Peds - RC Q's

Question 1

RC 2009 What volume of crystalloid do you bolus a peds trauma pt (in cc/kg)? <ol> <li>10</li> <li>20</li> <li>30</li> <li>40</li></ol>

Answer 1

2.

Question 2

<div>RC 2016 In a 6 month old, list 4 radiographic features suggesting DDH</div>

Answer 2

“Acetabulum: AI>25, rounded edges, poorly defined/widened teardrop, Lateral CEA <20<div>Femoral head: delayed ossification, assymetric, small nuclei</div><div>Others: break in shenton’s line, not in infeormedial corner of hilgenreiner’s and perkins line</div>”

Question 3

RC 2017 Name 8 risk factors for Pavlik harness failure.

Answer 3

<ul> <li>Patient Factors</li> <ul> <li>Pts with soft tissue or neuro disease (Pavlik is contraindicated!)</li> <ul> <li>myelodysplasia, CP or arthrogryposis</li> <li>Ehlers-Danlos</li> </ul> <li>Bilaterality</li> <li>Initial instability on presentation</li> <li>High-grade/severe dislocation</li> <li>Age at treatment initiation (>3 months)</li> <li>Male</li> <li>Compliance</li> </ul> <li>Imaging factors</li> <ul> <li>low % coverage of femoral head</li> <li>low alpha angle</li> <li>increased distance b/w middle of proximal metaphyseal border and Hilgenreiner’s line</li> <ul> <li>JPO 2009 - Predictive Factors for Unsuccessful Treatment of Developmental Dysplasia of the Hip by the Pavlik Harness</li> </ul> <li>increased distance b/w middle of metaphyseal border and ischial line</li> </ul></ul>

Question 4

<div>RC 2015, 16 - What are 3 radiographic findings of ischemic necrosis of the femoral head following DDH treatment? </div>

Answer 4

Salter Criteria<div><ul> <li>Head:</li> <ul> <li>Failure of appearance or growth of ossific nucleus at 1 year after reduction</li> <li>Increased density and fragmentation of ossified femoral head</li> </ul> </ul> <ul> <li>Physis</li> <ul> <li>Premature physeal closure</li> </ul> <li>Fem Neck</li> <ul> <li>Broadening of femoral neck</li> <li>Shortening of the femoral neck</li> </ul> <li>Residual deformity</li> <ul> <li>Coxa magna, plana, coxa vara, broad fem neck</li> </ul> <li>Proximal Femur</li> <ul> <li>Greater trochanter overgrowth</li> </ul></ul></div>

Question 5

<div>RC 2010 - Unilateral DDH in 8 month old, what is the most important clinical sign?</div>

Answer 5

<div>Range of motion (ROM) testing of the hip is important; a decrease in abduction is the most sensitive test result for DDH.</div>

<div>ROM will be normal in children younger than 6 months however, because contractures will not yet have developed</div>

Question 6

RC 2010 - List 5 Blocks to reduction in DDH in 10 month old?

Answer 6

Extra-articular: iliopsoas, AL, capsule<div>Intra-articular: pulvinar (fatty tissue in acetabulum), inverted labrum, hypertrophied ligamentum teres and TAL</div>

Question 7

<div>RC 2013 - All of the following pelvic osteotomies have normal articular cartilage articulating with head except</div>

<ol> <li>Dega</li> <li>Bernase PAO</li> <li>Chiari</li> <li>Salter</li></ol>

Answer 7

“C - chiari is SALVAGE<div><br></br></div><div><img></img><br></br></div>”

Question 8

RC 2012, 14 SCFE; when is the child predisposed to having the screw head impinge on the labrum?<div><ol> <li>2 screws</li> <li>1 screw if screw head is medial to the intertrochanteric line</li> <li>if screw head is distal to LT</li> <li>screw distal to apophysis</li></ol></div>

Answer 8

B.

Question 9

<div>RC 2012 SCFE what is true?</div>

<ol> <li>Two and one screw have the same risk of penetration</li> <li>Two and one screw have the same rate of chondrolysis</li> <li>Two screws has more torsional rigidity</li> <li>Higher risk of chondrolysis when using fully threaded screw</li></ol>

Answer 9

C

Question 10

RC 2011, 14, 16 - Give 4 indications for consideration of prophylactic pinning of the opposite hip in a child with SCFE.

Answer 10

“Young age (open TRC, age < 10 years)<div>Endocrinopathy</div><div>Renal Disease</div><div>History of radiation (MCQ ‘17)</div><div>High risk of poor follow up (?)<br></br></div>”

Question 11

<div>RC 2017 - 8 year old presents with right hip pain, afebrile, labs normal. Past medical history significant for leukemia treated with whole body radiation, now in remission. Radiographs shown have an unusual SCFE</div>

<ol> <li>Bilateral in situ pins</li> <li>MRA of femoral heads</li> <li>Biopsy</li> <li>Antibiotics</li></ol>

Answer 11

A. hx of radiation

Question 12

<ul> <li>RC 2012 - List 2 radiographic risk factors for SCFE development?</li><ul> </ul> </ul>

Answer 12

<ul><li>JAAOS 2006 - SCFE/AAOS Core Review</li><ul><li>Deep acetabulum</li><li>Increased physeal obliquity</li><li>decreased neck-shaft angle (coxa vara)</li><li>Decreased femoral anteversion</li></ul></ul>

Question 13

RC 2013 - What are 3 endocrine conditions associated with SCFE?

Answer 13

“Hypothyroidism (high TSH)<div>Hyperparathyroidism<br></br><div>Renal osteodystrophy (high BUN/Cr)</div><div>Panhypopituitarism</div><div>GH deficiency treated with growth hormone</div><div><br></br></div><div><br></br></div><div>Down’s at risk of SCFE given hypoT</div></div>”

Question 14

<div>RC 2013 - SCFE, all is true EXCEPT</div>

<ol> <li>Only occurs in a narrow age range</li> <li>Pin penetration proved to cause chondrolysis</li> <li>A chronic slip that has been pinned. Better to wait a few years before an osteotomy procedure.</li> <li>30% in the general population and 70% of renal etiology will have a bilateral slip on initial presentation</li></ol>

Answer 14

C - want to do osteotomy early<div><br></br></div><div>D - true</div>

Question 15

<div>RC 2018, 15, 16 - In patients with Perthes, all of these will benefit from a varus derotation osteotomy, except:</div>

<ol> <li>8 yo with Herring B </li> <li>7 yo with lateralized/subluxed hip</li> <li>Epiphyseal slip-in angle >20%</li> <li>Performing the osteotomy during initial or fragmentation phase of disease</li></ol>

Answer 15

Answer: B<div><div>A - will benefit</div> <div>B - indicates <b>hinge abduction</b> - ie needs a VALGUS osteotomy and not a VDRO</div> <div>C - Epiphyseal slip-in angle/index >20% is a good sign</div> <div>D- earlier better</div></div><div><br></br></div>

Question 16

<div>RC EXAM - Prognostic factors for Perthes - all except</div>

<ol> <li>Age</li> <li>Gender</li> <li>ROM</li> <li>Extent of head involvement</li></ol>

Answer 16

“C.<div><div>"”The lateral pillar classification (p < 0.0001) and the age at the onset of the disease (p = 0.0001) were both strong prognostic factors. Female patients did significantly worse than male patients if they were over the age of 8.0 years at the onset of the disease (p = 0.004).</div></div><div><br></br></div><div><br></br></div><div>RF FOR DEVELOPING PERTHES:</div><div><ul><li>positive family history</li><li>low birth weight</li><li>abnormal birth presentation</li><li>second hand smoke</li><li>Asian, Inuit, and Central European decent</li></ul></div>”

Question 17

<div>RC 2018, 10, 11, 13,... - List 4 clinical or radiographic factors associated with poor prognosis in Perthes</div>

Answer 17

“<ul> <li>Clinical</li> <ul> <li>Female</li> <li>Presentation >6 years</li> <li>Decreased hip ROM</li> </ul> </ul> <ul> <li>Radiographic - rmr classification systems!</li> <ul> <li>Lateral Pillar Classification B/C, C</li> <li>Two or more Catterall ““Head at Risk””</li> <ul> <li>Horizontal Physis</li> <li>Metaphyseal Cysts</li> <li>Lateral Subluxation</li> <li>Gage Sign - V shaped cyst in lateral physis</li> <li>Lateral Calcification</li> </ul> <li>Premature physeal closure</li> <li>Extent of subchondral fracture = whole head involvement</li> <li>Extent of femoral head/acetabular deformity at maturity</li> </ul></ul>”

Question 18

RC 2012 - 9 yr Boy perthes, with Herring B (they said Herring B) hip. What is the best option for management? <ol> <li>Observation</li> <li>ROM</li> <li>Containment surgery with either a femoral, pelvic or both </li> <li>Petrie casting</li></ol>

Answer 18

3.<div><div>Surgical treatment better in kids > 8, lateral pillar B, B/C</div></div>

Question 19

<div>RC 2011, 2014 - Give 6 causes of acquired coxa vara in pediatric patient</div>

Answer 19

“<ul> <li>Idiopathic: Perthes/AVN, SCFE</li> <li>Metabolic: Rickets</li> <li>Infectious: Septic Arthritis/Osteomyelitis</li> <li>Trauma: fem neck #, fem head dislocation</li> <li>Neoplastic: Fibrous Dysplasia</li> <li>Skeletal Dysplasia</li> <li>Pathologic Bone: OI</li> </ul> <div><img></img></div>”

Question 20

<div>RC 2011 - All are true about reasons to operate for coxa vara except? </div>

<ol> <li>HE angle > 60°</li> <li>Trendelenberg gait</li> <li>pain</li> <li>neck shaft of 110 deg</li></ol>

Answer 20

“D. N-S angle <90-100deg is indication for OR<div><br></br></div><div><ul> <li>Indications: RC EXAM</li> <ul> <li>Symptomatic limp, Trendelenburg gait or progressive deformity</li> <li>HE Angle > 60o</li> <li>Progressive decrease in neck-shaft angle to 90-100o</li></ul></ul><div>Tx: Valgus osteotomy +/- adductor tenotomy</div><div><br></br></div><div>Goal: Normal H-E angle = 16 Degrees (shoot for this, although <38 deg will only lead to 5% recurrence)<br></br></div><div><br></br></div><div><img></img><br></br></div></div>”

Question 21

<div>RC 2014, 2010 - All of the following are indicated in the management of a unilateral congenital knee dislocation in a newborn EXCEPT?</div>

<ol> <li>U/S of hips</li> <li>Serial casting</li> <li>Pavlik harness</li> <li>Open reduction</li></ol>

Answer 21

<div>C.</div>

<div>In the setting of a dislocated knee and hip, knee hyperextesion makes treatment in a Pavlik harness difficult and nearly impossible. The knee should be promptly addressed with manipulation and serial flexion casting. With knee flexion obtained, the patient should then be placed in a Pavlik harness with the knee flexed as simultaneous treatment of the hip and knee<br></br></div>

<div><br></br></div>

<div><br></br></div>

Question 22

“<div>RC 2012 - List 4 radiographic risk factors for progression of infantile Blount’s</div>”

Answer 22

<ul> <li>Metaphyseal-Diaphyseal Angle > 16 deg</li> <li>Multi-planar Deformity (varus, procurvatum of proximal tibia, IR of proximal tibia)</li> <li>Higher Langenskiold classification</li> <ul> <li>epiphysis: Medial sloping, joint depression</li><li>physis: Physeal bar across medial physis, Irregular/widened medial physis</li><li>metaphysis: Beaking of proximal medial tibial metaphysis</li> </ul></ul>

Question 23

<div>RC 2014 - A 16 month old healthy boy presents to your clinic with bowlegs. He ambulates appropriate for age, and is in the 60th percentile for his height and weight. You are shown an x-ray with varus knees, no abnormalities other than perhaps very slight beaking, metaphyseal-diaphyseal angle is measured and given to you at 12 degrees. What should you do?</div>

<ol> <li>Observe and follow up appointment</li> <li>KAFO</li> <li>Guided growth</li> <li>Proximal tibial osteotomy</li></ol>

Answer 23

A<div>Normal MDA is <10, at risk MDA 10-16</div><div>Treatment: <3 yrs, grade 1-2 –> observe or brace</div><div>>4 years, grade 3+ –> surgery<br></br></div>

Question 24

<div>RC 2009, 2010 - 26 month old child. Tibia vara with MDA angle of 19o. What do you do?</div>

<ol> <li>Rigid KAFO</li> <li>Extra-articular Osteotomy</li> <li>Intra-articular Osteotomy</li> <li>Hinged Knee Brace</li></ol>

Answer 24

A<div><div>MDA>16, but <4 years of age = BRACE = KAFO</div></div>

Question 25

<div>RC 2016 - In adolescent blounts disease, all are true about guided growth EXCEPT?</div>

<ol> <li>Poor outcomes for BMI > 35</li> <li>Dependent on growth remaining</li> <li>It is associated with a high rate of hardware failure</li> <li>Treatment has poor results in children over age 12</li></ol>

Answer 25

D.<div><ul><li>Funk SS (JPO 2016) Hemiepiphysiodesis Implants for Late-onset Tibia Vara</li> <ul> <li>60% surgical failure (required repeat OR for osteotomy, revision surgery, mechanical axis deviation > 40mm)</li> <ul> <li>Risk factors BMI >35, increased deformity (MAD >80mm)</li> <li>Higher risk of implant failure in younger kids</li> </ul> </ul></ul></div>

Question 26

<div>RC 2017 - You are called to the nursery to see a newborn with a foot deformity. Given clinical pictures and radiographs of posteromedial bowing. What should you advise the parents?</div>

<div>A. Will need serial casting</div>

<div>B. Should have amputation</div>

<div>C. Osteotomy for re-alignment</div>

<div>D. Will need to be followed for leg length discrepancy</div>

Answer 26

D.<div><div>We recommend all the children with CPMBT to be followed up periodically till skeletal maturity, to identify cases with residual bowing, ankle deformity, muscle weakness, and limb length inequality as active surgical intervention may be needed to correct these problems.</div></div><div><br></br></div>

Question 27

<div>RC 2016 - A 1 year old child is referred to your clinic with a severe LLD. Radiographs demonstrate absence of the tibia, femoral condylar hypoplasia. No active extension demonstrated. What is the best management? </div>

<div></div>

<ol> <li>Fibular transfer to create a single bone lower limb </li> <li>Through knee amputation </li> <li>Symes amputation </li> <li>MRI to assess for residual tibial anlage</li></ol>

Answer 27

“2.<div><br></br></div><div>No extensor mechanism - amp!</div><div><ul> <li>Treatment Principles:</li> <ul> <li>Type 1 –> knee disarticulation (no extensor mechanism)</li> <ul> <li>Brown Procedure:</li> <ul> <li>Centralization of the fibula under the femur</li> <li>Requires an extensor mechanism</li> </ul> </ul> <li>Type 2 –> proximal tibfib synostosis with Syme amputation</li> <li>Type 3 –> Syme amputation</li> <li>Type 4 –> centralize foot</li> </ul></ul></div><div><img></img><br></br></div>”

Question 28

<div>RC 2014, 2012 Regarding a Syme amputation, all are true EXCEPT?</div>

<div>a. Rigid socket is not necessary for good function</div>

<div>b. Long lever arm provides for good function</div>

<div>c. Often need a shoe lift on the contralateral side</div>

<div>d. Posterior migration of the heel pad may prevent weight-bearing</div>

Answer 28

C. shoe lift is needed for BOYD.<div><br></br></div><div><br></br></div>

Question 29

<div>RC 2018 - What is deformity of typical clubfoot position?</div>

<div>a.Pronation, forefoot adduction, varus hindfoot, plantar flexed</div>

<div>b.Pronation, forefoot adduction, valgus hindfoot, plantar flexed</div>

<div>c.Pronation, forefoot abduction, varus hindfoot, dorsiflexed</div>

<div>d.Pronation, forefoot adduction, valgus hindfoot, dorsiflexed</div>

Answer 29

A.<div><br></br></div><div>CAVE P</div><div>midfoot cavus and pronation</div><div>forefoot adductus</div><div>hindfoot varus and equinus</div>

Question 30

<div>RC 2018, 2011 - 2 yr old treated for previous treated for idiopathic club foot with ponsetti casting. He now presents with intoeing gait and has dynamic supination with gait? What is the best method of treatment?</div>

<ol> <li>tib ant transfer</li> <li>tib post transfer</li> <li>re cast </li> <li>med calc osteotomy</li></ol>

Answer 30

3. recast if <2 years

Question 31

<div>RC 2009 - Residual deformity after clubfoot treatment. Which has the worst functional outcome?</div>

<ol> <li>Weak gastroc / residual hindfoot deformity</li> <li>Hindfoot varus / forefoot adductus</li> <li>Forefoot adductus</li> <li>Residual hindfoot deformity / equinus contracture</li></ol>

Answer 31

D.<div><br></br></div><div><div>The most significant limitations in these treated clubfeet averaged (a) a 42% decrease in normal ankle motion, specifically lacking 65% of normal dorsiflexion, a consistent finding independent of treatment</div></div>

Question 32

<div>RC 2008 - Adult with treatment of foot condition with casting and surgery. Now has flat top talus. What was the condition: (2008)</div>

<ol> <li>TEV</li> <li>CVT</li></ol>

Answer 32

A<div><br></br></div><div><div>Flat-top talus has been described as a pathologic change secondary to idiopathic clubfoot condition and/or as a direct result of nonoperative manipulation involving forced dorsiflexion and molding of the cartilaginous talus. (foot ankle International)</div></div>

Question 33

<div>RC 2013 - 8 yo with cavus foot and pronated 1st ray with significant symptoms for at least 3 months. Coleman block test with correctable hindfoot. Best treatment</div>

<ol> <li>Lateralalizing calcaneus osteotomy</li> <li>Posteromedial release</li> <li>1st MT dorsiflexion osteotomy and plantar release</li> <li>Molded plantar orthosis</li></ol>

Answer 33

3. forefoot driven given Coleman block test –> needs forefoot procedure.<div><br></br></div><div>Similar Q… What is the best management?</div><div> <ol> <li>Plantar fascia and 1st MT osteotomy</li> <li>Calcaneal osteotomy and FDL transfer</li> <li>Observe</li> <li>Orthosis – as initial management</li></ol> <ol> <li>SIGH. </li> </ol><ul> <li>If NORMAL kid and mild deformity –> non-op</li> <li>If NEURO kid –> Op</li> <li>ANSWER: A</li> </ul></div>

Question 34

<div>RC 2008 - What is the main advantage of a closing wedge cuboid osteotomy over lateral calcaneal slide for cavus foot with metatarsus adductus?</div>

<ol> <li>Higher rate of union</li> <li>Better cosmesis</li> <li>Better correction of forefoot deformity</li> <li>Better correction of hindfoot deformity</li></ol>

Answer 34

3. osteotomy should be through the CORA<div><br></br></div><div><div>Shortening the lateral column will correct all elements of the deformity much better than a lateral calcaneal slide.</div><div><br></br></div><div><br></br></div></div>

Question 35

<div>RC 2015 - What orthotic will you prescribe for a 16yo boy with a subtle cavus foot (4 points)?</div>

Answer 35

<ul> <li>Custom, full length, semi-rigid orthotic</li> <li>Recessed first ray</li> <li>Lowered medial arch</li> <li>Lateral hindfoot wedge or post</li> <li>Heel cushion</li></ul>

Question 36

<div>RC 2015 - 12yo girl with persistent pain and disability 6mos after an ankle sprain. Apart from fibular collateral ligament injury, what findings will you find on XR or MRI (5 points)</div>

Answer 36

<ul> <li>X-ray:</li> <ul> <li>Subtle cavus foot</li> <li>Tarsal Coalition</li> <li>Anterior process of calcaneus fracture</li> <li>Lateral talar process fracture</li> <li>5th metatarsal fracture</li> </ul> </ul>

<ul> <li>MRI</li> <ul> <li>Peroneal tendon injury</li> <li>Syndesmotic Ligament Injury</li> <li>Osteochondral fragment</li> </ul></ul>

Question 37

<div>RC 2016 - What is true in congenital vertical talus?</div>

<ol> <li>Idiopathic and syndromic cases require casting</li> <li>Doesn’t require TAL</li> <li>Pinning of the TN joint is rarely indicated</li> <li>The calcaneus is in dorsiflexion</li></ol>

Answer 37

“A<div><br></br></div><div>D - calc and talus are both in equinus.</div><div>B/D - Tx: Reverse ponsetti casting (Dobb’s) with plantar flexion and inversion followed by pinning of TN with K-wire and TAL<br></br></div>”

Question 38

<div>RC 2012 - What is an Anatomic Description of CTV?</div>

<ul><ul> </ul></ul>

Answer 38

<ul><li>JAAOS 2015 - Congenital Vertical Talus</li><ul><li>Dorsal dislocation of the navicular on the talar head</li><ul><li>Hypoplastic and wedge shaped</li></ul><li>Hindfoot is equinus and valgus</li><li>Midfoot and forefoot are dorsiflexed and abducted</li></ul></ul>

Question 39

<div>RC 2012 - What is an anatomic description of CVT</div>

<ol> <li>Dorsolateral dislocation of the foot on the talus</li> <li>Equinus</li> <li>Cavovarus foot</li></ol>

Answer 39

A<div><br></br></div><div>irreducible dorsolateral navicular dislocation</div><div>vertically oriented talus</div><div>calcaneal eversion with attenuated spring ligament<br></br></div>

Question 40

<div>RC 2011 - What is a classic feature of CVT?</div>

<ol> <li>calcaneus is dorsiflexed</li> <li>contracted Achilles tendon</li> <li>contracted Post tib tendon</li> <li>hind foot in varus, inverted</li></ol>

Answer 40

Answer: B<div><br></br></div><div>1-calc and talus are PF</div><div>3-tib post is subluzed over medial mal (thus a dorsiflexor)</div><div>4-hindfoot in valgus</div>

Question 41

RC 2013, 2012 List 3 components of minimally invasive treatment of idiopathic congenital vertical talus.

Answer 41

<ul> <li>Serial Casting with Reverse Ponsetti Method (plantarflexion and inversion stretching)</li> <li>Percutaneous Achilles Tenotomy</li> <li>Percutaneous pinning of talonavicular joint</li> <li>Boots and bars (feet at 0deg)</li></ul>

Question 42

<div>RC 2018, 2016 - What is true when comparing the Triple-C osteotomy and an Evans lateral column lengthening for the treatment of pediatric flatfoot? (variation of this 2015, 2016 - see below)</div>

<div>a.The Evans procedure is better at correcting talar head coverage or talonavicular coverage </div>

<div>b.Triple C has is associated with higher complications than Evans</div>

<div>c.A complication of Triple C is CC joint subluxation</div>

Answer 42

A.<div><div>The calcaneal-lengthening osteotomy achieves better improvement of the relationship of the navicular to the head of the talus but it is associated with more frequent and more severe complications.</div></div>

Question 43

<div>RC 2015, 2016 What is part of the Evans procedure for a pediatric idiopathic flexible flatfoot:</div>

<div>A) Temporarily stabilize the CC and TN joints</div>

<div>B) 50% increase of fusion rate with autogenous bone graft</div>

<div>C) Can correct forefoot supination with opening wedge osteotomy of the medial cuneiform</div>

<div>D) Osteotomy of anterior process should be 4mm proximal to the CC joint</div>

Answer 43

<div>ANSWER: C - Mosca modification was classifically closing wedge, but you could do an opening wedge to address supination</div>

<div><br></br></div>

<div>GROUP CONSENSUS</div>

<div><br></br></div>

<div>A- false (only temporarily stability CC joint)</div>

<div>B - equivalent results auto=allograft</div>

<div>C - true</div>

<div>D - false (osteotomy should be 1.5cm prox)</div>

Question 44

<div>RC 2017 - 8 year old has a flexible flat foot. What is true?</div>

<div>A) Most can be managed with orthotics</div>

<div>B) Surgical plan would consist of soft tissue procedures</div>

<div>C) 30% have short Achilles</div>

Answer 44

C. short Achilles tendon accounted for 27% of the flat feet and was characterized by restricted ankle dorsiflexion.<div><br></br></div><div>A - orthotics dont help</div><div>B - surgery is often boney procedures</div>

Question 45

<div>RC 2010 - Child with multiple ankle sprains treated non-operatively. Pain in anterolateral aspect of ankle and symptoms for 3 months. No pain with ADLs. Unable to run more than 20 minutes. You are told that he has a tarsal coalition. List 2 treatment options at this time?</div>

Answer 45

Non-op<div>Orthotic/Immobilize with cast</div><div>Activity modification</div><div>NSAIDs</div>

Question 46

<div>RC 2011, 2014 What is not true about tarsal coalitions?</div>

<ol> <li>MRI is best for cross sectional size estimate</li> <li>talo-calcaneal common</li> <li>best see the calcaneonavicular coalition on an oblique xray</li> <li>may have non-bony coalition</li></ol>

Answer 46

A. CT is gold standard.

Question 47

<div>RC 2015 Given x-ray of a ball and socket ankle. What is the underlying pathology?</div>

<ol> <li>Ehlers-Danlos</li> <li>Post traumatic</li> <li>Lateral ligament instability</li> <li>Tarsal coalition</li></ol>

Answer 47

D.

Question 48

RC 2012 - 4 year old presents with toe walking, which is true? <div>A. Thought to have autosomal dominant inheritance</div> <div>B. Most are due to neurologic etiology</div> <div>C. Usually resolve without treatment</div>

Answer 48

“A.<div><br></br></div><div>B. most idiopathic</div><div><div> <div> <div><img></img></div> </div></div></div><div><div>C = false. resolve before 2 years, not >2.</div><div>No change in ankle ROM @ final f/u and 25% improvement in gait</div></div>”

Question 49

<div>RC 2008 12 y.o. with diastomatomyelia and an associated calcaneovalgus foot. What is the treatment?</div>

<ol> <li>Non-op, aggressive physio and AFO</li> <li>Peroneus brevis to longus transfer</li> <li>Tib Ant to calcaneus transfer</li> <li>Split posterior tibialis transfer</li></ol>

Answer 49

ANSWER: A<br></br><div><br></br></div><div>Calcaneovalgus foot is often L5 level, surgery can involve Tib ant to calcaneus. NONOP to start of course</div>

Question 50

“<div>RC 2011, 2014- Give 3 findings in the cervical spine in a patient with Down’s Syndrome</div>”

Answer 50

AAI<div>Atlanto-occipital instability (Rare)</div><div>Odontoid hypoplasia, Os odontoideum, Persistent dentocentral synchonrosis</div><div><br></br></div>

Question 51

<div>RC 2013, 2016 - All are true about the cervical spine in Down’s syndrome, EXCEPT: </div>

<ol> <li>Instability occurs only at the atlantoaxial level</li> <li>Cervical spine xrays have no predictive value of future spine problems</li> <li>In kids, if the patient is asymptomatic, they do not require screening prior to most sports participation</li> <li>25% of Down’s patients have cervical spine problems</li></ol>

Answer 51

A.<div><br></br></div><div>A - false: AAI and Atlanto-occipital are not uncommon</div><div>B - true</div><div>C - true. only screen HIGH RISK activities</div><div>D - true. 30%</div>

Question 52

RC Oral - Diagnostic Criteria for NF?

Answer 52

<div>At least 2 of:</div>

<div>Mnemonic: CAFÉ-SPOT</div>

<ul> <li>Café au lait spots (coast of california, smooth)</li> <li>Axillary and inguinal freckling</li> </ul>

<ul> <li>neuroFibromas</li> </ul>

<ul> <li>Eye (lisch nodules)</li> <li>Skeletal abnormality (bowing/thinning of long bone, pseudoarthrosis of tibia)</li> <li>Positive Family History</li> <li>Optic Tumor (optic glioma)</li></ul>

<div><br></br></div>

<div>Other Manifestations of NF?</div>

<div><ul><li>HEENT: 75% have learning disabilities, 33% have psychiatric disorders</li> <li>CVS: Increased risk for stroke, aortic stenosis, hypertension, congenital heart disease and vasculopathy</li> <li>Hypertension secondary to pheochromocytoma or renal artery stenosis<br></br></li> <ul> <li>Risk factor for early death</li> </ul> <li>Metabolic bone disease secondary to hypophosphatemic osteomalacia</li> <ul> <li>48% osteopenic</li> <li>25% osteoporotic</li> <li>Lowest BMD in lumbar spine</li> </ul> <li>Precocious puberty (CNS lesion)</li> <li>Short stature in 13-40%</li></ul></div>

Question 53

<div>RC 2018, 2013 - All of the following about neurofibromatosis scoliosis are true except:</div>

<ol> <li>In a dystrophic curve, the Cobb angle is not predictive of progression</li> <li>Dystrophic curves are most common </li> <li>If scoliosis presents younger than age 8, 70% will become dystrophic</li> <li>Associated with dural ectasia</li></ol>

Answer 53

B. dystrophic scoliosis is less common but more severe<div><ul> <li>Early age of onset (<7yo)</li> <li>Apical vertebra severely rotated</li> <li>Scalloped bone (concave loss of bone)</li> <li>Middle to lower thoracic area</li></ul></div>

Question 54

<div>RC 2012 - Conditions associated with NF-1; all except</div>

<ol> <li>Hypertension</li> <li>Malignant CNS tumor</li> <li>Short stature</li> <li>Acoustic Neuroma</li></ol>

Answer 54

D. Acoustic Neuroma is NF-2<div><br></br></div><div>malignant CNS tumour</div>

Question 55

<div>RC 2014, 2016 - Which of the following factors is NOT true regarding NF-1?</div>

<ol> <li>If father has the gene, worse for patient than if mother has the gene </li> <li>50% sporadic mutation </li> <li>6% tibial pseudarthrosis rate </li> <li>short stature</li></ol>

Answer 55

A. worse if mom has it<div><br></br></div><div>B - 50% sporatic is true, also Auto Dom.</div>

Question 56

<div>RC 2011 - What are 4 MRI findings of a patient with scoliosis and neurofibromatosis?</div>

Answer 56

MRI specific<ol> <li>Dural Ectasia (circumferential dilation/widening of the thecal sac, can lead to meningocele)</li> <li>Dumbbell Lesion (neurofibroma on nerve root)</li> <li>Paraspinal masses (plexiform neurofibromatosis)</li><li>intracanal neurofibromas</li></ol><div>In general - ie X-ray included</div><div><ul> <li>Posterior Vertebral scalloping</li> <li>Penciling ribs</li> <li>Rotation of ribs (look like twisted ribbons)</li> <li>Enlarged vertebral foramen (from the dumbbell lesion)</li> <li>Dysplastic Pedicles</li> <li>Spindling of the TPs</li> <li><b>Short, Sharp, kyphotic curve</b></li> <li><b>Severe rotation of apical vertebra</b></li></ul></div>

Question 57

RC 2012, 2011, 2008 12 yr F with # radius. Comes back with a dystrophic looking pseudoarthrosis. What would you find on exam? <ol> <li>hypoplastic thumb</li> <li>café au lait spots</li> <li>absent pec major</li> <li>Clinodactyly</li></ol>

Answer 57

B. 50% of forearm pseudarthosis are associated with NF1 (but only a small percentage of NF1 get forearm pseudarthrosis)

Question 58

RC 2011 - What are three conditions that have dural ectasia?

Answer 58

NF<div>OI</div><div>Marfans</div><div>EDS</div><div>AS</div><div>Acromegaly</div>

Question 59

<div>RC 2016 - All of the following genetics and tumor syndromes have been found to be associated, except:</div>

<ol> <li>Retinoblastoma (Rp-1) and osteosarcoma</li> <li>NF-1 and malignant central nervous system tumors</li> <li>EXT-1 and EXT-2 and multiple osteochondromas</li> <li>Chromosomal translocation and Ewing family of tumors</li></ol>

Answer 59

2. NF 1 assx with MPNST<div><br></br></div><div>1. true Rb and OS</div><div>3. true EXT and MHE</div><div>4. true EWS FLI1 and Ewings</div>

Question 60

<div>RC 2012 Tumor associations; all except:</div>

<ol> <li>Retinoblastoma (it said RF-1) is associated with increased risk of osteosarcoma</li> <li>Neurofibrillin (NF-1) gene is associated with malignant nerve tumors</li> <li>MET with Chondrosarcoma</li> <li>NF and Astrocytoma</li></ol>

Answer 60

C.<div>Retinoblastoma definitely associated with osteosarcoma è A is True <div></div> <div>JAAOS 2010 Orthopaedic manifestations of Neurofibromatosis type I</div> NF associated with MPNST (10-24% lifetime risk) è B is True Optic pathway gliomas affects 6% of patients = low grade pilocytic astrocytomas è D is True<br></br></div>

Question 61

<div>RC 2011- 9 year old with CP is a community ambulator with forearm crutches at home and at school but uses a wheelchair for long distances. What is his GMFCS?</div>

<div>A) I</div>

<div>B) II</div>

<div>C) III</div>

<div>D) IV</div>

Answer 61

C.<div>1-essentially normal</div><div>2-railing for stairs</div><div>3 - wheelchair for distances</div><div>4-wheelchair for most</div><div>5- wheelchair dependent</div>

Question 62

<div>RC 2009 - All are drugs for systemic CP spasticity except</div>

<ol> <li>Botox</li> <li>Dantrolene</li> <li>Baclofen</li> <li>Clonazepam</li></ol>

Answer 62

1. botox acts locally<div>all the rest act systemically</div>

Question 63

<div>RC 2008 - CP kid which is not a good prognostic factor</div>

<div>a. hand head to knee in 5 sec</div>

<div>b. IQ >90</div>

<div>c. ability to differentiate textures</div>

<div>d. 2 point <10mm</div>

Answer 63

“B<div>poor wording. maybe ‘IQ is not a prognostic factor’ at all</div>”

Question 64

<div>RC 2016 - What is the most reliable method for following CP hips? </div>

<ol> <li>Acetabular index </li> <li>Center edge angle </li> <li>Migration index </li> <li>Tonnis angle</li></ol>

Answer 64

“3.<div>MI>33 - subluxed - consider OR mx<br></br><div><br></br></div><div>Draw out perkins and hilgenreiner’s lines</div><div><img></img><br></br></div></div>”

Question 65

<div>RC 2015 - 9yo boy with cerebral palsy. Ambulatory with flexible equinovarus deformity. Failed AFO and PT. Weightbearing on lateral border of foot. Persistent pain and wants to discuss operative treatment.</div>

<div><div>(1) What muscles contribute to the deformity?</div></div>

<div>(2) What test would help in diagnosis?</div>

<div>(3) What operative intervention would you suggest?</div>

Answer 65

(1) Tibialis anterior and tibialis posterior = cavus; Gastroc/Achilles = equinus<div>(2) Gait analysis, EMG, confusion test</div><div>(3) Split tib ant transfer to lateral cuneiform/cuboid</div> <div>Posterior Tibialis fractional lengthening</div> <div>Gastroc resection/ Achilles lengthening</div>

Question 66

<div>RC 2010 Who is a poor Candidate for tendon transfers in CP? </div>

<ol> <li>Athetoid</li> <li>Diplegic</li> <li>Quadriplegic</li></ol>

Answer 66

A. poor control.<div><div>Best candidates for surgery are patients with hemiplegia, good voluntary control, motivation, and sensation</div></div>

Question 67

RC 2011 - which factor in CP, particularly in athetosis, is a contraindication to tendon transfers <ol> <li>Profound weakness of all muscle groups</li> <li>Poor voluntary control of transferred muscle</li> <li>Astereognosis</li> <li>Poor sensation</li></ol>

Answer 67

“2.<div>Among the cases with cerebral paralysis (CP), the most appropriate group for surgical intervention is the spastic group. Due to the challenges of performance and unpredictability of the results, surgery and especially dynamic tendon transfers are not recommended for the dyskinetic cases.</div><div><br></br></div><div><img></img><br></br></div><div><ul> <li>Spastic (65-80%) –> involves the cortex; pyramidal</li> <ul> <li>Increased tone or rigidity with rapid stretch</li> <li>Pyramidal dysfunction</li> <li>Associated with periventricular leucomalacia (PVL) on MRI</li> <li>Most often benefit from surgery</li> </ul> <li>Dyskinetic - Athetoid/dystonic (10%) –> basal ganglia</li> <ul> <li>Involuntary movements, athetosis, dystonia</li> <li>Extrapyramidal dysfunction</li> <li>Poor candidates for Tendon transfers</li> <li>Associated with Rh issues, less common in modern medicine</li> </ul> <li>Ataxia (5%) –> cerebellum</li> <ul> <li>Cerebellar dysfunction</li> <li>Balance and coordination disturbance</li> <li>Usually part of another syndrome, rare for isolated CP</li> </ul></ul></div>”

Question 68

<div>RC - 2017 A 12 year old with spastic CP comes in with 45o elbow flexion contracture. Excellent function. Independently ambulates. Which is not a viable procedure selection?</div>

<div>A) Fractional Biceps lengthening</div>

<div>B) Musculocutaneous neurectomy</div>

<div>C) Biceps tendon Z-lengthening</div>

<div>D) Flexor-pronator slide</div>

Answer 68

“B. Only do MCN neurectomy if full ROM<div><img></img><br></br></div><div><br></br></div>”

Question 69

<div>RC 2013, 2008 - Clinical exam of a boy with CP and intrinsic contracture would reveal which of the following?</div>

<ol> <li>MCPs extended, PIPs flexed</li> <li>MCPs extended, PIPs extended</li> <li>MCPs flexed, PIPs extended</li></ol>

Answer 69

“C. intrinsic plus. intrinsic muscles flex MCP and extend PIP<div><img></img><br></br></div>”

Question 70

<div>RC 2011 - Pt. With CP upper extremity with thumb in palm deformity. All are true except? </div>

<ol> <li>Web space contracture</li> <li>Spastic adductor</li> <li>Extensor of EDB</li> <li>Stiff MCP joint</li></ol>

Answer 70

“D. MCP is unstable and often requires capsulodesis/fusion.<div><div>Deformity: (1) spastic flexors and adductors, (2)flaccid extensors and abductors, (3) hyper mobile MP joint, and (4) web space skin contracture</div></div><div>Tx: Tx: Release of adductor pollicis, 1st dorsal interossei, FPB and FPL +/- web space deepening.<div><img></img><br></br></div></div>”

Question 71

<div>RC 2013 - Which osteotomy is contraindicated in an ambulatory child with a dislocated hip secondary to a sacral level Myelo.</div>

<ol> <li>Dega </li> <li>Pemberton</li> <li>Chiari</li> <li>Salter</li></ol>

Answer 71

3. Chiari is a salvage procedure.<div>Low level myelo means this is likely just DDH - treat as such!</div><div><br></br></div><div>Note that most hip procedures in myelo are contracture releases!</div>

Question 72

<div>RC 2011, 2010 Have a L4 myelomeningocele, what is the foot deformity? </div>

<ol> <li>varus deformity</li> <li>calcaneus deformity</li> <li>equinus</li> <li>foot valgus</li></ol>

Answer 72

2.<div><br></br></div><div>cavovarus - sacral level</div><div>calcaneus - L4>L5, tx with Split tib ant transfer or just tib ant tenotomy</div><div>calcaneovalgus - L4 or L5, tx same</div><div>clubfoot - high lumbar, low thoracic; try ponsetti, but likely need surgery</div>

Question 73

<div>RC 2010 -List the 4 Types of Neural Tube Defects</div>

Answer 73

“<div>myelodysplasia: failure of spinal cord closure</div><ul><li>Spina bifida occula - failure to fuse, elements contained</li><li>Meningocele - thecal sace protrudes without neuro elements</li><li>Myelomenigocele - thecal sac protrudes with neuro elements (ie out of spine)</li><li>Rachischisis - neural elements exposed to air; fatal</li></ul><div><img></img><br></br></div>”

Question 74

<div>RC 2018 - What is inheritance pattern of DMD and the protein involved</div>

<div>a.XLR with dysptrophin</div>

<div>b.XLR with fukutin</div>

<div>c.autoD with dys</div>

<div>d.autoD with fuk</div>

Answer 74

A.<div><ul> <li>Ortho Manifestations</li> <ul> <li>Calf pseudohypertrophy</li> <li>Scoliosis</li> <li>equinovarus foot deformity</li> <li>joint contractures</li> </ul> <li>Non-ortho manifestations</li> <ul> <li>Cardiomyopathy - 90%</li> <li>Static encephalopathy</li> <li>Malignant Hyperthermia</li> </ul></ul></div>

Question 75

<div>RC 2008 - Duchenne MD - All Except:</div>

<div><ol> <li>Often present with toe walking</li> <li>Apparent at birth</li> <li>X-linked</li> <li>Proximal muscle weakness</li></ol></div>

Answer 75

2. not apparent until walking age<div><br></br></div><div>1- all toe walk</div><div>3- XLR</div><div>4- prox mm weakness</div>

Question 76

<div>RC 2016, 2008 - All of the following are true regarding the use of steroids in Duchenne’s muscular dystrophy, except?</div>

<ol> <li>Improves muscle strength </li> <li>Prolongs ambulation </li> <li>Does not improve pulmonary function </li> <li>Osteopenia is a concern</li></ol>

Answer 76

3. it DOES improve pulm function.<div><br></br></div><div>Benefits</div><div><div>1) Improved muscle power, Decrease in rate of muscle loss</div> <div>2) Prolong respiratory function</div> <div>3) Decrease need for spinal surgery (secondary to avoiding wheelchair)</div> <div>4) Prolonged walking ability</div></div><div><br></br></div><div>Side Effects: Short stature, weight gain, acne, hypertension, infection, bruising</div><div><ol> <li>Cataracts</li> <li>Ulcers</li> <li>Skin: striae, thinning, bruising</li> <li>Short Stature</li> <li>Hypertension</li> <li>Hirsutism</li> <li>Hyperglycemia</li> <li>Infections</li> <li>osteoNecrosis</li> <li>Glycosuria</li> <li>Osteoporosis</li> <li>Obesity</li> <li>Immunosuppresion</li> <li>Diabetes</li></ol></div><div><br></br></div>

Question 77

RC 2013 List 3 benefits to using steroids (prednisone/deflazacort) in Duchenne’s muscular dystrophy?

Answer 77

<div>1) Improved muscle power </div>

<div>2) Decrease in rate of muscle loss</div>

<div>3) Prolong respiratory function</div>

<div>4) Decrease need for spinal surgery (secondary to avoiding wheelchair)</div>

<div>5) Prolonged walking ability</div>

Question 78

<div>RC 2012 - List 3 potential complications of using steroids in Duchenne’s muscular dystrophy?</div>

Answer 78

<div>Mnemonic for Corticosteroid Side effects/Complications: CUSSHHHINGOOID</div>

<ol> <li>Cataracts</li> <li>Ulcers</li> <li>Skin: striae, thinning, bruising</li> <li>Short Stature</li> <li>Hypertension</li> <li>Hirsutism</li> <li>Hyperglycemia</li> <li>Infections</li> <li>osteoNecrosis</li> <li>Glycosuria</li> <li>Osteoporosis</li> <li>Obesity</li> <li>Immunosuppresion</li> <li>Diabetes</li></ol>

Question 79

“<div>RC 2014, 2012 - Duchenne’s kid, 13 years old, scoliosis cobb angle 35 degrees, FEV 55%. Tx?</div> <ol> <li>wheelchair modifications</li> <li>bracing</li> <li>anterior + posterior fusion</li> <li>posterior only fusion</li></ol>”

Answer 79

4.<div>Indications for PSIF:</div><div>-Cobb20-30 deg (these are nasty curves)</div><div>-when pt becomes non-ambulatory</div><div>-FEV<35, or declining FEV</div><div>-poor response to steroids</div><div><br></br></div><div><div>sufficient spinal growth will have occurred in the child with DMD by age 10 or 11 years so that <b>posterior fusion will not result in a marked loss of trunk height or development of crankshaft deformity.</b></div></div>

Question 80

<div>RC 2015 - All of the following result in loss of sensation except:</div>

<div> a. Polio</div>

<div> b. CMT</div>

<div> c. Alcohol</div>

<div> d. Diabetes</div>

Answer 80

A. Disease caused by viral destruction of anterior horn cells in spinal cord and brain stem motor nuclei (ie motor weakness with normal sensation)<div><br></br></div><div>C - Peripheral neuropathy secondary to avitaminosis<br></br></div><div></div>

Question 81

<div>RC 2011 - What is true regarding achondroplasia?</div>

<ol> <li>point mutation of FGFR3</li> <li>hypertrophic zone is normal</li> <li>50 % are spontaneous presentations</li> <li>autosomal recessive</li></ol>

Answer 81

A. true.<div><br></br></div><div>B- false. although main defect is in proliferative zone (abnormal chondrocyte prolif), hypertrophic zone is also abnormal.</div><div>C - false. 80% spontaneous.</div><div>D - false. Auto D.<br></br><div><br></br></div><div><br></br></div></div>

Question 82

<div>RC 2008 - Achondroplasia, all of the following except</div>

<ol> <li>Foramen magnum stenosis</li> <li>X-linked</li> <li>Most common short limbed disproportionate dwarfism</li> <li>FGFR3</li></ol>

Answer 82

2. • Auto Dom.

Question 83

<div>RC 2013 - 3 year old child presents ataxic gait and Rhizomelic dwarfism, frontal bossing, midface hypoplasia. Has a history of obstructive sleep apnea. Has gibbus deformity and hyperreflexic on exam. What is the next appropriate step?</div>

<div>A) MRI of C1-C2</div>

<div>B ) MRI of foramen magnum</div>

<div>C) EMG</div>

<div>D) Sleep study</div>

Answer 83

B. FMS/basilar invagination.<div><br></br></div><div>A - dont see C1C2 instability (AAI) in Achondroplasia</div><div>D. sleep study is a SCREENING test - this patient has neuro findings - dont screen!</div>

Question 84

<div>RC 2011 - List 3 spine findings in Achondroplasia</div>

Answer 84

FMS, basilar invagination<div>TLK</div><div>Lumbar SS</div><div>Lumbar hyperlordosis</div>

Question 85

<div>RC 2014 - What is not true about achondroplasia and spine?</div>

<ol> <li>Atlantoaxial instability</li> <li>foramen magnum stenosis</li> <li>Lumbar Hyperlordosis</li> <li>Thoracolumbar kyphosis</li></ol>

Answer 85

A. No AAI in Achondroplasia

Question 86

<div>RC 2015 - 7yo kid with SED. Planning to do epiphysiodesis for genu valgum. What must you get pre-op?</div>

<ol> <li>C-spine flex/ext</li> <li>Scoliosis series</li> <li>MRI brain</li> <li>Polysomnography</li></ol>

Answer 86

A. up to 40% can be myelopathic for C-spine instability - AAI (odontoid hypoplastia, os odontoideum)<ul> <li>Inheritance: congenital: AD (severe), tarda: x-linked recessive (milder & late age 8-10)</li> <li>Morphology: short-trunk dwarf</li> <li>Ortho issues: genu varum/valgum, c-spine instability (odontoid hypoplasia), scoliosis, hip dislocations (coxa vara), valgus hips & knees, retinal detachment, early OA</li></ul><div></div>

Question 87

<div>RC 2015, 2013 - All of the following are true, except:</div>

<ol> <li>Mucopolysaccharidosis is a proportionate form of dwarfism</li> <li>San Fillipo is the most common form of mucopolysaccharidosis</li> <li>Duchenne’s is associated with calf hypertrophy</li> <li>Marfan’s is associated with arachnodactyly</li></ol>

Answer 87

<div>Answer: 3 - calf pseudohypertrophy</div>

<div><br></br></div>

1. true. other proportionate = cleidocranial dysplasia<div>2. maybe true. have read San Fillipo most common, but also Morquio.</div><div>4. true</div>

Question 88

<div>RC 2017 - Name 5 bone disorders that present in infancy/early childhood with periosteal calcification and thickened cortices?</div>

<div><br></br></div>

Answer 88

<div>Lovell and Winter’s (can’t remember from which chapter)</div>

<ul><li>Diaphyseal dysplasia</li><li>Osteopetrosis</li><li>Hyperphosphatasia</li><li>Junvenile paget’s disease</li><li>Craniodiaphyseal dysplasia</li><li>Ribbing disease</li><li>Caffey disease (infantile cortical hyperostosis)</li><li>Hardcastle syndrome</li></ul>

Question 89

<div>RC 2011 - Larsen’s syndrome. What is common?</div>

<ol> <li>elbow flexion contracture</li> <li>cervical kyphosis</li> <li>Sprengel’s deformity</li> <li>pectus excavatum</li></ol>

Answer 89

2.<div><div>ligamentous hyperlaxity, abnormal facial features, and multiple joint dislocations</div></div><div>cervical kyphosis (other dz with this is DD)</div><div>40% mortality in 1st year</div><div><br></br></div>

Question 90

<div>RC 2015 - Regarding arthrogryposis, all are true except?</div>

<div> a. bilateral hip dislocation</div>

<div> b. normal intelligence</div>

<div> c. progression of flexion contracture until skeletal maturity</div>

<div> d. internal rotation contracture of shoulder</div>

Answer 90

C. non-progressive flexion contracture - typically improves slightly.<div><br></br></div><div><br></br></div>

Question 91

<div>RC 2013 - Child with arthrogrypotic extension contracture. All of the following are possible to restore elbow flexion except: </div>

<ol> <li>Triceps</li> <li>Steindler flexorplasty</li> <li>Pec Major</li> <li>Anterior deltoid</li></ol>

Answer 91

“4.Deltoid NOT used.<div><br></br></div><div>extension contracture = cant FLEX</div><div><br></br></div><div>Non-op: stretching, serial castin</div><div>Triceps lengthening and release of posterior capsule</div><div>Tendon transfers to biceps include: pec, lat dorsi, triceps</div><div>Steindler flexorplasty (proximal tenodesis of flexor pronator mass) -<b> does not decrease flexor strength (MCQ 2008)</b></div><div><img></img><br></br></div>”

Question 92

<div>RC 2008 - Regarding the Steindler flexorplasty in arthrogryposis, which is not correct:</div>

<ol> <li>Techniques are described for proximal attachment to both bone and soft tissue</li> <li>It is associated with a 20% loss of flexion power (they didn’t say wrist or elbow)</li> <li>It results in elbow flexion strength being stronger in supination than pronation</li></ol>

Answer 92

2. You will slightly INCREASE Elbow Flexion, as the Flexor-Pronator mass is advanced proximal.<div><br></br></div><div> <ol> <li>You lose active elbow extension 30 degrees, final flexion stays same but more power, lose active pro/supination</li> <li>ADL’s – way better! è whoa. Let’s not get carried away here.</li> <li>Flexor/pronator mass advancement, so stretched out even more when in supination = stronger</li></ol><div><br></br></div><div><br></br></div></div>

Question 93

<div>RC 2015 - List the 6 orthopaedic findings for diagnosis of Marfan’s</div>

Answer 93

<div>The Ghent Nosology for diagnosis: “skeletal criteria”</div>

<ul> <li>General: ligamentous laxity, Arm-span to body height ratio > 1.05</li> <li>U/E: Arachnodactyly, Reduced elbow extension (<170 degrees)</li> <li>Chest: Pectus carinatum OR excavatum</li> <li>Spine: Scoliosis (With dural ectasia), Spondylolisthesis</li> <li>Hips: Protrusio acetabuli</li> <li>Feet: Pes planus (secondary to medial malleolus displacement)</li></ul>

Question 94

<div>RC 2013, 2010 - List 3 extraskeletal features of Marfan’s syndrome</div>

Answer 94

<div>Cardiac</div>

<ul> <li>Aortic dissection</li> <li>Mitral valve prolapse</li> <li>Aortic root dilatation</li> </ul>

<div>Resp</div>

<div><ul><li>Spontaneous pneumothoraces</li><li>Apical blebs</li></ul></div>

<div>Occular</div>

<ul> <li>Superior lens dislocation (slit lamp exam)</li> </ul>

<div>Neurological</div>

<ul> <li>Dural ectasia</li> <li>Meningocele</li> </ul>

<div>Other</div>

<ul> <li>Berry aneurysm in brain</li></ul>

Question 95

<div>RC 2016 - All of the following are associated with Marfan’s syndrome, except:</div>

<ol> <li>Type III Collagen</li> <li>Scoliosis</li> <li>Aortic dilatation</li> <li>Protrusio acetubuli</li></ol>

Answer 95

A.<div><ul> <li>marfans: AD, Inactivation of Fibrilin </li> <ul> <li>FBN1 in > 90% of cases</li></ul></ul><ul><ul><li>type 3 and 5 collagen is assx with EDS</li></ul></ul></div>

Question 96

<div>RC 2012 - Conditions with Ocular Manifestations: all of the following except</div>

<ol> <li>Homocysteinuria</li> <li>Marfans</li> <li>Neurofibromatosis</li> <li>Achondroplasia</li></ol>

Answer 96

D.<div><ul> <li>Homocysteinuria has inferior lens dislocation (homo’s go down to blow their friends)</li> <li>Marfan’s has superior lens dislocation (marfans grows up… they are tall)</li> <li>Neurofibromatosis has Lisch nodules in the iris.</li></ul></div>

Question 97

<div>RC 2013 - Which of the following are found in a patient with hypophosphatasia?</div>

<ol> <li>Low ALP, Normal Ca, Normal PTH</li> <li>Low ALP, High Ca Normal PTH</li> <li>High ALP, Low Ca, Normal PTH</li> <li>High ALP, Normal Calcium, High Cocaine</li></ol>

Answer 97

“Answer B. hypophosphatasia = LOW ALP (only dz to have this)<div><ul><ul><li>Auto Recessive.</li><li>ALP deficiency due to error/mutation in the isoenzyme of ALP</li> <ul> <li>no ALP to synthesize PO4 (important for bone formation)</li><li>zone of provitional calcification never forms</li></ul> </ul><li><img></img><br></br></li><li>only 2 have hyperCa</li><li>only 1 has low ALP</li></ul><div><br></br></div></div>”

Question 98

<div>RC Exam 2016 What is true regarding the inheritance of x-linked hypophosphatemic rickets? </div>

<ol> <li>If the father has the disease, 50% of his children will get it</li> <li>If the mother has the disease, 100% of sons will get it</li> <li>If the father has the disease, 100% of daughters will get it</li></ol>

Answer 98

“<div>Answer: C</div><div>X-linked dominant.</div><div><ul> <li>Cause: excess urinary phosphate losses</li> <ul> <li>Impaired renal tubular absorption of phosphate (renal phosphate wasting) –> hypophosphatemic</li> <li>Low PO4, high ALP, Normal Ca2+</li> </ul><li>Tx: Phosphate, calcitriol</li></ul></div><div><br></br></div> <div><img></img></div><div><br></br></div><div><img></img><br></br></div>”

Question 99

<div>RC Exam 2013 Osteomalacia causes which of the following</div>

<ol> <li>Increased mineralization after fracture</li> <li>Pseudofractures</li> <li>Biopsy shows increased mineralized osteoid matrix.</li> <li>Sasquatches have weak bone</li></ol>

Answer 99

2.<div><ul> <li>Osteomalacia is basically rickets in adults. (ie open physis –> rickets; closed –> osteomalacia)</li> <li>A metabolic bone diseasewheredefective mineralizationresults in alarge amount or unmineralized osteoid </li> <ul> <li>qualitativedefect as opposed to a quantitative defect like osteoporosis</li> </ul> <li>VitD Def –> low PO4 and Ca –> decreased bone mineralization. </li> <ul> <li>Same lab profile as Rickets</li> </ul> <li>People with osteomalacia are able to make osteoid but not mineralize it.</li> <li>Results in bone pain, low trauma fractures and proximal muscle weakness. Patients also get Looser’s Zones, which are pseudofractures.</li> <li>Tx: Vit D</li></ul></div>

Question 100

<div>RC 2017 - 12 year old presents with olecranon fracture while playing. Previous contra-lateral olecranon fracture year previously. Normal height, bad dentition. Previous fractures of both distal radius and left tibia. What should you do?</div>

<div>A) Start bisphosphonates</div>

<div>B) Skeletal survey for child abuse</div>

<div>C) Refer for renal work up</div>

<div>D) ...</div>

Answer 100

A.<div><br></br></div><div><div>Bisphosphonate Benefits: decrease bone pain, enhance well-being, improve muscle strength and mobility, improve vertebral shape, and decrease fracture rates</div></div>

Question 101

<div>RC 2013 - Osteogenesis Imperfecta, what is the least true: </div>

<ol> <li>Disease symptoms get better as a patient ages.</li> <li>Healed fractures have abnormal strength</li> <li>Heal bones slower</li> <li>Over 70% develop scoliosis</li></ol>

Answer 101

“C<div><br></br><div><div>-Fractures heal in normal time (with or without bisphosphonates), but do not remodel –> abnormal strength –> progressive bowing</div></div><div>-Symptoms improve with age, bone strengthens</div><div>-Scoliosis (70%): 60% have severe chest wall deformities –> pulm compromise is main cause of death in adults with OI</div><div>-other spine:</div><div><ul> <li>Spondylolisthesis 11% (vs 4% in normal pop’n)</li> <li>Spondylolysis 8% (vs 3%)</li> <li>Basilar Invagination (myelopathy)</li> <ul> <li>Decompression and posterior fusion</li> </ul> <li>Cervical Spine</li> <ul> <li>Can have basilar invagination and upper cervical kyphosis</li> <ul> <li>Some need shunts for obstructive hydrocephalus</li> </ul> <li>Need surgical stabilization (ant and post) but poor track record</li> </ul></ul></div></div>”

Question 102

RC 2011 - 6 yr old boy with distal radius # after minor trauma seen in clinic. Pt has had 4 #s with minor trauma in the last 12 months. Also has bowing of legs. What is the defect?<ol> <li>defect in collagen 1</li> <li>defect in collagen 2</li> <li>defect in phosphate</li> <li>child abuse</li></ol>

Answer 102

1.<div><br></br></div><div><div>a) defect in collagen 1 (OI, Ehler Dahnlos has one with type 1, some marfan pts (although main is fibrillin)</div> <div>b) defect in collagen 2- Kniest (COL 2A1) and SED</div> <div>c) defect in phosphate – hypophosphatemic ricket</div></div>

Question 103

<div>RC 2013 - What is not a side effect of bisphosphonate treatment in kids (2013)</div>

<ol> <li>Acute fever with administration</li> <li>Growth delay</li> <li>Prolonged effects on bone remodelling</li> <li>Immediate and transient hypocalcemia</li></ol>

Answer 103

Answer: B<div><br></br></div><div>bisphosphonates</div><div><br></br></div><div><br></br><div>1- true 85%</div><div>2- no growth delay</div><div>3- true. Decrease in bone remodelling and healing post-osteotomy</div><div>4- true<br></br><div><br></br></div><div><div>Side effects of Bisphosphonates</div> <div>1. Acute phase reaction: fevers, malaise, diarrhea, bone and muscle pain. Occur 1-3 days after administration.</div> <div>2. Transient Electrolyte abnormalities: hypocalcemia, hypophosphatemia, hypomagnesemia. These are mild and assymptomatic and resolve within a couple of days. Prevention can be done with Ca and Vit D supplementation</div> <div>3. Uveitis</div> <div>4. Thrombocytopenia</div> <div>5. Oral ulceration</div> <div>6. AVN of the jaw - only reported in adults, not in children.</div> <div>7. Exacerbation of reactive airway disease (like asthma)</div> <div>8. Cross the placenta so may affect the fetus (not reported)</div> <div>9. Has NOT been shown to delay healing of fractures in kids, but may delay healing of osteotomies </div> <div>10. Suppressed bone turnover markers for up to 2 years after treatment.</div></div></div></div>

Question 104

<div>RC 2009 - Proteus syndrome. What is associated?</div>

<ol> <li>Megalospondylodysplasia</li> <li>Café au lait</li> <li>Lisch Nodules</li> <li>Precocious puberty</li></ol>

Answer 104

A

Question 105

<div>RC 2018, 2015</div>

<div>What is true with regards to sickle cell anemia? </div>

<ol> <li>RBC’s can sickle at normal oxygen tension</li> <li>Presentation of bone infarct is similar to osteomyelitis</li> <li>Heterozygous individuals are symptomatic</li> <li>No increased risk of infection</li></ol>

Answer 105

B<div><ul> <li>Bone scan and radionuclide scan can differentiate bone infarct from OM</li> <ul> <li>OM = normal marrow uptake but abN bone scan</li> <li>Infarct = decreased marrow uptake with abN bone scan</li> </ul></ul></div>

Question 106

RC 2014, 12, 10 List 3 radiographic features of C2-3 pseudosubluxation

Answer 106

“<ul> <li>Spinolaminar line on posterior arches within 1.5mm of C2</li> <li>Reduction of subluxation with extension (<4mm subluxation is normal)</li> <li>No anterior soft-tissue swelling</li></ul> <ul> <li>References: AAOS Core Review, JAAOS 2011 - Pediatric Cervical Spine Trauma</li> </ul> <div><img></img></div><div><br></br></div><div>C2-C3 more common than C3-4</div>”

Question 107

<div>RC 2016 - Which is true of pseudosubluxation of cervical spine in pediatric patient? </div>

<ol> <li>Vertical facets </li> <li>Posterior vertebral step </li> <li>C3-4 subluxation is most common </li> <li>Intact posterior spinous line</li></ol>

Answer 107

“D.<div><br></br></div><div>1-horizontal facets in peds</div><div>3. C2-C3 more common</div><div><br></br></div><div>Spinolaminar line on posterior arches - anterior cortex of posterior arch of C2 should be within 1mm of this line<br></br></div><div><img></img><br></br></div>”

Question 108

<div>RC 2015 - List 4 ways in which radiographs of the cervical spine in children differ from those of skeletally mature patients?</div>

Answer 108

<ul> <li>AAOS Core Review 2/OKU Peds 3</li> <ul> <li>Increased ADI (>5mm abnormal)</li> <li>Pseudosubluxation of C2-C3</li> <li>Absence of cervical lordosis</li> <li>Widened retropharyngeal space (>6mm C2, >22mm at C6) - typically from crying</li> <li>Wedging of cervical vertebral bodies</li> <li>Neurocentral synchondroses (closure by age 6)</li> </ul> <li>JAAOS Pediatric Cervical Spine Trauma:</li> <ul> <li>Relatively Horizontal Facets</li> <li>Underdeveloped uncinate processes ( <li>Increased ligamentous elasticity</li> <li>Cartilaginous junction b/w VB and end plates</li></li></ul></ul>

<ul><li>paraspinal musculature weak</li><li>increase risk of SCIWORA</li><li>large head - spine board requires cut out</li><li>spinal column more elastic than cord</li></ul>

Question 109

<div>RC 2012, 2010 Regarding SCIWORA, what is true? </div>

<ol> <li>50% can be a delayed presentation</li> <li>most common in the T spine</li> <li>infantile cord can stretch 2 inches before rupture</li> <li>most commonly seen in 8-15yo</li></ol>

Answer 109

Answer: 1. up to 20-50% can be delayed<div><br></br></div><div>2. more common in C-spine</div><div>3 - It is believed that the spinal column can stretch up to 2 inches, whereas the spinal cord may rupture when stretched <1 cm.</div><div>4. most peds spine injuries between 15-19</div><div><br></br></div>

Question 110

<div>RC 2009 Odontoid Fracture in children <7 years. All of the following except:</div>

<ol> <li>25% non-union</li> <li>Usually occurs at synchondrosis between C2 body and dens</li> <li>Displacement usually anterior</li></ol>

Answer 110

“A. nonunion rate is 5-7%, can treat most nonop!<div><ul> <li>The C-2 is the most commonly injured vertebra in children, and odontoid synchondrosis fractures are among the more common cervical spine fractures in patients younger than 7 years of age. </li> <li>In young children, the axis is divided by synchondroses between the dens, body, and neural arches. The cartilaginous plate between the dens and the body of C-2 is an area of potential weakness that does not ossify until a child is 5 to 7 years old.<a>[</a>.</li> <li>The orientation of the odontoid fracture was reported for 36 patients, with 94% experiencing anterior displacement</li></ul></div>”

Question 111

<div>RC 2008 - L1 chance fracture in 14 year old. Had seatbelt sign and abdo pain. Most likely injury</div>

<ol> <li>Duodenum</li> <li>Spleen</li> <li>Liver</li> <li>Pancreas</li></ol>

Answer 111

1.

Question 112

<div>RC 2009, 2008. Which is NOT a risk factor for progression of scoliosis?</div>

<ol> <li>age</li> <li>gender</li> <li>thoracic curve</li> <li>pain</li></ol>

Answer 112

4.

Question 113

<div>RC 2015, 2014, 13 - All of the following are associated with C1-2 instability, except:</div>

<ol> <li>Achondroplasia</li> <li>Pseudoachondroplasia</li> <li>Mucopolysaccharidosis</li> <li>Down’s syndrome</li></ol>

Answer 113

A.<div><br></br></div><div>Achondroplasia: Foramen magnum stenosis, thoracolumbar kyphosis, lumbosacral hyperlordosis, spinal stenosis</div><div><br></br></div><div><br></br></div>

Question 114

<div>RC 2016 - List 5 radiographic findings in the cervical spine in juvenile rheumatoid arthritis</div>

Answer 114

<ul> <li>Anterior erosion of odontoid</li> <li>AP erosion of odontoid (apple-core)</li> <li>Atlantoaxial instability (subluxation of C1 on C2)</li> <li>Focal soft tissue calcification adjacent to the ring of C1 anteriorly</li> <li>Facet joint fusion (Ankylosis of zygoapophyseal)</li> <li>Growth abnormalities</li> <li>Subaxial subluxation (subluxation between C2 and C7)</li></ul>

Question 115

<div>RC 2018, 2014 - Four Clinical Findings that would suggest posterior shoulder dislocation in a six month old with a brachial plexus palsy?</div>

Answer 115

<ul> <li>Stay organized!</li> <li>Look</li> <ul> <li>Asymmetric axillary skin folds</li> <li>Apparent shortening of the humerus</li> </ul> </ul>

<ul> <li>Feel</li> <ul> <li>Palpable asymmetric fullness</li> <li>Palpable click during exam</li> </ul> </ul>

<ul> <li>ROM </li> <ul> <li>Rapid loss of passive external rotation between visits</li> </ul></ul>

Question 116

<div>RC 2013 - Which of the following is most true regarding neonatal brachial plexus injury?</div>

<ol> <li>Caesarian section eliminates the risk</li> <li>Lack of biceps flexion return by 6 months is suggestive of neurotmesis</li> <li>Most resolve without surgery</li> <li>Lower plexus injuries (Klumpke’s) are more common</li></ol>

Answer 116

C<div><br></br></div><div><div>Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise.</div> <ul> <li>Currently, the occurrence rate of brachial plexus palsy at the time of vaginal delivery ranges from 0.047% to 0.6% and for cesarean section from 0.0042% to 0.095%</li></ul></div>

Question 117

“<div>RC 2014 - Which of the following is true of birth brachial plexus palsy</div> <ol> <li>Phrenic nerve injury is indicative of root avulsion</li> <li>Horner’s usually associated with C5 injury</li> <li>No biceps at 3 months indicative of neurotemesis</li> <li>Neurotmesis is usually repairable</li></ol>”

Answer 117

A. Phrenic nerve involvement increases the likelihood of an avulsion injury and limited spontaneous recovery<div><ul><li>Horner’s syndrome is associated with injury to the stellate ganglion (cervicothoracic; C7 level). It is indicative of a pre-ganglionic lesion but NOT of C5 root injury specifically.</li> <li>No biceps function at 3 months has a poor prognosis, but is not necessarily indicative of neurotnemesis. Also, obstetrical brachial plexus injuries are typically a traction issue and complete neurotnemesis is rare.</li> <li>Neurotnemesis is NOT usually repairable à requires nerve/tendon transfers.</li></ul></div>

Question 118

<div>RC 2015 - What is not correct regarding obstetrical brachial plexus injury: (2015)</div>

<ol> <li>Should perform a primary nerve repair in Erb’s palsy within 3 months if no return of biceps function</li> <li>Decreased ROM of the shoulder will eventually lead to Xray changes</li> <li>De-rotational osteotomy of the forearm and proximal humerus are treatment options in some cases</li> <li>External rotators of the shoulder are weaker than the internal rotators</li></ol>

Answer 118

1. False – often spontaneous recovery; return of biceps by 2-3 months positive prognosticator <div></div><div><ul> <li>Preganglionic (CNS)-> nerve transfer (neurotization) at 3 months</li> <ul> <li>Sources: spinal accessory, intercostal, medial pectoral, phrenic</li> <li>Wire these nerves into subscapular nerve (for shoulder ER)</li> </ul> <li>Postganglionic (PNS, intact nerve root stump)-> microsurgical nerve grafting at 3-9 months</li> <ul> <li>Sources: sural nerve</li> </ul><ul><ul> </ul> </ul></ul></div>

Question 119

<div>RC 2008 - 7 year old with obstetrical brachial plexus injury and has posterior glenohumeral dislocation. What gives best outcome now</div>

<ol> <li>Subscap lengthening with capsular release</li> <li>Humerus derotational osteotomy</li> <li>Anterior open reduction with posterior capsular plication</li> <li>Neglect</li></ol>

Answer 119

B<div><div>Jaaos 2009 – remodelling possible younger than age 6, not much after this. ER rotational osteotomy places hand in more functional position. Anterior capsular release is described – to help with glenoid modeling – posterior capsular placation is not really described. For children with extensive glenohumeral deformity, the prevailing recommendation is an external rotational osteotomy of the humerus, rotating the arm into a more functional position of external rotation</div></div>

Question 120

<div>RC 2016 - Congenital pseudoarthrosis of clavicle. Which of these is NOT true?</div>

<ol> <li>Edges of pseudoarthrosis form physis-like end</li> <li>Synovial fluid found between ends</li> <li>Something about the position/relationship of the 2 ends</li> <li>Always at mid-clavicular region with larger sternal end that is superior, anterior translation relative to the acromial segment</li></ol>

Answer 120

“?D vs C<div><br></br></div><div>A, B, D true</div><div><br></br></div><div>D - ““Normally, the medial clavicular fragment was longer and situated higher up than the external one”” - not ALWAYS</div>”

Question 121

<div>RC 2008: What is true about Sprengel </div>

<ol> <li>Does not make a cosmetic or functional difference</li> <li>Can do up to age 12</li> <li>Clavicular osteotomy decreases incidence of neuro injury</li> <li>Does not makes a difference in abduction</li></ol>

Answer 121

“C.<div><div>osteotomy of clavicle may be required to prevent compression of N/V structures against first rib; (Woodward procedure) - best procedure.</div><div><br></br></div> <div>Age 12 is probably too old for this – better to do before age 7-8; does improve cosmesis as well as ROM.</div></div><div><br></br></div><div><div> <div> <div><img></img></div> </div></div></div>”

Question 122

<div>RC 2016 - A patient shows up in your office with a congenital radial head dislocation. She is skeletally immature. What is true about treatment with a radial head excision?</div>

<ol> <li>She will develop cubitus valgus</li> <li>Her radius will migrate proximally</li> <li>She is likely to develop a radioulnar syonstosis</li> <li>The radial head will regrow</li></ol>

Answer 122

D. Reformation of the radial head is the most common problem with excision of a congenital dislocation<div><br></br></div><div><ul> <li>Rare complications post excision for CRHD</li> <ul> <li>progressive cubitus valgus and potential associated ulnar neuropathy</li> <li>proximal migration of the radius with recurrent radiocapitellar impingement</li> <li>radioulnar synostosis</li> </ul></ul></div>

Question 123

<div>RC 2014, 2011 - What is not associated with radial club hand?</div>

<ol> <li>hypoplastic thumb</li> <li>thrombocytopenia</li> <li>cardiac defect</li> <li>elbow instability</li></ol>

Answer 123

D.<div><br></br><div><div>All children presenting with radial longitudinal deficiency, regardless of severity, require a renal ultrasound, echocardiogram, and complete blood count</div></div><div><br></br></div><div>Thrombocytopenia and absent radius (TAR)</div><div>VACTERL = vertebral, anal atresia, TE fistula, Renal anomaly, Limb deficiency</div></div><div><br></br></div><div>Treatment: centralization and pollicization</div>

Question 124

<div>RC 2011 - List 3 x-ray findings of Madelung’s deformity</div>

Answer 124

Generic: increase radial tilt, ulnar and palmar translation of carpus, lunate subsidence (traiangulation of carpus), dorsal ulnar prominence<div><br></br></div><div><ul> <li>Distal Radius</li> <ul> <li>Narrowing or absence of the ulnar aspect of the distal radial physis</li> <li>Anterior bowing of the radial shaft</li> <li>Increased radial inclination (aka increased ulnar tilt of the distal radial articular surface)</li> <li>Increased lunate fossa angle</li> <li>Increased volar inclination of distal radius</li> </ul> <li>Distal Ulna</li> <ul> <li>Dorsal Subluxation of the ulnar head</li> </ul> <li>Carpal bones</li> <ul> <li>Lunate subsidence</li> <li>Palmar and ulnar carpal displacement/translocation</li> </ul> <li>Signs of ulno-carpal impaction</li> <ul> <li>Sclerosis of the lunate</li> <li>Ulnar positive variance </li> </ul> <li>V-shaped proximal carpal row (not in JAAOS article, but from previous year’s notes)</li> </ul> <div></div> <div>From OKU PEDs 5</div> <ul> <li>There is limited growth at the volar ulnar aspect of the distal radial physis, which results in an </li> <ul> <li>increase in radial tilt</li> <li>ulnar translation of the carpus</li> <li>triangulation of the carpus</li> <li>prominent dorsal distal ulna</li> </ul></ul></div>

Question 125

<div>All are true regarding Madelung’s, except?</div>

<ol> <li>Result of abnormality in dorsoulnar aspect of distal radial physis</li> <li>Volar subluxation of the carpus</li> <li>Often ulnar positive variance</li> <li>Associated with Ollier’s</li></ol>

Answer 125

A<div><ul> <li>Madelung deformity is characterized by disturbance of growth at the volar and ulnar aspects of the distal radial physis</li> <li>Specific etiology unclear some believe it is caused by tethering of lunate to volar radius by Vicker’s ligament (short radiolunate)</li> <li>Occurs in females>males (4:1), bilateral in 74%, and associated with certain genetic conditions (Leri-Weill dyschondrosteosis, Ollier’s, Turner syndrome à SHOX gene)</li></ul></div><div><br></br></div>

Question 126

<div>RC 2015 - What is true regarding pediatric scaphoid fractures:</div>

<ol> <li>2/3 are distal pole fractures</li> <li>Usually undisplaced waist fracture</li> <li>Proximal pole fractures are common</li> <li>Account for 5% of upper extremity fractures in children</li></ol>

Answer 126

2<div><ul> <li><div>0.45% of pediatric upper extremity fracture</div></li><li>seventy-six (26.5%) occurred at the distal pole</li> <li>194 (67.6%) occurred at the waist</li> <li>seventeen (5.9%) occurred at the proximal pole</li></ul></div>

Question 127

<div>RC 2016, 2013 - Syndactyly. What is the most true?</div>

<ol> <li>Complex syndactyly means that they share a common nerve </li> <li>Functional improvement is an indication for surgery </li> <li>There is no possible surgery to fix the fused nail </li> <li>Skin bridge goes to the PIP level</li></ol>

Answer 127

B.<div> <ul> <li>Wrong Answers:</li> <ul> <li>A: complex: fused bone (not just soft tissue)</li> <li>C: Lateral nail folds may be recreated from two horizontal nail flaps on both side of fingers</li> <li>D:</li> </ul></ul></div>

Question 128

<div>RC 2008 Kid with big index finger with DIP and PIP stiffness, lipofibromatosis, gets in way of pinch between thumb and middle (young kid with a macrodactyly and associated finger stiffness)</div>

<ol> <li>index ray amp</li> <li>debulk</li> <li>epiphyseodesis</li> <li>liposuction</li></ol>

Answer 128

C.<div><br></br></div><div><div>Controversial – can try epiphysiodesis and debulk but may continue to recur – probably to amputation. Young kid means that will still have a long time of growth left and chance of recurrence</div> <div></div></div>

Question 129

<div>RC 2015 - All of the following are associated with short metacarpals except:</div>

<ol> <li>Congenital glaucoma</li> <li>Acrosyndactyly (McGill) or Arachnoidits (Sask)</li> <li>Hypoparathyroidism</li> <li>Sickle cell anemia</li></ol>

Answer 129

B?

Question 130

<div>RC 2013, 12, 08 - Kid with hypoplastic thumb and unstable MCP and CMC joint. What to do for definitive treatment?</div>

<ol> <li>Opponenplasty</li> <li>Index pollicization</li> <li>Splint</li> <li>Amputate</li></ol>

Answer 130

B.<div><br></br></div><div>Stable CMC = reconstruct/opponensplasty</div><div>Unstable CMC = pollicization</div>

Question 131

<div>RC 2016, 14, 11 - All of these are true regarding congenital trigger thumb, except:</div>

<ol> <li>Also called congenital clasp thumb</li> <li>Rarely bilateral</li> <li>Rarely triggers</li> <li>The tendon sheath is normal</li></ol>

Answer 131

A.<div>trigger thumb</div><div><div>-The cause of the trigger thumb is a mismatch in size from the FPL tendon and the A1 pulley. There is the development of a nodule on the FPL tendon called the Notta Nodule as well as thickening of the tendon sheath.</div></div><div><div>-Surgical treatment consists of release of both the A1 pulley. Resection of the Notta nodule on the FPL tendon is NOT required.</div></div><div><br></br><div><div>Congenital Clasp thumb (Orthobullets and lovell and winters):</div> <ul> <li>Condition characterized by deficient active thumb extension. Can progress with time to limitations in passive thumb extension as MCP joint and IP joint contractures develop, creating a rigid deformity. </li> <li>It is the main differential diagnosis for congenital trigger thumb.</li> <li>It occurs secondary to weakness or absence of either the EPL or EPB.</li></ul></div></div>

Question 132

<div>RC 2018, 2008- Young patient 12yrs with described flexion deformity at PIP joint of 25 degrees, tell you that it’s camptodactlyly, what you want to do for treatment?</div>

<div>a.Splint</div>

<div>b.Volar capsule release</div>

<div>c.Skin grafting volarly</div>

<div>d.Tendon transfer</div>

Answer 132

A<div><br></br><div><div>Generally speaking, the results of surgical treatment are otherwise poor, particularly if the proximal interphalangeal joint is fixed. Conservative treatment with stretching, splints and serial casts can be employed with some success.</div></div><div><br></br></div><div><div>· splinting / stretching = mixed results</div> <div>· surgical- only for significant flexion deformities w/ functional impairment = limited results</div> <div>- all identifiable pathology should be addressed</div> <div>- passive deformity - FDS tenotomy +/- FDS transfer to radial lateral band</div> <div>- fixed deformity - osteotomy vs. arthrodesis</div></div></div>

Question 133

RC 2014 - Give 3 considerations for safe application of a pediatric Halo

Answer 133

<ul> <li>JAAOS 2007 - Halo Fixator:</li> <ul> <li>CT indicated in kids under 10 to determine bone thickness and rule out cranial fractures</li> <li>Greater number of pins (10-12)</li> <li>Torque at 2-5 in-lb</li> </ul> </ul>

<ul> <li>Wheeless</li> <ul> <li>Avoid suture lines</li> <li>Avoid anterior pins (protect supraorbital nerves)</li> </ul> <ul> <li>Position: split mattress for slight extension</li> </ul></ul>

Question 134

<div>RC 2015 - 28 yo male presents for genetic counselling. Short stature, multiple hand and foot deformities, XRAY shows lytic lesions with calcifications in metacarpals and phalanges. What do you tell him?</div>

<ol> <li>half of his children will be affected</li> <li>none of his children will be affected</li> <li>all of his sons and none of his daughters will be affected</li> <li>all of his children will be affected</li></ol>

Answer 134

B.<div><div>Oilier’s or Mafucci’s consistent with presentation. Non-inherited disorders. Hence none of children’s necessarily affected.</div></div><div>multiple enchondromatosis - will increase risk of malignant transformation to chondrosarcoma</div><div><br></br></div><div>other spontaneous: Achondroplasia (also AD)</div>

Question 135

<div>RC 2018 Order of zones of physis from metaphysis towards joint:</div>

<div>a.Reserve, maturation, proliferative, hypertrophic</div>

<div>b.Hypertrophic, maturation, proliferative, reserve</div>

<div>c.Proliferative, hypertrophic, reserve, maturation</div>

<div>d.Hypertrophic, reserve, maturation, proliferative</div>

Answer 135

“B<div>mnemonic: My Huge Penis Really Excites = metaphysis - hypertrophic - proliferative - reserve - epiphysis<br></br><div><br></br></div><div><img></img><br></br></div><div><div>Joint - Reserve - Proliferative - Hypertrophic - Metaphysis</div></div><div><br></br></div><div>Reserve: Gauchers, pseudoachondroplasia</div><div>Prolif: Achondroplasia, Gigantism</div><div>Hypertrophic: SCFE, Rickets, Fracture</div><div>Metaphysis: renal SCFE</div></div>”

Question 136

<div>RC 2018 - What corresponds to peak growth velocity:</div>

<div>a.Closure of olecranon apophysis</div>

<div>b.Risser 1</div>

<div>c.Closure of triradiate cartilage</div>

<div>d.Menarche</div>

Answer 136

“A.<div><br></br></div><div><br></br></div><div><br></br><div><img></img><br></br></div></div>”

Question 137

RC 2010 List 3 factors to consider when thinking about doing a hemi-epiphyseodesis

Answer 137

<ul> <li>Patient: bone age of patient and amount of growth remaining</li> <li>Effect on entire limb</li> <li>degree of angular deformity</li> <li>“health” or status of the growth plate</li></ul>

Question 138

<div>RC 2009 - Pt has a limb length discrepancy. When do you consider lengthening the longer leg?</div>

<ol> <li>To correct varus deformity</li> <li>Never lengthen long leg</li> <li>If pelvic obliquity is more significant lengthen the leg to compensate for pelvic obliquity</li></ol>

Answer 138

3.<div><br></br></div><div><div>It is interesting to consider the possibility that such a patient could benefit from lengthening of the already long leg if the pelvic obliquity were greater than the leg-length discrepancy</div></div>

Question 139

<div>RC 2017 - 12 year old boy has 4.5 cm leg length discrepancy. Bone age is 14.5. Scanogram shows equal deficit from tibia and femur. What should be done?</div>

<div>A. Delayed epiphysiodesis of femur and tibia</div>

<div>B. Immediate epiphysiodesis of femur and tibia</div>

<div>C. Epiphysiodesis of femur</div>

<div>D. Lengthening with Ilizarov</div>

Answer 139

B.<div><ul> <li>Contralateral epiphysiodesis now will be ok for shoe lift</li> <ul> <li>1.5 years X 1.5cm/year at knee = 2.25cm stopped </li> <li>4.5-2.25 = 2.25 2.3 = 2.3 ok for shoe lift</li> </ul></ul></div>

Question 140

<div>RC 2015 - How best to assess limb length discrepancy in a child with a 20deg flexion contracture of the knee:</div>

<ol> <li>Xray scanogram</li> <li>Measure ASIS to medial malleolus</li> <li>Blocks</li> <li>CT scanogram</li></ol>

Answer 140

D.<div><br></br></div><div><div>A CT scanogram has the advantage of being able to calculate accurate length measurement in the presence of joint contractures, and typically utilizes a single anteroposterior scout film upon which digital length measurements can be made. In the presence of severe flexion contractures, lateral scout films can be added to improve measurement accuracy. .</div></div>

Question 141

<div>RC 2013 - What are 4 risk factors for the development of DVT associated with MRSA pediatric osteomyelitis?</div>

Answer 141

<div><div>Note: MRSA alone is RF for DVT</div><ul> <li>Clinical presentation/Patient Factors:</li> <ul> <li>Older age, >8 yrs</li> <li>Aggressive clinical course</li> <li>Prolonged fever</li> <li>Fewer days from symptoms to admission (suggests aggressive clinical course)</li> <li>Spine/pelvis/lower extremity OM</li> </ul> <li>Investigations</li> <ul> <li>Significantly elevated CRP > 150</li> <li>Significantly elevated ESR</li> <li>Positive blood cultures</li> </ul> <li>Treatment factors</li> <ul> <li>ICU admission</li> <li>Pulmonary involvement (septic emboli)</li> <li>Surgery needed for treatment</li> </ul></ul></div>

Question 142

<div>RC 2016, 2011 - List 4 long term complications of pediatric osteomyelitis?</div>

Answer 142

<ul> <li>Persistent Infection</li> <ul> <li>Chronic OM (occurs in 20%)</li> <li>Recurrent OM</li> <li>Brodie’s abscess</li> <li>Meningitis</li> </ul> <li>Growth disturbance / LLD</li> <li>Angular deformity (due to # or physeal arrest)</li> <li>Pathologic #</li> <li>Gait abnormality</li> <li>DVT (short term risk)</li> <li>Septic arthritis (short term risk)</li></ul>

Question 143

<div>RC 2009 - A kid steps on nail at cottage, what is your treatment</div>

<ol> <li>ID in ER, D/C and Return if any signs of infection</li> <li>ID in ER and cipro?</li> <li>ID in ER and ceftaz</li> <li>ID in OR and and iV Abx</li></ol>

Answer 143

A.<div><br></br></div><div><div>There are no fixed protocols for the initial management a puncture wound; debridement and irrigation with a 19G needle have been recommended. Especially dirty wounds do warrant initial debridement. </div> <div>Soft tissue infections are generally secondary to staph aureus, and bone or cartilage are secondary to pseudomonas, so no antibiotics are indicated at the time of injury. Wound exploration is indicated and if bone or joint infection has occurred, one of the newer beta-lactam antibiotics are usually administered, ceftazidime is presently favored. The duration of therapy necessary has not been established.</div></div>

Question 144

<div>RC 2014, 13, 12, 11 Except for joint aspiration, what are 4 clinical signs that are suggestive of septic arthritis from transient synovitis.</div>

Answer 144

Lab: WBC>12, ESR>40, CRP>20<div>CPx: inability to Wt Bear, Fever>38.5</div>

Question 145

<div>RC 2009 - 4 yo child has temp 38 deg, doesn’t want to WB, WBC = 15.5, ESR = 50.1. decreased hip ROM. What do you want to do?</div>

<ol> <li>Bone scan / wbc scan</li> <li>Admit / start IV abx</li> <li>Aspirate / possible open hip</li> <li>Admit for pain control / peds consult</li></ol>

Answer 145

C.

Question 146

<div>RC 2010 - 2 week old with effusion and ultrasound showing effusion and not moving arm. What is the most common organism</div>

<ol> <li>Staph. Aureus</li> <li>GBS</li> <li>Hib</li> <li>Neisseria meningitis</li></ol>

Answer 146

B. GBS is most common in neonates, otherwise Staph Aureus is.

Question 147

<div>RC 2017 Name 5 fractures associated with non-accidental trauma</div>

Answer 147

<div><ul><li>High Specificity=PMS</li> <ul> <li>Posteromedial rib fractures</li> <li>Metaphyseal “corner” / bucket handle fractures</li> <li>Scapula fractures</li> <li>Sternal fractures</li> <li>Spinous process fractures</li> </ul> <li>Moderate specificity</li> <ul> <li>Epiphyseal separations (distal humerus)</li> <li>Multiple fractures at various stages of healing</li> </ul> <li>Long bone fractures in non-ambulatory child</li></ul></div>

Question 148

<div>RC 2018 - What is NOT correct with respect to pediatric avulsion fractures</div>

<div>a.The majority of ASIS injuries can be managed nonoperatively</div>

<div>b.MRI is necessary to diagnose all these injuries</div>

<div>c.Tibial tubercle fractures usually need an operation</div>

<div>d.The apophyseal region is the weakest</div>

Answer 148

B.<div><ul> <li>Most injuries can be diagnosed with X-ray</li> <li>Avulsion injuries are the result of failure through the secondary apophysis. These injuries typically occur during athletic events via sudden contraction of the lower extremity musculature with kicking, sprinting, or jumping</li> <li>A: We recommend nonsurgical management for ASIS avulsion fractures in the pediatric and adolescent population because limited evidence supports superior outcomes with surgical intervention in these injuries.</li> <li>C: Tibial tubercle avulsion fractures should be managed early with surgical fixation, with special attention given to the compartments of the lower limb because compartment syndrome is a potential threat after these injuries</li></ul></div>

Question 149

<div>RC 2015 - 11 yo female gymnast with wrist pain - what would you expect to find on XRAY? </div>

<div> a. Positive ulnar variance</div>

<div> b. Decreased radial inclination</div>

<div> c. Negative ulnar variance</div>

<div> d. CMC arthritis</div>

Answer 149

“A.<div><ul> <li>Chronically: <b><u>Ulnar positive (maybe from radial physeal arrest)</u></b></li> <ul> <li>Widened physis</li> <li>Cysts</li> <li>Epiphyseal beaking</li> <li>Hazy transition zone, ill defined borders of physis</li> </ul> <li><img></img></li> </ul> <ul> <li>Treatment:</li> <ul> <li>Non-op: NSAIDs, rest, immob for 3-6/12, strengthen wrist flexors</li> <li>Operative: resection of physeal bridge, ulnar epiphysiodesis + shortening with radial osteotomy</li> </ul></ul></div>”

Question 150

“<div>RC 2018 - 18 year old female has knee pain. You’re shown multiple coronal MRI cuts of what I thought was a discoid meniscus with a tear / increased signal. What is the best treatment plan?</div> <div><img></img></div> <div>(except there were multiple cuts, and no arrow)</div> <ol> <li>Complete menisectomy</li> <li>Partial menisectomy and ensure the meniscus is stable</li> <li>Meniscus transplant</li> <li>Repair of meniscal tear</li></ol>”

Answer 150

B.<div><ul> <li>Current treatment emphasizes meniscal rim preservation (6-8 mm) with arthroscopic saucerization because of the evidence supporting the efficacy of the technique</li> <li>After saucerization, assessment of meniscal stability is performed, because peripheral stabilization is necessary in patients with unstable discoid variants. Stabilization may be achieved through all-inside, inside-out, or outside-in suture repair. Stabilizing the hypermobile meniscus contributes to the ultimate goal of meniscal preservation</li> <li>In young patients a formal inside-out meniscal repair may be performed, using a posterolateral incision to protect the peroneal nerve, popliteal vessels, and tibial nerve during suture retrieval.</li></ul></div>

Question 151

<div>RC 2015 - List 3 prognostic factors for development of OCD of the knee. (2015) - weird wording here…</div>

Answer 151

<ul> <li>Poor Prognosis of an established OCD lesion:</li> <ul> <li>Patient Factors</li> <ul> <li>Older age (ie younger = can treat non-op)</li> <li>Mechanical symptoms/loose fragment</li> </ul> <li>Lesion Factors</li> <ul> <li>Size of lesion (>15mm)</li> <li>Chronicity of lesion (Sclerosis)</li> <li>Integrity of cartilage</li> <li>Atypical location (patella, LFC)</li> </ul> </ul> <li>RFs for development of OCD lesions (OKU PEDS 5)</li> <ul> <li>Smaller intercondylar notch width index was associated with OCD of MFC</li> <li>Greater medial and posterior tibial slope has been reported in knees with MFC OCDs</li> <li>Varus alignment - MFC OCD; valgus align - lateral OCD </li> <li>Other years answers:</li> <ul> <li>Male gender</li> <li>Participation in high level sports</li> <li>African-Canadian race</li> <li>Presence of contralateral lesion (controversial, some studies say bilateral in only 7%, some say in 30%)</li> </ul> </ul></ul>

Question 152

<div>RC 2011 - In regards to microfracture treatment (of OCD), all are true except? </div>

<ol> <li>Younger age have better outcome</li> <li>Decreased BMI do better</li> <li>No correlation between MRI findings and clinical outcome</li> <li>Long term MRI findings show 50% of cases have evidence of fibrous filling of defect.</li></ol>

Answer 152

“3.<div><br></br></div><div><div>Mithoefer K (AJSM 2009) Clinical efficacy of the microfracture technique for articular cartilage repair in the knee</div> <ul> <li>"”Defect fill on MRI was highly variable and correlated with functional outcome””</li> </ul> <div></div> <div>Erggelet C (J Clin Orthop Trauma 2016) Microfracture for the treatment of cartilage defects in the knee joint</div> <ul> <li>Systematic review</li> <li>"”There is evidence from the described studies that younger patients under 30-40 years might benefit more from microfracture technique””</li></ul></div>”

Question 153

<div>Regarding cartilage repair techniques for a young patient, which is true? </div>

<ol> <li>No difference in techniques</li> <li>Mosaicplasty is more effective</li> <li>Allograft is more effective</li> <li>Microfracture is more effective.</li></ol>

Answer 153

A.<div><br></br></div><div><br></br></div>

Question 154

<div>RC 2018 - What is the most common location for a OCD lesion in the knee. Be Specific (worth like, 4 fing marks!)</div>

Answer 154

posterolateral aspect of MFC

Question 155

<div>RC 2009 Radiographic findings in OCD elbow in an 11year old female gymnast</div>

<ol> <li>Radial Head Enlargement</li> <li>Fragmentation of trochlea</li> <li>Fragmentation of radial heal</li> <li>Late physeal closure</li></ol>

Answer 155

“1.<div>Similar to Panner’s disease, irregularity and enlargement of the radial head also may be noted <div>Usually is capitellum – pitchers and gymnasts from excessive axial load. Get fragmentation of capitellum.</div> <div>In the late stages of humeral capitellum osteochondritis dissecans, one is likely to see radial head enlargement, premature distal humeral physeal arrest, and degenerative changes leading to incongruity between the articulation of the radial head and the humeral capitellum.</div></div><div><br></br></div><div><ul> <li>Differentiate from Panner Disease:</li> <ul> <li>Age<10 years, no trauma, bilateral, self-limited</li> <ul> <li>OCD: older patients and lesions do not heal</li> </ul> <li>Like a legg-calve-perthes</li> <li>Osteochondrosis of the entire capitellum with fissuring and fragmentation</li> <li>Don’t see isolated lesions, involves entire capitellum</li> </ul></ul></div><div><br></br></div>”

Question 156

<div>RC 2013, 12, 11 - Which of the following does not cause snapping in the adolescent hip?</div>

<ol> <li>Labrum</li> <li>Iliopsoas</li> <li>Rectus</li> <li>TFL</li></ol>

Answer 156

C.<div><ul> <li>Coxa Saltans</li> <ul> <li>External: ITB over GT</li> <li>Internal: iliopsoas over fem head</li> <li>Intra-articular: loose body, labrum</li> </ul></ul></div>

Question 157

<div>RC 2015 - 12yo girl with persistent pain and disability 6mos after an ankle sprain. Apart from fibular collateral ligament injury, what findings will you find on XR or MRI (5 points)?</div>

Answer 157

<ul> <li>Unclear if this is causes attributable to recurrent sprains or causes of lateral ankle pain</li> <ul> <li>Alignment: Subtle cavus foot</li> <li>Boney: Tarsal Coalition, </li> <ul> <li>Anterior process of calcaneus fracture</li> <li>Lateral talar process fracture</li> <li>Talar OCD</li> <li>5th metatarsal fracture</li> </ul> <li>Soft-tissue: Peroneal tendon injury</li> <ul> <li>Syndesmotic Ligament Injury</li> </ul> </ul> </ul>

<div>Or is it talking about concomitant pathology with an ankle sprain?</div>

<ul> <ul> <li>Peroneal tendon dislocation</li> <li>Peroneal tendon tear</li> <li>Peroneal retinaculum tear</li> <li>Talar OCD</li> <li>Avulsion fracture of distal fibula</li> <li>Varus tilt of the ankle</li> </ul></ul>

Question 158

<div>RC 2013, 12 - What are 4 surgical techniques for ACL reconstruction in an 11-year-old female athlete?</div>

Answer 158

IT Band extraphyseal reconstruction<div>All epiphyseal reconstruction</div><div>Partial Transphyseal (epiphyseal fem tunnel and transphyseal tibial)</div><div>Trans-physeal</div><div><br></br></div><div>Autograft>allograft</div><div>Hamstring>BPB (bone plug can cause physeal arrest)</div>

Question 159

<div>RC 2013 - 13 yr F with proximal humerus 60% displaced, 45 degrees angulated. What is the best treatment</div>

<ol> <li>ORIF</li> <li>CRPP</li> <li>Sling</li> <li>Thoracobrachial cast</li></ol>

Answer 159

B.<div><ul> <li><u>JAAOS: Acceptable reduction over age 10</u></li> <ul> <li><20-30o angulation</li> <li>50% displacement</li> </ul></ul></div><div><ul> <li><u>Dobbs, 2003: Acceptable alignment</u></li><li>Age < 7 - 75o angulation</li> <li>8-11 years - 60o angulation</li> <li>Older than 12 - 45o angulation</li></ul><div><br></br></div><div><br></br></div></div>

Question 160

<div>RC 2012, 10 - 9 yo boy sustains completely displaced irreducible proximal humerus #. Intraoperatively, what is the block to reduction? REPEAT</div>

<ol> <li>periosteum</li> <li>Supraspinatus</li> <li>LHB</li> <li>SHB</li></ol>

Answer 160

“3.”“it should be noted that, in up to 9.4% of surgical cases, the biceps tendon can be interposed in the fracture site and may require an open incision to successfully reduce the fracture before pinning”””

Question 161

“<div>RC 2012 - ““list the order of ossification centre of the elbow””</div>”

Answer 161

“CRITOE<div><br></br></div><div>Fusion: CTEROI - if there is an olecranon apophysis, there should be a medial epicondyle (ME last to fuse at 15-19 years; capitellum first to fuse at 12-14 years)</div><div><br></br></div><div><img></img><br></br></div>”

Question 162

<div>RC 2017 - What are three considerations with open reduction, internal fixation of a pediatric lateral condyle fracture?</div>

Answer 162

<ul> <li>Exposure: Preserving posterior blood supply by avoiding dissection (typically Kocher: anconeus (rad) and ECU (PIN))</li> <li>Reduction: Articular reduction mandatory - requires direct visualization of the articular surface </li> <ul> <li>metaphysis may not be perfectly reduced due to plastic deformation - this is ok</li> </ul> <li>Fixation: with percutaneous pins or compression screw</li></ul>

Question 163

<div>RC 2013, 2008 Undisplaced lateral condyle fracture in a child. What is the next best treatment?</div>

<ol> <li>Cast and follow up within a week</li> <li>Arthrogram</li> <li>ORIF</li> <li>MRI</li></ol>

Answer 163

“A.<div><br></br></div><div><ul> <li>JAAOS 2011: ““Nondisplaced fractures or those displaced ≤2 mm are managed with cast immobilization and frequent radiographic follow- up””</li><li>Displaced (>2mm) or rotated</li> <ul> <li>CRPP:</li> <ul> <li>2-4mm displacement</li> <li>Avoids soft tissue stripping (non-union, osteonecrosis)</li> </ul> <li>ORIF</li> <ul> <li>Significantly rotated or displaced</li> <li>Usually Kocher approach</li> <li>Risk of non-union due to soft tissue stripping</li> <ul> <li>No stripping posteriorly!!</li> </ul> <li>Fixation with wires usually</li> <ul> <li>Be careful with 3 wires –> increased loss of motion and lateral spurs</li> </ul> </ul> </ul></ul></div>”

Question 164

<div>RC 2017 - 12 year old girl presents 6 months after being treated non-operatively for a minimally displaced medial epicondyle fracture. There is a non-union, but she has full motion and no pain. What now?</div>

<ol> <li>ORIF with pins</li> <li>Place in above elbow cast</li> <li>Follow up in 6 months</li> <li>Get MRI to investigate for fibrous non-union</li></ol>

Answer 164

3.<div>JBJS 2001 Long term results of treatment of fractures of the medal humeral epicondyle in children <ol> <li>Nonunion of the medial epicondyle was found in all but two of our Group-I patients. In light of these results, we believe that nonunion of the medial epicondyle should no longer be considered a complication of nonsurgical treatment but rather should be thought of as an asymptomatic consequence of it</li> <li>The nonunion of the epicondylar fragment that was present in most patients who had been treated only with a cast did not adversely affect the functional results. Surgical excision of the medial epicondylar fragment should be avoided because the long-term results are poor.</li></ol></div>

Question 165

<div>RC 2018 - Prior to fixation, what is the sequence of reducing a paediatric type 2B supracondylar fracture of the distal humerus (worth 2.5 marks).</div>

Answer 165

<div>JBJS 2018</div>

<div><br></br></div>

<div>The steps of the surgical procedure consist of the following. </div>

<div>1. Position the patient supine with the affected extremity on a fluoroscopy detector or hand-table. </div>

<div><b><u>2. Perform closed reduction. </u></b></div>

<div>• Apply longitudinal traction with the elbow in 30° of flexion (milking maneuver if type 3) </div>

<div>• Correct medial or lateral translational displacement. </div>

<div>• Correct varus or valgus malalignment. </div>

<div>• Maintain traction and flex the elbow, placing pressure over the olecranon process to correct extension at the fracture site. </div>

<div>Consider pronation for PM displacement, supination for PL displacement</div>

<div>3. Assess reduction using anteroposterior, oblique, and lateral fluoroscopic views. </div>

<div>4. Place divergent pins from the lateral side, using 2 pins for type-II and 3 pins for type-III fractures. </div>

<div>5. Assess stability by moving the elbow through a range of motion under live fluoroscopy in the lateral projection. If the fracture is determined to be unstable with lateral-only pins, proceed with medial pin placement through a mini-open approach. </div>

<div>6. Cut the pins and bend them outside the skin. Then apply a long-arm bivalved cast.</div>

Question 166

<div>RC 2012 - 6 year-old girl presents to your emergency department with a type III supracondylar fracture of the elbow. She has a cold, blue hand with no pulses. She is also unable to flex her thumb. You do your closed reduction and pinning in the operating room. When you seen her in the PACU, her hand is warm, pink, and has no pulse. She is still unable to flex her thumb. What is the best treatment at this point?</div>

<div><ol> <li>Observe with close follow-up</li> <li>Bring back to OR for artery and nerve exploration </li> <li>Angio</li> <li>Remove K-wires</li></ol></div>

Answer 166

“1<div><ul> <li>Extension Types:</li> <ul> <li>AIN>Median>Radial>Ulnar (iatrogenic)</li> </ul> <li>Flexion Types (2%)</li> <ul> <li>Ulnar</li> </ul></ul><div><img></img><br></br></div></div>”

Question 167

<div>RC 2013, 08 - A 4 yo boy has a Type III supracondylar fracture with a cold and pulseless hand. What is most true?</div>

<ol> <li>After closed reduction, an angiogram is always needed</li> <li>It often takes 24 hours after reduction for a Doppler pulse to return.</li> <li>If a pulse doesn’t return, it can be ignored if the hand is otherwise well perfused.</li> <li>A complete occlusion of the brachial artery necessitates immediate reconstruction.</li></ol>

Answer 167

C.<div><ul> <li>Robb JE (JBJS Br 2009) The pink, pulseless hand after supracondylar fracture of the humerus in children</li> <ul> <li>Mangat described 19 kids with grade III treated at 6 hours from injury</li> <ul> <li>11 were observed –> pulse returned at 24 hours (2), 3 weeks (3), 1-3 months (2)</li> </ul> </ul></ul></div>

Question 168

<div>What is true regarding a type III supracondylar humerus fracture in a pediatric patient?</div>

<ol> <li>Limited remodeling for translational deformity</li> <li>Splinting in 120 degrees of flexion to maintain reduction is acceptable</li> <li>Equivalent outcomes with lateral and crossed pinning</li> <li>These require emergent surgical management</li></ol>

Answer 168

A.<div><ul> <li>A: true. Translational deformity has minimal remodelling potential and can lead to cubitus varus - the only acceptable deformity is angulation; rotation is also bad</li> <li>C: false. 2 lateral pins are clinically but NOT biomechanically equivalent to a crossed-pin construct - 3 lateral pins are equally strong as a crossed-pin construct; medial pin has an increased risk of ulnar nerve injury (NNH = 20) </li> <li>B: false. Splinting in hyperflexion increases the risk of compartment syndrome</li> <li>D: false. No evidence for timing threshold</li></ul></div>

Question 169

RC 2009 - Which of the following does not cause cubitus varus following Supracondylar #? <ol> <li>Flexion type </li> <li>Inadequate reduction</li> <li>Loss of fixation</li> <li>Underappreciation of medial comminution</li></ol>

Answer 169

A. flexion type can cause valgus deformity<div><div><br></br></div><div><br></br></div></div>

Question 170

RC 2015 - All of the following are true regarding a fishtail deformity of the distal humerus, except: <ol> <li>Associated with supracondylar humerus fracture</li> <li>Results from central physeal growth arrest</li> <li>Predisposes to early ulnohumeral degenerative changes</li> <li>Results in significant humeral length deficiency</li></ol>

Answer 170

D.<div><br></br></div>

Question 171

<div>RC 2018 - Variation of ?missed Monteggia # with posterior dislocating radial head - tx?</div>

<div>a. ulnar osteotomy to increase PUDA and posterior plate </div>

<div>b. ulnar osteotomy to decrease PUDA and posterior plate</div>

<div>c. closed reduction alone</div>

<div>d. flexible intramedullary nail</div>

Answer 171

“B. decreasing PUDA ‘pushes’ the RH anteriorly<div><br></br></div><div>Increasing PUDA pushes RH more out the back<br></br><div><br></br></div><div><img></img><br></br></div></div>”

Question 172

“<div>RC 2018, 2013 - 16yo female with isolated forearm fracture. You are shown an xray of patient with closed physes, anterior radial head dislocation, middle 1/3 ulna fracture and very distal ulna fracture (about 2 cm from distal ulna). What is the best treatment?</div> <div><img></img></div> <div>(This pic but also a distal ulna fracture - ie segmental)</div> <ol> <li>Closed reduction of ulna and radial head with a well molded above elbow cast in supination</li> <li>Closed reduction and intramedullary nail ulna and closed reduction of radial head</li> <li>Open reduction and internal fixation of ulna and radius</li> <li>Closed reduction and intramedullary nail fixation of ulna with closed redution of radius.</li></ol>”

Answer 172

3. get the ulna perfect (and then you the RH should just reduce)

Question 173

<div>RC 2009 - Type 2 Monteggia in 10 yr old, radial head dislocated posteriorly. How to treat?</div>

<ol> <li>reduce with flexion and pronation and pressure on radial head, above elbow cast in flexion and pronation</li> <li>reduce in flexion/supination with pressure on radial head, cast above elbow in flexion/supination</li> <li>reduce with extension and pressure on radial head, cast above elbow in extension</li> <li>open reduction with k-wire across radiocapitellar joint</li></ol>

Answer 173

3.<div><ul> <li>Anterior and Lateral Dislocations –> Flexion and supination for reduction</li> <li>Posterior –> longitudinal traction, direct pressure +/- supination</li></ul></div>

Question 174

<div>RC 2013, 12 What are 4 poor prognostic factors in a radial neck fracture in children?</div>

Answer 174

<ul> <li>Patient factors: Older patient (age>10y) *</li> <li>Injury Factors: Associated Injuries *</li> <li>Treatment Factors:</li> <ul> <li>Requires open reduction *</li> <li>Delayed treatment *</li> <li>Internal fixation</li> <li>Poor reduction</li> <ul> <li>Angulation >30deg *</li> <li>Translation >3mm *</li> </ul> </ul></ul>

<div>Reduction maneuvers</div>

<div>-Patterson: Traction in extension, varus, thumb pressure</div>

<div>-Israeli: elbow flexion to 90 deg with pron/sup with pressure on head</div>

<div>-esmarch</div>

<div>-perc</div>

<div>-metazau</div>

<div>-open</div>

Question 175

<div>RC 2017, 2009 - Both bones forearm # 10deg rotational malunion in the forearm, What is true?</div>

<ol> <li>A midshaft malunion will result in more decreased pronation</li> <li>A midshaft malunion will result in more decreased supination</li> <li>A distal malunion will result in more decreased pronation</li> <li>A distal malunion will result in more decreased supination</li></ol>

Answer 175

“B.<div><br></br></div><div><ul> <li>Rockwood and Greens:</li> </ul> <div>"”They observed a significantly greater loss of ROM in forearms with middle-third deformities than with distal-third deformities, with more supination being lost than pronation. They also observed a significant decrease of ROM with 15° of angulation. The greater decrease of ROM in middle-third deformities was attributed to the loss of the radial bow where the two forearm bones overlap at the extremes of pronation and supination””</div></div>”

Question 176

<div>RC 2018, 2017, 2012, 2009 - 12yo B comes in ten days after a salter-harris II distal radius with the 15° radial inclination on the AP and 50°apex volar on the lateral. What is the best treatment option?</div>

<div>a.ORIF with a plate</div>

<div>b.ORIF and percutaneous pinning</div>

<div>c.Repeat closed reduction and cast with appropriate mold</div>

<div>d.Cast with appropriate molding and observe</div>

Answer 176

D. observe, may need osteotomy down the line<div><br></br></div><div><ul> <li>Roth (2014) Criteria of acceptable alignment</li> <ul> <li><9 years: <30° true angulation</li> <li>9-12 years: <25° true angulation </li> <li>>12 years: <20° true angulation</li> </ul></ul></div>

Question 177

<div>RC 2013, 2011, 2010- What are 4 indications for percutaneous pinning of a distal radius fracture in the pediatric population?</div>

Answer 177

-intra-articular<div>-failure to reduce</div><div>-open</div><div>-segmental</div><div>-floating elbow</div><div>-acute CS</div>

Question 178

<div>RC 2015 What is the best predictor of re-displacement in a distal radius and ulna fracture in a 7yo:</div>

<ol> <li>Ulnar styloid fracture</li> <li>Cast index of 0.7</li> <li>Bayonet apposition</li> <li>Triple point index/Three point mould</li></ol>

Answer 178

3. previous answer 4 but recent evidence says main thing is INITIAL DISPLACEMENT<div><br></br></div><div>RF for failure is also OBESITY</div>

Question 179

<div>RC 2014 What is the risk of osteonecrosis in a pediatric displaced trans-cervical hip fracture?</div>

<ol> <li>100%</li> <li>60%</li> <li>30%</li> <li>15%</li></ol>

Answer 179

“ANSWER: C<br></br><div><br></br></div><div><img></img><br></br></div>”

Question 180

<div>RC 2011 - What has increased rate of ON in pediatric femoral neck fracture? </div>

<ol> <li>age</li> <li>Delbet IV</li> <li>fracture displacement</li> <li>Gender</li></ol>

Answer 180

3.<div><br></br></div><div><div>JAAOS 2018: Development of osteonecrosis is associated with<b> fracture displacement (9X higher risk if displaced vs not)</b>, fracture location (Delbet types I and II), and closed management via casting or closed reduction with internal fixation.</div></div>

Question 181

<div>RC 2017 - Name 3 principles for maintaining reduction in a length stable pediatric femur fracture managed with nancy nails</div>

Answer 181

<ol> <li>Canal fill at least 80%</li> <li>Use of titanium vs stainless steel nails</li> <ol> <li>Titanium nails 4X malunion rate than stainless steel (Wall JBJS 2008)</li> <li>Titanium nails 3-4X more expensive (Wall JBJS 2008)</li> </ol> <li>Pre-bending the nails to contact the intramedullary walls at the fracture site</li></ol>

<ul> <li>Pre-bending the nails (to 3X that of the canal diameter) to contact the intramedullary walls at the fracture site</li> <li>End caps- can stabilize the nail a bit like locking the nail</li> <li>There are locking elastic nails</li> <li>Titanium nails (<b>better torsional and axial compression strength</b>) instead of stainless steel nails (stiffer, less malunion, reoperation)</li> <li><b>Antegrade nails stronger with 1 C-shaped and 1 S-shaped instead of 2 retrograde C-shaped</b></li> <li>Retrograde provides higher torsional and bending stiffness</li></ul>

Question 182

<div>RC 2014 - A 5yo with a femur fracture treated is treated with a spica cast. What is an unacceptable deformity?</div>

<ol> <li>25 degrees malrotation</li> <li>2.5cm shortening</li> <li>20 degrees coronal plane angulation</li> <li>20 degrees sagittal plane angulation</li></ol>

Answer 182

“2. is unacceptable (should be <2cm)<div><br></br></div><div><img></img><br></br><div><br></br></div><div><div>Generally, for children aged 2 to 10 years, acceptablefracturealignment at union is</div><div>≤15° of varus or valgus angulation,</div><div>≤20° of anterior or posterior angulation</div><div>≤30° of malrotation</div></div><div><div>Shortening at union should be no more than 1.5 cm to 2.0 cm</div></div></div>”

Question 183

<div>RC 2015 - 54kg kid with a diaphyseal femur fracture. What is the most appropriate treatment?</div>

<ol> <li>Ex-fix</li> <li>Rigid IM nail</li> <li>Flexible IM nail</li> <li>Submuscular plate</li></ol>

Answer 183

2 (4 not unreasonable)<div><br></br></div><div><div>The time to full-weight bearing was shorter in IN (IN: 57.3 days, SP: 89.2 days, p<0.05). In surgical parameters, operative time seemed shorter in IN (IN: 94.7 min, SP: 104 min, p=0.095), and fluoroscopy time was shorter in IN (IN: 58s, SP: 109s, p<0.05) than SP group.</div><div><br></br></div><div><br></br></div></div>

Question 184

<div>RC 2013, 2011 - What are three intra-operative techniques to reduce avascular necrosis during antegrade, locked, rigid femoral nail for an adolescent fracture?</div>

Answer 184

<ul> <li>Nail: Trochanteric/lateral start point, Smallest nail size</li> <li>Technique: </li> <ul> <li>Minimal dissection (posterior dissection)</li> <li>Percutaneous</li> <li>Sharp reamers</li> </ul></ul>

Question 185

<div>RC 2013 - What is least likely to cause compartment syndrome when putting on a hip spica cast for a femur fracture in an 8 yo</div>

<ol> <li>Placing the below knee portion first and using it to place traction on the thigh</li> <li>Placing the spica in the seated position with the hip and knee at 90 degrees</li> <li>Including the foot in the spica</li> <li>Placing a spica with hip and knee flexed less than 90-90</li></ol>

Answer 185

D preferred. maybe B.<div><br></br></div><div><ul> <li>90/90 position (RC EXAM)</li> <ul> <li>Risk of compartment syndrome in this position</li> <li>Mubarak SJ (JPO 2006) Volkmann contracture and compartment syndromes after femur fractures in children treated with 90/90 spica casts</li> </ul> <li>Close follow up (every week x 3 weeks)</li> <li>Decreased risk of CS with applying smooth contours around popliteal fossa, limiting knee flexion to<90° and avoiding excessive traction (orthobullets)</li><li>foot out of spica allows serial exams</li></ul></div>

Question 186

<div>RC 2012 - Pediatric patient with midshaft femoral fracture. You plan to do retrograde femur elastic nailing. What % of the canal at the isthmus should you fill with your elastic nails?</div>

<ol> <li>60%</li> <li>70%</li> <li>80%</li> <li>90%</li></ol>

Answer 186

C.

Question 187

<div>RC 2015 - In a type II tibial eminence fracture...</div>

<div>What is the block to reduction?</div>

<div>What are the consequences of failed reduction? (2 points)</div>

Answer 187

<ul><li>Meniscus (medial)</li><li>Inter-meniscal ligament</li></ul>

<div><ul> <li>ACL Instability</li> <li>Stiffness/Notch Impingement</li></ul></div>

Question 188

<div>RC 2016 In a pediatric tibial spine/eminence fracture, all of the following are true, except:</div>

<ol> <li>ACL laxity and instability is a common complication and can cause functional impairment</li> <li>Meniscal and chondral injuries are not associated </li> <li>Associated with a larger femoral intercondylar notch</li></ol>

Answer 188

B is false - mesnical and chondral injuries are associated (30%, 7%)<div><br></br></div><div>A, C are true</div>

Question 189

<div>RC 2014, 12 - List 3 complications associated with pediatric tibial tubercle fracture?</div>

Answer 189

<ul> <li>Early: </li> <ul> <li>Compartment Syndrome</li> <li>Skin Necrosis</li> </ul> </ul>

<ul> <li>Late</li> <ul> <li>Prominent hardware</li> <li>Recurvatum Deformity</li> <li>Leg Length Discrepancy</li> <li>Hardware Irritation</li> <li>Re-fracture</li> <li>Stiffness</li> <li>Patella Baja</li> <li>Saphenous neuroma</li> <li>Non-union</li> </ul></ul>

Question 190

<div>RC 2017 - What is a complication of tibial tubercle fractures?</div>

<ol> <li>Compartment syndrome</li> <li>Foot drop</li> <li>Ligamentous injury</li> <li>…</li></ol>

Answer 190

A<div><br></br></div><div>Monitor for compartment syndrome, extension lag</div><div>Recurrent anterior tibial artery injury 4-20%<br></br></div>

Question 191

<div>RC 2015 - What artery is commonly implicated in compartment syndrome in tibial tubercle fractures:</div>

<ol> <li>Anterior tibial recurrent</li> <li>Peroneal artery</li> <li>Inferior patellar</li> <li>Posterior tibial recurrent</li></ol>

Answer 191

A<div><br></br></div><div><div>disruption of the recurrent anterior tibial recurrent artery can result in bleeding into the anterior compartment of the leg, leading to compression of the anterior tibial artery and deep peroneal nerve</div></div>

Question 192

<div>RC 2009 - A 4 year old has a proximal tibia fracture. What deformity may occur?</div>

<ol> <li>Varus</li> <li>Valgus</li> <li>Procurvatum</li> <li>Recurvatum</li></ol>

Answer 192

B. Cozens fracture is valgus. - cast in VARUS<div><br></br></div><div><br></br></div><div>resolves in 2 years</div>

Question 193

<div>RC 2008 - What is true regarding pediatric tibia fractures?</div>

<ol> <li>The average 11yr old will have 10mm of overgrowth</li> <li>10° of coronal displacement in an 8yr old will remodel adequately</li> <li>10° of rotation is unacceptable in any age</li> <li>the proximal tibial physis growth will be affected even with distal fractures</li></ol>

Answer 193

“C. (previously B)<div><br></br></div><div>overgrowth usually only 5-7mm</div><div><br></br></div><div>to simplify - just remember 5s: 5 deg v/v, 5 deg a/p, 5 deg rotation, 5mm<br></br><div><br></br></div><div><img></img><br></br></div></div>”

Question 194

<div>RC 2012 - What is true with regards to triplane fractures in children?</div>

<ol> <li>Results from lateral rotation </li> <li>Occurs because posteromedial physis closes first </li> <li>High risk of growth arrest </li> <li>Cannot happen with growth plates are fully open</li></ol>

Answer 194

“A.<div><br></br></div><div>B - false - centrally it closes first</div><div>C - risk of arrest is 7-20%</div><div><div>D. false - ““In seven of our cases the anteromedial part of the growth plate was fused, but in eight children the plate was completely open.””</div></div>”

Question 195

<div>RC 2012 - Which portion of the distal tibial physis is the last to fuse?</div>

<ol> <li>Anterolateral </li> <li>Central</li> <li>Anteromedial </li> <li>Posteromedial</li> </ol>

<div></div>

Answer 195

“A.<div><br></br></div><div><img></img><br></br></div>”

Question 196

<div>RC 2017 - Name 5 indications for MRI in juvenile scoliosis</div>

Answer 196

<div><ul> <li>Patient:</li> <ul> <li>Male, Age onset<11</li> <li>Abnormal neurological exam</li> <li>Cutaneous findings</li> <li>Syndromic, congenital</li> </ul> <li>Curve</li> <ul> <li>Left thoracic curve</li> <li>Rapid progression</li> <li>Short segment curve</li> <li>Hyperkyphosis</li> </ul></ul></div>

Question 197

<div>RC 2014, 12 - 12 yr old female with a 30 degree thoracic curve. List 6 ways to determine her skeletal maturity</div>

Answer 197

<ul> <li>Clinical</li> <ul> <li>Tanner staging (secondary sexual characteristics) - <3 = incr risk</li> <li>Menarche status -A person grows fastest one year before onset of menarche and usually <b>finishes growing 1.5-2 years after its onset.</b></li> </ul> <li>Radiograph</li> <ul> <li>Pelvis: Risser sign, Status of triradiate cartilage</li> <li>Gruelich and Pyle hand atlas</li> <li>Sauvegrain method (<b>olecranon physeal closure - corresponds to PHV</b>)</li> </ul></ul>

Question 198

<div>RC 2015 - All of the following are risk factors for failure of brace treatment in AIS, except:</div>

<ol> <li>Thoracic lordosis</li> <li>Smoking</li> <li>Obesity</li> <li>Male</li></ol>

Answer 198

B.<div><br></br></div><div>C-obesity = hard to brace</div><div>D-Males less complaint</div>

Question 199

<div>RC 2009 - 11 yr old girl has 23 deg scoliosis. She is pre-pubertal. You send her away for 4 months to do physio. Her scoli hasn’t changed. What do you do?</div>

<ol> <li>Boston Brace</li> <li>Milwaukee Brace</li> <li>Reassure patient / parents / FU in 4 months</li> <li>Posterior fusion</li></ol>

Answer 199

C.<div><ul> <li><25 deg - observe</li> <li>25-45 - brace if Risser 0-2</li> <li>>45 surgery</li></ul></div>

Question 200

<div>RC 2013 - What are the 3 components of the Lenke classification for adolescent idiopathic scoliosis?</div>

Answer 200

“<div><ul> <li>Curve Type (Identify structural curves)</li> <li>Thoracic Sagittal Modifier (kyphosis modifier)</li> <li>Lumbar Modifier (based on apex of lumbar curve)</li></ul><div><img></img><br></br></div></div>”

Question 201

<div>RC 2016 - Give 3 factors to consider when performing a selective thoracic fusion in AIS</div>

Answer 201

“<ul> <li>General Principles:</li> <ul> <li>Preserving motion segments</li> <li>Preventing junctional kyphosis</li> <li>Shoulder imbalance</li> </ul><li>thoracic-to-lumbar curve magnitude ratio >1.2</li> <li>an apical vertebral translation ratio >1.2</li> <li>preoperative lumbar curve <45°</li><li><img></img><br></br></li><li>OR Maybe</li> <ul> <li>Upper instrumented level</li> <ul> <li>Shoulder balance and kyphosis</li> </ul> <li>Lower Instrumented level</li> <ul> <li>Stable vertebrae</li> <li>Maintain motion segments below fusion </li> <li>Avoid L5 if possible</li> <li>Pelvic obliquity- extend fusion to pelvis</li> </ul> </ul></ul>”

Question 202

<div>RC 2015 - 14 yr old female with Right Thoracic curve and Left lumbar curve. List 3 radiographic features that are suggestive that this is a structural curve.</div>

Answer 202

<ul> <li>Largest Cobb Measurement</li> <li>Side Bending Cobb >25o</li> <li>Segmental Kyphosis > 20o</li></ul>

Question 203

RC 2018 What is NOT correct with respect to pediatric avulsion fractures <div>a.The majority of ASIS injuries can be managed nonoperatively</div> <div>b.MRI is necessary to diagnose all these injuries</div> <div>c.Tibial tubercle fractures usually need an operation</div> <div>d.The apophyseal region is the weakest</div>

Answer 203

B.

Question 204

<div>RC 2012 - List 3 radiographic features that are suggestive that this is a structural curve.</div>

Answer 204

<ul> <li>Lenke LG (JBJS 2001) Adolescent idiopathic scoliosis: a new classification to determine extent of spine arthrodesis</li> <ul> <li>Largest Cobb Measurement</li> <li>Side Bending Cobb >25o</li> <li>Segmental Kyphosis > 20o</li> </ul></ul>

Question 205

<div>RC 2012 - List 8 organ systems associated with congenital scoliosis</div>

Answer 205

<ul> <li>CNS - Spinal Dysraphism (18-33%) - diastematomyelia, tethered cord, syringomyelia</li> <li>Urogenital Anomalies</li> <li>Auditory anomalies</li> <li>VACTERL</li> <ul> <li>Vertebral anomalies</li> <li>Anorectal atresia</li> <li>Tracheoesophageal fistula</li> <li>Renal/vascular anomalies</li> <li>Cardiac defects</li> <ul> <li>ASD/VSD/PDA/tetrology</li> </ul> <li>Limb defects (radial club hand, thumb hypoplasia)</li> </ul></ul>

Question 206

<div>RC 2016 - Congenital scoli - what is the most common CNS abnormality?</div>

<ol> <li>Diastomatomyelia</li> <li>Chiari</li> <li>Tethered cord</li> <li>Intradural lipoma</li></ol>

Answer 206

“A.<div><br></br></div><div><div> <div> <div><img></img></div> </div></div></div>”

Question 207

<div>RC 2012 - Highest Rate of progression for congenital Scoliosis</div>

<ol> <li>Hemivertebrae (did not specify)</li> <li>Unilateral unsegmented Bar</li> <li>Double hemivertebrae</li> <li>Wedge</li></ol>

Answer 207

“B.<div><br></br></div><div><img></img><br></br></div>”

Question 208

<div>RC 2011 - When would you brace a congenital scoli?</div>

<div>A) progressive curve 2° to unsegmented bar</div>

<div>B) progressive curve 2° to hemivertebra</div>

<div>C) flexible compensatory curve below congenital curve</div>

<div>D) 13 decree scoli with kyphosis</div>

Answer 208

C.<div><br></br></div><div>Bracing is generally viewed as ineffective treatment for congenital curves; however, it may be used for compensatory curves of a normally segmented spine. Parson-ism<br></br></div>

Question 209

<div>RC 2009 - All of the following are associated w/ congenital thoracic scoliosis except:</div>

<ol> <li>Conductive hearing loss </li> <li>Obstructive uropathy</li> <li>VATER</li> <li>Tethered cord</li></ol>

Answer 209

A.<div><br></br></div><div>OKU: A urologic or müllerian duct abnormality (such as horseshoe kidney, renal aplasia, duplicate ureters, or hypospadias) is seen in up to 33% of patients.</div>

Question 210

<div>RC 2018, 2011 - Congenital scoliosis. Which is an indication for hemiepihysiodesis/ hemiarthrodesis?</div>

<ol> <li>Age 5 to 10</li> <li>Unilateral bar</li> <li>Curve less than 50</li> <li>Thoracic kyphosis</li></ol>

Answer 210

C.<div><ul> <li>Hedden D (JBJS 2007) Management Themes in Congenital Scoliosis</li> <ul> <li>Single hemi-vertebrae</li> <li>Deformity < 50o</li> <li>Child < 5 years (enough remaining growth)</li> <li>Short segment curve (<5 levels)</li> <li>Minimal sagittal plane deformity</li> </ul></ul></div>

Question 211

<div>RC 2010 - A child with a hemivertebra. What are 3 indications for being able to perform a hemi-epiphysiodesis?</div>

Answer 211

<ul> <li>Hedden D (JBJS 2007) Management Themes in Congenital Scoliosis</li> <ul> <li>Patient: Child < 5 years (enough remaining growth)</li> </ul> <ul> <li>Curve: </li> <ul> <li>Single hemi-vertebrae</li> <li>Deformity < 50o</li> <li>Short segment curve (<5 levels)</li> <li>Minimal sagittal plane deformity</li> </ul> </ul></ul>

Question 212

<div>RC 2014, 2010 - A 5yo female with congenital scoliosis, L5 fully segmented hemivertebrae with 50 degree LS angle. What is the best treatment?</div>

<ol> <li>L5 hemiepiphysiodesis</li> <li>L5 vertebrectomy </li> <li>Anterior and posterior fusion</li> <li>Posterior fusion</li></ol>

Answer 212

B.<ul> <li>Hemi-vertebrae Excision:</li> <ul> <li>Corrects deformity</li> <li>Ideal Indications:</li> <ul> <li>Hemi-vertebra at the lumbosacral junction (RC EXAM)</li> <li>Curves that have significant deformity and imbalance</li> </ul> </ul></ul>

Question 213

<div>RC 2018 - Regarding entirely metaphyseal distal radius fractures in children treated with closed reduction and casting with of the following is TRUE about re-displacement</div>

<ol> <li>Happens in 30%</li> <li>More common if younger than 10</li> <li>An above elbow cast prevents re-displacement</li> <li>Transverse patterns are more unstable</li></ol>

Answer 213

“A.<ul> <li>JPO 2015: Distal Radial Fractures in Children: Risk Factors for Redisplacement Following Closed Reduction</li> <li><img></img></li> <li>Redisplacement occurred in 39 of 135 cases (28.8%). Initial complete displacement was the most important risk factor for loss of reduction (odds ratio, 6.94; P = 0.001). Completely displaced fractures were 7 times more likely to redisplace than fractures with some bony contact or no translation. Achievement of anatomic reduction decreases the risk of redisplacement (odds ratio, 0.29; P = 0.046). Ten of the 39 fractures that lost position needed a second procedure (7.4%)</li></ul>”

Question 214

<div>RC 2013 - “Early onset” scoliosis in a 2 yr old.. All true EXCEPT</div>

<ol> <li>Rib overlap of the costovertebral junction (phase 2 rib) is suggestive of a progressive curve</li> <li>Higher chance of progression if the angle is >70°</li> <li>Most spontaneously resolve</li> <li>RVAD of 20° has a high chance of a non-progressive curve.</li></ol>

Answer 214

“D.<div><br></br></div><div>RFs for progression:</div><div>Cobb>20</div><div>Phase 2 Rib</div><div>RVAD>20</div><div>INtra-spinal path (get MR!)</div><div><br></br></div><div><img></img><br></br></div><div><img></img><br></br></div>”

Question 215

RC 2016 - List 4 risk factors for progression in infantile scoliosis

Answer 215

<ul> <li>JAAOS 2015 - Nonsurgical Management of Early-onset Scoliosis</li> <ul> <li>Cobb Angle > 20 deg</li> <li>Rib Phase (phase 2 rib)</li> <li>Rib Vertebral Angle Difference > 20 deg</li> <li>Intra-spinal pathology</li> </ul></ul>

<div><br></br></div>

<div>treatment:</div>

<div><ul> <li>If curve<20, RVAD<20 - observe<br></br></li><li>If curve >30deg, RVAD>20, phase 2 (ie RF for progession)</li> <ul> <li>Mehta derotation casting (more evidence than bracing)<br></br></li><li><div>More A-P pressure rather than medial to lateral squishing</div></li><li><div><div>70% no scoliosis following casting</div></div></li> </ul> <li>If curve >50deg: surgery</li> <ul> <li>Growing rods ONLY after age 3 (fewer complications)</li><li>complications 60%</li> <li>Fuse once reach adolescence or at least age 10</li> <ul> <li>Fusing >age 10 =>70% PFTs</li> <li>Goal for thoracic height T1-T12 >18-21cm</li> </ul> </ul></ul></div>

Question 216

<div>RC 2015 - What is not a complication of VEPTR:</div>

<ol> <li>Clavicle fracture</li> <li>Rib fracture</li> <li>Thoracic outlet syndrome</li> <li>Skin breakdown</li></ol>

Answer 216

1.<div><ul> <li>Complications in VEPTR and Rib-Based Distraction Devices</li> <ul> <li>Anchor problems:</li> <ul> <li>rib fracture/cradle migration</li> </ul> <li>Brachial Plexus problems:</li> <ul> <li>Direct trauma or impingement if implant too lateral and cephalad</li> <li>Compression of plexus against upper chest wall and clavicle/humerus at initial distraction and expansion</li> </ul> <li>Chest Wall Problems:</li> <ul> <li>Scarring and rib fusions</li> </ul> <li>Wound Complications and Infection</li> <li>Increased thoracic kyphosis, lumbar lordosis</li> </ul></ul></div>

Question 217

<div>RC 2011 - Juvenile scoliosis. Incidence of neuroaxis abnormalities?</div>

<ol> <li>less than 10%</li> <li>15% to 30%</li> <li>45% to 60%</li> <li>greater than 60%</li></ol>

Answer 217

B<div><br></br></div><div>Juvenile 4-10 years old. often progressive</div><div><ul> <li>20-25% have neural axis abnormality</li> <ul> <li>Must MRI if Cobb >20deg</li> </ul></ul></div>

Question 218

<div>RC 2018 List 8 risk factors that would make a patient more prone to receive a blood transfusion in the context of paediatric spine surgery.</div>

Answer 218

<ul> <li>Patient Factors: </li> <ul> <li>low body weight</li> <li>low pre-op Hb (expect 5g/dL loss)</li> <li>absence of EPO</li> <li>abnormal coagulation (blood dyscrasias, hemophilia, vDW; PT, aPTT, INR, low fibrinogen)</li> <li>valproic acid, antidepressants</li> <li>lack of autologous blood donation (pRBCs, whole blood, FFP)</li> </ul> <li>Deformity Factors: Cobb angle >50, <b>NM scoliosis (most important RF)</b></li> <li>Surgical Factors: Long OR time, Fusing>6 levels, Ponte osteotomies</li></ul>

Question 219

<div>RC 2014, 2012 A 14yo male is post-op from a posterior spinal instrumented fusion for adolescent idiopathic scoliosis. All blood loss was meticulously replaced by the anesthetist in the OR. He has a hemovac and foley in place. He is oliguric in PACU and for 24 hours post-op despite IV at maintenance and with replacement. What is the cause of his oliguria?</div>

<ol> <li>Excessive hemovac losses not reported by nursing</li> <li>Retroperitoneal hematoma</li> <li>Hypernatremia</li> <li>Decreased urine output with renal sodium excretion</li></ol>

Answer 219

D.<div><br></br></div><div>SIADH</div><div><br></br></div><div><div>Inappropriately high levels of ADH lead to excessive retention of free water and hyponatremia, which can result in fluid shifts into the intracellular fluid compartment and cerebral edema.</div></div><div><div>SIADH is thought to occur after spinal procedures because of stress, blood loss, invasion of the dura, and traction on the neural pathways.</div></div><div><div>Treatment for SIADH is fluid restriction and monitoring of serum and urine electrolytes and osmolality. If it is not recognized, sustained low-volume urine may be confused with hypovolemia, and increased fluid may be given. This can result in worsening hyponatremia, which can lead to pulmonary edema, cerebral edema, convulsions, coma, and death.</div></div>

Question 220

<div>RC 2012 - List 4 risk factors for SMA syndrome in peds scoliosis</div>

Answer 220

“<div><ul> <li>BMI < 25th percentile</li> <li><60% correction of thoracic curve on bending film</li> <li>Lenke Lumbar A</li> <li>Two stage procedure</li> <li>Thoracoplasty</li> <li>Combined anterior and posterior fusion</li></ul><div><img></img><br></br></div></div>”

Question 221

<div><br></br></div>

<div><div>RC 2012 - Highest Rate of progression for congenital Scoliosis</div> <ol> <li>Hemivertebrae (did not specify)</li> <li>Unilateral unsegmented Bar</li> <li>Double hemivertebrae</li> <li>Wedge</li></ol></div>

<div>RC 2012 - Three reasons for progression of congenital kyphosis</div>

Answer 221

“<div>2.</div><div><img></img><br></br></div><div><img></img><br></br></div>Type 1 (failure of segmentation)<div>Type 3 (mixed)</div><div>congenital vertebral dislocation</div><div><br></br></div><div>Types 1 and 3 have higher risk of neuro involvement as well</div><div><br></br></div><div><ul> <li>Hemi-epiphysiodesis and Hemi-arthrodesis</li> <ul> <li>Indications (RC EXAM)</li> <ul> <li>Best for single hemi-vertebrae</li> <li>Minimal deformity (<50o)</li> <li>Age<5 (Patient must have adequate growth remaining</li> </ul> </ul></ul></div>”

Question 222

<div>RC 2008 - Congenital kyphosis – which is true</div>

<ol> <li>type 2 more likely to cause neurologic problems</li> <li>amenable to bracing</li> <li>most likely cause of non-infectious paraplegia</li></ol>

Answer 222

C.<div><ul> <li>Types</li><li>1-Failure formation</li> <li>2-Failure segmentation</li> <li>3-Mixed</li></ul><div><div>congenital kyphosis- Uncommon, but neurologic deficits common, high risk of paralysis</div></div><div><br></br></div><div>1 - types 1/3 have higher risk of neuro problems</div><div>2 - bracing only for compensatory curves</div></div>

Question 223

<div>RC 2016 - List 4 predictors of instability and deformity in pediatric tuberculosis of the spine</div>

Answer 223

“<ul> <li>Gapping of the facet joints</li> <li>Retropulsion of infected vertebra</li> <li>Lateral listhesis</li> <li>Toppling</li><li>Three of more bodies involved</li> <li>Initial kyphosis > 30 deg</li> <li>Age < 15 years</li> </ul> <div></div> <div><img></img></div>”

Question 224

<div>RC Exam 2011 - 12 yr boy with T4-T12 (Scheuermann) kyphosis of 70 degrees. What is the treatment? </div>

<ol> <li>PT</li> <li>Fusion</li> <li>Boston Brace</li> <li>Milwaukee Brace</li></ol>

Answer 224

“D.<div><ul> <li>pain improves at skeletal maturity</li><li>The Milwaukee brace (CTLSO) is the brace recommended for the treatment of Scheuermann’s Disease</li> <ul> <li>Can use Boston (TLSO) if apex T9 or lower</li> </ul> <li>Indications for bracing:</li> <ul> <li>50-70o curve</li> <li>Riser 0-3</li> <li>Curve that is 40-50% correctable in brace</li> </ul> <li>Poor prognosticators:</li> <ul> <li>Curves > 75o</li> <li>Wedging > 10o</li> <li>Patient near or past skeletal maturity</li> </ul> <li>OR:</li> <ul> <li>Controversial indications</li> <li>Progressive kyphosis > 75o</li> <li>Pain not alleviated with conservative measures</li> </ul></ul></div>”

Question 225

<div>RC 2009 Congenital Muscular Torticollis. What is true? </div>

<ol> <li>Can palpate tumor</li> <li>Head turned towards lesion</li> <li>No known etiology</li> <li>50% get DDH</li></ol>

Answer 225

C.<div><ul> <li>unilateral shortening of SCM 2°: birth trauma, occlusion of venous flow, or hematoma</li> <li>fibrosis & palpable mass within 1st 4-6 wks of life (20-55% palpable)</li> <li>head tilts towards affected side & rotates away from affected side</li><li>DDH in 20%</li> <li>develop plagiocephaly (flat face) within 1st year of life if torticollis does not resolve</li><li>Tx: stretching (90% resolve in 1st year), then two head release</li></ul></div>

Question 226

<div>RC 2014, 2008 - A 12yo female presents with several months of back pain which is limiting her ability to participate in sports. After a complete history and physical exam, what is the most appropriate initial investigation?</div>

<ol> <li>Plain radiographs</li> <li>SPECT-CT</li> <li>MRI</li> <li>Technetium bone scan</li></ol>

Answer 226

A.<div><ul> <li>JAAOS 2016 - Evaluation and Diagnosis of Back Pain in Children</li> <ul> <li>Radiographs of the entire spine with the patient erect, standing position are indicated when the history or physical exam reveals localized pain, a neurologic deficit or clinical deformity</li> <li>SPECT-CT sensitive and specific for spondylosis</li> <li>MRI if a soft tissue problem is suspected</li> <li>66% of patients have no cause identified</li> </ul></ul></div>

Question 227

<div>RC 2018 - Which of the following is an indication for a CLO?</div>

<ol> <li>A child with a flatfoot and ill defined pain with activity</li> <li>A child with an incongruent TN joint (?and something else)</li> <li>A child with a tight heel cord and a flexible flatfoot that has failed non surgical treatment</li> <li>Overcorrection of a clubfoot with a congruent TN joint and a normal thigh foot angle</li> </ol>

<div><br></br></div>

Answer 227

<div>Answer: C>B</div>

<div></div>

<div>B - Marcel agrees. CLO will correct the incongruent TN joint.</div>

<div>D - Marcel thinks this answer is incorrect - you do not want to do a CLO if the TN joint is congruent as you risk making it incongruent</div>

Question 228

<div>RC 2018 Regarding entirely metaphyseal distal radius fractures in children treated with closed reduction and casting with of the following is TRUE about re-displacement</div>

<ol> <li>Happens in 30%</li> <li>More common if younger than 10</li> <li>An above elbow cast prevents re-displacement</li> <li>Transverse patterns are more unstable</li></ol>

Answer 228

“A.<div><ol> </ol> <ul> <li>JPO 2015: Distal Radial Fractures in Children: Risk Factors for Redisplacement Following Closed Reduction</li> <li><img></img></li> <li>Redisplacement occurred in 39 of 135 cases (28.8%). Initial complete displacement was the most important risk factor for loss of reduction (odds ratio, 6.94; P = 0.001). Completely displaced fractures were 7 times more likely to redisplace than fractures with some bony contact or no translation. Achievement of anatomic reduction decreases the risk of redisplacement (odds ratio, 0.29; P = 0.046). Ten of the 39 fractures that lost position needed a second procedure (7.4%).</li></ul></div>”

Question 229

<div>RC 2018 - All of the following are true regarding Syme amputations in children EXCEPT:</div>

<ol> <li>Heel pad migration is a common problem</li> <li>If you leave the calcaneus attached, the heel pad will grow as the child grows</li> <li>Children function as a level equal to their peers</li> </ol>

<div><br></br></div>

Answer 229

<div>Answer: B</div>

<div>Calc is gone when u do a syme</div>

Question 230

<div>RC 2018 - What is the most common location for a OCD lesion in the knee. </div>

Answer 230

<div>Posterolateral aspect of medial femoral condyle<br></br></div>

Question 231

<div>RC 2018 - In pediatric patients undergoing biopsy, when should samples also be sent for anaerobes, acid-fast bacilli and fungus</div>

<ol> <li>Should be sent in all patients</li> <li>Osteomyelitis with associated septic arthritis</li> <li>Osteomyelitis following a penetrating injury</li></ol>

Answer 231

C.<div>Anaerobic, fungal, and AFB cultures should only be used when there is a suspicion of penetrating inoculation, immunocompromise, or failed primary treatment<br></br></div>

Question 232

<div>RC 2018: A 10 year old kid has blounts. He is Lengenskoild V and has depression of the medial tibial plateau. Which of the following surgical options would be LEAST helpful?</div>

<ol> <li>Distal femoral osteotomy for compensatory valgus deformity</li> <li>Proximal tibial epiphiseolysis (?epiphiseodesis)</li> <li>Varus correcting proximal tibial osteotomy with medial plateau elevation</li> <li>Another proximal tibial osteotomy that sounded more like what we usually do</li></ol>

Answer 232

A.<div><ul> <li>For adolescent blounts, they do get distal femoral varus, so you can do a distal femoral <u>valgus</u> producing osteotomy</li> <li>B means- getting rid of the bar, which Stage V has.</li> <li>C is obviously true</li></ul></div>

Question 233

<div>RC 2018: which of the following is true regarding scoliosis surgery in a CP patient GMFCS V?</div>

<ol> <li>Risk of perioperative mortality is 0.5-1%</li> <li>Scoliosis surgery does not prolong life</li> <li>Development of scoliosis is directly correlated to GMFCS score</li> <li>Bracing is ineffective at controlling curves</li></ol>

Answer 233

C.<div><ul> <li>Sewell (JPO 2016) A Preliminary study to assess whether spinal fusion for scoliosis improves carer-assessed quality of life for children with GMFCS lvl IV/V CP</li> <ul> <li>Conclusion: Spinal fusion was associated with an increase in QoL. Change in pain was the most significant factor affecting QoL changes, and is therefore an important factor to consider when deciding upon surgery.</li> <li>50% of kids with level IV/V CP have scoliosis</li> </ul> </ul> <div>Management of Spinal Deformity in Cerebral Palsy- Imrie- Ortho Clin N Am- 2010</div> <div>. The incidence of scoliosis is directly related to their gross motor function classification system (GMFCS) level.</div> <div></div> <div>with a 0% to 7% mortality rate.5 Tsirikos and colleagues,76 in their extensive review of 287 consecutive CP patients, reported a 1% mortality rate, 6% deep infection rate, and 16% instrumentation problems.</div> <div></div> <div>Literature is inconclusive on whether bracing is effective or not.</div> <div></div> <div>Cant find anything about surgery prolonging life</div></div>

Question 234

<div>RC 2018: There is a 10 year old boy. He has recurrent patella instability and a TTTG measuring 26mm. Which of the following is the LEAST recommended course of action</div>

<ol> <li>Medial patellofemoral soft tissue reconstruction with hamstring (?or quad?) graft </li> <li>Supra-patellar soft tissue realignment procedure</li> <li>Tibial tubercle osteotomy</li> <li>?Medial soft tissue tenodesis of some sort</li></ol>

Answer 234

C<div><br></br></div><div>No TTO in skeletally immature pts</div>

Question 235

<div>RC 2018- Which is true for peds isthmic spondy?</div>

<div>a.Occurs at L4/5</div>

<div>b.Not usually associated with pars defect</div>

<div>c.Rare in the inuit polulation</div>

<div>d.Typically not associated with back pain</div>

Answer 235

Answer: D<div><br></br></div><div><ul> <li>A: false, Most common at L5/S1</li> <li>B: false, Isthmic (defect in the pars) spondylolisthesis is the more common type</li> <li>C: false, The prevalence of spondylolisthesis appears to be influenced by the racial or genetic background of the population studied. African Americans have the lowest rate of spondylolisthesis, 1.8%, whereas Inuit Eskimos have a prevalence of 50%. South Africans and whites fall in an intermediate range, 3.5% and 5.6%, respectively </li> <li>D *** spondy is associated with back pain</li> <ul> <li>In a study that compared 100 adolescent athletes and 100 adult athletes with LBP, 47% of adolescents were found to havespondylolysiscompared with only 5% of adults</li> <ul> <li>Micheli LJ, Wood R: Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med 1995;149(1):15–18</li> </ul><li><div>Spondylolysis has been rarely reported in infancy, but by age 6 years, the reported incidence of 5% approximates that of the adult population, but most children are asymptomatic</div></li> </ul></ul></div>

Question 236

<div>RC 2018 - What is the last bone to ossify in the foot:</div>

<div>a.Cuboid</div>

<div>b.Medial cuneiform</div>

<div>c.Navicular</div>

<div>d.Base of 5th phalanx</div>

Answer 236

“C.<div><br></br></div><div><img></img><br></br></div>”

Question 237

<div>RC 2018 - Which of the following is associated with an increased risk of complications with halo treatment in paediatric patients?</div>

<div>a.Re-tightening the screws at an appropriate interval</div>

<div>b.Placing the ring 2cm above the pinna</div>

<div>c.Placing the ring closer to the skull</div>

<div>d.Using 6 pins instead of 4</div>

Answer 237

B.<div><ul> <li>CT indicated in kids under 10 to determine bone thickness and rule out cranial fractures</li> <li>Greater number of pins (10-12)</li> <li>Torque at 2 in-lb</li></ul></div>

Question 238

“<div>RC 2018 - 18 year old female has knee pain. You’re shown multiple coronal MRI cuts of what I thought was a discoid meniscus with a tear / increased signal. What is the best treatment plan?</div> <div><img></img></div> <div>(except there were multiple cuts, and no arrow)</div> <ol> <li>Complete menisectomy</li> <li>Partial menisectomy and ensure the meniscus is stable</li> <li>Meniscus transplant</li> <li>Repair of meniscal tear</li></ol>”

Answer 238

B.Current treatment emphasizes meniscal rim preservation (6-8 mm) with arthroscopic saucerization because of the evidence supporting the efficacy of the technique

Question 239

RC 2018 - Describe what investigation to order and how to measure the tibial-tubercle trochlear-groove (TT-TG) ratio in patellar instability. What do you do if it is >25mm?

Answer 239

“<ul> <li>Axial CT, measuring from deepest trough of the trochlea to most prominent aspect of tibial tubercle</li> <li>Femoral cut should be one where the notch = 1/3 the total AP distance of the condyles</li> </ul> <div></div> <div><img></img></div><div><ul> <li>If the TT-TG is greater than 25 mm, what does this imply you will have to add to your surgical management?</li> </ul><ol> <li>Staged or concomitant Tibial Tubercle transfer/osteotomy</li> </ol></div>”

Question 240

<div>RC 2018 - All of the following are true regarding Syme amputations in children EXCEPT:</div>

<ol> <li>Heel pad migration is a common problem</li> <li>If you leave the calcaneus attached, the heel pad will grow as the child grows</li> <li>Children function as a level equal to their peers</li> <li>poor outcomes if multiple failed surgeries before syme</li></ol>

Answer 240

B - dont leave calc attached

Question 241

<div>RC 2012 - What is the last physis to fuse in the body?</div>

<ol> <li>Medial clavicle</li> <li>Lateral clavicle</li> <li>Distal femoral physis</li> <li>Olecranon</li></ol>

Answer 241

A. 20-25 years old

Question 242

<b>RC 2013, 2012 - Given a histologic diagram of the physeal zones and asked to identify and label all 5</b>

Answer 242

“<div>MHPRE</div><div><br></br></div><div>hypertrophic zone: come do me = calficiation, degeneration, maturation</div><div><img></img></div> <div></div> <div>· Reserve zone</div> <div>· Proliferating zone</div> <div>· Hypertrophic zone</div> <div>· -Maturation zone</div> <div>· -Degenerative zone</div> <div>· -Zone of provisional calcification</div> <div>· Metaphysis</div> <div>· -Primary spongiosa</div> <div>· -Secondary spongiosa</div>”

Question 243

<div>RC 2016 - A kid presents with hip pain with inability to weightbear, elevated ESR (50), elevated WBC (14) and a temperature of 37.8. What is the risk this is septic arthritis?</div>

<ol> <li>10%</li> <li>30%</li> <li>50%</li> <li>90%</li></ol>

Answer 243

D.<div><ol> <li>Fever</li> <li>Non-weight bearing</li> <li>ESR > 40</li> <li>WBC > 12,000</li> </ol> <ul> <li>3.0% –> 40% –> 93% –> 99% for sequential predictors</li> <li>Follow up study: 9.5% –> 35% –> 73% –> 93%</li> </ul> <ul> <li>CRP > 20 added later ***</li></ul></div>

Question 244

<div>RC 2018: which of the following is true regarding scoliosis surgery in a CP patient GMFCS V?</div>

<ol> <li>Risk of perioperative mortality is 0.5-1%</li> <li>Scoliosis surgery does not prolong life</li> <li>Development of scoliosis is directly correlated to GMFCS score</li> <li>Bracing is ineffective at controlling curves</li></ol>

Answer 244

<div><div>Answer: C (D?)</div> <ul> <li>A few recall issues between schools here…</li> <li>May have been an except question with D as answer...</li> <li>Facts</li> <ul> <li>CP scoliosis is related to GMFCS (5 have 100% rate)</li> <li>Peri-op Mortality is 0-7% - 1% commonly quoted</li> <li>Improves Care giver QOL (main indication)</li> <li>Bracing doesn’t reliably prevent curve progression</li> </ul></ul></div>

Question 245

<div>RC 2013, 2016 - All are true about the cervical spine in Down’s syndrome, EXCEPT: </div>

<ol> <li>Instability occurs only at the atlantoaxial level</li> <li>Cervical spine xrays have no predictive value of future spine problems</li> <li>In kids, if the patient is asymptomatic, they do not require screening prior to most sports participation</li> <li>25% of Down’s patients have cervical spine problems.</li></ol>

Answer 245

A.<div><ul> <li>Spine</li> <ul> <li>Odontoid hypoplasia</li> <li>Atlantoaxial instability</li> <li>Occipito-cervical instability</li> <li>Subaxial instability/cervical stenosis</li> </ul><li>Screening (C-spine Flex/ex views):</li> <ul> <li>Indications: </li> <ul> <li>participation in high risk sports (gymnastics/diving)</li> <li>Screening before surgery</li> </ul> <li>Once identified asymptomatic patients should be followed</li> </ul> <li>Management:</li> <ul> <li>Approach</li> <ul> <li>ADI <4.5mm –> AAT</li> <li>ADI 4.5-10mm–> limit high risk activities</li> <li>ADI >10mm surgery</li> </ul> </ul></ul></div>

Question 246

<div>RC 2017 - 12 year old presents with olecranon fracture while playing. Previous contra-lateral olecranon fracture year previously. Normal height, bad dentition. Previous fractures of both distal radius and left tibia. What should you do?</div>

<div>A) Start bisphosphonates</div>

<div>B) Skeletal survey for child abuse</div>

<div>C) Refer for renal work up</div>

<div>D) ….</div>

Answer 246

a.<div>Osteogenesis imperfecta <ol> <li>Olecranon avulsion fractures are highly suspicious for osteogenesis imperfecta</li> <li>brownish opalescent teeth (dentinogenesisimperfecta) =alteration in dentin</li> <li>brown/blue teeth, soft, translucent, prone to cavities</li> <li>affects primary teeth > secondary teeth</li> </ol> <div>Answer: A</div></div>

Question 247

RC ORAL - closed reduction technique for ddh

Answer 247

“technique<ul><li>closed reduction<ul><li>reduce using the Ortolani maneuver (hip flexion and abduction while elevating the greater trochanter)</li></ul></li><li>arthrogram<ul><li>used to confirm the reduction</li><li>must obtain concentric reduction with < 5mm of contrast pooling medial to femoral head and no interposition of the limbus<ul><li>medial dye pool > 7mm associated with poor outcomes and AVN</li></ul></li><li>also helps identifyanatomic blocks to reduction</li></ul></li><li>adductor tenotomy<ul><li>perform if the patient has an unstable safe zone (i.e. if excessive abduction is required to maintain the reduction)</li></ul></li><li>spica casting<ul><li>immobilize in 100° ofhip flexion and 45° ofabduction with neutral rotation for 3 months<ul><li>"”human position””</li><li>wide abduction associated with AVN (aim for < 55°abduction)</li></ul></li><li>confirm reduction withCT scan in spica castwithselective cuts to minimize radiation to the child<br></br></li><li>change cast at 6 weeks</li></ul></li></ul>”

Question 248

RC 2013 -5 yo child with right sided missed congenital hip dislocation. The BEST treatment would be: <div>a) Traction followed by open reduction and innonimate osteotomy</div> <div>b) Traction followed by open reduction</div> <div>c) Open reduction with femoral shortening osteotomy and innominate osteotomy</div> <div>d) Open reduction with innonimate osteotomy</div>

Answer 248

C.<div><br></br></div><div><div>ANSWER: C</div> <div> 2013</div> <div> <i>Ryan MG (JBJS 1998) One stage treatment of congenital dislocation of the hip in children three to ten years old. Functional and radiographic results</i></div></div>

Question 249

RC 2015, 2013 -3yo child, 3mos post innominate osteotomy for DDH. 30deg abduction contracture. Best treatment plan? <div>a. Admit for intensive PT</div> <div>b. Femoral shortening osteotomy</div> <div>c. Traction</div> <div>d. Reassure and do nothing</div>

Answer 249

D.<div>· 2009, 2015</div> <div>· Bohm P (JBJS 2002) Salter Innominate Osteotomy for the treatment of DDH in Children</div> <div>o After removal of the spica cast, two other hips had a flexion and abduction contracture, which resolved after a short period of physiotherapy</div>

Question 250

RC 2012 -12 yr F with painful heel. Pain worse at night, better with NSAIDS and rest. Best test to give diagnosis? <div>a. MRI</div> <div>b. CT</div> <div>c. Bone scan</div> <div>d. SPECT</div>

Answer 250

B. Hard given the lack of information with this question, but certainly concerning for osteoid osteoma therefore CT is best option

Question 251

Indications for bilateral pinning of SCFE

Answer 251

1. Young age (open TRC, age <10)<div>2. Endocrinopathy</div><div>3. Renal disease</div><div>4. History of irradiation</div><div>5. Poor follow up</div><div>6. Down syndrome - poor communication</div>

Question 252

All of the following associations are true, except?<div><div>a.Duchenne and calf hypertrophy</div><div>b.San filippo is the most common mucopolysacharidosis</div><div>c.Proportionate dwarfism is phenotype of mucopolysacharidosis</div><div>d.Marfan’s is associated with arachnodactyly</div></div>

Answer 252

“<div>Sal Filippo and Morquio are the most common forms</div><div>Proportionate dwarfism IS associated with MPS</div><div>Marfan’s IS associate with arachnodactyly</div><div><br></br></div><div>A (PSEUDOhypertrophy)</div><div><div>• <b>X-linked recessive</b></div> <div>• Age of onset: 2-4 years</div> <div>• Almost entirely male (except for rare cases with Turner’s)</div> <div>• 30% from new spontaneous mutation</div> <div>• Pathogenesis: dystrophin maintains muscle membrane stability –> <b>lack of dystrophin </b>–> membrane damage during contraction –> activated inflammatory cascade –> muscle cell death</div> <div>• Presentation: </div> <div>• Progressive weakness in proximal muscle groups that descends symmetrically</div> <div>• <b>Absence of sensory deficits</b><b></b></div> <div>• <b><span>Pseudo-hypertrophy</span></b> of the calves by age 3-4</div> <div>• Not muscle –> fibrofatty tissue infiltration</div> <div>• Diagnosis: PCR for dystrophin gene preferred diagnostic modality</div> <div>• Peri-operative Considerations:<b><span>MALIGNANT HYPERTHERMIA</span></b></div></div>”

Question 253

<div>All of the following are true regarding femoral nerve palsy with Pavlik harness treatment except?</div>

<div>a. 2.5% rate</div>

<div>b. Spontaneously resolve in 60%</div>

<div>c. Can be bilateral</div>

<div>d. Associated with a higher incidence of surgery</div>

Answer 253

“<div>Answer: B</div> <div></div> <div><i>Ref: Murnaghan ML, et al. Femoral Nerve Palsy in Pavlik Harness Treatment for Developmental Dysplasia of the Hip. J Bone Joint Surg Am. 2011;93:493-9 </i><i></i></div> <div>• <b><i>Incidence:</i></b> 2.5% (30/1,218)</div> <div>• All femoral nerve palsies occurred either on the treatment side of a patient with unilateral DDH or on one side of a patient with bilateral developmental dysplasia of the hip. </div> <div>• <b><i>Onset: </i></b>11 of the 30 palsies presented at < 1 week, 15 presented at the 1 week and the remaining 4 presented at > 1 week. </div> <div>• <b><i>Anthropometrics:</i></b> On the average, the palsy group patients were <b>older</b> (56 vs. 22 days), <b>taller</b> (55 vs. 51 cm), <b>heavier </b>(4.8 vs. 3.7 kg), and with relatively elevated <b>BMI</b> (15.5 vs. 14.3 kg/m2). </div> <div>• There was no significant difference in birth weight, bilaterality, sex, or ethnicity. </div> <div>• <b><i>Outcome:</i></b> The success rate of Pavlik harness treatment in our control group was 94%. The success rate for the patients who devel- oped a femoral nerve palsy (the palsy group) was 47% (p < 0.0001). </div> <div>• <b><i>Return to function: </i></b><b><span>All patients had return of femoral nerve function</span></b>; however, there was substantial variability in the speed of return </div> <div>• Patients in whom Pavlik harness treatment was successful had return of femoral nerve function at an average of five days. </div> <div>• Patients in whom Pavlik harness treatment was not successful had return of femoral nerve function at an average of fifteen days. </div> <div>• <b><i>Management:</i></b> Nineteen patients with femoral nerve palsy were treated with temporary suspension of harness treatment and subsequent reapplication when femoral nerve function returned. Six were treated with adjustment of the Pavlik harness to reduce hip flexion. Five were managed with complete abandonment of the harness, with four requiring subsequent closed or open reduction of the hip. </div> <div>• <b><span>There was no correlation between the method of management of the femoral nerve palsy and the success of treatment. </span></b></div> <div></div> <div></div> <div><b><i>MISC Notes:</i></b><b><i></i></b></div> <div>• The correct hip position should be 90-100° of flexion and 20-40° of abduction. </div> <div>• Risk factors include: </div> <div>• Maintaining the hip flexion >120°</div> <div>• Heavier children</div> <div>• Higher degree of dysplasia</div> <div>• Initial treatment options include:</div> <div>• Adjustment of the Pavlik harness and observation of quadriceps function over time</div> <div>• Temporary cessation of the Pavlik harness</div> <div>• Complete abandonment of the harness. </div> <div>• <i>Little data is available to compare the effectiveness of these strategies.</i></div>”

Question 254

14F with CP, is ambulatory with jump gait, hip flexion contracture of 15^o, knee flexion contracture of 35^o, ankle PF contracture of 10^o. How would you correct this? (RC 2019)<div>A. Medial hamstring release only</div><div>B. Medial hamstring release and distal femoral extension osteotomy</div><div>C. Medial hamstring release and anterior distal femur hemiepiphysiodesis</div><div>D. Medial and lateral hamstring release</div>

Answer 254

Ans: B<div>This patient has a jump gait with a true ankle equinus. 14 yeras - minimal to no growth potential left, cannot use guided growth (not C). Medial hamstring release alone used only in mild knee flexion contractures (<5^o) (not A).</div><div>- Technique: fractional lengthening at myotendinous junction</div><div>- Complications: hamstring contractures often recur, especially in jump gait</div><div><br></br></div><div>Supracondylar femur extension osteotomy +/- patellar tendon advancement or shortening</div><div>- Indications: knee flexion deformities of 10-30^o, with severe quadriveps lag close to or already at skeletal maturity</div><div>- A normal popliteal angle is about 25^o, and popliteal angles >50^oor knee contractures suggest significant hamstring tightness that should be treated with hamstring lengthening or other procedures (B). Lateral hammy release as well may lead to excessive weakness)</div><div><br></br></div><div>Equinus: TAL or gastroc recession. Note: do not address the ankle in apparent equinus)</div>

Question 255

6 y/o kid has plantar flexion contracture of 10^owith knee extended, corrects to 0 with knee flexion. Has had a trial of botox and serial casting, which intially helped but has since worn off by 3 months. What do you do next? (RC 2019)<div>A. Achilles lengthening</div><div>B. Repeat botox</div><div>C. Accommodative orthotics</div><div>D. Gastroc. recession</div>

Answer 255

“Ans: D<div><br></br></div><div>Silfverskiold test</div><div>- Improved ankle DF with knee flexed = gastrocnemius tightness</div><div>- Equivalent ankle DF with knee flexion and extension = achilles tightness</div><div><br></br></div><div>Recurrence after surgical correction of equinus is not uncommon</div><div>- 18% for diplegic patients, 41% with hemiplegia</div><div>Diplegic patients age <4 at time of surgery most likely to suffer recurrence (worse disease or growth?)</div><div><br></br></div><div>Tx options</div><div>- Non-op: manipulation and casting, Botox, AFO, solid AFO (don’t use hinge if excessive DF in midstance)</div><div>- Op: <b>best to delay until at least 4 (allow development of musculotendinous units) - TAL vs. gastrocs recession (Strayer). Rarely isolated procedure.</b></div>”

Question 256

<div>What is true about congenital radioulnar synostosis?</div>

<ol><li><div>Supination contracture</div></li><li><div>Does not improve with resection</div></li><li><div>Is typically distal or medial forearm</div></li><li><div>2:1 male to female ratio</div></li></ol>

Answer 256

“Ans: B<div><br></br></div><div><div><span>Ref: Orthobullets</span></div><ul><li><div>3:2 male to female</div></li><li><div>Fixed forearm <span>pronation</span> ~30° (this is position of arm in utero)</div></li><ul><li><div>Considered<span> </span><span>failure of differentiation</span><span></span></div></li><li><div>Usually proximal</div></li><li><div>60% bilateral</div></li></ul></ul><ul><li><div>If patient presents with limited ROM but normal radiographs, MRI to r/o cartilaginous synostosis</div></li></ul><ul><li><div><span>Classification</span></div></li></ul><ul><li><div>Type 1 - Complete proximal synostosis with no formation of radial head</div></li><li><div>Type 2 - Rudimentary radial head present (often dislocated posteriorly)</div></li></ul><ul><li><div><span>Management:</span><span></span></div></li><ul><li><div><span>Generally non-op</span> if unilateral deformity and not limiting</div></li><ul><li><div>Resection of Synostosis is bad, don’t do this —> will recur</div></li></ul><li><div>Operative Options:</div></li><ul><li><div>Derotation Osteotomy</div></li><ul><li><div><span>High risk of compartment syndrome</span></div></li></ul></ul></ul></ul>Higher risk if >85° correction<br></br></div>”

Question 257

<div>8M with a Monteggia fracture Bado II with posterior radial head dislocation and PIN neuropathy describe your initial management?</div>

<div><br></br></div>

<div>A. Closed reduction with 100 degrees flexion and pronation</div>

<div>B. Closed reduction with 100 degrees flexion and supination</div>

<div>C. Open reduction of ulna, nerve exploration, closed reduction of radial head</div>

<div>D. Closed reduction in extension with pronation</div>

Answer 257

“<div>Answer: D<span><br></br><br></br></span></div><div><span>Ref: Wheelless</span></div><ul><li><div><span>Treatment:</span><span></span></div></li><ul><li><div><span>For type I, III, and IV Monteggia injuries, immobilize elbow in 100° of flexion w/ forearm fully </span><span>supinated</span><span> x 6 weeks</span></div></li></ul></ul><ul><li><div><span>For type II injuries, immobilize elbow </span><span>extended</span><span> x 4 weeks</span><span><br></br><br></br></span></div></li></ul><div><span>Ref: Orthobullets</span></div><ul><li><div><span>Closed reduction of ulna and radial head dislocation and long arm casting</span></div></li><ul><li><div>Indications</div></li><ul><li><div>Bado Types I-III with</div></li><ul><li><div>Radial head is stable following reduction</div></li><li><div>Length stable ulnar fracture pattern</div></li></ul><li><div>Reduction technique</div></li><ul><li><div>Traction</div></li><ul><li><div>Radial head will reduce spontaneously with reduction of the ulna and restoration of ulnar length</div></li><li><div>For Type I, elbow flexion is the main reduction maneuver</div></li></ul></ul></ul></ul></ul><ul><li><div>Immobilization</div></li><ul><li><div>Type I: 110° of flexion and <span>full supination </span>to tighten IOM and relax biceps tendon</div></li><li><div>Type II: full extension</div></li><li><div>Type III: full extension and valgus mold</div></li></ul></ul><div></div><div><span>Ref: The assessment and treatment of nerve dysfunction after trauma around the elbow. CORR. 2004.</span></div><ul><li><div>Most injuries are neuropraxia and are exacerbated by open exploration</div></li><li><div>Couldn’t really find anything to support position after splinting in this group except that it should be in 70° of flexion (other types are at 100° flexion) with supination</div></li></ul>”

Question 258

“All of the following associations are true except (RC 2019)<div>A. Duchenne and calf hypertrophy</div><div>B. San Filippo is the most common mucopolysaccharidosis</div><div>C. Proportionate dwarfism is a phenotype of MPS</div><div>D. Marfan’s is associated with arachnodactyly</div>”

Answer 258

“Answer: A<div><br></br></div><div>DMD<div><ul><li><div><span>X-linked recessive</span></div></li><ul><li><div>Age of onset: 2-4 years</div></li></ul></ul><ul><li><div>Almost entirely male (except for rare cases with Turner’s)</div></li><li><div>30% from new spontaneous mutation</div></li><li><div>Pathogenesis: dystrophin maintains muscle membrane stability –> <span>lack of dystrophin </span>–> membrane damage during contraction –> activated inflammatory cascade –> muscle cell death</div></li><li><div>Presentation:</div></li><ul><li><div>Progressive weakness in proximal muscle groups that descends symmetrically</div></li></ul></ul><ul><li><div><span>Absence of sensory deficits</span></div></li></ul><ul><li><div><span>Pseudo-hypertrophy</span> of the calves by age 3-4</div></li></ul><ul><li><div>Not muscle –> fibrofatty tissue infiltration</div></li></ul><ul><li><div>Diagnosis: PCR for dystrophin gene preferred diagnostic modality</div></li><li><div>Peri-operative Considerations:<span>MALIGNANT HYPERTHERMIA</span></div></li></ul><div><b>MPS</b></div></div></div><div>- All are AR except Hunter syndrome (X-linked)</div><div>- San Fillippo = most common form</div><div>- Hurler = most severe form</div><div>- Present with proportionate dwarfism (MPS and cleidocranial dysplasia)</div>”

Question 259

Conditions with Ocular Manifestations: all of the following except:<div>A. Homocysteinuria</div><div>B. Marfans</div><div>C. Neurofibromatosis</div><div>D. Achondroplasia</div>

Answer 259

Answer: D<div><br></br></div><div><div>Ocular Manifestations:</div><ul><li><div>Marfans</div></li><ul><li><div>Dislocated lens (superior)</div></li></ul><li><div>Homocysteinuria</div></li><ul><li><div>Etopia lentis</div></li><li><div>Myopia</div></li><li><div>Glaucoma</div></li><li><div>Optic atrophy</div></li><li><div>Reinal detachment</div></li><li><div>Cataracts</div></li><li><div>Black bones and DDD</div></li></ul><li><div>NF</div></li><ul><li><div>Lisch nodules</div></li></ul><li><div>Achondroplasia</div></li><ul><li><div>Associated conditions</div></li><ul><li><div>Medical conditions</div></li><ul><li><div>Weight control problems</div></li><li><div>Hearing loss</div></li><li><div>Tonsillar hypertrophy</div></li></ul></ul></ul></ul>Frequent otitis media<br></br></div>

Question 260

<div>All of the following are true regarding femoral nerve palsy with Pavlik harness treatment except? (RC 2019)</div>

<div><br></br></div>

<div>A. 2.5% rate</div>

<div>B. Spontaneously resolve in 60%</div>

<div>C. Can be bilateral</div>

<div>D. Associated with a higher incidence of surgery</div>

Answer 260

“<div>Answer: B</div> <div><span>Ref: Murnaghan ML, et al. Femoral Nerve Palsy in Pavlik Harness Treatment for Developmental Dysplasia of the Hip. J Bone Joint Surg Am. 2011;93:493-9</span></div> <ul> <li><span>Incidence:</span> 2.5% (30/1,218)</li> <ul> <li>All femoral nerve palsies occurred either on the treatment side of a patient with unilateral DDH or on one side of a patient with bilateral developmental dysplasia of the hip.</li> </ul> <li><span>Onset: </span>11 of the 30 palsies presented at < 1 week, 15 presented at the 1 week and the remaining 4 presented at > 1 week.</li> <li><span>Anthropometrics:</span> On the average, the palsy group patients were <span>older</span> (56 vs. 22 days), <span>taller</span> (55 vs. 51 cm), <span>heavier </span>(4.8 vs. 3.7 kg), and with relatively elevated <span>BMI</span> (15.5 vs. 14.3 kg/m2).</li> <ul> <li>There was no significant difference in birth weight, bilaterality, sex, or ethnicity.</li> </ul> <li><span>Outcome:</span> The success rate of Pavlik harness treatment in our control group was 94%. The success rate for the patients who devel- oped a femoral nerve palsy (the palsy group) was 47% (p < 0.0001).</li> <li><span>Return to function: </span><span>All patients had return of femoral nerve function</span>; however, there was substantial variability in the speed of return</li> <ul> <li>Patients in whom Pavlik harness treatment was successful had return of femoral nerve function at an average of five days.</li> <li>Patients in whom Pavlik harness treatment was not successful had return of femoral nerve function at an average of fifteen days.</li> </ul> <li><span>Management:</span> Nineteen patients with femoral nerve palsy were treated with temporary suspension of harness treatment and subsequent reapplication when femoral nerve function returned. Six were treated with adjustment of the Pavlik harness to reduce hip flexion. Five were managed with complete abandonment of the harness, with four requiring subsequent closed or open reduction of the hip.</li> <ul> <li><span>There was no correlation between the method of management of the femoral nerve palsy and the success of treatment.</span></li> </ul> </ul> <div></div> <div><span>MISC Notes:</span></div> <ul> <li>The correct hip position should be 90-100° of flexion and 20-40° of abduction.</li> <li>Risk factors include:</li> <ul> <li>Maintaining the hip flexion >120°</li> <li>Heavier children</li> <li>Higher degree of dysplasia</li> </ul> <li>Initial treatment options include:</li> <ul> <li>Adjustment of the Pavlik harness and observation of quadriceps function over time</li> <li>Temporary cessation of the Pavlik harness</li> <li>Complete abandonment of the harness.</li> <li><span>Little data is available to compare the effectiveness of these strategies.</span></li> </ul></ul>”

Question 261

“<div><span>What is true regarding surgical treatment for syndactyly? (RC 2019)</span></div><div><br></br></div><div>A.Web creep from scar</div><div>B. Nerve injury</div><div>C. Vascular injury</div><div>D. Growth arrest</div>”

Answer 261

“<div>Answer: A</div> <ul> <li>Syndactyly is a condition wherein ≥ 2 digits are fused together.</li> <li><span>Most commoncongenital malformation of the limbs</span></li> <li>M > F</li> <li>Caucasians > African Americans</li> <li><span>Pathophysiology</span></li> <li>Failure of apoptosis to separate digits</li> <li><span>Genetics</span></li> <li><span>Autosomal dominant</span>in cases of pure syndactyly</li> <ul> <li>Reduced penetrance and variable expression</li> <ul> <li>Positive family history in 10-40% of cases<br></br> </li> </ul> </ul> </ul> <div><img></img></div> <ul> <li><span>Treatment</span></li> <li>Digit release</li> <ul> <li><span>If multiple digits are involved perform procedure in2 stages</span> (do 1 side of a finger at a time)to avoid compromising vasculature</li> <ul> <li>Release digits with significant length differences first to avoid growth disturbances</li> </ul> </ul> <li>Release border digits first (ring-little, and thumb-index) at < 6mths because of differential growth rates between ring-little and between thumb-index digits</li> <ul> <li>Middle-ring syndactyly can be released later <span>(2yr old) </span>as because middle and ring digits have similar growth rates</li> <li>Thus if syndactyly involving index-middle-ring-small digits, relesae index-middle and ring-small first, and leave the central syndactyly (middle-ring) for 6 months later</li> <li>Do all releases before school age</li> </ul> <li><span>Bilateral hand releases</span></li> <li>Perform simultaneously if child is < 18 months (less active)</li> <li>Perform staged if child is > 18 months (more active, hard to immobilize bilateral limbs simultaneously)</li> <li><span>Complications</span></li> <li>Web creep</li> <ul> <li><span>Most common complication of surgical treatment (8-60%)</span></li> </ul> <li>Nail deformities</li></ul>”

Question 262

“<div><span>What is the most predictive of poor outcome in knee OCD? (RC 2019)</span></div><div><br></br></div><div>A.Stability</div><div>B. Size</div><div>C. Status of the physis</div><div>D. Site on condyle</div>”

Answer 262

“<div>Answer: C</div> <ul> <li>OCD is an acquired, <span>potentially reversible</span> idiopathic <span>lesion of subchondral bone</span> resulting in delamination and sequestration with or without articular cartilage involvement and instability.</li> <li>While there is a typical location (medial femoral condyle) and thickness, these do <span>not </span>appear to be predictive of healing.</li> <li>A fluid signal on MRI behind the lesion indicates that the fragment is unstable and is less likely to heal.</li> <li>Paletta et al. reviewed quantitative bone scans to find that 100% of patients with open femoral physes that had activity behind the lesions went on to heal but none healed in adolescents with closing physes.</li> </ul> <div><span>Juvenile form</span></div> <ul> <li>Prognosis correlates with:</li> <ul> <li>Age</li> <ul> <li>Younger = better</li> <li><span>Open phases are </span><span>the best predictor </span>of successful non-operative management</li> </ul> <li>Location</li> <ul> <li>Lesions in the <span>lateral femoral condyle and patella have </span><span>poorer </span><span>prognosis</span></li> </ul> <li>Appearance</li> <ul> <li><span>Sclerosis on x-rays correlates with poor prognosis</span></li> <li>Synovial fluid behind the lesion on MRI correlates with worse prognosis</li> </ul> </ul> </ul> <div><span>Adult form:</span></div> <ul> <li><span>Worse prognosis</span></li> <li><span>Usually symptomatic and leads to DJD if untreated</span></li></ul>”

Question 263

“<div><span>All are true regarding the use of flexible nails for humeral shaft fractures in peds, except? (RC 2019)</span></div><div><br></br></div><div>A. Low risk of radial nerve</div><div>B. Low risk of delayed union</div><div>C. Should not use in OI</div><div>D. Shortening is well tolerated in UE</div>”

Answer 263

“<div>Answer: C</div> <div><span>REF: Kelly DM. Flexible Intramedullary Nailing of Pediatric Humeral Fractures: Indications, Techniques, and Tips. J Pediatr Orthop. 2016 Jun;36 Suppl 1:S49-55.</span></div> <ul> <li>As with many fractures in children, treatment has traditionally involved closed management with traction, casts, splints, and braces. Over time, the desire for more anatomic alignment, shorter hospitalizations, quicker return to activity, and improved pain control has resulted in more frequent surgical treatment of many pediatric long-bone fractures.</li> <li>Intramedullary rodding is indicated for patients with OI to manage deformity and help treat recurrent fractures.</li></ul>”

Question 264

<div>Femoral neck fracture in peds, what is true? (RC 2019)</div>

<div>A. Rate of ON is 5%</div>

<div>B. It is ok to cross the physis with fixation</div>

<div>C. Capsular decompression</div>

<div>D. Age < 11 is a risk factor for ON</div>

Answer 264

“<div>Answer: B</div> <div><span>Ref: Spence D, et al. Journal of Ped Orthop. 2016;36(2):111–116.</span></div> <ul> <li>Osteonecrosis occurred in 20 (<span>29%</span>) of the 70 patients.</li> <li>Predictors of ON included:</li> <ul> <li><span>Fracture displacement</span></li> <li><span>Fracture location</span></li> </ul> <li>Patient age, type of fixation, mechanism of injury, capsular decompression, postoperative alignment, and performance of reduction were not predictive of osteonecrosis after femoral neck fracture.</li> <li><span>Ref: Patterson JT, et al. Management of Pediatric Femoral Neck Fracture. JAAOS 2018</span></li> <li>At long-term follow-up, adverse outcomes, which include pain and disability secondary to osteonecrosis, coxa valga, proximal femoral physeal arrest, and nonunion, are reported in 20 to 30% of patients.</li> <li>The medial portion of the femur gives rise to the capital femoral epiphysis from one or multiple ossific nuclei beginning at age 4 to 6 months and fuses through the proximal femoral physis at age 14 to 16 years.</li> <li>Injury to the trochanters apophysis or the abductor musculature may disturb growth and angulation of the femoral neck, producing coxa valga, whereas overgrowth may result in coxa vara.</li> <li><span>ON occurs in 16% to 47% of pediatric proximal femoral fractures.</span></li> <ul> <li><span>Most common complication!</span></li> <li><span>The reported rates of ON according to the Delbet classification are 38% to 50% for type I, 28% for type II, 8% to 18% for type III, and 5% to 10% for type IV.</span></li> <li><span>Age > 10 years is a risk factor</span></li> <li><span>Nonunion reported in up to 10% of patients</span></li> <ul> <li><span>Most common with type II</span><span> fractures and least common in type IV</span></li> </ul> <li>Coxa vara = 18%</li> <li>Premature physical closure = 20-62%</li> </ul> <li>Although early reduction of adult hip fractures improves outcomes, the effect of early versus late fracture reduction on outcomes in children remains unclear.</li> <ul> <li><span>Recent studies have demonstrated that shorter time to reduction (<12 hours) did </span><span>not </span><span>reduce the rate of osteonecrosis in children with femoral neck fractures and may in fact be a positive predictor of ON.</span></li> </ul> <li>When closed reduction is performed with the patient on a fracture table, the hip is <span>hyperextended</span> with <span>abduction</span> and <span>IR</span>, and slight knee flexion is maintained.</li> <li>Transphyseal screws are ideally placed no less than 5 mm from the subchondral bone of the femoral head.</li> <li><span>Stable fracture fixation should not be compromised to spare the physis.</span></li> <ul> <li>Transphyseal fixation is recommended for fracture management in patients aged >10 years.</li> </ul> <li>Risk of nonunion and femoral head-neck offset from malunion, acceptable reduction in type II fractures consists of < 5° of angulation and < 2 mm of cortical translation.</li> <li>Acceptable reduction in type III fractures consists of < 10° of angulation, with <span>varus malalignment being most common.</span></li></ul>”

Question 265

“Blood supply to the femoral head - all are true EXCEPT? (RC 2019)<div>A. Branches of the medial and lateral femoral circumflex arteries traverse the physis at birth, but attenuate by age 3-4 years, leaving no vascular communication between the metaphysis and epiphysis until physeal fusion occurs at age 14-17</div><div>B. The posterior superior branch of the lateral ascending circumflex artery comes from the LFCA</div><div>C. The MFCA supplies the femoral epiphsis via a posteriorinferior branch to the capital epiphysis as well as retinacular vessels that traverse the posterior neck</div><div>D. The contribution of vessels from the ligamentum teres decreases from birth to age 4 months and increases from age 8 years to provide a peak of 20% of total supply to the femoral head in early adulthood before declining with age</div>”

Answer 265

“Answer: B<div><br></br></div><div><div><span>Ref: Patterson JT, et al. Management of Pediatric Femoral Neck Fracture. JAAOS 2018</span></div><ul><li><div>Branches of the MFCA and LFCA traverse the physis at birth but attenuate by age 3 to 4 years, leaving no vascular communication between the metaphysis and epiphysis until physeal fusion occurs at age 14 to 17 years.</div></li><li><div>The <span>posterior superior branch</span> of the <span>lateral ascending circumflex (arises proximally from the MFCA)</span> artery travels posterosuperior to the physis and enters the anterolateral capital femoral epiphysis as the dominant capital blood supply at age 3 to 4 years. <span>This vessel arises proximally from the MFCA (see figure below)</span>, which also supplies the femoral epiphysis via a posteroinferior branch to the capital epiphysis as well as retinacular vessels that traverse the posterior neck.</div></li><li><div>The contribution of vessels from the ligamentum teres decreases from birth to age 4 months and increases from age 8 years to provide a peak of 20% of total supply to the femoral head in early adulthood before declining with age.</div></li></ul><div><img></img></div></div>”

Question 266

“All are true except, regarding traumatic juveline amputees? (RC 2019)<div><span><br></br></span></div><div><span>A. BKA increases expenditure by 60%</span></div><div><span>B. Time in double leg stance is decreased with weight-bearing on prosthetic</span></div><div><span>C. Using crutches requires 300% standard energy</span></div><div><span>D. In traumatic amputation at all levels they have the same oxygen consumption because of decreased gait speed</span></div>”

Answer 266

“<div><span>Answer: B</span></div><br></br><div><span>BKA tends to be 10-40% additional energy expenditure, AKA is thought to be ~60%.</span></div><br></br><div><span>Ref: Jeans KA, et al. </span><span>Effect of Amputation Level on Energy Expenditure During Overground Walking by Children with an Amputation.</span><span> </span><span>JBJS: 2011;5(93)49-56.</span></div><ul><li><div><b>Unilateral transfemoral and hip disarticulation </b>amputations resulted in significantly reduced walking speed (80% and 72% of normal, respectively) and increased VO2 cost (151% and 161% of normal, respectively), while the heart rate was significantly increased in the hip disarticulation group (124% of normal).</div></li><li><div>Compared with the controls, the children with a bilateral amputation walked significantly slower (87% of normal), with an elevated heart rate (119% of normal) but a similar energy cost.</div></li><li><div><b>Children with a Syme amputation, transtibial amputation, or knee disarticulation walked with essentially the same speed and oxygen cost as did normal children in the same age group.</b></div></li></ul><br></br><div><span>Ref: Are Gait Parameters for Through-knee Amputees Different From Matched Transfemoral Amputees? Clin Orthop Relat Res. 2019 Apr;477(4):821-825.</span></div><ul><li><div>No differences in <span>gait velocity</span></div></li><li><div>No differences in <span>gait cadence</span></div></li><li><div>No difference in <span>stride length</span> or <span>stride width</span></div></li><li><div>No difference in the <span>work of ambulation</span><span><br></br><br></br></span></div></li></ul><div><span>Ref: Knee Disarticulation versus Transfemoral Amputations: Functional Outcomes. J Orthop Trauma. 2019 Jan 22.</span></div><ul><li><div>No significant differences found with regard to SF-36, PEQ, LLQ, and Tegner activity scores.</div></li></ul>”

Question 267

“<div><span>In Congenital scoliosis, measurements can vary +/- 3° (95% C.I). How many degrees are needed in two separate measurements to determine if the curve has actually increased?</span> (RC 2019)</div> <ol> <li>3</li><li>4</li> <li>6</li> <li>7</li></ol>”

Answer 267

“<div>Answer: D</div><div><span>Ref: Variability in Cobb angle measurements in children with congenital scoliosis. J Bone Joint Surg Br. 1995 Sep;77(5):768-70.</span></div>”

Question 268

What is the rate of scoliosis progression based on the type of anomaly? (Congenital, 5 types)<div><br></br></div>

Answer 268

<div>Block: <2^o/year</div>

<div>Wedge: <2^o/year</div>

<div>Hemivertebra: 2-5^o/year</div>

<div>Unilateral Bar: 5-6^o/year</div>

<div>Unilateral bar with contralateral hemivertebra: 5-10^o/year</div>

Question 269

Work-up for congenital scoliosis? (4)

Answer 269

Echocardiogram<div>Renal U/S</div><div>MRI spine</div><div>C-spine radiographs</div>

Question 270

“<div><span>RC 2019 - Regarding early-onset scoliosis and pulmonary function, all are true except?</span></div><div><br></br></div><div>A. Thoracic height <18</div><div>B. Fusion above T1-2</div><div>C. More levels included in the thoracic spine fusion</div><div>D. Early fusion before age 12</div>”

Answer 270

“<div>Answer: B</div> <ul> <li>The greatest increase in the number of alveoli in normal children occurs in the first 2 years of life. Although lung volumes continue to increase into mid-adolescence, <span>alveolar multiplication typically is complete by age 8 years. </span>For this reason, surgery during the first 8 years of life is proposed to create the greatest disturbance in pulmonary development.</li> </ul> <ul> <li><span>FVC was statistically correlated with the percent of the thoracic spine that had been fused,</span> and was strongly related to the length of the thoracic spine from T1 to T12 on the anterior- posterior radiograph.</li> <li>Interestingly, patients who achieved 22 cm of thoracic height measured between T1 and T12 had near normal pulmonary function. This has led many EOS surgeons to adopt 22 cm as a goal in thoracic growth.</li></ul>”

Question 271

What are blocks to reduction of the tibial eminence fragment?

Answer 271

1. Anterior horn of the meniscus (medial > lateral)<div>2. Intermeniscal ligament</div><div>3. Rotated fracture fragment</div>

Question 272

What are the complications of tibial eminence fracture? (7)

Answer 272

1. Loss of fixation<div>2. Prominence of hardware</div><div>3. Loss of motion</div><div>4. Re-operation (higher in screw vs. suture fixation)</div><div>5. ACL laxity</div><div>6. Arthrofibrosis</div><div>7. Non-union</div>

Question 273

“<div>What is the most important factor in causing arthrofibrosis in tibial spine injuries in kids? (RC 2019)</div><div><span><br></br></span></div><div><span>A. Open fixation > arthroscopic</span></div><div><span>B. Length of immobilization</span></div><div><span>C. Screw > suture</span></div><div><span>D. Injury to meniscus</span></div>”

Answer 273

“Answer: B<div><br></br></div><div><div><span>Ref: Tibial eminence fractures in children: earlier posttreatment mobilization results in improved outcomes. J Pediatr Orthop. 2012 Mar;32(2):139-44.</span></div><br></br><span>Conclusions:</span><ul><li><div>After definitive treatment, early implementation of ROM rehabilitation results in a more rapid return to full activity. <span>ROM therapy within 4 weeks of treatment results in sooner return to full activity and decreases the likelihood of eventual arthrofibrosis.</span> In surgical patients, postoperative immobilization results in a longer delay until return to full activity and a higher rate of arthrofibrosis.</div></li></ul></div>”