Pediatric Orthopaedic MCQS ONLINE BANK 1

PREFERRED RESPONSE 3

 

Improved medical management has changed musculoskeletal outcomes for individuals with hemophilia. Patients with severe hemophilia receiving prophylactic administration of factor VIII may never develop a target joint that requires further orthopaedic intervention. Patients with moderate hemophilia and those patients with severe hemophilia not receiving prophylactic treatment will still develop joints that have recurrent hemarthroses. When recurrent hemarthrosis continues despite optimal medical management, synovectomy is indicated. While synovectomy is predictable in its ability to decrease joint bleeding, it does not necessarily improve joint range of motion or prevent the development of hemophilic arthropathy over time. It will not reverse articular damage to the joint once it has developed.

 

(SAE13PE.91) A 13-year-old boy who has a history of a pituitary adenoma has an unstable unilateral slipped capital femoral epiphysis. What is the indication for prophylactic pinning of the contralateral, unslipped side? Review Topic

 

1. Patient gender

2. Patient age

3. Presentation with an unstable slipped epiphysis

4. Coexisting endocrine disorder

 

PREFERRED RESPONSE 4

 

Endocrine disorders post the highest risk for bilateral involvement, and prophylactic pinning of the uninvolved side is most often recommended. Risk of contralateral slippage is highest in the youngest patients. In a study by Riad and associates, all girls younger than age 10 and all boys younger than age 12 presenting with a unilateral slipped capital femoral epiphysis subsequently developed a contralateral slip. Initial presentation of an unstable slip has not been shown to be an independent risk factor for later contralateral slippage.

 

(OBQ13.179) A 3-year-old boy is referred to you because of "abnormal radiographs". The child's radiographs are shown in Figures A and B. This patient is at increased risk for all of following conditions EXCEPT: Review Topic

 

 

1. Appendicular fractures

2. Osteomyelitis

3. Cranial nerve palsies

4. Coxa vara

5. Vertebral compression fractures

 

PREFERRED RESPONSE 5

 

The clinical presentation is consistent with osteopetrosis. Osteopetrosis is associated with appendicular fractures, osteomyelitis, cranial nerve palsies, and coxa vara. Osteopetrosis is not associated with vertebral compression fractures.

 

Osteopetrosis is caused by genetic mutations affecting acidification of Howship’s lacuna. Proton pump mutations are most common (60%), followed by mutations in the chloride channel CLCN7 (12%) and mutations in carbonic anhydrase II (<5%). The difference mutations drive the clinical phenotype and lead to the three different types of osteopetrosis including: malignant infantile (AR), intermediate (AR) and benign type II (AD).

 

Landa et al. reviewed surgical management of osteopetrosis. For fractures, they recommend pre-drilling pin and screw holes, and using nails instead of plates. For arthroplasty, they recommend opening the medullary canal with drill bits of increasing diameter, and short femoral stems (THA).

 

Dietz et al. reviewed genetic disorders with orthopaedic manifestations. The gene for autosomal recessive osteopetrosis is found on 1p21-13.

 

Figure A is an AP radiograph of the chest and upper extremities demonstrating marked generalized bone sclerosis. Figure B is an AP radiograph of the pelvis and lower extremities showing Erlenmeyer flask femora and incidental inguinal hernia. Illustration A shows endobone (bone-within-bone) formation. Illustration B shows sandwich vertebrae (rugger jersey spine).

 

Incorrect Answers:

Answer 1: They are at increased incidence of appendicular fractures (lifelong prevalence, 40-60%). This is because calcified cartilage and thick trabeculae remain in the diaphysis, and cartilage has inferior mechanical properties to bone.

Answer 2: There is an increased incidence of osteomyelitis. This is due to the lack of marrow vascularity in osteopetrotic bone and impairment of white cell function. This is of concern after fracture fixation and arthroplasty. Answer 3: Cranial nerve palsies arise because of compression of cranial nerves by overgrowth of the skull foramina. The optic and auditory nerves are most affected (optic > auditory > trigeminal > facial) Answer 4: There is increased incidence of coxa vara. They arise from nonunion of femoral neck fractures, or stress-induced microfractures in the femoral neck.

 

(SAE13PE.62) What genetic defect is responsible for achondroplasia? Review Topic

 

1. Trisomy of chromosome 21

2. Defect in collagen, type 1, alpha 1 (COL1A1)

3. Defect in fibroblast growth factor 3 (FGF-3)

4. Defect in fibroblast growth factor receptor 3 (FGFR-3)

 

PREFERRED RESPONSE 4

 

In achondroplasia the defect is always in the same location on this gene (a defect in FGFR-3), and most children share a very similar clinical phenotype. Achondroplasia is not caused by a defect in the gene for FGF-3, the growth factor itself, but rather the gene coding for the receptor. Trisomy of chromosome 21 is responsible for Down syndrome. Defects in the COL1A1 gene are found in some types of osteogenesis imperfecta. Unlike achondroplasia, the defects occur throughout the gene, with more than 200 mutation sites reported.

 

(SAE10PE.49) An 8-year-old girl was treated for a Salter-Harris type I fracture of the right distal femur 2 years ago. She has symmetric knee flexion, extension, and frontal alignment to her contralateral knee. She has a 1-cm limb-length discrepancy of the femur. She has always been in the 50th percentile for height and her skeletal age matches her chronologic age. She has a complete physeal closure of the right distal femur. What is the expected limb-length discrepancy at maturity? Review Topic

 

1. 3 cm

2. 6 cm

3. 10 cm

4. 14 cm

5. 18 cm

 

PREFERRED RESPONSE 2

 

The child has a near complete central physeal arrest of the distal femur. She will develop worsening limb-length discrepancy. She is growing at the average rate for the population. The distal femoral physis grows roughly at a rate of 9 mm/year. Girls finish their growth roughly at 14 years. Thus, at maturity, the uninjured side will be

6.4 cm longer than the injured side. Since she has not developed an angular deformity at this point and her arrest is central, she is unlikely to develop angular deformity in any plane.

 

(OBQ15.107) A 7-year-old boy presents to the ED with visible right elbow deformity after a fall on the playground. His injury films are shown in figures A and B. The injury is closed, and there is a palpable radial pulse with a well-perfused hand. He undergoes multiple attempts at closed reduction and percutaneous pinning with 3 lateral pins in the operating room. Final radiographs show some gapping at the fracture site. At the end of the case, the radial pulse is no longer palpable and the hand appears pale. What is the next best step in management? Review Topic

 

 

 

1. Place a medial pin to further stabilize the fracture

2. Remove all of the pins and displace the fracture

3. Obtain an emergent CT angiogram to assess arterial flow

4. Explore the artery

5. Splint the arm in extension as the fracture is now stabilized

PREFERRED RESPONSE 2

 

The patient has a type III supracondylar humerus fracture that lost a palpable radial pulse after closed reduction. Due to continued gapping at the fracture site, the next best step is to remove the pins, displace the fracture, and reassess perfusion as the brachial artery was likely interposed in the fracture site during the reduction maneuver.

 

The management of supracondylar humerus fractures is dictated significantly by the neurovascular examination. Loss of pulse and a pale, cool hand warrants emergent closed reduction and percutaneous pinning. If the vascular status does not change, open exploration is warranted. When a hand becomes pulseless and cool after reduction, it is typically due to the brachial artery being interposed in the fracture site. Undoing the reduction can often help. If there is still evidence of vascular compromise, open exploration is warranted. A pale (poorly perfused) hand or any change in neurovascular status requires urgent intervention. A pink, pulseless but well perfused hand can be observed.

 

Carter et al. surveyed over 300 pediatric orthopaedic surgeons on the management of type III supracondylar humerus fractures. They found an increasing trend toward lateral pin configuration and non-emergent delayed treatment.

 

Abzug et al. reviewed current concepts regarding management of supracondylar humerus fractures. They report an increased trend in surgical management of type II supracondylar humerus fractures. For the pink pulseless hand, they recommend admission for observation and splinting in 45 degrees of flexion.

 

Babal et al. reviewed nerve injuries in pediatric supracondylar humerus fractures. Anterior interosseous nerve palsy ranks highest, with ulnar nerve palsy highest with flexion type injuries. Medial pinning leads to risk of iatrogenic ulnar nerve injury.

 

Figures A and B are AP and lateral elbow radiographs showing a Gartland type III supracondylar humerus fracture.

 

Incorrect Answers:

Answer 1: Fracture stability is unlikely to be the reason for vascular compromise Answer 3: The utility of CT angiogram is limited when there is clinical evidence of vascular compromise

Answer 4: Undoing the reduction is the first step. If vascular status does not improve, open exploration is warranted Answer 5: This would not addressed the compromised vascular status

(SAE13PE.97) A 2-year-old boy was evaluated for toe-walking and clumsiness that were not present when he first walked at 1 year. His calves were noted to be quite large. He had a rigid equinus contracture of 10 degrees. When getting up from the floor, he rose to a tripod position and walked his hands up his legs until he was upright. Which of the following tests is most useful at this time? Review Topic

 

1. Radiographs of his legs

2. Nerve conduction testing of his peripheral nerves

3. Creatine kinase blood level

4. MRI scan of his brain and spine

 

PREFERRED RESPONSE 3

 

This history is classic for Duchenne muscular dystrophy, a condition present in approximately 1 in 3500 live male births. The disorder is caused by absent dystrophin in muscle; consequently, the creatine kinase levels at symptom onset are quite high (often > 25000 IU/L) (reference range, 55-365 IU/L). This is not a nerve disorder, so nerve tests, radiographs of the legs, and MRI scans of the neural axis will not yield a diagnosis.

 

(OBQ15.169) A 5-year-old boy complains of atraumatic foot pain that is aggravated by weight-bearing and an antalgic limp for a few days. He is splinted for 2 weeks by his pediatrician and referred to your office. Examination is unremarkable. Radiographs are shown in Figures A through C. What is the next best step? Review Topic

 

 

 

1. MRI

2. Serum inflammatory markers and biopsy

3. Bone scan

4. Weight bearing cast

5. Non-weight bearing cast

 

PREFERRED RESPONSE 4

 

This child has Kohler's disease of the navicular. Weight-bearing cast immobilization (for 4-6weeks) is appropriate. Splinting for 2 weeks is insufficient.

 

Idiopathic avascular necrosis (AVN) of the navicular arises because the intraosseous blood flow of the navicular is centripetal, leaving a central watershed area. The primary blood supply is via perforating branches of the dorsalis pedis. Patients present with midfoot pain between 2-9 years of age. Navicular sclerosis, fragmentation, and flattening are noted radiographically.

 

Digiovanni et al. reviewed AVN in the foot. Nonsurgical management is routine. Cast immobilization will provide earlier resolution of symptoms. Weight-bearing will not affect outcome. The navicular will regain a normal appearance over time.

 

Aiyer and Hennrikus reviewed pediatric foot pain. That state that up to 25% of Kohler's disease is bilateral. They agree that casting for 4-6weeks will mitigate symptoms and increase the rate of symptom resolution.

 

Figures A through C are AP, oblique and lateral foot radiographs showing navicular flattening and sclerosis consistent with Kohler's disease.

 

Incorrect Answers:

Answer 1: Cross-sectional imaging is usually not required, but may be necessary if the diagnosis is not clear or if pain persists (>6 months) to exclude tarsal coalition (may be purely cartilaginous). Answer 2: Inflammatory markers and bone biopsy are unnecessary. The diagnosis is clear and there is no suspicion of infection. Answer 3: Bone scan will show decreased radionucleotide uptake. This study is unnecessary.

Answer 5: Weight-bearing will not affect outcome. Non-weight bearing is unnecessary and also difficult to enforce in a 5-year-old.

 

(SBQ13PE.29) A 10-year-old girl presents to your office accompanied by her mother to discuss cosmetic concerns regarding her feet pictured in Figure A. They recently migrated to the U.S. and this is the first medical evaluation for this complaint. The father's feet apparently look similar. The remainder of the patient's physical

examination is normal. The parents should be counseled that children with this condition have: Review Topic

 

 

 

 

1. Delayed motor milestones, and cardiac and renal work up are necessary

2. Normal motor milestones, but cardiac and renal work up are necessary

3. Delayed motor milestones, but no further work up is necessary

4. Normal motor milestones, and no further work up is necessary

5. No chance of passing on this trait to children, as it results from a spontaneous genetic mutation

 

PREFERRED RESPONSE 4

 

This patient has post-axial polydactyly of the feet. Children with this condition exhibit normal motor milestones. If the remainder of the physical examination is normal, no further work up is necessary.

 

Post-axial polydactyly is a common autosomal dominant trait. As such, there is usually a family history. In the absence of other physical exam abnormalities, this condition is not associated with systemic disorders. Normal motor development can be expected, though surgical treatment may be undertaken to facilitate cosmesis or shoe-wear.

 

Phelps et al. reviewed supernumerary digits in 61 patients at an average of 15 year follow up. They found 94% good to excellent results. Poor results were associated with pre-axial duplications and persistent hallux varus.

Figure A is a clinical photo showing bilateral post-axial polydactyly of the foot. Incorrect answers:

Answers 1 and 3. Normal motor milestones are expected.

Answer 2. No further work up is necessary if the remainder of the physical exam is normal. Additionally, this child is 10 years old and is unlikely to have significant

cardiac or renal conditions without any manifestations. Answer 5. This is an autosomal dominant condition.

 

(SAE10PE.32) A child with an idiopathic clubfoot is successfully treated by the Ponseti method. The risk of recurrence of the deformity is most dependent on which of the following factors? Review Topic

 

1. Maternal age

2. Positive family history

3. Family's compliance with bracing

4. The child's age at walking

5. The child's body mass index

 

PREFERRED RESPONSE 3

 

The recurrence rate of clubfoot deformity after successful correction by the Ponseti method has been shown to inversely correlate with reported brace compliance. Maternal age, walking age, and body mass index have not been correlated to recurrence. A positive family history increases the risk of a child being born with a clubfoot but does not influence the recurrence rate.

 

(SAE07PE.45) A 12-year-old boy reports limping and chronic knee pain that is now inhibiting his ability to participate in sports. Clinical examination and radiographs of the knee are normal. Additional evaluation should include Review Topic

 

1. mechanical alignment radiographs.

2. stress radiographs of the knee.

3. comparison radiographs of both knees.

4. an erythrocyte sedimentation rate and a C-reactive protein.

5. examination of the hip.

 

PREFERRED RESPONSE 5

 

While all of the answers may be appropriate, radiating pain from hip pathology must be excluded. At this age, a slipped capital femoral epiphysis is likely. Therefore, the hip must be examined.

 

(SAE07PE.43) Duchenne’s muscular dystrophy is a genetic disorder that is transmitted by which of the following modes of inheritance? Review Topic

 

1. X-linked

2. Autosomal-dominant

3. Autosomal-recessive

4. Chromosomal duplication

5. Chromosomal deletion

 

PREFERRED RESPONSE 1

 

Patients with Duchenne’s muscular dystrophy show progressive muscular weakness because of the absence of dystrophin and have the clinical picture of progressive muscle weakness. The condition is an X-linked genetic disease.

 

(SAE08OS.18) A 2-year-old girl has the fracture shown in Figures 5a and 5b. This fracture is most commonly associated with which of the following entities? Review Topic

 

 

 

1. Neurofibromatosis

2. Child abuse

3. Osteogenesis imperfecta type II

4. Osteopetrosis

5. Achondroplasia

 

PREFERRED RESPONSE 1

 

The radiographs reveal constriction of the tibial diaphysis in the region of the fracture, which is characteristic of the dysplastic type of pseudarthrosis of the tibia. Neurofibromatosis occurs in approximately 50% of children who have anterolateral bowing with or without pseudarthrosis of the tibia. The appearance of this fracture differentiates it from those resulting from child abuse. Type II osteogenesis imperfecta is usually lethal in the perinatal period. Radiographs in children with osteopetrosis show overly dense bones. Achondroplasia is not associated with fractures of the tibia.

 

(SAE07PE.34) A 10-year-old girl who is Risser stage 0 has back deformity associated with neurofibromatosis type 1 (NF1). She has no back pain. Examination shows multiple cafe-au-lait nevi with normal lower extremity neurologic function and reflexes. Standing radiographs of the spine show a short 50-degree right thoracic scoliosis with a kyphotic deformity of 55 degrees (apex T8). A 10-degree progression in scoliosis has occurred during the past 1 year. There is no cervical deformity. MRI shows mild dural ectasia, primarily in the upper lumbar region. Management should consist of Review Topic

 

1. observation with repeat radiographs in 6 months.

2. a thoracolumbosacral orthosis (TLSO).

3. in situ posterior spinal fusion without instrumentation, followed by full-time TLSO bracing.

4. anterior spinal convex hemiepiphysiodesis.

5. combined anterior and posterior spinal arthrodesis with instrumentation.

 

PREFERRED RESPONSE 5

 

Scoliotic deformities in patients with NF1 are often dysplastic with short, angular curves. Posterior arthrodesis is made more difficult by the presence of kyphosis and of weak posterior elements caused by dural ectasia. Combined anterior and posterior spinal arthrodesis is generally preferred for progressive dysplastic curves to maximize deformity correction and to decrease the risk of pseudarthrosis. Anterior fusion may also prevent crankshaft phenomenon in young children. Brace treatment is not effective for large, rigid, or dysplastic curves.

(OBQ13.217) An orthotic that provides laterally based hindfoot posting support would be most useful for which of the following conditions? Review Topic

 

1. Painful accessory navicular

2. Middle facet coalition

3. Flexible flat foot

4. Metatarsus adductus

5. Flexible cavovarus foot

 

PREFERRED RESPONSE 5

 

Lateral support in the form of hindfoot posting would be most beneficial for a patient with a flexible cavovarus foot.

 

Cavovarus feet may be seen in multiple conditions, including Charcot-Marie-Tooth disease. The initial deformity is plantarflexion of the first ray, which is often followed by compensatory hindfoot varus. In flexible deformities, orthotics that post the lateral forefoot and lateral heel should be utilized.

 

Schwend et al. review the etiology, diagnosis and management of the cavus foot in children. They note that shoe inserts with lateral support can be used in patients when there is flexibility to the hindfoot. Recession of the orthotic to accommodate a plantarflexed first ray is also beneficial.

 

Illustration A shows an orthotic with lateral foot posting and a recessed area for the first metatarsal head. Illustration B shows an AP radiograph of the left foot demonstrative of an accessory navicular. This may be associated with a flatfoot deformity. Illustration C shows a lateral radiograph of a right foot with a middle facet coalition. This may give rise to a rigid, painful flatfoot deformity. Illustration D shows a lateral radiograph of a right foot with collapse of the medial longitudinal arch. This patient had a flexible flatfoot that was painful. Illustration E shows an AP radiograph of a left foot with evidence of metatarsus adductus. Note the alignment of the 2nd metatarsal axis relative to the proximal articular surface of the middle cuneiform. In this case, the metatarsus adductus angle (MAA) was 24 degrees (normal is < 20 degrees).

 

Incorrect Answers:

Answers 1, 2, 4: These conditions may be associated with a flatfoot deformity and would not benefit from a lateral posting based orthotic. Answer 3: There is no role for orthotics in the treatment of the pediatric flexible flatfoot unless there are symptoms directly attributed to the flatfoot.

(SAE10PE.84) What is the most common causative bacteria in septic arthritis in children? Review Topic

 

1. Staphylococcus aureus

2. Brucella melitensis

3. Haemophilus influenzae

4. Kingella kingae

5. Streptococcus pneumonia

 

PREFERRED RESPONSE 1

 

The spectrum of causative bacteria and frequency of occurrence of specific pathogens in septic arthritis are similar to those seen in osteomyelitis, with Staphylococcus aureus being the most common. Other common causative organisms include Kingella Kingae, Streptococcus pneumonia, Klebsiella species, Salmonella, Brucella melitensis, and Haemophilus influenzae.

 

(SAE07PE.61) A 3-year-old child has refused to walk for the past 2 days. Examination in the emergency department reveals a temperature of 102.2 degrees F (39 degrees C) and limited range of motion of the left hip. An AP pelvic radiograph is normal. Laboratory studies show a WBC count of 9,000/mmP3P, an erythrocyte sedimentation rate (ESR) of 65 mm/h, and a C-reactive protein level of 10.5 mg/L (normal < 0.4). What is the next most appropriate step in management? Review Topic

 

1. Technetium Tc 99m bone scan

2. Intravenous antibiotics

3. Oral antibiotics

4. CT of the hips

5. Aspiration of the left hip

 

PREFERRED RESPONSE 5

 

Examination reveals an irritable hip, creating a differential diagnosis of transient synovitis versus pyogenic hip arthritis. Kocher and associates described four criteria to help predict the presence of infection: inability to bear weight, fever, ESR of more than 40 mm/h, and a peripheral WBC count of more than 12,000/mmP3P. This patient meets three of the four criteria, with a positive predictive value of 73% to 93% for joint infection. Therefore, aspiration of the hip is warranted, with a high likelihood that emergent hip arthrotomy will be indicated. Ideally, intravenous antibiotics should be administered after culture material has been obtained from needle aspiration of the hip. An urgent bone scan is better indicated as a screening test for sacroiliitis or diskitis. If the arthrocentesis proves negative, CT or MRI of the pelvis may be indicated to rule out a pelvic or psoas abscess.

 

(SBQ13PE.16) A 4-week-old infant who had been born with a dislocated hip has been treated in a Pavlik Harness since 1 week of age. Parents have been compliant with the prescribed bracing protocol, and no complications or neurologic abnormalities have been noted. The hip remains Ortolani positive. Figure A shows the ultrasound image obtained in the office. What is the next best step in management? Review Topic

 

 

 

1. No further treatment

2. Continue Pavlik Harness treatment

3. Convert to semi-rigid abduction brace

4. Perform a hip arthrogram with closed vs. open reduction under general anesthesia

5. Perform a pelvic osteotomy

 

PREFERRED RESPONSE 3

 

This is a 4 week old infant with DDH who has failed Pavlik harness treatment for 3 weeks. Figure A is an ultrasound image demonstrating a dislocated hip.

 

Initial treatment for an infant with a dislocated, but reducible ("Ortolani positive") hip is bracing in a Pavlik Harness. The Pavlik harness is a dynamic brace that requires normal muscle function and tone to help keep the hip in a reduced position. If this treatment fails to hold the hip reduced after three weeks of treatment, the harness should be discontinued to prevent "Pavlik Harness Disease" which involves erosion of the posterior acetabulum as the femoral head is inappropriately being held against it.

 

After failure of Pavlik harness treatment, if the hip remains subluxated, the next step in treatment is to convert to a semi-rigid orthosis of another 2-3 weeks. If the semi-rigid brace likewise fails to keep the hip reduced, then hip arthrogram with closed vs. open reduction and spica-cast placement can be planned.

 

Swaroop and Mubarak present a study using a protocol of initial pavlik harness treatment with weekly ultrasound assessment for 3 weeks. If the hip remained unstable but reducible, then semi-rigid abduction bracing with continues weekly ultrasounds were done for an additional 2-3 weeks. This treatment protocol had a 93% success rate, which compared favorably to protocols not including the abduction

brace.

 

Hedequist et al. presented a review of 15 patients treated similarly with intial pavlik harness treatment for 3-4 weeks, and then abduction bracing if the remained unstable but reducible. They found that abduction bracing produced a stable hip within 1-2 months.

 

Illustration A shows a baby wearing a semi-rigid orthosis. Illustration B is the hip ultrasound image from Figure A with labels added. Illustration C is an ultrasound of a hip that is not dislocated.

 

Incorrect answers:

 

Answer 1: The hip remains dislocated and thus requires further treatment. Answer 2: After three weeks of failed Pavlik harness use, it should be discontinued to prevent "Pavlik Harness Disease." Answer 4: Semi-rigid orthosis bracing should be attempted for another 2-3 weeks before arthrogram and open vs closed reduction is planned. Answer 5: There are further steps in treatment before a pelvic osteotomy should be considered.

 

(OBQ14.183) A 6-year-old boy presents to the emergency room after falling off a trampoline and landing on his elbow. Examination reveals good radial and ulnar pulses, and a warm, pink, sensate extremity. Radiographs are shown in Figures A and

B. He is taken to the operating room for fluroscopic-guided closed reduction and the surgeon creates a 2 pin construct. He then notices that the pulses have disappeared and in spite of ambient warming and blood pressure elevation, are undetectable by doppler ultrasound for half an hour. The hand is paler and cooler than the contralateral side. What is the next best step? Review Topic

 

 

 

1. Splint and observe postoperatively.

2. Remove the pins and perform closed reduction without internal fixation

3. Explore the brachial artery

4. Remove the pins and pin the fracture in the initial displaced position

5. Arteriogram evaluation of the brachial artery

 

PREFERRED RESPONSE 3

 

This child has an extension Gartland type III supracondylar fracture of the humerus with an initially warm, pink, extremity with progressive circulatory compromise after reduction/pinning. Exploration is indicated.

 

Pulselessness occurs 10-20% of the time following extension type supracondylar fractures. Most authors recommend observation of the pink, pulseless limb as in the majority of cases, vascular spasm will resolve in 12-24 hours and/or the collateral circulation will be adequate. Isolated nerve injuries are usually neuropraxia and can be observed. Pulseless hands with AIN or median nerve palsy warrant early exploration because of the high probability of arterial entrapment at the fracture site, or tethering.

 

Choi et al. performed a review of 1255 pediatric supracondylar fractures treated at a single institution. There were 33 pulseless fractures (2.6%). All 24 well perfused patients did well postoperatively without vascular repair, although 10 remained pulseless. Of the 9 poorly perfused patients, 4 underwent vascular repair and 2 developed compartment syndrome. They concluded that patients with poor perfusion were at increased risk of vascular repair and compartment syndrome.

 

Franklin et al. reviewed pediatric supracondylar fractures with neurovascular compromise. They recommend: (1) observation for 48h for the pulseless, well-perfused hand, (2) exploration if the pulse disappears after reduction, (3) exploration for pulseless hands with AIN/median nerve palsy, (4) delay of 8-21 hours did not increase the risk of complications.

 

Figures A and B are AP and lateral radiographs showing a Gartland type III supracondylar fracture of the humerus.

 

Incorrect Answers:

Answer 1: Exploration is necessary if the pulse disappears following reduction/fixation because of possible kinking or entrapment of the vessel at the fracture site or tethering by adjacent soft tissue brought about by reduction. Answer 2: The fracture is unstable and internal fixation is necessary following reduction.

Answer 4: Pinning an unreduced fracture is never indicated. Answer 5: Arteriogram evaluation alone is insufficient. Open exploration is the first step to exclude entrapment and soft tissue tethering. Once the vessel is freed, intraoperative arteriogram is performed to exclude intimal damage.

(SAE12FA.84) A tall, thin 17-year-old basketball player and his parents request an evaluation of his flexible (hypermobile) pes planus/planovalgus foot deformities. As part of his evaluation, the orthopaedic surgeon notes pectus excavatum, disproportionately long arms, and scoliosis. In addition to providing treatment of his feet, what test or evaluation should the patient be referred for? Review Topic

 

1. Cardiovascular evaluation

2. Ophthalmologic evaluation

3. MRI of the spine

4. Radiographs of the hip

5. Genetic testing

 

PREFERRED RESPONSE 1

 

The current diagnostic criteria for Marfan syndrome, called the Ghent criteria, are based on clinical findings and family history. The role of genetic testing in establishing the diagnosis is limited, because testing for FBN1 mutations is neither sensitive nor specific for Marfan syndrome. By making the diagnosis and arranging for cardiovascular evaluation, the orthopaedic surgeon can help prevent sudden death in these patients. The cardiovascular manifestations, including dissection and dilation of the ascending aorta and mitral valve prolapse, are responsible for nearly all of the precocious deaths of patients with Marfan syndrome. Patients with Marfan syndrome do have problems with protrusio acetabuli, scoliosis, and opthalmologic problems but the life-threatening problem that must be considered is the risk of cardiovascular sudden death.

 

(SAE09TR.27) A 7-year-old girl is hit by a motor vehicle and sustains the isolated ipsilateral injuries shown in Figures 16a and 16b. What is the optimal definitive method of treatment? Review Topic

 

 

1. Spica cast immobilization

2. Rigid reamed nailing of the femur and a short leg cast

3. Flexible nailing of the femur and tibia

4. Reamed nails of the femur and tibia

5. Spanning external fixator

 

PREFERRED RESPONSE 3

 

The child has isolated ipsilateral femoral shaft and tibial shaft fractures. Spica cast immobilization is unlikely to accommodate for shortening and alignment in this child with multiple levels of injury. In this instance, efforts should be made to mobilize a least one level of the limb; therefore, treatment should include flexible nailing of the femur and tibia. Rigid reamed nails are not indicated in this young patient secondary to risk of a growth arrest and osteonecrosis of the proximal femur.

 

(SAE07PE.48) Late surgical treatment of posttraumatic cubitus varus (gunstock deformity) is usually necessitated by the patient reporting problems related to Review Topic

 

1. tardy ulnar nerve palsy.

2. posterior glenohumeral subluxation.

3. posterolateral rotatory subluxation of the elbow.

4. poor appearance.

5. snapping medial triceps.

 

PREFERRED RESPONSE 4

 

Cubitus varus, elbow hyperextension, and internal rotation are all typical components of the gunstock deformity. This deformity results from malunion of a supracondylar fracture of the humerus. All of the problems listed above have been reported as

sequelae of a gunstock deformity, although the malunion usually causes no functional limitations. Unacceptable appearance is the most common reason why patients or parents request corrective osteotomy.

 

(OBQ13.107) A 12-year-old male patient is scheduled to undergo femoral lengthening. The 2 techniques at your disposal are (1) femoral lengthening along the mechanical axis of the limb with an external fixator, and (2) femoral lengthening along the anatomical axis of the femur with a telescoping nail. What happens to the mechanical axis of the limb when performing these techniques? Review Topic

 

1. There is no mechanical axis deviation in (1), and medial mechanical axis deviation in (2).

2. There is lateral mechanical axis deviation in (1) and medial mechanical axis deviation in (2).

3. There is no fixed direction of mechanical axis deviation in either technique.

4. There is medial mechanical axis deviation in (1) and lateral mechanical axis deviation in (2).

5. There is no mechanical axis deviation in (1), and lateral mechanical axis deviation in (2).

 

PREFERRED RESPONSE 5

 

With femoral lengthening of the limb along its mechanical axis, the goal is overall mechanical axis preservation and this is not altered. When lengthening the limb along the anatomical axis of the femur, there is lateral mechanical axis deviation (LAD).

 

There is a difference of approximately 7° between the mechanical axis of the limb and the anatomical axis of the femur. Lengthening along the anatomical axis of the femur leads to lateral MAD. Similarly, shortening along the anatomical axis of the femur leads to medial MAD.

 

Kasis et al. described limb shortening of 4cm using external fixator assistance to dial in compression before fixation with a blade plate. They claimed this allowed correction of any tendency to medialize the mechanical axis of the limb prior to plate fixation.

 

Burghardt et al. described femoral lengthening over a telescoping nail and found lateral shift of the mechanical axis in 26 of 27 limbs, although many were minor and inconsequential. As a rule of thumb, the mechanical axis will shift about 1 mm laterally for every 1 cm of lengthening.

 

Illustration A illustrates how when lengthening with an external fixator (left), the mechanical axis can be preserved. On the other hand, when lengthening over a nail

(right), the anatomical axis is preserved, but there is lateral MAD (ISKD, intramedullary skeletal kinetic distractor).

 

Incorrect Answers:

Answers 1 to 4: There is no change in mechanical axis when lengthening along the MECHANICAL axis. When limb deformity is corrected along the ANATOMICAL axis: If the limb is shortened, the mechanical axis moves MEDIAL. If the limb is lengthened, the mechanical axis moves LATERAL.

 

(OBQ15.81) A defect in the gene coding for fibrillin-1 would lead to which diagnosis? Review Topic

 

1. Osteogenesis Imperfecta

2. Neurofibromatosis

3. Achondroplasia

4. Pseudoachondroplasia

5. Marfan Syndrome

 

PREFERRED RESPONSE 5

 

A defect in fibrillin-1 is the underlying cause of Marfan Syndrome.

 

Marfan Syndrome is a genetic disorder of connective tissue typically caused by a mutation in the gene coding for the fibrillin-1 protein. Affected patients are typically very tall with long limbs and thin fingers and toes. Marfan Syndrome patients have many common features including ectopic lens, aortic root dilation, scoliosis, protrusio acetabuli, and ligamentous laxity.

 

Shirley et al. present a review of Marfan Syndrome with emphasis on the musculoskeletal manifestations including ligamentous laxity, protrusio acetabuli, and scoliosis. They note that scoliosis in these patients, when compared to those with idiopathic scoliosis, commonly progresses faster, is more resistant to bracing, and has a higher association with dural ectasia.

 

Dean presents a review of Marfan Syndrome and its underlying genetic cause of a mutation in fibrillin. They state that diagnosis can be made using the Ghent nosology (see Illustration A) which can diagnose or rule out the condition in 86% of patients. They caution using these criteria in young children as some features of Marfan Syndrome may not present until later ages.

 

Illustration A is a summary of the 2010 Revised Ghent nosology for diagnosing Marfan Syndrome.

Incorrect Answers:

Answer 1- Osteogenesis Imperfecta is caused by a defect in the COL1A1 or COL1A2 genes which code for Type I collagen. Answer 2- Neurofibromatosis is caused by a defect in the NF1 gene which codes for the neurofibromin protein. Answer 3- Achondroplasia is caused by a mutation in fibroblast growth factor receptor 3 (FGFR3). Answer 4- Pseudoachondroplasia is caused by a defect in the cartilage oligomeric matrix protein (COMP).

 

(OBQ13.114) A mother brings in her 6-month-old infant with a knee deformity. The child had previously been treated with serial casting in flexion for 3 month at an outside facility. Examination reveals passive hyperextension to 25° and passive flexion to 15° as shown in Figures A and B respectively. A lateral radiograph of the knee is shown in Figure C. What is the most appropriate next step in treatment? Review Topic

 

 

 

1. Serial above-knee casting in extension for 4 weeks.

2. Serial above-knee casting in flexion for 4 weeks.

3. Arthroscopic anterior cruciate ligament division, followed by above-knee casting

4. Percutaneous quadriceps recession, followed by above-knee casting

5. Open VY quadriceps plasty, followed by above-knee casting

 

PREFERRED RESPONSE 5

 

The clinical presentation is consistent with recurrent Grade III congenital dislocation of the knee (CDK) that has not responded to casting in a six month old infant. VY quadricepsplasty (VYQ) is is the most appropriate next step in treatment.

 

Congenital knee dislocation is rare. The etiology is thought to be quadriceps contracture. It is associated with developmental dysplasia of the hip (DDH) and clubfoot (CTEV). In newborn infant, casting or bracing with the knee in flexion

should be performed. If this fails, percutaneous or open VY quadricepsplasty, followed by above-knee casting, is indicated.

 

Abdelaziz et al. proposed a new grading system (Tarek CDK grading system-see Illustrations A and B) and treatment protocol as follows: (1) Serial casting for Grade 1 regardless of age and in neonates with grade 2 <1mth. If flexion to >90° is achieved within 4 weeks, then serial casting is continued; if range remains <90°, percutaneous quadriceps recession (PQR) is performed. (2) PQR is performed in Grade 2 CDK in infants >1 month of age upon presentation. (3) VY quadricepsplasty is indicated in patients with Grade 3 CDK or in recurrent cases.

 

Klingele et al. describe ACL shortening and reinforcement in 2 patients with congenital knee dislocation who developed ACL incompetence due to elongation. They conclude that stabilizing and reinforcing the ACL may prevent long-term anterior instability, hyperextension and recurrent deformity.

 

Figures A and B show the range of motion of the knee (25deg hyperextension to 15deg flexion). Figure C is a lateral radiograph showing congenital dislocation of the knee. Illustrations A and B show the Tarek grading system. Illustration C shows the different techniques of quadricepsplasty (upper row, structures divided and skin incisions used; lower row, how lengthening of the quadriceps mechanism is achieved). The most common PQR is the Roy-Crawford technique. The most common VYQ is the Curtis-Fisher technique.

 

Incorrect Answers:

Answer 1: Casting in extension is not indicated. Answer 2: Serial casting in flexion is deemed unsuccessful if 90 deg is not attained within 4 weeks. Surgical intervention is then indicated. Answer 3: If both quadriceps tendon and ACL are divided, only fair results are seen. ACL division alone is not indicated. Answer 4: Percutaneous quadriceps recession can be performed for infants with Grade II CDK at presentation. For older infants that have failed previous casting, this procedure is unlikely to be successful and a more extensive open release is necessary.

 

(SAE13PE.60) A 3-year-old boy who was treated with Ponseti-method casting demonstrates supination of the affected foot during swing phase of gait. His ankle has 20 degrees of active and passive dorsiflexion and 45 degrees of plantar flexion. What is the most appropriate treatment? Review Topic

 

1. Anterior tibialis tendon lengthening

2. Anterior tibialis tendon transfer to a dorsal lateral foot position

3. Anterior tibialis tendon transfer through the interosseous membrane to the calcaneus

4. Posterior tibialis tendon transfer through the interosseous membrane to the dorsum of the foot

PREFERRED RESPONSE 2

 

Dynamic supination is a known residual problem after the Ponseti casting technique is used. Ponseti applied the principles of the Garceau procedure and transferred the entire anterior tibialis tendon to the lateral cuneiform. The anterior tibialis continues to act as a dorsiflexor of the foot but with a more advantageous trajectory. Lengthening the anterior tibialis by itself will not redirect the pull of the muscle. Likewise, the posterior tibialis tendon transfer through the interosseous membrane will not address the supinating force of the anterior tibialis. It is used when the anterior and lateral compartment muscles are either not functioning or weak in relationship to the posterior tibialis. The anterior tibialis tendon transfer to the calcaneus has been used successfully in myelodysplasia for calcaneal deformity.

 

(SAE08OS.171) A 13-year-old boy has a radiographically mild, clinically stable slipped capital femoral epiphysis (SCFE). What is the most appropriate treatment? Review Topic

 

1. Spica casting

2. Open reduction and internal fixation

3. Single screw in situ fixation of the epiphysis

4. Two-screw in situ fixation of the epiphysis

5. Crutches and no weight bearing for 6 weeks

 

PREFERRED RESPONSE 3

 

The accepted treatment of a stable SCFE lesion involves fixation of the epiphysis in situ with a single screw that is perpendicular to the epiphysis and central in both the AP and lateral planes. Constructs such as the three-screw inverted triangle configuration have increased rates of penetration of the femoral head as well as femoral head osteonecrosis. Spica casting was once a popular treatment modality but is associated with a high incidence of chondrolysis and is no longer recommended. Closed reduction attempts increase the risk of osteonecrosis.

 

(SBQ13PE.46) What developmental milestones are likely to be present in a 30-month-old child? Review Topic

1. Hand dominance established

2. Hops on one foot

3. Heel-to-toe walk

4. Puts shoes on correct feet

5. Manages buttons

 

PREFERRED RESPONSE 1

 

Hand dominance is usually established in the third year of life.

 

Normally, children younger than 2 years of age are ambidextrous. In some normal cases this persists after 2 years. Although there is some variability in this timing, strong hand preference in a younger child may be the result of a neurologic deficit.

 

Frankenburg et al. used the Denver Developmental Screening Test (DDST) to evaluate 1036 Denver area children from 2 to 6.4 years. The ages at which 25, 50, 75 and 90 percent of children could perform tasks were calculated to establish norms for the sample. The authors stress that the DDST is not an intelligence test, but rather a screening test to be used in clinical practice to determine whether a child's development is within the normal range.

 

Illustration		A		shows		the		DDST.
Incorrect								answers.
Answer	2:		Normal	for	5		years	old
Answer	3:		Normal	for	5		years	old
Answer	4:		Normal	for	4		years	old

Answer 5: Normal for 4 years old

 

(SAE13PE.115) What is the best description of this fracture? Review Topic

 

 

 

1. Gartland type I supracondylar humerus fracture

2. Gartland type II supracondylar humerus fracture

3. Gartland type III supracondylar humerus fracture

4. Flexion-type supracondylar humerus fracture PREFERRED RESPONSE 3

The radiographs show a Gartland type III supracondylar humerus fracture. Although multiple classification systems exist that describe supracondylar humerus fractures, Gartland's classification is simple and widely used. Type I fractures are nondisplaced according to this classification. Type II fractures are displaced with a variable amount of angulation, but the posterior cortex of the humerus is intact. Type III fractures are completely displaced with no cortical contact. In flexion-type supracondylar humerus fractures, the distal fragments are anterior to the humeral shaft. The most appropriate treatment method for this fracture is attempted closed reduction and pin fixation. Closed reduction and casting is inappropriate for a Gartland type III supracondylar humerus fracture. Although open reduction may be required in some cases, most supracondylar humerus fractures, even those that are severely displaced, can be treated with closed reduction and percutaneous pin fixation (and this should be the initial approach). Although olecranon traction is an option in managing these fractures, it involves repeated radiographs and prolonged hospitalization and is not widely used in North America. The preoperative examination is consistent with a radial nerve injury. Neuropraxias are common in supracondylar humerus fractures, with anterior interosseous nerve injury being the most common, followed by radial nerve. Ulnar nerve injuries occur in flexion-type supracondylar fractures and occasionally as the result of medial pin placement during surgery. The recurrent motor branch of the median nerve supplies the thenar muscles.

 

(SAE13PE.88) Figure 88 is the anteroposterior elbow radiograph of an 8-month-old boy who had swelling and decreased use of his left elbow. His neurovascular examination is intact and he has no fever or chills. What is the most appropriate initial treatment? Review Topic

 

 

 

1. Obtain an MRI scan

2. Apply a long-arm splint

3. Closed reduction with pinning

4. Open reduction with pinning PREFERRED RESPONSE 3

This child has a Salter-Harris-type I fracture of the distal humerus. Standard treatment is closed reduction with or without internal fixation with pins. An MRI scan is typically not needed. Applying a splint without reduction will leave the fracture to heal in a suboptimal position. Open reduction is rarely necessary and would not be the most appropriate initial treatment.

 

(SBQ13PE.111) A 42-year old male presents with painful calluses under the head of his 1st and 5th metatarsals. Based on the physical exam findings in figures A and B, which of the following statements is true? Review Topic

 

 

 

1. The patient has a positive "too many toes sign"

2. The patient has a flexible hindfoot varus deformity

3. The patient has an isolated gastrocnemius contracture

4. The patient has a flexible hindfoot valgus deformity

5. The patient has a rigid hindfoot varus deformity

 

PREFERRED RESPONSE 2

 

The findings from the Coleman block test suggest that this patient has flexible hindfoot varus deformity.

 

The Coleman block test is used to separate FLEXIBLE forefoot-driven hindfoot varus from FIXED OR RIGID hindfoot varus. A flexible hindfoot with a fixed plantarflexed first ray will correct to neutral or some degree of valgus with the Coleman block test, indicating that correction of the forefoot position should correct the hindfoot varus. A rigid hindfoot will not correct to neutral or valgus.

 

Younger et al. reviewed the presentation, etiology, diagnosis and management of cavovarus foot deformities. They reviewed the importance of the Coleman block test in assessing the cause and treatment of hindfoot varus.

Paulos et al. reviewed the surgical outcomes of 27 patients who were treated for cavovarus foot deformity using a standardized treatment program based on the flexibility of the deformity. At the two year follow-up 85% of patients reported acceptable results with no major complications.

 

Figure A illustrates the initial examination of the hindfoot varus prior to the Coleman block test. Figure B depicts the patient with a block under the lateral side of the forefoot, and the hindfoot correcting to valgus. The video demonstrates how to perform the Coleman block test.

 

Incorrect Answers:

Answer 1: The "too many toes sign" is an indicator of forefoot abduction often seen in adult acquired flatfoot deformity, where more than one and half to two toes are seen laterally when observing the patient from behind. Answer 3: An isolated gastrocnemius contracture cannot be diagnosed using the Coleman block test. The Silfverskiöld test is more appropriate for that situation. Answer 4: The patient does not have a flexible hindfoot valgus deformity. Answer 5: The Coleman block test illustrates that the hindfoot deformity is NOT rigid.

 

(SAE11OS.186) Figures 186a and 186b are the radiographs of a 10-year-old girl who sustained an injury 2 days ago after jumping off another girl's shoulders while cheerleading. She is unable to walk and has no other injuries. Examination reveals swelling below the knee and a palpable defect at the tibial tubercle. The knee is ligamentously stable medial-lateral and anterior-posterior. What is the next most appropriate step in management? Review Topic

 

 

 

1. MRI scan of the knee

2. CT scan of the knee

3. Open reduction and internal fixation

4. Excision of the fragment

5. Application of a long-leg cast

 

PREFERRED RESPONSE 3

 

The radiographs show the patella elevated and the patellar ligament insertion retracted greater than 2 cm. The most appropriate treatment is repair of the patellar ligament. Excision of the fragment and application of a cast will not restore quadriceps function. A CT scan will only demonstrate what is evident on the radiographs and an MRI scan is not needed because the knee is ligamentously stable.

 

(SAE09FA.82) A 12-year-old girl who plays softball has chronic lateral hindfoot aching pain that is aggravated by weight-bearing activity. She reports that the pain has recurred after initial improvement with cast immobilization, and it continues to limit her overall level of activity. Radiographs are seen in Figures 40a through 40c. What is the most appropriate surgical treatment? Review Topic

 

 

 

1. Correction of the flatfoot deformity

2. Achilles tendon lengthening followed by orthotic support

3. Excision of the tarsal coalition

4. Sinus tarsi debridement

5. Triple arthrodesis

 

PREFERRED RESPONSE 3

 

The patient has a calcaneonavicular tarsal coalition. Symptoms of calcaneonavicular coalitions typically are seen between the ages of 10 and 14 years. The cause of pain has not been clearly established. It has been postulated that the coalition stiffens with maturity and microfractures can result, producing pain. Resection of a calcaneonavicular coalition generally has been associated with a satisfactory result. Soft-tissue interposition, most commonly using the extensor digitorum brevis muscle,

appears to be helpful. A hindfoot arthrodesis (usually triple) would be reserved if coalition resection proves to be unsuccessful. Achilles tendon lengthening and orthotic support, as well as debridement of the sinus tarsi, are not expected to result in a satisfactory outcome. The patient does not have a flatfoot deformity.

 

(SBQ13PE.64) A 5-year-old boy presents to clinic for evaluation of bilateral foot deformities shown in Figure 1. He is fully active and has no pain. The feet appear normal when he is sitting on the examination table, and there is supple passive motion at the subtalar joint. Passive ankle dorsiflexion is to neutral with knee in extension and 15 degrees with knee in flexion. What is the most appropriate next step? Review Topic

 

 

 

 

1. Spine MRI

2. Standing radiographs of the bilateral feet

3. Gastrocnemius stretching and nightime use of ankle foot orthosis

4. Gastrocnemius stretching and use of UCBL orthotic when ambulating

5. Gastrocnemius stretching

 

PREFERRED RESPONSE 5

 

The patient is presenting with bilateral flexible pes planovalgus (or flexbile flatfoot). The most appropriate treatment in patients with a tight heel cord and no pain is gastrocnemius stretching

 

A flexible flatfoot in a child typically resolves spontaneously. Radiographs are typically indicated when there is pain to rule out other conditions. Treatment for patients without pain includes observation and gastrocnemius stretching. If there is pain, soft arch support or a more rigid UCBL can be used, but orthotics do not change the natural history. In patients with continued tightness in the heel cord despite aggressive stretching, gastrocnemius lengthening may be necessary.

 

Mosca reviews the management of flexible flatfeet in children and adolescents. He reports that there is no compelling evidence that an arch can be created with use of

orthotics. He proposes the following algorithm: patients with asymptomatic flatfeet are observed; symptomatic flatfeet with tight heel cords undergoing stretching until they become asymptomatic; symptomatic flatfeet with tight heel cords that do not respond to stretching (rare cases) are considered for surgery.

Figure A shows a young a patient with bilateral flatfeet when standing. Incorrect Answers:

Answer 1: Spinal abnormalities are not associated with pes planovalgus. Spinal cord

abnormalities can seen in patients with cavovarus deformity Answer 2: Radiographs are indicated when there is pain to rule out other conditions. Answer 3: Ankle foot orthoses are not used for pes planovalgus Answer 4: UCBL would be indicated if the patient was having pain.

 

(SBQ13PE.42) Submuscular bridge plating is appropriate treatment for which of the following? Review Topic

 

1. A 2-month-old female with displaced, spiral, mid-diaphyseal femur fracture

2. A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with

   <2cm shortening

3. A 7-year old boy with a transverse, non-comminuted mid-diaphyseal femur fracture

4. A 7-year-old boy with a highly comminuted mid-diaphyseal femur fracture

5. A 15-year-old girl with a displaced butterfly fragmented mid-diaphyseal femur fracture

 

PREFERRED RESPONSE 4

 

Submuscular bridge plating is appropriate for length-unstable femur fractures in skeletally immature patients ages 6 years and older.

 

Traditional plating of diaphyseal femur fractures in children has been abandoned due to the large incision and significant periosteal stripping involved. Submuscular plating with limited incisions and percutaneously applied fixation is a more biologically friendly way to achieve rigid internal fixation in length-unstable fracture patterns. External fixation is another acceptable option for these fractures. Locked plating, on the other hand, provides an 'internal external fixator,' avoids pin site issues and allows rapid mobilization while providing a biologically favorable environment for healing.

 

Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. They concluded that there was insufficient evidence regarding submuscular bridge plating to include it in the guideline.

 

Flynn et al. review the management of pediatric femoral shaft fractures. The note that

the narrow indications for plating of pediatric femoral fractures are open fractures, multiple trauma, head injury or compartment syndrome in patients less than 12 years old. Plating allows rigid fixation with readily available equipment and allows for rapid mobilization.

 

Hedequist et al. present a Technical Tricks paper in which they detail their surgical technique for submuscular bridge plating. They recommend this fixation strategy for patients between age 6 and skeletal maturity with comminuted diaphyseal femur fractures that are not easily treated by other methods.

 

Illustration A shows a preoperative and postoperative radiograph of a comminuted pediatric femur fracture treated with submuscular plating.

 

Incorrect answers:

Answer 1: Children less than 6 months may be treated with spica casting or Pavlik harness. Pavlik is generally favored due to its ease of application and use and lower risk of skin complications Answer 2: This patient is most appropriately treated with spica casting. Answer 3: Length stable fractures can be treated with flexible intramedullary nails Answer 5: Skeletally mature patients with mid-diaphyseal femur fractures should be treated rigid intramedullary nails

 

(SBQ13PE.88) A 12-month-old boy attends a government regulated childcare center. His parents are called after a fall. Non-accidental trauma has been ruled out. On physical examination the right elbow is swollen and tender. He is unwilling to allow you to move the arm. Radiographs of the elbow are shown in Figure A. What is the orthopaedic management of this injury? Review Topic

 

 

 

1. Observation only

2. Elbow sling for 3 to 4 weeks

3. Rigid elbow immobilisation for 4 to 5 weeks

4. Admit for 24-48 hours for continuous intracompartmental pressure measurements

5. Operative fixation with percutaneous pinning PREFERRED RESPONSE 5

This patient presents with a distal humeral physeal separation. The most appropriate treatment would be closed reduction with internal fixation with percutaneous pins.

 

Displaced distal humerus physeal separation is typically seen in children under the age of 3 and has a high association with child abuse. The diagnosis can be a difficult as radiographs of a distal humeral physeal separation may be subtle. Often, radiographs show no obvious fracture, but can appear like an elbow dislocation since the secondary ossification centers have not yet developed. MRI or arthrogram can be used to aid in diagnosis.

 

Shrader et al. reviewed pediatric supracondylar fractures and pediatric physeal elbow fractures. They state the key to diagnosis of distal humerus physeal separation is the assessment is the radial head–capitellum relationship. These injuries should be fixed with closed reduction and smooth wire pinning. An elbow arthrogram may be considered intraoperatively for these patients because of the difficulty visualizing the distal humeral anatomy in children so young.

 

Skaggs et al. reviewed the diagnosis and management of pediatric elbow fractures. He states that child abuse should be suspected in all cases of elbow fracture when the child is less than 3 years of age and/or the injury pattern occur from a shearing mechanism. The displacement of physeal elbow fractures is almost always posteromedial.

 

Figure A shows AP and lateral radiographs with posteromedial displacement of the radial and ulnar shafts relative to the distal humerus. This is consistent with distal humeral physeal separation.

 

Incorrect Answers:

Answers 1,2,3,4: Distal humeral physical separation should be managed operatively. MRI or arthrograms may be ordered to rule out physeal separation. The risk of compartment syndrome is low. Continuous intracompartmental pressure measurements are not recommended.

 

(SAE10PE.64) The newborn foot deformity seen in Figures 64a and 64b should initially treated with Review Topic

 

 

1. observation with possible stretching.

2. serial casting.

3. medial surgical release.

4. posterior medial surgical release.

5. dynamic ankle-foot orthosis.

 

PREFERRED RESPONSE 1

 

Mild to moderate metatarsus adductus is best treated with observation and possible passive stretching exercises because most of these feet will self correct. Numerous types of shoes, braces, and splints have been devised but the efficacy of these have not been determined. Serial casting is reserved for severe metatarsus adductus in the infant, although a medial surgical release may be indicated if the deformity is symptomatic and persists beyond age 4 years.

 

(SAE10PE.88) A 4-year-old girl falls off a swing and injures her right elbow. The radiographs are shown in Figures 88a and 88b. What is the most likely diagnosis? Review Topic

 

 

 

1. Displaced right olecranon fracture

2. Right elbow dislocation with spontaneous reduction and entrapped medial epicondyle fragment

3. Effusion of the right elbow without an identifiable radiographic fracture

4. Nondisplaced right lateral condyle fracture of the distal humerus

5. Right Gartland type I supracondylar humerus fracture PREFERRED RESPONSE 1

To accurately diagnose skeletal injuries around the elbow in children, the practitioner must be knowledgeable about the progressive ossification centers. In this case, at age 4 years, a female will have a partially ossified capitellum, radial head, and medial epicondyle. The trochlea, olecranon, and lateral epicondyle ossification centers should remain fully cartilaginous at this stage of development. The irregularity in the area of the olecranon on the radiograph represents a displaced fracture requiring accurate reduction and fixation to ensure restoration of articular congruity and full elbow function. The presence of a posterior fat pad sign on the radiograph is indicative of a traumatic effusion, but there is an identifiable fracture in this patient. Olecranon fractures are commonly seen in children with osteogenesis imperfecta.

 

(SAE13BS.17) A 14-year-old boy sustained a right forearm fracture after a moderate-speed fall while skateboarding. He was previously treated for fractures of his left femur and right tibia, all from low-energy mechanisms. He has had some mild vertigo since school age, but otherwise has had an unremarkable birth and growth history. His family history is significant for frequent fractures (his mother). On examination, he has slightly blue sclerae, grossly normal hearing, and normal dentition. Chest, abdomen, and pelvis radiographs reveal a mild curvature of the spine (Cobb angle 10 degrees) and suggestion of a slightly large aortic knob. Findings from a nonaccidental trauma workup were normal. This boy's bones are fragile because of a gene mutation affecting what protein? Review Topic

 

1. Fibroblast growth factor receptor (FGFR)

2. Fibrilin

3. Collagen

4. Cartilage oligomeric matrix protein PREFERRED RESPONSE 3

This patient exhibits characteristics of osteogenesis imperfecta caused by a collagen mutation. FGFR3 mutations are responsible for achondroplasia. Fibrillin mutations are thought to cause Marfan syndrome. Cartilage oligomeric matrix protein mutations are found in patients with pseudoachondroplasia.

 

(SAE07PE.10) An 18-month-old boy with obstetric brachial plexus palsy is being evaluated for limited right shoulder motion. Physical therapy for the past 6 months has failed to result in improvement of the contracture. Which of the following studies is necessary prior to any shoulder reconstruction? Review Topic

 

1. Electromyography

2. MRI of the shoulder joint

3. MRI of the brain

4. Radiograph of the elbow

5. Aspiration of the right shoulder

 

PREFERRED RESPONSE 2

 

The child sustained a brachial plexus injury at birth, and internal rotation/adduction contractures frequently develop at the shoulder. Initial treatment should consist of physical therapy to increase the range of motion. If this fails, as in this patient, MRI is used to evaluate the glenohumeral joint. Commonly, there is joint deformity with increased retroversion of the glenoid and even posterior shoulder subluxation. If the deformity is mild, an anterior release, coupled with teres major and latissimus transfers, is very effective. If the deformity is severe and the shoulder is unreconstructable, then humeral derotation osteotomy is the procedure of choice. MRI of the brain, a radiograph of the elbow, and aspiration of the shoulder would not be helpful.

 

(SAE07PE.73) A 22-month-old girl has cerebral palsy. Which of the following findings is a good prognostic indicator of the child’s ability to walk in the future? Review Topic

 

1. Asymmetric tonic neck reflex

2. Moro reflex

3. Extensor thrust

4. Positive parachute reaction

5. Absent foot placement

 

PREFERRED RESPONSE 4

For the parachute test, the examiner holds the child prone and then lowers the child rapidly toward the floor. The parachute reaction is normal or positive if the child reaches toward the floor. The Moro or startle reflex should not be present beyond age 6 months. Asymmetric tonic neck reflex, extensor thrust, and absent foot placement are abnormal findings at any age.

 

(OBQ15.239) Which of the following developmental milestones is expected to occur in children aged between 12 to 18 months? Review Topic

 

1. Builds towers of 4 or more blocks

2. Transfer toys from one hand to the other

3. Jumping

4. Walk without assistance

5. Throws ball overhand PREFERRED RESPONSE 4

Children aged between 12 to 18 months are expected to walk independently, without assistance.

 

Developmental milestones are things most children can do by a certain age. Categories include (1) social and emotional, (2) language and communication, (3) cognitive, and (4) movement/physical development. When a child reaches 18 months of age, the movement/physical development milestones include the ability to walk alone, walk up steps with assistance, pull toys while walking, help undress themselves, drink from a cup and eat with a spoon.

 

Burnett et al. studied the development of gait in twenty-eight children whom were filmed sequentially throughout the initial period of independent gait. They found that the adult pattern of gait appeared within 40 - 55 weeks following the initiation of independent gait.

 

Sutherland et al. also studied the development of gait. They studied over 160 children and showed that most children develop a mature gait pattern by the age of 3 years old. They concluded that there are 5 important determinants of mature gait. They include duration of single leg stance, walking velocity, cadence, step length and ratio of pelvic span to ankle span.

 

Incorrect Answers:

Answer 1: Builds towers of 4 or more blocks should occur between the age of 2 to 3 years old.

Answer 2: Transfer toys from one hand to the other should occur between the age of 6 to 9 months.

Answer 3: Jumping should occur between the age of 2 to 3 years old. Answer 5: Throws ball overhand should occur between the age of 18 to 24 months.

 

(SAE10PE.51) An 11-year-old girl is struck in the leg by a loaded sled while sledding and is seen in the emergency department; she is reporting severe knee pain. Radiographs are read as normal. Examination reveals that she is exquisitely tender over the proximal tibial physis. The neurovascular examination is normal. What is the next step in management? Review Topic

 

1. Splinting, admission, and frequent neurovascular checks

2. Cylinder cast and discharge

3. Emergent knee arthroscopy

4. Four-compartment calf fasciotomy

5. Non-weight-bearing, a knee immobilizer, and follow-up in 1 week

 

PREFERRED RESPONSE 1

 

The anatomic lesion in this patient is not exactly defined, but she has most likely sustained an injury about the knee. A Salter-Harris type I proximal tibial physeal fracture is likely. The normal radiograph reading can be misleading because these injuries may displace and spontaneously reduce. The child is at risk of compartment syndrome although she is currently not displaying signs of it. Thus, even though this injury may seem trivial by radiographic findings, it should be treated like a knee dislocation with a risk of late developing compartment syndrome. MRI or CT may be necessary to define the injury. She does not require emergent treatment, but merits close observation for possible compartment syndrome. Any of the possible injuries about the knee can be unstable and require internal fixation after reduction.

 

(SAE10PE.19) The clinical factors shown to most significantly predict the long-term outcome of Perthes disease of the hip include which of the following? Review Topic

 

1. Limb-length discrepancy, range of motion of the hip

2. Age at presentation, range of motion of the hip

3. Age at presentation, limb-length discrepancy

4. Range of motion, pain/limp for more than 6 months

5. Limb-length discrepancy, pain/limp for more than 6 months

PREFERRED RESPONSE 2

 

Age at presentation and range of motion of the hip are the two most significant predictors of long-term outcome. Younger patients and patients who maintain range of motion of the hip are more likely to have a good outcome. In Herring's study, children with a chronologic age of younger than 8 years or a bone age of less than 6 years had significantly more favorable outcomes compared with older children. Limited hip range of motion may be due to muscle spasm early on, or synovitis; but in late disease, it may reflect incongruity of the joint. Classifications based on femoral head shape have also been correlated to prognosis. Significant shortening of the affected hip is not common.

 

(SBQ13PE.87) A 4-week-old child is suspected to have classic arthrogryposis, also known as amyoplasia. Clinical examination and hip ultrasound reveal a unilateral, non-reducible, hip dislocation. What do you recommend to reduce the hip? Review Topic

 

1. Pavlik harness application

2. Semi-rigid abduction brace application

3. Skeletal traction

4. Early closed reduction and spica casting

5. Delayed open reduction with or without pelvic and femoral osteotomy

 

PREFERRED RESPONSE 5

 

Delayed open reduction with or without pelvic and femoral osteotomy is recommended in the management of unilateral hip deformities associated with amyoplassia. This procedure should be performed at 6-9 months of age. In order to proceed with reduction, there must be a reasonable arc of flexion/extension and active movement of the lower limbs.

 

Amyoplasia is the most common recognizable form of arthrogryposis. It most commonly occurs as a sporadic symmetric contracture syndrome that is characterized by symmetrical limb involvement, normal to above-average intelligence, and often a midline facial hemangioma. Approximately 80% of children with amyoplasia will have involvement of the hip ranging from soft tissue contractures to unilateral or bilateral hip dislocations.

 

Bevan et al. reviewed arthrogryposis. They state that open hip reduction is recommended for the management of unilateral dislocation. There is more controversy with regard to the treatment of bilateral hip dislocations. Open reduction can be performed by a medial or anterolateral approach, with or without pelvic and

femoral osteotomy. This procedure is generally delayed for 6-9 months to facilitate the procedure.

 

Bernstein et al. also reviewed arthrogryposis. They state that the term 'arthrogryposis' encompasses a broad spectrum of diseases, all with the common phenotype of multiple congenital contractures.

 

Illustration A shows the characteristic features of an infant with severe arthrogryposis. Note the internal rotation of the shoulders, elbow and knee hyperextension, flexed and ulnarly deviated wrists, flexed finger, external rotation of hips and bilateral clubfeet.

 

Incorrect answers:

Answer 1, 2: The use of Pavlik harness and semi-rigid braces are typically not effective in teratology hip dislocations. Answer 3: Skeletal traction alone would not reduce the hip, (though it may be used as an adjunct for a very proximal dislocation). Answer 4: Closed reduction and casting is generally unsuccessful in achieving a stable long-term reduction in these patients.

 

(OBQ14.92) A 15-year-old male jumps off a 6 foot ramp and lands awkwardly. His knee swells up immediately and he is taken to the emergency room. Figures A is a sagittal CT scan image. In the next 3 hours, he complains of increasing leg pain. This is likely because of injury to which of the following structures? Review Topic

 

 

 

1. Lateral femoral cutaneous nerve

2. Medial inferior genicular artery

3. Infrapatellar branch of the saphenous nerve

4. Anterior tibial recurrent artery

5. Lateral inferior genicular artery

 

PREFERRED RESPONSE 4

This child has a tibial tuberosity avulsion fracture with intraarticular extension. There is a risk for anterior compartment syndrome of the leg because of rupture of the anterior tibial recurrent artery located around the lateral border of the tibial tubercle. The vessels retract under the fascia, leading to bleeding into the anterior compartment.

 

Tibial tubercle fractures usually occur during aggressive quadriceps contraction during sports. The Ogden classification classifies this by site of fracture (Type I, through the tubercle; Type II, at the level of the tibial physis; Type III, extending through the anterior tibial epiphysis). Other complications include extensive soft tissue damage, periosteal stripping, vascular compromise and intra-articular damage.

 

Pandya et al. reviewed 41 tibial tubercle fractures. They found compartment syndrome or vascular compromise in nearly 10%. They found that the degree of injury was underestimated 50% of the time when classified using lateral radiographs alone. They recommend CT scan or MRI as an adjunct. If intra-articular involvement is seen, arthroscopy or open arthrotomy should be performed.

 

Pape et al. describe 2 case reports of anterior compartment syndrome after tibial tubercle fracture. The compartment syndrome occurs as a result of proximity of the tibial tubercle physis to the anterior tibial recurrent artery.

 

Figure A shows the sagittal reconstruction CT image showing intraarticular involvement. Illustrations A and B are axial and coronal CT images in the subchondral region showing the fracture line traversing the zone between fused and unfused physis (see Illustration C for physeal closure pattern). Illustration C shows the direction of closure of the proximal tibial physis. In the sagittal plane, the proximal tibial physis closes from posterior to anterior, then to the tubercle apophysis which closes from proximal to distal also. In the coronal plane, the physis closes from medial to lateral. In the axial plane, the physis closes from posteromedial to anterolateral. Illustration D shows the anterior tibial recurrent artery.

 

Incorrect Answers:

Answers 1, 2, 3, 5: These nerves and vessels are not avulsed by a tibial tuberosity avulsion fracture.

 

(SAE08OS.45) An 8-year-old boy sustains a 100% displaced extension-type supracondylar humerus fracture. Examination reveals no sensory deficit. Capillary refill is approximately 1 second. The patient is unable to flex the index distal interphalangeal joint and the thumb interphalangeal joint. The remainder of the motor examination is normal. Which of the following best explains these physical findings? Review Topic

 

1. Volkmann ischemic contracture

2. Radial nerve palsy

3. Ulnar nerve palsy

4. Median nerve palsy

5. Anterior interosseous nerve palsy

 

PREFERRED RESPONSE 5

 

Preoperative nerve deficit is common in children with displaced extension-type supracondylar humerus fractures (approximately 20%). Commonly injured nerves include the anterior interosseous nerve (a branch of the median nerve), the median nerve, and the radial nerve. The physical examination findings are most consistent with an anterior interosseous nerve palsy. The ulnar nerve is the most likely nerve to be injured in flexion-type supracondylar humerus fractures.

 

(OBQ15.247) A 14-year-old female has anal hemorrhoids. The General Surgical team has asked for a consultation in regards to her history of hand, wrist, and ankle joint pain and swelling over the past 3 years. Her physical examination reveals a swollen left wrist, right knee and left ankle. Lab work shows low hemoglobin, low albumin, elevated erythrocyte sedimentation rate (ESR), elevated antinuclear antibody (ANA) count, and a negative rheumatoid factor. Radiography of the affected joints are normal. What additional work up is required prior to her rectal surgery? Review Topic

 

1. C-reactive protein (CRP)

2. Synovial fluid analysis of affected joints

3. Blood cultures

4. Cervical radiographs

5. Bethesda assay

 

PREFERRED RESPONSE 4

 

This patient has a diagnosis of Juvenile Idiopathic Arthritis (JIA). Flexion-extension c-spine radiographs should be ordered to rule out atlantoaxial instability prior to surgery.

 

JIA is a persistent autoimmune inflammatory arthritis lasting more than 6 weeks in a patient younger than 16 years of age. Serologic testing for this condition will usually show elevated ESR/CRP, low hemoglobin, low albumin and an elevated anti-nuclear antibody (ANA) count, as well as negative rheumatoid factor and positive HLA-B27. Radiographs of the c-spine should be considered in patients undergoing intubation as cervical kyphosis, facet ankylosis, and atlantoaxial subluxation is associated with this condition.

 

Punaro et al. reviewed rheumatologic conditions in children. The typical patient with

oligoarticular JIA is a white female (5:1, F:M), with a peak onset between ages 1 and 3 years. Nearly half of patients have monoarticular involvement, with the knee and ankle being most commonly involved. Uveitis is typically chronic, bilateral, and asymptomatic.

 

Borchers et al. reviewed juvenile idiopathic arthritis (JIA). They state that no laboratory test can conclusively establish a rheumatic diagnosis. They state that laboratory tests will be negative for systemic inflammation and antinuclear antibody (ANA) test has no use in screening for JIA, as it has a high false positive rate.

 

Incorrect Answers:

Answer 1: Both ESR and CRP are usually elevated in this condition and provide no further benefit for the operative management of this patient. Answer 2: This patient has chronic joint swelling and pain. Joint aspirates and synovial fluid analysis would not be required. Answer 3: There is no suspicion for an acute infection. Therefore, blood cultures are not required.

Answer 5: A Bethesda assay is used to measure the amount of factor VIII or IX antibody in the blood, for patients with hemophilia.

 

(SAE08OS.5) Surgical treatment of an adult cavovarus foot with fixed forefoot valgus that does not correct on Coleman block testing should consist of Review Topic

 

1. lateral column lengthening through the calcaneal anterior process.

2. a medial displacement calcaneal osteotomy.

3. first metatarsal-cuneiform fusion in increased plantar flexion.

4. dorsiflexion osteotomy of the first metatarsal and a medial displacement calcaneal osteotomy.

5. dorsiflexion osteotomy of the first metatarsal and a lateral displacement calcaneal osteotomy.

 

PREFERRED RESPONSE 5

 

Cavovarus feet are characterized by plantar flexion of the first metatarsal and hindfoot varus. A rigid cavovarus hindfoot does not correct on Coleman block testing. Correction of these rigid deformities requires either lateral displacement or lateral closing wedge osteotomies of the calcaneus and dorsiflexion osteotomies of the involved metatarsals. Lateral column lengthening procedures are used to correct painful flatfoot deformities.

(SAE11OS.70) A 15-year-old girl sustained the injury shown in Figures 70a and 70b when she jumped from the back of a moving truck. She is seen in the emergency department 2 hours after her injury. She has no other injuries. Her foot is warm and she has a normal motor and sensory examination. Pulses are only evident on Doppler. What is the most appropriate management? Review Topic

 

 

 

1. MRI scan of the knee

2. CT scan of the distal femur

3. Application of a long-leg cast

4. Arteriogram of the extremity

5. Reduction and fixation of the fracture

 

PREFERRED RESPONSE 5

 

The radiographs reveal a distal femoral fracture that is often associated with a neurovascular injury at the level of the fracture. Initial treatment should be to reduce the fracture, stabilize it, and then reevaluate the extremity for neurovascular function. A CT scan, arteriogram, or MRI scan would not help and would delay treatment. A cast would not be appropriate because access to the extremity is necessary and it would not provide stabilization for vascular repair if it is required.

 

(SAE07PE.66) A 12-year-old boy with an ankle fracture undergoes closed reduction under sedation in the emergency department. Figure 27 shows a lateral radiograph of the ankle after two attempts at closed reduction. Based on these findings, treatment should now consist of Review Topic

 

 

1. at least two more attempts at closed reduction in the emergency department before the patient’s sedation wears off.

2. at least two attempts at closed reduction in the operating room under general anesthesia with muscle relaxation.

3. acceptance of the reduction because the alignment is satisfactory and growth problems are rare with Salter-Harris type I fractures.

4. open reduction, extraction of any interposed periosteum, and smooth wire fixation to prevent nonunion.

5. open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

 

PREFERRED RESPONSE 5

 

The widening of the physis associated with incomplete reduction of this fracture suggests that periosteum is interposed at the fracture site. Clinical and animal study findings suggest that the interposed periosteum may lead to premature physeal closure. Repeated forceful attempts at reduction may subject the physis to further injury and should be avoided. Growth problems are common in children with Salter-Harris type I fractures of the lower extremities. Nonunions are rare in children with Salter-Harris type I fractures.

 

(SAE08AN.98) A 4-month-old infant is unable to flex her elbow as a result of an obstetrical brachial plexus palsy. This most likely illustrates a predominate injury to what structure? Review Topic

 

1. C4

2. Upper trunk

3. Posterior cord

4. Lateral cord

5. Musculocutaneous nerve

PREFERRED RESPONSE 2

 

Erb’s palsy is the most common form of obstetrical plexus palsy resulting in C5, C6, or upper trunk deficits. This causes loss of shoulder abduction and elbow flexion. The biceps muscle and the brachialis muscles are predominately responsible for flexion of the elbow. Each of these muscles is innervated by individual branches of the musculocutaneous nerve which are supplied predominately by axons from the C6 nerve root and the upper trunk of the brachial plexus

 

(SAE10PE.31) A 9-month-old nonambulatory girl is seen in the emergency department with a fracture of her right forearm. The mother says she fell from the changing table yesterday and continues to cry and not use her right arm. Radiographs are shown in Figure 31. Treatment should consist of which of the following? Review Topic

 

 

 

1. Closed reduction and a long arm cast

2. Closed reduction, a long arm cast, and a skeletal survey

3. Closed reduction, a long arm cast, a skeletal survey, and a referral to child protective services

4. Closed reduction and a long arm cast, a bone scan, and referral to child protective services

5. Closed reduction and a long arm cast, MRI of the brain, and a referral to child protective services

 

PREFERRED RESPONSE 3

 

The occurrence of a forearm fracture in a 9-month-old child has a greater than 50% chance that the injury is due to child abuse. It is mandatory to report this to child protective services unless there is some compelling reason that it is definitely not child abuse. In addition, a skeletal survey should be requested to look for other injuries. A bone scan would show other injuries, but a skeletal survey is a more

efficient way to evaluate for other fractures. A MRI of the brain is not indicated unless fundoscopic examination reveals an abnormality.

 

(SAE07PE.55) A 6-month-old child is seen in the emergency department with a spiral fracture of the tibia. The parents are vague about the etiology of the injury. There is no family history of a bone disease. In addition to casting of the fracture, initial management should include Review Topic

 

1. a skeletal survey to rule out other fractures.

2. a punch biopsy of the skin for collagen analysis to rule out osteogenesis imperfecta.

3. DNA testing for osteogenesis imperfecta.

4. blood studies for calcium, phosphorus, and alkaline phosphate levels.

5. blood studies for parathyroid hormone levels.

 

PREFERRED RESPONSE 1

 

Unwitnessed spiral fractures should raise the possibility of child abuse, especially prior to walking age. With nonaccidental trauma being considered in the differential diagnosis, a skeletal survey is indicated to determine if there are other fractures in various stages of healing.

 

(SBQ13PE.60) If a child develops dynamic supination after treatment of idiopathic clubfoot with Ponseti casting, at what age would it be appropriate to consider transfer of the tibialis anterior tendon to the lateral dorsum of the foot? Review Topic

 

1. In the first six months of life, immediately following failed cast treatment

2. 12 months

3. 4 years

4. 12 years

5. 15 years

 

PREFERRED RESPONSE 3

 

Tibialis tendon transfer to the dorsum of the foot should be performed to address dynamic supination when the lateral cuneiform has ossified. This is typically after at least 2 years of age and usually not before age 3.