Complete arrest = ulnar epiphysiodesis * Ulnar shortening osteotomy * Radial osteotomy * Corrects angular deformity * Distraction osteogenesis

Answer 66

1. \<4 = MFCA, LFCA and artery of ligamentum teres 2. \> 4= MFCA predominately

Answer 67

1. Avoid incising capsule across intertrochanteric line 2. Avoid posterior dissection of the femoral neck

Answer 68

1. Osteomyelitis 2. Simple and aneurysmal bone cysts 3. Fibrous dysplasia 4. Langerhans cell histiocytosis 5. Osteogenesis imperfecta 6. Disuse osteopenia 7. Metabolic bone disease 8. Malignancy

Answer 69

Inferior compression side of the neck

Answer 70

Delbet classification * Type IA = transphyseal without dislocation of epiphysis * Type IB = transphyseal with dislocation of epiphysis * Type II = transcervical * Type III = cervicotrochanteric * Type IV = intertrochanteric

Answer 71

1. Perform urgently within 24 hours 2. Age \<10 perform on radiolucent operating table, ≥10 perform on fracture table 3. Perform with hip in extension, slight abduction and internal rotation, apply longitudinal traction and gentle adjustments in leg position 4. Avoid forceful manipulation 5. Anatomic reduction is desired but some angulation is acceptable 6. Closed reduction is preferred and usually successful

Answer 72

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

Answer 73

1. Anterior (Smith-Peterson) * Requires separate incision for fixation 2. Anterolateral (Watson-Jones) 3. Lateral (Hardinge)

Answer 74

1. Fracture stability is more important than preservation of the physis 2. Transphyseal screw fixation is the most stable and is recommended for most fractures 3. Physis-sparing fixation is less stable (recommended only in children \<4 to 6) 4. Fracture fixation is dependent on patient age, patient size and skeletal maturity 5. Capsular decompression should be performed after fracture reduction and fixation 6. Spica cast use is dependent on fracture type, fracture fixation and patient size

Answer 75

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

Answer 76

1. Type IA * Age \<2 = closed reduction spica cast * Age 2-9 = 2 smooth pins and spica cast * Age ≥10 = transphyseal fixation 2. Type IB * Open reduction 3. Type II and III * Age \<6 = closed reduction and spica casting * +/- supplemental fixation in patients ≥2 years in spica cast * Acceptable reduction Type II = \<5° angulation and \<2mm cortical translation * Acceptable reduction Type III = \<10° angulation (varus more common) * Displaced fractures (if unable to be managed by closed reduction) * \<4 years = smooth K wires * 4-9 years = physeal sparing cannulated screws * \>10 years = Transphyseal cannulated screws, proximal locking plate (unstable patterns) 4. Type IV * Age \<6 = closed reduction and spica casting * +/- supplemental fixation in patients ≥2 years in spica cast * Acceptable reduction Type IV = \<10° angulation * Age \>6 = stabilization with a pediatric sliding hip screw, blade plate, or proximal femoral locking plate * \<10 consider physeal sparing screw * \>10 consider transphyseal screw

Answer 77

1. Placed no less than 5mm from the subchondral bone 2. Avoid posterior perforation or screw placement in the anterolateral quadrant of the epiphysis (reduce risk of iatrogenic injury to blood vessels) 3. Avoid transphyseal fixation in patients \<10 (however stable fixation should not be compromised to spare the physis) 4. Postoperatively can TTWB with crutches if stable pattern

Answer 78

1.Osteonecrosis (most common) * What are the predictors for osteonecrosis? * Fracture type * Type IB = highest risk (100%) * Type I (38%) \> Type II (28%) \> Type III (18%) \> Type IV (5%) * Reported rates of osteonecrosis according to the Delbet classification are 38% to 50% for type I, 28% for type II, 8% to 18% for type III, and 5% to 10% for type IV. * Older patient * Age \>10 * Displaced fractures * What is the Ratliff classification of osteonecrosis? * Type I = entire femoral head * Type II = segments of femoral head * Type III = femoral neck 2. Coxa vara * Femoral neck shaft angle \<120 3. Premature physeal closure * Can lead to coxa valga or vara (asymmetric arrest) * Can lead to LLD 4. Nonunion * Up to 10% * Most common in Type II * Management is a valgus osteotomy 5. Chondrolysis 6. Infection 7. Posttraumatic SCFE 8. Overgrowth of the femoral shaft

Answer 79

\<36 months

Answer 80

1. ≤6 months a.Pavlik harness * Early spica casting 2. 6 months – 5 years * Stable fracture pattern * Early spica casting * Unstable fracture pattern * Traction with delayed spica casting * External fixator 3. 5-11 years * Length stable fracture and patient \<100lbs * Flexible IM nails * Length unstable fracture OR very proximal/distal fracture OR any weight * Submuscular plating 4. ≥11 years * Patient ≤100lbs * Flexible IM nails * Patient \>100lbs * Antegrade rigid IM nail * Proximal or distal fracture OR comminution * Submuscular plating

Answer 81

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

Answer 82

1. Largest nail possible * Each nail should be 40% of the minimum diameter of the diaphysis 2. Two nails * Achieving 80% canal fill 3. Prebend nails * 30 degree C-shaped bend at the level of the fracture 4. Opposite bends of the two rods at the fracture site (spread within the diaphysis) * Resists bending 5. Divergence of rods in metaphysis * Torsional control

Answer 83

Lateral trochanteric entry point

Answer 84

1. Piriformis * Femoral head osteonecrosis 2. GT tip * Proximal femoral valgus * Femoral neck narrowing * GT physeal arrest

Answer 85

1. Symptomatic – soft-tissue irritation, knee effusion, loss of knee ROM 2. Asymptomatic – no consensus on removal

Answer 86

1. Salter-Harris I – II * Nonoperative (bivalved long leg cast) * Nondisplaced * \<2mm displacement after closed reduction * Operative * Reducible but unstable * Two crossed transphyseal smooth pins (antegrade or retrograde) 2. SH II with large Thurston-Holland fragment * Percutaneous partially threaded cannulated screw * In metaphysis parallel to physis and perpendicular to fracture 3.SH III – IV * Nonoperative * Nondisplaced * Operative * \>2mm displacement * Closed possible open reduction to achieve reduction * 4.5- to 7.3-mm cannulated screws are placed parallel to the articular surface of the epiphysis and/or metaphysis

Answer 87

40-90% * Higher in distal femur than other locations * Risk depends on SH type (SH IV \> SH I)

Answer 88

1. Salter Harris I – II * Nonoperative * Nondisplaced * \<2mm displacement after closed reduction * Operative * \>2mm displacement after closed reduction * Remove blocks to reduction – periosteum, pes anserine tendons, ligament * Two crossed transphyseal smooth pins * Retrograde are farther from joint * Antegrade are less technically challenging 2. Salter Harris III – IV * Nonoperative * Nondisplaced * Operative * \>2mm displacement * Direct visualization – screws or wires parallel to physis in epiphysis or metaphysis

Answer 89

Proximal to distal

Answer 90

12-17, usually male

Answer 91

1. Type I - junction of the distal and proximal apophysis * Type IA = nondisplaced/minimally displaced * Type IB = displaced and hinged at junction * Type IC = patellar tendon periosteal sleeve avulsion 2. Type II - junction of tibial tubercle and proximal epiphysis * Type IIA = not comminuted b.Type IIB = comminuted 3. Type III - extend intra-articular (most common) * Type IIIA = not comminuted * Type IIIB = comminuted 4. Type IV - fracture of the tibial tuberosity that extends posteriorly along the proximal tibial physis creating an avulsion of the entire proximal epiphysis 5. Type V - extends intra-articular and posteriorly along physis of proximal tibia (‘Y’ pattern) Note: Ogden modification of Watson-Jones classification was from Type I-III with subclassification A/B * Frankl added type IC

Answer 92

1. Nonoperative * Nondisplaced or minimally displaced (\<2-3mm) Type I 2. Operative * Displaced Type I * Type II-V * Midline anterior incision * Parapatellar arthrotomy or arthroscopy if intra-articular extension * Generally, 2-3 4.0mm cannulated screws with washers are inserted through the tubercle into the metaphysis and epiphysis * Consider prophylactic anterior compartment fasciotomy

Answer 93

1. Genu recurvatum * Rare as most injuries occur as growth is slowing down 2. Compartment syndrome * Anterior tibial recurrent artery at risk 3. Hardware irritation

Answer 94

8-14 years

Answer 95

Meyers and McKeever classification * Type I - minimally displaced * Type II - anterior displacement with intact posterior hinge * Type III - complete fracture displacement * Type IV - complete fracture displacement with fragment rotating out of fracture bed OR comminuted

Answer 96

1. Type I * Nonoperative, long leg cast in slight flexion 2. Type II * Closed reduction and casting * Aspiration of hematoma and injection of local anaesthetic, extend knee fully or near full, long leg cast * Acceptable reduction is \<3mm displacement on lateral view * Operative * \>3mm displacement on lateral view * Open arthrotomy or arthroscopic * Suture fixation through tibial tunnel OR antegrade cannulated screws in epiphysis OR combination * Perform EUA following fixation

Answer 97

1. Anterior horn of meniscus (medial \> lateral) 2. Intermeniscal ligament 3. Rotated fracture fragment

Answer 98

1. Loss of fixation 2. Prominence of hardware 3. Loss of motion 4. Reoperation * Higher in screw vs. suture fixation 5. ACL laxity 6. Arthrofibrosis 7. Nonunion

Answer 99

1. Pearls * Continually palpate calf compartments. * Address concomitant pathology before managing the avulsion fracture * Disengage any interposed soft tissue 2. Pitfalls * Remove only the necessary portions of the intermeniscal ligament * Leave at least 1 to 2 cm between tunnels * Maintain tension on all sutures while each one is tied 3. Potential Complications * Loss of motion/arthrofibrosis * Residual displacement or laxity * Nonunion or malunion * Growth disturbance

Answer 100

1. Minimally displaced, short spiral or oblique fracture of the tibia shaft without fracture of the fibula 2. Caused by low energy twist or fall

Answer 101

1. Nonoperative * Long leg cast for 4-6 weeks, then short leg cast for 4-6 weeks (PTB cast if proximal shaft) * Indications: Nondisplaced fractures, Displaced fractures with acceptable closed reduction * Age \>8 * \<5° varus/valgus * \<5° sagittal malalignment * \<1cm of shortening * \<50% translation * Age \<8 * \<10° varus/valgus * \<10° sagittal malalignment * \<1cm shortening * 100% translation * Toddler fracture * 4 weeks immobilization 2. Operative * indications: open fracture, polytrauma, floating knee, some segmental fractures, severe swelling, concern for compartment syndrome, vascular injury, unstable fractures not maintained by nonoperative means Surgical options for the management of tibial diaphyseal fractures * uniplanar and multiplanar External fixation * Indications: high energy unstable fracture, Severe soft tissue injury * compressive plating * Indications: low grade open fractures with simple pattern (soft tissue dissection and exposure already performed * Lateral limited contact locked plating * Indications: open (potentially closed) comminuted or segmental fractures (patterns otherwise difficult to maintain reduction with flexible nails or ex fix) * Technique: 2 small incisions are made proximal and distal to the fracture site on the lateral side of the tibia, using blunt dissection to the periosteum to minimize inadvertent damage to the peroneal nerve. 3.5mm or 4.5mm LCP is then advanced in the sub muscular plane and secured with at least percutaneous 3 locking screws proximal and distal to the fracture site * Elastic stable IM nailing * Indications: closed fractures not amenable to cast treatment * advantages: extraphyseal, allows early WB, early activity and joint mobility, minimally invasive, allows monitoring of soft tissue and compartments

Answer 102

Cast wedging

Answer 103

Proximal 1/3

Answer 104

1. Timing * 18 month transitional period prior to complete closure * Complete closure at 14 in girls and 16 in boys 2. Progression of closure * Central \> anteromedial \> posteromedial \> posterolateral \> anterolateral

Answer 105

1. Nonoperative * Closed reduction and casting * Delay greater than a week increases risk of physeal injury with closed reduction Operative * Failure of closed reduction * Open reduction and casting * Unstable fracture * Percutaneous fixation * ORIF * Thurston-Holland fragment allows for screw fixation parallel to physis and perpendicular to fracture

Answer 106

1. Presentation * Medial malleolus fractures * Tillaux fractures – avulsion of anterolateral distal tibia epiphysis (AITFL insertion) 2. Nonoperative * \<2mm displacement 3. Operative * \>2mm displacement * Anterolateral approach for Tillaux fractures * Medial approach for medial malleolus fractures * Screw fixation within the epiphysis parallel to physis

Answer 107

1. Presentation * Triplane * Sagittal plane through epiphysis, axial plane through physis and coronal plane through metaphysis * Medial malleolus (vertical) 2. Nonoperative * \<2mm displacement 3. Operative * \>2mm displacement or \>2mm physeal gap * Medial malleolus fracture * Medial approach * Screw into epiphysis and metaphysis parallel to physis * Triplane fracture - closed reduction and perc screws OR open reduction if reduction not achieve by closed means - epiphyseal fracture is usually amenable to anteroalteral or posteromedial placed screws parallel to the physis - metaphyseal fragment usually gets captured wit direct anterior to posterior based screws

Answer 108

1. Increasing Salter Harris classification (SHV \> SHI) 2. Physeal gap \>3mm 3. Periosteum entrapped in fractures site 4. High energy injury

Answer 109

1. Corrective osteotomy for angular deformity 2. Fibular epiphysiodesis to limit overgrowth and lateral impingement 3. Physeal bar resection may be considered if \<50% of the physis is compromised and \>2 years or \>2cm of growth remain * Peripheral bars approached directly * Central bars through metaphyseal window Best indications for bar resection (as per Jarvis) * Younger children * Smaller bar * Shorter time interval (since bar development) * Central is better than peripheral * Traumatic etiology (as opposed to infectious, etc) * Healthy surrounding physis

Answer 110

1. First to appear = greater trochanter 2. Last to fuse = ASIS

Answer 111

McKinney Modified Classification * Type I - Nondisplaced * Type II - Displacement \<2cm * Type III - Displacement ≥2 cm * Type IV - Symptomatic nonunion; painful heterotopic bone growth

Answer 112

1. Ischial tuberosity, ASIS, AIIS, pubic symphysis and iliac crest 2. Nonoperative * Indicated for all nondisplaced and minimally displaced 3. Operative * Displacement \>2cm * Persistent pain following nonoperative * Impingement syndrome (AIIS)

Answer 113

Child abuse prevention and treatment act (american): any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse, or exploitation; or an act or failure to act, which presents an imminent risk of serious harm

Answer 114

1. No/vague explanation for significant injury. 2. Denial of trauma in setting of significant boney injury. 3. Mechanism of entry, not consistent with fracture type, energy associated with fracture or severity of injury. 4. Injury inconsistent with a child’s physical and/or developmental capabilities. 5. Inconsistent history across caregivers or changing histories provided by caregivers. 6. Different different witnesses with different explanations. 7. Injuries resulting from a family/domestic violence incident. 8. Previous history of inflicted trauma. 9. Witnessed inappropriate behaviour to a child placing them at risk of NAT 10. Delay in seeking care for injury.

Answer 115

Indicated in the evaluation of a suspicious injury in any child younger than two years * recommends the study be repeated in 2 to 3 weeks to assess for healing of non- or minimally displaced injuries, such as rib fractures, or better distinguished normal variance from healing injuries

Answer 116

Osteogenesis imperfecta, menkes syndrome, juvenile idiopathic osteoporosis, osteopenia of immaturity, scurvy, copper deficiency, vitamin D deficient rickets

Answer 117

1. Trauma. (Most common) 2. Vascular insult, surgical positioning, overexertion, infection, neonatal, phenomena, or snake or insect bites.

Answer 118

Adolescent males

Answer 119

1. Tibial shaft (greatest risk) 2. Forearm/wrist and foot (second) 3. Combined supracondylar displaced forearm fracture = 33% risk of ACS 4. Fractures associated with nerve palsies (delay presentation due to decrease sensation) (median n in supracondylar, peroneal n. In tibial shaft) 5. Spica cast management of femoral shaft fractures. 6. Crush injuries.

Answer 120

Increasing anxiety, agitation and analgesia requirement

Answer 121

1. Ensure normotensive - hypotension should be avoided (decreases perfusion pressure to tissue) 2. Remove circumferential dressings - bivalving and splitting the cast by 0.5cm has been shown to decrease pressure by 47% in the anterior compartment and 33% in the deep posterior compartment of the leg 3. Maintain limb at heart height - elevation can reduce arteriovenous pressure gradient 4. Provide supplemental oxygen

Answer 122

1. Emergent decompressive fasciotomy 2. Myonecrosis should not be debrided at time of fasciotomy - muscle recovery is more robust than adults - myonecrosis has an 80fold increased risk of functional deficit 3. Wound closure should be delayed - VAC may eliminate need for split thickness skin grafts 4. Delayed diagnosis still warrants decompression - in presence of tissue and nerve damage a fasciotomy is warranted due to children’s potential for recovery

Answer 123

1. ≥4mm 2. Type 2 fractures are typically ≥2 and <4mm of displacement (articular surface intact) 3. Type 3 fracture are typically ≥4mm of displacement (articular surface incongruent)

Answer 124

Greatest distance between the humerus and the fracture fragment on any radiographic views (AP, later, internal oblique)

Answer 125

Nonop indications - ≤2mm displacement (weiss type 1) Operative - >2mm displacement (weiss type 2 and 3) - Incongruent articular surface - Progressive displacement on serial radiographs - Failure of nonop treatment (delayed healing or inability to maintain or tolerate casting)

Answer 126

1. Long arm cast with elbow at 90° and forearm in neutral rotation 2. Weekly radiographs for 3 weeks 3. Cast continues for 4-6 weeks, remove once bridging and lack of tenderness demonstrated at fracture site

Answer 127

1. Open reduction 2. Age >10 3. Greater fracture angulation 4. Greater fracture displacement 5. Time to surgery <2 days (suggest more severe injury)

Answer 128

8 year old (more common in males)

Answer 129

Fibula fracture present - risk of valgus alignment (due to contraction of anterior and lateral musculature) Fibula fracture absent - risk of varus alignment (due to contraction of anterior muscles and tethering of the intact fibula) 60% will develop varus angulation in the first 2 weeks

Answer 130

Apex anterior angulation, varus malalignment, single plane deformities have a greater ability to remodel, whereas apex posterior, valgus malalignment, and multiplanar deformities have less ability