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Pediatrics 2013 Flashcards

1
Q
  1. Based on the findings shown in Figures 3a and 3b, what is the most likely diagnosis?
  2. Mucopolysaccharidosis
  3. Osteogenesis imperfecta
  4. Legg-Calvé-Perthes disease of both hips
  5. A history of developmental hip dysplasia that has been treated
  6. A history of developmental hip dysplasia that has not been treated
A
  1. Mucopolysaccharidosis

RECOMMENDED READINGS

Link B, de Camargo Pinto LL, Giugliani R, Wraith JE, Guffon N, Eich E, Beck M. Orthopedic manifestations in patients with mucopolysaccharidosis type II (Hunter syndrome) enrolled in the Hunter Outcome Survey. Orthop Rev (Pavia). 2010 Sep 23;2(2):e16. PubMed PMID: 21808707.

Crossan JF, Wynne-Davies R, Fulford GE. Bilateral failure of the capital femoral epiphysis: bilateral Perthes disease, multiple epiphyseal dysplasia, pseudoachondroplasia, and spondyloepiphyseal dysplasia congenita and tarda. J Pediatr Orthop. 1983 Jul;3(3):297-301. PubMed PMID: 6409926.

Kitoh H, Kitakoji T, Kawasumi M, Ishiguro N. A histological and ultrastructural study of the iliac crest apophysis in Legg-Calve-Perthes disease. J Pediatr Orthop. 2008 Jun;28(4):435-9. PubMed PMID: 18520280.

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2
Q
  1. Figures 13a through 13f are the coronal and sagittal CT scans of a boy who sustained a Salter-Harris II fracture through the physis of the distal tibia, with an associated Salter-Harris I distal fibula fracture at 10 years of age. He was treated with closed reduction and cast immobilization. Now at age 12, he is asymptomatic and has a lower limb-length discrepancy that is 1 cm shorter on the involved side and bone age consistent with standards for 13-year-olds. His parents should be informed that
  2. his growth has stopped and no additional visits are necessary.
  3. the areas of physeal closure are too complex for reliable bar resection.
  4. differntial continued growth between the tibia and fibula is unlikely􀀃 􀀖􀀑􀀃􀀃􀀃􀀃􀁇􀁌􀁉􀁉􀁈􀁕􀁈􀁑􀁗􀁌􀁄􀁏􀀃􀁆􀁒􀁑􀁗􀁌􀁑􀁘􀁈􀁇􀀃􀁊􀁕􀁒􀁚􀁗􀁋􀀃􀁅􀁈􀁗􀁚􀁈􀁈􀁑􀀃􀁗􀁋􀁈􀀃􀁗􀁌􀁅􀁌􀁄􀀃􀁄􀁑􀁇􀀃􀁗􀁋􀁈􀀃􀂿􀁅􀁘􀁏􀁄􀀃􀁌􀁖􀀃􀁘􀁑􀁏􀁌􀁎􀁈􀁏􀁜􀀑
  5. epiphyseodesis of the contralateral tibia and fibula is indicated to reestabkish length equality􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀁈􀁓􀁌􀁓􀁋􀁜􀁖􀁈􀁒􀁇􀁈􀁖􀁌􀁖􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁆􀁒􀁑􀁗􀁕􀁄􀁏􀁄􀁗􀁈􀁕􀁄􀁏􀀃􀁗􀁌􀁅􀁌􀁄􀀃􀁄􀁑􀁇􀀃􀂿􀁅􀁘􀁏􀁄􀀃􀁌􀁖􀀃􀁌􀁑􀁇􀁌􀁆􀁄􀁗􀁈􀁇􀀃􀁗􀁒􀀃􀁕􀁈􀁈􀁖􀁗􀁄􀁅􀁏􀁌􀁖􀁋􀀃􀁏􀁈􀁑􀁊􀁗􀁋􀀃􀁈􀁔􀁘􀁄􀁏􀁌􀁗􀁜􀀑
  6. physeal bar resection with interposition of fat or bone cement is indicated to permit continuedgrowth of the distal tibia.
A
  1. the areas of physeal closure are too complex for reliable bar resection.

RECOMMENDED READINGS

Rathjen KE, Birch JG. Physeal injuries and growth disturbances. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins’ Fractures in Children, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:99-131.

Kang HG, Yoon SJ, Kim JR. Resection of a physeal bar under computer-assisted guidance. J Bone Joint Surg Br 2010 Oct;92(10):1452-5. PubMed PMID: 20884987.

Marsh JS, Polzhofer GK. Arthroscopically assisted central physeal bar resection. J Pediatr Orthop 2006 Mar-Apr;26(2):255-9. PubMed PMID: 16557145.

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3
Q
  1. A 10-year-old boy has had the insidious onset of anterior knee pain in both knees for 3 months. He had no inciting traumatic event and no pain at night or when walking, but has pain when ascending stairs or running. Examination reveals full active and passive range of motion of both knees, no hip pain with log roll, mild swelling over the tibial tubercle of both knees, and reproduction of the knee pain with direct palpation of the tibial tubercles. The most appropriate next step should include
  2. a 3-phase bone scan.
  3. an MRI scan of both knees.
  4. core strengthening exercises.
  5. bilateral tibial tubercle osteotomies.
  6. nonsteriodal antiinflammatory drugs, activity moidification and gentle quadriceps stretching􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀁑􀁒􀁑􀁖􀁗􀁈􀁕􀁒􀁌􀁇􀁄􀁏􀀃􀁄􀁑􀁗􀁌􀀐􀁌􀁑􀃀􀁄􀁐􀁐􀁄􀁗􀁒􀁕􀁜􀀃􀁇􀁕􀁘􀁊􀁖􀀏􀀃􀁄􀁆􀁗􀁌􀁙􀁌􀁗􀁜􀀃􀁐􀁒􀁇􀁌􀂿􀁆􀁄􀁗􀁌􀁒􀁑􀀏􀀃􀁄􀁑􀁇􀀃􀁊􀁈􀁑􀁗􀁏􀁈􀀃􀁔􀁘􀁄􀁇􀁕􀁌􀁆􀁈􀁓􀁖􀀃􀁖􀁗􀁕􀁈􀁗􀁆􀁋􀁌􀁑􀁊􀀑
A
  1. nonsteriodal antiinflammatory drugs, activity moidification and gentle quadriceps stretching􀀃

RECOMMENDED READINGS

Frank JB, Jarit GJ, Bravman JT, Rosen JE. Lower extremity injuries in the skeletally immature athlete. J Am Acad Orthop Surg. 2007 Jun;15(6):356-66. Review. PubMed PMID: 17548885.

Gholve PA, Scher DM, Khakharia S, Widmann RF, Green DW. Osgood Schlatter syndrome. Curr Opin Pediatr. 2007 Feb;19(1):44-50. Review. PubMed PMID: 17224661.

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4
Q
  1. A 15-year-old girl involved in a motor vehicle collision has severe back pain and is unable to move or feel her legs. The emergency medical technician noticed a large ecchymotic area on her back at the thoracolumbar junction. What is the most appropriate initial evaluation?
  2. A CT scan of the entire spine
  3. Placement of a Foley catheter
  4. Radiographs of the thoracolumbar junction
  5. Evaluation of the bulbocavernosus reflex􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀀨􀁙􀁄􀁏􀁘􀁄􀁗􀁌􀁒􀁑􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁅􀁘􀁏􀁅􀁒􀁆􀁄􀁙􀁈􀁕􀁑􀁒􀁖􀁘􀁖􀀃􀁕􀁈􀃀􀁈􀁛
  6. Evaluation of the airway, breathing, and circulation
A
  1. Evaluation of the airway, breathing, and circulation
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5
Q

35.

Figures 35a and 35b are the radiographs of a 9-year-old boy who fell from a tree and sustained a left elbow fracture. With open reduction and internal fixation, which techniqye would ninimize after-surgery lateral spurring?

  1. Screw fixation of the fracture
  2. Bone wax over the lateral metaphysis
  3. Removal of the Kirschner wires by 3 weeks after surgery
  4. Delayed range of motion until 6 weeks after surgery
  5. Anatomical restoration of the lateral periosteum
A
  1. Anatomical restoration of the lateral periosteum

RECOMMENDED READINGS

Beaty JH, Kasser JR. The elbow: physeal fractures, apophyseal injuries of the distal humerus, osteonecrosis of the trochlea, and T-condylar fractures. In: Beaty JH, Kasser JR, eds. Rockwood & Wilkins’ Fractures in Children. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:533-593.

Pribaz JR, Bernthal NM, Wong TC, Silva M. Lateral spurring (overgrowth) after pediatric lateral condyle fractures. J Pediatr Orthop. 2012 Jul;32(5):456-60. PubMed PMID: 22706459.

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6
Q

43.

A 10-year-old girl has the injury seen in Figures 43a and 43b. She is treated with closed reduction andpercutaneous pinning with smooth Kirschner wires. What is the most common complication of thisfracture?

  1. Medial meniscus tear
  2. Arthrofibrosis of the knee􀀃 􀀕􀀑􀀃􀀃􀀃􀀃􀀤􀁕􀁗􀁋􀁕􀁒􀂿􀁅􀁕􀁒􀁖􀁌􀁖􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁎􀁑􀁈􀁈
  3. Distal femoral growth arrest
  4. Superficial peroneal nerve palsy􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀀶􀁘􀁓􀁈􀁕􀂿􀁆􀁌􀁄􀁏􀀃􀁓􀁈􀁕􀁒􀁑􀁈􀁄􀁏􀀃􀁑􀁈􀁕􀁙􀁈􀀃􀁓􀁄􀁏􀁖􀁜
  5. Lateral femoral condyle osteochondral fracture
A
  1. Distal femoral growth arrest

RECOMMENDED READINGS

􀀪􀁄􀁕􀁕􀁈􀁗􀁗􀀃􀀥􀀵􀀏􀀃􀀫􀁒􀁉􀁉􀁐􀁄􀁑􀀃􀀨􀀥􀀏􀀃􀀦􀁄􀁕􀁕􀁄􀁕􀁄􀀃􀀫􀀑􀀃􀀷􀁋􀁈􀀃􀁈􀁉􀁉􀁈􀁆􀁗􀀃􀁒􀁉􀀃􀁓􀁈􀁕􀁆􀁘􀁗􀁄􀁑􀁈􀁒􀁘􀁖􀀃􀁓􀁌􀁑􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀃􀁌􀁑􀀃􀁗􀁋􀁈􀀃􀁗􀁕􀁈􀁄􀁗􀁐􀁈􀁑􀁗􀀃􀁒􀁉􀀃􀁇􀁌􀁖􀁗􀁄􀁏􀀃Garrett RB, Hoffman EB, Carrara H. The effect of percutanous pin fixation in the treatment of distal femoral physeal fractures. J Bone Joint Surg Br. 2011 May;93(5):689-94. Review. PubMed PMID:21511937.

Arkader A, Warner WC Jr, Horn BD, Shaw RN, Wells L. Predicting the outcome of physeal fractures ofthe distal femur. J Pediatr Orthop. 2007 Sep;27(6):703-8. PubMed PMID: 17717475.

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7
Q
  1. Figure 49 is the radiograph of a child with a forearm fracture. Access to follow-up care will be limited in most regions of the United States by
  2. body mass index.
  3. patient comorbidities.
  4. type of immobilization in place.
  5. referral expertise.
  6. the number of orthopaedic surgeons willing to see pediatric patients.
A
  1. the number of orthopaedic surgeons willing to see pediatric patients.
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8
Q

56.

A 13-year-old boy sustained the injury shown in Figure 56a. Closed treatment under general anesthesia was performed within 3 hours. Posttreatment CT scans shown in Figures 56b through 56d revealed acceptable results. At the 7-week visit, the boy has remained asymptomatic and has begun some running despite being given instructions for activity restrictions. Figures 56e through 56g show current standing anteroposterior, standing “false profile”, and supine internally rotated radiographs of the hip. Based on these findings, the parents shoudl be informed that

  1. there is concern about possible chondrolysis.
  2. there is no further concern about possible osteonecrosis.
  3. the hip is not completely reduced.
  4. the radiographs show evidence of osteonecrosis of the femoral head.
  5. heterotopic ossification is the result of the patient’s early return to activity􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀁋􀁈􀁗􀁈􀁕􀁒􀁗􀁒􀁓􀁌􀁆􀀃􀁒􀁖􀁖􀁌􀂿􀁆􀁄􀁗􀁌􀁒􀁑􀀃􀁌􀁖􀀃􀁗􀁋􀁈􀀃􀁕􀁈􀁖􀁘􀁏􀁗􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁓􀁄􀁗􀁌􀁈􀁑􀁗􀂶􀁖􀀃􀁈􀁄􀁕􀁏􀁜􀀃􀁕􀁈􀁗􀁘􀁕􀁑􀀃􀁗􀁒􀀃􀁄􀁆􀁗􀁌􀁙􀁌􀁗􀁜􀀑
A
  1. there is concern about possible chondrolysis.

RECOMMENDED READINGS

Blasier RD, Hughes LO. Fractures and traumatic dislocations of the hip in children. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins’ Fractures in Children, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:861-891.

Hamilton PR, Broughton NS. Traumatic hip dislocation in childhood. J Pediatr Orthop 1998;18:691-694. PubMed PMID: 9746428.

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9
Q
  1. A 12-year-old right-handed girl has right shoulder pain after pitching baseball. Examination reveals right shoulder tenderness to palpation over the anterolateral aspect and mild weakness with resisted internal rotation and abduction. Radiographs of her shoulder reveal no abnormalities. What is the most appropriate next step in management?
  2. MRI scan of the right shoulder
  3. MR arthrogram of the right shoulder
  4. Glenohumeral corticosteroid injection
  5. Arthroscopic evaluation and repair of the middle glenohumeral ligament
  6. 2-month hiatus from pitching followed by a progressive throwing program
A
  1. 2-month hiatus from pitching followed by a progressive throwing program

RECOMMENDED READINGS

Chen FS, Diaz VA, Loebenberg M, Rosen JE. Shoulder and elbow injuries in the skeletally immature athlete. J Am Acad Orthop Surg. 2005 May-Jun;13(3):172-85. Review. PubMed PMID: 15938606.

McFarland EG, Ireland ML. Rehabilitation programs and prevention strategies in adolescent throwing athletes. Instr Course Lect. 2003;52:37-42. Review. PubMed PMID: 12690839.

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10
Q
  1. Figures 70a through 70e are the radiographs and MRI scan of a 12-year-old boy with worsening thigh pain. What is the most appropriate definiitive surgical treatment?

􀁓􀁄􀁌􀁑􀀑􀀃􀀃􀀺􀁋􀁄􀁗􀀃􀁌􀁖􀀃􀁗􀁋􀁈􀀃􀁐􀁒􀁖􀁗􀀃􀁄􀁓􀁓􀁕􀁒􀁓􀁕􀁌􀁄􀁗􀁈􀀃􀁇􀁈􀂿􀁑􀁌􀁗􀁌􀁙􀁈􀀃􀁖􀁘􀁕􀁊􀁌􀁆􀁄􀁏􀀃􀁗􀁕􀁈􀁄􀁗􀁐􀁈􀁑􀁗􀀢1. Observation with repeat follow up in 3 months

  1. Curettage and placement of a bone graft substitute
  2. Incision and drainage and placement of antibiotic beads
  3. Resection of the distal one-third of the femur and knee fusion
  4. Resection of the distal two-thirds of the femur and custom implant
A
  1. Resection of the distal two-thirds of the femur and custom implant

RECOMMENDED READINGS

Maheshwari AV, Bergin PF, Henshaw RM. Modes of failure of custom expandable repiphysis prostheses: a report of three cases. J Bone Joint Surg Am. 2011 Jul 6;93(13):e72. PubMed PMID: 21776557.

Campanacci L, Manfrini M, Colangeli M, Alí N, Mercuri M. Long-term results in children with massive bone osteoarticular allografts of the knee for high-grade osteosarcoma. J Pediatr Orthop. 2010 Dec;30(8):919-27. PubMed PMID: 21102223.

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11
Q

74/For treatment of displaced supracondylar humeral fractures in children, the AAOS clinical practice guideline, The Treatment of Pediatric Supracondylar Humerus Fractures, recommends closed reduction and pin fixation using which pin configuration

  1. 1 medial and 1 lateral
  2. 1 medial and 2 lateral
  3. 2 medial and 1 lateral
  4. 2 to 3 lateral
  5. 2 to 3 medial
A
  1. 2 to 3 lateral

RECOMMENDED READINGS

Howard A, Mulpuri K, Abel MF, Braun S, Bueche M, Epps H, Hosalkar H, Mehlman CT, Scherl S, Goldberg M, Turkelson CM, Wies JL, Boyer K; American Academy of Orthopaedic Surgeons. The treatment of pediatric supracondylar humerus fractures. J Am Acad Orthop Surg. 2012 May;20(5):320-7. PubMed PMID: 22553104.

Herring JA, ed. Tachdjian’s Pediatric Orthopaedics. 4th ed. Philadelphia, PA: WB Saunders; 2008:1431- 1435.

Weinstein SL, ed. The Pediatric Spine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:753-769.

Beaty JH, Kasser JR, eds. Rockwood & Wilkins’ Fractures in Children. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:405-427.

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12
Q
  1. A 2-week-old infant has an Ortolani positive right hip. She is placed in a Pavlik harness with her hips flexex to 120 degrees. Three days after the harness is started, her parents notice she is not extending her right knee. What is the most likely reason for the change?
  2. Septic right knee
  3. Right femoral nerve palsy
  4. Avascular necrosis of the right hip
  5. Compartment syndrome of the right leg
  6. Development of right hip Pavlik harness disease
A
  1. Right femoral nerve palsy

RECOMMENDED READINGS

Murnaghan ML, Browne RH, Sucato DJ, Birch J. Femoral nerve palsy in Pavlik harness treatment for developmental dysplasia of the hip. J Bone Joint Surg Am. 2011 Mar 2;93(5):493-9. PubMed PMID: 21368082.

Weinstein SL, Mubarak SJ, Wenger DR. Developmental hip dysplasia and dislocation: Part II. Instr Course Lect. 2004;53:531-42. Review. PubMed PMID: 15116642.

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13
Q
  1. An otherwise healthy 5-year-old girl underwent closed reduction and percutanous pin fixation of an uncomplicated supracondylar fracture of the distal humerus. Four weeks later, radiographs show bone healing and the 2 smooth Kirschner wires are removed. The patient has range of motion from 30 degrees of flexion to 90 degrees of flexion. You inform the parents that

􀁒􀁉􀀃􀃀􀁈􀁛􀁌􀁒􀁑􀀃􀁗􀁒􀀃􀀜􀀓􀀃􀁇􀁈􀁊􀁕􀁈􀁈􀁖􀀃􀁒􀁉􀀃􀃀􀁈􀁛􀁌􀁒􀁑􀀑􀀃􀀃􀀼􀁒􀁘􀀃􀁌􀁑􀁉􀁒􀁕􀁐􀀃􀁋􀁈􀁕􀀃􀁓􀁄􀁕􀁈􀁑􀁗􀁖1. spontaneous play and gentle household chores will almost always allow a patient to regain full elbow range of motion.

  1. progressive static splinting should be initiated immediately to regain full elbow extension.
  2. constant-force (spring loaded) splinting should be initiated immediately to regain full elbow flexion
  3. formal therapy sessions emphasizing forearm rotation should begin immediately.
  4. arthroscopic anterior capsular release is commonly indicated following a pediatric supracondylar humerus fracture.
A

􀁒􀁉􀀃􀃀􀁈􀁛􀁌􀁒􀁑􀀃􀁗􀁒􀀃􀀜􀀓􀀃􀁇􀁈􀁊􀁕􀁈􀁈􀁖􀀃􀁒􀁉􀀃􀃀􀁈􀁛􀁌􀁒􀁑􀀑􀀃􀀃􀀼􀁒􀁘􀀃􀁌􀁑􀁉􀁒􀁕􀁐􀀃􀁋􀁈􀁕􀀃􀁓􀁄􀁕􀁈􀁑􀁗􀁖1. spontaneous play and gentle household chores will almost always allow a patient to regain full elbow range of motion.

RECOMMENDED READINGS

Zionts LE, Woodson CJ, Manjra N, Zalavras C. Time of return of elbow motion after percutaneous pinning of pediatric supracondylar humerus fractures. Clin Orthop Relat Res 2009 Aug;467(8):2007-10. PubMed PMID: 19198963.

Lee S, Park MS, Chung CY, Chung CY, Kwon DG, Sung KH, Kim TW, Choi IH, Cho TJ, Yoo WJ, Lee MS. Consensus and different perspectives on treatment of supracondylar fractures of the humerus in children. Clin Orthop Surg 2012 Mar;4(1):91-7. PubMed PMID: 22379561.

Keppler P, Salem K, Schwarting B, Kinzl L. The effectiveness of physiotherapy after operative treatment of supracondylar humeral fractures in children. J Pediatr Orthop 2005 May-Jun;25(3):314-6. PubMed PMID: 15832145.

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14
Q

94 An 8-year-old girl underwent a drainage procedure of her left hip joint 3 days ago. She is being treated with appropriate antibiotics. She remains febrile, has left anterior groin pain, keeps her left hip flex at about 20 degrees, and resists any left hip extension. T1 and T2 STIR images in the axial, coronal, and sagittal projections are shown in Figures 94a through 94f. What conclusions can be drawn from these findings?

  1. These are expected MRI scan findtings following drainage of acute septic arthritis of the hip
  2. In addition to the septic hip joint, there is osteomyelitis of the iliac wing and involvement of several muscle groups including the psoas.

􀀃􀀃􀀃􀀃􀀃􀀃􀀃􀀖􀀑􀀃􀀃􀀃􀀃􀀷􀁋􀁈􀁕􀁈􀀃􀁌􀁖􀀃􀁖􀁘􀁉􀂿􀁆􀁌􀁈􀁑􀁗􀀃􀁕􀁈􀁆􀁘􀁕􀁕􀁈􀁑􀁗􀀃􀃀􀁘􀁌􀁇􀀃􀁌􀁑􀀃􀁗􀁋􀁈􀀃􀁋􀁌􀁓􀀃􀁍􀁒􀁌􀁑􀁗􀀃􀁌􀁗􀁖􀁈􀁏􀁉􀀃􀁗􀁒􀀃􀁈􀁛􀁓􀁏􀁄􀁌􀁑􀀃􀁗􀁋􀁈􀀃􀁊􀁌􀁕􀁏􀂶􀁖􀀃􀁆􀁒􀁑􀁗􀁌􀁑􀁘􀁈􀁇􀀃􀁇􀁌􀁖􀁆􀁒􀁐􀁉􀁒􀁕􀁗􀀑3. There is sufficienct recurrent fluid in the hip joint itself to explain the girl’s continued discomfort

  1. The MRI scans confirm osteomyelitis of the femoral head􀀃􀀃􀀃􀀃􀀃􀀃􀀃􀀃􀀃􀀗􀀑􀀃􀀃􀀃􀀃􀀷􀁋􀁈􀀃􀀰􀀵􀀬􀀃􀁖􀁆􀁄􀁑􀁖􀀃􀁆􀁒􀁑􀂿􀁕􀁐􀀃􀁒􀁖􀁗􀁈􀁒􀁐􀁜􀁈􀁏􀁌􀁗􀁌􀁖􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁉􀁈􀁐􀁒􀁕􀁄􀁏􀀃􀁋􀁈􀁄􀁇􀀑
  2. The septic arthritis of the hip is now proven to be secondary to a sarcoma of the iliacus muscle.
A
  1. In addition to the septic hip joint, there is osteomyelitis of the iliac wing and involvement of several muscle groups including the psoas.
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15
Q
  1. A 2-week-old infant has had decreased spontaneous motion of the right upper limb since birth. There were no birth fractures and no infection is present. Persistent posture is shown in Figure 97a, and the posture during a Moro response is shown in Figure 97b. Examination reveals full passive and active motion of the neck. Based on these findings, the parentse should be instructed to implement what actionsfor the next 3 months?
  2. Perform passive stretching for the neck; most important: rotate the head toward the involvedlimb and extend the cervical spine.
  3. Perform passive stretching for the involved shoulder and elbow; most important: move the shoulder to extension/adduction and internal rotation.
  4. Perform passive stretching for the involved shoulder and elbow; most important: move the shoulder to elevation/abduction and external rotation.
  5. Perform passive stretching for hte involved hand; most important: move the fingers into flexion and the interphalangeal joints and the thumb into adduction-flexion􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀀳􀁈􀁕􀁉􀁒􀁕􀁐􀀃􀁓􀁄􀁖􀁖􀁌􀁙􀁈􀀃􀁖􀁗􀁕􀁈􀁗􀁆􀁋􀁌􀁑􀁊􀀃􀁉􀁒􀁕􀀃􀁗􀁋􀁈􀀃􀁌􀁑􀁙􀁒􀁏􀁙􀁈􀁇􀀃􀁋􀁄􀁑􀁇􀀞􀀃􀁐􀁒􀁖􀁗􀀃􀁌􀁐􀁓􀁒􀁕􀁗􀁄􀁑􀁗􀀝􀀃􀁐􀁒􀁙􀁈􀀃􀁗􀁋􀁈􀀃􀂿􀁑􀁊􀁈􀁕􀁖􀀃􀁌􀁑􀁗􀁒􀀃􀀃 􀀃􀀃􀀃􀀃􀀃􀀃􀀃􀃀􀁈􀁛􀁌􀁒􀁑􀀃􀁄􀁗􀀃􀁗􀁋􀁈􀀃􀁌􀁑􀁗􀁈􀁕􀁓􀁋􀁄􀁏􀁄􀁑􀁊􀁈􀁄􀁏􀀃􀁍􀁒􀁌􀁑􀁗􀁖􀀃􀁄􀁑􀁇􀀃􀁗􀁋􀁈􀀃􀁗􀁋􀁘􀁐􀁅􀀃􀁌􀁑􀁗􀁒􀀃􀁄􀁇􀁇􀁘􀁆􀁗􀁌􀁒􀁑􀀐􀃀􀁈􀁛􀁌􀁒􀁑􀀑
  6. Refrain from performing any passive stretching; let the infant move spontaneously and monitor for improvement.
A
  1. Perform passive stretching for the involved shoulder and elbow; most important: move the shoulder to elevation/abduction and external rotation.

Erb’s palsy

RECOMMENDED READINGS

Waters PM. Update on management of pediatric brachial plexus palsy. J Pediatr Orthop 2005 Jan- Feb;25(1):116-26.PubMed PMID: 15614072.

Waters PM. The upper limb. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopaedics, ed. 6. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:921-985.

Herring JA. Disorders of the upper extremity. In: Herring JA, ed. Tachdjian’s Pediatric Orthopaedics, 3rd ed. Philadelphia, PA: WB Saunders; 2002:379-512.

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16
Q
  1. An 18-month-old boy is evaluated because he is not walking. He is found to have generalized hypotonia,

asymmetry in his muscle strength, with his proximal muscles weaker than his distal muscles, absent deep tendon reflexes, and tongue fasculations. What is the most appropriate next steps in determining a diagnosis?

  1. Obtain a skeletal survey.
  2. Schedule a muscle biopsy.
  3. Electromyography and nerve conduction velocity studies
  4. Referral for genetic testing of the survival motor neuron 1 gene
  5. Referral for genetic testing to evaluate for trisomy 21
A
  1. Referral for genetic testing of the survival motor neuron 1 gene

RECOMMENDED READINGS

􀀰􀁈􀁖􀂿􀁑􀀃􀀤􀀏􀀃􀀶􀁓􀁒􀁑􀁖􀁈􀁏􀁏􀁈􀁕􀀃􀀳􀀧􀀏􀀃􀀯􀁈􀁈􀁗􀀃􀀤􀀬􀀑􀀃􀀶􀁓􀁌􀁑􀁄􀁏􀀃􀁐􀁘􀁖􀁆􀁘􀁏􀁄􀁕􀀃􀁄􀁗􀁕􀁒􀁓􀁋􀁜􀀝􀀃􀁐􀁄􀁑􀁌􀁉􀁈􀁖􀁗􀁄􀁗􀁌􀁒􀁑􀁖􀀃􀁄􀁑􀁇􀀃􀁐􀁄􀁑􀁄􀁊􀁈􀁐􀁈􀁑􀁗􀀑􀀃􀀭􀀃􀀤􀁐􀀃􀀤􀁆􀁄􀁇􀀃Shapiro F, Specht L. The diagnosis and orthopaedic treatment of childhood spinal muscular atrophy, peripheral neuropathy, Friedreich ataxia, and arthrogryposis. J Bone Joint Surg Am. 1993 Nov;75(11):1699-714. Review. PubMed PMID: 8245065.

17
Q
  1. A physician is called to the well-baby nursery to consult regarding an otherwise healthy female newborn; the clinician states that “one of the baby’s legs is backwards.” Examination of the involved limb reveals intact circulation and motor functions. Radiographs are shown in Figures 114a through 114c. Based on these findings, what is the most appropriate initial treatment?
  2. Casting on bracing with the knee in flexion
  3. Casting or bracing with the knee in extension
  4. Anterior knee release should be performed in about 6 months.
  5. An MRI scan of the knee should be obtained before beginning any attempt at treatment.
  6. Observation should be conducted for 3 weeks with the expectation of gradual spontaneous improvement.
A
  1. Casting on bracing with the knee in flexion

RECOMMENDED READINGS

Schoenecker PL, Rich MM. The lower extremity. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopaedics, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1158-1211.

􀁎􀁑􀁈􀁈􀀃􀃀􀁈􀁛􀁌􀁒􀁑􀀑􀀃􀀃􀀭􀀃􀀦􀁋􀁌􀁏􀁇􀀃􀀲􀁕􀁗􀁋􀁒􀁓􀀃􀀕􀀓􀀔􀀔􀀃􀀤􀁓􀁕􀀞􀀘􀀋􀀕􀀌􀀝􀀔􀀗􀀖􀀐􀀜􀀑􀀃􀀳􀁘􀁅􀀰􀁈􀁇􀀃􀀳􀀰􀀬􀀧􀀝􀀃􀀕􀀕􀀗􀀙􀀛􀀔􀀘􀀛􀀑Klingele KE, Stephens S. Management of ACL elongation in the surgical treatment of congenital knee dislocation. Orthopaedics 2012 Jul;35(7):e1094-8. PubMed PMID: 22784907.

18
Q
  1. Figures 122a and 112b are the radiographs of a 3-year-old girl with a flexed interphalangeal joint of the thumb on the left hand. Her parents notice that she has been unable to extend the interphalangeal joint of her thumb for 18 months; however, she has no pain and is able to fully use her hand. The parents deny any previous trauma to her hand. Examination reveals no tenderness, full motion of the metacarpophalangeal joint, and passive extension of the interphalangeal joint to 25 degrees short of neutral. A small volar mass is palpated at the level of the metatarsophalangeal joint. What is the most appropriate next step?
  2. Observation for 6 months
  3. Release of the A1 pulley of the thumb
  4. Repair of the flexor pollicis longus tendon􀀃 􀀖􀀑􀀃􀀃􀀃􀀃􀀵􀁈􀁓􀁄􀁌􀁕􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀃀􀁈􀁛􀁒􀁕􀀃􀁓􀁒􀁏􀁏􀁌􀁆􀁌􀁖􀀃􀁏􀁒􀁑􀁊􀁘􀁖􀀃􀁗􀁈􀁑􀁇􀁒􀁑
  5. Extension osteotomy of the proximal phalanx
  6. Physical therapy for improved extensor pollicis longus strength
A
  1. Release of the A1 pulley of the thumb

RECOMMENDED READINGS

􀀶􀁋􀁄􀁋􀀃􀀤􀀶􀀏􀀃􀀥􀁄􀁈􀀃􀀧􀀶􀀑􀀃􀀰􀁄􀁑􀁄􀁊􀁈􀁐􀁈􀁑􀁗􀀃􀁒􀁉􀀃􀁓􀁈􀁇􀁌􀁄􀁗􀁕􀁌􀁆􀀃􀁗􀁕􀁌􀁊􀁊􀁈􀁕􀀃􀁗􀁋􀁘􀁐􀁅􀀃􀁄􀁑􀁇􀀃􀁗􀁕􀁌􀁊􀁊􀁈􀁕􀀃􀂿􀁑􀁊􀁈􀁕􀀑􀀃􀀭􀀃􀀤􀁐􀀃􀀤􀁆􀁄􀁇􀀃􀀲􀁕􀁗􀁋􀁒􀁓􀀃􀀶􀁘􀁕􀁊􀀑􀀃Marek DJ, Fitoussi F, Bohn DC, Van Heest AE. Surgical release of the pediatric trigger thumb. J HandSurg Am. 2011 Apr;36(4):647-652.e2. PubMed PMID: 21463727.

19
Q
  1. The posteroanterior radiograph seen in Figure 138 is of a 15-year-old girl who is evaluated for scoliosis. She has a slightly elevated right shoulder, a moderate rib prominence of forward bend test, and normal strength and reflexes in her lower extremities. She is 2 years postmenarchal, The radiograph reveals a 30-degree right thoracic and 25-degree left lumbar scoliosis. What is the most appropriate treatment?
  2. Observation
  3. Obtain a total spine MRI scan
  4. Apical vertebral body stapling
  5. Posterior spinal fusion from T4-L1
  6. Use of a custom thoracolumbar orthosis for 23 hours per day
A
  1. Observation

RECOMMENDED READINGS

Richards BS, Bernstein RM, D’Amato CR, Thompson GH. Standardization of criteria for adolescent idiopathic scoliosis brace studies: SRS Committee on Bracing and Nonoperative Management. Spine (Phila Pa 1976). 2005 Sep 15;30(18):2068-75; discussion 2076-7. Review. PubMed PMID: 16166897.

Negrini S, Minozzi S, Bettany-Saltikov J, Zaina F, Chockalingam N, Grivas TB, Kotwicki T, Maruyama T, Romano M, Vasiliadis ES. Braces for idiopathic scoliosis in adolescents. Spine (Phila Pa 1976). 2010 Jun 1;35(13):1285-93. Review. PubMed PMID: 20461027.

20
Q
  1. Figures 143a through 143d are the radiographs of a 13-year-old girl who sustained a knee injury during a volleyball game. She has been otherwise asymptomatic, denies any previous musculoskeletal injury, and has been playing competitive team sports for several years. Examination of her forearms reveals neutral rotation position with restricted pronation-supination on the dominant right and complete absence of pronation-supination on her left arm. What is the most appropriate intervention?
  2. Early total elbow arthroplasty
  3. Immediate physical therapy and progressive splinting
  4. Resection of the radial heads after skeletal maturity
  5. Immediately avoid sports that require repetitive use or impact loading of the upper limbs.
  6. Rotational osteotomy to position the dominant hand in pronation and the nondominant hand in supination.
A
  1. Resection of the radial heads after skeletal maturity

RECOMMENDED READINGS

Waters PM. The upper limb. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopaedics, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:921-985.

Yamazaki H, Kato H. Open reduction of the radial head with ulnar osteotomy and annular ligament reconstruction for bilateral congenital radial head dislocation: a case with long-term follow-up. J Hand Surg Eur Vol 2007 Feb;32(1):93-7. PubMed PMID: 17129644.

21
Q
  1. A 15-year-old patient sustained the injuries shown in Figures 151a through 151c in a motor vehicle collision and is otherwise medically stable. What is the most appropriate treatment?
  2. A spica cast on the right and hanging-arm cast on the left
  3. A right cephalomedullary femoral nail, right long-leg cast, and left hanging-arm cast
  4. A right cephalomedullary femoral nail, right intramedullary tibial rod, and left hanging-arm cast
  5. Multiple screws across the right femoral neck, right long-leg cast, and left humeral intramedullary rod
  6. Multiple screws across the right femoral neck, right intramedullary tibial rod, and left humeral intramedullary rod
A
  1. Multiple screws across the right femoral neck, right intramedullary tibial rod, and left humeral intramedullary rod

RECOMMENDED READINGS

American Academy of Pediatrics Section on Orthopaedics; American Academy of Pediatrics Committeeon Pediatric Emergency Medicine; American Academy of Pediatrics Section on Critical Care; American Academy of Pediatrics Section on Surgery; American Academy of Pediatrics Section on Transport Medicine; American Academy of Pediatrics Committee on Pediatric Emergency Medicine; Pediatric

Orthopaedic Society of North America, Krug SE, Tuggle DW. Management of pediatric trauma. Pediatrics. 2008 Apr;121(4):849-54. Review. PubMed PMID: 18381551.

Boardman MJ, Herman MJ, Buck B, Pizzutillo PD. Hip fractures in children. J Am Acad Orthop Surg. 2009 Mar;17(3):162-73. Review. PubMed PMID: 19264709.

22
Q
  1. A 10-year-old gymnast fell from the parallel bars and sustained an elbow dislocation. It is appropriately reduced in the emergency department acutely. What is the most appropriate treatment option?
  2. Splinting for 10 days, then begin protected range of motion
  3. Immediate range of motion and return to activities as tolerated
  4. Long-arm cast for 4 weeks, then begin protected range of motion
  5. Long-arm cast for 6 weeks, then splint for an additional 2 to 3 weeks
  6. Surgical repair of the medial collateral ligament and long-arm cast for 4 weeks
A
  1. Splinting for 10 days, then begin protected range of motion

RECOMMENDED READINGS

Andrews JR, Wilk KE, Groh G. Elbow rehabilitation. In: Brotzman SB, ed. Clinical Orthopaedic Rehabilitation. Philadelphia, PA: Mosby-Yearbook; 1996:67-71.

Harrelson GL, Leaver-Dunn D. Elbow rehabilitation. In: Andrews JR, Harrelson GL, Wilk KE, eds. Physical Rehabilitation of the Injured Athlete. 2nd ed. Philadelphia, PA: WB Saunders; 1998:554-588.

Protzman RR. Dislocation of the elbow joint. J Bone Joint Surg Am. 1978 Jun;60(4):539-41. PubMed PMID: 670278.

23
Q
  1. Figure 168a is the initial radiograph and Figure 168b is the radiograph taken after a reduction was performed on a 15-year-old girl who fell from a horse. She has had persistant pain and swelling in her left shoulder since presentation. She has full motor function and sensation in her left arm and is 1.5 years postmenarchal. The most appropriate next treatment step is
  2. immobilization in a hanging-arm cast.
  3. fracture immobilization with a figure-of-8 brace􀀃 􀀕􀀑􀀃􀀃􀀃􀀃􀁉􀁕􀁄􀁆􀁗􀁘􀁕􀁈􀀃􀁌􀁐􀁐􀁒􀁅􀁌􀁏􀁌􀁝􀁄􀁗􀁌􀁒􀁑􀀃􀁚􀁌􀁗􀁋􀀃􀁄􀀃􀂿􀁊􀁘􀁕􀁈􀀐􀁒􀁉􀀐􀀛􀀃􀁅􀁕􀁄􀁆􀁈􀀑
  4. fracture fixation with an antegrade locked intramedullary nail􀀃 􀀖􀀑􀀃􀀃􀀃􀀃􀁉􀁕􀁄􀁆􀁗􀁘􀁕􀁈􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀃􀁚􀁌􀁗􀁋􀀃􀁄􀁑􀀃􀁄􀁑􀁗􀁈􀁊􀁕􀁄􀁇􀁈􀀃􀁏􀁒􀁆􀁎􀁈􀁇􀀃􀁌􀁑􀁗􀁕􀁄􀁐􀁈􀁇􀁘􀁏􀁏􀁄􀁕􀁜􀀃􀁑􀁄􀁌􀁏􀀑
  5. open reduction and internal fixation with a blade plate􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀁒􀁓􀁈􀁑􀀃􀁕􀁈􀁇􀁘􀁆􀁗􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀁌􀁑􀁗􀁈􀁕􀁑􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑􀀃􀁚􀁌􀁗􀁋􀀃􀁄􀀃􀁅􀁏􀁄􀁇􀁈􀀃􀁓􀁏􀁄􀁗􀁈􀀑
  6. closed reduction and percutaneous pinning.
A
  1. closed reduction and percutaneous pinning.

RECOMMENDED READINGS

Dobbs MB, Luhmann SL, Gordon JE, Strecker WB, Schoenecker PL. Severely displaced proximal humeral epiphyseal fractures. J Pediatr Orthop. 2003 Mar-Apr;23(2):208-15. PubMed PMID: 12604953.

24
Q
  1. An 18-month-old boy has a bowleg deformity. His parents have noticed an increase in the appearance of the deformity since he started walking at 12 months of age. Examination reveals full range of motion of his hips and knees with a mild bowleg deformity. He walks with a 10-degree internal foot progression angle and has no lateral knee thrust. What is the most appropriate next treatment step?
  2. Continued observation
  3. Start bilateral antivarus bracing
  4. Recommend guided growth surgery
  5. Recommend bilateral proximal tibial osteotomies
  6. Obtain bilateral knee MRI scans to evaluate for medial physeal bars
A
  1. Continued observation

RECOMMENDED READINGS

Sabharwal S, Zhao C. The hip-knee-ankle angle in children: reference values based on a full-length standing radiograph. J Bone Joint Surg Am. 2009 Oct;91(10):2461-8. PubMed PMID: 19797583.

Davids JR, Blackhurst DW, Allen BL Jr. Clinical evaluation of bowed legs in children. J Pediatr Orthop B. 2000 Oct;9(4):278-84. PubMed PMID: 11143472.

25
Q
  1. Figures 177a and 177b are the radiographs of a 7-year-old boy with spastic cerebral palsy. He has quadriparetic invovlement and is unable to ambulate. He has very limited abduction, 30 degrees of flexion contractures, and pain on abduction. Bilateral varus osteotomies are scheduled with acetabular procedures to improve stability. Which type of acetabular osteotomy should be performed?
  2. Dega iliac
  3. Salter iliac
  4. Pemberton iliac
  5. Steele triple
  6. Ganz or Bernese periacetabular
A
  1. Dega iliac

RECOMMENDED READINGS

Karlen JW, Skaggs DL, Ramachandran M, Kay RM. The Dega osteotomy: a versatile osteotomy in the treatment of developmental and neuromuscular hip pathology. J Pediatr Orthop. 2009 Oct- Nov;29(7):676-82. PubMed PMID: 20104144.

Chung CY, Choi IH, Cho TJ, Yoo WJ, Lee SH, Park MS. Morphometric changes in the acetabulum after Dega osteotomy in patients with cerebral palsy. J Bone Joint Surg Br. 2008 Jan;90(1):88-91. PubMed PMID: 18160506.

26
Q
  1. A child sustained the injury shown in Figure 182 1 month ago. The parents did not follow up with orthopaedic care. What is the most likely reason for parents to not follow through?
  2. Concern about cost
  3. Instructions were too difficult to follow
  4. The parents do not understand the plan.
  5. The parents do not agree with the physician’s treatment plan.
  6. Recommendations conflict with the parents’ personal beliefs􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀀵􀁈􀁆􀁒􀁐􀁐􀁈􀁑􀁇􀁄􀁗􀁌􀁒􀁑􀁖􀀃􀁆􀁒􀁑􀃀􀁌􀁆􀁗􀀃􀁚􀁌􀁗􀁋􀀃􀁗􀁋􀁈􀀃􀁓􀁄􀁕􀁈􀁑􀁗􀁖􀂶􀀃􀁓􀁈􀁕􀁖􀁒􀁑􀁄􀁏􀀃􀁅􀁈􀁏􀁌􀁈􀁉􀁖
A
  1. The parents do not agree with the physician’s treatment plan.
27
Q
  1. The radiographs in Figures 187a through 187c were obtained 10 months after closed reduction and percutaneous pin fixation of a minimally displaced(Jacobs type 1) lateral condyle fracture of the distal hmerus in an otherwise healthy 4-year-old girl. She has regained full elbow and forearm range of motion and has resumed all preinjury activities without pain or swelling at the elbow. What information can be given to the parents about teh current radiographic findings?
  2. A spike of bone at the tip of the lateral condyle is frequently seen, is attributed to periosteal displacement from the injury, and should be functionally insignificant
  3. An osteochondroma at the lateral condyle has resulted from displacement of a piece of the physeal plate that occurred at the instant of injury.
  4. The irregularity at the lateral condyle is sometimes known as a “Pelkan spur,” and implies an underlying vitamin C deficiency
  5. The irregularity may have a significant cartilaginous componenet with teh capitellar dmange, and an MRI arthrogram is indicated.
  6. The minimal cubitus varus is an infrequent sequela, but will almost always remodel and develop into a normal carrying angle.
A
  1. A spike of bone at the tip of the lateral condyle is frequently seen, is attributed to periosteal displacement from the injury, and should be functionally insignificant

RECOMMENDED READINGS

Skak SV, Olsen SD, Smaabrekke A. Deformity after fracture of the lateral humeral condyle in children. J Pediatr Orthop B 2001 Apr;10(2):142-52. PubMed PMID: 11360781.

Beaty JH, Kasser JR. The elbow: physeal fractures, apophyseal injuries of the distal humerus, osteonecrosis of the trochlea, and T-condylar fractures. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkins’ Fractures in Children, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:591-660.

28
Q
  1. A 5-year-old boy sustained a vertical shear fracture of the pelvis, such that his left hemipelvis is displaced upward 2 cm. A CT scan reveals widening of the pubic symphysis, mild external rotation of the left hemipelvis, and a small avulsion fracture of the left sacrum. He has no abdominal or urologic injury. What is the best next treatment step?
  2. Ambulation nonweight-bearing on the left for 6 weeks
  3. Closed reduction with a spica cast for 2 months
  4. Cosed reduction witha posterior sacroiliac screw fixation􀀃 􀀖􀀑􀀃􀀃􀀃􀀃􀀦􀁏􀁒􀁖􀁈􀁇􀀃􀁕􀁈􀁇􀁘􀁆􀁗􀁌􀁒􀁑􀀃􀁚􀁌􀁗􀁋􀀃􀁄􀀃􀁓􀁒􀁖􀁗􀁈􀁕􀁌􀁒􀁕􀀃􀁖􀁄􀁆􀁕􀁒􀁌􀁏􀁌􀁄􀁆􀀃􀁖􀁆􀁕􀁈􀁚􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑
  5. Closed reduction with application of an anterior external fixator
  6. Closed reduction with an anterior external fixator and posterior sacroliliac screw fixation. 􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀀦􀁏􀁒􀁖􀁈􀁇􀀃􀁕􀁈􀁇􀁘􀁆􀁗􀁌􀁒􀁑􀀃􀁚􀁌􀁗􀁋􀀃􀁄􀁓􀁓􀁏􀁌􀁆􀁄􀁗􀁌􀁒􀁑􀀃􀁒􀁉􀀃􀁄􀁑􀀃􀁄􀁑􀁗􀁈􀁕􀁌􀁒􀁕􀀃􀁈􀁛􀁗􀁈􀁕􀁑􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀀦􀁏􀁒􀁖􀁈􀁇􀀃􀁕􀁈􀁇􀁘􀁆􀁗􀁌􀁒􀁑􀀃􀁚􀁌􀁗􀁋􀀃􀁄􀁑􀀃􀁄􀁑􀁗􀁈􀁕􀁌􀁒􀁕􀀃􀁈􀁛􀁗􀁈􀁕􀁑􀁄􀁏􀀃􀂿􀁛􀁄􀁗􀁒􀁕􀀃􀁄􀁑􀁇􀀃􀁓􀁒􀁖􀁗􀁈􀁕􀁌􀁒􀁕􀀃􀁖􀁄􀁆􀁕􀁒􀁌􀁏􀁌􀁄􀁆􀀃􀁖􀁆􀁕􀁈􀁚􀀃􀂿􀁛􀁄􀁗􀁌􀁒􀁑
A

RECOMMENDED READINGS

Sink AL, Blaiser D. Fractures of the pelvis. In: Beaty JH, Kasser JR, eds. Rockwood & Wilkins’ Fractures in Children. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:743-768.

Banerjee S, Barry MJ, Paterson JM. Paediatric pelvic fractures: 10 years experience in a trauma centre. Injury. 2009 Apr;40(4):410-3. Epub 2009 Feb 20. PubMed PMID: 19232592.

29
Q
  1. An otherwise healthy adolescent girl was treated for left slipped capital femoral epiphysis. The contralateral hip had not slipped, but was stabilized prophylactically with a single cannulated screw. The implants were removed after 1 year. The pelvic radiographs (Figures 215a and 215b) and the MRI scans of the hip that had not originally slipped (Figures 215c through 215e) were obtained 10 months after screw removal (22 months after the original fixation). Which findings are shwon in these studies?
  2. Both hips are normal and no further assessments will be needed.
  3. A neoplasm has developed in the femoral head on the unslipped side.
  4. There is now increased risk for a slip in the hip and a new screw should be inserted.
  5. Osteonecrosis has developed in the unslipped hip adjacent to the previous screw position.
  6. The crew track in the bone has not filled spontaneously as expected and grafting should be considered.
A
  1. Osteonecrosis has developed in the unslipped hip adjacent to the previous screw position.

RECOMMENDED READINGS

Lubicky JP. Chondrolysis and avascular necrosis: complications of slipped capital femoral epiphysis. J Pediatr Orthop B 1996;5(3):162-7.PubMed PMID: 8866280.

30
Q
  1. Figures 224a and 224b are the radiographs of a skeletally mature child with cerebral palsy and worsening diffculty with sitting who meets Gross Motor Function Classification System level IV criteria. Surgery is planned. What is the most appropriate treatment option?
  2. Anterior fusion from T12 to L5
  3. Anterior release from L1 to L4 and posterior fusion from T2 to L5
  4. Anterior release from L1 to L4 and posterior fusion from T12 to L5
  5. Posterior fusion from T2 to the sacrum
  6. Posterior fusion alone from T2 to L5 with Aponte osteotomies from L1 to L4
A
  1. Posterior fusion from T2 to the sacrum

RECOMMENDED READINGS

Imrie MN, Yaszay B. Management of spinal deformity in cerebral palsy. Orthop Clin North Am. 2010 Oct;41(4):531-47. Review. PubMed PMID: 20868883.

McCarthy JJ, D’Andrea LP, Betz RR, Clements DH. Scoliosis in the child with cerebral palsy. J Am Acad Orthop Surg. 2006 Jun;14(6):367-75. Review. PubMed PMID: 16757676.

31
Q

239.

A 4-year-old boy sustained the fracture seen in Figures 239a and 239b. Examination reveals normal sensation to light touch throughout his left hand. Specific mtor testing shows he is able to exend his ipsilateral thumb fully and cross his fingers, but is unable tactively flex the distal interphalangeal joint of his ipsilateral index finger. What is the most likely etiology o fhis motor deficit?

  1. Neuropraxia of the radial nerve
  2. Neuropraxia of the anterior intraosseous nerve
  3. Development of compartment syndrome
  4. Laceration of the flexor digitorum profundus of the index finger􀀃 􀀗􀀑􀀃􀀃􀀃􀀃􀀯􀁄􀁆􀁈􀁕􀁄􀁗􀁌􀁒􀁑􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀃀􀁈􀁛􀁒􀁕􀀃􀁇􀁌􀁊􀁌􀁗􀁒􀁕􀁘􀁐􀀃􀁓􀁕􀁒􀁉􀁘􀁑􀁇􀁘􀁖􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁌􀁑􀁇􀁈􀁛􀀃􀂿􀁑􀁊􀁈􀁕
  5. Laceration of the flexor digitorum superficialis of the index finger 􀀘􀀑􀀃􀀃􀀃􀀃􀀯􀁄􀁆􀁈􀁕􀁄􀁗􀁌􀁒􀁑􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀃀􀁈􀁛􀁒􀁕􀀃􀁇􀁌􀁊􀁌􀁗􀁒􀁕􀁘􀁐􀀃􀁖􀁘􀁓􀁈􀁕􀂿􀁆􀁌􀁄􀁏􀁌􀁖􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀀃􀁌􀁑􀁇􀁈􀁛􀀃􀂿􀁑􀁊􀁈􀁕
A
  1. Neuropraxia of the anterior intraosseous nerve

RECOMMENDED READINGS

Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop. 2010 Apr-May;30(3):253-63. PubMed PMID: 20357592.

Bashyal RK, Chu JY, Schoenecker PL, Dobbs MB, Luhmann SJ, Gordon JE. Complications after pinning of supracondylar distal humerus fractures. J Pediatr Orthop. 2009 Oct-Nov;29(7):704-8. PubMed PMID: 20104149.

32
Q
  1. Figures 251a and 251b are the radiographs of a 2-year-old boy who is otherwise healthy. Clinical photographs of the prosthesis and the child are shown in Figures 251c through 251e. What recommendations should be given to the parents?
  2. Surgical hip reduction and acetabuloplasty should be performed now, anticipating staged femoral lengthening.
  3. Physical therapy to regain ankel dorisflexion shoudl begin to maximize the success of prosthetic fitting􀀃 􀀕􀀑􀀃􀀃􀀃􀀃􀀳􀁋􀁜􀁖􀁌􀁆􀁄􀁏􀀃􀁗􀁋􀁈􀁕􀁄􀁓􀁜􀀃􀁗􀁒􀀃􀁕􀁈􀁊􀁄􀁌􀁑􀀃􀁄􀁑􀁎􀁏􀁈􀀃􀁇􀁒􀁕􀁖􀁌􀃀􀁈􀁛􀁌􀁒􀁑􀀃􀁖􀁋􀁒􀁘􀁏􀁇􀀃􀁅􀁈􀁊􀁌􀁑􀀃􀁗􀁒􀀃􀁐􀁄􀁛􀁌􀁐􀁌􀁝􀁈􀀃􀁗􀁋􀁈􀀃􀁖􀁘􀁆􀁆􀁈􀁖􀁖􀀃􀁒􀁉􀀃
  4. Epiphyseodesis of the proximal tibia should be performed now to minimize the functional discrepancy between the tibia and fibula
  5. Ankle equinus in the current prosthesis is acceptable because this may facilitate substitution for knee function in an eventual Van Ness rotationplasty.
  6. Syme’s amputation and fitting with an above-knee prostehtic design is recommended􀀃 􀀘􀀑􀀃􀀃􀀃􀀃􀀶􀁜􀁐􀁈􀂶􀁖􀀃􀁄􀁐􀁓􀁘􀁗􀁄􀁗􀁌􀁒􀁑􀀃􀁄􀁑􀁇􀀃􀂿􀁗􀁗􀁌􀁑􀁊􀀃􀁚􀁌􀁗􀁋􀀃􀁄􀁑􀀃􀁄􀁅􀁒􀁙􀁈􀀐􀁎􀁑􀁈􀁈􀀃􀁓􀁕􀁒􀁖􀁗􀁋􀁈􀁗􀁌􀁆􀀃􀁇􀁈􀁖􀁌􀁊􀁑􀀃􀁌􀁖􀀃􀁕􀁈􀁆􀁒􀁐􀁐􀁈􀁑􀁇􀁈􀁇􀀑
A
  1. Ankle equinus in the current prosthesis is acceptable because this may facilitate substitution for knee function in an eventual Van Ness rotationplasty.

RECOMMENDED READINGS

􀀰􀁒􀁕􀁌􀁖􀁜􀀃􀀵􀀏􀀃􀀦􀁒􀁘􀁏􀁗􀁈􀁕􀀐􀀲􀂶􀀥􀁈􀁕􀁕􀁜􀀃􀀦􀀑􀀃􀀷􀁋􀁈􀀃􀁆􀁋􀁌􀁏􀁇􀀃􀁚􀁌􀁗􀁋􀀃􀁄􀀃􀁏􀁌􀁐􀁅􀀃􀁇􀁈􀂿􀁆􀁌􀁈􀁑􀁆􀁜􀀑􀀃􀀬􀁑􀀝􀀃􀀰􀁒􀁕􀁕􀁌􀁖􀁖􀁜􀀃􀀵􀀷􀀏􀀃MOrrissy RT, Giavendoni BJ, Coulter-O/Berry C. The child with a limb deficiency. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopaedics. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006:1329-1381.

􀀤􀁏􀁐􀁄􀁑􀀃􀀥􀀤􀀏􀀃􀀮􀁕􀁄􀁍􀁅􀁌􀁆􀁋􀀃􀀭􀀬􀀏􀀃􀀫􀁘􀁅􀁅􀁄􀁕􀁇􀀃􀀶􀀑􀀃􀀳􀁕􀁒􀁛􀁌􀁐􀁄􀁏􀀃􀁉􀁈􀁐􀁒􀁕􀁄􀁏􀀃􀁉􀁒􀁆􀁄􀁏􀀃􀁇􀁈􀂿􀁆􀁌􀁈􀁑􀁆􀁜􀀝􀀃􀁕􀁈􀁖􀁘􀁏􀁗􀁖􀀃􀁒􀁉􀀃􀁕􀁒􀁗􀁄􀁗􀁌􀁒􀁑􀁓􀁏􀁄􀁖􀁗􀁜􀀃􀁄􀁑􀁇􀀃􀀶􀁜􀁐􀁈􀀃

33
Q
  1. Figure 262 is the radiograph of a 15-year-old with cerebral palsy who meets Gross Motor Function Classification System level V criteria. What is the most appropriate treatment?
  2. Bilateral open reduction and pelvic osteotomies
  3. Hip abduction bracing with administration of onabotulinum toxin A
  4. Hip abduction bracing without administration of onabotulinum toxin A
  5. No treatment or radiographic follow up is needed unless the patient is in pain
  6. No treatment at this point, but close radiographic follow up is needed to monitor for progression
A
  1. No treatment or radiographic follow up is needed unless the patient is in pain

RECOMMENDED READINGS

Bischof FM, Chirwa TF. Daily care activities and hip pain in non-ambulatory children and young adults with cerebral palsy. J Pediatr Rehabil Med. 2011;4(3):219-23. PubMed PMID: 22207098.

Gamble JG, Rinsky LA, Bleck EE. Established hip dislocations in children with cerebral palsy. Clin Orthop Relat Res. 1990 Apr;(253):90-9. Review. PubMed PMID: 2180606.

34
Q
A

5. OITE (41 decks)

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