Pediatrics

Question 1

Does the literature support leg length discrepancies after transphyseal ACL reconstruction in skeletally immature patients?

Answer 1

Several studies have not show any leg-length discrepancy. If performing transphyseal fixation should avoid oblique tunnel position, high-speed tunnel reaming, and increasing tunnel diameter (>8mm).

Question 2

What is characteristic of a patient with diplegia cerebral palsy?

Answer 2

Right and left side affected equally. Minimal spasticity in upper limbs. Lower limb spasticity predominates.

Question 3

What are thought to be causes of cerebral palsy?

Answer 3

perinatal TORCH infections, prematurity (most common), anoxic injuries, head injuries, and meningitis.

Question 4

What is the most common neurapraxia associated with supracondylar humerus fractures?

Answer 4

AIN (Branch of median nerve)

Unable to flex IP joint of thumb and DIP joint of index finger.

A-OK sign

Question 5

What is the second most common neurapraxia associated with supracondylar humerus fractures?

Answer 5

Radial nerve.

Can’t exten wrist, MCP joint, or IP joint fo thumb.

Rembmer PIP and DIP can still be extended via intrinsic function of ulnar nerve.

Question 6

What neurapraxia is associated with flexion type supracondylar fractures?

Answer 6

ulnar nerve.

Intrinsic function. cross fingers over.

Question 7

What are the ossification centers of the elbow and when do they first ossify?

Answer 7

Capitellum 1

Radial Head 4

Medial Epicondyle 6

Trochlea 8

Olecranon 10

Lateral epicondyle 12

CRMTOL

Question 8

Which ossification center is the last to fuse in the elbow?

Answer 8

Medial Epicondyle at 17.

Capitellum 12

Radial Head 15

Medial Epicondyle 17

Trochlea 12

Olecranon 15

Lateral Epicondyle 12

Question 9

Which supracondylar humerus fracture type is most likely to require an open reduction?

Answer 9

Flexion type.

Question 10

What is considered poorly perfused in regards to capillary refill?

Answer 10

> 2 seconds.

Question 11

Where should the anterior humeral line fall in children 5 or older? Where should it fall in children less than 5?

Answer 11

5 or older is should intersect the middle third of the capitellum.

In children less than 5 it should touch the capitellum.

Question 12

What is Baumanns angle?

Answer 12

Line parallel to the longitudinal axis of the humeral shaft and a line along the lateral condylar physis as viewed on the AP image.

Normal is 70-75 degrees.

Deviation of more than 5-10 degrees indicates coronal plane deformity.

Question 13

What is a an indication for pinning SCH fractures other than extension and flexion types?

Answer 13

Medial column collapse.

Question 14

What is a concerning risk of floating elbow in pediatric patients?

Answer 14

Compartment syndrome.

Question 15

What is the brachialis sign in regards to SCH fractures in pediatric patients?

Answer 15

ecchymosis, dimpling/puckering atecubital fossa, and or palpable subcutaneous bone.

Indicates proximal fragment buttonholed thorugh brachialis.

Question 16

How should pins be inserted for flexion type SCH fractures?

Answer 16

Pins should be inserted in extension.

Question 17

What difference is there in stability between three lateral pins and crossed pins?

Answer 17

No significant difference but corssed pins are strongest to torsional stress.

Question 18

In what cases are three pins required over two for SCH fractures?

Answer 18

Comminution and Gartland type III and IV.

Question 19

If having to place a medial pin for SCH fracture how can you reduce ulnar nerve injury?

Answer 19

Place medial pin with elbow in extension.

Use small medial incision.

Question 20

What is the most common complication associated with SCH fractures?

Answer 20

Pin Migration 2%.

Question 21

What causes cubitus varus in pediatric patients?

What functional limitation does it cause?

Answer 21

Fracture varus malunion.

It is not caused by growth disturbance.

Usually only a cosmetic issue and causes little functional limitation.

Question 22

What is a complication of immobilizing a SCH in greater than 90 degrees of elbow flexion?

Answer 22

Increase in deep volar forearm compartment pressures. Leading to Volkmann ischemic contractures.

Question 23

What should be done about post-operative stiffness after CRPP of SCH fx?

Answer 23

allow patient to work on motion on their own.

Literature doesn’t support physical therapy.

Almost always resolved by 6 months.

Question 24

Olecranon avulsion fracture is highly suspicious of which condition?

Answer 24

Osteogensis imperfecta.

Question 25

What is the Milch classification of pediatric elbow fractures?

Answer 25

Type I fracture line is lateral to trochlear groove. Less common. Elbow is stable.

Type II fracture line is medial to trochlear grove. More common. More unstable.

Question 26

What does the lateral ecchymosis imply in a lateral condyle fracture of the distal humerus?

Answer 26

tear in the aponeurosis of the brachioradialis and signals an ustable fracture.

Question 27

What view best shows fracture displacement of pediatric lateral condyle fracture?

Answer 27

Internal oblique view.

This is because fracture is posterolateral.

Question 28

What is an indication for open reduction of lateral condyle fracture of the distal humerus?

Answer 28

Articular incongruity.

Greater than 4mm of displacement.

Question 29

Where is the blood supply located for the lateral condyle?

Answer 29

Posteriorly.

This is why an anterolateral approach is used.

Question 30

What is the most common complication of pediatric lateral condyle fractures?

Answer 30

Stiffness.

Question 31

What is a complication of not aligning the periosteum after fixation of a lateral condyle fracture?

Answer 31

Lateral overgrowth or spurring.

Question 32

What is the most common cause of Cubitus valgus after lateral condyle fracture?

Answer 32

More commonly due to nonunion but it can be due to lateral physeal arrest.

Slow progressive ulnar nerve palsy caused by stretch.

Incidence is 10%. Less common than cubitus varus

Question 33

What is treatment for cubitus valgus?

Answer 33

Supracondylar osteotomy after skeletal maturity and ulnar nerve transposition.

Question 34

What is more common after cubitus varus or cubitus valgus?

Answer 34

cubitus varus.

Question 35

Unsuccesful outcomes with radial head fractures in pediatric patients has been correlated with what age?

Answer 35

Age > 10 yrs.

Question 36

What complications must you have a high suspicion for after pediatric radial head fracutres?

Answer 36

forearm compartment syndromes.

Question 37

Will you see a fat pad sign with radial neck fractures?

Answer 37

Not always as a portion of the radial neck is extra-articular so fat pad signs and effusion may be absent.

Question 38

What is the criteria for treating a radial neck fracture with immobilization alone.

Answer 38

<30 degrees of angulation

<3mm translation

7 days of immobilization followed by early ROM.

Question 39

When is open reduction of a radial neck fractute indicated?

Answer 39

> 45 degrees of persistent angulation after attempt at closed percutaneous reduction.

Open reductions have been associated with greater loss of motion, increased osteonecrosis, and synostosis. Controversial as it is not known if this is due to worse fractures undergoing open reduction.

Question 40

What should you do to protect the radial nerve during a Kocher approach?

Answer 40

Pronate.

Question 41

What after 20-40% of radial head fractures but usually does not affect function?

Answer 41

Radial head overgrowth.

Question 42

When should a rigid nail be considered in pediatric femur fractures?

Answer 42

Age >= 11 years

Weight > 49 kg

Very proximal or distal fractures

Unstable comminuted or long oblique fracture patterns.

Question 43

What is the starting point for a lateral trochanteric entry nail?

Answer 43

At the tip of the greater trochanter.

Angle should be 12 degrees offset to the anatomic axis of the femur.

Piriformis fossa should be avoided to avoid the arterial blood supply.

Question 44

At what age can acetabular index be measured on an AP radiograph?

What is a normal measurement?

Answer 44

2 years

25 degrees or less.

Question 45

When can you attempt closed reduction of tibial eminence fractures?

Answer 45

Less than 5mm otherwise ORIF vs AAIF.

Question 46

What is the pathoanatomy of a nursemaids elbow?

Answer 46

subluxation of annular ligament which then becomes interposed between radial head and capitellum.

Rare after 5 years of age.

Question 47

At what age do pediatric elbow dislocations usually occur?

Answer 47

Older children 10-15 years.

Question 48

What is the most common associated fracture with a pediatric elbow dislocation?

Answer 48

avulsion of the medial epicondyle.

Question 49

Most common neuropraxia seen with pediatric elbow dislocations?

Answer 49

Ulnar Nerve.

Question 50

What should be part of your differential when seeing pediatic elbow dislocations, especially radiocapitellar joint?

Answer 50

Congenital dislocations.

Question 51

What is the anatomic classification of pediatric elbow dislocations?

What is it based on?

Which one is most common?

Answer 51

Posterolateral, posteromedial, anterior (rare), and divergent.

position of the proximal radio-ulnar joint in relation to the distal humerus.

posterolateral.

Question 52

How long should a stable pediatric elbow dislocation be immobilized after reduction?

Answer 52

minimize to 1-2 weeks.

Question 53

What is the most important part to visualize on post reduction radiographs of a pediatric elbow dislocation?

Answer 53

medial epicondyle to ensure it is not within the joint.

Question 54

What is the most common complication following treatment of pediatric elbow dislocations?

Answer 54

loss of terminal extension.

Most often due to prolonged immobilization.

Question 55

What should you look for in an isolated pediatric radial head dislocation?

Answer 55

Need to look for plastic deformation of the ulna.

Rare to have an isolated radial head dislocation.

Question 56

In what position should a Bado I type fracture be immobilized?

Answer 56

Bado 1 is anterior dislocation of radial head.

Axpe anterior ulna.

110 degrees of flexion with full supination to tighten interosseous membrane and relax biceps tendon.

Question 57

In what position should a Bado II type fracture be immobilized?

Answer 57

Bado II is posterior radial head dislocation.

Apex posterior ulna.

Immobilize in full extension.

Question 58

How should a Bado III type fracture be immobilized?

Answer 58

Lateral radial head dislocation.

apex lateral proximal ulna.

Immobilize in full extension and valgus mold.

Question 59

Most common neurapraxia associated with Moteggia fractures?

Answer 59

PIN.

10% of acute injuries.

Almost always spontaneously resolves.

Question 60

Most common nerve injury with pediatric both bone forearm fractures?

How often does it occur?

Answer 60

Median nerve

1% of fractures.

Question 61

Acceptable reduction parameters for pediatric both bone forearm fractures?

Answer 61

Question 62

Is there a difference in outcomes of distal both bone forearm fractures treated in short arm casts vs long arm casts?

Answer 62

No increase in loss of reduction with short arm casts.

Question 63

What difference in in union rates, radial bow, and rotations is there between flexible IMN and ORIF of pediatric both bone forearm fractures?

Answer 63

None.

Question 64

What is the refracture rate following treatment of both bone forearm fractures?

Answer 64

5-10%

Associated with greenstick patterns and plate removal.

Question 65

How much does motion improve after resection of synostosis following pediatric both bone forearm fractures?

Answer 65

Rarely leads to any improvement in motion.

Question 66

When do you consider operative intervention for pediatric proximal humerus fractures?

Answer 66

Open fx.

Neurologic injury.

fractures displaced more than 50% in children greater than 11 years old.

Question 67

What is the most common fracture in children under 16 years old?

Answer 67

Distal radius fracture.

Question 68

What is the growth rate of the distal radius physis?

Answer 68

5.25mm/yr.

40% growth of upper extremity.

75% growth of the radius.

Question 69

What other injuries can be seen with pediatric distal radius fractures and must be ruled out?

Answer 69

DRUJ

Ulnar styloid

Elbow injuries

Scapholunate interval

Question 70

What directional deformity is least likely to remodel?

Answer 70

Rotational deformities.

Question 71

What angulation is acceptable in a pediatric distal radius fracture for ages < 9 yrs?

> 9 yrs?

Answer 71

30 degrees

20 degrees

Question 72

How much bayonette apposition is acceptable in pediatric both bone forearm and distal radius/ulna fractures?

Answer 72

<1cm.

Question 73

Loss of reduction for a distal radius fracture treated with a cast is associated with?

Answer 73

poor cast index.

sagital/coronal widths need to .8 or less.

Question 74

Indications for CRPP of pediatric distal radius/ulna fractures?

Answer 74

Unstable patterns

Unable to reduce initially

Loss of reduction at follow-up

SH1 or 2 fractures in setting of neurovascular compromise

Compartment syndrome

Question 75

Risk factors for thermal injuries with casting?

Answer 75

Water > 74F

More than 8 layers

Placing cast while setting on pillow

Wrapping fiberglass over plaster.

Question 76

What apophyseal avulsion is seen with hamstrings or adductors?

Answer 76

ischial avulsion.

Question 77

What eccentric muscle contraction can lead to a AIIS avulsion?

Answer 77

Rectus femoris.

Question 78

What apophyseal avulsion involves the sartorius?

Answer 78

ASIS

Question 79

What muscles are involved in pubic symphysis and iliac crest avuslions?

Answer 79

Abdominal muscles

Question 80

What muscles is involved in a lesser trochanter apophyseal avulsion?

Answer 80

iliopsoas.

Question 81

Which pelvic ring injury is most common in pediatric patients?

Answer 81

lateral compression.

Question 82

Do pediatric pelvic ring injuries have a higher or lower rate of hemorrhage when compared to adult pediatric ring injuries?

Answer 82

lower.

Question 83

What injuries are associated with pediatric pelvic ring fractures?

At what rate do these occur?

Answer 83

CNS and abdominal visceral injuries.

> 50%

Question 84

How are pediatric pelvic ring fractures with instability and < 2cm of displacement treated?

Answer 84

Bed rest followed by progressive mobilization.

Question 85

How are apophyseal avulsions of the pelvis and proximal femur treated when they have 2cm of displacement.

Answer 85

Non-operative.

Need >2-3 cm for operative treatment.

PWB for 2-4 weeks

Stretching and strengthening at 4-8 weeks

Return to sport at 8 weeks if asymptomatic

Question 86

Rate of premature closure of triradiate cartilage with acetabular fractures?

Answer 86

<5%

Higher risk in children < 10yrs old at time of injury.

Question 87

What is the most common orthopaedic reason for hospitalization in pediatric patients?

Answer 87

Femur fractures.

Question 88

Is early surgical intervention recommended in children with closed head injureis and femur fractures?

Answer 88

Yes, children to not have the increased pulmonary complications that are seen in Adults.

Decreased length of hospital stays.

Question 89

What femur fracture patterns and up to what age can be treated in a pavlik harness?

Answer 89

Any pattern

< 6 months of age

Question 90

What children can undergo spica casting for femoral fractures?

What are relative contraindications?

Answer 90

Up to 5 years of age.

polytrauma, open fractures, and shortening >2-3cm

Question 91

Indications for flexible intramedullary nailing for femur fractures?

Answer 91

5-11 years.

Less than 49kg

Length stable.

Question 92

How would you treat a distal femoral buckle fracture in a 5 year old?

Answer 92

Long leg cast. Spica not needed for distal buckle fractures.

Can also treat non-displaced SH 1&2 distal femur fractures in LLC.

Question 93

What is the most common complication seen with flexible intramedullary nailing of femur fractures?

Answer 93

pain near knee at insertion site of nails.

Question 94

What secondary deformities of the proximal femur can occur after IMN via greater trochanteric insertions?

Answer 94

Narrowing of the femoral neck

Premature fusion of greater trochanter apophysis

Coxa valga

Hip subluxation

Question 95

What is the most common complication in patients <10 years old with femur fractures?

Answer 95

Overgrowth leading to leg length discrepancy.

.7-2 cm that typically occurs within 2 years of injury.

This is why shortening in treatment is acceptable

Question 96

How is a Thurston-Holland fragment created?

Answer 96

Salter-Harris II fracture

Physis fails on tension side.

Metphysis fails on compression side

Question 97

What is the rate of physeal arrest after distal femoral physeal fracture?

Answer 97

30-50%

Increased incidence with increased fracture displacement and SH type.

SH1 36%

SH2 58%

SH3 49%

SH4 64%

Question 98

What is the first epiphysis in the body to ossify?

Answer 98

Distal femoral.

Question 99

Growth rates of lower extremity physes?

Answer 99

Proximal femur 3mm

Distal femur 9mm

Proximal tibia 6mm

Distal tibia 5mm

Question 100

Most common cause of irreducible SH1 and SH2 fractures of the distal femur?

Answer 100

interposed periosteum on the tension side of the fracture.

Question 101

Indiction for physeal bridge excision that occurs after distal femur fracture?

Answer 101

physeal bar of <50%

2 years or more and 2.5cm of growth remaining.

Question 102

What is more common in pediatric patients hip fracture of hip dislocations.

Answer 102

hip dislocations.

80% are traumatic posterior dislocations

Can occur due to low injury sports injuries in children less than 10 years of age

Question 103

Study of choice for post hip reduction imaging of a child?

Answer 103

MRI

Better to evaluate soft tissues and cartilaginous hip

Less radiation

Question 104

When open reducing a pediatric hip dislocation which approach should be used?

Answer 104

Should be perfromed in the direction of the dislocation

So either kocher-langenbeck or Smith-Peterson

Question 105

What is current thoughts on the most common cause of osteonecrosis in pediatric hip dislocations?

Answer 105

Delayed time to reduction of more than 6 hours.

Rates of AVN 3-15%

Decreased incidence in children under age of 5.

Question 106

What does injury to greater trochanteric apophysis lead to?

Overgrowth?

Answer 106

Shortening of GT and coxa valga

Overgrowth leads to coxa vara

Question 107

Describe the Delbet Classification?

Answer 107

Question 108

Treatment for proximal femur fractures in pediatric patients if non-displaced and pt is < 4yrs old?

Answer 108

Closed reduction and spica abduction casting.

Question 109

What is the difference in how displaced intertrochanteric fractures and proximal are treated in pediatric patients less than 4 yrs and older than 4 yrs?

Answer 109

Older than 4 yrs Cannulated screws

Less than 4 yrs smooth or threaded pins/K wires

Question 110

Should you cross the femoral head physis in proximal femur fractures?

Answer 110

Consider stoppin short of physis in 4-6 year olds.

Cross physis when there is little metaphyseal bone and patients are > 12 years old.

Otherwise controversial.

If not crossing physis should place in post-op spica.

Question 111

What is the most common complication of pediatric hip fractures?

Answer 111

AVN

Question 112

What is the 2nd most common complication of proximal femur fractures?

Answer 112

Coxa vara

Defined as a neck-shaft angle <120 degrees

More common if fracture is treated non-operatively

Question 113

Treatment of Coxa Vara that occurs after proximal femoral fractures?

Answer 113

Pts 0-3 with neck-shaft angle >110 degrees will remodel

Mild coxa vara in 6-8 year olds can perfrom surgical arrest of trochanteric apophysis

Subtrochanteric or intertrochanteric valgus osteotomy. For older patients with non-union or severe trendelenburg limp of FAI.

Question 114

What mechanism typically caused a pediatric tibial eminence fracture?

Answer 114

rapid deceleration or hyperextension/rotation of the knee.

Same mechanism that would cause ACL tear in adults.

Question 115

What is the most common reason for failed closed reduction of a tibial eminence fracture?

Answer 115

meniscal tear with entrapment of the naterior horn of the medial meniscus being the most common.

Question 116

Most common complication with tibial eminence fractures?

Answer 116

Loss of motion, especially loss of extension. May be due to impingment due to incomplete reduction.

Arthrofibrosis is most common with surgical reconstruction.

Question 117

What tibial eminence fracture con be treated non-operatively?

What is the recommended protocol?

Answer 117

Type I (less than 3mm displacement and Type II (minimally displaced with intact posterior hinge).

+/- aspiration with injection of lidocaine. closed reduction with extension. Then casting in full extension for 3-4 weeks. Gradual rehab program.

Question 118

How do patellar sleeve fractures usually occur?

In what population do the most commonly occur?

Answer 118

Indirect injury from quadriceps contraction applied to a flexed knee.

Males 5:1. Age 8-12. <1% of pediatric fracrues but >50% of pediatirc patellar fracutres.

Question 119

What are Kocher’s Criteria?

Answer 119

fever >= 38.5 C

Refusal to bear weight on the affected extremity

ESR > 40

WBC > 12k

Question 120

Does tibial tubercle fractures occur by concentric contraction during jumping or eccentric contraction during forced knee flexion?

Answer 120

Trick question, it occurs from both mechanisms.

Question 121

What are the two ossification centers of the tibial tubercle?

Answer 121

proximal tibial physis is the primary ossification center.

tibial tubercle physis is the secondary ossification center.

phsis closes from posterior to anterior and proximal to distal this is why the tubercle physis is at greater risk of injury.

Question 122

What artery has been implicated in compartment syndrome after tibial tubercle fracture?

Answer 122

Recurrent anterior tibial artery.

Question 123

What is different when treating a periosteal sleeve avulsion tibial tubercle fractures as oppossed to a displaced fracture extending through the tubercle?

Answer 123

Need to immobilize the sleeve avulsion for 8-10 weeks as oppossed to 4-6 weeks becuase soft tissue healing vs bone healing.

Question 124

What is the most common complication following surgical repair of a tibial tubercle fracture?

What deformity can occure after a tubercle fracture?

Answer 124

Bursitis from harware irritation.

Recurvatum because anterior arrests while posterior continues to grow.

Uncommon to see leg length discrepancies because of the age at which these occur 12-15 yrs.

Question 125

Describe the predictable closure of the proximal tibia physis.

Answer 125

Sagittal plane- posterior to anterior

Coronal plane-medial to lateral

Axial plane- posteromedial to anterolateral

Question 126

Does the medial collateral ligament insert proximal or distal to the proximal tibial physis?

Answer 126

Distal.

Question 127

What is Cozen’s phenomenon?

Answer 127

tendency of a proximal tibial metaphyseal fracture to develop a late valgus deformity.

Should be casted in extension with a varus mold.

Valgus deformity usually resolves spontaneously

Develops 5-15 months after injury with maximum deformity at 12-18 months.

Incidence as high as 50-90%

Question 128

Treatment for a cozen fracture?

Answer 128

Observe for 12-24 months. Most spontaneously resolve.

Average deformity at its worst 18 degrees.

Average final deformity of 6 degrees.

guided growth or osteotomy rarely indicated for deformities > 15-20 degrees near skeletal maturity.

Usually have a limb length discrepancy on average of 9mm with the affected limb being longer.

Question 129

Acceptable reduction of a pediatric tibia diaphyseal fracture?

Answer 129

<50% of translation

< 1cm of shortening

<5-10 degrees of angulation in the sagittal and coronal planes

Question 130

Tibial shaft fracture with intact fibula will fall into?

Tibial shaft fracture with associated fibula fracture will fall into?

Answer 130

Varus

Valgus and recurvatum

Question 131

What is a tillaux fracture?

Answer 131

Salter-Harris III fracture of the anterolateral distal tibia.

Cased by avulsion of the anterior inferior tibiofibular ligament.

More common in girls.

Seen in kids nearing skeletal maturity. Older than triplane fracture age group.

Question 132

What is the mechanism of injury that leads to a tillaux fracture?

What distinguishes it from a triplane fracture?

Answer 132

Supination-external rotation injury.

Lack of coronal plane fracture in the posterior distal tibial metaphysis.

Question 133

What is the pattern of distal tibial physeal closure?

Answer 133

Central -> anteromedial -> posteromedial -> lateral

Question 134

Non-operative treatment of a Tillaux Fracture

Answer 134

Reduction by dorsiflexing and then internally rotating foot.

Long leg cast (to control rotation) for 3-4 weeks.

Short leg cast or CAM boot 2-4 weeks.

Question 135

What is a type V Saltar-Harris fracture?

Is there a type VI?

Answer 135

Crush injury to the physis. Dificult to identify initially, usally diagnosis made on follow-up.

Yes. Rare. Perichondral ring injury that results from an open injury such as a lawnmower injury or iatrogenic.

Question 136

What amount of physeal widening is acceptable to treat non-operatively?

Answer 136

< 3mm.

Question 137

Which Saltar-Harris ankle fracture has the highest rate of growth distrubance?

Answer 137

SH IV medial malleolus fracture.

Question 138

Risk factors for growth arrest after saltar-harris fractures?

Answer 138

Degree of initial displacement. 15% incresed risk for every 1mm of displacement.

Residual physeal displacement > 3mm.

High-energy injury mechanism.

SHIII and IV fractures

Question 139

When is physeal bar resection indicated after pediatric ankle fractures?

Answer 139

< 20 degrees of angulation with < 50% of physeal involvement and > 2 years of growth remaining.

Question 140

When is an ipsilateral fibular epiphysiodesis indicated after a pediatric ankle fracture?

Answer 140

Bar of > 50% and > 2 years of growth remaining.

Question 141

What deformity can occur after triplane, SH1, and SH2 ankle fracutres?

Answer 141

Rotational deformity.

External foot rotation angle.

Treatment is derotational osteotomy.

Question 142

Which fracture typically happens in younger patients Tillaux or Triplane?

Answer 142

Triplane fractures (average age is 13 years old.)

Question 143

What are the three components of a triplane fracture?

Answer 143

Fracture through epiphysis, physis, and metaphysis.

The orientation can differ depending on the type of triplane fracture. Lateral vs medial.

Lateral: Epiphysis sagittal with metaphyseal coronal

Medial: Epiphysis coronal with metpahyseal sagittal

Question 144

What are the common cutaneous and musculoskeletal manifestations of Neurofribromatosis?

Answer 144

cage au lait spots, axillary freckling, lisch nodules in the eye, scoliosis, long bone bowing, and pseudoarthrosis.

anterolateral tibial bowing.

Question 145

What pediatric patient may be a candidate to undergo a selective dorsal rhizotomy?

Answer 145

4-8 year old with spastic diplegia who is ambulatory and has no evidence of athetosis.

Involves selective resection of the L2-S1 nerve roots that do not show a myographic or clinical response to stimulation.

Question 146

What is athetosis?

Answer 146

slow, involuntary, convoluted, writhing moevements of the fingers, hands, toes, and feet.

Question 147

What is the most common infectious organism in neonates?

Answer 147

Group B Strep

Question 148

True or false children with mycobacteria tuberculosis are more likely to have extrapulmonary involvement?

Answer 148

True

Question 149

Risk factor for development of a DVT in children with osteomyelitis?

Answer 149

CRP>6

surgical treatment

age >8 years old

MRSA

infrequent complication in children.

Question 150

Position of the hip that has the least amount of intracapsular pressure?

Answer 150

flexion, abduction, and internal rotation.

How a child with transiet synovitis or septic arthrits may present.

Question 151

What are some lab values that can be used to distinguish transient synovitis from septic arthrits?

Answer 151

CRP 20mg/L or 2mg/dl. Less than that more likely synovitis. More than that more likely septic arthritis

If aspiration is perfromed Synovial WBC cutoff of 50,000WBC

Other things are fever is mild or absent in synovitis

Question 152

What age is pediatric septic hip arthritis most common?

Answer 152

first few years of life.

50% of cases occur in children younger than 2 years of age.

Question 153

Rsik factors for neonatal septic arthritis?

Answer 153

prematurity

Cesarean section

NICU

Invasive procedures, even venous catheterization and heel puncture

Question 154

What is a provocative test to evaluate a patient for a psoas abscess?

Answer 154

Psoas sign which is pain caused by extension and internal rotation of the limb.

Question 155

What is the treatment of choice for a large psoas abscess?

Answer 155

Percutaneous ultrasound or CT guided drainage.

Open drainage is indicated for a secondary psoas abscess that has spread from the bowel as both can be addressed at the same time.

Question 156

Is there a surgical correction for Sprengel deformity?

Answer 156

Yes

Indicated for children with severe cosmetic concerns or functional deformities (abduction < 110-120 degrees)

Best to perform surgery from 3 to 8 years of age. Greater risk of nerve impairment after the age of 8.

Woodward of Greeen procedure. Can imporve abduction by 40-50 degrees. Basically detatch and move medial parascapular muscles to allow scapular to migrate inferiorly.

Question 157

Where and what side does congenital pseudoarthrosis of the clavicle most commonly occur?

Answer 157

Right side.

Middle 1/3

two ossification centers. One medial and one latera.

Question 158

What is the pathophysiology of coxa vara?

Answer 158

proximal femoral cartilaginous physis or ossification center defect in the inferior femoral neck.

No clear inheritance pattern.

Question 159

What are the different etiologies of coxa vara?

Answer 159

developmental

Congenital (such as PFFD)

Acquired (SCFE, Perthes, infection)

Dysplasia ( OI, Jansen, Schmid, SED)

cretinism

Question 160

What measurement is considered a varus neck shaft angle in pediatric proximal femurs?

Answer 160

< 120 degrees

Question 161

What is Hilgenreiner-iphyseal angle used for?

How is it measured and what is a normal and abnormal measurement?

Answer 161

Assessment of coxa vara

angle between Hilgenreiner’s line and a line through proximal femoral epiphysis.

Normal < 25 degrees

<45 degrees unlikely to progress

54-60 degrees requires close follow-up even if asymptomatic.

Question 162

Goals of corrective valgus derotation osteotomy?

Answer 162

Over-correct varus neck shaft angle. Reduce Hilgenreiner physeal angle to < 38 degrees.

Correct leg length discrepancy

Correct hip anteversion/retroversion

re-establish abductor msucle tensioning

Question 163

What occurs in 70% of infants with obstetric brachial plexopathy?

Answer 163

Glenohumeral dysplasia

See increased glenoid retroversion, humeral head flattening, posterior humeral head subluxation

Caused by internal rotation contracture.

Question 164

What is the prognosis for obstetric brachial plexopathy?

Answer 164

90% of cases will resolve spontaneously without intervention.

Recovery may occur for up to 2 years.

Question 165

What are favorable variables for spontaneous recovery from obstetric brachail plexopathy?

Poor prognostic variables?

Answer 165

GOOD: Erb’s Palsy, Complete recovery if biceps and deltoid are anti-gravity by 3 months, and early twitch biceps activity.

POOR: Lack of biceps function by 3 months. Preganglionic injuries(worst prognosis as they are avulsions from the cord. Seen with Loss of rhomboid fuction, and elevated hemidiaphragm). Horner’s syndrome. C7 involvement. Klumpke palsy.

Question 166

What percent of obstetric brachial plexopathies with Horner’s Syndrome will recover?

Answer 166

10% recover spontaneous motor function.

Question 167

Loss of rhomboid funtion and elevated hemidiaphragm signify what kind of plexopathy?

Answer 167

preganglionic injury

avulsion from the cord

will not recover spontaneously

Question 168

When should EMG be used for obstetric brachial plexopathies?

Answer 168

rarely

poor reliability

Often underestimate the severity of injury.

Question 169

What is the most common type of obstetric brachial plexopathy?

Answer 169

Erb’s Palsy (C5,6)

Question 170

What is Erb’s Palsy

Answer 170

Brachial plexopathy C5,6

Best prognosis for spontaneous recovery

adducted, internally rotated shoulder

Pronated forearm, extended elbow

C5: axillary, suprascapular, and musculocutaneous nerve deficiency.

C6: radial nerve deficiency

Question 171

What is Klumpke’s Palsy?

Answer 171

C8,T1 Brachial plexopathy

Rare

deficit of all the small muscles of hand (ulnar and median nerves

Claw Hand: wrist in extreme extension, hyperextension of MCP due to loss of hand intrinsics, and flexion of IP joints fue to loss of hand intrinsics.

Poor prognosis

Frequently associated with a preganglionic injury and Horner’s Syndrome

Question 172

What is treatment for a preganglionic obstetric brachial plexus palsy?

When should it be done?

Answer 172

Neurotization using expendable motor fascicles from the median and ulnar nerves to biceps and brachialis branches of the musculocutaneous nerves.

Before 3 months of age.

Question 173

What is the difference between neurotization and nerve transfer?

Answer 173

nerve transfer refers to fasciciles from one nerve transferred into another nerve that supplies a muscle.

Neurotization refers to placing nerve fascicles directly into a neuromuscular junction of a muscle.

Question 174

What is a Hoffer procedure?

Answer 174

Latissimus dorsi and teres major transfer.

Indicated for persistent internal roation contracture or external rotation weakness without glenohumeral dysplasia in children with a history of brachial plexopathy.

Question 175

What is a Wickstrom procedure?

Answer 175

proximal humeral derotation osteotomy.

Indicated for persistent internal roation conractures or external rotation weakness with glenohumeral dysplasia.

Question 176

What is the treatment for elbow flexion contractures after obstetric brachial plexopathy?

Answer 176

< 40 degrees: serial nighttime elbow extension splinting. Prevent progression but does not correct contracture.

> 40 degrees: serial elbow extension casting

Operative for severe persistent contrctures. Perform anterior capsular release with biceps/brachialis tendon lengthening. There is a high recruurence rate with this.

Question 177

What is done for phrenic nerve palsys from obstetric plexopathies?

Answer 177

If persistent may require diaphragm plication.

Question 178

What is the treatment for residual forearm supination contracture after obstetric brachial plexopathies?

Answer 178

Intact passive pronation -> biceps rerouting transfer

Limited passive forearm pronation -> forearm osteotomy with biceps rerouting tendon transfer

Question 179

What is a teratologic hip?

Answer 179

dislocated in utero and irreducible on neonatal exam.

pseudoacetabulum.

associated with neuromuscular conditions and genetic disorders.

Commonly seen with arthrogryposis, myelomeningocele, Larsen’s syndrome, Ehlers-Danlos

Question 180

What is the most common orthopaedic disorder in newborns?

Answer 180

Hip dyslplasia.

Question 181

What are the risk factors for hip dysplasia?

Answer 181

Firstborn

Female

Breech

Family history

Oligohydramnios

More common in left hip due to left occipur anterior being the most common intrauterine position of the fetus.

Question 182

Where is acetabular deficiency in spastic cerebral palsy?

Answer 182

posterosuperior

typical deficiency for hip dysplasia is anterior or anterolatera.

Question 183

What are the associated conditions with hip dysplasia?

Answer 183

Known as “packaging deformities”

Congenital muscular torticollis

Metatarsus adductus

Congenital knee dislocation

Question 184

What physical exam maneuvers can be performed at >3months to 1 year to screen for hip dysplasia?

Answer 184

Ortolani and Barlow rarely positive after three months

Limitation in hip abduction

Leg length discrepancy

Klisic test (Line from long finger placed over GT and ASIS should point to umbilicus if the hip is normal. If it is dislocated it will point half way between umbilicus nad pubis.

Question 185

What physical exam findings will you find in a child greater than one who is walking who has hip dysplasia?

Answer 185

Pelvic obliquity

Lumbar lordosis

Trendelenburg gait

toe walking

Question 186

When does the femoral head begin to ossify?

Answer 186

By 6 months.

Question 187

Desbribe the following ragiographic lines:

Hilgenreiner’s Line

Perkin’s Line

Shenton’s Line

Acetabular Index

CEA of Wiberg

Answer 187

Femoral head ossification should be inferior to this line.

Femoral head ossification should be medial to this line.

Should be a continuous arc between inferior border of the femoral neck and the superior margin of the obturator foramen.

Angle formed by H and a line from a point on the lateral triradiate cartilage to a point on lateral margin of acetabulum. Should be < 25 deg in patients > 6 months

Angle from P line and a line from the center of the femoral head to the lateral edge of the acetabulum. < 20 deg is considered abnormal. Only reliable in patients > 5 years old.

Question 188

What are possible blocks to reduction of a dysplastic hip?

What should be done after to confrim reduction?

Answer 188

Inverted labrum

Inverted limbus (fibrous tissue)

transverse acetabular ligament

Hip Capsule (contracted by the iliopsoas tendon causing an hourglass deformity)

Pulvinar

LIgamentum teres

ARTHROGRAM

Question 189

Treatment recommended for a 4 month old found to have hip dysplasia with a dislocated hip that is reducible?

Answer 189

Pavlik harness for those <6 months old.

Contraindicated in teratologic hip dislocations, spina bifida, and spasticity.

Question 190

Treatment for hip dysplasia in 6-18 month olds?

Answer 190

closed reduction and spica casting

Question 191

Treatment for a 20 month old child who has failed closed reduction for right hip dislocation?

Answer 191

open reduction and spica casting for 18-24 month old children.

Question 192

Treatment for a 3 year old with residual hip dysplasia on x-ray with coxa valga?

Answer 192

Open reduction with a femoral osteotomy

Pelvic osteotomies are more commonly used in childre > 4 years old and those with an increased acetabular index.

Question 193

What are complications related to Pavlik harnesses?

Answer 193

AVN (seen with extreme abduction > 60 degrees, due to impingement of the posterosuperior retinacular branch of the medial femoral circumflex artery)

Transient femoral nerve palsy seen with hyperflexion.

Pavlik disease, which is erosion of the pelvis superior to the acetabulum. IMPORTANT TO DISCONTINUE THE HARNESS IF THE HIP IS NOT REDUCED BY 3-4 WEEKS.

Question 194

What should you do with a infant who is 4 weeks old and has been treated in a Pavlik harness for over three weeks but remains Ortolani positive?

Answer 194

Convert to a semi-rigid abduction brace with weekly ultrasounds for another 3-4 weeks.

Question 195

How much medial dye pooling is concerning on an arthrogram performed after a closed reduction of a dysplastic hip?

Answer 195

>7mm is associated with poor outcomes and AVN

Want < 5mm

Question 196

What can be done if an unstable safe zone is required to maintian reduction of a dysplastic hip?

Answer 196

adductor tenotomy if > 60 degrees is required to maintian reduction.

Question 197

What position should the limb be immobilized in a spica cast for a child with hip dysplasia?

Answer 197

100 degrees of flexion

45-55 degrees of abduction

Neutral rotation

Confrim after with imaging.

Change cast at 6 weeks. 3 months total of treatment.

Question 198

Which approach should be used for open reduction of a hip with dysplasia in a child? Medial or Anterior?

Answer 198

Anterior in children > 12 months. Advantages: capsulorrhaphy can be performed. decreased risk of AVN

Medial in children < 12 months. PROS: directly addresses blocks to reduction, decreased blood loss CONS: unable to perform capsulorrhaphy and higher risk of AVN

Question 199

What are the two salvage pelvic osteotomies used for hip dysplasia?

Answer 199

Shelf

Chiari

Question 200

What pelvic osteotomies require an open triradiate cartilage?

Answer 200

Salter, Steele(Triple), and Pemberton.

Dega as well but this is only for severe cases. Favored in neuromuscular dislocations and patients with posterior acetabular deficiency.

Question 201

When are children with delayed diagnosis of hip dysplasia and a dislocated hip better off treated non-operatively?

Answer 201

Bilateral dislocations function better if 6 years of age or older.

Unilateral dislcoation better if patient is > 8 years old.

Question 202

What is cloacal exstrophy?

Answer 202

Where bladder exstrophy ivolved wht intestingal track as well.

1/200,000 infants

Question 203

What MSK issue is seen in patients with bladder exstrophy?

Answer 203

Acetabuli are 12 degrees retroverted.

Without pubis to tether the anterior ring the posterior elements retrovert

Waddling gait with external foot progression.

PELVIC OSTEOTOMY IS PERFORMED IN ORDER TO DECREASE TENSION ON THE BLADDER AND ABDOMINAL WALL REPAIR. Not required in newborns, skin traction and hip flexed 90 degrees is enough. Plate fixation > 8 yrs. Otherwise ex-fix.

Question 204

What is the single greatest risk factor for SCFE?

Answer 204

Obesity.

Other risk factors include males, acetabular retroversion and femoral retroversion, males, and specific ethnicities(african americans, pacific islanders, and latinos.

Question 205

Which zone of the physis does the SCFE occur through?

Answer 205

Hypertrophic zone.

Question 206

What conditions are associated with SCFE?

What are the indications for an endocrine work-up?

Answer 206

Hypothyroidism (most common, will see an elevated TSH)

Renal osteodystrophy

Growth Hormone deficiency

Panhypopituitarism

Down Syndrome

Child is < 10 years old

Weight is < 50th percentile

Question 207

Would the inability to ambulate unless using crutches indicated a stable or unstable SCFE?

What is important about the unstable vs stable designation?

Answer 207

Stable.

Unstable would be if the child cannot ambulated even with the help of assistive devices.

Its prognostic. Unstable have a higher risk of osteonecrosis 47% vs <10%.

Unstable should be treated urgently.

Question 208

What can symptom can present with a SCFE and lead to misdiagnosis.

What is this symptom due to?

Answer 208

Knee pain

pain activation of the medial obturator nerve.

Question 209

What is the Drehmann sign?

Answer 209

Obligatory external rotation during passive flexion of the hip found in children with a SCFE.

Due to a combination of synovitis and impingement of the displaced anterior-lateral femoral metaphysis on the acetabular rim.

Question 210

What is Klein’s line?

Answer 210

Line drawn along the superior border of the femoral neck.

Will intersect lateral femoral head in a normal hip.

Question 211

When should you considere contralateral hip prophylactic fixation of a SCFE?

What about capsulotomy and open reduction?

Answer 211

<10 years of age, open triradiate cartilage, endocrine disorders, and obese males.

Contoversial, if done only in unstable SCFES where intracapsular pressur eis double.

Really never, maybe severe slips that are unstable.

Question 212

Describe how a screw should be positioned for percutaneous in situ fixation of a SCFE

Answer 212

One cannulated partially threaded screw is usually sufficient.

Starts on anterior aspect of femur in order to cross perpendicular to physis.

Should be center center in epiphysis

5 threads accorss physis

Screw should be less than 5mm from subchondral bone.

Question 213

What is the modified Dunn procedure?

Answer 213

Surgical hip dislocation with open capital realignment and fixation to correct the acute proximal femoral deformity in SCFEs.

Question 214

What osteotomy is used to treat SCFE patients who go on to have restricted hip flexion motion, and external rotation deformity?

Answer 214

Imhauser osteotomy.

Flexion, internal roation, and valgus-producing proximal femoral osteotomy.

Question 215

What is the cause of PFFD?

What are the associated conditions?

Answer 215

primarily sporadic

autosomal dominant form associated with sondic hedge-hog gene. WILL HAVE DYSMORPHIC FACIES

Fibular hemimelia (50%), ACL deficiency, coxa vara, and knee contractures

Question 216

When can PFFD be treated with limb lengtheing with or without contralateral epiphysiodesis instead of some sort of amputation, rotationplasty, or arthrodesis and ablation?

Answer 216

Predicted limb length < 20cm at maturity

Stable hip and functional foot

Femoral lenght > 50% of opposite side

Femoral head present (Aitken classifications A&B)

Contraindictaions inculde unaddressed coxa vara, proximal femoral neck pseudoarthrosis, or acetabular dysplasia.

Question 217

When can you consider performing a Van Ness rotationplasty vs Amputation and knee fusion in a patient with PFFD?

Answer 217

If foot is predicted to be at knee level can do a Van Ness rotationplasty with or without hip stabilization depending on codition of hip joint. Should be do early once child has reached one year of age. Do not perform if child > 12 yrs.

If foot is predicted to be proximal to contralateral knee joint then syme amputation with knee fusion.

Question 218

What is Legg-Calve-Perthes?

Answer 218

Idiopathic avascular necrosis of the proximal femoral epiphysis in children.

Treatment is generally observation when < 8 yrs and femoral and/or pelvic osteotomy when > 8 yrs.

Question 219

What does symmetrical involvement of bilateral hips with perthes suggest?

Answer 219

Multiple epiphyseal dysplasia.

typically Perthes is asymmetrical asynchronous involvement.

Question 220

What do up to 75% of patients with Legg-Calve-Perthes have some form of?

Answer 220

coagulopathy

thrombophilia present in up to 50% of patients

Possible association with Protein S and Protein C deficiencies.

ADHD associated in 33% of cases.

Bone age is delayed in 89% of patients.

Question 221

What is the most important good prognositc indicator for children with Legg-Calve-Perthes?

Answer 221

Age < 6 yrs at presentation.

Approximately half of patients develop premature ostoarthritis secondary to an aspherical head.

Question 222

Describe the stages of Legg-Calves-Perthes

Answer 222

Waldenstrom

Question 223

Describe the lateral Pillar (Herring) Classification of Legg-Calves-Perthes.

Answer 223

Question 224

What is the Stulberg classification used for in Legg-Calves-Perthes?

Answer 224

Gold standard for rating residual femoral head deformity and joint congruence.

Recent studies show poor interobserver and introbserver reliability.

Question 225

What are the classic physical exam signs of Legg-Calves-Perthes?

Answer 225

Painless limp

Insidious onset

Loss of internal rotation and abduction

Tendelenburg giat

Question 226

What are the main goals of non-operative treatment of Legg-Calves-Perthes?

Answer 226

Keep the femoral head contianed and maintaing good motion.

Activity restricition, protected weight bearing, and physical therapy exercises.

60% do not require operative intervention.

Bracing and casting for containement have not been found to be helpful.

Question 227

What two osteotomies may be indicated for Children > 8 yrs of age with Lateral Pillar B or B/C Perthes hips?

Answer 227

Shelf osteotomy of the pelvis to prevent lateral subluxation and resultant lateral epiphyseal overgorwth

Abduction-extension osteotomy to reposition the hinge sement away from the acetabular margin, correct shortening from fixed adduction, and improve abductor mechanism by adding contractile length.

Question 228

Children with what conditions can have congenital knee dislocations?

What are associated conditions?

Answer 228

myelomeningocele, arthrogryposis, and Larsen’s syndrome

50% will have hip dysplasia

Clubfoot.

Metatarsus adductus

Question 229

What is the treatment algorithim for a child with both a congential knee dislocation and a dislocated hip?

Answer 229

Treat knee first.

Then Pavlik harness for hip.

Cannot get patient into Pavlik harness until knee is no longer dislocated.

Question 230

When do you consider surgical treatment for a congenital knee dislocation?

Answer 230

Knee that cannot be passively reduced beyond 30 degrees of flexion in a child that is > 6months of age.

Failure to gain 30 degrees of flexion after 3 months of casting.

Goal of surgery is to obtain 90 degrees of flexion.

Question 231

Treatment for a predicted leg length discrepancy of 2-5 CM

Answer 231

epiphysiodesis or other from of shortening of affected limb.

Question 232

Treatment for LLD projected to be >5cm but < 20cm?

Answer 232

Lengthening of affected side with shortening of long side.

Question 233

What are the principles of distraction osteogenesis?

Answer 233

Metaphyseal corticotomy to preserve medullary canal and blood supply

Wait 5-7 days then begin distraction

Distract 1mm/day

Following distraction keef fixator on for as many days as you lengthened. Lengthening over a nail has the advangtage that the ex-fix can be removed sooner.

Question 234

Where is a popliteal cyst normally located in a child?

Answer 234

Betwen the semimembranosus and medial head of the gastrocnemius.

From herniated posterior knee joint capsule synovium.

Mass will transilluminate

Majority resolve spontaneously.

Question 235

What are the risk factors for infantile Blount’s disease?

Answer 235

Overweight children

Early walkers <1 year

Hispanic and black

Best outcomes with early diagnosis and unloading of the medial joint.

Question 236

Describe the process of physiologic genu varum.

Answer 236

Genu varum is normal in children less than 2 years.

Migrates to neutral around 14 months.

Peak genu valgum at 3 years of age.

Genu valgum migrates back to normal physiologic valgus at 7 years of age.

Question 237

What conditions can be associated with pathologic genu varum?

Answer 237

Rickets

OI

MED, SED

Metaphyseal dysostosis (Schmidt, Jansen).

Focal fibrocartilaginous defect.

Thrombocytopenia absent radius.

Proximal tibial physeal injury.

GENU VARUM COMMONLY ASSOCIATED WITH INTERNAL TIBAIL TORSION.

Question 238

What is the metaphyseal-diaphyseal angle of Drennan used for?

Answer 238

Used to assess Blounts

Angle formed by line connectedin metaphyseal beaks and a line perpendicular to the longitudinal axis of the tibia.

> 16 degrees is considered abnormal. 95% Chance of progression.

< 10 degrees has a 95% chance of natural resolution of the bowing.

Question 239

When is brace treatment with a KAFO indicated for blounts?

Answer 239

Only in infantile blounts.

Stage I and II children < 3 yrs

Bracing must continue for approximately 2 years for resolution of bony changes

Improved outcomes if unilateral. Poor results with obesity and bilaterality.

If working should see improvement within 1 year.

Question 240

When is a proximal tibia/fibula vlagus osteotomy indicated?

Answer 240

Stage I and II children > 3 years

Any child >= 4 years

Stage III, IV, V, and VI

Failure of brace treatment

Metaphyseal-diaphyseal angle > 20 degrees.

Perfrom osteotomy below tibia tubercle. Overcorrect into 10-15 degrees of valgus

Consider prophylactic anterior compartment release.

Question 241

What orthopaedic conditions are associated with Neurofibromatosis?

Answer 241

Scoliosis.

Anterolateral bowing of the tibia.

Bowing of forearm leading to ulnar and radial pseudoarthrosis.

Question 242

Which type of Neurofibromatosis is most common?

Which kind is associated with bilateral vestibular schwannomas?

Answer 242

NF1 most common. Known as Von Recklinghaussen disease.

NF2 is associated with bilateral vestibular schwannomas.

Question 243

What physical exam findings are consistent with Neurofibromatosis?

Answer 243

Hemihypertrophy

Cafe-au-lait spots

Axillary freckling

Scoliosis

Anterolateral bowing and pseudoarthrosis of the tibia.

Dermal Plexiofrom (bag of worms, associated with multiple nerves instead of one) may be seen.

Lisch nodules- benign pigmented hamartomas of the iris.

Verrucous hyperplasia. Oral mucosa lesion.

Question 244

What tumors are associated with neurofibroma?

Answer 244

Wilms tumor(nephroblastoma)

Neurofibroma (plexiform type): pathognomonic for NF1, only in 4% of patients. Can undergo malingnant transformation to neurofibrosarcoma.

Question 245

What is dystrophic scoliosis?

When do you see it?

Answer 245

Typically thoracic kyphoscoliosis with a short segmented sharp curve involving 4-6 vertebrae?

Distorted ribs and vertebrae

Neurofibromatosis Type 1.

Question 246

Anterolateral bowing is associated with what disease?

Answer 246

Neurofibromatosis

Question 247

What is anteromedial tibial bowing associated with?

Answer 247

Fibular hemimelia

Question 248

What is thought to be the cause of posteromedial bowing?

Answer 248

Abnormal intrauterine positioning.

Dorsiflexed foot pressed against anterior tibia.

Will develop leg length discrepancy and calcaneovalgus deformity.

Question 249

Treatment for tibial pesudoarthrosis in a patient with neurofibromatosis.

Answer 249

Bone grafting with surgical fixation.

Total contact casting if anterolateral tibial bowing without pseudoarthrosis or fracture.

< 4 yrs extend fixation to clacaneus

5-10 years extend fixation to Talus.

Question 250

What is the most common congenital long bone deficiency?

Answer 250

Fibular deficiency.

Leads to anteromedial tibial bowing.

No known inheritance pattern.

Linked to sonic hedge-hog gene.

Question 251

What conditions are associated with fibular deficiency(anteromedial tibial bowing)?

Answer 251

Ball and socked ankle.

Talipes equinovalgus

trasal coalition(50%)

Absent lateral rays.

PFFD and Coxa Vara

DDH

Genu valgum (secondary to lateral femoral condyle hypoplasia)

LLD

Question 252

What is a Farmer’s Procedure?

Answer 252

Use of a free vascularized fibular graft from the contralateral leg to treat tibial pseudarthrosis.

Placment of Lizarov or Taylor Spatial frame for bone lengthening.

Question 253

If it comes to amputation for a patient with anterlateral tibial bowing and a pseudoarthrosis what amputation should be performed?

Answer 253

Sympe amputation.

Pseudoarthrosis is managed by the prosthetic socket.

Calf muscles are not as robust making BKA less desirable for coverage.

Question 254

On average when does fragmentation of the proximal femoral epiphysis occur in patients with LCP?

Answer 254

6 months.

Question 255

What is the most common associated condition with posteromedial tibial bowing?

Answer 255

Leg length discrepancy on average of 3-4 cm.

Posteromedial tibial bowing usually corrects over 5-7 years.

need to monitor, may require age appropriate epiphysiodesis.

Question 256

What is the inheritance pattern of tibial deficiency?

What are the associated conditions.

Answer 256

autosomal dominant inheritance pattern.

ectrodactyly (cleft hand), preaxial polydactyly, and ulnar aplasia.

Treatment is determined by stability of knee joint.

Question 257

What is a cause of anterolateral tibal bowing besides neurofibromatosis?

Answer 257

Tibial deficiency.

Question 258

What are the three main causes of intoeing?

Answer 258

Femoral anteversion.

Metatarsus adducts (infants)

Internal tibial torsion (toddlers)

Question 259

What is the demographics for femoral anteversion?

Pathophysiology?

Associated conditions?

Prognosis?

Answer 259

2:1 girls, 3-6 yrs of age, can be hereditary.

Packaging disorder. Often bilateral.

DDH, Metatarsus adducts, and congenital muscular torticollis.

Question 260

What should you be concerned for in a 4 year old child that sits in the W position and has an awkward running style?

Answer 260

Femoral anterversion.

Question 261

What tests should be performed to evaluate a child with intoeing.

Answer 261

Look at foot for any deformity (metatarsus adductus). Evaluate hindfoot and subtalar motion.

Tbial torsion: Thigh-foot angle in prone position. Infants 5 deg internal with range -30 to 20. Age 8 mean 10 deg ext. Range -5 to 30.

Femoral anteversion: hip motion in prone position. IR- Normal is 20-60. >70 deg is abnormal. ER- Normal is 30-60. < 20 deg is abnormal.

Trochanteric prominence angle test estimates IR when greater trochanter is most prominent.

Question 262

What is the treatment for a 9 yo child with 5 degrees of external rotation?

Answer 262

Derotational femoral osteotomy.

Performed at the intertrochanteric level.

Amount of correction needed can be calculated by (IR-ER)/2

Question 263

What is the prognostic difference between external tibial torsion and internal tibial torsion?

Answer 263

External tibial torsion may actually cause disability and degrade physical performance.

Question 264

What is miserable malalignment syndrome?

Answer 264

Combination of external tibial torsion with femoral anteversion.

Question 265

What coditions are associated with external tibial torsion?

Answer 265

Miserable malaignment syndrome?

Osgood-Schlatter disease

Osteochondritis dessicans

Early degenerative joint disease

Neuromuscular conditions such as myelodysplasia and polio.

Question 266

What is the operative indication for external tibial torsion?

When is it indicated?

Answer 266

Supramalleolar rotational osteotomy.

Proximal tibial osteotomies are avoided secondary to higher risk factors associated with this procedure.

Children older than 8 years of age with > 40 degrees of external rotation.

Question 267

What is the difference between metatarsus adductus and skew foot?

Answer 267

Metatarsus adductus is adduction of forefoot with normal hindfoot alignment.

Skew foot (also known as serpentine foot) has tarsometatarsal adductus with abnormal hindfoot alignment: talonavicular lateral subluxation and hindfoot valgus.

Nonoperative treatment for skew foot is usually ineffective.

Question 268

What is the prognosis for metatarsus adductus?

Answer 268

Most resolve spontaneoulsy.

Require parent manipulation and at most casting. Only exceptsion is if it is a rigid deformity.

No longterm pain or decreased function.

Question 269

What is an atavistic great toe?

Answer 269

Congenital hallux varus.

Question 270

Treatment for metatarsus adducts?

Answer 270

Operative treatment indicated in > 5 yr olds who fail non-op reatement, have difficult with shoe wear, and pain.

Perform lateral column shortening with cuboid closing wedge osteotomy and medial column lengthening with cuneiform opening wedge osteotomy, medial capsular release, and abductor hallucis longus recession for atavistic first toe.

Question 271

What is the most common type of hereditary motor-sensory neuropathy?

Answer 271

Charcot-Marie-Tooth

Characterized by genetic mutations in myeling proteins that lead to leg muscle atrophy and loss of sensation and proprioception in early adulthood.

Most commonly inherited autosomal dominant but can be recessive or X-linked.

Question 272

What muscles are affected in Charcot-Marie-Tooth?

Answer 272

Peroneus brevis-usually first affected and most profound. Leads to imbalance and varus deformity.

Tibialis anterior-weakness leading to drop foot.

Intrinsic muscles of the hand and foot- check for wasting of 1st dorsal interossei in hands

Question 273

What are the orthopaedic manifestations of Charcot-Marie-Tooth?

Answer 273

Pes cavovarus

Hammer toes

Hip dysplasia

Scoliosis

Hand muscle atrophy and weakness

Question 274

What is the difference between Type 1 and Type 2 Charcot-Marie-Tooth?

Answer 274

Question 275

What causes the cavovarus foot in Charcot-Marie-Tooth?

Answer 275

Weak tibialis anterior is overpowered by unaffected peroneus longus.

Leads to plantar flexion of the first ray.

Question 276

What will be found on EMG of a patient with Charcot-Marie-Tooth?

Answer 276

Low nerve conduction velocities

Prolonged distal latencies

found in peroneal, ulnar, and median nerves

Can also see low amplitude nerve potentials due to axonal loss.

Question 277

What causes the varus positioning of the foot in Charcot-Marie-Tooth disease?

Answer 277

A normal tibialis posterior overpowering weak peroneus brevis.

Question 278

What soft tissue reconstruction procedures are indicated in Charcot-Marie-Tooth disease for patients with:

Cavus

Plantar Flexed first ray

Dorsifelxion weakness leading to drop foot

Ankle equinous

Toe clawing

Answer 278

Plantar release.

Peroneus longus to brevis- decreases plantarflexion force on the first ray without weakening eversion.

Posterior tibial tendon transfer to dorsum of foot.

Gaxtrocnemius recession vs TAL. Gastroc recession preferred.

Jones transfer(s) EHL to neck of 1st MT and lesser toe extensors to 2nd-5th MT necks

Question 279

How often does scoliosis occur in children with CMT?

What is the characteristic curve?

Treatment?

Answer 279

10-20% of the time.

Left thoracic and kyphotic curve.

Bracing not effective. Progressive deformity > 50 degrees = fusion and isnstrumentation.

Question 280

If you have a unilateral cavovarus foot in a child what must be ruled out?

Answer 280

Tethered spinal cord or spinal cord tumor.

Question 281

What conditions may present with a cavovarus foot?

Answer 281

CMT Disease

Cerebral Palsy

Freidreich’s Ataxia

Spinal cord lesions

Polio

Question 282

What will be some of the presenting history and complaints for a patient with a cavovarus foot?

Answer 282

Lateral ankle pain and recurrent ankle sprains.

Lateral foot pain, can lead to fifth metatarsal stress fractures.

Plantar calluses under 1st and 5th metatarsal heads.

Plantar fasciitis

Question 283

What is signified by a Meary’s Angle > 4 degrees?

Answer 283

Meary’s angle is the talo-first metatarsal angle on a lateral foot x-ray.

When it is > 4 degrees apex dorsal it is consistent with a cavovarus foot.

Apex plantar associated with pes plano valgus.

Question 284

What age do you expect calcaneonavicular coalition?

Talonavicular coalition?

Answer 284

8-12 years.

12-15 years.

Calcaneonavicular is most common.

Question 285

What deformities can you see with a coalition?

Answer 285

Flattening of longitudianl arch

Abduction of forefoot

Valgus hindfoot

Peroneal spasticity

Question 286

How is nonsyndromic tarsal coalition inherited?

Answer 286

Autosomal dominant

Question 287

Associated conditions with tarsal coalition?

Answer 287

Fibular hemimelia

carpal coalition

FGFR-associated cronaiosynostosis (FGFR-1, 2, and 3)

Apert Syndrome

Pfeiffer Syndrome

Crouzon Syndrome

Jackson-Weiss Syndrome

Muenke Syndrome

Question 288

What is first line treatment for tarsal coalitions?

Answer 288

Immobilization with casting and analgesics.

6 weeks

30% of symptomatic patients will become pain free.

Shoe inserts may actually cause more discomfort because the defomrity is rigid.

Question 289

What is a major indication for or against coalition resection that is also used as a prognostic indicator?

Answer 289

The amount of joint that the coalition involves.

>50% found to have poor outcomes. Considere arthrodesis in this case

Resection better if < 50%

Question 290

When is a triple arthrodesis indicated for a pediatric patient with tarsal coalition?

Answer 290

Failed resection.

Degenerative changes in other joints.

Multiple coalitions.

Greater than 50% involvement of posterior facet of subtalar joint.

Child needs to be older than 12 to prevent limitatin on foot growth.

Question 291

Describe a flexible pes plano valgus?

Answer 291

collapse of medial longitudinal arch

Hindfoot valgus

Forefoot abduction

Corrects when rising onto toes.

Question 292

Treatment for a flexible pes planovalgus.

Answer 292

Observation. Almost always resolves spontaneously, especially in asymptomatic patients. Arch develops with age.

Strethcing, shoewear modifications, and orthotics.

Important to understand that orthotics do not change natural history of the diesease.

Question 293

Surgical treatment for flexible pes planovalgus in pediatric patient.

Answer 293

Calcaneal Lengthening Osteotomy(Evans procedure)

With or without cuneiform osteotomy.

Possible peroneal tendon lengthening.

Sliding calcaneal osteotomy can correct the hindfoot valgus.

Plantar based closing wedge osteotomy of the first cuneiform corrects the supination deformity.

Question 294

What percent of congenital vertical talus is associated with a neuromuscular disease or chromosomal aberration?

Answer 294

50%

Myelomeningocele

Arthrogyrposis

Diastematomyelia

Congenital dislocation of the hip

Cerebral palsy

Spinal Muscular Artrophy

Hip dysplasia

50% Bilateral. 2:1 M:F

Question 295

What is the pathoanatomy of congenital vertical talus?

Answer 295

Rigid foot deformity: irreducible dorsolateral navicular dislocation, vertically oriented talus, and calcaneal eversion with attenuated spring ligament.

Soft tissue contractures: Displacement of peroneal longus and posterior tibialis tendon so they function as dorsiflexors rather than plantar flexors. Contracture of achilles tendon.

Question 296

What is Kohler’s Disease?

Who does it commonly occur in?

Answer 296

Avascular necrosis of the navicular bone.

Children 4-7 yrs.

4:1 Boys to Girls.

Central 1/3 of the navicular is a watershed zone. Makes it susceptbile to injury.

Last bone in the foot to ossify.

Self-limited after 1-3 years.

Question 297

What is the recommended treatment for Kohler disease?

Answer 297

Always non-operative management.

Immobilization with short leg walking cast.

Question 298

What is Sever’s disease?

In what population is it seen?

Answer 298

Overuse injury of the calcaneal apophysis.

Immature athletes participating in running and jumping sports.

Just before or during peak growth.

self-limiting entity.

Question 299

What is the recommended treatment for Sever’s Disease?

Answer 299

Activity modification.

Achilles tendon stretches.

Ice.

Heel cups or heel pads.

NSAIDs.

Short leg cast immobilization if persistent.

Recurrence is common but surgery is never the answer on the test.

Question 300

What is the most common musculoskeletal birth defect?

Answer 300

Clubfoot

Congenital talipes equinovarus

1:1000

Highest prevalence in Hawaiians and Maoris

80% clubfoot is an isolated deformity.

Question 301

What contractures contribute to the characteristic deformity in clubfoot?

Answer 301

CAVE

Cavus: tight intrinsics, FHL, and FDL

Adductus of forefoot: tight tibialis posterior

Varus: tight tendoachilles, tibialis posterior, tibialis anterior

Equinus: tight tendoachilles

Question 302

What is the boney deformity of clubfoot?

Answer 302

Talar neck is medially and plantarly deviated.

Calcaneus is in varus and rotated medially around talus.

Navicular and cuboid are displaced medially.

Question 303

What abnormality of the anterior tibial artery is common regardless of etiology of clubfoot?

Answer 303

Hypoplasia or absence.

Question 304

What conditions can be associated with clubfoot?

Answer 304

Arthrogryposis

Diastrophic dysplasia

Myelodysplasia

Tibial hemimelia

Amniotic band syndome (Streeter dysplasia)

Pierre Robin Syndrome, Opitz syndrome, Larsen syndrome, and prune-belly syndrome

Question 305

What do you see on physical exam with a clubfoot besides the foot deformities?

Answer 305

Small calf

Shortened tibia

Medial and posterior foot skin creases.

Question 306

What relationship is seen between the talus and the calcaneus in clubfoot?

Answer 306

Hindfoot parallelism.

Talus and calcaneus are less divergent than normal.

Talocalcaneal angle <25 degrees on a dorsiflexion lateral (Turco view).

Question 307

What is the success rate of the Ponseti method?

What should you counsel parents about the childs lifetime limitations?

Answer 307

90% success in avoiding comprehensive surgical rlease.

Children can be expected to walk, run, and be fully active in the absence of other comorbidities.

Question 308

When is surgical intervention necessary in club feet?

Answer 308

80-90% will need a heel cord tenotomy.

Resistant or recurrent club feet who have failed Ponseti casting and bracing.

Posteromedial soft tissue release and tendon lengthening. Stiffness and pain is common.

Extent of soft tissue release correlates with long-term function.

Should be done at 9-10 months of age in non-syndromic feet so walking is not delayed.

Question 309

How should a FAO (foot abduction orthosis be used in club feet?

Answer 309

Full time for 3 months then at night (+/-) naps for 2-4 years.

FAO noncompliance is biggest risk factor for deformity recurrence.

Question 310

How should dynamic supination be treated in a child who has been treated for club foot?

Answer 310

Can do whole or split tibialis tendon transfer.

Whole tendon transfer seems to be the preferred answer choice for OITE.

Tib Ant should be transferred to lateral cuneiform.

Required 30-50% of the time

Should be perfomred at 2-5 yrs.

Question 311

Describe the Ponseti method.

Answer 311

Correct in order of CAVE deformity.

Question 312

What foot deformity is associated with a dorsal bunion of the 1st MTP that alos has a muscular strength imbalance between anterior tibialis and peroneus longus?

Answer 312

Congenital talipes equinovarus.

Weak peroneus longus with stronger flexor hallucis and anterior tibial tendon lead to a dorsiflexed first metatarsal.

Question 313

What is the inheritance pattern of polydactyly of the foot?

Answer 313

Autosomal dominant

1:500 births.

Question 314

When is operative treatment for a congenital curly toe indicated?

Answer 314

Rarely

Severe cases with nail deformity.

Child should be > 3 yrs old.

Tenotomy as effective as transfer.

Question 315

What is another name for an epiphyseal bracket?

Answer 315

Delta phalanx

Aberrant cartilage extending along the diaphysis interfers with normal longitudinal growth.

Found in short tubular bones. 11% found in the great toe.

Leads to a short wide triangular or trapezoidal phalanx.

Question 316

How is a Delta phalanx best treated?

Answer 316

Excision of the bracketed epiphysis with fat graft interposition.

Early intervention leads to more chance for angular correction and longitudinal growth.

Question 317

What is cerebral palsy?

Answer 317

Nonprogressive motor neuron disease (static encephalopathy) due to injury to the immature brain.

By definition should be diagnosed before 2 years of age.

Most common cause of chronic childhood disability.

2-3:1000 live births.

Question 318

What are the orthopaedic manifestations of cerebral palsy?

Answer 318

Fractures

Contractures

Upper extremity deformities

Hip subluxation and dislocation

Spinal deformity

Foot deformities

Gait disorders

Question 319

When do you consider using pamidronate in children with cerebral palsy?

Answer 319

> or = 3 fractures with a DEXA Z-score < 2 SD

Question 320

True or False a pre-operative MRI is performed before Scoliosis surgery in all patients with Cerebral Palsy?

Answer 320

False, the indications for MRI are the same as other scoliosis patients.

Question 321

Describe the three classifications systems for cerebral palsy.

Answer 321

Physiologic

Anatomic

Gross Motor Function Classification Scale (GMFCS)

Question 322

What percentage of children with CP get progressive hip subluxation?

Answer 322

50% off patients with spastic quadripalegic CP.

Question 323

Which way does dislocation occur in a child with CP?

Answer 323

posterior and superior >95% of the time.

Question 324

What is Reimers migration index?

Answer 324

Percent of femoral head with no acetabular coverage.

Most accurate method to identify and monitor hip stability.

<33% = at risk

>33% = subluxated hip.

Question 325

When should a girdlestone procedure be performed for a child with CP who has a chronically dislocated hip?

Answer 325

Never.

No longer performed because it uniformly causes pain.

Question 326

What are the salvage technique(s) for symptomatic and chronically dislocated hips in cerebral palsy?

Answer 326

Vagus support osteotomy- femoral head resection + valgus subtrochanteric femoral osteotomy. Called the McHale technique.

Castle resection-interposition arthroplasty- Proximal femur is ressected at the level of the lesser trochanter so there are no remaining muscle attatchement to lead to further deformity. Oversew abductors, psoas, and hip capsule over acetabulum.

Total hip arthroplasty is an option in ambulatory patients.

Question 327

What are the operative soft tissue and reconstructive procedures and associated indications for a subluxated hip in a child with Cerebral Palsy?

Answer 327

Question 328

When performing a hip adductor tenotomy what nerve must you watch out for?

What complication does neurectomy lead to?

Answer 328

Obturator nerve.

Hip Abduction contracture.

Question 329

What is the point of Single-Event Multi-Level Surgery (SEMLS) in children with cerebral palsy?

Answer 329

Addresses the multiple planes and levels of deformity during a single surgery to avoid annula suergeries and prolonged bouts of recovery required after each surgical session.

Question 330

What is the difference between primary and secondary deviations in children with CP and a gait deformity?

Answer 330

Primary deviations- Those caused by the primary CNS insult: spasticity, weakness, compromised proprioceptive pathways

Secondary deviations- Growth related deviations that arise due to abnormal loading in the setting of primary gait deviations: Muscle contractures, bony deformities, and joint subluxations or deviations.

Question 331

What is the difference between qualitative and quantitative gait analysis?

Which is better?

Answer 331

Qualitative is descriptive, tries to simplify and classify. Often unsuccessful.

Quantitative- Uses technology to characterize the gait in all three planes of the deformity.

Quantitative is more accurate.

Question 332

What is pedobarography?

Answer 332

Special force plate that shows contact pressures through the stance phase.

Question 333

What role does chemodenervation play in cerebral palsy with regards to gait?

Answer 333

Use of botulinum neruotoxin A may be used to temporize certain muscle groups in order to delay surgical management.

Can also be used as a primary treatment modality.

Doesn’t work for fixed deformity.

Question 334

When can you consider percutaneous heel cord lengthening in children with CP and equinous contracture?

Answer 334

Should be delayed until the patient is at least 6 years old to prevent recurrence.

Question 335

What is a stiff knee gait?

What is the recommended treatment?

Answer 335

Common in spastic diplegic CP.

Characterized by limited knee flexion in swing phase due to rectus femoris firing out of phase (seen on EMG)

Rectus transfer- tranfer it posterior to the center of rotation of the knee so that rectus activation creates a knee flexion vector.

Question 336

In children with CP what procedure would you recommend for the following:

4 degree knee flexion deformity?

20 degree knee flexion deformity in a 11 y/o girl?

30 degree knee flexion deformity in a 15 y/o boy?

Answer 336

Medial hamstring lengthening- Fractional lengthening at the myotendinous junction. Not uncommon for contractures to recur.

Guided growth surgery- two years of growth remaining 10-25 degree deformity.

Supracondylar femur extension osteotomy +/- patellar tendon advancement or shortening- 10-30 degree deformity with severe quadriceps lag in patients close to skeletal maturity

Question 337

What is a normal popliteal angle?

Answer 337

25 degrees.

Question 338

What is the most common foot deformity in cerebral palsy?

Answer 338

Equinous contracture.

Question 339

For what pediatric foot deformity would you use a Evan’s lateral calcaneal lengthening osteotomy?

Answer 339

Flexible Pes Planovalgus.

Question 340

What is the most common associated congenital abnormality with spina bifida?

Answer 340

Type II Arnold-Chiari Malformation.

70% also have hydrocephalus

Question 341

What potential allergic complication should you be concerned about in a patient with myelomeningocele?

Answer 341

Latex Allergy

Type 1 IgE mediated hypersenitivity.

Should be distinguished from other latex allergies which is a Type 4 hypersensitivity or contact dermatitis that is T cell mediated.

Question 342

What is the difference between spinal bifida oculta, meningocele, and myelomeningocele?

Answer 342

Defect in vertegral arch with confined cord and meninges

Protruding sac without neural elements

Protruding sac with neural elements.

Question 343

What lab study can be performed to screen for spina bifida?

Answer 343

Alpha-fetoprotein

Elevated in 75% of children with open spina bifida.

Obtain during second trimester.

Question 344

What is often confused with an infectious process in children with cerebral palsy?

What is the recommended treatment?

Answer 344

Fractures of long bones due to osteopenia.

Higher frequency the higher the level of the defect. Common in the hip and the knee in children 3-7 years of age.

Short perior of immobilization in a well padded cast for fracture in acceptable alignment. Avoid long term immobilication which can lead to osteopenia and repeat fractures.

Question 345

How should a child’s hip with spina bifida and a dislocated hip be treated?

Answer 345

OBservation.

Surgical treatment is highly controversial due to a high rate of failure.

Question 346

When is a hip flexion contracture considered operatvie in a child with spina bifida?

What procedure is recommended?

Answer 346

> 40 degrees.

Anterior release and tenotomy of iliopsoas, sartorius, rectus femoris, and tensor fascia lata.

Question 347

What is the most common foot deformity seen with spina bifida?

How is it different from the idiopathic version?

Answer 347

talipes equinovarus 30% of the time.

Very rigid and insensate. Serial casting still treatment of choice but there is a high complication rate.

Question 348

What is sacral agenesis highly associated with?

How does it differ from myelodysplasia?

Answer 348

Maternal diabetes

Protective sensation is usually intact so there is a lesser rate of decubitus ulcers. Even though this is the case they still can have sensory deficits.

Question 349

What is an expected outcome of untreated complete sacral ageneiss?

Answer 349

Progressive kyphosis.

Child is unable to support the trunk without using his hands for support.

Should be treated with a spinal stabilization procedure.

Question 350

What disease is charaterized by lesions in dorsal root ganglia, corticospinal tracts, dentate nuclei in the cerebellum and sensory peripheral nerves?

Answer 350

Friedreich’s Ataxia

Most common form of spinocerebellar degenerative disease.

Onset between 7-15 yrs. Age of onset related to number of GAA repeats.

Question 351

What conditions are associated with Friedrich’s Ataxia?

Answer 351

Pes cavovarus foot

Scoliosis. Guaranteed if onset of disease is before 10. Progression of scoliosis if onset is before 15.

Cardiomyopathy. Coenzyme Q and other antioxidants have been shown to decrease rate of cardiac deterioration but they do not effect ataxia.

Question 352

How would you describe the gait of someone with Friedrich’s Ataxia?

Answer 352

staggering wide base gait.

Question 353

What physical exam findings can you find with a patient with Friedrich’s Ataxia?

Answer 353

Classic triad: Ataxia, areflexia, and positive plantar response

Weakness

Nystagmus

Scoliosis

Cavovarus food: rigid and associated claw toes.

Question 354

What will and EMG show in a patient with Friedrich’s Ataxia?

Answer 354

defects in motor and sensory.

increase in polyphasic potentials.

conduction velocities are decreased in upper extremities.

Question 355

What trearment is recommended for patients with Friedrich’s Ataxia and a cavovarus foot?

Answer 355

Observation if non-ambulatory. Bracing and stretching not helpful because it is rigid.

Early dieseas in ambulatory patient: plantar release, tranfers, +/- metatarsal and calcaneal osteotomy.

Late disease in nonambulatory who have issues with tranfers can consider triple arthrodesis.

Question 356

What disease is consistent with a child that has adducted and internally rotated shoulders. No flexion creases in the elbows. Hips flexed, abducted, and externally rotated. Normal intelligence, facies, sensation, and viscera?

Answer 356

Arthrogryposis

Question 357

What orthopaedic manifestations are seen in Arthrogryposis?

Answer 357

Upper extremity deformity: absence of shoulder muscles, thin limbs, elbows extended, wrists flexed and ulnarly deviated, intrinsic plus deformity, adducted no thumbs, and no flexion crease at the elbow.

Teratologic hip subluxation/dislocation.

Knee contractures

Clubfoot or vertical talus

C-Shaped scoliosis(33%)

Higher rate of fractures.

Question 358

What studies should be performed at three months of age in a baby diagnoses with arthrogryposis?

Answer 358

Neurologic studies

Enzyme tests

Muscle biopsies

Question 359

What treatment is recommended for upper extremity deformity in arthrogryposis?

Answer 359

First line of treatment is passive manipulation and serial casting.

Operative should be considered after the age of 4. Includes soft tissue releases, tendond transfers, and osteotomies.

Question 360

How should a child with a irreducible teratalogic hip dislocation and a 40 degree knee flexion contracture be treated?

Answer 360

Hamstring release of the knee, best performed early at 6-9 months. Should be done before the knee.

Only way to reduce teratologic hip dislocations is with an open reduction and likely a femoral shortening osteotomy.

Question 361

At what ages do you d a medial approach for an open hip reduction?

Anterior approach?

Answer 361

up to 12 months.

After 12 months.

Question 362

What is dolichostenomelia?

Answer 362

Long narrow limbs.

Arm span is greater than height.

Question 363

What orthopaedic conditions are associated with Marfan Syndrome?

Answer 363

Arachnodactyly(long slender digits)

Scoliosis (50%)

Protrusio acetabuli (15-25%)

Ligamentous laxity -> recurrent dislocations

Pes planovalugs

Dural ectasia (60%)

Meningocele

Pectus excavatum or carinatum

Question 364

What non-orthopaedic conditions are associated with Marfan Syndrome?

Answer 364

Cardiac: aortic root dilation, aortic dissection, and mitral valve proplapse.

Superior lens dislocations (60%)

Spontaneous pneumothorax

Skin striae and recurrent hernias.

Question 365

What is the difference between and AFO and a PLSO?

Answer 365

AFO controls the foot in both stance and swing phase.

PLSOControls excessive ankle plantar flexion in the sing phase but doesn’t control anything in stance phase and allows for ankle forsiflexion.

Question 366

What is Larsen’s Syndrome?

Answer 366

rare genetic disorder

characterized by findings of:

ligamentous hyperlaxity

Abnormal facial features (flattened nasal bridge, hypertelorism, and prominent forehead).

Multiple joint dislocations.

Question 367

What are the orthopaedic manifestations of Larsen’s Syndrome?

Answer 367

Hand deformities

Scoliosis

Clubfeet

Cervical kyphosis: May present with extremity weakness secondary to myelopathy. Caused by hypoplasia of the cervical vertebrae. Need to obtain screening radiographs to avoid catastrophic complications.

Joint locations often include knees and radial heads that are bilateral.

Question 368

How should cervical kyphosis but no neurologic defects be treated in a 14 month old with Larsen’s Syndrome?

Answer 368

Posterio cervical fusion.

With neurolgic defects should be treated with anterior/posterior cervical decompression and fusion.

Question 369

How are hip dislocations in Larsen’s syndrome treated?

Answer 369

Can attempt closed reduction but only once. Rarely succesful.

Usually need open reduction but even this is controversial in bilateral dislocations. If being performed should be performed early and only once.

Question 370

How are knee dislocations in Larsen’s syndrome treated?

Answer 370

Closed reduction and casting can be attempted. Often not succesful

Open reduction with femoral shortening and collateral ligament excision when they remain unstable after closed reduction.

Question 371

What is the most common genetic disease resulting in death during childhood?

Answer 371

spinal muscular atrophy

Progressive weakness starts proximally and moves distally.

Question 372

What is the pathophysiology of spinal muscular atrophy?

Answer 372

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

Question 373

What is the inheritance of spinal muscular atrophy?

Answer 373

autosomal recessive

Question 374

What is the classification for spinal muscular atrophy?

Answer 374

Question 375

What is one way you can distinguish Duchenne’s Muscual Dystrophy from Spinal Muscular Atrophy on physical exam?

Answer 375

Presence or absence of deep tendon reflexes.

Duchenne’s they are present while they absent in SMA.

Tongue fasciculations present in SMA.

Question 376

How is SMA diagnosed?

What medication has been FDA approved for treatment?

Answer 376

DNA analysis and muscle biopsy.

Nusinersen administered intra-thecally.

Question 377

What are the orthopaedic manifestations of SMA?

Answer 377

Hip dislocations- treated with observation alone. Typically painless and there is a high rate of recurrence.

Scoliosis

Lower extremity contractures.

Question 378

What is the rate of scoliosis in SMA?

When does it occur?

Does it typically progress?

Answer 378

almost everyone

By 2-3 years

Often progressive.

Question 379

What is the treatment a patient with Scoliosis and SMA?

Answer 379

Bracing can be used will delay but not prevent surgery in children younger than 10 years.

Operative is PSF with fusion to pelvis.

Need to address any hip contractures first.

Keep a laminectomy area free of fusion for administration of NUsinersen.

If curve > 100 degrees. PSF with anterior release and fusion.

Curves are typically very flexible.

Question 380

How should hip, knee, and ankle contracture typically be treated in children with SMA.

Answer 380

Physical therapy.

Surgical release usually not ideal given function is not improved in non-walkers and recurrence is common.

Question 381

What disease affects young males only and begins between 2-6years of age?

Answer 381

Duchenne Muscular Dystorphy

X-linked recessive.

Question 382

What is the treatment for Duchenne Muscular Dystrophy?

Answer 382

Prednisone .75mg/kg/day for a 5-7 year-old child with progressive disease.

Significant positive effect on disease progression: Delays deterioration of pulmonary function. Acutely imporves strength, slows progressive weakening, prevents scoliosis, and prolongs ambulation.

Pulmonary care with nightly ventilation.

Question 383

What are the side effects of medical treatment for Duchenne’s?

Answer 383

Osteonecrosis

Weight gain

Cushingoid appearance

GI symptoms

Mood lability

Headaches

Short stature

Cataracts

Question 384

What is the common foot deformity seen with Duchenne?

What is the treatment?

Answer 384

Equinovarus

Stretching, PT, and night time AFO.

If not helping operative: tendinoachilles lengthening with posterior tibialis tendon transfer and toe flexor tenotomies.

Question 385

What are the associated medical conditions with Achondroplasia?

Answer 385

Weight control problems

Hearing loss

Tonsillar hypertrophy

Frequent otitis media

Question 386

What features can you see on physical exam for a patient with achondroplasia?

Answer 386

Rhizomelic dwarfism ( Shorter Humerus and Femur)

Frontal bossin

Trident hands

Genu varum

Radial head subluxation

Muscular hypotonia in infancy

Thoracolumbar kyphosis and excessive lordosis.

Question 387

An imaging a patient has a champagne glass pelvis, squared iliac wings, and inverted V in distal femur physis. What disease do they have?

Answer 387

Achondroplasia

Question 388

When might you consider upper extremity lengtheing in a child with Achondroplasia?

Answer 388

If it is necessary to maintian ADL’s.

Question 389

What is the treatment for genu varum in a patient with Achondroplasia?

Answer 389

If having pain, fibular thrust, and progressive deformity then tibia +/- femoral osteotomy.

Based on CORA

Question 390

What is Multiple Epiphyseal Dysplasia?

Answer 390

Form of dwarfism characterized by irregular delayed ossification at multiple epiphyses.

Caused by failure of formation of secondary ossification center (epiphysis).

Spectrum of disorders with a spectrum of phenotypes.

Presents between age 5-14 years.

Question 391

What is most commonly affected in MED?

Answer 391

Proximal humerus

Proximal femur

Question 392

What is a form of short limbed disproportionate dwarfism?

Answer 392

MED

Question 393

A patient has the following physical exam fingings, what is the disease process?

Normal facies, spine, intelligence, and neurologic exam.

Valgus knee, short stubb fingers and toes, and some joint contractures.

Answer 393

MED

Question 394

What will radiographs of a patient with MED show?

Answer 394

Irregular delayed ossification at multiple epiphyses

Bilateral proximal femoral epiphyseal defects

Valgus knee with flattened femoral condyles and double layer patella.

Short stunted metacarpals

Short metatarsals.

Question 395

How can you differentiate MED from spondyloepiphyseal dysplasia?

Answer 395

Spondyloepiphyseal dysplasia involves the following:

Involves the spine.

Has a sharp curve.

Atlantoaxial instability and cervical myelopathy.

This is a mutation in type II collagen.

Question 396

How do you differenitate Perthes from MED?

Answer 396

MED will have symmetric bilatera presentation with early acetabular changes and lack of metaphyseal cysts.

Can perform skeletal survery.

Question 397

What is usually the treatment for MED?

Answer 397

Physical therapy.

NSAIDS for early OA

Childhood hip deformities usually resolve by skeletal maturity.

Occassionally with do realigning osteotomy or hemiepiphysiodesis at the knee for progressive genu valgum.

Question 398

Where is diastrophic dysplasia most common?

Answer 398

Finland.

Question 399

What phsical exam findings and features are consistent with diastrophic dysplasia?

Answer 399

Rhizomelic shortening

Cleft palate 60%

Cauliflower ears 80%

Hitchhikers thumb

Thoracolumbar scoliosis

Severe cervical kyphosis

Genu Valgum

Skewfoot

Rigid clubfeet

Question 400

What disease should be expected in a patient with hypoplastic or absent clavicles?

Answer 400

Cleidocranial dysplasia (dysostosis)

Rare 1 in 1,000,000

Failure of intramembranous ossification

Question 401

What are the orthopaedic manifestations of Cleidocranial dysplasia?

Answer 401

propoertionate dwarfism

clavicle dysplasia/aplasia

wormian bones

Frontal bossing

Delayed fontanelle ossification

coxa vara

shortened middle phalanges of 3-5 fingers

delayed ossification of pubis

delayed eruption of permanent teeth

Question 402

What is usually the only orthopaedic operative procedure performed on patients with cleidocranial dysplasia?

Answer 402

Coxa vara with a neck shaft angle of less than 100 degrees.

Question 403

What are the orthopaedic manifestations of mucopolysaccharidoses?

Answer 403

Porportionate dwarfism

Increased rate of carpal tunnel syndrome

C1-C2 instability

Delayed hip dysplasia

Abnormal epiphyses

Bullet shaped phalanges

Genu Valgum

Question 404

Nonorthopaedic conditions associated with Mucopolysaccharidoses?

Answer 404

Complex sugars in the urine

visceromegaly

Corneal clouding

Cardiac disease

Deafness

mental retardation (Except Morquio syndrome)

Enlarged skull

Question 405

What role does bone marrow transplant play in mucopolysaccharidoses?

Answer 405

Improved life expectancy.

Doesn’t alter orthopaedic manifestations.

Question 406

How do you differentiate Morquio, Hurler, San Filippo, and Hunter syndrome?

Answer 406

Morquio: Odontoid hypoplasia that leads to cervical instability. Obtain flexion-etension x-rays.

Hurler: Gargolylism, finger triggering

Morquio and Hurler have corneal clouding the other two have clear corneas.

Question 407

What are the orthopaedic manifestations of OI?

Answer 407

ligamentous laxity

short stature

scoliosis

codfish vertebrae

basilar invagination

Olecranon apophyseal avulsion fx

Coxa Vara

Congenital anterolateral radial head dislocations.

Question 408

What are the non-orthopaedic manifestations of OI?

Answer 408

Blue sclera

Dysmorphic triangle shaped facies

Hearing loss 50%

Dentinogenesis imperfecta

Vormian skull bones

Hypermetabolism: Increased risk of hyperthermia, hyperhidrosis, tachycardia, tachypnea, and heat intolerance

Think skin prone to subcutaneous hemorrhage

Mitral valve prolapse and aortic regurgitation.

Question 409

What leads to saber shin?

Answer 409

Multiple fractures of the tibia in children with Osteogenesis imperfecta.

Question 410

What can lead to apnea, altered consciousness, ataxia, and myelopathy.

Answer 410

Basilar invagination.

Usually in the third or fourth decade of life. However, it can present as early as the teenage years.

Question 411

What are some important considerations regrading bisphosphonate use and osteogenesis imperfecta?

Answer 411

Indicated in most cases of OI to reduce fractrue rate, pain, and improve amublation.

Does not affect development of scoliosis

Need to maintain bisphosphonate free period around the time if IM rodding

Question 412

How would you treat the following fractures in a child with OI?

18 month old with displaced both bone forearm fracture?

6 year old with displaced both bone forearm fracture?

16 year old with displaced both bone forearm fracture?

Answer 412

Reduction and casting: Fractures in children under 2 should be treated the same as children without OI.

Telescoping IM rods

IM rods, even in teenages who are no longer growing. Too high a risk of refracture with plates.

Question 413

Macrocephaly, hepatosplenomegaly, and osteomyelitis of the mandible or dental abscesses would be characteristic of what disease process?

Answer 413

Osteopetrosis. Autosomal recessive form. This form has more frequent fractures and overall worse prognosis.

Autosomal dominant form is usually asymptomatic. Patients usually first learn about the disease after fracture.

Question 414

How should fractures in a patient with osteopetrosis be managed?

Answer 414

For all but proximal femur fractures usually prolonged casting and non-weight bearing. There is increased risk of malunion and refracture. Exhibit delayed healing.

Proximal femur fracture. Use plate and screws. Avoid IMN. Slow steady drilling with constant cooling and changing of the drillbit.

Question 415

What is the medical management for osteopetrosis?

Answer 415

Autosomal recessive: Bone marrow transplant and high dose calcitriol (1,25 dihydroxy vitamin D).

Autosomal Dominant: Interferon gamma-1beta

Question 416

What medical conditions are associated with Down Syndrome?

Answer 416

Mental Retardation

Cardiac disease (50%)

Endocrine disorders(hypothyroidism)

Premature aging

Duodenal atresia

Hypothyroidism

Alzheimer’s disease

Question 417

What are the orthopaedic manifestations of down syndrome?

Answer 417

Generalized ligamentous laxity and hypotonia

Short stature

C1-C2 instability

Occipitocervical instability

Delayed motor milestones (Walk at 2-3 years of age)

Hip subluxation and dislocation

Patellofemoral instability and dislocation

Scoliosis and psondylolisthesis

Pes planus, metatarsus primus varus

SCFE

Question 418

What physical exam findings are often found in down syndrome?

Answer 418

Flattened facies

Upward slanting eyes

Epicanthal folds

Single palmar crease (simian crease)

Ligamentous laxity

Scoliosis

Question 419

How often and when does hip instability occur for children with down syndrome?

Answer 419

5%

occurs between age 2-10 years

Young with no bony changes or dislocation -> Abduction bracing

Older or symptomatic -> Capsulorrhaphy and pelvic and fremoral varus osteotomies.

Question 420

What foot deformity is seen in 50% of patients with down syndrome?

How should it be treated?

Answer 420

Pes planus or Planovalgus

Orthotics if symptomatic. Rarely but if refractory to orthotics then surgical correction.

Can also see Metatarsus primus varus and Hallux valgus (25%)

Question 421

What is the diagnostic criteria for JIA?

Answer 421

Must rule out infection.

Must include one of the following: Rash, presence of RF, iridocyclitis, c-spine involvement, pericarditis, tenosynovitis, intermittent fever, or morning stiffness.

Inflammatory arthritis lasting > 6 weeks in a patient younger than 16 years of age.

Question 422

What is the prognosis of JIA?

Answer 422

50% patients symptoms resolve without sequelae

25% are slightly disabled

25% have crippling arthritis or blindness

Best prognosis pauciarticular > polyarticular > systemic

Question 423

What radiographs should be obtained in patients with JIA?

Answer 423

Flexion-extension neck radiographs to rule out atlantoaxial instability.

Question 424

Which leg is typically longer in JIA?

Answer 424

The affected leg is typically longer.

Seen in oligoarticular disease

Can consider epiphysiodesis

Question 425

What treatment is recommended for JIA?

Answer 425

DMARDs and frequent opthalmologic exams.

High dose apsirin and NSAIDs are used less frequently.

intra-articular steroid injections.

Slit-lamp examination twice yearly if ANA (-), every 4 months if ANA (+)

Eye involvement can be indolent and lead to blindness.

Question 426

What work-up should all patients with Ehlers Danlos get?

Answer 426

Cardiac evaluation with Echo.

1/3 of patients have aortic root dilatation.

Question 427

What can be considered in a patient with joint pain and instability who has Ehler’s Danlos Syndrome?

Answer 427

Joint arthrodesis.

Soft tissue procedures are unlikely to be succesful in hypermobile joints.

Question 428

What constitutes hypermobility on the Beighton-Horan Scale?

Answer 428

5 or more points. Out of a 9 point scale.

Passive hyperextension of each small finger >90 deg 1 point each

Passive abduction of each thumb to the surface of the forearm 1 point each

Hyperextenion of each knee > 10 deg 1 point each

Hyperextension of each elbow > 10 deg 1 pint each

Forward flexion of trunk with palms on floor and knees fully extended 1 point.

Question 429

What are the orthopaedic manifestations of hemophilia?

Answer 429

Arthropathy- synovitis, cartilage destruction, joint deformity, and pseudotumor.

Pseudotumor is a intramuscular hematoma.

Iliacus hematoma may compress femoral nerve. Presents with paresthesias in the L4 distribution.

Leg length discrepancy, fractures, and compartment syndrome.

Question 430

What is Jordan’s sign?

Answer 430

squaring of patella and femoral condyles in hemophiliacs.

Question 431

How is a synovectomy performed in a patient with hemophilia?

Answer 431

First radioactive synoviorthesis (destruction of synovial tissue with intra-articular injection of radioactive agent)

Followed by surgical synovectomy.

Show to reduce recurrence.

Question 432

What is the most common cause of femur fracture in an infant?

Answer 432

Nonaccidental trauma.

Question 433

What percent of fractures due to non-accidental trauma occur in children younger than 5 years of age?

Answer 433

90%

Question 434

What is the most common cause of death in children?

What is the second most common cause of death?

Answer 434

Accidental injury.

Abuse.

Question 435

What are high specificity fractures for pediatric abuse?

Answer 435

Metaphyseal corner fracture.

Bucket handle fracture

Posteromedial rib fracture

Scapula fracture

Sternal fractures

Spinous process fractures.

Question 436

Cervical spine fractures are more common after trauma in what age group of children?

Answer 436

< 8 years-old

This is due to the fact that restraints do not fit young children.

Question 437

What is a Broselow tape used for?

Answer 437

Used with pediatric patients to help estimate medication doses, size of equipment, shock voltage for defibrillator etc.

Question 438

What is different about the airway in a child compared to an adult.

Answer 438

Smaller, larger tongue, floppy epiglottis, and large occiput.

Larynx is higher and more anterior. Sits at the level of the C2-C3 vertebral body compared with C6-C7 in the adult.

Makes visualization more difficult.

Question 439

What is the most common cause of cause of cardiorespiratory arrest in pediatric trauma patient?

Answer 439

Hypoventilation

Question 440

How much blood volume must be lost before seeing hypotension in a pediatric patient?

Answer 440

25-30%

Hypotension is a late sign.

Question 441

What is recommended for resucitation in the pediatric patient regarding fluids and blood?

Answer 441

Initial bolus of NS 20ml/kg

After two boluses give PRBC 10ml/kg

Question 442

What is the pediatric equivalent to an adult AC joint separation?

Answer 442

Distal clavicle physeal separation.

The periosteal sleeve and physis remain attached to the AC and CC ligaments.

Question 443

At what age do pediatric proximal humeral fractures peak?

Answer 443

15 years.

More common in adolescents.

Question 444

When does the following secondary ossifications centers appear in the proximal humerus?

Epiphysis

GT

LT

Answer 444

6 months

1-3 years

4-5 years

Closes at 14-17 in girls and 16-18 in boys.

Question 445

What are the acceptable parameters for non-operative management of a pediatric proximal humerus fracture?

Answer 445

<10 years old = Any degree of angulation

10-12 years old = 60-75 degrees of angulation

>12 years old = up to 45 degrees of angulation or 2/3 displacement.

Question 446

What structure most commonly prevents closed reduction of a proximal humerus fracture?

Answer 446

Long head of the biceps.

Question 447

What percent of pediatric shaft fractures are associated with a radial nerve palsy?

Answer 447

5%

Question 448

What degee of angulation can be accepted in a pediatric humeral shaft fracture and still have an excellent outcome from remodeling?

Answer 448

20 degrees for older children. 35-45 degrees in young children.

Should watch proximal third fractures in children over 10 years of age. These are the ones that go on to deformity.

Should also examine any shaft fracture for pathologic lesions or abuse as these injuries are relatively rare.

Malunion of up to 20-30 degrees is well tolerated.

Question 449

True or false. Transphyseal fracture of the distal humerus is associated wth:

Tardy ulnar nerve plasy

Cubitus varus deformity

Avascular necrosis of the medial condyle

Answer 449

False, this is associated with lateral condyle fractures.

True

True

Question 450

What should be performed at the time of CRPP for a distal humeral physeal fracture?

Answer 450

Arthrogram.

Posterior approach often easiest and avoids damage to articular cartilage.

Helps visualize starting points on capitellum and assessment of the quality of reduction.

Mix equal parts saline and contrast.

Question 451

What is the radiographic difference between pediatric elbow dislocation and and a transphyseal separation?

Answer 451

Posteromedial for transphyseal separation where elbow dislocations are typically posterolateral.

Question 452

How long should you follow a child after a distal humerus physeal separation?

Answer 452

2-4 years to insure there is no growth arrest, deformity, or osteonecorsis.

70% will have cubitus varus. This is cause by AVN, malunion, or growth arrest. Tx is a lateral closing wedge osteotomy.

Question 453

What demographic do you usually see medial epicondyle fractures in?

Answer 453

boys age 9-14. (75%)

Question 454

What is a medial condyle fracture associated with in 50-60% of cases?

Answer 454

Elbow dislocation.

Most spontaneously reduce but fragment remains incarcerated in joint in 15% of cases.

Question 455

What radiographs and why should be obtained in pediatric medial epicondyle fractures?

Answer 455

Besides standard elbow radiographs should obtain a internal oblique view.

This is done to evaluate displacement.

Can also obtain a distal humeral axial view. Obtained by angling beam 25 degrees anterior to long axis of humerus. This is the most accurate radiograph.

Question 456

Are valgus instability and ulnar nerve dissfuction absolute or relative indications for operative fixation of a medial epicondyle fracture?

Answer 456

relative.

Absolute are open fractures and incarcerated medial epicondyle fractures.

Question 457

What degree of displacement is typically indicated for non-operative treatment of a medial epicondyle fracture?

Answer 457

<5mm displacement

Elbow should be immobilized 3 weeks in a long arm cast with the elbow flexed to 90 degrees.

Question 458

True or false radiographic union is 9 times more likely with operative treatment of medial epicondyle fractures?

Answer 458

True

Question 459

What is the most common complication after medial epicondyle fractures?

Answer 459

Elbow stiffness.

Most common whether treated non-operatively or operatively.

Question 460

What is the recommended treatment for a asymptomatic lateral condyle fracture non-union?

Answer 460

Observation

Fixation only recommended if there is pain, instability, or cubitus valgus with ulnar nerve palsy.

Question 461

What is Dejerine Sottas Syndrome?

Answer 461

Hereditary motor-sensory neuropathy that is less common than CMT.

Has an early onset demyelinating motor and sensory neuropathy.

Question 462

What is dolichostenomelia?

Answer 462

Unusually long limbs.

Seen in patients with Marfan Syndrome.

Question 463

Which pediatric elbow fracture has the highest risk of non-union when treated non-operatively?

Answer 463

lateral condyle fractures.

Question 464

What is normal acetabular index in an infant?

Answer 464

27.5 degrees.

> 35 degrees suggests acetabular dysplasia.

Question 465

If performing saucerization of a discoid meniscus how much peripheral rim should be left?

Answer 465

6-8mm

Question 466

What fixation strategy of a SCFE increases risk of AVN?

Answer 466

Hardware placement into the posterosuperior femoral neck.

There has not been shown to be any increased risk with 1 vs 2 screws.

Question 467

What is the most common metatarsal fracture in toddlers?

Answer 467

1st metatarsal shaft

Question 468

This image is an example of what disease?

Answer 468

Spondyloepiphyseal dysplasia (SED)

disproportionate dwarfism, spinal involvement, and a barrel chest.

From a COL2A1 mutation

Question 469

This image is an example of what disease?

Answer 469

Diastrophic dysplasia

Image shows “hitch hikers” thumb and “cauliflower ear”

Also will see cleft palate and short-limbed dwarfism

Due to a sulfate transport mutation.

Question 470

What disease is depicted in the attached image?

Answer 470

Cleidocranial dysplasia

Due to a defect in core-binding factor alpha 1 (CBFA-1)

Causing dwarfism and absent clavicles.

Question 471

What disease is depicted in the attached image?

Answer 471

Multiple epiphyseal dysplasia (MED)

Due to a COMP mutation.

Causes disproportionate dwarfism with multiple epiphyses involved, shortened metacarpals, valgus knees, but no spinal involvement.

Question 472

What is an aneurysmal bone cyst?

Answer 472

Benign, non-neoplastic reactive bone lesion filled with multiple blood filled cavities.

Primary form: now known to be a neoplasm as it is driven up upregulation of the ubiquitin-specific protease USP6 (tre2) gene on 17p13 when combined by translocation with a promoter pairing. Most common translocation t16;17

Secondary form: No translocation, not neoplastic.

Question 473

What is this an example of?

Answer 473

Developental coxa vara

Due to an ossification defect of the inferior femoral neck.

Results in a morphologically short femoral neck with a relatively vertical physis and decreased femoral anteverion.

The Hilgenreiner’s-epiphyseal angle is used to grade the severity and likelihood of progression as well as to assess the adequacy of deformity correction following osteotomy.

Vaglus overcorrection is recommended.

Question 474

Rate of physeal arrest after distal femoral fractures?

Answer 474

According to Basener et al.

36% of SH 1 fractures

58% SH 2

49% SH 3

64% in SH 4

Question 475

What is Drehmanns Sign?

Answer 475

Obligate external rotation of the hip with hip flexion.

Seen in SCFEs.

Question 476

How should a congenital knee dislocation in a 7 month old that can be passively flexed to 25 degrees be treated?

Answer 476

Should be treated with open reduction typically at 6 months of age but before the age of 1.

Exception is if it can passively flex past 30 degrees.

Question 477

What growth arrest can be seen in pediatric midshaft femur fractures?

Answer 477

Tibial tubercle growth arrest -> recurvatum

Question 478

What may be the significance of the neurocentral synchondrosis?

Answer 478

It is a cartilaginous gorwth place that has been implicated as a potential cause of adolescent idiopathic scoliosis.

Develops between the centrum and posterior neural arches.

Closes cervical 5-6 years, lumbar 11-12 years, and thoracic 14-17 years.

Question 479

What are the two most significant predictors of long term outcome in patients with Perthes Disease?

Answer 479

Age at presentation.

Range of motion of the hip.

Question 480

What does this picture depict if this is a 6 year old boy who has difficulty with abduction and external rotation with history of a difficult birth?

Answer 480

Putti sign- copnensatory scapulothoracic motion to adduct the arm resulting in elevation of the superomeidal border of the scapula.

Brachial Plexus Birth Palsy leads to varign degrees of gleno humeral dysplasia with different recommended treatment.

TYPE II and III latissimus dorsi/ teres major tendon transfers for rotatoru cuff weakness and minimal GH joint deformity

Type III and IV: Open/arthroscopic GH reduction , anterior soft tissue contracture releases, posterior tendon transfers for weakness and moderate GH joint deformity

Type IV and V: Humeral derotational osteotomy for persistent internal rotation contractures and external rotation weakness

Question 481

Neurofibromatosis can be associated with what forearm disorder in pediatric patinets?

Answer 481

While much less common than congenital pseudoarthrosis of the tibia, congenital pseudoarthrosis of the forearm is associated with neurofibromatosis in about 50% of cases.

Question 482

Posttraumatic physeal arrest is most common at which physis?

Answer 482

2 is distal femur

Distal tibia, specifically distal medial tibia.

Question 483

What is the recommended treatment for elbow flexion contractures that are the result of brachial plexus birth palsies?

Answer 483

contractures <35 degrees treat with serial nightime extension splinting.

contractures >35 degrees treat with serial casting.

Failure on non-operative treatment can be surgically managed with anterior capsular release and concomitant lengthening of the biceps and brachialis tendons.

It is thought that these contractures develop because of persistent triceps weakness from C7 root injuries.

Question 484

what is depicted in the image?

Answer 484

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

Found in LCP and indicates a more severe disease course.

The other 4 “at risk signs from Catterall are:

1 Calcification lateral to the epiphysis

2 Lateral subluxation of the femoral head

3 a horizontal physis

4 metaphyseal cysts

Question 485

Repetitive overuse injuries of the physis in gymnansts occur through what zone of the physis?

Answer 485

Zone of provisional calcification

Metaphyseal perfusion is disrupted, which inhibits calcification